COLPOCLEISIS: VAGINAL OBLITERATIVE PROCEDURES

http://www.youtube.com/watch?v=ExQq30qbbJE&feature=youtu.be

      Vaginal obliteration procedure for treatment of advanced pelvic floor prolapse.   Obliteration  of the vagina is an option for the surgical management of advanced symptomatic POP in  women who are not engaging in vaginal intercourse.  These procedures are indicated in a selected group of patients, usually frail elderly patients,     who are unable or do not wish to undergo more involved procedures such as hysterectomy and vaginal vault suspension. These patients are no longer desire for sexual function. These procedures can sometimes be performed under local or regional anaesthesia/ pudendal blocks.

Has relative good success rate  of between 85-100% patients either satisfied or very satisfied with the surgery. There was 5% regrat rate, especially interms of loss of sexual function. 

Indications:

·        Advanced prolapse

·        Medical unfit patients/ Frail elderly patients

·        Patient request simpler operation and failed previous sugeries

·        Patients with advance or Gobal Pelvic floor Failure ( GPFF)

·        Sexually not active

     Advantage

       ·        Short operating time

       ·        Minimal blood loss and complications

       ·        Day care procedure
       ·        Excellent cure rates (85-100%)

    Disadvantage

•     Recurrence of prolapse
•     Injuries to bladder/ rectum
•     Unable to perform sexual intercourse
•     Uterus still in situ, there is a remote possibility of cervical or endometrial carcinoma, pyometra
•    Regrat of loss of sexual function

1. Partial colpocleisis ( Le Port):

First performed by Neugebaucer in 1867, in this procedure the cervix and uterus is left behind and segment of anterior and posterior vaginal mucosa are removed.

Procedure:

·        Can be done under local or regional anesthesia

·       Opposite rectangular areas on the anterior and posterior    vaginal walls   are denuded of the epithelium.

·        The denuded epithelial areas are then sutured to each other with the uterus reduced to a proximal position so that the anterior rectal wall and the base of the perivesical fascia around the bladder base are fused.

·        Approximating the opposing walls of the vagina prevents descent of the uterus and practically obliterates the vagina.

·        The rectangular areas are designed so that a continuous lumen from the vaginal apex on both sides of the obliterated space will persist. This lumen serves to drain vaginal and uterine secretions.

2. Total Colpoclesis ( Complete Colpectomy): In post-hysterectomy vaginal vault prolapse patients or after a vaginal hysterectomy . First described by DeLancey and Morley

          Procedure:

·        The vaginal mucosa is completely excised.

·        A series of purse-string sutures are placed so that the vaginal fascial           and muscular layers are inverted.

·        The vagina is completely obliterated.

Complications:

•        Risk of injuries to bladder or rectum
•        Infection
•        De Nova  or persistance of stress urinary incontinence   (25-30%, FitzGerald & Brubaker et al)
•        Reversible Urethral occlusion ( 10%, Von Pechmann et al) 
•       Vaginal Evisceration ( very rarely)
•       Post operative regret of Loss of sexual function

References:

1.  A Prospective Analysis of Total Colpocleisis for Severe Uterovaginal Prolapse Journal of Pelvic Surgery. 7(2):72-78, March/April 2001. Terry Grody, Marvin H. MD; Merchia, Vikas MD; Nyirjesy, Paul MD; Kaplan, Eugene MD; Chatwani, Ashwin J. MD

CONSERVATIVE TREATMENT FOR URINARY INCONTINENCE

Dr Rozihan Ismail, Dr Aruku Naidu

There are 4 main types of urinary incontinence
1. Stress urinary incontinence (SUI)
2. Urge incontinence
3. Voiding difficulties and overflow incontinence
4. Urinary fistulae

Stress urinary incontinence– conservative treatment
• Reserved for those cases which are unsuitable or unfit for surgery.
• In younger woman who has not completed her family, further pregnancy may result in a recurrence of 
   incontinence.
• In patients with mild SUI.

Options:

• Pelvic floor exercises/ Kegals exercise
• Use of vaginal cones
• Perineometer
• Devices - vagina, Urethra, Electronic

Pelvic muscle training (Kegel exercise)
Very effective if regularly carried out. Seven times more likely to cure SUI than those with no treatment. Perform for 3-4 months before determining its success. Three sets of 8-12 slow maximal contractions sustained for 6-8 seconds and repeated 3-4 times per week.


Vaginal cones are useful adjuncts to pelvic floor exercises.




Perineometer
Placed in the vagina. Objective recording of pelvic muscle floor strength can be carried out. Used to aid pelvic floor exercises by enabling the woman to gauge the strength of the contraction generated.
 
Perineometer

Devices
1. Vaginal devices to support the bladder neck.
2. Urethral plug (either at the external meatus or in the urethra).
3. Electronic devices: Stimulation of the pudendal nerve with electrodes placed in the vagina or
       Anus, causes pelvic floor contraction and help to teach women which muscle to contract

Urge incontinence – conservative treatment

• Fluid management
• Behavioural therapy - bladder training- biofeedback
• Pharmacotherapy
•  Maximal electrical stimulation

Fluid management
For mild or intermittent symptoms. Amount (reduce intake= 1.5 to 2 lites). Type (avoid caffeine, alcohol).

Behavioural therapy
Bladder training:

a) Goals- correct voiding patterns, improve the ability to suppress urge, increase bladder capacity and 

    continence

b) Includes: pelvic muscle training, scheduled voiding intervals with stepped increases, suppression of urge
     with distraction or relaxation techniques

Biofeedback:

Involves the use of electronic equipment to monitor a normally unconscious physiological process, and to convey this information to the individual so that a change in a particular direction may be brought about. The information is fed back as an audible, tactile, or visual signal.

Pharmacotherapy
Most popular method of treatment. Antimuscarinic, calcium channel blocker, tricyclic antidepressants or antidiuretic drugs. Refer to chapter on drugs for details.

Electrical stimulation
Intravaginal or transanal electrode.

Voiding difficulties and overflow incontinence – conservative treatment
2 main causes of voiding difficulties and overflow incontinence;

•  Detrusor hypotonia
• Outflow obstruction

General measures:
Mild cases – no treatment required. Associated with drug therapy eg anticholinergic side effects – withdraw the treatment whenever possible. Double voiding (void a second time after a few minutes of first void).
Change in voiding position (more upright position) in patients where voiding difficulties follow operations for incontinence. Long term prophylactic antibiotics to prevent recurrent UTI.

Detrusor hypotonia – acute
In the presence of acute urinary retention, the bladder will require initial rest – achieved by use of a catheter on free drainage for a few weeks. Teach the women clean intermittent self catheterization (CISC) after each void, measuring the residual on each occasion. Stop once residual < 100 ml.

Detrusor hypotonia – chronic
If main symptom is nocturia – advise to reduce fluid intake in the evening combined with CISC before going to bed. For long standing problem – the only treatment is long term CISC (preferable to indwelling catheter as the incidence of UTI is lower and the lifestyle more normal)

Outflow obstruction
Mainly surgical treatment. Refer to chapter on surgical treatment of urinary incontinence.

Urinary fistula – conservative treatment
Vesico-vaginal fistula; Management depends on the underlying cause and duration of the abnormality.

Urinary fistula secondary to surgical trauma:
If recognized, may be repaired within 24hrs. Most fistulae present between 4 and 21 days when avascular necrosis occurs. Need continuous urethral catheterization since the defect may close spontaneously over a period of 6 weeks with appropriate antibiotic cover.

Urinary fistula secondary to obstetric trauma:
Rarely seen nowadays. Tissue loss following an obstetric slough injury needs bladder drainage and antibiotic treatment. It is essential that tissue loss has ceased and infection is controlled prior to surgery (may delay up to 3 months)

Uretero-vaginal fistula;

Ureteric injury should be dealt with immediately even if only by nephrostomy to protect renal

REFERENCES

1.    Weiss BD. Diagnostic Evaluation of urinary incontinence in geriatric patients. American Academy of Family Medicine June 1998; 1-14.

2.    Chin CM. Urodynamic Investigations for assessment of bladder dysfunction: Part 1.Medical progress 1999; 26(8): 15-18.

3.    Chin CM. Urodynamic investigations: Part 2. Medical progress 1999; 26(9): 15-20.

4.    Lapitan MCM. The role of the pelvic floor in urinary incontinence and other urological conditions. Medical progress 1999; 26(10): 27-32.

5.    Hilton P. Anatomy and physiology of lower urinary tract and the pathiphysiology of urinary incontinence and sensory disorders of lower urinary tract. Urogynaecology: The investigations and management of urinary incontinence in women 1997; 2: 1-16.

6.    Jarvis G. Female urinary incontinence: which patients ? which test ?. Urogynaecology: The investigations and management of urinary incontinence in women 1997; 2: 43-58.

7.    Thompson JD, Wall LL, Growdon WA et al. Urinary stress incontinence.Te Linde’s Operative Gynaecology 1992; 7: 887-940.

8.    Abrams P, Wein AJ. The Overactive bladder; A widespread and treatable condition 1998; 1: 1–54.