PELVIC ORGAN PROLAPSE, uterine prolapse , cystocele, rectocele, urethrocele, supports of uterus, sling surgeries, pessaries, grades of prolapse, uterine preserving surgery for pop, pelvic floor repair, vaginal hysterectomy, ward mayos surgery, pop q grading, grading of prolapse, laproscopic surgeries for prolapse, peregee, apogee , mesh repair, tot, tvt, colpo suspension, colpoclysis, SUI management, epidemiology of prolapse, decubitus ulcer, best ppt for pelvic organ prolapse, better understanding of pelvic organ prolapse and pelvic floor.
PELVIC ORGAN PROLAPSE, uterine prolapse , cystocele, rectocele, urethrocele, supports of uterus, sling surgeries, pessaries, grades of prolapse, uterine preserving surgery for pop, pelvic floor repair, vaginal hysterectomy, ward mayos surgery, pop q grading, grading of prolapse, laproscopic surgeries for prolapse, peregee, apogee , mesh repair, tot, tvt, colpo suspension, colpoclysis, SUI management, epidemiology of prolapse, decubitus ulcer, best ppt for pelvic organ prolapse, better understanding of pelvic organ prolapse and pelvic floor. dr . m. gokul reshmi, dr. gokulreshmi m
PELVIC ORGAN PROLAPSE, uterine prolapse , cystocele, rectocele, urethrocele, supports of uterus, sling surgeries, pessaries, grades of prolapse, uterine preserving surgery for pop, pelvic floor repair, vaginal hysterectomy, ward mayos surgery, pop q grading, grading of prolapse, laproscopic surgeries for prolapse, peregee, apogee , mesh repair, tot, tvt, colpo suspension, colpoclysis, SUI management, epidemiology of prolapse, decubitus ulcer, best ppt for pelvic organ prolapse, better understanding of pelvic organ prolapse and pelvic floor.
PELVIC ORGAN PROLAPSE, uterine prolapse , cystocele, rectocele, urethrocele, supports of uterus, sling surgeries, pessaries, grades of prolapse, uterine preserving surgery for pop, pelvic floor repair, vaginal hysterectomy, ward mayos surgery, pop q grading, grading of prolapse, laproscopic surgeries for prolapse, peregee, apogee , mesh repair, tot, tvt, colpo suspension, colpoclysis, SUI management, epidemiology of prolapse, decubitus ulcer, best ppt for pelvic organ prolapse, better understanding of pelvic organ prolapse and pelvic floor. dr . m. gokul reshmi, dr. gokulreshmi m
Pelvic organ prolapse
Etiology of pelvic organ prolapse
Vaginal vault prolapse
Etiological factors of vault prolapse
Signs and symptoms of vaginal vault prolapse
Diagnosis of vaginal vault prolapse
Treatment measures
Genital prolapse is the descent of one or more of the genital organ (urethra, bladder, uterus, rectum or Douglas pouch or rectouterine pouch”) through the fasciomuscular pelvic floor below their normal level.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Pelvic organ prolapse
Etiology of pelvic organ prolapse
Vaginal vault prolapse
Etiological factors of vault prolapse
Signs and symptoms of vaginal vault prolapse
Diagnosis of vaginal vault prolapse
Treatment measures
Genital prolapse is the descent of one or more of the genital organ (urethra, bladder, uterus, rectum or Douglas pouch or rectouterine pouch”) through the fasciomuscular pelvic floor below their normal level.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
1. Definition of prolapse
Descent of one or more of vaginal segments
(ANT., POST., APEX)
ICS 2002
Leading edge of any vaginal segment
≥ -1cm above hymenal remnant
NIH 2001
2. Lifetime risk for surgery for prolapse /
urinary incontinence
11%
(ACOG 2007)
>30% require repeat surgery
(Progress 2007)
3. Possible risk factors
Genetic predisp.
Vaginal birth
Parity
Menopause
Advancing age
Prior pelvic surgery
Connective tissue dis.
↑ IA pressure
Obesity
Chronic constipation
↑ Straining
ACOG 2007
7. The vagina can be divided into three levels.
Reprinted from DeLancey (1992, AJOG)
Ischial spine & sacrospinous
ligament
Levator ani
Pubocervical fascia
Rectovaginal fascia
9. Level 1: The cardinal-uterosacral ligament complex
provides apical attachment of the uterus and vaginal
vault to the bony sacrum. Uterine prolapse occurs
when the cardinal-uterosacral ligament complex
breaks or is attenuated.
Level 2: The arcus tendineous fascia pelvis and the
fascia overlying the levator ani muscles provide
support to the middle part of the vagina.
Level 3: The urogenital diaphragm and the perineal
body provide support to the lower part of the vagina.
10. LEVEL I SUPPORT
This level consists of the cardinal and
uterosacral ligaments attachment to the
cervix and upper vagina
11. LEVEL II SUPPORT
This support consists of the paravaginal
attachments that are contiguous with the
cardinal/uterosacral complex at the ischial spine.
These are the connective tissue attachments of
the lateral vagina anteriorly to the arcus
tendineus fascia pelvis and posteriorly to the
arcus tendineus rectovaginalis.
Detachment of this connective tissue from the
arcus tendineus fascia pelvis leads to lateral or
paravaginal anterior vaginal wall prolapse.
12. Level II
POP at this level can be described as a central
hernia
through the pubocervical fascia—i.e. a
cystocoele and/or an
enterocoele or
rectocoele—when herniation is occurring
through the rectovaginal fascia in the upper or
middle part
13. LEVEL III SUPPORT
The perineal body, superficial and deep perineal
muscles, and fibromuscular connective tissue
comprise level III.
Collectively, these support the distal one-third of
the vagina and introitus. The perineal body is
essential for distal vaginal support as well as
proper function of the anal canal.
Damage to level III support contributes to
anterior and posterior vaginal wall prolapse,
gaping introitus, and perineal descent.
14. Weakening of / Dysfunction
↓
↓ ↓
Lev.ani Endopelvic fascia
Direct injury & its condensn.
Denervation Congenital
Age related
Child birth injury
19. a lateral cystocele, also termed paravaginal or
displacement cystocele. Rugae are present, which
indicates that loss of support is lateral rather than central
24. SYMPTOMS
VAG. URINARY BOWEL SEXUAL
ACOG RECOMMENDATIONS (Level A):
The only symptom specific to prolapse is the awareness
of a vaginal bulge or protrusion. For all other pelvic
symptoms, resolution with prolapse treatment cannot be
assumed
27. Urinary Frequency
Most women void 8 times per day or less.
Without a history that reflects increased fluid
intake, increased voiding may indicate
urge incontinence,
urinary tract infection,
calculi, or urethral pathology, and
should prompt additional evaluation.
In women with IC, the number of voids may
commonly exceed 20 per day.
Williams Gynecology
28. Urinary Retention
It is important to determine if the patient
adequately empties her bladder. Often
incomplete emptying can result in
incontinence associated with either stress
or urgency.
The term overflow incontinence is no
longer used.
Williams Gynecology
29. Williams Gynecology
The volume of urine lost with each episode
may also provide diagnostic clues.
Large volumes are typically lost following the
spontaneous detrusor contractions associated
with urge urinary incontinence and may often
involve loss of the entire bladder volume.
In contrast, women with SUI usually describe
smaller volumes lost.
30. Postvoid dribbling is classically
associated with urethral diverticulum,
which may often be mistaken for urinary
incontinence
31. BOWEL SYMPTOMS
Incontinence (because of common risk
factors)
Feeling of incomplete emptying
Straining during defecation
Urgency
Splinting / Digital pushing
33. Lancet 07
Although patients with pelvic organ
prolapse sometimes attribute back and
pelvic pain to their prolapse, very little
evidence is available to show that the
disorder causes pain. The complaint of
pain in a woman with prolapse should
prompt clinicians to search for other
sources of the pain before attributing it to
the disorder.
34. Examination
Resting Straining Retract post
wall to see
Dorsal / Squatting / Lt. lateral / ant wall
Lithotomy / standing prolapse &
Sims speculum vice versa.
Bivalve speculum
P/V P/R R/V
35. The extent of prolapse of the anterior
vaginal wall can be assessed by placing a
Sim’s speculum in the vagina to retract the
posterior vaginal wall
The blade is then placed to retract the
anterior vaginal wall and she strains again
to reveal any posterior prolapse.
36. Lancet -07
A bivalve speculum is inserted and the cervix or—in
women who have had a hysterectomy—vaginal cuff
is identified to assess apical vaginal support. While
the patient strains the speculum is slowly withdrawn
and the descent of the vaginal apex is noted
A rectovaginal examination can be useful to identify
presence of a rectocoele and establish the integrity of
the perineal body
A bimanual and rectal examination is undertaken to
rule out coexistent gynaecological or rectal
pathological fi ndings.
37. Bivalve speculum to assess apical vaginal
support (cervix / vaginal cuff)
Patient strains --speculum gradually
withdrawn
38. The Marshall test, otherwise known as the Marshall-
Bonney test, is performed by placing an index finger and
the second finger on either side of the bladder neck.
With the bladder relatively full, the patient is instructed to
perform Valsalva or cough. The 2 fingers at the bladder
neck serve to support the proximal urethra during
Valsalva maneuver. The absence of leakage with
bladder neck elevation and the presence of leakage with
loss of bladder neck support confirms stress urinary
incontinence due to urethral hypermobility. However, the
Marshall test is neither sensitive nor specific enough to
diagnose stress urinary incontinence by today's
standards. Thus, the Marshall test is not widely practiced
today.
39. BJOG Bonney's test—fact or
fiction?
Bonney test produced significant increases in
the urethral closure pressure and transmission
of impulse from the abdomen to the urethra
which indicated occlusion of the urethra rather
than elevation of the bladder neck. The Bonney
test does not differentiate between patients with
sphincter weakness and those with bladder
instability and therefore should be discarded.
Received 5 December 1985, Accepted 10 May
1986
40. Q-tip test: This test is performed by inserting a
sterile lubricated cotton swab (Q-tip) into the
female urethra. The cotton swab is gently
passed into the bladder and then slowly pulled
back until the neck of the cotton swab is fit
snugly against the bladder neck. The patient
then is instructed to perform a Valsalva
maneuver or to contract the abdominal muscles.
Excessive motion of the urethra and bladder
neck (hypermobility) with straining is an
important finding for type II stress incontinence.
A Q-tip excursion angle greater than 35°
indicates urethral hypermobility
41. NICE UI
The Q-tip, Bonney, Marshall, and Fluid-Bridge
tests are not recommended in the assessment of
women with UI.
A urine dipstick test should be undertaken in all
women presenting with UI to detect the
presence of blood, glucose, protein, leucocytes
and nitrites in the urine.
43. Williams Gynecology
Enterocele can only definitively be diagnosed by
observing small bowel peristalsis behind the vaginal wall
In general, bulges at the apical segment of the posterior
vaginal wall should implicate enteroceles, whereas
bulges in the distal posterior wall are presumed to be
rectoceles.
Further distinction may be found during standing
rectovaginal examination. A clinician's index finger is
placed in the rectum and thumb on the posterior vaginal
wall. Small bowel may be palpated between the rectum
and vagina, confirming enterocele.
44. Danforth
Detection of an enterocele is performed
best in the awake, straining patient by
noting a mass of small intestine between
the rectum and vagina; it may not be
suspected in a supine individual at rest.
45. Valsalva / Cough stress testing with full
bladder with reduced prolapse
46. Danforth
In instances in which the uterus is not
necessarily going to be removed, uterine
support should be tested before it is
assumed that the uterus is well supported.
This can be done by grasping the cervix
with a tenaculum or ring forceps and
applying traction until it stops descending.
Occult prolapse, in which the cervix comes
below the hymenal ring, can be detected
in this way
47. The five stages of prolapse
Stage 0: No prolapse
Stage I: The most distal portion of the prolapse is >1 cm
above the level of the hymen
Stage II: The most distal portion of the prolapse is ≤1cm
proximal or distal to the hymen
Stage III: The most distal portion of the prolapse is >1 cm
below the hymen but protrudes no further than 2 cm
less than the total length of the vagina
Stage IV: Complete eversion of the vagina
48. The staging system is not as sensitive as
the POPQ for description and follow-up of
individual patients.
49. Pelvic muscle function assessment
Palpate pelvic muscles a few cms. inside
hymen : 4 & 8 o’clock
Baseline tone / Increase with contraction
50. May identify women who benefit from pelvic
muscles exercise
Women taught
51. For women with positive prolapse
reduction stress test results who are
planning vaginal prolapse repair, tension-
free vaginal tape (TVT) midurethral sling
(rather than suburethral fascial plication)
appears to offer better prevention from
postoperative stress incontinence
52. Need for ancillary testing beyond a
comprehensive history and physical examination
depends largely on the
patient’s presenting symptoms. Most
women will need little additional testing.
Those with pelvic organ prolapse who
complain of lower urinary-tract symptoms
should undergo urinalysis and post-void
residual volume testing with a urethral
catheter or bladder ultrasound.
Lancet 07
53. Lancet 07
Urodynamic assessment :
with substantial urinary incontinence,
irritative voiding symptoms, or
voiding dysfunction.
Although urodynamics are currently being used
to predict postoperative urinary incontinence,
findings of a randomised trial have disputed the
usefulness of this test as a predictor of altering
surgical management
54. Prevention of VAULT PROLAPSE following
VAGINAL HYSTERECTOMY
McCALL culdoplasty
Approximating the uterosacral ligaments
using continuous sutures so as to
obliterate the peritoneum of posterior cul-
de-sac as high as possilble.
After midline approximation the uterosacrals
fixed to the vault.
55. A similar procedure described for abdominal
hysterectomy.
Uterosacrals identified prior to dividing them
from the uterus
(Progress 2007)
56. SACROSPINOUS FIXATION at the time of
vaginal hysterectomy is recommended for
MARKED UTEROVAGINAL PROLAPSE
WHEN the VAULT DESCENDS to
INTROITUS DURING CLOSURE
(at the end of ant. vag. wall closure)
(RCOG 2007 oct)
57. Incidence of vault prolapse after
hysterectomy
↓
↓ ↓
After vag. After abd.
(for prolapse) (non prolapse)
12% 2%
(J Reprod Med 1999)
59. Urodynamic studies(cont..)
↓ ↓ ↓
Obstructed Atonic Overactive
voiding bladder ↓
↓ ↓ surgery will
good prog. less not improve
after cystocoele favourable symptoms
repair
60. R / V examination
Anterior displacement of rectal finger
towards vagina --- rectocoele
Pt. asked to strain
Non rugated vag. epithelium proximal to
examining finger --- enterocoele
61. McCall culdoplasty
Uterosacral ligament SUSPENSION for
VAGINAL APEX
Upto 3 sutures placed in each uterosacral
ligament & incorporated into the ant & post
vaginal
(fibromuscular layers + vag epith.)
Some surgeons approximate
The uterosacral lights in midline
Done if esp.redundant cul-de-sac
62. McCALL Culdoplasty (cont..)
↓ ↓
Excessive redundant Otherwise
cul-de-sac suspend the rt & lt
Approximate the 2 vag. apex to ipsilateral
uterosacrals in uterosacral ligament
midline
↓ Less post op bowel
vaginally done by dysfunction
McCALL
63. Post. Colporrhaphy
Midline plication of subepithelial vaginal
tissue
Traditionally MEDIAL PORTION of
LEVATOR ANI PLICATED
Largely abandoned because of dyspareunia
ACOG 2007
68. Pessaries (cont..)
Clinicians should discuss option with ALL
WOMEN WHO have SYMPTOMATIC
PROLAPSE
Should be considered before surgery
ACOG 2007
Women who fail / decline pessary are
candidates for surgery
LANCET 2007
71. STRESS INCONTINENCE
Improves as prolapse extends beyond
hymen possibly from urethral obstruction
Latent stress incontinence in
symptomatically continent – also called
OCCULT / MASKED
72. ACOG RECOMMENDATIONS
(Level A):
Stress-continent women with positive stress
test results (prolapse reduced) are at higher
risk for developing postoperative stress
incontinence after prolapse repair alone
compared with women with negative stress
test results (prolapse reduced)
73. ACOG RECOMMENDATIONS
(Level A):
For stress-continent women planning
abdominal sacral colpopexy, regardless of
the results of preoperative stress testing,
the addition of the Burch procedure
substantially reduces the likelihood of
postoperative stress incontinence without
increasing urgency symptoms or
obstructed voiding.
75. The following recommendations and conclusions
are based on limited or inconsistent scientific
evidence (Level B): ACOG 2007
Compared with vaginal sacrospinous
ligament fixation, abdominal sacral
colpopexy has less apical failure and less
postoperative dyspareunia and stress
incontinence, but is also associated with
more complications.
76. Women Considering Pregnancy
Ideally, childbearing should be complete
before considering surgery for prolapse to
avoid the theoretical but plausible risk of
recurrent prolapse after subsequent
pregnancy and delivery. For women who
become pregnant after prolapse repair,
decisions regarding mode of delivery
should be made on a case-by-case basis;
evidence to guide such decisions is
lacking.
77. Complications were more frequent in
women aged 80 years and older and in
women who had reconstructive rather than
obliterative surgery.
78. Stress urinary incontinence Green 04
complaint of involuntary leakage during effort or exertion, occurs
at least weekly in one third of adult women.
basic evaluation of women with stress urinary incontinence
includes a history, physical examination, cough stress test,
voiding diary, postvoid residual urine volume, and urinalysis.
Formal urodynamics testing may help guide clinical care, but
whether urodynamics improves or predicts the outcome of
incontinence treatment is not yet clear.
The distinction between urodynamic stress incontinence
associated with hypermobility and urodynamic stress
incontinence associated with intrinsic sphincter deficiency
should be viewed as a continuum, rather than a dichotomy, of
urethral function.
79. Q-Tip Test
If urethra is poorly supported, it may display hypermobility
during increases in intra-abdominal pressures.
To assess mobility, a clinician places the soft end of a cotton
swab into the urethra to the urethrovesical junction. Failure to
insert the swab to this depth typically leads to errors in
assessment of urethrovesical junction support. Termed the Q-
tip test, this evaluation may be uncomfortable and application
of intraurethral analgesia may prove helpful. Commonly, 1
percent lidocaine jelly is placed on the cotton swab prior to
insertion. Following placement, Valsalva maneuver is
prompted, and the swab angle excursion at rest and with
Valsalva maneuver is measured with a goniometer or
standard protractor (Fig. 23-8).
An angle excursion at rest or with Valsalva maneuver greater
than 30 degrees above the horizontal indicates urethral
hypermobility, and may help direct planning of surgical
treatment for stress incontinence
80. post void residual volume
of less than 50 mL is regarded as normal
greater than 150–200 mL are regarded as
abnormal.
In older women, up to 100 mL may be regarded
as normal, depending on the circumstances
NOVAK:provided the patient has voided 150 mL
or more, a PVR less than or equal to 100 mL is
acceptable
81. Overactive bladder syndrome
(OAB)
Urgency that occurs with or without urge UI and
usually with frequency and nocturia.
OAB that occurs with urge UI is known as ‘OAB wet’.
OAB that occurs without urge UI is known as ‘OAB
dry’.
These combinations of symptoms are suggestive of
the urodynamic finding of detrusor overactivity, but
can be the result of other forms of urethrovesical
dysfunction.
82. Expert opinion concludes that
symptomatic categorisation of UI based on
reports from the woman and history taking
is sufficiently reliable to inform initial, non-
invasive treatment decisions.