Child birth trauma, constipation, chronic cough, obesity, menopause and aging are factors leading to weakness of pelvic floor muscles and laxity of ligaments that hold the pelvic organs in place, resulting in pelvic organ prolapse and urinary incontinence, women usually feel something protruding from the vagina, deep pelvic pain or just vaginal widening and sexual discomfort .

Types of prolapse:

*Uterine prolapse:        fall of the uterus into the vaginal lumen.

*Vaginal wall prolapse:                                                                                 
   - Cystocele:               bulging of the bladder base into the anterior vaginal wall                               
   - Rectocele:               bulging of the rectum into the posterior vaginal wall
   - Enterocele:              bulging of the small intestines into the posterior vagina   
   - Vault prolapse:        fall of the vaginal roof, after a hysterectomy                          

                             Bladder bulge into anterior vaginal wall                        Rectum bulge into posterior vaginal wall
                                    due to a defect in the pubo-cervical fascia                   due to a defect in the recto-vaginal septum

Treatment:

Conservative methods like pelvic floor exercises and pessaries are used at first.

In extensive uterine or vaginal vault prolapse, suspension surgery is necessary to restore normal position of a fallen uterus or vaginal roof, and in some cases of uterine prolapse, when a woman is over 50 or has completed her family, a vaginal or abdominal hysterectomy may bethe best option.

A conventional vaginal wall repair is done to correct and restore the position and function of a bulging or fallen bladder into the anterior vaginal wall (Cystocele) or rectum bulge into the posterior vaginal wall  (Rectocele).

A new minimally invasive surgical technique is now available for the treatment of pelvic organ prolapse using the Perigee or Apogee mesh systems by AMS or the Prolift mesh System by Johnson & Johnson, both these systems utilize a synthetic polypropylene mesh prosthesis which is applied by a special device under the bladder wall or above the rectum, to lift and restore normal pelvic organ position and function.

Biological graft materials are now gaining popularity in pelvic floor reconstructive surgery ( SiS, Pelvicol, Veritas, A.M.R )
                                                                                                                       

2- Urinary Incontinence:

Affects 60% of women between the ages of 35 - 70 years, symptoms are involuntary loss of urine with a cough, sneeze, poor bladder control, compelling urge to urinate, loss of urine before reaching the toilet, and frequent urination at night. Child birth trauma, ageing, constipation, chronic cough, and obesity are factors leading to weakness of the pelvic floor muscles and laxity of ligaments causing lack of support to the pelvic organs and urine leakage.


 Types of urinary incontinence:

- Over Active Bladder - Frequent need to urinate or a compelling desire to pass urine.
- Stress Urinary Incontinence- Escape of urine during a cough, sneeze, or laughing
- Nocturnal Enuresis –Unconscious bed wetting at night. 

- Overflow incontinence- overflow of urine due to neurological causes.                       
- Urinary Fistula – An abnormal passage between the bladder & vagina.
- Interstitial cystitis- Recurrent inflammation and infection of the bladder wall. 

   Non surgical treatment:                                                                                      

 1- Behavior Therapy & Bladder Retraining: (40% success rate)

    * Urinating according to a timetable, so gradually the time between trips to the bathroom increases as the patient’s bladder control improves.

     * Avoiding dietary irritants to the bladder such as: spicy foods, vinegar, citrus fruits, berries chocolate, coffee, tea, mayonnaise, NutraSweet, guavas, grapes, and carbonated drinks.
 2 - Pelvic Floor Excersises (kegel Exercises): Highly effective when done correctly (40% success rate)
 3- Physiotherapy: Pelvic floor muscle electrical stimulation with vaginal and anal probes. 
 4- Medical treatment: Highly effective in over active bladder
     Anticholinergics: Toltaridine 2mg - Oxybutanin Hcl 5mg 
     Antispasmodics:  Flavoxate 200mg - Trospium Cl 20mg 
     Muscarinic receptor agonist: Darifenacin 7.5mg or 15 mg                        
 5- Peri-urethral injection: Minimal invasive technique achieving continence by injection  of  Macroplastique or Durashpere in the periurethral tissue forming a sphincter (60% success rate)  
 6- Artificial Sphincter: A device inserted in the urethra that opens a valve for voiding  by a hand held remote control.  
 7- Urethral inserts (FemSoft ) and vagianl pessries are used to temporarily  control urine leakage.
                            
                                         FemSoft                              Pessary          Peri-urethral injection

  Surgical treatment: 
 
  - Abdominal Burch Colpo suspension   (85% success rate) 

  - Vaginal Sling Procedures:  (85% -  92% success rate)       
    

      1st generation: Pubo-Vaginal Sling  ( TVT, Sparc, IVS )
    A mesh tape is introduced from the vagina to exit behind the suprapubic bone,  and forms  a U shaped sling around the mid urethra to support it and stop urine leakage.   

      2nd generation: Trans-Obturator Sling (TVT-0, TOT,Obtryx, Monarc) 
    The tape is introduced via the pelvic obturator foramen, forms a V shaped sling around the mid urethra, it has less complications than the TVT sling and takes only 15 minutes to apply.    
                    
                               TOT Sling                             Mini Arc Sling                  
   
      3rd generation: Sub-Urethral Slings ( TVT secure, Mini Arc Sling)        
     A 8.5 cm tape sling, is introduced via a single incision in the vagina to support the mid urethra, this new minimal invasive procedure is gaining popularity, it has less complications than the previous generation slings, does not require a cystoscopy, takes 10 minutes to perform, and has a 92% success rate.

                           Stress incontinence - Urine Leak                  Tape sling - No Urine Leak                                                    

 

3-Female Sexual Dysfunction: 

 -Sexual health education, counseling, and psychotherapy based on honest, confidential communication.
 - Medical tretment and hormonal suplements for decrease libido.
 -Vaginal cosmetic surgery, to enhance, and restore the youthful appearance and function of the sexual organs, regaining self esteem, or correct congenital defects,  traumatic, and birth injuries.

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- Pelvic health care:                Female Pelvic Health Care Systems

1-Routine pelvic examination; of the vulva, vagina, cervix, uterus, urethra, bladder, rectum, and perimeum.
    (Vaginal swabs – PAP smears – HPV testing & vaccination – cervical & endomertial biopsy )

2-Pelvic floor exercises to strengthen pelvic muscles, preventing prolapse, and urinary incontinence

3- Early diagnosis and treatment of:

·        Pelvic organ disorders: Prolapse – incontinence – menopause – sexual dysfunction.

·        Abnormal uterine bleeding

·        Urinary tract infection

·        Pelvic pain

·        Vaginal infection

.        Pelvic infection 

.        Cervical infection


Evaluation:

                                                                                                                                                                                                                                                 
Proper evaluation and diagnosis is critical to successful correction of the problem, during your first visit, your doctor will conduct an interview consultation followed by a comprehensive physical and pelvic exam, and he may recommend lab and other special tests such as:

 Cystoscopy - A diagnostic procedure that allows us to look inside the urethra and bladder.
 Hysteroscopy - A diagnostic procedure that allows us to look inside the uterus.
 Ultrasound - Sound waves that study the bladder, urethra, Kidneys and other pelvic organs
 Urodynamic test- Evaluates bladder and urethral function, including storing and emptying urine
 Intravenous pyelography - x ray and dye are used to show the bladder, ureters, and pelvic organs.
 MRI – Magnetic Resonance Imaging to diagnose any pelvic tumor or disorder.    
 EMG – Evaluates the integrity and nerve function of the pelvic floor muscles.