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Ürojinekoloji - www.jinekolojivegebelik.com

  1. 1. UPDATE IN UROGYNAECOLOGY <ul><li>Bern ar d T. Haylen </li></ul><ul><li>St. Vincent’s Clinic , Mater & Randwick Urodynamic Centres, Sydney </li></ul><ul><li>www.bladder.com.au </li></ul>
  2. 2. UROGYNAECOLOGY <ul><li>AREA OF GYNAECOLOGY AND FEMALE </li></ul><ul><li>UROLOGY INVOLVING THE ASSESSMENT </li></ul><ul><li>AND TREATMENT OF LOWER URINARY </li></ul><ul><li>TRACT AND PELVIC FLOOR DYSFUNCTION </li></ul><ul><li>INCLUDING UTERINE AND VAGINAL </li></ul><ul><li>PROLAPSE </li></ul>
  3. 3. INCIDENCE OF UROGYNAECOLOGICAL PROBLEMS <ul><li>OVERALL: </li></ul><ul><li> High </li></ul><ul><li>INCONTINENCE: </li></ul><ul><li> 34% Australian women (11% severe) </li></ul><ul><li>PROLAPSE: </li></ul><ul><li>50% of postmenopausal women at routine gynaecological examination will have some degree of prolapse </li></ul>
  4. 4. UROGYNAECOLOGY <ul><li>DIAGNOSES </li></ul>
  5. 5. UROGYNAECOLOGY - COMMON DIAGNOSES <ul><li>URODYNAMIC STRESS INCONTINENCE </li></ul><ul><li>(USI) - 70% </li></ul><ul><li>DETRUSOR OVERACTIVITY (DO) – 15%-40% </li></ul><ul><li>VOIDING DIFFICULTIES – 14%-39% </li></ul><ul><li>(Definition dependent) </li></ul><ul><li>UTERINE/VAGINAL PROLAPSE - 65% </li></ul>
  6. 6. UROGYNAECOLOGY - URODYNAMIC STRESS INCONTINENCE (USI) <ul><li>The diagnosis of USI is urinary incontinence due to weakness or incompetence of the bladder neck and/or urethral sphincter closure mechanisms that normally maintain continence </li></ul><ul><li>The symptom of stress incontinence is the involuntary loss of urine with coughing, sneezing, running, jumping etc. This is the most likely associated symptom of USI. </li></ul>
  7. 7. UROGYNAECOLOGY - DETRUSOR OVERACTIVITY (DO) <ul><li>Abnormal contractions of the intrinsic bladder (detrusor) musculature </li></ul><ul><li>Irritable bladder symptoms such as frequency, urgency, urge incontinence and nocturnal enuresis are more likely to be present with this condition </li></ul>
  8. 8. UROGYNAECOLOGY – VOIDING DIFFICULTY <ul><li>Abnormally slow or incomplete micturition </li></ul><ul><li>Abnormally slow urine flow rate or high postvoid residual urine volume </li></ul><ul><li>If high residual (over 30mls) – recurrent urinary tract infections can ensue </li></ul><ul><li>May be due to hypotonic or atonic bladder or bladder outflow obstruction </li></ul>
  9. 9. UROGYNAECOLOGY - UTERINE/VAGINAL PROLAPSE <ul><li>Abnormal descent into the vagina of the uterus, bladder (cystocoele) vaginal vault (enterocoele) or rectum (rectocoele) </li></ul><ul><li>560 Consecutive urogynaecology patients with incidence of: </li></ul><ul><li>. Uterine prolapse (15% overall) </li></ul><ul><li>. Cystocoele (57% overall) </li></ul><ul><li>. Rectocoele (41% overall) </li></ul><ul><li>. Enterocoele ( 8% overall) </li></ul>
  10. 10. UROGYNAECOLOGY - OTHER DIAGNOSES <ul><li>MIXED DIAGNOSES: </li></ul><ul><li>It’s very common for women to have more than one of the most common diagnoses e.g USI/DO, USI/prolapse </li></ul><ul><li>Women with prolapse often have USI and may also have DO and voiding difficulties </li></ul><ul><li>INTERCURRENT DIAGNOSES: </li></ul><ul><li>8% of urogynaecology patients will have other pelvic pathology (e.g. fibroids, ovarian pathology) whilst many more will have other gynaecological symptomatology. </li></ul><ul><li>OTHER DIAGNOSES: </li></ul><ul><li>. Inflammation, Fistula, Urethral Diverticulum </li></ul>
  11. 11. UROGYNAECOLOGY – RECURRENT URINARY TRACT INFECTIONS <ul><li>One of the most common bacterial infections in General Practice. </li></ul><ul><li>40% women affected sometime in their life </li></ul><ul><li>27% have a recurrence within 6 to 12 months </li></ul><ul><li>Definition: uncertain to date </li></ul><ul><li>“ 2 or more symptomatic and medically documented UTI in the last 12 months” </li></ul>
  12. 12. UROGYNAECOLOGY – RECURRENT URINARY TRACT INFECTIONS <ul><li>1140 consecutive first visit referrals for urogynaecological assessment </li></ul><ul><li>Full history, examination, urodynamics </li></ul><ul><li>Prevalence: 18.6% </li></ul><ul><li>Main Risk factors: </li></ul><ul><li>Nulliparity: 3.7x (18-50yrs); 1.8x (over 50) </li></ul><ul><li>Postvoid Residual (PVR): over 30mls </li></ul>
  13. 13. UROGYNAECOLOGY <ul><li>AETIOLOGY </li></ul><ul><li>(for background reading) </li></ul>
  14. 14. UROGYNAECOLOGY – AETIOLOGY OF URODYNAMIC STRESS INCONTINENCE <ul><li>1: CHILDBIRTH : Number 1 cause by far </li></ul><ul><li>Risk Factors: Vaginal delivery; heavy baby (>4kg); prolonged 2 nd stage labour (>1hr pushing). Caesarean section protective in short term. </li></ul><ul><li>2: MENOPAUSE: Mean age for presentation of women with urinary tract and pelvic floor dysfunction is 55 years. </li></ul><ul><li>3: HYSTERECTOMY: Much incontinence present but not discussed at time of hysterectomy. Some new dysfunction post-hysterectomy with voiding difficulties not uncommon. </li></ul>
  15. 15. UROGYNAECOLOGY – AETIOLOGY OF DETRUSOR OVERACTIVITY <ul><li>MANY THEORIES: </li></ul><ul><li>1: IDIOPATHIC: Absence of inhibitory neuro-transmitters or increased spontaneous detrusor contractions </li></ul><ul><li>2: NEUROGENIC: Lesions to frontal lobe, pontine lesions or lesions above S2-4 give detrusor overactivity </li></ul><ul><li>3: OBSTRUCTIVE: Postsurgical or with prolapse </li></ul><ul><li>4: INFECTIVE: </li></ul>
  16. 16. UROGYNAECOLOGY – AETIOLOGY OF PROLAPSE <ul><li>1: CHILDBIRTH </li></ul><ul><li>2: HYSTERECTOMY </li></ul><ul><li>3: MENOPAUSE </li></ul><ul><li>4: PREVIOUS PROLAPSE / INCONTINENCE SURGERY </li></ul>
  17. 17. UROGYNAECOLOGY – AETIOLOGY OF VOIDING DIFFICULTY <ul><li>1: BLADDER OUTFLOW OBSTRUCTION </li></ul><ul><li>Idiopathic . Drugs (e.g tricyclics) </li></ul><ul><li>Postoperative . Obstructive effect of prolapse </li></ul><ul><li>Psychogenic . Distal urethral (ageing) changes </li></ul><ul><li>Infective . External pressure (retroversion) </li></ul><ul><li>2: HYPOTONIC / ATONIC BLADDER </li></ul><ul><li>Postpartum retention </li></ul><ul><li>LMN Lesion (diabetes, peripheral neuropathy) </li></ul><ul><li>Overdistension </li></ul>
  18. 18. UROGYNAECOLOGY <ul><li>ASSESSMENT </li></ul>
  19. 19. UROGYNAECOLOGY - INITIAL ASSESSMENT - (ALL PRACTITIONERS) <ul><li>1: HISTORY – </li></ul><ul><li>Full history with symptoms of incontinence, bladder irritability, prolapse and voiding difficulty sought </li></ul><ul><li>2: EXAMINATION – </li></ul><ul><li>General, Clinical Stress Leakage, Sims Speculum (prolapse), Bimanual </li></ul><ul><li>3: MSU </li></ul><ul><li>4: BLADDER CHART </li></ul><ul><li>5: POSTVOID RESIDUAL (U/S)/ RENAL TRACT U/S: if recurrent UTI </li></ul>
  20. 20. UROGYNAECOLOGY - COMMON SYMPTOMS <ul><li>1: INCONTINENCE: </li></ul><ul><li>Stress, Urge, Coital, Nocturnal </li></ul><ul><li>2: IRRITATIVE: </li></ul><ul><li>Urgency, Frequency (> 7), Nocturia (>1) </li></ul><ul><li>3: VOIDING: </li></ul><ul><li>Hesitancy, Poor stream, Sense of incomplete emptying, Need to immediately revoid, Strain to void </li></ul><ul><li>4: PROLAPSE: </li></ul><ul><li>Pelvic pressure, Vaginal lump, Sacral backache, </li></ul><ul><li>Dyspareunia. </li></ul><ul><li>5 : OTHER: </li></ul><ul><li>Gynaecological (pelvic pain, menstrual dysfunction), Neurological, Diabetes </li></ul>
  21. 21. UROGYNAECOLOGY - ROLE OF SYMPTOMS <ul><li>MOST WOMEN WITH PELVIC FLOOR </li></ul><ul><li>DYSFUNCTION WILL PRESENT WITH </li></ul><ul><li>MULTIPLE SYMPTOMS SUGGESTIVE OF </li></ul><ul><li>MORE THAN ONE UROGYNAECOLOGICAL </li></ul><ul><li>DIAGNOSIS. </li></ul>
  22. 22. UROGYNAECOLOGY – COMMON SIGNS <ul><li>A: CLINICAL STRESS LEAKAGE: </li></ul><ul><li>. Bladder FULL , Standing or left lateral position </li></ul><ul><li>. Occult stress – prolapse reduced to see leakage </li></ul><ul><li>B : PROLAPSE (UTERINE/VAGINAL) </li></ul><ul><li>. Bladder EMPTY , Left lateral (Sims) position </li></ul><ul><li>C: INTERCURRENT GYNAE/UROLOGY PATHOLOGY: </li></ul><ul><li>. Bimanual pelvic examination </li></ul><ul><li>. Speculum examination </li></ul><ul><li>. Vulval examination </li></ul><ul><li>. Vaginal ultrasound examination ( generally </li></ul><ul><li>specialist assessment) </li></ul>
  23. 23. FEMALE URINARY INCONTINENCE: CLINICAL EXAMINATION <ul><li>GRADING OF PELVIC ORGAN PROLAPSE (POP) - ICS </li></ul><ul><li>For each of uterine prolapse, cystocoele, rectocoele, enterocoele </li></ul><ul><li>GRADE 0: No prolapse </li></ul><ul><li>GRADE 1: Descent towards vaginal introitus (>1cm above hymen) </li></ul><ul><li>GRADE 2: Descent to vaginal introitus (hymen +/- 1cm from hymen) </li></ul><ul><li>GRADE 3: Descent through introitus (> 1cm below hymen) </li></ul><ul><li>GRADE 4: Prolapse totally outside introitus </li></ul><ul><li>(uterine grade 4 = “procidentia”) </li></ul>
  24. 24. Figure 1: Prolapse staging – 0,1,2,3,4 (uterine – by the position of the leading edge of the cervix) N.B. vaginal eversion in stages 3 & 4 Symphysis Position: Section 2D (ii/iii) BH / JL 2007 0 1cm 1cm Hymen Bladder (Empty) Rectum 4 3 2 1
  25. 25. Figure 11: Pelvic Organ Prolapse Stage 2 Anterior Vaginal Wall Prolapse Position: Section 2D (v) OR Section 4E (i) Stage 4 Enterocele / Vaginal Vault Prolapse Position: Section 2D (iv) OR Section 4E (i) Stage 3 Uterine Prolapse Position: Section 2D (iii) OR Section 4E (i)
  26. 26. <ul><li>33% of women with symptoms of pelvic floor dysfunction will have frequency and/or dysuria - ? UTI </li></ul><ul><li>UTI might cause or exacerbate symptoms of pelvic floor dysfunction </li></ul><ul><li>  Recurrent UTI’s might be a reflection of a chronic abnormally high postvoid residual (above 30mls can lead to recurrent UTI’s) </li></ul>UROGYNAECOLOGY – ROLE OF MID STREAM URINE
  27. 27. UROGYNAECOLOGY – ROLE OF BLADDER DIARY <ul><li>3 DAYS CHARTING TIME AND AMOUNT OF EACH VOID, FLUID INTAKE AND EPISODES OF INCONTINENCE </li></ul><ul><li>Indicator of urinary frequency or nocturia ( this can be altered by bladder training) </li></ul><ul><li>Indicator of average voided volume (should be 200-300mls) </li></ul><ul><li>Indicator of severity of incontinence (number of leaks) </li></ul><ul><li>Indicator of above average (>2 litres) or below average (under 1 litre) fluid intake </li></ul>
  28. 28. Figure 2: Bladder Diary This simple chart allows you to record the fluid you drink and the urine you pass over 3 days (not necessarily consecutive) in the week prior to your clinic appointment. This can provide valuable information. • Please fill in approximately when and how much fluid you drink, and the type of liquid. • Please fill in the time and the amount (in mls, or ounces) of urine passed, and mark with a star if you have leaked or mark with a “P” if you have needed to change your pad. (Please find below an example of how to complete this form.) Summary Frequency = 9 Nocturia = 1 Urine pr oduction / 24 hour = 1250 ml Maximum voided volume = 300 ml Average void = 125 ml Position: Section 2F (i/ii) DATE/TIME DD.MM.YY LIQUID INTAKE (mls) VOLUME OF URINE (mls. or ounces) LEAKS PAD CHANGE 21.02.06 0215 150 0715 250 0800 Mug coffee 250ml 0820 60 P 0930 Cup Orange juice 1000 100 1200 2 mugs coffee 1400 300 1430 20 1530 Cup of Tea 200ml P 1600 100 1800 Cup of Tea 200ml 1900 100 2000 Glass Beer 200ml 20 2030 Glass wine 50ml 2200 P 2300 150
  29. 29. UROGYNAECOLOGY – INITIAL GENERAL MEASURES <ul><li>WEIGHT LOSS : often reduces symptom of stress incontinence </li></ul><ul><li>REDUCED CAFFEINE : reduced frequency, bladder irritability </li></ul><ul><li>IMPROVE CHEST CONDITIONS: or other exacerbating factors for stress incontinence </li></ul><ul><li>VAGINAL OESTROGENS: May improve frequency, nocturia, urgency and condition of the vaginal mucosa. Little proven benefit for incontinence over placebo </li></ul><ul><li>MEDICATIONS: Adverse effect of diuretics, Minipress </li></ul><ul><li>PHYSIOTHERAPY: Best if incontinence is mild to moderate and stress incontinence is the main symptom </li></ul>
  30. 30. UROGYNAECOLOGY <ul><li>? REFERRAL / </li></ul><ul><li>URODYNAMIC TESTING </li></ul>
  31. 31. UROGYNAECOLOGY – REFERRAL FOR URODYNAMICS <ul><li>MIXED SYMPTOMS - Diagnosis uncertain </li></ul><ul><li>SEVERE SYMPTOMS </li></ul><ul><li>FAILURE OF INITIAL MEASURES </li></ul><ul><li>DEFINITIVE TREATMENT ANTICIPATED : - Surgery for Urodynamic Stress Incontinence </li></ul><ul><li>- Anticholinergics for Detrusor Overactivity </li></ul>
  32. 32. UROGYNAECOLOGY – AIMS OF URODYNAMICS (a) <ul><li>1: IDENTIFY/ ELIMINATE DETRUSOR OVERACTIVITY </li></ul><ul><li>TEST: Cystometry </li></ul><ul><li>  </li></ul><ul><li>2 : IDENTIFY/ ELIMINATE VOIDING DIFFICULTIES </li></ul><ul><li>TESTS : Urine flow rate, Residual urine, Voiding cystometry </li></ul><ul><li>  </li></ul>
  33. 33. UROGYNAECOLOGY – AIMS OF URODYNAMICS (b) <ul><li>3: CONFIRM PRESENCE OF URODYNAMIC STRESS INCONTINENCE </li></ul><ul><li>TESTS: Stress urine leakage, ultrasound </li></ul><ul><li>imaging </li></ul><ul><li>  </li></ul><ul><li>4: IDENTIFY PRESENCE OF PROLAPSE AND INTERACTION WITH OTHER BLADDER DYSFUNCTION </li></ul><ul><li>  </li></ul><ul><li>5: ASSESS SEVERITY OF ALL DIAGNOSES PRESENT </li></ul>
  34. 34. UROGYNAECOLOGY – URODYNAMICS – WHAT’S INVOLVED? <ul><li>1 hour assessment – Including initial and final discussion </li></ul><ul><li>History and Examination </li></ul><ul><li>Vaginal Ultrasound (Bladder neck, postvoid residual and pelvic, uterine assessment) </li></ul><ul><li>Uroflowmetry </li></ul><ul><li>Filling and voiding cystometry </li></ul>
  35. 35. UROGYNAECOLOGY <ul><li>URODYNAMIC TESTING </li></ul><ul><li>- CRITERIA FOR DIAGNOSES </li></ul><ul><li>( Further Reading) </li></ul>
  36. 36. UROGYNAECOLOGY – Dx OF GENUINE STRESS INCONTINENCE <ul><li>CLINICAL STRESS LEAKAGE (Examination, Pad Test) </li></ul><ul><li>BLADDER STABLE </li></ul><ul><li>(or stable when leakage occurs) </li></ul><ul><li>IMAGING EVIDENCE – </li></ul><ul><li>Bladder neck incompetent </li></ul>
  37. 37. Figure 5: Schematic diagram of filling cystometry Flow rate mls/sec P abd cmH 2 O P det cmH 2 O P ves cmH 2 O Fill volume mls 30 40 20 10 20 40 60 80 20 40 60 80 20 40 60 80 100 200 300 400 FD ND SD U filling cystometry voiding cystometry CC 48 year old female with urinary frequency. No phasic activity during filling. Voided with normal flowrate at normal detrusor pressure. Normal study. FD = First Desire to Void, ND = Normal desire to void, SD = Strong desire to void, U = Urgency, CC = Cystometric Capacity (permission to void given). Position: Section 3C (v – vii), Section 3D (iii/iv) BH / JL 2007
  38. 38. UROGYNAECOLOGY – Dx OF DETRUSOR OVERACTIVITY <ul><li>CYSTOMETRY – </li></ul><ul><li>PRESENCE OF UNSTABLE BLADDER CONTRACTIONS ON FILLING OR PROVOCATION ASSOCIATED WITH SYMPTOM OF URGENCY </li></ul><ul><li>Bladder Capacity normally 500mls with < 10cm H20 pressure rise </li></ul><ul><li>Pressure increases over 15cm H20 abnormal </li></ul><ul><li>Under 400mls capacity is low </li></ul>
  39. 39. Figure 9: Schematic diagram of detrusor overactivity Flow rate mls/sec P abd cmH 2 O P det cmH 2 O P ves cmH 2 O Fill volume ml 30 40 20 10 20 40 60 80 20 40 60 80 20 40 60 80 100 200 300 400 FD ND SD U filling cystometry voiding cystometry L L 52 year old female with urgency and frequency. Phasic activity during filling. Leakage associated urgency and detrusor contractions. L = leakage, MCC = Maximum Cystometric Capacity. U MCC Position: Section 3D (v:b) & Section 4B (i) BH / JL 2007
  40. 40. UROGYNAECOLOGY – Dx OF VOIDING DIFFICULTIES <ul><li>SLOW URINE FLOW – </li></ul><ul><li>(Under 10 th Centile of Liverpool Nomogram) </li></ul><ul><li>HIGH RESIDUAL URINE – </li></ul><ul><li>Over 30mls is abnormal. 85% of women have no residual </li></ul><ul><li>VOIDING CYSTOMETRY - </li></ul><ul><li>. No Contraction, poor or no flow - Hypotonic or atonic </li></ul><ul><li>. Strong Contraction, slow flow - Bladder outflow obstruction </li></ul>
  41. 41. Figure 4: Liverpool Nomogram for maximum urine flow rate in women Reference: 20 Position: Section 3A (ix) Equation: Ln (Maximum flow rate) = 0.511 + 0.505 x Ln (voided volume) Root mean square error = 0.340
  42. 42. Reference: 23 Figure 10: Voiding difficulty Vaginal Probe (Ultrasound) Pubis Example of voiding difficulty Voided volume = 250ml Qmax = 15mls/sec < 10 th centile on Liverpool Nomogram and / or Post void residual (TV USS) = 78ml PVR = (H x D) x 5.9 – 15 = X ml PVR = (4.5 x 3.5) x 5.9 – 15 = 78ml Reference: 20 Position: Section 4D (i) Height (H=4.5) Depth (D=3.5) X
  43. 43. UROGYNAECOLOGY <ul><li>URODYNAMIC STRESS </li></ul><ul><li>INCONTINENCE </li></ul><ul><li>- MANAGEMENT </li></ul>
  44. 44. UROGYNAECOLOGY – CONSERVATIVE TREATMENT OF USI <ul><li>PHYSIOTHERAPY: </li></ul><ul><li>50-65% improvement, 20-40% cure if properly supervised. 40 Contractions per day for maximal compliance. </li></ul><ul><li>AIDS TO PHYSIO: </li></ul><ul><li>. Perineometer </li></ul><ul><li>. Vaginal Cones </li></ul><ul><li>. Electrical Stimulation </li></ul><ul><li>MECHANICAL DEVICES: </li></ul><ul><li>. Tampons </li></ul><ul><li>. Pessaries </li></ul>
  45. 45. <ul><li>SURGERY FOR USI </li></ul><ul><li>Minimally Invasive : </li></ul><ul><li>. Tension-free Vaginal </li></ul><ul><li>Tape – J & J </li></ul><ul><li>. “Advantage” - Boston </li></ul><ul><li>Traditional </li></ul><ul><li>Colposuspension </li></ul>UROGYNAECOLOGY – SURGICAL TREATMENT OF USI
  46. 46. UROGYNAECOLOGY – TENSION-FREE VAGINAL TAPE (TVT) <ul><li>Minimally invasive, day-only or overnight surgery </li></ul><ul><li>Inert prolene mesh – no rejection or infection </li></ul><ul><li>Most scientifically proven continence surgery in the history of Urogynaecology </li></ul><ul><li>Around 800,000 TVT’s performed worldwide (20,000 in Australasia) </li></ul><ul><li>Excellent combination with prolapse surgery </li></ul><ul><li>90% success rate (Primary USI) </li></ul>
  47. 47. UROGYNAECOLOGY <ul><li>DETRUSOR OVERACTIVITY </li></ul><ul><li>- MANAGEMENT </li></ul>
  48. 48. UROGYNAECOLOGY – TREATMENT OF DETRUSOR OVERACTIVITY <ul><li>CAN BE DIFFICULT – </li></ul><ul><li>50% response from most treatments versus 30% for placebo </li></ul><ul><li>MILD/MODERATE: Behavioural </li></ul><ul><li>. Bladder Training </li></ul><ul><li>. Maximal electrical stimulation </li></ul><ul><li>. ? Acupuncture/ Hypnosis </li></ul><ul><li>MODERATE/SEVERE: Medication </li></ul><ul><li>. Anticholinergics </li></ul><ul><li>. Antidepressant </li></ul><ul><li>. Antidiuretics </li></ul>
  49. 49. UROGYNAECOLOGY – BLADDER TRAINING FOR DETRUSOR OVERACTIVITY <ul><li>SUPPRESS URGENCY </li></ul><ul><li>INCREASE VOIDED VOLUMES </li></ul><ul><li>DECREASED FREQUENCY </li></ul><ul><li>DECREASED URGENCY </li></ul>
  50. 50. UROGYNAECOLOGY – DRUG TREATMENT OF DETRUSOR OVERACTIVITY - DAYTIME <ul><li>PROPANTHELINE ( Probanthine ) </li></ul><ul><li>- (15 - 30mg tds) - anticholinergic </li></ul><ul><li>OXYBUTYNIN (Ditropan) ( 2.5 - 5mg tds) – musculotrophic, antispasmodic, anticholinergic </li></ul><ul><li>. Patch form available ( Oxytrol) </li></ul><ul><li>TOLTERODINE (Detrusitol) (1 - 2mg BD) </li></ul><ul><li>antispasmodic, antimuscarinic - reduced S/E </li></ul><ul><li>SOLIFENACIN ( Vesicare ) – 5 -10mg daily </li></ul><ul><li>- antimuscarinic - probably least S/E </li></ul>
  51. 51. UROGYNAECOLOGY – DRUG TREATMENT OF DETRUSOR OVERACTIVITY – NIGHT TIME <ul><li>IMIPRAMNE (Tofranil) (25-75mg) </li></ul><ul><li>AMITRYPTALINE (Endep) (10-25mg) </li></ul><ul><li>DESMOPRESSIN ACETATE (Minirin) (200mcg ½ - 1 nocte) - Antidiuretic for enuresis </li></ul>
  52. 52. UROGYNAECOLOGY <ul><li>UTEROVAGINAL PROLAPSE </li></ul><ul><li>- MANAGEMENT </li></ul>
  53. 53. UROGYNAECOLOGY – TREATMENT OF UTEROVAGINAL PROLAPSE <ul><li>A: CONSERVATIVE: Future child bearing desired; younger (under 34) Medically compromised </li></ul><ul><li>physiotherapy </li></ul><ul><li>ring pessary </li></ul>
  54. 54. UROGYNAECOLOGY – TREATMENT OF UTEROVAGINAL PROLAPSE <ul><li>B : Future childbearing </li></ul><ul><li>unlikely : under 40 years </li></ul><ul><li>conservative measures </li></ul><ul><li>unsuitable </li></ul><ul><li>Manchester repair & sacrospinous hitch (St. Vincent’s Repair ) </li></ul>
  55. 55. UROGYNAECOLOGY – TREATMENT OF UTEROVAGINAL PROLAPSE <ul><li>C : No future childbearing: </li></ul><ul><li>over 40 years </li></ul><ul><li>vaginal hysterectomy + repairs +/- sacrospinous hitch (easiest effective vaginal vault support) </li></ul>
  56. 56. UROGYNAECOLOGY – SURGICAL TREATMENT OF PROLAPSE <ul><li>1 : UTERINE: </li></ul><ul><li>. Family Complete - Vaginal Hysterectomy </li></ul><ul><li>. Family Incomplete - Manchester </li></ul><ul><li>2: CYSTOCOELE: </li></ul><ul><li>. Primary - Anterior Repair </li></ul><ul><li>. Recurrent - Anterior or Paravaginal Repair </li></ul><ul><li>3: RECTOCOELE: Posterior Vaginal Repair </li></ul><ul><li>4: ENTEROCOELE: </li></ul><ul><li>. Small: Posterior Vaginal Repair </li></ul><ul><li>. Medium/Large: Sacrospinous Hitch (90% Success ) </li></ul>
  57. 57. UROGYNAECOLOGY <ul><li>RECURRENT UTI / </li></ul><ul><li>VOIDING DIFFICULTY </li></ul><ul><li>- MANAGEMENT </li></ul>
  58. 58. UROGYNAECOLOGY – RECURRENT UTI <ul><li>MEDICAL THERAPY: </li></ul><ul><li>Milder: 1 – 2 Courses antibiotics then </li></ul><ul><li>Hiprex 1Gm / Vit C 500mg each BD for </li></ul><ul><li>3 – 5 months according to no. of UTI </li></ul><ul><li>Stronger: Rotating low dose antibiotics </li></ul><ul><li>e.g Keflex 500mg, ½ Triprim, or Macrodantin 100mg each nocte 2/12 with cranberry tablet mane </li></ul><ul><li>Strongest: Long term Noroxin </li></ul>
  59. 59. UROGYNAECOLOGY – RECURRENT UTI <ul><li>SURGICAL THERAPY: </li></ul><ul><li>. If many UTIs: Cystoscopy </li></ul><ul><li>. Poor flow, High PVR, No prolapse </li></ul><ul><li>Cystoscopy & urethral dilatation </li></ul><ul><li>. Poor flow, High PVR, Prolapse </li></ul><ul><li>? Cystoscopy & prolapse repair. </li></ul>
  60. 60. UROGYNAECOLOGY – TREATMENT OF VOIDING DIFFICULTIES <ul><li>CAUSE TREATMENT </li></ul><ul><li>. Uterine/Vaginal Prolapse . Repair Prolapse </li></ul><ul><li>. Idiopathic High Residual . Longterm UTI Prophylaxis </li></ul><ul><li>(Recurrent UTI’s) (Hiprex/ Macrodantin) </li></ul><ul><li>. Postoperative, Postpartum . Catheterisation </li></ul><ul><li>(Suprapubic/ Self-cath) </li></ul><ul><li>. Distal Urethral Stenosis . Urethral dilatation </li></ul><ul><li>Vaginal oestrogens </li></ul>
  61. 61. UPDATE IN UROGYNAECOLOGY <ul><li>Bern ar d T. Haylen </li></ul><ul><li>St. Vincent’s Clinic , Mater & Randwick Urodynamic Centres, Sydney </li></ul><ul><li>www.bladder.com.au </li></ul>

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