1- Pelvic Organ Prolapse: سقوط اعضاء حوض المرأة - الرحم و المهبل
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
Diagnosis:
A complete pelvic examination of every organ and structure is imperative to assure a correct diagnosis and decide on the treatment protocol.
-Urethra & Bladder: Are examined for urethral hyper mobility (Qtip test) - Bladder descent - Urinary incontinence
-Vaginal walls: Examined for anterior and posterior wall prolapse (Central - Lateral - Apical)
-Uterus & Cervix: Examined for (size - position - prolapse )
-Pelvic floor muscles, ligaments, perineum, and anal sphincter: Examined for integrity, tears, and weakness.
*Uterine prolapse: is mainly due to weakness of the pelvic floor muscles and ligament laxity (Uterosacral ligaments, Cardinal ligaments, and The Arcus Tendinius Fascia Pelvis (ATFP) ligament). This condition needs surgical correction by pelvic surgery, or a minimal invasive posterior sling procedure.
*Vaginal prolapse:
Cystocele (anterior vaginal wall prolapse): is a fall or bulg of the bladder base into the anterior vaginal wall, due to weakening or tearing of the pelvic Pubo-cervical ligament (PCL) the ligaments that carries the bladder, it can be a midline (central) tear in the PCL or a lateral detachment defect, which may require the use of a surgical mesh system. Common complaints are, feeling a vaginal bulge, pelvic discomfort, difficulty in evacuating the bladder, sexual discomfort, and recurrent urinary tract infection.
Rectocele (posterior vaginal wall prolapse): is an abnormal bulging of the rectum into the posterior vaginal wall, due to weakening or tearing of the pelvic Recto- vaginal septum (RVS), the ligament that holds the rectum in place. The degree and severity of protrusion varies from patient to patient, common presenting complaints include the feeling of a vaginal bulge, constipation or poor evacuation of stool, and a feel of vaginal widening and discomfort.
Rectocele is often not an isolated condition, anterior vaginal wall prolapse and enterocele may be concomitant.
Enterocele (Apical vaginal wall prolapse): is a bulge of the bowel at the apex of the vagina due to weakness of the pelvic fascia supporting the apex.
Vaginal vault prolapse: is a herniation of the vaginal apex after a hysterectomy due to weak ligament support.
Treatment: رفع الرحم و تصليح مهبلي امامي - خلفي
Conservative methods: Physiotherapy, pelvic floor exercises (Kegel Excercises), and pessaries are used at first.
Surgical methods: Pelvic Floor Reconstruction:
Suspension surgery: for uterine or vaginal vault prolapse is necessary to restore a fallen / prolapsed uterus or vaginal apex, to its normal position. The lax ligaments are shortened if possible, but if the laxity is extensive, the use of new synthetic mesh or biological material can be utilized to elevate the uterus or vagina. This can be done both abdominally or vaginally according to the patients condition.
In some cases of uterine prolapse, when a woman is over 50 or has completed her family, a vaginal or abdominal hysterectomy may be the best option.
Standard vaginal wall repair:
-Anterior colporrhaphy: by repairing the tear in the pubo-cervical fascia (PCL), this procedure will correct and restore the position and function of a bulging or fallen bladder into the anterior vaginal wall (Cystocele). This tear can be either central or lateral, lateral tears are more difficult to repair.
-Posterior colporrhaphy : will repair the tear in the recto-vaginal septum (RVS), to correct the bulge into the posterior vaginal wall (Rectocele).
-Perineorrhaphy: when old lacerations are present in the perineal body, this procedure will effectively repair the torn or stretched deep and superficial muscles, suture together a torn anal sphincter, decrease the external vaginal diameter, and build up the perineum.
This will restore the vagina to its normal anatomical position, enhance its appearance, decrease its diameter, and optimize its physiological function.
it also helps correct urinary problems, and relieves pelvic pain, and congestion.
Surgical Mesh & Biological graft augmentation: when the prolapse is extensive and the supporting tissue and ligaments are severely damaged,
and need extra support. New minimally invasive surgical procedures using synthetic polypropylene mesh systems (Anterior & Posterior Elevate - Prolift +M) or biological graft material (Tissue generated matrix) are used.
These systems are applied by a special device under the bladder wall, and above the rectum, through a vaginal incision,
acting as a neo ligament, to lift and restore normal pelvic organ position and function.
Biological graft materials are now gaining popularity in pelvic floor reconstructive surgery, and have less side effects.
2- Urinary Incontinence: علاج السلس البولي
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, gradually 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:
Stress incontinence
- 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, Aris ).
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 Tape sling
Urine Leak No Urine Leak
Urinary fistula الناسور البولي
Vesico-vaginal fistula - Vesico-uterine fistula - Vesico-cervico-uterine:
All these types of fistula are due to trauma to the ureter or bladder during surgery, or a necrotic fistula (pressure) during labour, they are repaired by suturing the defect in the bladder wall in a special way, this can be done both vaginally and abdominally according to the level and area of the fistula.
Uretero-vaginal fistula:
Is due to a surgical trauma to the ureter and is usually repaired by re-implanting the severed again ureter into the bladder.
Fecal fistula:
Is due to trauma to the pelvis or perineum, or a delivery of a large baby, tearing the anal sphincter on its way out, and is repaired vaginally after adequate bowel preparation.
3-Female Sexual Dysfunction: اضطرابات الصحة الجنسية
- 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.
- Correction surgery for old circumcision تصليح الطهارة القديمة
- Evaluation of pelvic disorders:
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.
سقوط أعضاء الحوض (الرحم – المهبل – المثانة – الشرج).
1. سقوط الرحم فى تجويف الهبل.
2. سقوط المهبل:
· سقوط جدارى المهبل مع المثانة (أمامى) أو الشرج (خلفى) أو الأثنين معاً.
· سقوط سقف المهبل بعد استئصال الرحم.
قد تؤدى الولادات المتكررة وخاصة المتعثرة منها، والكحة والإمساك المزمن، والسمنة المفرطة، وكذلك التحول الفسيولوجى لهرمونات الأنوثة فى مرحلة معينة من العمر الى ارتخاء الاربطة وضعف عضلات الحوض بما يقلل من دعمها لأعضاء الحوض فيحدث سقوط للرحم والمهبل والمثانة والشرج. كما قد يظهر الرحم أو جدارى المهبل من فتحة المهبل وتتعرض المريضة لآلآم فى الحوض وأسفل الظهر أو تتعرض لاتساع مهبلى وعدم الراحة فى المعاشرة الزوجية.
السلس البولى لدى النساء.
1. سلس بولى إجهادى: تسرب البول عند الكحة، أو الضحك، أوالعطس، أو الإنحناء للصلاة.
2. سلس لبولى نذرى: عدم القدرة فى التحكم فى التبول وتسرب البول قبل الوصول الى دورة المياة.
3. سلس بولى لا إرادى: يحدث عند الأطفال والبنات المراهقات حتى 20 سنة.
4. سلس بولى دائم: ناسور بولى بين المثانة والمهبل إثر عملية ولادة متعثرة أو جراحة.
يعانى 60% من النساء بين 35 الى 70 سنة من السلس البولى وتسرب البول لا إرادياً وعدم التحكم فى التبول، مما يؤدى الى التوتر النفسى وإعاقة القيام بالمهام اليومية، والعزلة، وصعوبة الإبقاء على الوضوء لأداة الصلاة.
وقد تؤدى الولادات المتكررة والكحة المزمنة ونقص هرمونات الأنوثة فى مرحلة معينة من العمر الى ضعف عضلات الحوض والاربطة الملازمة للمثانة ومجرى البول، مما يقلل من دعمها لمجرى البول فيفقد الإحكام ويتسرب البول.
و توجد عدة طرق لعلاج السلس البولى منها تمارين Kegel الرياضية لتقوية عضلات الحوض، والإمتناع عن تناول الشاى والقهوة والشطة أو حقن مجرى البول بمادة Macroplastique وعن طريق أسلوب علاجى جديد ذو تدخل جراحى محدود يتم بمقتضاه وضع شريط مهبلى TOT أو TVT كدعامة لمجرى البول لبقائه محكما عند حدوث ضغط على المثانة مثل عند الكحة والضحك والإنحناء للصلاة. وتعود السيدة بعد العملية التى تستغرق حوالى 15 دقيقة الى ممارسة حياتها بشكل طبيعى. وتجدر الإشارة الى أنه تم تركيب أكثر من مليون شريط من هذا النوع فى انحاء العالم بنسبة نجاح 90%.
For an appointment call:
Tel: (+2) 0122-3675300
Email: info@urogyn-eg.com
