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1. Prolapse of pelvic organs 1 By Fasika A

2. Pelvic organ PROLAPSE (Pop) Definition –is a bulge or protrusion of pelvic organs and their associated segments into or through the vagina. POP is a protrusion/descent of uterus and cervix to or out of the vaginal canal 2

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4. Epidimology Exact prevalence - is difficult to ascertain, due to Lack of consistent definitions: Variable staging Number of women who seek care for POP is unknown A woman has an estimated lifetime risk of 12% to undergo surgery for prolapse 50 % of women older than age 50 have some degree of pelvic organ prolapse, but fewer than 20% seek treatment. 4 By Fasika A

5. This may be due to a number of reasons, including lack of symptoms, embarrassment, or misperceptions about available treatment options Ethiopia Community-based study in rural Ethiopia (2016) Prevalence of symptomatic POP ( 1:1000) SPHMMC -15 % of major gynecologic operations 5 By Fasika A

6. Pathophysiology Pelvic organ support is maintained by complex interactions of the pelvic floor muscles pelvic floor connective tissue, and vaginal wall Pelvic organ prolapse results from attenuation of this supportive structures, whether by actual tears or “breaks” or by neuromuscular dysfunction or both.

7. Supports of the uterus, are categorized in to three tier system Upper tier, includes: Endopelvic fascia covering the uterus Round ligament Broad ligament It is the weakest part and it maintain the uterus in anteverted position

8. Middle tier, includes: Condensations of endopelvic fascia Cardinal / Transverse cervical ligament Utero sacral ligament Pubocervical ligament Pubourethral ligament Is the strongest support of the uterus Inferior/ Lower tier Pelvic diaphragm: Levator ani muscle Perineal body: Fibro muscular condensation between the vagina & the rectum

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11. Factors associated Damage to pelvis floor support by : prolonged labor , early first stage pushing , inappropriate instrumental delivery , 3 rd stage mismanagement, frequent child birth Aging –estrogen deficiency Congenital weakness of pelvic floor supports Increased intra a dominal pressure by-chronic cough ,constipation , ascites, obesity Race-white are more affected 11

12. Differential Diagnosis Vaginal wall cyst Tumors of the urethra and bladder Urethral diverticulum Skene's and Bartholin's glands cysts Cervical/endometrial tumors ( pedunculated myoma or endometrial polyps); if prolapsed through a dilated cervix. Elongated cervix

13. Clinical grading of UVP Grade 0 Normal position for each respective site Grade 1 Descent halfway to the hymen Grade 2 Descent to the hymen Grade 3 Descent halfway past from the hymen Grade 4 Maximum possible descent for each site 13

14. Clinical manifestations of POP Symptoms Sensation of vaginal bulging or protrusion Seeing or feeling a vaginal or perineal bulge Pelvic or vaginal pressure Heaviness in pelvis or vagina Urinary Symptoms Stress urinary and urge incontinence (SUI), urinary frequency, urinary retention, recurrent urinary tract infection

15. Bowel symptoms Incontinence, feeling of incomplete emptying, constipation Sexual symptoms and pain Dyspareunia, decreased lubrication, decreased sensation Pelvic and Back Pain 15 By Fasika A

16. Physical examination Pelvic examination The vulva and perineum are examined for signs of vulvar or vaginal atrophy, lesions, Examination of prolapsed organ begins by asking a woman to attempt Valsalva maneuver prior to placing a speculum in the vagina .

17. If the full extent of prolapse cannot be demonstrated, a woman should be examined in a speculum . Rectovaginal examination may be useful in evaluating the posterior compartment to distinguish a posterior vaginal wall defect Bimanual examination is performed to identify other pelvic pathology Investigations CBC , Hematocrit, Blood group & Rh, urine culture , U/A RFT U/S for residual volume, kidneys, abdominal masses 17

18. Management principle Based on your level if you diagnose this POP, you should refer/consult to the hierarchy level. But there are measurements Considered in women with Mild to moderate prolapse (stage I & II) Those who desire preservation of future childbearing Those who do not desire surgical intervention. The goals of a conservative therapy approach to the treatment of prolapse are as follows Prevent worsening prolapse Decrease the severity of symptoms Increase the strength, endurance, and support of the pelvic floor musculature Avoid or delay surgical intervention

19. Includes;- 1 . Pelvic Floor Muscle trainings(PFMT) = Kegel exercises 2 . Mechanical Devices = Pessaries 3 . Estrogen; in postmenopausal women 4 . Weight reduction in obese patients 5 . Modification of life style = avoid heavy exercise

20. Surgical Manchester operation Lefort`s Ventro suspention TransVaginal hysterectomy Trans abdominal hysterectomy 20

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24. Cystocele Down ward displacement of the bladder which appears as bulge in the anterior vaginal wall Anterior vaginal prolapse describes an anterior vaginal wall defect where the bladder is associated with the prolapse Urinary symptoms are also common. Feeling of incomplete emptying of the bladder Stress incontinence Urinary frequency RX kegles exercise in mild cases Estrogen supplementation for post term woman Vaginal pessaries Surgery –anterior vaginal colporrhaphy 24

25. Rectocele Posterior vaginal wall prolapse describes a posterior vaginal wall defect. The rectum develops traps stool and constipation results Defecation difficulty in rectocele Rx In severe –surgery to repair the defect 25

26. SAMPLE HISTORY Chief complaint: Mass protruding per vagina of 2 years and 2 month duration. HPI This is a 55 years old para 8, patient who has been amenorrheic for the last 6 years; was relatively healthy until she presented with protruding mass of 2 years, which begins to get worse since 6 months back. The mass protrudes out up on standing, coughing and lifting heavy objects and returns on attaining supine position. The mass was soft and she was able to push back the mass manually. It is painless and not associated with abnormal bleeding or foul smelling discharge. She also complains of dragging type of lower abdominal pain which doesn’t radiate and get exacerbated when she stands and strains while relieved upon rest. 26 By Fasika A

27. For this reason she went to a local health center and was referred to Jimma hospital. She also has frequent urination, urgency, leakage of urine while coughing or sneezing and a burning sensation during urination . Due to urinary frequency, she was forced to reduce her water intake during work. Her first delivery was 35years back and her last was 10 years back. All of her children were born through spontaneous vaginal delivery at her house attended by traditional birth attendants. Labor, lasted less than 6 hours in all cases. All her children are alive and healthy. None of her pregnancies had antepartum or post-partum complications. She works in a factory as a daily laborer. The job requires heavy lifting and lots of strenuous activities . Otherwise:- She has no history of vaginal bleeding or discharge; She has no history of reddish discoloration of urine. She has no history of abdominal swelling or distention. She has no history of chronic cough, 27 By Fasika A

28. She has no previous history of constipation. She has no history of trauma to the pelvis or gynecological surgery. She has no history of similar illness in the family. She has no personal and family history of chronic illness like DM, hypertension or asthma . She has no color change to the mass or ulceration. She has no history of urinary retention, change in bowel habits. She is not sexually active currently. 28 By Fasika A

29. Pertinent physical examination: General appearance: Stable, comfortable, well-nourished and cooperative during physical examination. Vital sign: BP=130/80 mm Hg. PR=88 beats/min. RR=18 breaths/min To=36.00C Examination of external genitalia: atrophic vulva, inverted triangle like hair distribution. There is FGM, No ulcers, discolorations, pruritus or warts. Digital vaginal examination: a soft, non-tender and reducible mass felt bulging from the vaginal wall. After straining a mass protruding per vagina is seen half way past the hymen. No cervical motion tenderness. Recto vaginal examination: no peristalsis felt behind the vaginal wall 29 By Fasika A

30. THANK U

31. Lower Urinary Tract Dysfunction

32. Physiology of Micturation Storage phase: Filling rate: 0.5-5 ml/min As bladder fills, walls stretch to maintain a constant tone Voiding Phase: When volume of 250 ml reached, a sensation of bladder filling is perceived. Desire to void is by stimulation of stretch receptors in the bladder wall. Involves both spinal and higher centers 32 By Fasika A

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34. Peripheral Nerves in Micturition Parasympathetic (cholinergic) - Bladder contraction Sympathetic - Bladder Relaxation (β adrenergic) Sympathetic - Bladder neck and urethral contraction (α adrenergic) Somatic ( Pudendal nerve) - contraction pelvic floor musculature

35. Peripheral Nerves in Micturition

36. Urinary incontinency Definition : it is involuntary loss of urine that is asocial or hygienic problem and that is objectively demonstrable Why is Incontinence Important ? Social stigmata - leads to restricted activities and depression Medical complications - skin breakdown, increased urinary tract infections Hospitalization

37. Epidemiology Urinary Incontinence is Often Under-Diagnoses and Under-Treated It affects 26% of reproductive age group 50-75 % of patients never describe symptoms to physicians 80% of urinary incontinence can be cured or improved

38. Classification of incontinence 1. Stress incontinence Involuntary leakage on effort or exertion, or on sneezing or coughing the generated intra-abdominal pressure causes a coincident rise in intravesical pressure SUI affects 29 – 75 % of general population 2. Urge incontinence Also called detrusor hyperactivity , UUI affects = 33 % of general population a perceived strong imminent need to void 38 By Fasika A

39. 3 . Mixed incontinence (stress and urge combined) 4 . Overflew incontinence with urinary retention Over distention of bladder Bladder outlet obstruction; stricture, BPH, cystocele, Non-contractile baldder (hypoactive detrusor or atonic bladder); diabetes, spinal injury, medications 5 . Bypass incontinence = Genitourinary fistulas 39 By Fasika A

40. PATHOPHYSIOLOGY Continence requires the complex coordination of muscle contraction and relaxation, Appropriate connective tissue support, and integrated innervation and communication between these structures These mechanisms can be challenged by uninhibited detrusor contractions, marked increases in intraabdominal pressure, and degradation or dysfunction of the various anatomic components of the continence mechanism 40 By Fasika A

41. Risk Factors for Urinary Incontinence Age Obesity Smoking Pregnancy Childbirth Menopause Functional impairment Chronically increased abdominal pressure Chronic cough Constipation Occupational lifting 41 By Fasika A

42. Diagnosis History Urinary symptom Past medical Hx infection , atrophic vaginitis, restricted mobility, and stool impaction Physical examination Inspection – Palpation Diagnostic Testing U/A, Urine culture, Post void residual volume Urodynamic Testing 42 By Fasika A

43. DDX Urethral diverticulum  Congenital urethral abnormalities  ectopic ureter 43 By Fasika A

44. Evaluation of Urinary Incontinence History age, parity, type of delivery frequency of leakage what provokes, what help to stop the leakage what makes the leakage worse has been treated previously DM HTN PTB

45. History………. Is she smoking and alcohol consumption Physical examination Chest pathologies Neurologic abnormalities Pelvic examination done with full bladder U/S

46. Investigation U/A Urodynamic sudies cystomethery

47. Non pharmacology Treatment Options Reduce amount and timing of fluid intake Bladder training Patient education Scheduled voiding Habit training Prompted voiding Pelvic floor exercises ( Kegel Exercise) Pessaries Chronic catheterization

48. Pharmacological Interventions Urge Incontinence Oxybutynin Propantheline Tofranil Stress Incontinence Phenyl propanolamine ( Ornade ) Estrogen Surgical procedure like - Sling Procedures

49. GENITO URETHRAL FISTULA 49 By Fasika A

50. Fistula – abnormal communication between two or more epithelial surfaces Obstetric fistulas are abnormal communications between the genital tract and the urinary tract (urogenital fistula) or the gastrointestinal tract (most commonly, rectovaginal fistula) These fistulas result in urinary or fecal incontinence 50 By Fasika A

51. Incidence True incidence of genitourinary fistula is unknown Uncommon in well developed –is usually the result of a complication of pelvic surgery Common in resource limited countries – Obstructed labor is the cause of the majority of VVF in these settings – It is estimated that a million or more women in sub-Saharan Africa currently have an unrepaired VVF, with between 30,000 new cases occurring each year The current total capacity for fistula repair in sub-Saharan Africa is estimated to be around 10,000 cases per year 51 By Fasika A

52. Types of obstetric fistula These can be Vesicovaginal ;- Communication between the urinary blader and vagina Urethro viginal ;- Communication between the urinary urethra and vagina Vesico uterine;- Communication between the urinary blader and uterus Rectovaginal ;- Communication between the rectum and vagina Of genitourinary fistulas, the vesicovaginal fistula is most common 52 By Fasika A

53. Etiology and Risk factor Congenital genitourinary fistulas are rare, but if found, commonly associated with other renal or urogenital abnormalities. Most GUF are acquired and typically result from either obstetric trauma or pelvic surgery Obstetric Trauma: For industrialized countries, most fistulas occur iatrogenically from pelvic surgery, and the generally accepted incidence derives from data on surgeries Whereas in developing countries, more than 70 percent of genitourinary fistulas arise from obstetric trauma, specifically from prolonged or obstructed labor 53 By Fasika A

54. The MOST important contributing factor for the development of obstetric fistula is prolonged or obstructed labor – The BEST strategy to address obstetric fistula is to prevent obstructed labor by e – providing safe and timely emergency obstetric car “The sun should not rise or set twice on a woman in labor” When OL is unrelieved, the presenting fetal part is impacted against soft tissue of the pelvis and a wide spread ischemic vascular injury develops, that results in pressure tissue necrosis and subsequent fistula formation 54 By Fasika A

55. Factors associated with fistula formation in developing countries Childbearing at a young age Female genital mutilation, may significantly narrow the vaginal introitus and obstruct labor Prolonged or obstructed labor Anatomic malpresentation of the presenting fetal part 55 By Fasika A

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57. Clinical feature Continuous leakage of urine symptoms of fever, chills, malaise, flank pain, and gastrointestinal symptoms . Diagnosis History Primigravidea Obstructed labor Continious leakage of urine

58. Physical examination Ammonic smell flank or abdominal tenderness due to hydronephrosis Identify the site and number of fistula

59. Investigation U/A HCT RFT Cystometery

60. Supportive Management Good referral system Catheterization Psychological support

61. Surgical treatment Done after 3 month of diagnosis of fistula Supra trigonal fistulas (fistulas above the inter ureteric ridge) were typically approached transabdominally . Infratrigonal fistulas (fistulas below the interureteric ridge) were corrected transvaginally .

62. Post operative care Stool softeners for 21 days Keep the catheter for 14 days On discharge - Advise to pass urine aduquately - Avoid coitus for 2-3 days - Avoid pregnancy for 3 years - Subsequent delivery with elective C/S

63. Complication Incontinence of urine or stool Chronic pyelonephritis, hydronephrosis and bladder stones Renal failure Vaginal stenosis and dyspareunia Chronic irritation of skin from contact with urine and stool Malnutrition Depression and anxiety Inability to work Social isolation and Stigmatization 63 By Fasika A

64. prevention Primary prevention Adolescent nutrition – Education and empowerment for women Delaying marriage and child bearing Secondary prevention Birth preparedness and complication readiness, including transportation and family decision making – Skilled attendance at every birth – Monitoring of every labor with the partograph for early recognition of obstructed labor Ready access to high quality emergency obstetric care Community awareness raising and education about prevention and treatment of obstetric fistula 64 By Fasika A

65. prevention Tertiary prevention Early recognition of developing or developed fistula in women who have had an obstructed labor or genital trauma Standard protocol at health centers for management of women with fistula to prevent further damage 65 By Fasika A

66. Q: Approximately 2 weeks after her instrumental assisting delivery, the patient comes to your office complaining of a constant loss of urine throughout the day. As she reported, She denies any urgency or dysuria. What is the most likely explanation for this complaint? – a. Failure of the procedure b . Urinary tract infection c . Vesicovaginal fistula – d . Detrusor instability e . Diabetic neuropathy 66 By Fasika A

67. 3/27/2024 67 THANK YOU!!!!!!!