This document discusses pelvic organ prolapse and incontinence in women. It begins with definitions of prolapse and types of urinary incontinence. It then discusses the symptoms, causes, physical examination findings, and treatment options for prolapse, stress urinary incontinence, and fecal incontinence. For prolapse, treatment options include pessaries, pelvic floor exercises, and various surgical procedures depending on the degree of prolapse. For urinary incontinence, treatment involves behavioral modifications, medications, and surgeries like slings or colposuspension. For fecal incontinence, treatments include bulking agents, medications, biofeedback, and surgeries like sphincteroplast
Vaginal prolapse is a condition in which structures such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself may begin to prolapse, or fall out of their normal positions.
Classification & conservative surgeries for prolapseIndraneel Jadhav
Stage 0
no prolapse
- Aa,Ba,Ap,Bp are all at -3
- C or D between tvl and < tvl -2
Stage I
most distal portion > 1cm above level of hymen
Stage II
<1cm proximal to or distal to the plane of hymen
Stage III
>1cm below the plane of the hymen
Stage IV
complete eversion, distal portion at least (tvl -2 cm)
Urinary Tract Fistulas -(VVF) Etiology, Diagnosis, ManagementVikas V
Urinary Tract Fistulas - Etiology, Diagnosis, Management
Surgical and Relevant Anatomy, Classification, eitiology, VVF in Detail, Examination and Diagnosis, Management of VVF - Both Conservative And Surgical Management - Steps of Surgical Management, Post operative Management.
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
Vaginal prolapse is a condition in which structures such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself may begin to prolapse, or fall out of their normal positions.
Classification & conservative surgeries for prolapseIndraneel Jadhav
Stage 0
no prolapse
- Aa,Ba,Ap,Bp are all at -3
- C or D between tvl and < tvl -2
Stage I
most distal portion > 1cm above level of hymen
Stage II
<1cm proximal to or distal to the plane of hymen
Stage III
>1cm below the plane of the hymen
Stage IV
complete eversion, distal portion at least (tvl -2 cm)
Urinary Tract Fistulas -(VVF) Etiology, Diagnosis, ManagementVikas V
Urinary Tract Fistulas - Etiology, Diagnosis, Management
Surgical and Relevant Anatomy, Classification, eitiology, VVF in Detail, Examination and Diagnosis, Management of VVF - Both Conservative And Surgical Management - Steps of Surgical Management, Post operative Management.
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
Please find the power point on Utero-Vaginal Prolapse. I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Pelvic organ prolapse
Pelvic Organ Prolapse
Most common gynaecological problem.
Amongst parous women.
A form of hernia.
Anatomy of Uterus
Anteversion and anteflexion position.
Lies between rectum and bladder.
Cervix pierces the vagina at the right angle to the axis of vagina.
Supports of Uterus
Uterus is held in position by 3 tier support system.
Upper tier
Middle tier
Inferior tier.
Upper tier
Primarily, maintains the uterus in anteverted position.
The structures responsible are:
Endopelvic fascia.
Round ligaments.
Broad ligaments.
Middle tier
Constitutes the strongest support of uterus.
Responsible structures are:
Pericervical ring.
Pelvic cellular tissues.
Inferior tier
Indirect support of uterus.
Responsible structures are pelvic floor muscles including:
Levator ani
Endopelvic fascia
Levator plate
Perineal body
Urogenital diaphragm
Anatomical Factors
Gravitational stress.
Parturition stress.
Pelvic floor weakness.
Inherent weakness of supporting structures.
Acquired Predisposing Factors
Trauma of vaginal delivery causing injury :
Ligaments
Endopelvic fascia
Levator muscle
Perineal body
Pudendal nerve and muscle damage due to
repeated child birth.
Congenital Predisposing Factors
Inborn weakness of supporting structure.
Aggravating factors
Post menopausal atrophy
Poor collagen tissue repair with age.
Increased intra abdominal pressure.
Occupational hazards
Asthenia
Obesity
Fibroid/Polyp
Clinical Degrees Of Uterine Prolapse
Symptoms
Feeling of something coming out per vaginum.
Backache or dragging pain in pelvis
Dyspareunia
Urinary symptoms
Bowel symptoms
Clinical examination
Inspection and palpation.
General examination.
Pelvic examination
Uterine prolapse
Management of Prolapse
Preventive
Conservative
Surgery
Preventive Measures
Pelvic floor exercise during puerperium.
Avoid strenuous activities.
Avoiding prolonged cough.
Avoiding constipation.
Avoiding heavy weight lifting.
Avoiding future pregnancy too early.
Conservative Management
Indications :
Asymptomatic women
Mild degree prolapse
POP in early pregnancy
Treatment :
Oestrogen replacement therapy.
Kegel exercise
Pessary treatment
Surgical Management of Prolapse
Restorative
Extirpative
Obliterative
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
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of 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 leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
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. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
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- Prix Galien International Awards Ceremony
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
1. Pelvic organ prolapse & incontinence
Dr Bhaskar J Paul
Associate professor
Obstetrics and Gynaecology
2. Learning Objective
• Q1 Definition of prolapse
• Q3 what are the symptoms of pelvic floor disorders in women ? What are the
symptoms of abnormal function of the lower urinary tract associated with pelvic
floor problems in women and how can this condition be treated ?
• Q5 . What are the symptoms of abnormal function of the gastrointestinal tract in
women with pelvic floor problem ?
• Q6 . how does prolapse of the internal reproductive organs in women come about ?
• Q8. what are the findings on physical examination of women with a cystocele or
rectocele and what is the treatment ?
• What are the findings on physical examination of a prolapsed uterus ? What are the
three possible treatments for a patient with prolapsed complaints ?
3. A 64 years old multipara
presents with loss of small
amount of urine when she
coughs or laughs or lifts heavy
objects
On examination she has a
second degree uterovaginal
prolapse on standing position
an relieves on lying position.
She is mildly constipated and
some times needs digitalisation
to initiate defecation
Clinical
problem
What you can offer to this
woman ?
.
Your
solution
10. Level 1 support (Delency )
• Level 1 : uretero sacral and cardinal ligament complex
11. Level 2 support
• Level II- Pelvic fascias and paracolpos
– Fascial septae connects mid vagina to the pelvic sidewalls
– Anteriorly
• Pubocervical
– Posteriorly
• Rectovaginal facia
– which connects the vagina to the white line on the lateral pelvic wall
through arcus tendinous
12. Level 3 support
• Level III-Levator ani muscle
– supports the lower one-third of vagina.
– Anteriorly
• Urethra
• Urogenital diaphragm
• Pubis
– laterally
• Levator ani fascia
– Posteriorly
• Perineal body
Level II and III detail. In level III, the vagina is fused to the
medial surface of the levator ani muscles, urethra, and
perineal body. The anterior surface of the vagina at its
attachment to the arcus tendineus fascia pelvis forms the
pubocervical fascia, while the posterior surface forms the
rectovaginal fascia
13. Causes and pathophysiology LQ 6
• Menopause
• birth injury
• Prolonged bearing down in the second stage
• Delivery of a big baby
• Rapid succession of pregnancies
• Lack of rest in peurperium
• Peripheral nerve injury
• raised intra-abdominal pressure
• Surgeries
• Congenital
14. Pathophysiology
• Menopause
– prolapse are of menopausal age when the pelvic floor muscles
– d/t oestrogen deficiency and decreased collagen content in fascias
atonicity and asthenia that follow menopause
15. Cause related to child birth
excessive stretching
of the pelvic floor
muscles and
ligaments
overstretching causes
atonicity
Perineal tear is less
harmful than
overstretching
whereas torn
muscle could be
stitched or toned up
16. Cause related to raised abdominal pressure
• chronic bronchitis,
• large abdominal tumours or
• obesity
• Smoking,
• chronic cough and
• constipation
18. Symptoms LQ 3 & 5
• General symptoms
• Backache
– uterosacral strain
• Towards evening
relieved by rest
• Decubitus ulcer
• benign and is present on dependant part.
• d/t venous stasis tissue anoxia
• With third degree uterine prolapse and procidentia prevents
penetration and orgasm due to a lax outlet (coital difficulty )
19. Symptoms related to LUT LQ 3
• imperfect control of micturition
• Frequency of micturition
– (diurnal or nocturnal)
– (d/t chronic cystitis & incomplete emptying of the bladder)
• Manual reduction of the cystocele into the vagina with their fingers
• Straining to pass urine
• Stress incontinence
• Ureteric obstruction and hydronephrosis (severe massive prolapse)
20. Symptoms related to lower gastrointestinal tract
(Bowel symptoms )LQ 5
• Urgency
• Straining
• Feeling of incomplete emptying
• Pressure on vagina or perineum to start or complete
defaecation
21. Evaluation and Findings LQ 8 & 9
Anterior compartment
• Sim’s speculum retracting
posterior vaginal wall
• Look for cystocele
• Lateral cystocele or
paravaginal defect
• Urethrocele } stress
incontinence
Middle compartment
• Degree of descent
• Ulceration of cervix
• Vagina may show
keratinisation
• Vaginal examination –
length of cervix,position
and mobility of uterus,any
adnexal mass
• Cervical cytology
Posterior compartment
• Sim’s speculum retracting
anterior vaginal wall
• Enterocele – bulge
appears from above
downwards
• Rectal examination –
impulse on
• tip of finger- enterocele
• pulp - rectocele
• Bimanual examination-
r/o pelvic mass
22. Evaluation of the pelvic floor
• Pubococcygeus part of levator ani assessed at 4 and 8 o’clock
position
• Perineal body
• Rectal examination – tone of anal sphincter
24. Pelvic organ prolapse quantification POPQ
Anterior wall
• A
• B
• C
Posterior wall
• A
• B
• c
Other 3
parameters
• gH
• PB
• TvL
25. Differential diagnosis
• Vulval cyst or tumour
• Cysts of anterior vaginal wall
• Urethral diverticula
• Congenital elongation of cervix
– vaginal portion of the cervix is elongated and
– no vaginal prolapse.
– deep fornices
• Cervical fibroid polyp
• Chronic inversion
26. Treatment : prophylaxis
Antenatal physiotherapy ,relaxation exercises,due attention to weight gain
and anaemia
Proper supervision and management of second stage of labour
A generous episiotomy
Low forceps delivery if there is delay in second stage
Suture perineal tear
Postnatal exercises and physiotherapy
early postnatal ambulation
Adequate spacing of births
Avoid multiparity
Prophylatic HRT in postmenopausal women
27. Treatment
• Surgical
– in women over 40
• Conservative management
– mechanical devices and
– pelvic floor muscle exercises ,abdominal massage,
• in mild degrees of prolapse,
• surgery not desired by patient ,
• in whom child bearing is not complete
• Should be advised 3 to 4 months following delivery
• Pregnancy – contraindication for surgery
28. Pessary (conservative treatment)
• Indications
A young woman planning a pregnancy
During early pregnancy (<18 weeks)
Puerperium
Temporary use while clearing infection and decubitus ulcer
A woman unfit for surgery
In case a woman refuses for surgery
29. Surgical approach
• Ward-Mayo’s operation-vaginal hysterectomy with pelvic floor
repair with or without:
sacrospinous colpopexy –vault suspended from sacrospinous
ligament
• Fothergill’s or Manchester operation –uterus preserved and part
of cervix is cut
• Shirodkar’s Extended Manchester operation-both cervix and
uterus preserved
• Le Fort’s operation –obliterative procedure of anterior and
posterior walls of vagina
31. Learning objectives
• LQ1 : definition of urinary incontinence : stress incontinence,
urge incontinence, mixed incontinence ,
• LQ 2 : incidence of urinary incidence : how does it changes
throughout
• LQ 7: what are the causes of urinary incontinence in women?
what are the treatment option for two types of incontinence ?
42. Components of urodynamic study
• The following are the different component of urodynamic
study cystometry
• Uroflowmetry :
• Filling cystometry
• Video uro dynamics
• Ambulatory urodynamic monitoring
• Urethral pressure profile
• Electromyography
45. Fecal incontinence : learning questions
• LQ 10 : what physical examination should be conducted on a
patient with fecal incontinence ? What are the treatment
options ?
46. Fecal continence :Causes
• Damage to anal sphincters
• Neurologic causes
• Decreased distensibility of the rectum
• Fecal impaction
• Diarrhoea
• Idiopathic