Ben Herbert Alex Wojtowicz

Transcription

1 Ben Herbert Alex Wojtowicz

2 54 year old female presenting with: Dragging sensation Urinary incontinence Some faecal incontinence HPC Since May 14 had noticed a mass protruding from the vagina when going to the toilet. Occurring more frequently, now present every time the patient voids urine or empties bowels It is easily reducible and patient does this each time

3 Parity (+what type of delivery) LMP If post menopausal Any HRT? Any PMB? Sexually active? Pain or bleeding? Urinary symptoms Determine whether stress or urge incontinence Frequency and progression Bowel symptoms Bowel habits Manual evacuation necessary? Cervical smear up to date? PMH PSH (including infertility investigations, c-section, hysterectomy, ectopic pregnancy) DH Allergies (remember latex if examining patient) Ask about contraception/hrt FH SH

4 Abdo: Feel for any tenderness or pelvic masses PV: Speculum and Bimanual exam. Use Simms speculum in left lateral position to determine whether anterior or posterior wall involvement. If indicated can take swabs at the same time and cervical smear (only if it is due) Can ask patient to cough to accentuate prolapse

5 Pelvic organs are maintained in position by supporting ligaments, fascia and pelvic floor muscles Levator ani Pubococcygeus Puborectalis Iliococcygeus

6 Uterus present Uterus: uterocele Anterior wall: cystocele Posterior wall: rectocele No uterus present Vaginal vault Anterior wall: cystocele Posterior wall: rectocele More than one type of prolapse can occur simultaneously, and for management it is important to identify what symptoms they are causing.

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8 GRADE POSITION OF MOST DISTAL PROLAPSE SITE 0 No prolapse 1 Halfway to hymen 2 To hymen 3 Halfway past hymen 4 Maximum descent Easy to evaluate this staging system, although there is some issue with inter-observer reproducibility. Other variations are used

9 STAGE POP-Q MEASUREMENT S Stage 0 Aa, Ap, Ba, Bp = - 3cm and C or D - (TVL- 2cm) Stage 1 Stage 0 criteria not met and leading edge < -1cm Stage 2 Leading edge - 1cm but + 1cm Stage 3 Leading edge > + 1cm but < + (TVL - 2) cm Very precise staging criteria, using multiple measurements Useful in staging for surgery and in research studies For a good article and description: ewarticle/814321_2 Stage 4 Leading edge + (TVL 2) cm

10 On examination: Grade 2 prolapse visible on inspection and coughing Cusco Speculum exam normal, cervix visible no abnormality Uterus soft, mobile and non-tender No adnexal masses Using Simms speculum: posterior wall prolapse grade 2, anterior wall prolapse grade 1

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13 Management is dependent on symptoms, patient choice and a risk/benefit analysis Treatment is indicated where there are symptoms of: Urinary Bowel Sexual dysfunction Treatment generally not indicated in asymptomatic women

14 Expectant Conservative Vaginal Pessary Pelvic Floor Exercises Oestrogen Therapy Surgical Associated with recurrence/re-operation rate of 30% Various surgical procedures and approaches Success is based on severity of symptoms, extent of prolapse and patient expectations

15 Choice of conservative or surgical management, what would you do? Ring pessary inserted, option to evaluate for any benefit Offered surgical repair, although long waiting list

16 0 GPnotebook.com Baden WF, Walker TA, Lindsay HJ. The vaginal profile. Tex Med J. 1968;64:56-58 Bump RC, Mattiasson A, Bo K et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynaecology. 1996; 175:13 Prolapse-%20AR%20BSUG%20F1.pdf

17 Normal mechanisms for maintaining continence How these break down to produce different types of incontinence.

18 Filling Phase Bladder distends to collect urine Leakage is prevented by urethral sphincters Emptying Phase Relaxation of sphincters and detrusor contraction Cerebral control delays micturition until appropriate

19 Bladder Capacity Various ways of measuring Functional Volume causing active urge to urinate What is normal functional bladder capacity? This is the looking for a toilet volume Actual anatomic maximum volume can be much higher Can sense bladder distension from 150ml

20 Phase defined by sympathetic control Lowers resting detrusor tone Increases tone in bladder neck & internal urethral sphincter Stretch receptors modulate parasympathetic activity Low volume means low PS activity Increased PS tone = Detrusor contraction

21 Urethral Sphincters Internal Sympathetic Its contraction is key mechanism here Along with increased tone of bladder neck External Somatic Via pudendal nerve (S2-4) Mechanism by which conscious control is exercised Pelvic Floor Muscles stabilise urethra against raised intra-abdominal pressure

22 Sacral Reflex Parasympathetic fibres respond to filling bladder Internal sphincter relaxes Detrusor contracts Micturition occurs unless inhibited by conscious control Via external sphincter

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24 Mechanism Intra-abdominal pressure increases beyond what can the pelvic floor can compensate for This disrupts sphincter function More common in women Symptoms occur with: Coughing Lifting Physical activity

25 Pelvic Floor Weakness Increased Pressure Trauma E.g. childbirth; surgery Obesity Post-Menopausal Loss of oestrogen alters urethral sphincter and pelvic floor function During pregnancy itself Smoking (chronic cough) Prolapse Evidence of extent of pelvic floor dysfunction and loss of support

26 Mechanism Detrusor contraction is easily stimulated Occurs with little warning can t find a toilet in time

27 Overactive bladder syndrome Idiopathic Worse with stress and some dietary triggers Local irritation UTI Bladder stones Interstitial cystitis Neurological Spastic bladder Loss of detrusor inhibition E.g. spinal cord injury, MS, diabetes, etc NB Essentially the opposite of flaccid neurogenic bladder Retention due to spasticity of the external sphincter

28 Poor voiding leads to urinary retention e.g. prostate enlargement or other obstruction Neurogenic (flaccid) bladder with loss of detrusor contraction Dribbling of urine through obstruction when pressure is high enough in the bladder from retention Urinary equivalent of spurious diarrhoea

29 Normal changes with age Ability to delay micturition after first urge = Decreased Detrusor stretch receptors less sensitive less time to plan Residual volume = Increases Decreased detrusor contractility <50ml is normal at any age <100ml for >60 years old Functional Capacity = Technically increases Reduced sensation means delayed onset of urge Net Outcome = Increased frequency of micturition Functional incontinence Can t get to bathroom in time due to general health, e.g. arthritis or dementia

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32 Continence Theory: ging_on_the_urinary_tract.html Continence Images: d.jpg