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BENIGN GYNECOLOGY

DIAGNOSTIC AND SURGICAL PROCEDURES IN GYNECOLOGY Diagnostic Procedures o Colposcopy discussed in another tutorial o Laparoscopy Definition: The passage of a telescope into the abdominal cavity to allow inspection of pelvic and abdominal organs Diagnostic Indications Unexplained pelvic pain. Sub fertility: To inspect uterus, tubes, ovaries and assess tubal patency: o Dye is instilled per vaginum into the uterus, and will allow an assessment of whether the tubes are patent. Investigation of small adnexal masses. Staging of endometriosis. Diagnosis of ectopic pregnancy Therapeutic Indications Tubal ligation Adhesiolysis Ablation of endometriotic spots Benign ovarian cystectomy Salpingectomy/salpingostomy for ectopic pregnancy Procedural Steps Day-case admission. General anaesthetic. Semi-lithotomy position. Bladder emptied (to avoid bladder injury). Cervix cannulated to facilitate anteversion of the uterus & thereby visualisation of pelvic organs. Skin incision made in umbilical base. Verres needle inserted in umbilical base until tip of needle in peritoneal cavity. CO2 insufflated via Verres to achieve intraperitoneal pressure of 20mmHg. Primary trocar is then inserted at umbilicus and allows passage of laparoscope. Secondary ports may be inserted under direct vision Gas expelled and instruments withdrawn at completion of procedure Complications Failed entry to peritoneal cavity (leading to surgical emphysema). Visceral injury: o Risk of visceral injury is 1:250. o Those at particularly high risk include obese and very thin women and those with abdominal scarring from previous surgery. Risk of conversion to laparotomy o Hysteroscopy and Curettage Definition: Passage of a telescope per vaginam through the cervix to allow visualisation of the endometrial cavity. Curettage of the cavity provides endometrial tissue for diagnostic purposes Diagnostic Indications 1

Postmenopausal bleeding. Abnormal bleeding in a patient over 40 years or in a patient under 40 years whose menstrual disturbance is refractory to medical therapy. The objective in these indications is to exclude endometrial cancer Therapeutic Indications Removal of an endometrial polyp. Resection of a submucosal fibroid. Evacuation of retained products of conception following an incomplete miscarriage

Surgical Procedures o Abdominal Hysterectomy Definitions: Total hysterectomy involves removal of uterus and cervix. Subtotal hysterectomy implies that the cervix is conserved Specific Indications Uterine cancer. (TAH is combined with bilateral salpingoophorectomy (BSO) & pelvic lymph node dissection). Ovarian cancer (TAH BSO and omentectomy). Menorrhagia refractory to medical or more conservative surgical therapy. Symptomatic uterine fibroids. Endometriosis refractory to less radical therapy Procedure Suprapubic transverse (Pfannenstiel) incision. Lower midline vertical incision only if more extensive exposure is required (e.g. ovarian cancer/ large fibroids). Ovarian, uterine and uterosacral pedicles and vaginal angles clamped, cut and ligated. If the patient is younger than 45 years, ovaries are usually conserved provided there is no oestrogen-dependent malignancy or ovarian pathology Complications Haemorrhage. Urinary tract injury (Bladder/ ureter). Bowel injury. Acute menopausal symptoms if ovaries removed o Vaginal Hysterectomy Advantage: preferable to abdominal hysterectomy because it entails less morbidity and a shorter postoperative recovery period Indications 2nd or 3rd degree uterine prolapse. Any other benign indication for hysterectomy where the uterus is accessible per vaginum Contraindications Genital tract malignancy. o As a general rule, if there is any suspicion of malignancy or if there are likely to be pelvic adhesions it is recommended that the hysterectomy should be performed abdominally Uncertain ovarian pathology. Large uterine fibroids. Previous abdominal surgery leading to adhesions 2

Procedure General or spinal anaesthesia. Circumferential incision made on cervix. Bladder freed and dissected upwards. Peritoneal cavity is opened anteriorly (uterovesical pouch) and posteriorly (Pouch of Douglas). Uterosacral, uterine artery and ovarian pedicles clamped, cut and ligated. Uterus removed and ovaries inspected to exclude significant ovarian pathology. Associated vaginal wall prolapse repaired. Vaginal vault closed Complications Haemorrhage. Vault haematoma (may become infected). Urinary tract injury (bladder/ ureter). Vaginal shortening (particularly if pelvic floor repair performed). o Leading to dyspareunia Conversion to abdominal hysterectomy: all patients must be warned of possibility in advance of surgery

o Myomectomy Purpose: fibroid resection Removal of fibroids individually may be appropriate in a woman who wishes to conserve her uterus Risks/Complications A/w greater blood loss than hysterectomy Myomectomy scar on the uterus may be at risk of rupture in a subsequent labour, such that these patients are usually advised to undergo elective Caesarean section, especially if the endometrial cavity has been opened o Tubal Reconstructive Surgery Purpose: correction of tubal occlusion resulting from salpingitis, endometriosis or previous sterilization, in order to restore fertility Failure: Poor results reflect both the tendency for inflammed tubes to become blocked again and underlying microscopic tubal damage Risks: subsequent tubal ectopic pregnancy o Pelvic Floor Repair Anterior Colporrhaphy (repair) Purpose: Designed to correct a cystocoele or Cysto-urethrocoele w/ or w/o stress incontinence Procedure o Involves excision of a portion of vaginal skin and placement of support sutures to pubocervical fascia. o Fascial sutures elevate & support bladder neck. o Excess vaginal skin excised & vaginal wall closed. o Urinary catheter placed for 24-48 hours postoperatively Complications o Urinary retention. o Vaginal shortening. o Bladder/ urethral injury Posterior Colporraphy Purpose: repair of rectocele 3

Procedure o Portion of posterior vaginal wall excised. o Underlying levator ani muscles exposed and joined with interrupted sutures in midline Complications o Dyspareunia. (Due to over-enthusiastic closure of levator ani muscles and removal of excess posterior vaginal wall skin)

MENORRHAGIA Definitions o Menorrhagia: heavy regular periods o Metrorrhagia: heavy irregular periods This term is rarely used now o The term menorrhagia is often used to include all types of abnormal uterine bleeding including regular and irregular cycles Causes o Common Dysfunctional Uterine bleeding: Commonest cause -60% of cases Fibroids Endometriosis Adenomyosis Endometrial hyperplasia Polycystic ovary syndrome o Uncommon Thyroid disease Coagulation disorders Von Willebrands disease Idiopathic thrombocytopenia Anticoagulant therapy (warfarin and aspirin) Chronic PID Endometrial carcinoma Copper IUCD (used as treatment for endometriosis) Dysfunctional Uterine Bleeding o Definition: Abnormal bleeding in the absence of organic pathology, such as the following: Tumour: e.g. Fibroids, cervical polyp, cervical CA, endometrial hyperplasia or CA. Pregnancy: e.g. Threatened abortion, ectopic. Inflammation: e.g. endometriosis, PID o Epidemiology: Most common at extremes of reproductive life Often associated with anovulatory cycles o Symptoms Heavy regular periods: e.g.. 5-7/28 Heavy irregular periods: e.g.. 5-7/20-36 Prolonged regular periods: e.g.. 10-14/28 Prolonged irregular periods: e.g.. 10-14/20-36 Quantify blood loss Clots, flooding, double pads, staining of clothes, bed or furniture, time off work, restriction of social activities, Dysmenorrhoea Inter-menstrual bleeding (ie. bleeding between periods) and Post-coital bleeding It is very important to ask every patient about these symptoms as they are usually indicative of underlying pathology o Signs BMI: Obesity associated with hyper-oestrogenism Palpable abdominal mass: Most likely to be fibroid uterus Bimanual pelvic examination 5

Inspect cervix, exclude tumour, polyp. Size, position, shape, consistency, mobility, tenderness of uterus Adnexal masses Prolapse o Investigations of DUB Full hx and exam, including vaginal exam Full blood count: Features of iron deficiency anaemia Thyroid function test: Only if there are clinical features to suggest thyroid disease Coagulation screen: Only if clinically indicated Ultrasound scan: out rule fibroids, ovarian cyst, etc Endometrial biopsy Rarely indicated in woman < 40 Main Indication: to exclude atypical hyperplasia or endometrial carcinoma Method o Outpatient biopsy - e.g. Pipelle o Hysteroscopy - outpatient or GA o D&C - a diagnostic, not a therapeutic procedure Hysteroscopy o Treatment Options Non-surgical Non-hormonal medication o Prostaglandin synthetase inhibitors Mefenamic acid 500 mg tds, days 1-5 of cycle o Antifibrinolytic agent Tranexamic acid 1000 mg tds, days 1-5 of cycle Hormonal medication o Oral contraceptive pill If no contraindications May take 2 or 3 packs back to back ie. W/o the usual 7 day break o Progestogen Norethisterone 5mg tds x 21/28 Useful if woman has irregular cycle o Mirena Intrauterine System Contains 52 mg levonorgestrel Releases 20 mcg levonorgestrel per day over 5 years Advise of possibility of irregular bleeding initially (for up to 6 months) followed by amenorrhoea Frequently used first line for treatment of menorrhagia especially in perimenopausal women o Danazol rarely used Useful if there is endometriosis Androgenic side-effects o GNRH analogues Short term treatment (maximum 6 months) for endometriosis or to shrink fibroids before surgery Long term use leads to reduction in bone density Surgical 6

Hysterectomy o Abdominal or Vaginal Vaginal route not suitable if there are large fibroids o Total or subtotal Cervix is not removed in subtotal hysterectomy therefore the patient must be advised of need to continue having smears o Transverse or midline incision o +/- bilateral salpingo-oophorectomy Myomectomy removal of a fibroid o Consider if woman wishes to retain her fertility, otherwise hysterectomy is a better option o Pre-treat with GnRH analogue to shrink and de-vascularise fibroid o Risk of severe haemorrhage which may necessitate hysterectomy o Will need caesarean section subsequently if the endometrial cavity is opened at the time of myomectomy o May need hysterectomy later if fibroids recur o May be a hysteroscopic, laparoscopic or open procedure depends on position of fibroids Endometrial resection or ablation o Minimally invasive, day case procedure o 80% satisfaction rate o Balloon ablation has replaced endometrial resection o Usually causes oligomenorrhoea rather than amenorrhea o Only suitable if family is complete o Must use contraception afterwards

Other Uterine artery embolization o May be used to treat single or small numbers of fibroids o An alternative treatment to myomectomy o Done by radiologists via catheter in femoral vein o Causes avascular necrosis of the fibroid(s) o Further research required to evaluate this technique

DYSMENORRHEA & ENDOMETRIOSIS Dysmenorrhea o Definition: pain during menstruation Lower abdominal discomfort radiating to lower back and legs May be associated with intestinal symptoms and malaise o Incidence: 30-50% of menstruating women One of the most frequent reasons for absenteeism o Primary Dysmenorrhea Features Begins with the onset of ovulatory cycles Within the first 2 years of menarche Pain is most severe on the day prior to and during menses Aetiology: No significant pelvic pathology. Prostaglandins are thought to have a role. High levels of PGF2 are found in the menstrual blood of women with dysmenorrhoea. o PGF2 contractility of the myometrium thus resulting in dysmenorrhoea Treatment Discussion and reassurance Medical Treatment: Non-hormonal or hormonal o Prostaglandin synthesis inhibitors: NSAIDs reduce the production of PGF2 and reduce pain eg mefenamic acid and ibuprofen o Combined Oral Contraceptive pill: suppression of ovulation reduces dysmenorrhoea. The OCP can be taken cyclically or for 3 months continuously o Depot Progestogens: medroxy progesterone acetate (DMPA) can be given in a dose of 150 mg IM every 3 months o Levonorgestrel intrauterine system (Mirena) reduces menstruation and dysmenorrhoea. It can be difficult to insert the Mirena coil in nulliparous women o Secondary Dysmenorrhea Dysmenorrhoea due to pelvic pathology: fibroids, adenomyosis, endometriosis, pelvic infection Management: History, Examination including pelvic examination If normal clinical examination then trial of medical management If there is pelvic mass or tenderness on examination an ultrasound or diagnostic laparoscopy should be performed Failed medical treatment for dysmenorrhoea warrants a diagnostic laparoscopy Endometriosis o Definitions Presence of endometrial tissue outside the lining of the uterine cavity Proliferation of endometrium in any site other than the uterine mucosa o Epidemiology Age: common in reproductive age group True incidence unknown Endometriosis seen at laparoscopy in: 6% of women undergoing laparoscopic sterilization

o Sites

21% of women being investigated for infertility Histology: Endometrial Glands with Stroma +/- Inflammatory Reaction. Hereditary ( among sisters). Pelvic Adenomyosis 50%: endometrial tissue w/ in the myometrium Ovary 30% Pelvic peritoneum 10% Fallopian tube Vagina Bladder & rectum Pelvic colon Ligaments Extrapelvic: umbilicus, scars (laproscopic), lungs and pleura, etc

o Pathogenesis: many theories Retrograde Menstraution: endometrial tissue from the uterus is shed during menstruation and transported through the fallopian tubes implanting on pelvic structures. Direct Transplantation: probable explanation for endometriosis that develops in episiotomy, cesarean section, and other scars after surgery. Lymphatic/Blood vessel spread: probably accounts for dissemination outside pelvis Coelomic Metaplasia Theory: theory proposes that the coelomic (peritoneal) cavity contains undifferentiated cells or cells capable of dedifferentiating into endometrial tissue Altered Immunity: There is evidence for altered cell-mediated immunity predisposing to development of endometriosis Genetic Factors: Appear to play a role in susceptibilty to developing endometriosis. 7% chance of developing endometriosis if a first degree relative is affected. Concordance has been observed in twins o Marcroscopic Appearance Uterine: adenomyosis A) Diffuse (common): symmetrically enlarged uterus, firm consistency B) Localized (occasional): uterus asymmetrically enlarged, firm consitency Cross section of uterus: whorled appearance w/ small hemorrhagic areas which are islands of endometrial bleeding Ovary The ovary is enlarged and cystic Surface - Burnt match head appearance Tunica albuginea - thickened Chocolate cysts (endometriomas) o Diagnosis History and exam Symptoms o Asymptomatic in many cases o Pain Dysmenorrhoea Dyspareunia Dyschesia pain passing stools Dysuria 9

o Backache o Acute abdomen o Bleeding: Menorrhagia Cyclic haematuria during menstruation Cyclic bleeding per rectum during menstruation o Infertility Pelvic Exam o Pelvic tenderness o Fixed retroverted uterus o Nodularity of the Pouch of Douglas and uterosacral ligaments o Ovaries may be enlarged and tender Investigations Ultrasound will detect endometriotic cysts on ovaries but may be normal Laparoscopy gold standard to confirm diagnosis, can treat simultaneously o Endometriosis looks red, brown, black (powderburn) or clear (atypical) Cystoscopy and proctosigmoidoscopy may be indicated if patient has haematuria or PR bleeding Serum CA-125 non-specific marker, may be mildly elevated Differentials Ovarian cysts Pelvic inflammatory disease Other causes of nodularity in pouch of douglas such as tuberculosis peritonitis and metastases of ovarian cancer. Other causes of haematuria, bleeding per rectum and acute abdominal pain if the patient presents with one of these symptoms

o Ovarian and Rectal Endometriosis Ovarian Endometriosis = Endometrioma Formed by invagination of the ovarian cortex after accumulation of menstrual debris from bleeding of endometriotic implants. Chocolate cysts seen at laparoscopy Rectovaginal Septum Endometriosis Nodules are formed by hyperplasia of smooth muscles and fibrous tissue surrounding the infiltrated tissue. No cyclical bleeding as the endometriotic tissue is enclosed in nodules o Treatment Considerations: age, symptoms, stage (I-IV), desire to preserve fertility Recognize Goals: Pain Management & Preservation / Restoration of Fertility Discuss with Patient: o Disease may be chronic and not curable o Optimal treatment unclear IVF o Endometriosis does not generally impair the results of IVF o It is preferable not to cauterize ovarian endometriomas if IVF or ICSI may be required in case of destruction of ovarian tissues Not clear if the optimum treatment for endometriosis is medical, surgical or a combination of both Expectant Young, asymptomatic infertile patient with mild endometriosis. 10

If pregnancy not achieved w/ in 12-18mo hormonal or surgical treatment is indicated Medical Symptomatic patients with minimal or mild lesions: o Analgesics: for pain o Prostaglandin inhibitors o NSAIDs o Opiods Pregnancy is associated with regression of endometriosis and improvement in symptoms Hormonal Types o Oestrogen o Combined oral contraceptive pill o Progestogens oral or intrauterine device (Mirena) o Danazol o GnRH analogues Indications o Small endometriotic lesions o Recurrence after conservative surgery o Preoperative for 6-12 weeks to decrease size of endometriotic lesions o Postoperative for residual lesions o When surgery is contraindicated or refused by the patient Aims o 1) Pseudopregnancy Combined low-dose OCP (6 - 18 months to inhibit ovulation and menstruation and induce decidualization of endometriotic tissues). Progestagens (to avoid oestrogenic side effects) Medroxy progesterone acetate (Depo Provera) can be given in a dose of 150 mg IM every I - 3 months o 2) Pseudomenopause (induction of amenorrhea) Danazol Weak Androgen Suppresses LH / FSH Endometrial Regression/Atrophy Expensive Side-Effects: Weight Gain, Masculinization, Vocal Changes (may be permanent) GnRH analogues Initially stimulates FSH / LH Release. Down-Regulates GnRH Rec FSH/LH oestradiol Long-Term Success Varies. Expensive. Use Limited by Hypoestrogenic Effects o Main concern is decrease in bone density o Generally dont use for longer than 6 months Add-Back Oestrogen and used for longer duration o Reduces negative effect of hypo-oestrogenic state on bone mineral density o Relieves hot flushes Gestrinone 11

Synthetic 19 Nor steroid: marked anti-progesterogenic and anti-oestrogenic effects + mild androgenic properties Endocrine effects similar to those of Danazol which leads mainly to inhibition of ovarian steroidogenesis Lack of information on long term safety Surgical: Laparoscopy / Laparotomy Excision Resection of Endometrioma. Lysis of Adhesions, Cul-de-sac Reconstruction. Uterosacral Nerve Ablation. Presacral Neurectomy. Appendectomy. Uterine Suspension (? Efficacy). Hysterectomy +/- BSO: curative

INFECTIOUS DISEASES IN GYNECOLOGY: No OG lecture, following copied from IC2 REGUB lecture Background Why are increased levels of STI important? o 1. Transmissible o 2. Indicative of increased levels of unsafe sex / Inter-relationship with HIV o 3. Long term sequelae o 4. Psychosocial implications S.T.D. Role in enhanced H.I.V. Transmission o Disruption of mucosal surfaces o Increased H.I.V. secretion o Increased numbers of H.I.V. cell receptors Diagnosis of S.T.I. o 1. Microscopy o 2. Culture o 3. DNA amplification techniques - PCR o 4. Serology Taking a sexual history: Sexual Contacts o Who - Regular / Casual o When - Most recent / Past Year / Total partners o Where - Ireland / Abroad o How - A / V / O o Protection - Recent / General o Hx of risk factors in partner - Bisexual / IVDU More than one infection may be present Think about HIV Consider local anti-microbial resistance patterns What about the partner (s) Remember the psychosocial issues Syphilis Cause: Treponema pallidum Worldwide, has recently had slight increase in incidence Transmission o Sexual o Vertical 12

o Parenteral Clinical o Incubation 3 - 90 days o Can be a-sx o Primary Chancre: red, raised edge Regional lymphadenopathy o Secondary 2 - 12 weeks post primary Parenchymal Constitutional: flu-like illness, diarrhea, maculopapular skin rash CNS (35%): may p/w acute meningitis o Latent Early Late Syphilis Cardiovascular: aortic valve probs, aortic arch distortion Neurosyphilis Gummatous Syphilis o CONGENITAL SYPHILIS: screened for in pregnancy, v rare now Diagnosis: o Dark ground microscopy - Acute infection: scrape cells away and can see treponema o Serology Non-specific (non-treponemal reaginic antibodies) R.P.R.: rapid plasma reagent test Specific Treponema pallidum EIA TPPA T. pallidum Line Assay see individual Ab bands o CSF Serology Treatment o Procaine penicillin no resistance yet, but sometimes trouble b/c only i.m. o Amoxicillin o Doxycycline o Jarisch Herxheimer reaction: release of Ag from killed bact anaphylactic-like rxn

Gonorrhoea Cause: Neisseria gonorrhoeae, G- diplococci Worldwide distribution: incidence increasing Clinical o Males Urethritis Epididymitis o Females Cervicitis PID o General Anorectal, pharyngeal and disseminated infection (eg arthralgia, etc) o Neonatal Diagnosis o Microscopy o Culture: hard to culture, b/c needs 99% CO2 and stable temp 13

o PCR Treatment o Ceftriaxone o Cefixime: not as effective if oral gonorrhea o Spectinomycin

Human Papilloma Virus Commonest S.T.I. Subclinical / Clinical Infection Clinical o Clinical H.P.V. Infection o Anal warts o Genital warts o Low grade cervical dysplasia: H.P.V. 6 and 11 Diagnosis o Clinical o Biopsy o H.P.V. D.N.A. o Vaccine: one for 6/11 and one for 16/18, give to girls before sexually active Oncogenesis o Anogenital carcinoma: H.P.V. 16 and 18 o High grade cervical dysplasia Treatment o Cryotherapy o Podophyllotoxin o Trichloroacetic acid o Imiquimod: immune modulator stimulates body to get rid of virus locally o Laser therapy o Electrocautery o Surgical excision Herpes Simplex Virus Genital Herpes o Most common cause of genital ulceration o 20,000 cases per year U.K. o HSV 1 and HSV 2 Clinical o Primary attack Genital ulceration: more superficial than syphilitic, v painful Dysuria Flu like symptoms o Recurrent attacks more common with HSV 2 o Neonatal HSV: ggeneralized infection, skin mucous membranes brain associated with primary infection in late pregnancy Diagnosis o Viral culture o Electron microscopy o Type specific antibodies Treatment doesnt affect outcome of disease, but can be suppressed symptomatically o Aciclovir o Famciclovir 14

o Valaciclovir Non Gonoccocal Urethritis Chlamydia trachomatis (D,E,F,G) only one that can be tested for Ureaplasma urealyticum Mycoplasma hominis Chlamydia Clinical most (50% women, 70% men) completely a-sx o Cervicitis PID o Urethritis o Epididymitis o Proctitis o Reiters syndrome o NB Often asymptomatic 70% Long Term Sequelae o PID - Risk with repeat attacks o Ectopic pregnancy o Infertility o Chronic pelvic pain Diagnosis o D.N.A. amplification techniques highly sensitive and specific P.C.R. Ligase chain reaction Treatment o Doxycycline: take ~1wk, but pts may be non-compliant b/c of SEs o Erythromycin o Azithromycin o Ofloxacin Screening: CDC Recommendation o Annual screening of sexually active adolescents o Annual screening of sexually active women aged 20-25 o More frequent screening if significant risk factors o Screening of older women with risk factors (new partner, multiple partners). Trichomonas Vaginalis TV - flagellated protozoan Symptoms o Vaginal discharge + / - offensive odour o Vulval itching o Dysuria o 10 - 50% asymptomatic Signs o Vaginal discharge 70% - frothy, yellow o Vulvo-Vaginitis o 5 - 15% normal examination Investigations o Wet smear o Culture - modified Diamond media o PCR - Not routinely available Complications 15

o Associated with premature rupture of membranes, low birth weight Treatment o Metronidazole 2g o Metronidazole 400mgs BD x 5-7 days Management of sex partners o Partners should be treated - can cause urethritis in men o Abstinence till both partners treated and for 7 days after a single dose regime

Chancroid Haemophilus ducreyi Worldwide - 90% symptomatic cases in men Presentation o Incubation 1 - 6 weeks o Ulcer o Tender inguinal lymphadenopathy o Suppuration and adenitis o Sinus formation Differential diagnosis o Syphilis o Herpes o LGV Diagnosis o Microscopy o Culture o PCR Treatment o Aspiration o Antibiotics o Azithromycin o Ceftriaxone o Ciprofloxacin o Erythromycin HIV Infection Epidemiology o 38.6 mil living w/ HIV o 25 mil have died o 4.1 mil Risk Factors o 1. Sexual contact (a) Heterosexual transmission - commonest route worldwide (b) Homosexual transmission o 2. Vertical Transmission o 3. Contaminated needles o 4. Blood Transfusion o 5. Tissue/Organ donation o 6. Occupational exposure Prevention Strategies o 1. Sexual Contact Education Changes in sexual behaviour Condom usage 16

Number of Partners Management of other sexually transmitted diseases o 2. Vertical Transmission Ante natal Screening Anti Retrovirals Mode of delivery - Caesarian Section Breast Feeding IVDU o Education o Drug Treatment Programmes o Needle Exchange Blood Transfusion/Tissue Organ Transplant o Voluntary self exclusion o Screening o Residual risk 1: 5,000.000 in Ireland Occupational Exposure o Safe work practices o Personal protective wear o Education/Training Indications for HIV Testing o 1. Behavioural risk o 2. Clinical conditions associated with HIV o 3. Other sexually transmitted diseases o 4. Ante natal screening o 5. Children born to HIV positive mothers o 6. Those who received blood between 1978 and 1985 in Ireland Spectrum of HIV Disease o Asymptomatic carriage AIDS o Factors affecting disease presentation Age Sex Geographic location Behavioural history Treatment status CD4 count - important role in staging disease o Clinical Spectrum HIV disease Persistent generalized lymphadenopathy 2 or more enlarged nodes at 2 or more extra inguinal sites Oral Disease Oral candidiasis Oral hairy leukoplakia Cutaneous Disease Herpes simplex infection (HSV) Fungal infections GIT Disease Candida or HSV oesophagitis, Cryptosporidum Pulmonary disease PCP, TB Neurological diseases Cryptococcal meningitis 17

Cerebral toxoplasmosis HIV neuropathy Malignancies Kaposis Sarcoma Non Hodgkins Lymphoma: CNS or Peripheral Hodgkinss Disease Cervical Cancer AIDS Death Nos. Down by 48% between 1996 and 1997: Factors contributing to decline: Use of potent anti-retroviral drugs Improved prophylaxis against opportunistic infection Growing experience amongst health care professionals

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SEXUAL ASSAULT & DOMESTIC VIOLENCE Definition of Rape o Rape can be defined as sexual assault with penile penetration of the vagina w/o consent The crime may be classified as rape if the penile contact is with a location other than the vagina, or if the offender uses another body part or object to achieve vaginal penetration. o Rape is a legally defined crime rather than a medical diagnosis. The specific legal definition of rape varies between jurisdictions Adult Sexual Assault Victim Assessment o Immediate emotional care Ensure safety Provide emotional support Be non-judgemental Be gentle o Encourage victim to describe assault o History General: Date & time of assault What acts were committed Age, race, parity Ejaculation Last menstrual period Bathed since assault Sexual Last consensual intercourse Sexual pattern Contraception Alleged assault Penetration Condom use Weapons o Physical General Vital signs Emotional status Body surface: contusions, abrasions, lacerations General physical exam- Skin, mouth, breast, extremities Genitalia Vulva, vagina (lacerations, abrasions, ecchymoses, haematoma) o Forensic collection Describe trauma Take photographs Toxicology screening Specimen collection: Semen, Sperm, acid phosphatase (secreted by the prostate gland present in large amts in seminal fluid), nail clippings, pubic hair combings, blood sample Culture for Gonorrhoea & Chlamydia Wet prep for motile sperm & trichomonads 19

Collect clothing Offer RPR/VDRL, HIV and Hepatitis B & C testing

o Medical treatment All injuries treated appropriately. Tetanus toxiod. Hepatitis B vaccine protects if exposed during assault, 2 follow-up doses needed. Antibiotic prophylaxis Ceftriaxone 125mg IV once only (Gonorrhoea) plus Metronidazole 2g PO once only (Trichmoniasis) plus Azithromycin 1g PO once only (Chlamydia) or Doxcycycline 100mg PO bd x7 days HIV prophylaxis not recommended due to lack of data Pregnancy prevention Emergency contraception offered. Psychological management Assess for: Acute phase adjustment: irritability, tension, anxiety, fatigue, depression, ruminations/flashbacks Behavioural changes: alcohol abuse, drug abuse, overeating, PTSD Extreme fear- council or refer for evaluation and management o Follow-up care: In 2 to 3 weeks Assess psychological and emotional status Wet Prep to rule out BV and Trichomoniasis Gonorrhoea culture & Chlamydia testing Recommend Syphilis & HIV serology in 3-4 months Arrange for Hepatitis B vaccine 2nd (1-2 months) and 3rd(4-6 months) doses Child Sexual Assault o Important Points: Definition: When a child engages in sexual activity for which he/she cannot give consent, is unprepared for developmentally, cannot comprehend, and/or an activity that violates the law or social taboos of society 90% victimized by parents, family or family friend Children should be interviewed without the parents present, if at all possible Presentation may be evidenced with a variety of medical complaints such as: Evaluation of possible sexual abuse Routine care Acute evaluation of medical or behavioural concern o Evaluation: History (caregiver & patient) Determine what words the child uses to describe his or her body parts. Allowing the child to use a doll or drawing to describe what happened may be helpful in obtaining and clarifying information. The patient may disclose more details during the course of the physical exam At the end of the history, it is important that the child understands that he or she did the right thing in telling what happened, that he or she did nothing wrong, and that he or she is not in trouble Physical examination +/- Forensic evidence collection 20

The decision to perform a forensic examination should be made by individuals with training and experience in child sexual assault Forensic evidence (usually as a rape kit) should generally be collected from children who are evaluated within 24h of the incident in the following situations: o There is reasonable concern that a sexual assault has occurred. o The child has a genital injury as the result of alleged sexual abuse. o Clothing or linen associated with the assault is available. o There are other concerning clinical features The yield for forensic examinations in children is low. Semen is identified from body swabs more commonly in older children and rarely identified in any children more than 24 hours after an alleged assault Prepubertal children with genital discharges who may have been sexually abused should be tested for sexually transmitted infections +/- Screening for STD

o Management Must include attention to the immediate medical and social needs of patients and families, as well as to the local requirements for mandated reporting. Prepubertal children who have no symptoms of sexually transmitted disease should not receive antibiotic prophylaxis. Children who are prescribed prophylaxis should have specimens sent for culture prior to treatment Children who have been sexually abused may experience psychological and behavioural sequelae. They and their families should be offered a referral to a mental health professional. Decisions regarding HIV prophylaxis are usually made on a case by case basis Domestic Violence o Definition: An intentional controlling or violent behaviour by a person who is or was in an intimate relationship with the victim and that may include physical abuse, sexual assault, emotional abuse, economic control, and/or social isolation of the victim o Patients who should be asked about DV: 1. Female trauma victims 2. Female emergency room patients 3. Women with chronic abdominal pain 4. Women with chronic headaches 5. Pregnant women, especially with injuries (DV during pregnancy) 6. Women with sexually transmitted diseases 7. Elders with injuries o Prevalence Women 2-6 million women per year are assaulted by spouses/partners 40% of wives are beaten 10% of wives are raped May be increased during pregnancy For every 200 assaults, only 28 reported and only 3 arrests Children 6% are victims of violence Estimated 500,000 cases per year Elder abuse 21

Also increasing No firm data Most often by family member/caregiver

o Assess involvement in DV situation Screen all women Emotional abuse Physical abuse Forced sexual relations Fear of partner, other person Feel safe at home? Identify presence of domestic violence Physical abuse o Hitting o Slapping o Kicking o Choking o Assault or threat with weapons Sexual abuse o Unwanted touching o Sexual name-calling o Unfaithfulness o False accusations o Forced sex o Hurtful sex Emotional/psychological abuse o Undermine self-worth o Deprivation of sleep or emotional support o Unpredictability of response to life situations o Threats o Destruction of personal property o Partner overly controlling o Limits victims contact with others o Inappropriately close surveillance o Restricts activities Offer safety immediate safety or escape plan Provide advocacy and support o Non-judgmental o Victim may choose not to leave situation at that time Counsel patients for short-term safety o Is it safe to go home? o Are your children safe? o Can you stay with a friend or family? o Do you need a shelter? o Local Resources Local support agencies Gardai, Store street Garda station, Dublin Women's Aid National Free phone Helpline Tel: 1800 341 900 Ascend: North Tipperary-based support service for women experiencing violence Mna Feasa Women's Domestic Violence Project based in Cork 22

Dublin Rape Crisis Centre 1 800 77 88 88 Ruhama Working with & for women in prostitution Childline 1 800 666 666 Resources for batterer and victim Goals end violence Focus victims safety Purpose of intervention o Acceptance of responsibility for violence o Discontinue violent behaviour o Develop non-violent attitudes and behaviours

o Legally Obligation to Report: Varies by countries Spousal abuse reportable Elder, child abuse reportable o Facts about level of violence: The Sexual Abuse and Violence in Ireland (SAVI) Report (2002) found that 1 in 4 women had experienced some form of sexual abuse in their lifetime and 1 in 5 had experienced sexual assault as adults. In 2003, the Women's Aid helpline answered almost 13,000 calls. 1 in 3 of these related to physical violence, 13% to sexual abuse Between January 1996 and the end of June 2005, 109 women were murdered in Ireland, 72 of these in their own homes. In those cases which have been resolved (up to the end of June 2005), all were perpetrated by a man and almost half were perpetrated by the woman's partner or ex-partner. A survey conducted by Dublin's Rotunda Maternity Hospital in 2000, found that in a sample of 400 pregnant women, 1 in 8 had experienced abuse at the hands of their partner while pregnant A survey of women attending GP surgeries in 2002 found that 2 in 5 women who had been involved in a sexual relationship with a man, had experienced violence. This violence ranged from being punched in the face to being choked

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MENOPAUSE Permenopause / Climacteric o Climacteric: refers to the years preceding the final menstrual period (FMP), also called premenopausal years A/w change in the length of the menstrual cycle and the development of symptoms of oestrogen deficiency such as hot flushes and night sweats Menses may become heavier and erratic during these years Definition of Menopause: Final menstrual period, ie. the diagnosis can only be made o Cessation of menstruation due to loss of ovarian function Epidemiology o Median age at menopause is 50.8 years o W/ current Western life expectancy, >1/3 lifespan is postmenopausal Conditions of oestrogen deficiency & ageing have assumed much greater importance Physiology o Menopause occurs when the supply of oocytes become exhausted o A newborn girl has 0.5 million oocytes in her ovaries, 1/3 are lost before puberty. o During the reproductive years 20-30 primordial follicles develop per cycle and become atretic. o A woman has on average 400 cycles during her lifetime, therefore the majority of oocytes are lost spontaneously rather than through ovulation o Estradiol production by granulose cells o Proportion of anovulatory cycles progesterone production o Estrogen loss of negative feedback FSH and LH The relationship of the last period to the rise in FSH is not constant and FSH/LH levels may be raised for months/years before the menopause o After the menopause the oestradiol production from the ovary is negligible o Circulating androstenedione produced by the adrenals is converted to oestrone in adipose cells. Obese women therefore have higher circulating oestrogen levels and are at greater risk of endometrial hyperplasia & cancer o Oestrone is a less potent oestrogen than oestradiol o Androstenedione and testosterone production continues from postmenopausal ovary Etiology o Physiological o Radiation Induced o Side effect of chemotherapy o Surgical Symptoms and Signs o Vasomotor instability Hot flushes & night sweats: Sudden, intense hot feeling over face & chest +/- Warning feeling or aura beforehand +/- Palpitations, sweating, nausea, dizziness, anxiety, headache Flushing & perspiration Lasts for a few seconds to a few minutes Night sweats disturb sleep Knock-on effects of tiredness / depression / poor performance Occurs secondary to hormonal changes at menopause 24

Reduced oestrogen resets hypothalamus Severity of symptoms related to suddenness of onset of menopause Chemotherapy, surgical removal of ovaries associated w/ more severe symptoms Sx experienced by 75% of women and continue for at least 5 years in 25% patients Major quality of life impact: 15% women seek medical help for hot flushes

o GU atrophy (vagina, vulva, urethra, trigone): Pruritus vulvae, vaginitis/dryness, urethral synd Lower oestradiol levels result in thinner skin at vulva & vagina, decreased secretions & loss of elasticity May result in difficulty with intercourse and occasional vaginal bleeding Vaginal pH increases Vaginal oestrogen cream / pessaries are effective treatments Non-hormonal therapies may also be effective Cystitis-like symptoms due to lower oestradiol levels affecting bladder trigone Treated with oral hydration +/- antibiotics Vaginal oestrogen cream / pessaries are effective o Other S/S: insomnia, irritability, mood disturbances, libido, skin atrophy Osteoporosis (gradual decrease in trabecular bone) o Bone resorption by osteoclasts is accelerated by the menopause In the first 4 years after menopause there is a 3% loss of bone mass, falling to 0.6% loss annually there after Greatest rate of loss in 1st 2 years Increased risk of fractures: distal radius, vertebral, upper femur Vertebrae, hip & radius most commonly affected 40% women > 65 yrs sustain a fracture 25% women > 65yrs develop wedge fractures of the spine Risk factors include low body mass index, smoking, caucasian Osteoporosis has significant impact on health service resources o Protective Measures Stop smoking Weight-bearing Exercise (at least 30 minutes/day) Good nutrition including dietary calcium Medications: HRT Bisphosphonates e.g. alendronate SERM (selective estrogen receptor modulators): tamoxifen, raloxifene Calcium supplements & Vitamin D Strontium Heart Disease in Menopause o Impact: Leading cause of death for Irish women (1/2 1/3 deaths) o Risk Factors: Ageing is main determinant of heart disease BP, cholesterol, weight, diabetes, family history Smoking, low exercise, diet o Role of HRT Oestrogen deficiency formerly thought to be major contributor and HRT a major preventive agent Recent data suggests HRT is not protective and in vulnerable patients can make 25

cardiovascular disease worse Difficult to balance the risks of HRT with benefits final decision should be individualised in each case

Diagnosis o Clinical diagnosis o Made retrospectively when a woman has had no menstruation for 1 year o Serum FSH > 30 U/L usually indicative of menopause Management o Hormonal treatment therapy Oestrogen supplementation is the basis of HRT Unopposed oestrogen cannot be given to women with a uterus because it will cause endometrial hyperplasia and malignancy. These women must receive combined HRT oestrogen and progestogens. o It can be given in a cyclical or continuous preparation Women who have had a hysterectomy are suitable for oestrogen only HRT Mode of Administration: Oral taken daily Transdermal patches Subcutaneous implants Topical - creams, vaginal pessaries Oral HRT Oral has more beneficial effect than parenteral therapy on lipid profile but is more thrombogenic Preparations are oestrogen only or combined oestrogen and progesterone Cyclical combined HRT a monthly withdrawal bleed, used perimenopausally Continuous combined no bleed HRT is suitable for women > 2 years since FMP Irregular bleeding > 6 months after commencing HRT needs further investigation Tibolone o Synthetic steroid with weak oestrogenic, progestogenic and androgenic effects o Can be started > 2yrs after the final menstrual period and is an alternatively to the higher dose oestrogen-progesterone preparations Raloxifene o Selective oestrogen receptor modulator which has oestrogenic effect on bone and lipid metabolism but minimal effect on breast and uterine tissue. o It is not effective for the management of vasomotor symptoms but it is protective against osteoporosis Transcutaneous HRT Avoid the 1st pass metabolism hepatic side effects on lipid and coag factors Available in oestrogen and combined preparations Applied weekly or twice weekly Some local side effects of the patches: skin reactions Subcutaneous Implants Oestradiol implanted subcutaneously in the abdomen every 6 months Not used that often now: occasionally inserted at the time of a TAH/BSO With continuous use the effects of the oestrogen become weaker and the implants need to be replaced more frequently this is known as tachyphylaxis Vaginal HRT 26

Oestradiol tablets or pessaries or vaginal cream Local HRT for the treatment of atrophic vaginitis Should not be used for long periods in women with a uterus because of the risk of unopposed oestrogen and endometrial cancer

SEs of HRT Endometrial Cancer: unopposed oestrogen results in a 4-fold increased risk of endometrial cancer Venous Thromboembolism: 4 fold increased risk in first 6 months of use Cardiovascular: increased incidence of MI and CVA in the first year of use Minor side effects: nausea, breast tenderness Breast Cancer o Increased risk of breast cancer with use of HRT o Highest risk with long-term use: risk not increased with <5 years use o Greater risk with combined therapy than oestrogen alone o For every 1000 women taking HRT for 10 years there are 6 additional cases of invasive breast cancer Duration of HRT The shortest possible time for symptom control Not recommended for longer than 2 3 years HRT is no longer the first line treatment for osteoporosis. o Alternative non-hormonal meds: eg. bisphosphonates, SERMs, Strontium Most menopausal problems are managed by the GP o Usually the GP who commences women on HRT for symptom control and monitors them while on treatment. o Women are referred to gynaecology clinics if GP is having difficulty controlling the Sx or the woman has other significant co-morbidities Contraindications to HRT Any irregular vaginal bleeding that has not been fully investigated Pregnancy Venous thromboembolism Liver disease Breast cancer Any oestrogen dependent tumour

o Non- Hormonal Therapy Natural phyto-oestrogens (legumes) Acupuncture/ homeopathy Clonidine: central acting alpha agonist reduces vasomotor symptoms Postmenopausal Well Being o 6 monthly GP visit o Cervical Smears every 3 years until 65 years o BP check o Bloods: lipid profile o Mammogram annually if on HRT or 3 yearly if not on HRT o DEXA Bone Scan (every 1-3 yrs) o Any irregular vaginal bleeding should be investigated 27

GENITAL PROLAPSE Classification o Urethrocele o Cystocele o Uterine (grade 1-3) o Enterocele o Rectocele o Vault

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o Incidence o 12-30% of multiparous women, 2% of nuliparous women Increases w/ age: most common in post-menopausal multiparous women o Common indication for surgery: 20% of major gyne surgical cases Etiology o Congenital: possible weakness already present in nuliparous women o Childbirth Prolonged second stage of labour Fetal macrosomia High parity o Menopause o Raised intra-abdominal pressure Chronic cough Obesity Chronic constipation o Post-op: 1% of cases, results from poor vaginal vault support at time of hysterectomy Uterine Prolapse o Grades: First degree: Slight descent of uterus Second degree: Cervix protrudes through introitus Third degree (complete procidentia): Entire uterus outside vagina o Symptoms: worse in erect position Dragging discomfort and feeling of something coming down Backache Urinary symptoms Stress incontinence Frequency, urgency Incomplete emptying Bowel symptoms: difficulty w/ defecation Bleeding due to excoriation on clothes Coital difficulties 28

o Signs Demonstrate Prolapse Stress incontinence Examine in left lateral position with Sims speculum Cervix often elongated Procidentia ulceration Vaginal atrophy Exclude pelvic or abdominal masses General examination: anaesthetic assessment o Investigations MSU +/- Urodynamics, cystometry, cystoscopy +/- IVP (procidentia) Anaesthetic assessment o Treatment Considerations: Severity of symptoms Family completed Predisposing factors o Obesity o Chronic cough o Constipation Fitness for surgery Request for permanent cure Options Conservative measures o Eliminate chronic cough o Stop smoking QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. o Avoid heavy lifting o Weight loss o Pelvic floor physiotherapy Ring Pessary o Indications Unfit for surgery: age, other illnesses, etc Does not want surgery Pregnant Family not complete o Change pessary every 6 months Surgery o Anterior colporrhaphy o Posterior colpoperineorrhaphy o Manchester (Fothergill) repair o Vaginal hysterectomy o Burch colposuspension o Colposacropexy Vaginal Vault Prolapse o May occur following hysterectomy o Older types of vaginal repair unsatisfactory o High recurrence rates 29

o o o o

Abdominal repair- colpopexy Vaginal repair- sacrospinous fixation New surgical techniques use prolene mesh Posterior intravaginal sling

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URINARY INCONTINENCE Definition: involuntary loss of urine w/ demonstratable leakage which is a social or hygienic problem Incidence o 10 - 20% of the female population are incontinent of urine on one or more occasions per month o The prevalence increases > 75 years when 25-50% of women are incontinent Predisposing factors: o Faecal impaction o Decreased mobility o Confusional states o Specific drugs such as diuretics and hypnotics Types o o o o o Genuine Stress incontinence Detrusor Over activity Urinary retention with overflow (uncommon) Vesicovaginal fistula or ureterovaginal fistula Congenital Abnormalities: ectopic ureter

Physiology of Micturation o Urine storage and release are controlled by the central nervous system (CNS) through reflexes that coordinate the activity of Bladder (smooth muscle) Urethra (smooth and striated muscles) Pelvic floor striated muscle o Continence is maintained at the level of the bladder neck. The proximal urethral sphincter, at the bladder neck, and the proximal urethra maintains continence

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Clinical Presentation o Loss of urine with activity: Incontinence on coughing, laughing, sneezing o Urgency: irresistible desire to pass urine and urge incontinence is associated with that desire o Nocturnal enuresis o It is essential to establish how these symptoms affect her lifestyle o When asking about Sx inquire how often in the last week they has an accidental leak w/: 31

A physical activity, such as coughing , sneezing, lifting, or exercising A feeling of strong, sudden need to pass your urine that did not allow you to get to the toilet fast enough

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o History o General History Medical, neurological, genitourinary history Obstetrical history Surgical history Review medications Diet o Incontinence History Onset, frequency of leakage, need for absorbent products Precipitating events Cough, exercise, medications, childbirth, surgery, pelvic estrogen status Lower urinary tract symptoms Urgency, frequency, nocturia, enuresis, dysuria, hematuria, pain, pelvic pressure, vaginal dryness, dyspareunia Fluid intake Schedule, amount, type Medications: Diuretics, anti-hypertensives ( -blockers) Previous treatments and effects on incontinence Voiding Diary Fluid intake: Time, type, amount Urine output: Time, amount Urine leakage o Time, amount o Precipitating events (cough, sneeze, exercise, sex) o Associated symptoms (urgency, dysuria, frequency) Pad usage: Number, type Excess intake or output o Consider diabetes mellitus or insipidus and psychogenic polydypsia Physical Exam o Concerns Abdominal: Mass Pelvic: Prolapse, mass, atrophy, voluntary pelvic floor contraction Rectal: Mass, tone, voluntary contraction Sacral neurological: Sensation, reflex, foot movements 32

o Pelvic Exam Prolapse Mass Atrophy Perineal skin condition Paravaginal support Palpation of anterior vaginal wall and urethra Quantify degree of pelvic relaxation Assess ability to perform and strength of voluntary pelvic muscle contraction Determine degree of estrogenization of pelvic structures o Sacral Neurological Exam Sensation Reflex Anal wink (S2-S5) Bulbocavernosus (S2-S3) Foot movements Voluntary contraction of anal sphincter Lower extremity muscle strength o Rectal Exam Mass Sphincter tone at rest and active Voluntary contraction Perineal sensation Fecal impaction o Urinalysis Bacteriuria Hematuria Pyuria Glycosuria Proteinuria o Other Basic Tests Postvoid residual Straight catheter with 14 French catheter and 2% xylocaine jelly Ultrasound (bladder scanner) Stress Test or Cough Test Objectively confirms stress incontinence Usually performed at 300 cc bladder or maximum bladder capacity Standing position Pad Test Quantifies urine loss Simple Cystometry Detects bladder compliance, the presence of detrusor contractions, and determines bladder capacity Urodynamic Assessment o Definition: a study which is able to investigate both the phase of bladder filling and the phase of bladder voiding o Filling Urodynamic Assessment Cystometrogram The bladder is filled via a urethral catheter with sterile saline at room temperature 33

running at 100mls/min The detrusor pressure (pressure within the bladder) is measured o As the bladder is an intra-abdominal organ the actual pressure in the bladder = detrusor pressure + intra-abdominal pressure o Measured indirectly by measuring the P in the bladder and subtracting the intraabdominal P which is measured with a vaginal or rectal catheter Indications o Symptoms of both stress and urge incontinence o Any patient who has failed to respond to medical or surgical treatment Disadvantages: loss of dignity and risk of introducing infection Genuine Stress Incontinence Total bladder pressure will be raised at the moment of incontinence but the detrusor pressure is unchanged Detrusor Over activity/Overactive bladder Total bladder pressure and the detrusor pressure will be equally elevated at the time of incontinence

o Voiding Urodynamic Assessment Definition: assessment during voiding where the measurement include total volume voided, the peak flow of urine voided, the detrusor activity required to produce the flow Demonstrate residual urine eg bladder filled by 500mls but voided 350mls Genuine Stress Incontinence o Definition: Leaking of urine in the presence of raised intra-abdominal pressure (eg sneezing, coughing, laughing) and the absence of detrusor activity Occurs when there is weakness of the proximal and distal urethral sphincter mechanism o Etiology: no single cause Pregnancy: vaginal delivery may cause denervation of the pudendal nerve and damage to the supporting tissues of the urethra Prolapse: prolapse is not a cause of GSI but deficiency of the supporting tissues which causes prolapse and also GSI Menopause: lack of oestrogen reduces the maximal urethral closure pressure. This results in a higher pressure in the bladder and GSI occurs Collagen Disorders Obesity o Treatment Conservative: pelvic floor exercises, vaginal cone, medication Purpose: Alter the magnitude of intra-abdominal P (i.e., stress) on the bladder Types o Alterations of fluid and voiding habits Appropriate amount of total fluid per day (2-3 L/day is sufficient) Avoid caffeinated and alcoholic beverages Regular voiding intervals Consider prophylactic voiding every 2-3 hours during day (assuming normal fluid intake) Adjust voiding frequency based on bladder diary to keep voided volume less than 350-400 cc o Behavioral therapy to intra-abdominal pressure Bladder retraining Pelvic muscle rehabilitation (exercises) 34

Requires motivated patient No consistent technique Patient must be able to correctly perform a voluntary pelvic muscle contraction Patient must strengthen the muscle AND recruit the muscle contraction during increases in intra-abdominal pressure Best for mild stress incontinence that occurs w/ cough or sneeze; less effective for exercise-induced incontinence Cough control Stop smoking Treatment of underlying pulmonary conditions Treatment of allergies Weight loss Exercise modification Reduce heavy lifting Avoid chronic straining with constipation o Devices Intravaginal support Vaginal Cones: Used in women who are unable or minimally able to generate a pelvic muscle contraction o Gives patient goal and ability to determine if performing contraction correctly Intraurethral occlusive Pros and Cons o Less invasive o Cure rates low but improvement often seen o Can be used in women considering further childbearing o Response dependent on patient compliance

Surgical: Advantages o Higher cure rates o Response less dependent on patient compliance o Recommended that childbearing be completed o Invasive with risk of intra-operative and postoperative complications that can lead to new problems (voiding dysfunction, urge incontinence) Role: does not replace the physiological mechanism but supports the bladder neck and proximal urethra and prevents incontinence associated with raised intraabdominal pressure Types o Tension Free Vaginal Tape (TVT) Minimally invasive: spinal anaesthesia/Sedation/ GA Prolene mesh is inserted transvaginally at the level of the midurethra using 2 trocars 90% success rates Complications: Vascular Injury, vessel or bowel or bladder injury, voiding difficulties, erosion of tape through urethra, tape too tight, urge incontinence o Burch Colposuspension Very common prior to introduction of TVT Suprapubic procedure in which non-absorbable sutures are placed retropubically to approximate the paravaginal tissues to the 35

ileopectineal ligament Success rate 80-90% (70% at 15yrs postop) Complications: voiding difficulties, prolapse, detrusor over activity o Suburethral Slings Sling placed like a hammock between 2 areas of the abd wall Passed from the abd wall, under the urethra and back to the abd wall Used in a minority of women Other Trial Treatments o Microparticulate silicone into the proximal urethra in cases of very scarred urethra o Artificial Sphincter insertion

Medical Treatment Duloxetine o Recently approved medication for treatment of GSI o Mode of action: serotonin and noradrenaline re-uptake inhibitor o Blocking the reuptake of 5-HT and NE increases activation of -1 adrenergic and 5-HT2 receptors, increasing pudendal nerve activity o Increase in pudendal nerve activity strengthens the sphincter contraction o Urethral sphincter contraction helps to prevent urine leakage when pressure is exerted on the bladder

Detrusor Over activity o 2nd most common cause of urinary incontinence in women o Aetiology is unknown Occasionally it can be pathological as a result of neuropathy (multiple sclerosis) or bladder neck obstruction o Symptoms Urgency: sudden desire to pass urine Urge Incontinence: unable to reach the toilet without becoming incontinent following an urge to void Frequency Nocturia > 2 times per night o Diagnosis: history and filling cystometrogram

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o Treatment Behavioural therapy Aims to re-establish central control of the bladder Biofeedback and bladder retraining are slow but in highly motivated women have 80% success rates Principles of bladder retraining o Exclude frequency o Explain the diagnosis to the patient and the rationale of the intervention o Instruct the patient to void every 2 hours during the day. Explain that she should not void in between, she must wait or be incontinent o Give praise when the 2 hourly voiding is successfully achieved and then extend the time at half hourly intervals o Drug treatment can be used to augment Behavioural therapy Medications Anticholinergic agents: the neurotransmitter which cause the detrusor muscle to contract is Ach, therefore anticholinergics inhibit detrusor muscle contraction o 70% have improvement of symptoms o Side effects: dry mouth, blurred vision, constipation 15% patient stop the medication because of the side effects o Examples: oxybutynin, tolteridine, propiverine, trospium Tricyclic antidepressants also have anticholinergic action and can be used Local Oestrogen: small role in improving local tissues Surgery Not the main treatment option for detrusor instability Reserved for women in who have severe symptoms that have not responded to conservative treatment Clam Ileocystoplasty

Other Causes of Urinary Incontinence o Fistulae Types Vesicovaginal Ureterovaginal Ureterovaginal Symptoms of incontinence all the time Fistula may be seen on vaginal examination or may require radiological imaging 37

Aetiology: obstructed labour or more commonly as a result of cervical malignancy or side effect of radiation Treatment: surgery if possible but in post radiation may require ileal conduit

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