tag:blogger.com,1999:blog-10412299838259099362024-03-05T00:41:29.096-08:00Aruku's Pelvic Health CentreDato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.comBlogger36125tag:blogger.com,1999:blog-1041229983825909936.post-8510058622319413022022-04-06T20:33:00.000-07:002022-04-06T20:33:16.192-07:00<p style="text-align: center;"><span style="font-size: x-small;">Disclaimer: This article is purely for education purpose & consent has been taken from the patients to display the images/ video. Some of the pictures & diagrams are uploaded from google images. Would like to thank all patients, contributors & owners for the google images for their pictures/video to be used in this article. </span></p><p style="text-align: center;"><span style="font-size: x-large;">Haematocolpos</span></p><p style="text-align: justify;"><span style="font-family: arial;">What is Haematocolpos: It i<span style="background-color: white; color: #202122;">s a medical condition in which the vagina (colpos) </span><span style="background-color: white; color: #202122;">is filled/pooled with menstrual blood. It is </span><span style="background-color: white; color: #202122;"> due to the blockage of menstrual blood flow. The word hematocolpos stands for </span><i style="background-color: white; color: #202122;"><b> '</b>an accumulation of blood within the vagina</i><span style="background-color: white; color: #202122;">'. It is often caused by obstruction to the outflow of menstrual blood flow through the vagina. </span></span><span style="background-color: white; color: #202122; font-family: arial;">Haematometra which is the collection of blood in the uterus is sometime related with haematocolpos. The intense pressure & back flow of the obstructed blood leads to formation of Haematometra. In this articles, i will confine our discussion to simple Haematocolpos only. </span><span style="background-color: white; color: #202122; font-family: arial;"> Below are example causes of haematocolpos. </span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjey5xKrE7ofVnlhXuloP4CIrZkrHwYqEuRtYP_Wj5XOBHKm9DWh4wErI5yjLaIHEJql8SuCs0dnRCufJ2v0N-E00LjT3JJRadASOl6N5lWGwuWbWqmx0kZ1VM8f43ob9n7Zr8WKHU8taYsiqBMf7xfj0Pp0R4Kvbh7ghwCSe4e-8-uvz8e9C7fxWoVOw" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="667" data-original-width="685" height="278" src="https://blogger.googleusercontent.com/img/a/AVvXsEjey5xKrE7ofVnlhXuloP4CIrZkrHwYqEuRtYP_Wj5XOBHKm9DWh4wErI5yjLaIHEJql8SuCs0dnRCufJ2v0N-E00LjT3JJRadASOl6N5lWGwuWbWqmx0kZ1VM8f43ob9n7Zr8WKHU8taYsiqBMf7xfj0Pp0R4Kvbh7ghwCSe4e-8-uvz8e9C7fxWoVOw=w478-h278" width="478" /></a></span></div><p style="text-align: justify;"><span style="font-family: arial;"><span style="background-color: white; color: #202122;">a. Imperforate hymen</span></span></p><p style="text-align: justify;"><span style="font-family: arial;"><span style="background-color: white; color: #202122;"></span></span></p><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEiM8YMKo_dNg0AIkm3Vh3QI_JODlJ1lLoQW5Wd7_ZQQWI-rl-DaSKc1qWm2MhKkh2m_7c40_1h1FqZqP803HFcThdWAH80qBGFxqR_n4d_mnvpXWALGQaf4EFgLFBjdUU_VYCkOHO1siJHsdtMWXH5Fyez3mGS0oGawmjLkKYmGRN6BJe2wVH7L7FW69w" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="657" data-original-width="499" height="215" src="https://blogger.googleusercontent.com/img/a/AVvXsEgkhsbEM2REzT57ypjzfPyiwax5_Uhwic7m8bkBqzhNPk7NJaFwB9Hc-92Ss4pdWFcrlMF-R0Wj2NBSzAQrBFdfQBuG7fhqwDdZhfra_p-jiAcWXMmJuuQzanwIPTru4nQZByy8am9cIUYkEnTYNB0zWo0VY57wg3YpdNfiCH9hsGcqWWLQKls1t-Xpkg=w239-h215" width="239" /><img alt="" data-original-height="398" data-original-width="510" height="212" src="https://blogger.googleusercontent.com/img/a/AVvXsEiM8YMKo_dNg0AIkm3Vh3QI_JODlJ1lLoQW5Wd7_ZQQWI-rl-DaSKc1qWm2MhKkh2m_7c40_1h1FqZqP803HFcThdWAH80qBGFxqR_n4d_mnvpXWALGQaf4EFgLFBjdUU_VYCkOHO1siJHsdtMWXH5Fyez3mGS0oGawmjLkKYmGRN6BJe2wVH7L7FW69w=w245-h212" width="245" /></a></div></div><span style="font-family: arial;"><span style="background-color: white; color: #202122;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgkhsbEM2REzT57ypjzfPyiwax5_Uhwic7m8bkBqzhNPk7NJaFwB9Hc-92Ss4pdWFcrlMF-R0Wj2NBSzAQrBFdfQBuG7fhqwDdZhfra_p-jiAcWXMmJuuQzanwIPTru4nQZByy8am9cIUYkEnTYNB0zWo0VY57wg3YpdNfiCH9hsGcqWWLQKls1t-Xpkg" style="margin-left: 1em; margin-right: 1em;"><div class="separator" style="clear: both; text-align: center;"><br /></div></a></span></span></div><p style="text-align: justify;"><span style="font-family: arial;"><span style="background-color: white; color: #202122;">b. vaginal atresia</span></span></p><p style="text-align: justify;"><span style="font-family: arial;"><span style="background-color: white; color: #202122;"></span></span></p><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><img alt="" data-original-height="480" data-original-width="640" height="190" src="https://blogger.googleusercontent.com/img/a/AVvXsEg09sKoik8YNNWpCdEV0zwnh3c5ogtrte__8txltX2l_9MQk30zC-mbt4jVslp1H5ypgBRnIPl65pBFxCCxDJ4zlRgYqzuR7BFjHk0qH9lwLgZOarz3QyunL1jotofOiDKPHiBiySXXj8N-KNHKb6lbHWH01XlHdoNsQPA9_q-nSRFObasN6HblRj3upw=w253-h190" width="253" /><a href="https://blogger.googleusercontent.com/img/a/AVvXsEg09sKoik8YNNWpCdEV0zwnh3c5ogtrte__8txltX2l_9MQk30zC-mbt4jVslp1H5ypgBRnIPl65pBFxCCxDJ4zlRgYqzuR7BFjHk0qH9lwLgZOarz3QyunL1jotofOiDKPHiBiySXXj8N-KNHKb6lbHWH01XlHdoNsQPA9_q-nSRFObasN6HblRj3upw" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="600" data-original-width="577" height="170" src="https://blogger.googleusercontent.com/img/a/AVvXsEjsbuk-cgNFYMq8XLdDwB7L7OGUX2t5KYjtiMO50rQU05vfMb9ZtFKt8WzON_s7jTPexwqpcRfv-tuna-t4ArjWQhTecCx1hyBfIPa12-Vg3ahDyxLovKIB6xJ3lSZcEDfqPd70bn_eVBY9fVzu72cMzXWysqpP_g6kTEkXabtJUSCpwtokRiuKy-Opew=w219-h170" width="219" /></a></div><br /></div><br /></div><span style="background-color: white; color: #202122;"><div class="separator" style="clear: both; margin-left: 1em; margin-right: 1em; text-align: center;"><div style="text-align: left;"><span style="margin-left: 1em; margin-right: 1em;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjsbuk-cgNFYMq8XLdDwB7L7OGUX2t5KYjtiMO50rQU05vfMb9ZtFKt8WzON_s7jTPexwqpcRfv-tuna-t4ArjWQhTecCx1hyBfIPa12-Vg3ahDyxLovKIB6xJ3lSZcEDfqPd70bn_eVBY9fVzu72cMzXWysqpP_g6kTEkXabtJUSCpwtokRiuKy-Opew" style="margin-left: 1em; margin-right: 1em;"></a><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjsbuk-cgNFYMq8XLdDwB7L7OGUX2t5KYjtiMO50rQU05vfMb9ZtFKt8WzON_s7jTPexwqpcRfv-tuna-t4ArjWQhTecCx1hyBfIPa12-Vg3ahDyxLovKIB6xJ3lSZcEDfqPd70bn_eVBY9fVzu72cMzXWysqpP_g6kTEkXabtJUSCpwtokRiuKy-Opew" style="margin-left: 1em; margin-right: 1em;"></a><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhK44HBoLO7qFXWoRW6I0mqcMZ81-YjPdJloP6LnXz7ekMZ-iv8IJSswBTxnNjnxk2nVrNCVikMZqm6mrJ2wGn0tJWSn43RyG2PK03HZU1lCirajvT1u7mQzAGeufVFmwldovYURh-BF1wjAYpRR5TolCoNeTCSo5ZtghB0RdoxGTk3e68pbwSamrgcOw" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1337" data-original-width="1473" height="188" src="https://blogger.googleusercontent.com/img/a/AVvXsEhK44HBoLO7qFXWoRW6I0mqcMZ81-YjPdJloP6LnXz7ekMZ-iv8IJSswBTxnNjnxk2nVrNCVikMZqm6mrJ2wGn0tJWSn43RyG2PK03HZU1lCirajvT1u7mQzAGeufVFmwldovYURh-BF1wjAYpRR5TolCoNeTCSo5ZtghB0RdoxGTk3e68pbwSamrgcOw=w208-h188" width="208" /></a><img alt="" data-original-height="2033" data-original-width="1697" height="196" src="https://blogger.googleusercontent.com/img/a/AVvXsEhTbMTtAEFfIc3CXWMaDlG8EVH2TbnJou1hIcrnja9Z_DU59gvCVJ92Ys3Ktu0oPQtuMiiLlJTES0oFkvuqNzqmCdIKcWJcAq1tVa3e8ERLv6w0DJSpa_P02vLePfleLDxttsjychWlMIVzWW5l3pucVSiCsa7tplcG8UOD3P01HAGaxRkr76y7ofy3eQ=w224-h196" width="224" /></div><img alt="" data-original-height="2141" data-original-width="1533" height="179" src="https://blogger.googleusercontent.com/img/a/AVvXsEgbVKXWTAlUE57Sg40Ug7QK28RQol1LU_SMtXIh323_fpPQr4aCxIGUj90e8qL3PGPGLMBQVn2_XeSZBDr6FDVmrJlDv3A0AhebiPrlaHm3jeymjM71K5449sxMCQtSuxQfPVZOKQiLIfo8_3BCSuQ-7dIxjk-yjxDw5bbyOgfOhrKv87jikwicYuVMXA=w224-h179" width="224" /></span><a href="https://blogger.googleusercontent.com/img/a/AVvXsEh8Dq6ypbe2LMJh5ZxkPQSaqLhRlkJsGeBEm6lvi6a8edq1jLwarfkARP0fLpHms0HJ9OouCRDneAZ3BQd_xybv5_cBDo2y8-tqtXtmpXD3TRYfPT4EVoiBppCD0PeFa479ezuWysX4vaoqONiyVJRZSNR5Wk57_27nPQ6oz75cB6iZxv-oyYjRGBoj5w" style="margin-left: 1em; margin-right: 1em; text-align: center;"><img alt="" data-original-height="1985" data-original-width="1849" height="181" src="https://blogger.googleusercontent.com/img/a/AVvXsEh8Dq6ypbe2LMJh5ZxkPQSaqLhRlkJsGeBEm6lvi6a8edq1jLwarfkARP0fLpHms0HJ9OouCRDneAZ3BQd_xybv5_cBDo2y8-tqtXtmpXD3TRYfPT4EVoiBppCD0PeFa479ezuWysX4vaoqONiyVJRZSNR5Wk57_27nPQ6oz75cB6iZxv-oyYjRGBoj5w=w207-h181" width="207" /></a></div><div class="separator" style="clear: both; margin-left: 1em; margin-right: 1em; text-align: center;"></div><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjsbuk-cgNFYMq8XLdDwB7L7OGUX2t5KYjtiMO50rQU05vfMb9ZtFKt8WzON_s7jTPexwqpcRfv-tuna-t4ArjWQhTecCx1hyBfIPa12-Vg3ahDyxLovKIB6xJ3lSZcEDfqPd70bn_eVBY9fVzu72cMzXWysqpP_g6kTEkXabtJUSCpwtokRiuKy-Opew" style="margin-left: 1em; margin-right: 1em;"><br /></a></div></span></div><p style="text-align: justify;"><span style="font-family: arial;"><span style="background-color: white; color: #202122;">c. transverse septum</span></span></p><p style="text-align: justify;"><span style="font-family: arial;"><span style="background-color: white; color: #202122;"></span></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial;"><span style="background-color: white; color: #202122;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjfMwoZXXmXD_xiY9lNvk2eJLNBgwlUZ8f1WXRt9jklbxNAW2To2A5P-XTtReSan7JqygmVup1dmg3pO-MSNBOgIZlBowPXegyCgmckLb4ttY0GPmosswrht2Sv_Bki-mzq-H-jeGireThCdjy0cmwg4FBEGiHsCy3DdutSEWV8Ami0WL4bajY4c-NZ5Q" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="348" data-original-width="295" height="177" src="https://blogger.googleusercontent.com/img/a/AVvXsEjfMwoZXXmXD_xiY9lNvk2eJLNBgwlUZ8f1WXRt9jklbxNAW2To2A5P-XTtReSan7JqygmVup1dmg3pO-MSNBOgIZlBowPXegyCgmckLb4ttY0GPmosswrht2Sv_Bki-mzq-H-jeGireThCdjy0cmwg4FBEGiHsCy3DdutSEWV8Ami0WL4bajY4c-NZ5Q=w249-h177" width="249" /></a></span></span><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgNGesrf2xubvlr-N9txtQXHjRnybiKxddHoTI5JaIt9MqxkQLkDFf9Bjszhb2LOeWWl2nwBu9Uu8_vXdRqBD2c0ay0UF1Nc9RKIwVsrm96QW5pAfuSE4rOpFPVFoSsBFlojgKYazVKL8Vtwqx1DwG2tAKkQOd8cwxeSKDKGKh5j9Rsnyec0MnGCvU3vQ" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="403" data-original-width="389" height="178" src="https://blogger.googleusercontent.com/img/a/AVvXsEgNGesrf2xubvlr-N9txtQXHjRnybiKxddHoTI5JaIt9MqxkQLkDFf9Bjszhb2LOeWWl2nwBu9Uu8_vXdRqBD2c0ay0UF1Nc9RKIwVsrm96QW5pAfuSE4rOpFPVFoSsBFlojgKYazVKL8Vtwqx1DwG2tAKkQOd8cwxeSKDKGKh5j9Rsnyec0MnGCvU3vQ=w208-h178" width="208" /></a></div><span style="font-family: arial;"><span style="background-color: white; color: #202122;"><br /></span></span><p style="text-align: justify;"><span style="font-family: arial;"><span style="background-color: white; color: #202122;">d. Mullerian Duct Anomalies</span></span></p><p style="text-align: justify;"><span style="font-family: arial;"><span style="background-color: white; color: #202122;"></span></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial;"><span style="background-color: white; color: #202122;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjrWDl77bQj1yWw58gu9hIMKyYCorC8slimkwBeyh_ypzTZPwTZgWqG7VokEYXW7rxBa0S4avV0IFa2hVsN-UEKTujcgBfOdqZS4kV2NlGY05Ytj1UhV7YMSX94-D1fUb6kaAGITYShRYV4kr1Z0lCBC_iuLMbuxBmxoxN6OfTKWT1uU4nfqB_tthJlPA" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1644" data-original-width="1500" height="188" src="https://blogger.googleusercontent.com/img/a/AVvXsEjrWDl77bQj1yWw58gu9hIMKyYCorC8slimkwBeyh_ypzTZPwTZgWqG7VokEYXW7rxBa0S4avV0IFa2hVsN-UEKTujcgBfOdqZS4kV2NlGY05Ytj1UhV7YMSX94-D1fUb6kaAGITYShRYV4kr1Z0lCBC_iuLMbuxBmxoxN6OfTKWT1uU4nfqB_tthJlPA=w196-h188" width="196" /></a><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjH2A_vuLRlA73c2XCh6VGQUCCdvCyDX9VaIJw9ok7RP7kYgdAQJwqmp6iKsXqPle_GtpBZ_zw-GZZJtJupVa5TackkRiPdimLBQIc7i0x7lftu712Vwn4JKLi7GO3zgsLtJtQAw2vDmVrZyQ2pogsHbKkIhtE6v5g0oGREEkmp48F13iU0YAIm2vjv7A" style="background-color: transparent; margin-left: 1em; margin-right: 1em; text-align: center;"><img alt="" data-original-height="683" data-original-width="775" height="162" src="https://blogger.googleusercontent.com/img/a/AVvXsEjH2A_vuLRlA73c2XCh6VGQUCCdvCyDX9VaIJw9ok7RP7kYgdAQJwqmp6iKsXqPle_GtpBZ_zw-GZZJtJupVa5TackkRiPdimLBQIc7i0x7lftu712Vwn4JKLi7GO3zgsLtJtQAw2vDmVrZyQ2pogsHbKkIhtE6v5g0oGREEkmp48F13iU0YAIm2vjv7A=w185-h162" width="185" /></a></span></span></div><span style="font-family: arial;"><span style="background-color: white; color: #202122;"><br /></span></span><p style="text-align: left;"><span style="background-color: white;"><span style="color: #202122; font-family: arial;">Typical Clinical presentation are as below: all these case were manged by me. These cases presented in different scenarios with different physical findings. Tha manage are tailored based on the underlying cause/pathology and was dealt accordingly.</span></span></p><p style="text-align: left;"><span style="font-family: arial;"><span style="background-color: white; color: #202122;"><b>Case 1:</b></span></span></p><p style="text-align: justify;"><span style="font-family: arial;"><span style="background-color: white;"><span style="color: #202122;">A 12 year old girl, presented to casualty with severe lower abdominal pain. She has this cyclical pain for few months before. She has not attain menarche yet. On examination, the secondary sex characteristics are present. On abdominal examination, there was a 16 week size pelvic mass & its tender on palpation. Perineal examination, there was bluish bulging from the vaginal out let. Pelvic Ultrasound sound showed a large Haematocolpos. The uterus was normal with slight thickened ET & there was some fluid in POD. DX: Imperforate Hymen. Investigation is usually pelvic ultrasound is sufficient. Treatment is usually a simple cruciate incision or elliptical incision of the hymen. Hymen can usually be spaced (hymen spacing surgery). In this case a cruciate incision was made. The staled blood was drained passively. Patient recovered uneventfully.</span></span></span></p><p style="text-align: justify;"><span style="font-family: arial;"><span style="background-color: white;"><span style="color: #202122;"></span></span></span></p><div class="separator" style="clear: both; text-align: center;"><div style="text-align: left;"><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial;"><span style="background-color: white;"><span style="color: #202122;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgzF1cGu7-Ech9t7XxiLPy190cm_B56i8iyXNn7cI9eXlZ2TmjbmTBd04UWqSIOGGhZ8OxuwqSMYht89QXdVblTlwSFU39GmmcxOblUoFLouas6sdFFe-eBn_rD-hCnnKBizMyoCoE6_wTdKBPDJS8RrYJJuOEnu1-0BcFCrAWT1jdfDYk6frSWzu0FfQ" style="margin-left: 1em; margin-right: 1em;"></a><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEiEjzs1PqsmxXzZWk4SBrWK_aUgAYBX1Q_OvOVbOX2QSSA7QyANYCDCSrkH4cEhkcmaCyZRSWzpjc0qV0W4Lioin14ZfCYFEOG07IZePxwNErDHxHPzt-PAP7ZUR17w0zfBun-PeKgQBmdWy83iUxgDAxHVm0dtCutgA8LNA2GVgu-UL-oHeRJhhKcw_g" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="913" data-original-width="1534" height="151" src="https://blogger.googleusercontent.com/img/a/AVvXsEiEjzs1PqsmxXzZWk4SBrWK_aUgAYBX1Q_OvOVbOX2QSSA7QyANYCDCSrkH4cEhkcmaCyZRSWzpjc0qV0W4Lioin14ZfCYFEOG07IZePxwNErDHxHPzt-PAP7ZUR17w0zfBun-PeKgQBmdWy83iUxgDAxHVm0dtCutgA8LNA2GVgu-UL-oHeRJhhKcw_g=w204-h151" width="204" /></a><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgzF1cGu7-Ech9t7XxiLPy190cm_B56i8iyXNn7cI9eXlZ2TmjbmTBd04UWqSIOGGhZ8OxuwqSMYht89QXdVblTlwSFU39GmmcxOblUoFLouas6sdFFe-eBn_rD-hCnnKBizMyoCoE6_wTdKBPDJS8RrYJJuOEnu1-0BcFCrAWT1jdfDYk6frSWzu0FfQ" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="210" data-original-width="375" height="139" src="https://blogger.googleusercontent.com/img/a/AVvXsEgzF1cGu7-Ech9t7XxiLPy190cm_B56i8iyXNn7cI9eXlZ2TmjbmTBd04UWqSIOGGhZ8OxuwqSMYht89QXdVblTlwSFU39GmmcxOblUoFLouas6sdFFe-eBn_rD-hCnnKBizMyoCoE6_wTdKBPDJS8RrYJJuOEnu1-0BcFCrAWT1jdfDYk6frSWzu0FfQ=w237-h139" width="237" /></a></div><br /></span></span></span></div></div></div><p style="text-align: justify;"><span style="background-color: white; color: #202122; font-family: arial; text-align: left;"><b>Case 2:</b></span></p><p style="text-align: justify;"><span style="font-family: arial;"><span style="background-color: white;"><span style="color: #202122;">13 year old girl presented to the casualty with primary amenorrhea & cyclical abdominal pain and difficulty pass urine. On examination, the sexual characteris was normal. The abdomen was distended. Vaginal examination. there were no vaginal opening. There was no perineal bulging. PR there was a gap in between the forchette and the the upper border of the vaginal. The pelvic ultrasound showed a large haematocolpos and some haematometra ( blood collection in the uterus). DX: Vaginal Atresia</span></span></span></p><p style="text-align: justify;"><span style="font-family: arial;"><span style="background-color: white;"><span style="color: #202122;"></span></span></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: arial;"><span style="background-color: white;"><span style="color: #202122;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEiTqPwjWkfK5eHvNGYgE2d4e1NOEt9QpO3vlmPbDvzWg6hvFKbHM7Yz9Roy-6MupGZxC7gEGAEGn_v4ktWro74IelnrQSDqhR7_-bjZq4Y3VJ10B3v3Z_OVmxl8-rXcWSlLxxQeDLjjBmg9rT5Ips-jPMSr8i9b_yCqpxOo7x3JIRZjt3aWHE1-JS1TKA" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="460" data-original-width="621" height="180" src="https://blogger.googleusercontent.com/img/a/AVvXsEiTqPwjWkfK5eHvNGYgE2d4e1NOEt9QpO3vlmPbDvzWg6hvFKbHM7Yz9Roy-6MupGZxC7gEGAEGn_v4ktWro74IelnrQSDqhR7_-bjZq4Y3VJ10B3v3Z_OVmxl8-rXcWSlLxxQeDLjjBmg9rT5Ips-jPMSr8i9b_yCqpxOo7x3JIRZjt3aWHE1-JS1TKA=w242-h180" width="242" /></a></span></span></span></div><span style="font-family: arial;"><span style="background-color: white;"><span style="color: #202122;"><div><span style="font-family: arial;"><span style="background-color: white;"><span style="color: #202122;"><br /></span></span></span></div>Investigation: pelvic Ultrsaound/ MRI</span></span></span><div><br /></div><div><span style="font-family: arial;"><span style="background-color: white;"><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgLDaNTZhPZSP1PKLRPfTAnzz-rSqT6nS-WA0WgWNuxNP4ivtC1a0W4LRxnbPtkJW_BBjGIrIb16aVEyuBOvHjBcYCkMsphSsogTEGXXJdGSHJl1UWPdDCR9nlvrJ40dF7R1gWVRZNTStpHL58zIsAxt86RvybPeO3L2vwCiuXmgIjkm8OMXbd6YxVrog" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="183" data-original-width="276" height="184" src="https://blogger.googleusercontent.com/img/a/AVvXsEgLDaNTZhPZSP1PKLRPfTAnzz-rSqT6nS-WA0WgWNuxNP4ivtC1a0W4LRxnbPtkJW_BBjGIrIb16aVEyuBOvHjBcYCkMsphSsogTEGXXJdGSHJl1UWPdDCR9nlvrJ40dF7R1gWVRZNTStpHL58zIsAxt86RvybPeO3L2vwCiuXmgIjkm8OMXbd6YxVrog=w262-h184" width="262" /></a><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='227' height='192' src='https://www.blogger.com/video.g?token=AD6v5dyegUnuREUC_mkO9c_X8NLJSXXvxzsSIul1YrjAN_oNGDIGt7fiwN-TJPRHu2SG6WhKZuq45rewDUsEKH_rzg' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div><br /></div><span style="color: #202122;"><br /><div style="color: black; font-family: "Times New Roman";"><span style="font-family: arial;"><span><span style="color: #202122;">Treament: Vaginaplasty & Recreation of vagina.</span></span></span></div><div style="color: black; font-family: "Times New Roman"; text-align: justify;"><span style="font-family: arial;"><span><span style="color: #202122;">In this case, There was a 2.5 cm of fibrous tissue noted between the vaginal outlet and the lower margin of haematocolpos. The large haematocolpos has helped in stretching the vagina and made the recreation of vaginal easier. Care has to be taken to identify the anterior & Posterior structures. A CBD is useful to assess the anatomy of the urethra. A large bore needle and syringe can be used to find the correct plan between the outlet & haematocolpos. When the correct plane is identified, than, one can use a fine scissors to create a tunnel along the needle to reach the haematocolpos. The upper vaginal margin can be opened & the Haematocolpos can be drained. The upper vaginal margin are than stretched & reattached with the forchette/ or the vaginal outlet. A small fenton operation may be necessary in some cases to facilitate the attachment. The create tunnel/vaginal than be dilated with large hegar dilators to provide a reasonable vaginal diameter. Patient are also advised to continue to dilated the vagina once the healing process taken place. Dilatation prevents vaginal stenosis. </span></span></span></div></span></span></span></div><div><span style="font-family: arial;"><span style="background-color: white;"><div class="separator" style="clear: both; text-align: center;"><b><br /></b></div></span></span></div><div><span style="background-color: white; color: #202122; font-family: arial;"><b>Case 3:</b> </span></div><div><span style="font-family: arial;"><span style="background-color: white;"><span style="color: #202122;"> </span></span></span></div><div><div style="text-align: justify;"><span style="background-color: white;"><span style="color: #202122; font-family: arial;">!2 plus girl presented with recurrent pelvic pain, aw vomiting & urinary frequency. Examination revealed mass in the lower abdomen with tense swelling. VE finding showed a small vaginal opening & there was a thick septum about 1.5 com from the vaginal outlet. The hymen was seen. A diagnosis of complete transverse septum was made. The septum was excised & the haematocoplos was released without any issues. Patient recovered well. She obtained her regular periods after the procedure & there were no further heamatocolpos.</span></span></div><p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><div style="text-align: left;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEi-6WDW5KDE--pZr9ibUoVArevAzUtxj1jlsElQCjbL6iJOU71pEOJhxJ6iJzddLsQCDE4xuTmuoq-BRHpapkb8eZcwk-64PXiGMCPSXdd-y828irpOsK4fibWVlKjvv4_K1m5GBnBfMS8xFb5K3geLyDONFc4ZhE6FF9qGQ1KLaHqj8uLkjapbr3vDfA" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="3561" data-original-width="2729" height="218" src="https://blogger.googleusercontent.com/img/a/AVvXsEi-6WDW5KDE--pZr9ibUoVArevAzUtxj1jlsElQCjbL6iJOU71pEOJhxJ6iJzddLsQCDE4xuTmuoq-BRHpapkb8eZcwk-64PXiGMCPSXdd-y828irpOsK4fibWVlKjvv4_K1m5GBnBfMS8xFb5K3geLyDONFc4ZhE6FF9qGQ1KLaHqj8uLkjapbr3vDfA=w206-h218" width="206" /></a><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhT26ua2sMz0PQ7FwLnRLXqpRdFpUTuXjeeLmRnsFZeKFv-wyrmyr0mNF8I4TvJYqwa9I33xyhGIXitfWYEEGkWdCfX7Kx0XAOe1jj6OGm9ijwWGzE82yYIaf60M7s82O_OJLTidCnHhcVI0RXRVZb_zWIGCVu68mKwNEMkN1iCgACRmCWJB0LG82rPbQ" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="3745" data-original-width="2633" height="212" src="https://blogger.googleusercontent.com/img/a/AVvXsEhT26ua2sMz0PQ7FwLnRLXqpRdFpUTuXjeeLmRnsFZeKFv-wyrmyr0mNF8I4TvJYqwa9I33xyhGIXitfWYEEGkWdCfX7Kx0XAOe1jj6OGm9ijwWGzE82yYIaf60M7s82O_OJLTidCnHhcVI0RXRVZb_zWIGCVu68mKwNEMkN1iCgACRmCWJB0LG82rPbQ=w209-h212" width="209" /></a><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhT26ua2sMz0PQ7FwLnRLXqpRdFpUTuXjeeLmRnsFZeKFv-wyrmyr0mNF8I4TvJYqwa9I33xyhGIXitfWYEEGkWdCfX7Kx0XAOe1jj6OGm9ijwWGzE82yYIaf60M7s82O_OJLTidCnHhcVI0RXRVZb_zWIGCVu68mKwNEMkN1iCgACRmCWJB0LG82rPbQ" style="margin-left: 1em; margin-right: 1em;"></a><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhd0-r-SYCEXWyW6iSZxJsI2iwet6nsRIH-OqC0dA4C6xdVp_ThlGiwXKNL2iBsCxP4nLzKmcWVpt36YBPAEFw7E2i7hLN50RZWvltEXOm0LmjqlJ7OevWhr7v6_VmLn27uym00k-XIEgFtONEvRsWmxwzJFKMvWLz-K1EWbDgDOtpW4Hl_HGmwBj7V9w" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="3537" data-original-width="2745" height="195" src="https://blogger.googleusercontent.com/img/a/AVvXsEhd0-r-SYCEXWyW6iSZxJsI2iwet6nsRIH-OqC0dA4C6xdVp_ThlGiwXKNL2iBsCxP4nLzKmcWVpt36YBPAEFw7E2i7hLN50RZWvltEXOm0LmjqlJ7OevWhr7v6_VmLn27uym00k-XIEgFtONEvRsWmxwzJFKMvWLz-K1EWbDgDOtpW4Hl_HGmwBj7V9w=w219-h195" width="219" /></a></div><br /></div></div><a href="https://blogger.googleusercontent.com/img/a/AVvXsEi-6WDW5KDE--pZr9ibUoVArevAzUtxj1jlsElQCjbL6iJOU71pEOJhxJ6iJzddLsQCDE4xuTmuoq-BRHpapkb8eZcwk-64PXiGMCPSXdd-y828irpOsK4fibWVlKjvv4_K1m5GBnBfMS8xFb5K3geLyDONFc4ZhE6FF9qGQ1KLaHqj8uLkjapbr3vDfA" style="margin-left: 1em; margin-right: 1em;"><br /></a></div><b><span style="font-size: medium;">Case 4. </span></b></div><div><br /></div><div style="text-align: justify;"><span style="font-size: medium;">33 yrs, patient who was married for 7 year. c/o chronic pv discharge & occasional pelvic pain and primary infertility. Has normal periods monthly. No dysmenorrhea. Abdominal examination: flabby abdomen. VE= deep vagina, difficult to see the cervix. moderate bulging at the left vaginal wall. Ultrasound of pelvis: Large ? Haematometra with Didelphys uterus. The left kidney was absent. Both ovaries seen and appeared normal.</span></div><div style="text-align: justify;"><span style="font-size: medium;">CT Scan: Didelphys uterus with large left vaginal collection (Abscess). The Right kidney normal. Left kidney absent. </span><span style="font-size: medium;">DX: Ohira syndrome: Delayed & atypical presentation (Left Pyocolpo</span>s)</div><div><div style="text-align: justify;"><br /></div><p></p><p style="text-align: left;"></p><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEg-SPyc-1uxYHcsck2m952Qj8_YV5KsBn2QX86HS5eQC_PcWarMTY5cDD9gGNK93FfZpooMUqqGCx3IBZsmfGIj9YGWpXfZKOb_AZKVTZivwjIUBe0vOGVqhEjHq7i1P8ejNier4NB4OVLJNA-rCZIHNtt0_OxG2DXmtzdu257dTdHgAvrhfFiNCMdG-w" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1709" data-original-width="2593" height="189" src="https://blogger.googleusercontent.com/img/a/AVvXsEg-SPyc-1uxYHcsck2m952Qj8_YV5KsBn2QX86HS5eQC_PcWarMTY5cDD9gGNK93FfZpooMUqqGCx3IBZsmfGIj9YGWpXfZKOb_AZKVTZivwjIUBe0vOGVqhEjHq7i1P8ejNier4NB4OVLJNA-rCZIHNtt0_OxG2DXmtzdu257dTdHgAvrhfFiNCMdG-w=w234-h189" width="234" /></a><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhCjcDjZdrGoJV9XH0m6PG1ngU1PLmtUq2nWvSr1XTTUVWn6ksaXm_9s_P8NBM9yl24GLKmfPpuWd8nSj3NyILWD0S-0DQDUIVEA4twjPaXntoToVPfwlYeckKh3vtyYexSs_Vrq4xfPDoQYFKNANeceg5W0tEWZbYg7dCewtaBMMLwkSnX7zhzyKKuRA" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="2361" data-original-width="2497" height="194" src="https://blogger.googleusercontent.com/img/a/AVvXsEhCjcDjZdrGoJV9XH0m6PG1ngU1PLmtUq2nWvSr1XTTUVWn6ksaXm_9s_P8NBM9yl24GLKmfPpuWd8nSj3NyILWD0S-0DQDUIVEA4twjPaXntoToVPfwlYeckKh3vtyYexSs_Vrq4xfPDoQYFKNANeceg5W0tEWZbYg7dCewtaBMMLwkSnX7zhzyKKuRA=w206-h194" width="206" /></a></div></div><br />Treatment: EUA, Excision of the septum & Diagnostic Laparoscopy was carried out<p></p></div><div style="text-align: left;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjH2A_vuLRlA73c2XCh6VGQUCCdvCyDX9VaIJw9ok7RP7kYgdAQJwqmp6iKsXqPle_GtpBZ_zw-GZZJtJupVa5TackkRiPdimLBQIc7i0x7lftu712Vwn4JKLi7GO3zgsLtJtQAw2vDmVrZyQ2pogsHbKkIhtE6v5g0oGREEkmp48F13iU0YAIm2vjv7A" style="font-family: arial; margin-left: 1em; margin-right: 1em; text-align: center;"><img alt="" data-original-height="683" data-original-width="775" height="183" src="https://blogger.googleusercontent.com/img/a/AVvXsEjH2A_vuLRlA73c2XCh6VGQUCCdvCyDX9VaIJw9ok7RP7kYgdAQJwqmp6iKsXqPle_GtpBZ_zw-GZZJtJupVa5TackkRiPdimLBQIc7i0x7lftu712Vwn4JKLi7GO3zgsLtJtQAw2vDmVrZyQ2pogsHbKkIhtE6v5g0oGREEkmp48F13iU0YAIm2vjv7A=w219-h183" width="219" /></a></div><div style="text-align: left;"><br /></div><div style="text-align: left;"><span style="font-size: medium;"><b>Conclusion:</b></span></div><div style="text-align: left;"><span style="background-color: white; color: #202122; font-family: sans-serif; text-align: justify;">The causes for Hematocolpos are diverse. The above 4 causes are the mostly encountered. The treat is usually surgical. There are different surgical treatments which needs to be undertaken to cure it. In extreme case like </span><span style="background-color: white; color: #202122; font-family: sans-serif; text-align: justify;">congenital cervical atresia, a</span><b style="background-color: white; color: #202122; font-family: sans-serif; text-align: justify;"> </b><span style="background-color: white; color: #202122; font-family: sans-serif; text-align: justify;">complete hysterectomy may be necessary.</span><sup class="reference" id="cite_ref-ReferenceA_15-1" style="background-color: white; color: #202122; font-family: sans-serif; line-height: 1; text-align: justify; unicode-bidi: isolate; white-space: nowrap;"></sup></div><div style="text-align: left;"><p style="background-color: white; color: #202122; font-family: sans-serif; margin: 0.5em 0px; text-align: justify;">For the women who have an <u>i</u>mperforate hymen, a minor surgery is sufficient. An incising for the hymenic membrane or hymenotomy is sufficient to facilitate menstrual flow. In some case with tight outlet, patients may be required to insert dilators into the vagina for a few minutes each day for a few days post the surgery to avoid the incision being closed on its own or to maintain it patency. The surgical correction of a transverse septum and vaginal atresia can be difficult if the surgery is not carefully planned. Postoperative complications, such as vaginal stenosis and re-obstruction can occur, especially when the septum/vagina is thick. In such cases long term dilation with vaginal dilators may be necessary.The thickness and location of the septum is most commonly evaluated by transperineal ultrasound or MRI before attempting its resection. Mullerian duct anomalies can be changing & the surgical treatment planned need to be tailored toward relieve the acute symptoms & long term maintenance for the sexual & reproduction function in such patients. In such cases a preoperative assessment with imaging techniques and multi discipline approach may be necessary to provide effective & long term good outcome. </p></div>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-78273707301555382112022-03-16T21:26:00.000-07:002022-03-16T21:26:36.004-07:00<p style="text-align: center;"><span style="font-size: medium;"><b>GENITAL
INFECTION IN
GYNAECOLOGY </b></span></p><p style="text-align: center;"><span style="font-size: medium;"><b>( MEDICAL STUDENTS LECTURE & NOTES) 2022</b></span></p><p style="text-align: justify;">The Nature and Role of Physiological Vaginal
Discharge.</p><p style="text-align: justify;">● Normal for woman to have some degree of vaginal discharge. </p><p style="text-align: justify;">● Normal - white to yellowish (d/t oxidation). </p><p style="text-align: justify;">● Contents: Mucous, desquamated epithelial cells, bacteria and fluid from
endometrial.</p><p style="text-align: justify;">● There is slight odour but it’s not strong. pH: acidic (4-5). </p><p style="text-align: justify;">● The role :
○ To carry away dead cells and bacteria thus keeps the vagina clean.</p><p style="text-align: justify;"> ○ Acidic - act as defense mechanism against pathogens.</p><p style="text-align: center;"><b>COMMON GENITAL INFECTION IN GYNAECOLOGY:</b></p><p style="text-align: justify;"><span style="font-size: medium;"><b>Vulvovaginal Candidiasis</b></span></p><p style="text-align: justify;">Causal organism: Candida albicans (gram +ve oval yeast). </p><p style="text-align: justify;">Predisposing factors: Pregnancy (40%), DM, high-dose combined OCP, HIV. </p><p style="text-align: justify;">Signs & symptoms: Vulval itching, thick white curdy discharge (vaginal thrush),
dyspareunia, dysuria, vulval oedema, redness, normal vaginal pH. </p><p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjQFrbuKrGj0nJ3x8bGxPJjKlx9Ps3RFFV8iEkCPUPNOSw3f1O6oKkbnNVHy1sRhGGzbKtjomGSQSA0GAysi0ufS2HTbYVKAWdHpGNmBd63L31IfFg8EqsheJ6pehFGJYBnGcQjhOmPICMJ4vLXXFP65kKxy28Xh7KFCuxxuXuPb74B0H9kQVshHTCgew" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="245" data-original-width="326" height="199" src="https://blogger.googleusercontent.com/img/a/AVvXsEjQFrbuKrGj0nJ3x8bGxPJjKlx9Ps3RFFV8iEkCPUPNOSw3f1O6oKkbnNVHy1sRhGGzbKtjomGSQSA0GAysi0ufS2HTbYVKAWdHpGNmBd63L31IfFg8EqsheJ6pehFGJYBnGcQjhOmPICMJ4vLXXFP65kKxy28Xh7KFCuxxuXuPb74B0H9kQVshHTCgew=w264-h199" width="264" /></a></div><br /><br /><p></p><p style="text-align: justify;">Diagnosis: High vaginal swab -> gram stain/wet film examination. </p><p style="text-align: justify;">Treatment: Imidazole oral/pessary (oral contraindicated to pregnant women), nystatin cream/pessary, </p><p style="text-align: justify;"><span style="font-size: medium;"><b>Tricomoniasis </b></span></p><p style="text-align: justify;"><span style="text-align: left;">Causal organism: Trichomonas vaginalis (flagellate protozoa). </span></p><p style="text-align: justify;"><span style="text-align: left;">Predisposing factors: Multiple sexual partners, unprotected sex. </span></p><p style="text-align: justify;"><span style="text-align: left;">Signs & symptoms: Vulval itching, frothy yellowish green discharge, dysuria,
strawberry cervix.
Diagnosis: </span></p><p style="text-align: justify;"><span style="text-align: left;"></span></p><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEivM9EvydpHsQkBGH6IkPEsKVXs738mGWa3PFl37_fwtf67PGOcLfkVw5JyHTz8BbTL6J9fuQolOx1ynZfovgPS-G0oiTM6W60CbMFgpKjf3thDLYPJBsXx6BTqGtEXSBfCAJkpOvK2XGY82QxjduBt7yUZj1dFTSZuXX3BQoBFygD3HKPvVF-yoQI_Ag" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="214" data-original-width="320" height="151" src="https://blogger.googleusercontent.com/img/a/AVvXsEivM9EvydpHsQkBGH6IkPEsKVXs738mGWa3PFl37_fwtf67PGOcLfkVw5JyHTz8BbTL6J9fuQolOx1ynZfovgPS-G0oiTM6W60CbMFgpKjf3thDLYPJBsXx6BTqGtEXSBfCAJkpOvK2XGY82QxjduBt7yUZj1dFTSZuXX3BQoBFygD3HKPvVF-yoQI_Ag=w209-h151" width="209" /></a><img alt="" data-original-height="214" data-original-width="219" height="146" src="https://blogger.googleusercontent.com/img/a/AVvXsEgB9QV-41bJfEE3VYIn-01sRhGOiivwH4D68jT4FdmWX5YJ9CTeR4SYoU6uIFszDpaLZn72yY1Ciju09ejTsXNdeDU5JnzmMiqO1KOu5MqrmOZbQ_UBbdbGQwlj5J1i14PH7lPwEN7hr9VKriPUebjtFzQhM3yBrS8_a5OwTIMloh149VaLpi_MK1qw-w=w197-h146" width="197" /></div><div style="margin-left: 1em; margin-right: 1em; text-align: left;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgB9QV-41bJfEE3VYIn-01sRhGOiivwH4D68jT4FdmWX5YJ9CTeR4SYoU6uIFszDpaLZn72yY1Ciju09ejTsXNdeDU5JnzmMiqO1KOu5MqrmOZbQ_UBbdbGQwlj5J1i14PH7lPwEN7hr9VKriPUebjtFzQhM3yBrS8_a5OwTIMloh149VaLpi_MK1qw-w" style="margin-left: 1em; margin-right: 1em;"><br /></a></div></div><p style="text-align: justify;"><span style="text-align: left;">Investigation: High vaginal swab, μscopy of vaginal discharge, saline wet mount.</span></p><p style="text-align: justify;"><span style="text-align: left;"> </span><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgZ0tqtk9XfA9XkFd5XL4iIqp285TQONyd5ICn18-DyW_WdJM460M-g47lgQuo_yMT9q1rhPP_E1pmE1QYhrhC_cqJ76hj_ZC3n7M_5NcKc7jYhAU6tBCJktKnE7HJg32ixBKuGNr0KB4AH-u6ngBABeh8AJrga61XGtq7QzuCJ1FjVpr62mN052A8PCQ" style="margin-left: 1em; margin-right: 1em; text-align: center;"><img alt="" data-original-height="214" data-original-width="213" height="197" src="https://blogger.googleusercontent.com/img/a/AVvXsEgZ0tqtk9XfA9XkFd5XL4iIqp285TQONyd5ICn18-DyW_WdJM460M-g47lgQuo_yMT9q1rhPP_E1pmE1QYhrhC_cqJ76hj_ZC3n7M_5NcKc7jYhAU6tBCJktKnE7HJg32ixBKuGNr0KB4AH-u6ngBABeh8AJrga61XGtq7QzuCJ1FjVpr62mN052A8PCQ=w196-h197" width="196" /></a></p><p style="text-align: left;">Treatment; Metronidazole</p><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><b><br /></b></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-size: medium;"><b>Bacterial Vaginosis </b></span></div><div class="separator" style="clear: both; text-align: left;"><br /></div>Bacterial Vaginosis
Causal organism: Gardnerella vaginalis, Mycoplasma hominis, Bacteroides spp.,
Mobilincus spp.<div><br /><div>Predisposing factors: Multiple sex partners, douching, lack of good lactobacilli. </div><div><br /></div><div>Signs & symptoms: Fishy malodourous discharge, more common during menses. </div><div><br /></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEiviyzZBHd1drfP9dmfGgQv9qabKBZMRXQvQI6L1GqSYHFwf5UPpEZ-GMaN-MQolNdkh3bkdJx2R8s_C67PCfRV1b6aKdrkLuaN4wsif-G-3vIQ3M3zaGDfbThKjkm6Udn0tLVT6Tp0WDAAkjH8RlJguGfOfRx2ktixhCE3XKJRVLZj4-4CAnr7iF0EvQ" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="207" data-original-width="282" height="205" src="https://blogger.googleusercontent.com/img/a/AVvXsEiviyzZBHd1drfP9dmfGgQv9qabKBZMRXQvQI6L1GqSYHFwf5UPpEZ-GMaN-MQolNdkh3bkdJx2R8s_C67PCfRV1b6aKdrkLuaN4wsif-G-3vIQ3M3zaGDfbThKjkm6Udn0tLVT6Tp0WDAAkjH8RlJguGfOfRx2ktixhCE3XKJRVLZj4-4CAnr7iF0EvQ=w279-h205" width="279" /></a></div><br /></div><div>Diagnosis: Amsel criteria (≥3 criteria for diagnosing bacterial vaginosis)
a) Presence of clue cells (stippled appearance) - μscopic examination.
b) Creamy greyish white discharge - naked eye.
c) Vaginal pH > 4.5.
d) Release of a characteristic fishy odour on addition of alkali. </div><div><br /></div><div>Treatment: Metronidazole, clindamycin.</div><div><b><span style="font-size: medium;"><br /></span></b></div><div><b><span style="font-size: medium;">Gonorrhoea </span></b></div><div><span style="font-size: medium;"><b><br /></b></span></div><div>Causal organism: Neisseria gonorrhoeae (gram -ve diplococcus). </div><div><br /></div><div>Predisposing factors: Multiple sex partners, early age of onset of sexual activity. </div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEiw4cBtOmNHeymqPnOrefmNgSwuF_Xbif1b4ctQ59xHO8wZkHm7NNjqhEjlMfHL-Jl0LSLmoRbVxrFU4fG4i8rEo6I99skUSB6rHWJdAIUKMztFwOBIaB494yxL3GEPHL7SlTiQlnYqM82cbz8l-fMlcdbzuEqzPBZ0HbDdSNZWSESvePV0WUt3Fd6yDA" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="247" data-original-width="493" height="160" src="https://blogger.googleusercontent.com/img/a/AVvXsEiw4cBtOmNHeymqPnOrefmNgSwuF_Xbif1b4ctQ59xHO8wZkHm7NNjqhEjlMfHL-Jl0LSLmoRbVxrFU4fG4i8rEo6I99skUSB6rHWJdAIUKMztFwOBIaB494yxL3GEPHL7SlTiQlnYqM82cbz8l-fMlcdbzuEqzPBZ0HbDdSNZWSESvePV0WUt3Fd6yDA=w414-h160" width="414" /></a></div><br />Signs & symptoms: Greenish mucopurulent discharge, pelvic tenderness, proctitis,
rectal bleeding.</div><div><br /></div><div>Diagnosis: Vaginal swab -> gram stain/Thayer-Martin agar (blood chocolate agar
with antibiotics).</div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEikvmwerYAjDHFaHNp9TGMjKaApvuDG-g7slevfCBooZDR1CwVJubxZ65t0CR4vgJRz8YpAJLFzp6Rj9nqNKK4vqauV0nELrJG5nlSUBHrkyoMNDigUp9UGVc728aQoObyh4i9TUpUCejPNL4KYGrTfqU6TAM0INR6OrPBRiMUES2qJDqqQEqPcnBYWWA" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="193" data-original-width="285" height="179" src="https://blogger.googleusercontent.com/img/a/AVvXsEikvmwerYAjDHFaHNp9TGMjKaApvuDG-g7slevfCBooZDR1CwVJubxZ65t0CR4vgJRz8YpAJLFzp6Rj9nqNKK4vqauV0nELrJG5nlSUBHrkyoMNDigUp9UGVc728aQoObyh4i9TUpUCejPNL4KYGrTfqU6TAM0INR6OrPBRiMUES2qJDqqQEqPcnBYWWA=w264-h179" width="264" /></a></div><br /></div><div>Treatment: Cefixime, ceftriaxone, spectinomycin.</div><div><span style="font-size: large;"><span style="font-size: small;"><br /></span></span></div><div><span style="font-size: large;"><span style="font-size: small;"><div class="separator" style="clear: both; text-align: left;"><br /></div></span></span><span style="font-size: medium;"><b>Genitourinary Chlamydia</b></span></div><div><br /></div><div><span>Causal organism: Chlamydia trachomatis (gram -ve, obligate intracellular parasite).</span></div><div><span><br /></span></div><div><span>Predisposing factors: Multiple sex partners, early age of onset of sexual activity.</span></div><div><span><br /></span></div><div><span>Signs & symptoms: Mucopurulent discharge, postcoital and intermenstrual
bleeding, dysuria. Late stage: Conjunctivitis and pneumonia. </span></div><div><span><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgRS567FfkGLvEbtWPrvwWLQ9OefoYHhdiLIgVaFA6_tmGcZkPUtWup95MHWzKMdZsuvn8gM8cdiekxgypi2T_BYrRYppJg8xzvhf1CgJz9Lgg7lTttSvX8VniKdOIe8luuLxe-YyEYZpnOG2lrWQ-0-6AwGjAu9ZOqFm2mxcINGldZ31zvbO9LTkpBPA" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="214" data-original-width="262" height="192" src="https://blogger.googleusercontent.com/img/a/AVvXsEgRS567FfkGLvEbtWPrvwWLQ9OefoYHhdiLIgVaFA6_tmGcZkPUtWup95MHWzKMdZsuvn8gM8cdiekxgypi2T_BYrRYppJg8xzvhf1CgJz9Lgg7lTttSvX8VniKdOIe8luuLxe-YyEYZpnOG2lrWQ-0-6AwGjAu9ZOqFm2mxcINGldZ31zvbO9LTkpBPA=w236-h192" width="236" /></a></div></span></div><div><span><br /></span></div><div><span>Diagnosis: Nucleic acid amplification technique, RT-PCR, culture. </span></div><div><span><br /></span></div><div><span><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjBxVSLsJCVBmYvWBWUvOvvx7EG6J5WV4fzoBmJEjCasOgCIOz50srNDHlF7vbWks1oBed1miwROmobWnZAFrnfoLwnUg3aSYCpxDM4mfqcFwEu5d9857zernWnMAdxnUfq93bAzdkuOdebztGIznHXkwBv2Z68BC8D406wpTL9FXCy0AADEByvYst1rg" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="174" data-original-width="261" height="176" src="https://blogger.googleusercontent.com/img/a/AVvXsEjBxVSLsJCVBmYvWBWUvOvvx7EG6J5WV4fzoBmJEjCasOgCIOz50srNDHlF7vbWks1oBed1miwROmobWnZAFrnfoLwnUg3aSYCpxDM4mfqcFwEu5d9857zernWnMAdxnUfq93bAzdkuOdebztGIznHXkwBv2Z68BC8D406wpTL9FXCy0AADEByvYst1rg=w265-h176" width="265" /></a></div><br /></span></div><div><span>Treatment: Doxycycline, azithromycin, erythromycin, amoxicillin.<span style="font-size: medium;"><b><br /><br /></b></span><br /></span><p></p><p style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: center;"><br /></div></div><p></p></div></div>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-47502379483180080952022-03-16T20:09:00.000-07:002022-03-16T20:09:35.932-07:00<p> <b><span style="font-size: 16.0pt; line-height: 115%;">Clerking Format for FEMALE PATIENTS (all,
Obstetrics little different)</span></b></p>
<p class="MsoNormal"><b style="mso-bidi-font-weight: normal;">(INTRO)</b>My Patient
name is ………………………..,she is a (age)….. old (Race )……….. lady,<span style="mso-spacerun: yes;"> </span><b style="mso-bidi-font-weight: normal;">Gravida……..
Para……….</b><span style="mso-spacerun: yes;"> </span>IF PREGNANT GRAVIDA
….,<span style="mso-spacerun: yes;"> </span>IF NOT PREGNANT & HAS CHILDREN
PARA………. .<o:p></o:p></p>
<p class="MsoNoSpacing" style="text-align: justify;">She is known case of ……………..( any Medical
Problem or issues) eg Diabetse for 10 years and Hypertensive for 3 years. <b style="mso-bidi-font-weight: normal;">If any MEDICAL PROBLEMS <o:p></o:p></b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b style="mso-bidi-font-weight: normal;">EG Diagnose as pulm TB , 3 months ago and currently on anti Tb
treatment<o:p></o:p></b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b>(CHIEF COMPLAIN)</b></p>
<p class="MsoNoSpacing" style="text-align: justify;">She presented with history of
………………………………etc…<b style="mso-bidi-font-weight: normal;">EG.she presented with
low grade fever & vomiting for 2 days <o:p></o:p></b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b style="text-align: left;">(HPI): HISTORY OF
PRENSENT ILLNESS</b></p>
<p class="MsoNoSpacing">Mrs ………. Eg<span style="mso-spacerun: yes;"> </span>case
describe c/o in detail, ass factors, aggravating & relieving factors<o:p></o:p></p>
<p class="MsoNoSpacing" style="text-align: justify;">She was well until last Friday
when she develop low grade fever, the fever was of sudden onset, there were no
chills or rigor. She denied any body aches, headaches or pain behind her eyes(
periorbital pain). The fever settle after one day but on the 2<sup>nd</sup> day
she experience severe vomiting<o:p></o:p></p>
<p class="MsoNoSpacing" style="text-align: justify;">She vomited between 15-120 times, the vomitus
is basically food & water she took, there is no bilous or blood in the
vomitus. It was non projectile. There were no obvious aggravating factors. The
vomiting slowly improved after taking some medication…….???<o:p></o:p></p>
<p class="MsoNoSpacing" style="text-align: justify;">On further questioning, she
denied any diarrhea, abdominal cramps or pain, she has no history of taking
food in any unhygienic places.<span style="mso-spacerun: yes;"> </span>Etc etc<o:p></o:p></p>
<p class="MsoNoSpacing" style="text-align: justify;">Inview of this she seek
medical advice from the health<span style="mso-spacerun: yes;"> </span>clinic
(KKIK……..) from there she was referred to serdang hospital for further management………
She has been in the ward for last 2 days. She was put on intravenous fluid
& given some medication. She condition has improve since then. She has been
investigated for………… &<span style="mso-spacerun: yes;"> </span>what is the
treatment & management in the hospital……………<o:p></o:p></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b>SYSTEMIC REVIEW:…………………………………….</b>No headaches, blurring of vision, no
body rashes, etc etc related to your history</p><p class="MsoNoSpacing" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNoSpacing"><b style="text-align: justify;">MENSTRUAL HISTORY</b></p>
<p class="MsoNoSpacing" style="text-align: justify;">She attained her menarche at
the age of 12 ( …….) age. The cycle has been regular with 28-30 cycles. Her
flow is between 5-7 days. There were no menorrhagia (heavy period) or
dysmenorrhea (painful periods). Her LMP (last Normal Menstrual Period ) is on
the 12. October 2016. She is up to date with her pap smears. Her last pap
smear was done in 2016, and she was told it was normal<o:p></o:p></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b>PAST OBSTETRICS HISTORY</b></p>
<p class="MsoNoSpacing" style="text-align: justify;">She is para 2, has 2 children
age 7 & 2. Both the children were delivered by caesarean section for breech
presentation ( baby upside down). The weigh 3 & 3.3 kg. There were no
intrapartum & postpartum ( during & after delivery) complications. Both
the children are well & alive. She breast fed her children for 6 months….(
breast feeding or bottle feeding or mix)<o:p></o:p></p>
<p class="MsoNoSpacing" style="text-align: justify;">In between pregnancy she took
contraception ( OCP, IUCD etc…..)<o:p></o:p></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b>(PAST MEDICAL HISTORY)</b></p><p class="MsoNoSpacing" style="text-align: justify;"><b><o:p></o:p></b>In terms of his past medical
hIstory, He was diagnosed to have PTb in Sandakan , She
was diagnose PTB after she presented with chronic cough & history of LOA,
LOW…………, Full assessment was carried out & the diagnosis was confirmed by +
sputum for AFB. She was subsequently started with anti-Tb treatment. She has
taken the anti TB treatment for last 3 months at the chest clinic/ Health
clinic. She is very compliant to the treatment. All her family members were
screened & they tested negative.</p><p class="MsoNoSpacing" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNoSpacing" style="text-align: justify;"><o:p> S</o:p><b>HE IS NOT ALLERGIC TO ANY MEDICATIONS OR FOOD ( Better to put after
medical h/o so don’t forget)</b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><o:p> </o:p><b>PAST SURGICAL HISTORY</b></p>
<p class="MsoNoSpacing" style="text-align: justify;">She never had any operations
before………<o:p></o:p></p>
<p class="MsoNoSpacing" style="text-align: justify;">If got operations…….. ? what
op & years any complications ( eg……. She had 2 CSection on 2009 & 2017)<o:p></o:p></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b> </b><b>FAMILY HISTORY</b></p>
<p class="MsoNoSpacing" style="text-align: justify;">She is the youngest of 8
siblings / the third of 4 siblings. His parents are still alive & well. His
mother is also diabetic but not hypertensive. His father has no medical
illness. All his sibling is well and has no similar illness. There were no one
in her family with PTB<o:p></o:p></p>
<p class="MsoNoSpacing" style="text-align: justify;"><o:p> </o:p><b>PERSONAL/SOCIAL HISTORY</b></p>
<p class="MsoNoSpacing" style="text-align: justify;">She is married to EN………………………,
she works as a………………., her partner works as……………………….. they live in a flat/
single storey teres / double storey teres/ single or double storey
bungalow/condominium I ……………………………kajang/serdang………. The house is well equipped with adequate basic amenities like
water & electricity. Their combine monthly income is RM 2000. They have
……….children. She and her partner does
not smoke cigarette or consume alcohol. He also does not indulge in high risk behaviors’.
She take s balance diet with 2-3 serving of meat per week. Recently after
contracting with PTB she had loss about 3 kg<o:p></o:p></p>
<p class="MsoNoSpacing" style="text-align: justify;"><o:p> </o:p><b>IN SUMMARY, MY PATIENT Pn/madam……………..,
A KNOWN CASE OF DIABETES PTb diagnosed 3 months ago & still on anti-TB
treatment presented with low grade fever with severe vomiting</b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b> PROVISIONAL DIAGNOSIS:……………………………………………….</b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b> </b><b>DIFFERENTIAL DIAGNOSIS:1 …………………………………………</b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b> 2………………………………………….<o:p></o:p></b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b> 3. …………………………………………<o:p></o:p></b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b>HOW WOULD YOU MANAGE:………………………………………..<o:p></o:p></b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b>I would like to do some investigation:, l would like to do FBC to see
any evidence of infection. I also would like to check his renal function to see
if there any evidence of renal impairment. LFT to look for hypoalbuminemia. As
per symptoms an ECG & Chest x-ray may provide me with any evidence of pleural effusion or cardiac failure. Others…………………………..</b></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><b>1.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-weight: normal; line-height: normal;">
</span></b><!--[endif]--><b>Blood
test FBC, RP, LFT …………whey & reasons<o:p></o:p></b></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><b>2.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-weight: normal; line-height: normal;">
</span></b><!--[endif]--><b>Sputum
AFB, C&S<o:p></o:p></b></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><b>3.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-weight: normal; line-height: normal;">
</span></b><!--[endif]--><b>Cxray,
ecg, echo whey & interpretations<o:p></o:p></b></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><b>4.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-weight: normal; line-height: normal;">
</span></b><!--[endif]--><b>Other
test d-dimer, Doppler studies, CT scan, MRI etc………..</b></p><p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -.25in;"><b>5. The options for this patient are A. CONSERVATIVE MANAGEMENT LIKE...</b></p><p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -.25in;"><b> B. MEDICAL TREATMENT LIKE.....</b></p><p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l0 level1 lfo1; text-align: justify; text-indent: -.25in;"><b> C. SURGICAL OPTIONS INCLUDING .........</b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b> </b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b> </b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b> </b></p><p class="MsoNoSpacing" style="text-align: justify;"><b style="mso-bidi-font-weight: normal;"><br /></b></p>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-32390000979831830772021-07-21T20:26:00.001-07:002021-07-21T20:27:35.564-07:00CYSTOSCOPY IN WOMEN<p><span style="font-family: arial;"><span style="text-align: justify;">A non invasive procedure to visualize the lower urinary
tract system. Mainly credited to Kelly for developing the female
cystoscopy. </span><span style="text-align: justify;">Hopkin’s introduce the
fiberoptic telescopy in 1950’s.</span></span></p><p class="MsoNormal"><span style="font-family: arial;"><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: arial;">Cystoscopy divided into:</span></p><p class="MsoNormal"><span style="font-family: arial;"><o:p></o:p></span></p>
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l4 level1 lfo1;"><span style="font-family: arial;">Urethroscopy<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l4 level1 lfo1;"><span style="font-family: arial;">Rigid cystoscopy<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l4 level1 lfo1;"><span style="font-family: arial;">Flexible cystoscopy<o:p></o:p></span></li>
</ul>
<p class="MsoNormal"><span style="font-family: arial;"><o:p> </o:p>Intrumentation: </span></p>
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l1 level1 lfo2;"><span style="font-family: arial;">Telescopy ( 0, 30, 70
degrees)<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2;"><span style="font-family: arial;">Sheathes<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2;"><span style="font-family: arial;">Bridges<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2;"><span style="font-family: arial;">Rigid cystoscopy<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2;"><span style="font-family: arial;">Distension media: Water or
Normal saline<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2;"><span style="font-family: arial;">Other accessory
instruments: biopsy forceps, grasping forceps, scissors, stone crusher,
Ellipe hydrostatic bottle, electrocautery system. </span></li></ul><div><span style="font-family: arial;"><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6oumF06Um0OlsV-09_IREYB4ozsfH1cqONVUfqObs1XzGrpgGcJkjD73-n66bJiuV4CU3jvtVyXxAV-0DgLFMp9vHk8yCN8SO0Q7ZsI7vyBmfSeSpXRns_b5EyvoqjIXXGeHjBWsTPFJ0/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="352" data-original-width="468" height="201" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6oumF06Um0OlsV-09_IREYB4ozsfH1cqONVUfqObs1XzGrpgGcJkjD73-n66bJiuV4CU3jvtVyXxAV-0DgLFMp9vHk8yCN8SO0Q7ZsI7vyBmfSeSpXRns_b5EyvoqjIXXGeHjBWsTPFJ0/w214-h201/image.png" width="214" /></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjy_kumTHPoepm0RKroFJM1xRh9Eyh1ON_jSrVQVr6nOr015BA6ij12A3Wrr4_F1amB8C0YgUaGA_TIsBTTW9ydqRnyt5v9e0bp4AyzFSNPfldNNUD05UwuFXKn3nbWjSFmhiOvmfTyn1hr/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="375" data-original-width="500" height="204" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjy_kumTHPoepm0RKroFJM1xRh9Eyh1ON_jSrVQVr6nOr015BA6ij12A3Wrr4_F1amB8C0YgUaGA_TIsBTTW9ydqRnyt5v9e0bp4AyzFSNPfldNNUD05UwuFXKn3nbWjSFmhiOvmfTyn1hr/w231-h204/image.png" width="231" /></a></div></div></span></div><div><span style="font-family: arial;"><br /><br /></span></div><div><span style="font-family: arial;">Indications: </span><b style="font-family: arial;">Diagnostic or operative</b></div>
<p class="MsoNormal"><span style="font-family: arial;"><b>Diagnostic:</b> Investigative and diagnostic tool for symptoms & signs for urinary problems<o:p></o:p></span></p>
<p class="MsoNormal" style="margin-left: 37.8pt; text-align: left; text-indent: -0.25in;"></p><ul style="text-align: left;"><li><span style="font-family: arial;"><span style="text-indent: -0.25in;"> </span><span style="text-indent: -0.25in;">Investigation for microscopic or gross
haematuria</span></span></li><li><span style="font-family: arial;"><span style="text-indent: -0.25in;"><span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.25in;">Infection ( acute or chronic, recurrent)</span></span></li><li><span style="font-family: arial;"><span style="text-indent: -0.25in;"><span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.25in;">Inflammation like Interstitial cystitis,
radiation cystitis</span></span></li><li><span style="font-family: arial;"><span style="text-indent: -0.25in;"><span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.25in;">Overactive bladder symptoms</span></span></li><li><span style="font-family: arial;"><span style="text-indent: -0.25in;"><span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.25in;">Voiding dysfunction symptoms</span></span></li><li><span style="font-family: arial;"><span style="text-indent: -0.25in;"><span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.25in;">Suspected fistulas</span></span></li><li><span style="font-family: arial;"><span style="text-indent: -0.25in;"><span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.25in;">Assessment for staging of cervical cancer</span> </span></li></ul><div><span style="font-family: arial;"><b>Operative Procedures: </b>Treat bladder conditions or diseases</span></div><div><span style="font-family: arial;"><b><br /></b></span></div><ul style="margin-top: 0in;" type="disc"><li class="MsoNormal" style="mso-list: l2 level1 lfo4;"><span style="font-family: arial;">Periurethral collagen
injection for USI/ ISD<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo4;"><span style="font-family: arial;">Intravesicle injections of
steroids, botox for intractable DI/ IC<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo4;"><span style="font-family: arial;">Removal of small bladder
calculi<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo4;"><span style="font-family: arial;">Removal of foreign bodies
like sutures, tape/mesh, polyps & masses<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo4;"><span style="font-family: arial;">Biopsy of abnormal area / tumors</span></li>
</ul>
<p class="MsoNormal"><span style="font-family: arial;"><b>Procedure: </b></span><span style="color: red; font-family: arial;"><b>https://www.youtube.com/watch?v=pjfXBximSBQ</b></span></p><p class="MsoNormal"><span style="font-family: arial;"><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="background-color: white; color: #111111;"><span style="font-family: arial;">Cystoscopy may be done using a local anesthetic using lignocaine jelly, under sedation or under general anesthesia in some cases esp patients requiring operative procedure</span></span></p><p class="MsoNormal"></p><ul><li style="text-align: justify;"><span style="background-color: white; color: #111111;"><span style="font-family: arial;">Prior to cystoscopy, empty the bladder</span></span></li><li style="text-align: justify;"><span style="background-color: white; color: #111111;"><span style="font-family: arial;">Assemble cystoscopy as required flexible or rigid (need to assemble the outer sheath, telescope & the bridge)</span></span></li><li style="text-align: justify;"><span style="background-color: white;"><span style="font-family: arial;"><span style="color: #111111;">Test the cystoscopy system in good working condition & white- balance it. </span></span></span></li><li style="text-align: justify;"><span style="background-color: white;"><span style="font-family: arial;"><span style="color: #111111;">Introduce the cystoscopy with slow water flow to expel any air & to facilitate the introduction of the tip of scope smoothly through the external meatus & the urethra. inflate the bladder with NS/water up to 200-400mls to get full view of the bladder.</span></span></span></li><li style="text-align: justify;"><span style="background-color: white;"><span style="font-family: arial;"><span style="color: #111111;">Inspect the bladder systematically from the doom & walk through the bladder in clock wise manner.</span></span></span></li><li style="text-align: justify;"><span style="background-color: white;"><span style="font-family: arial;"><span style="color: #111111;">look for the ureteric orifices & trigon area. The distance between the 2 ureteric orifices is about 4 cm</span></span></span></li><li style="text-align: justify;"><span style="background-color: white;"><span style="font-family: arial;"><span style="color: #111111;">inspect the bladder neck & as the scope is withdrawn, inspect the urethra ( usually abloy 4cm length)</span></span></span></li><li style="text-align: justify;"><span style="background-color: white;"><span style="font-family: arial;"><span style="color: #111111;">After the procedure, empty the bladder & apply local anaesthetic gels.</span></span></span> </li></ul><div style="text-align: justify;"><div class="separator" style="clear: both; text-align: center;">Normal appearance on cystoscopy</div></div><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dzNsvWIbfOhM4KdJOXBLRcbAIV695HX1tfEmau_v-uJYtbKtTCiyd2vhp7QRaajIZCaIuh91uiZlRE1kL1mOQ' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div><br /><div style="text-align: justify;"><br /></div><p></p>
<p class="MsoNormal"><span style="font-family: arial;">Complications:<o:p></o:p></span></p>
<p class="MsoNormal"></p><ul style="text-align: left;"><li><span style="text-indent: -0.25in;"><span style="font-family: arial;">Injuries to the urethra, bladder wall</span></span></li><li><span style="font-family: arial;">Bladder perforation</span></li><li><span style="font-family: arial;">Bladder infection 3-5%</span></li><li><span style="font-family: arial;">Bleeding esp after biopsies/ operative procedures</span></li><li><span style="font-family: arial;">Pain</span></li></ul><p></p><p class="MsoListParagraphCxSpFirst" style="mso-list: l3 level1 lfo5; text-indent: -0.25in;"><span style="font-family: arial;"><o:p></o:p></span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l3 level1 lfo5; text-indent: -0.25in;"><span style="font-family: arial;"><o:p></o:p></span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l3 level1 lfo5; text-indent: -0.25in;"><span style="font-family: arial;"><o:p></o:p></span></p>
<p class="MsoListParagraphCxSpLast"><span style="font-family: arial;">Reporting the findings:</span></p><p class="MsoListParagraphCxSpLast"><span style="font-family: arial;">Normal appearance of the bladder; the dome with bubble, bothe the ureteric orifices, trigon area & the bladder neck</span></p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal"><o:p></o:p></p><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><img alt="" data-original-height="688" data-original-width="931" height="206" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitBNdZHPjsDHTrIuOYAj8wFfETYB_g0jBdPffo0qzd4YQrvmMuIzqxp3N9FMh_zwDlwCuCiL1kW1x0tkHW9K29vanN0J0EaoE8aIIG6It8QG5AAUDMjANnE7ItwuJDejwp0RH4JNablLe_/w241-h206/image.png" width="241" /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgo_0GDOY3amzX8bE0xTLmuHkLwVNFNqh2GIzBb4NnsPYccZBK0jEqM9XxaTZSJScac6C2MvipxYBxOvBq3InUs1112viB26S9Rtm2JulwuCatvZ93qxhwFxgDUyiGoOD6Pd67Txy2uso7-/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="698" data-original-width="930" height="202" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgo_0GDOY3amzX8bE0xTLmuHkLwVNFNqh2GIzBb4NnsPYccZBK0jEqM9XxaTZSJScac6C2MvipxYBxOvBq3InUs1112viB26S9Rtm2JulwuCatvZ93qxhwFxgDUyiGoOD6Pd67Txy2uso7-/w254-h202/image.png" width="254" /></a></div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitBNdZHPjsDHTrIuOYAj8wFfETYB_g0jBdPffo0qzd4YQrvmMuIzqxp3N9FMh_zwDlwCuCiL1kW1x0tkHW9K29vanN0J0EaoE8aIIG6It8QG5AAUDMjANnE7ItwuJDejwp0RH4JNablLe_/" style="margin-left: 1em; margin-right: 1em;"><br /></a></div><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; margin-left: 1em; margin-right: 1em; text-align: center;"><span style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="690" data-original-width="920" height="199" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgEc-lJnOrC0Kv5Jgg3E3HluHXnqudpTOtL97PZp3x6XLZb2Tcq6kjBBmzcx_XjtdlpoaOEvbDp_xu54b0-JT7KU37hyphenhyphen03P7InwDdjYKNwGZZmOO7rT-a5Xbv6-dIpYiIe6ktepkWIJl-IG/w188-h199/image.png" width="188" /></span><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpBenxIBAWVg-p4fWJz4ZpD8s13Z04w-fMSagzBFiomKXwDoYf_aOe7VGJo-UYSZAWPeAsL2csa1o02VMKhSHXjSuN5j_I_DcCi72OgxuJzAICuzVx7Bp-7OBm-WC1r9zp5HFpoGjgLFi5/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="682" data-original-width="912" height="195" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpBenxIBAWVg-p4fWJz4ZpD8s13Z04w-fMSagzBFiomKXwDoYf_aOe7VGJo-UYSZAWPeAsL2csa1o02VMKhSHXjSuN5j_I_DcCi72OgxuJzAICuzVx7Bp-7OBm-WC1r9zp5HFpoGjgLFi5/w201-h195/image.png" width="201" /></a></div></div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhfG0h8WHB7eCFRJzhRGzMDihuWMAKSyugbNm1X6nt3FGLXDIIwhUipbD7jQfVyZd8sk2sWNxSsPjgShbFgFDJoG2UGCv2g8mZkStv4wQW7eh-b5IRNUKKXTcxrfSONrljw3uwumlo1shC_/" style="margin-left: 1em; margin-right: 1em;"><br /></a></div>Abnormality observed on cystoscopy<div><br /></div><blockquote style="border: none; margin: 0 0 0 40px; padding: 0px;"><blockquote style="border: none; margin: 0 0 0 40px; padding: 0px;"><blockquote style="border: none; margin: 0 0 0 40px; padding: 0px;"><div style="text-align: left;"> Rain drop sign as in Interstitial cystitis</div></blockquote></blockquote></blockquote><div style="text-align: left;"><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjcNzyXiPBt1RsJholUe-X84N6s8vgn-Tmy_h9FAz_AfbTSkbc9sj98TzIy9uJb0eHq6fKp-8sXrvYJoyFfgzBqgryNn-fENoi-eu02h3fnuDfTYBjqRy0aTVEiuIVpKY8uvJAqvdQ0wGjE/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="688" data-original-width="936" height="191" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjcNzyXiPBt1RsJholUe-X84N6s8vgn-Tmy_h9FAz_AfbTSkbc9sj98TzIy9uJb0eHq6fKp-8sXrvYJoyFfgzBqgryNn-fENoi-eu02h3fnuDfTYBjqRy0aTVEiuIVpKY8uvJAqvdQ0wGjE/w196-h191/image.png" width="196" /></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIlFkvkuZINEhIXwijRiu7I3qIPRhbC1EMlO1Uf6skxjBIwHgDUI6DaWXezHKpqdL7pxLb-ih_4PJPBKOcyShyphenhyphen9iqTFIIGPZTLfLsjcn_LQNbZpBLk8Ug7UvQ-qPEm-TXCnEfDADzxrw1l/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="696" data-original-width="930" height="180" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIlFkvkuZINEhIXwijRiu7I3qIPRhbC1EMlO1Uf6skxjBIwHgDUI6DaWXezHKpqdL7pxLb-ih_4PJPBKOcyShyphenhyphen9iqTFIIGPZTLfLsjcn_LQNbZpBLk8Ug7UvQ-qPEm-TXCnEfDADzxrw1l/w205-h180/image.png" width="205" /></a></div></div><br /></div><div> Foreign body- mesh /TVT tape, stone</div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgyEishJJvlB0KqdIYwhvQ0MXTbNt2YPSAp1amCax8SkUlrvkFN5q2dUdkMmfZTqLO8RRVd8QtEn9c7rBrVkylM7A1_WVZ0nkulujIH86j2yV2-fzIiWB_toxjhPcatbaHoAU5mbwf4syAy/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="690" data-original-width="928" height="238" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgyEishJJvlB0KqdIYwhvQ0MXTbNt2YPSAp1amCax8SkUlrvkFN5q2dUdkMmfZTqLO8RRVd8QtEn9c7rBrVkylM7A1_WVZ0nkulujIH86j2yV2-fzIiWB_toxjhPcatbaHoAU5mbwf4syAy/" width="320" /></a></div><br /> Bladder perforation:</div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhzd6N-4fMAVkvKsubaOdXFU-0yIdPZ_j7PyWeHLIkg7mTGsVER9ItqGwO7GYl1mXGjbgWyU8NQZ8QmIqnFKE_kMpJ2JqgVqvSRtBNvuf5abfZMJq8cFKxCu95h3dJd-RzAiEBZbaSDglL8/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="696" data-original-width="944" height="236" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhzd6N-4fMAVkvKsubaOdXFU-0yIdPZ_j7PyWeHLIkg7mTGsVER9ItqGwO7GYl1mXGjbgWyU8NQZ8QmIqnFKE_kMpJ2JqgVqvSRtBNvuf5abfZMJq8cFKxCu95h3dJd-RzAiEBZbaSDglL8/" width="320" /></a></div> </div><div> </div><div> Bladder Polyp<p></p></div><div><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBAa-UcqkL6lUzsSBQ94UOLzWY5gZRYh3cMbp3pmCihmcIOYhrUn0CBWhtfUZuu6i1KKw81yapKCMtm6ClfZuedz5hyphenhyphenA6fO91OBwdgKjXetfJfVovPIbdEmGNR9WkvFAQ619mqZ05WEOA7/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="700" data-original-width="933" height="190" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBAa-UcqkL6lUzsSBQ94UOLzWY5gZRYh3cMbp3pmCihmcIOYhrUn0CBWhtfUZuu6i1KKw81yapKCMtm6ClfZuedz5hyphenhyphenA6fO91OBwdgKjXetfJfVovPIbdEmGNR9WkvFAQ619mqZ05WEOA7/w205-h190/image.png" width="205" /></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvLbbkxqaNInz658M9ck4jLMOs0w1krZGVL2o3iDublBpuBfhyphenhyphenkHwT_r5MJ4mIDvswU4eh3toWpC0D14yXrAmcAtXhmrQTb5RFygoyOaNFxz3DpVTZM9q6vsK8aDxiVZkZwQXQXRDgEatf/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="698" data-original-width="930" height="190" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvLbbkxqaNInz658M9ck4jLMOs0w1krZGVL2o3iDublBpuBfhyphenhyphenkHwT_r5MJ4mIDvswU4eh3toWpC0D14yXrAmcAtXhmrQTb5RFygoyOaNFxz3DpVTZM9q6vsK8aDxiVZkZwQXQXRDgEatf/w184-h190/image.png" width="184" /></a></div><br /></div><div><br /></div><div>Disclaimers: some pictures & video was uploaded from you-tube & google images</div><div>The above article is for teaching purpose</div><div>I would like to pay credit to all the contributors for the above pictures & videos</div><div>consent for exhibition of the pictures & video has been obtain from the patients</div><div><br /></div>References:</div><div><br /></div><div>1. https://www.youtube.com/watch?v=q1gDwLaz8oI<br /><br /></div>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-38217618529232082012021-06-24T20:56:00.001-07:002021-06-24T20:56:33.666-07:00SURGERY FOR FEMALE STRESS URINARY INCONTINANCE<p style="text-align: justify;"><b> <span style="text-align: justify;">General considerations</span></b></p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<span style="text-align: justify; text-indent: -0.5in;">1.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> D</span></span><span style="text-align: justify; text-indent: -0.5in;">iversity on choice of surgical procedure. Burch colposuspensions/ fascial slings/ MUS/Injectables</span><br /><blockquote style="border: none; margin: 0px 0px 0px 40px; padding: 0px; text-align: left;"></blockquote><span style="text-align: justify; text-indent: -0.5in;">2.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-align: justify; text-indent: -0.5in;">Indication should be significant loss of urine creating
social or hygienic problem </span><div><span style="text-align: justify; text-indent: -0.5in;">3. </span><span style="text-align: justify; text-indent: -0.5in;">Most procedures aim to repositioning of bladder neck
and urethra in a supported retropubic </span><span style="text-align: justify; text-indent: -0.5in;">position. Others aim to provide increased
urethral resistance by improving urethral coaptation.</span><div><p class="MsoNormal" style="margin-left: 0.75in; mso-list: l5 level1 lfo1; tab-stops: list .75in; text-align: justify; text-indent: -0.5in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-left: 0.75in; mso-list: l5 level1 lfo1; tab-stops: list .75in; text-align: justify; text-indent: -0.5in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-left: 0.75in; mso-list: l5 level1 lfo1; tab-stops: list .75in; text-align: justify; text-indent: -0.5in;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;"><b><o:p> P</o:p><span style="text-align: left;">reoperative considerations</span></b></p></div></div><span style="text-align: justify; text-indent: -0.5in;">1.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-align: justify; text-indent: -0.5in;">History taking, physical examination, laboratory
testing and imaging. </span><br /><div style="text-align: left;"><p class="MsoNormal" style="text-align: justify;"><span style="text-indent: -0.5in;">2.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.5in;">Thorough evaluation of all pelvic floor organs should
be done preoperatively, In some cases full Urodynaemics studies may be
indicated.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="text-indent: -0.5in;">3.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.5in;">Perioperative antibiotic treatment in the operating
room.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="text-indent: -0.5in;">4.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.5in;">General, regional, or local anaesthesia according to
the procedure performed and patient </span><span style="text-indent: -0.5in;">condition</span></p><p class="MsoNormal" style="text-align: justify;"><span style="text-indent: -0.5in;">5.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.5in;">Dorsal lithotomy positioning, prepping and draping the
abdomen and vagina in a sterile fashion.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="text-indent: -0.5in;">6.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.5in;">Draining the bladder with a Foley catheter at the
beginning of the procedures.</span></p></div><div><p class="MsoNormal" style="margin-left: 0.75in; mso-list: l3 level1 lfo2; tab-stops: list .75in; text-align: justify; text-indent: -0.5in;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;"><b><o:p> </o:p>Operative and postoperative general considerations when
performing vaginal surgery</b></p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;"><span style="text-indent: -0.5in;">1.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.5in;">Cystourethroscopy performed at the end of the procedure
is recommended to verify that the bladder is intact, that no sutures are
traversing the urethra or bladder, and that ureters are patent.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="text-indent: -0.5in;">2.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.5in;">The vagina may need to be packed at the end of the
procedure to facilitate hemostasis in some cases. Packing can be removed
postoperative few hours to the next day.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="text-indent: -0.5in;">3.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.5in;">Indwelling catheter or suprapubic catheter is left in
the bladder in come cases and as when is needed.</span></p><p class="MsoNormal" style="margin-left: 0.75in; mso-list: l0 level1 lfo3; tab-stops: list .75in; text-align: justify; text-indent: -0.5in;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;"><o:p> </o:p><b><u>SUBURETHRAL SLING PROCEDURES</u> (MUS)</b></p>
<ol start="1" style="margin-top: 0in;" type="1">
<li class="MsoNormal" style="mso-list: l4 level1 lfo4; tab-stops: list .5in; text-align: justify;">Suburethral sling is a strip of material that is
tunneled underneath the bladder neck and/or proximal urethra or midurethra
and then attached to above structure such as rectus facia or pelvic
sidewall to create a posterior support, or hammock effect to the bladder
neck and proximal urethra.<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l4 level1 lfo4; tab-stops: list .5in; text-align: justify;">Slings are used for all kinds of stress urinary
incontinence including anatomical urinary stress incontinence(urethral
hypermobility) and can be<span style="mso-spacerun: yes;">
</span>completely transvaginally, or with combination of transvaginal and abdominal
approach.<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l4 level1 lfo4; tab-stops: list .5in; text-align: justify;">Sling materials include:<o:p></o:p></li>
<ol start="1" style="margin-top: 0in;" type="A">
<li class="MsoNormal" style="mso-list: l4 level2 lfo4; tab-stops: list 1.0in; text-align: justify;">Autologous sling such as fascia lata or rectus
abdominis, harvested at the time of surgery<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l4 level2 lfo4; tab-stops: list 1.0in; text-align: justify;">Homologous material such as cadaveric fascia lata<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l4 level2 lfo4; tab-stops: list 1.0in; text-align: justify;">Synthetic slings: Applied retropubically or
transobtoratorly.<o:p></o:p></li>
</ol>
<li class="MsoNormal" style="mso-list: l4 level1 lfo4; tab-stops: list .5in; text-align: justify;">Minimally invasive sling procedures have been
introduced including the<span style="mso-spacerun: yes;"> t</span>ension free vaginal tape using polypropene tapes.</li></ol><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;"><b><span style="mso-spacerun: yes;"> </span><o:p></o:p>Suburethral slings</b></p>
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l2 level1 lfo5; tab-stops: list .5in; text-align: justify;">Transvaginal tape (TVT) is becoming popular choice as
effective minimally invasive anti-incontinence surgery. <o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo5; tab-stops: list .5in; text-align: justify;">Long term results of up to 17 years showed comparable
objective and subjective cure rate as to Burch colposuspension.<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo5; tab-stops: list .5in; text-align: justify;">The Tension free vaginal Tape (TVT) is the only sling
but that is put at the mid-urethra level. Hence, the name Transvaginal
Tape (keeping the TVT abbreviation) was suggested. <o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo5; tab-stops: list .5in; text-align: justify;">To reduce such complications, The transobturator approach (TOT). Initial results were comparable with TVT with minimal complications.<o:p></o:p></li>
</ul>
<p class="MsoNormal" style="text-align: justify;"><b><o:p> </o:p>Operative technique of TVT
(Tension-free vaginal tape) & Transobturator apparoach (TOT)</b></p>
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l1 level1 lfo6; tab-stops: list .5in; text-align: justify;">Positioning and preparation as in preoperative
consideration for vaginal surgery.<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo6; tab-stops: list .5in; text-align: justify;">Local, regional, or general anesthesia can be used.<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo6; tab-stops: list .5in; text-align: justify;">Two 5mm long abdominal incisions are made 5cm apart
just above the superior rim of the pubic bone (TVT). Small stab incision
is made at the ischiopubic angle at the same level as the clitoris (TOT).<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo6; tab-stops: list .5in; text-align: justify;">A 1.5cm long vaginal wall incision is made over the
midurethra, 1cm proximal to the external urethral meatus.<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo6; tab-stops: list .5in; text-align: justify;">Bilateral paraurethral dissection of vaginal wall is
performed.<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo6; tab-stops: list .5in; text-align: justify;">A prolene tape attached on both ends to trocars/needles
and covered by a plastic sheath is used. One of the trocars/needles is
introduced and advanced through the vaginal incision, the urogenital
diaphragm, and the retropubic space in close contact to the posterior
aspect of the pubic bone until its tip is brought out to the abdominal
incision. TOT has similar approach but the needles are introduced either
through inside out as in TVTo or from out side in as other TOT’s.<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo6; tab-stops: list .5in; text-align: justify;">Using the trocar/ needles at the other end of the
sling, this step is then repeated, on the contralateral side.<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo6; tab-stops: list .5in; text-align: justify;">Cystoscopy is performed to rule out bladder or
urethral damage.<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo6; tab-stops: list .5in; text-align: justify;">Once bladder and urethral integrity have been
verified, the trocars/needles on both sides removed and hence the tape is
pulled all the way through the abdominal incision. The tape tension is
further adjusted under the urethra. <o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo6; tab-stops: list .5in; text-align: justify;">The plastic sheath covering of the tape is removed.
The friction between the tape and the tissue canal created by the trocars
serves to hold the sling in place with no need for additional suture
fixation of the sling. <o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo6; tab-stops: list .5in; text-align: justify;">Abdominal and vaginal incisions are closed.<span style="mso-spacerun: yes;"> </span><o:p></o:p></li>
</ul>
<p class="MsoNormal" style="text-align: justify;"><b><o:p> </o:p>Complications:</b></p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l2 level1 lfo5; tab-stops: list .5in; text-align: justify;">Bladder perforation ( 5% with TVT, almost nil with TOT)<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo5; tab-stops: list .5in; text-align: justify;">Bowel Injuries ( 0.7/1000)<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo5; tab-stops: list .5in; text-align: justify;">vascular injuries ( 0.7/1000)<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo5; tab-stops: list .5in; text-align: justify;">Bleeding<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo5; tab-stops: list .5in; text-align: justify;">Voiding dysfunction (2.8% or 23/1000- 79/1000)<o:p></o:p></li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo5; tab-stops: list .5in; text-align: justify;">Overactive bladder.<o:p></o:p></li><li class="MsoNormal" style="mso-list: l2 level1 lfo5; tab-stops: list .5in; text-align: justify;">Tape erosion/exposure ( <1%)</li>
</ul>
<p class="MsoNormal" style="text-align: justify;"><o:p> </o:p></p><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dxh0c6o86TCx_XPVGV6igmmLnr41mj_y0OlUUWyNWnrepBFMjbNhrKDkvk871vhYGOJSzpExO89h6Kt2q3stA' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div><br /><p></p><p class="MsoNormal" style="text-align: justify;"><b>References</b></p><p class="MsoNormal" style="text-align: justify;">1. Transobturator tape for Stress Incontinence: North Queensland Experience NAidu A, Lim YN, Barry C et al . <span face="BlinkMacSystemFont, -apple-system, "Segoe UI", Roboto, Oxygen, Ubuntu, Cantarell, "Fira Sans", "Droid Sans", "Helvetica Neue", sans-serif" style="background-color: white; text-align: left;"><i><b>Aust N Z J Obstet Gynaecol. 2005 Oct;45(5):446-9</b></i></span></p><p class="MsoNormal" style="text-align: left;"><span face="BlinkMacSystemFont, -apple-system, Segoe UI, Roboto, Oxygen, Ubuntu, Cantarell, Fira Sans, Droid Sans, Helvetica Neue, sans-serif"><span style="background-color: white;">2. Does the MORNAC Transobturator sling cause post-operative voiding dysfunction? A prospective study. Barry C, Naidu A, Lim YN et al. </span></span><span face="BlinkMacSystemFont, -apple-system, "Segoe UI", Roboto, Oxygen, Ubuntu, Cantarell, "Fira Sans", "Droid Sans", "Helvetica Neue", sans-serif" style="background-color: white;"><i><b>Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan;17(1):30-4</b></i></span></p><p class="MsoNormal" style="text-align: left;"><span face="BlinkMacSystemFont, -apple-system, "Segoe UI", Roboto, Oxygen, Ubuntu, Cantarell, "Fira Sans", "Droid Sans", "Helvetica Neue", sans-serif" style="background-color: white;">3. </span><span style="text-align: justify; text-indent: -0.25in;">Transobturator sub-urethral suspension, an approach
worth changing to?.<b><i>Malaysian Journal of O & G: 2005 ( Suppl)</i></b></span></p><p class="MsoNormal" style="text-align: left;"><span style="text-align: justify; text-indent: -0.25in;"><b>4.</b></span><span lang="EN" style="text-align: justify; text-indent: -0.25in;"><span style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"><b> </b> </span></span><span lang="EN" style="text-align: justify; text-indent: -0.25in;">Transobturator Tape(TOT) procedure:
The Ipoh Experience <b><i>JUMMEC 2011;14(1)</i></b></span></p><p class="MsoNormal" style="text-align: left;"><a href="http://jummec.um.edu.my/filebank/published_article/2967/JuMMEC%202011%2014" style="font-family: "Times New Roman", serif;" target="_blank">http://jummec.um.edu.my/filebank/published_article/2967/JuMMEC%202011%2014</a><span style="font-family: "Times New Roman", serif;">(1)%2010-20.pdf</span></p><p class="MsoNormal" style="margin-left: 24pt; mso-list: l0 level1 lfo1; tab-stops: list 24.0pt; text-align: justify; text-indent: -0.25in;"><b><i><o:p></o:p></i></b></p><p class="MsoNormal" style="text-align: left;"><span face="BlinkMacSystemFont, -apple-system, Segoe UI, Roboto, Oxygen, Ubuntu, Cantarell, Fira Sans, Droid Sans, Helvetica Neue, sans-serif"><span style="background-color: white;"> 5. Seventeen years' follw-up of the tension-free vaginal tape procedure for stress incontinence. Nilsson CG et al . Int Urogynaecol J 24(8)</span></span></p><h1 class="nova-e-text nova-e-text--size-xl nova-e-text--family-sans-serif nova-e-text--spacing-none nova-e-text--color-grey-900 research-detail-header-section__title" style="background-color: white; color: #111111; font-family: Roboto, Arial, sans-serif; font-size: 1.375rem; font-weight: 400; line-height: 1.2; margin-bottom: 0px; margin-top: 0px; padding: 10px 0px 5px;"><br /></h1>
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<p class="MsoNormal"><o:p> </o:p></p></div>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-25133915519521910602021-06-22T01:08:00.000-07:002021-06-22T01:08:13.480-07:00MISSION ULAAN BAATOR, MONGOLIA<p style="text-align: justify;">I had an opportunity to provide some training for young doctors & specialist in Ulaan Baator on OASIS & Urogynae update. A team of 4 urogynaecologist ( Me, Dr Ng Poh Yin, Dr Tan GI & Dr Ida Lily Waty) manage to organise & execute this valuable training. It took us near full one day to reach Ulaan Baator, as there is no direct flights from KL. The Trip was co-organise by MUGS & Mongolian Urogynae society and Mongolian O & G society. During this trip we had lectures on OASIS & wet lab / hands on sessions with the mongolian trainees & specialist. The day 2 was mainly an update in Urogynaecology. The training was well accepted. We had nearly 40 doctors from different parts of Mongolia participated in the training.</p><p>Following the training course, we also had life time opportunity to explore deep part of Mongolia. It was vast & unexplored territory. </p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQ_axufzN5qMovedx6-57BidQkuN3RV4wBmR4LOc1qElxd7ZXu3Ytr483NRFuK_KTDd55CHIc6JMZHwHBG_-P70rExaVJe30dkB8yjOsDItgxj33SDe8X-QhPRyO0EzTU1q5NrJ8y3KDaB/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1003" data-original-width="1188" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQ_axufzN5qMovedx6-57BidQkuN3RV4wBmR4LOc1qElxd7ZXu3Ytr483NRFuK_KTDd55CHIc6JMZHwHBG_-P70rExaVJe30dkB8yjOsDItgxj33SDe8X-QhPRyO0EzTU1q5NrJ8y3KDaB/" width="284" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjS4VxxfHgGZk-oFqiQMxjcT8aFTpIrP8JroqUrE9Xg6Jk7WtmkIHvyeIRJ6BXmybsB70Fv62om6hyphenhyphenYRxkax7IehdKx8I9iS0PRFJGgVTiyS-DHIBDH2ecaqhDWIHxpchtyTXBLn1c0TnjR/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1536" data-original-width="2048" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjS4VxxfHgGZk-oFqiQMxjcT8aFTpIrP8JroqUrE9Xg6Jk7WtmkIHvyeIRJ6BXmybsB70Fv62om6hyphenhyphenYRxkax7IehdKx8I9iS0PRFJGgVTiyS-DHIBDH2ecaqhDWIHxpchtyTXBLn1c0TnjR/" width="320" /></a></div><br /><br /></div><div style="text-align: justify;">Mongolia is a country sandwiched by Russia in the north & china in the south-east. It has vast steppe land. The total population is about 4 million & more than half of them live in Ulaan Baator (Capital of Mongolia). Mongolia was at one time a great country. Genghis Khan is a great Mongol emperor who had conquered large part of Central Asia and China in 13 & 14th century.</div><div style="text-align: justify;"><br /></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh5Oq2uzC8EcSVDgkqHxmWdaxh4QbwYIhTWlhHZOFigtl-a8yHPnowu6_rizi6Tb5zL-JavcF546vuht5NiwB8xAyugeCFwPwxJWY0bD5uled2nYpvT3fOgUSUfeygzw86seAuAgfVtZTJq/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1536" data-original-width="2048" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh5Oq2uzC8EcSVDgkqHxmWdaxh4QbwYIhTWlhHZOFigtl-a8yHPnowu6_rizi6Tb5zL-JavcF546vuht5NiwB8xAyugeCFwPwxJWY0bD5uled2nYpvT3fOgUSUfeygzw86seAuAgfVtZTJq/" width="320" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjq151vR91jPqTjrThYkxvEs0vHPU4k8_bXwSy8FgmB_sBfg0xPibxifyjAb7w_8aeFymShhIzCFxemQBJY_m7HbzCXhAkjWtu5ZsvtDxyBpbcap4x1dBfSCabWzE9tDvooDepZ3GZV6Pxi/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1536" data-original-width="2048" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjq151vR91jPqTjrThYkxvEs0vHPU4k8_bXwSy8FgmB_sBfg0xPibxifyjAb7w_8aeFymShhIzCFxemQBJY_m7HbzCXhAkjWtu5ZsvtDxyBpbcap4x1dBfSCabWzE9tDvooDepZ3GZV6Pxi/" width="320" /></a></div><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; margin-left: 1em; margin-right: 1em; text-align: left;"><div style="margin-left: 1em; margin-right: 1em; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhav8nB8yfP8pQX4r26QZxx_bNvWPOwXGRCEgED0047VtV2vqzmalZqnGY_E4IoxYNbWtQa30BvMKTxuTIMxiEO2ieW1oFm8mGWKtfSCP5lVrtW38FCeVodvaq0P6E_JLAAtTa49oKrILF6/" style="margin-left: 1em; margin-right: 1em;"><br /></a></div></div></div><br /></div><div class="separator" style="clear: both; text-align: justify;"> The Ulaan Baator City is a modern City. The Main hospital is well equipped and up to date.</div><div style="text-align: justify;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUsMx6xu0IWBJJG3UV8m2uhwD7d3-TS7BAmCTNicmljwN5QadNf4c21gP9vY9pvrDu66VuXAxYjMK_EgrI63LcYFqchOqFU05SGgLvNVStSpUJv5i0-Y764-pbHWxX8zkLQaQx4mZwJ2XD/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="2048" data-original-width="1536" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUsMx6xu0IWBJJG3UV8m2uhwD7d3-TS7BAmCTNicmljwN5QadNf4c21gP9vY9pvrDu66VuXAxYjMK_EgrI63LcYFqchOqFU05SGgLvNVStSpUJv5i0-Y764-pbHWxX8zkLQaQx4mZwJ2XD/w228-h240/SEPTEMBER+500.JPG" width="228" /></a><img alt="" data-original-height="2048" data-original-width="1536" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjM-Jg2RcT7m1Q2KHgPaHjgzV-Zh2iPiqUXzzu3z1Zyv02mYtxSUXCTpOBssJhuJ_C2b6olTHIBB1_K2ggQk3C3EVIhx0UBhbxKY-Ig1RFy4ZLKP2n60k_QAMTI09vRqKr0IV0oD4TKjBYa/w241-h240/SEPTEMBER+497.JPG" width="241" /></div><br /></div><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjM-Jg2RcT7m1Q2KHgPaHjgzV-Zh2iPiqUXzzu3z1Zyv02mYtxSUXCTpOBssJhuJ_C2b6olTHIBB1_K2ggQk3C3EVIhx0UBhbxKY-Ig1RFy4ZLKP2n60k_QAMTI09vRqKr0IV0oD4TKjBYa/" style="margin-left: 1em; margin-right: 1em;"><br /></a></div> The country has beautiful terrin. The people are super friendly and welcoming. <br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiod_D0acmtuujkr0yZ2c6vT5koLaHBp1p4NqdCiPAMtOcDaKI8ec1HmQQvmsvtw3q2-2ih5k4c7De-s9oCHDSZLWBcMG5_VoYNUcDL_V87-OEcK3EbbxAqQKmxrxI15ax8xq7CquEWTqgR/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="2048" data-original-width="1536" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiod_D0acmtuujkr0yZ2c6vT5koLaHBp1p4NqdCiPAMtOcDaKI8ec1HmQQvmsvtw3q2-2ih5k4c7De-s9oCHDSZLWBcMG5_VoYNUcDL_V87-OEcK3EbbxAqQKmxrxI15ax8xq7CquEWTqgR/w237-h240/SEPTEMBER+543.JPG" width="237" /></a><img alt="" data-original-height="2048" data-original-width="1536" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhav8nB8yfP8pQX4r26QZxx_bNvWPOwXGRCEgED0047VtV2vqzmalZqnGY_E4IoxYNbWtQa30BvMKTxuTIMxiEO2ieW1oFm8mGWKtfSCP5lVrtW38FCeVodvaq0P6E_JLAAtTa49oKrILF6/w244-h240/SEPTEMBER+549.JPG" width="244" /></div></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><object class="BLOG_video_class" contentid="" height="266" id="BLOG_video-" width="320"></object></div><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><object class="BLOG_video_class" contentid="" height="266" id="BLOG_video-" width="320"></object></div><br /><br /><span style="text-align: left;">Overall it was a great teaching & exploration trip for all of us</span></div>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-75433834826318992762021-06-16T21:12:00.002-07:002021-06-17T00:35:56.031-07:00PERI-URETHRAL AND PERINEAL-VAGINAL MASSES: HOW TO DEAL WITH IT ?<p><span style="text-align: justify;">Periurethral, perineal or vaginal masses are masses or swelling around the urethral meatus, vaginal area or the perineal region. The incidence is less than 4%. The main presentation is feeling a swelling or mass around the meatus, vagina & vulva, difficulty in passing urine, urethral discharge and pain on sexual intercouse. There is limited information / literature on the exact incidence, diagnosis and management for this conditions.</span></p><div class="separator" style="clear: both; text-align: justify;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitXCDM20jOPaO9OibH8rzls3ZE88ebR0FcNpOPfw1oG_Bc4Zc6eo4WifH360ojv2EoW5oZJpnmm8SsrnTTzIInp_JzETihAljJrqml7BhhrUT3QRnRqHlmi_pO9sexqaJGKxmAMFaN892W/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="472" data-original-width="576" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitXCDM20jOPaO9OibH8rzls3ZE88ebR0FcNpOPfw1oG_Bc4Zc6eo4WifH360ojv2EoW5oZJpnmm8SsrnTTzIInp_JzETihAljJrqml7BhhrUT3QRnRqHlmi_pO9sexqaJGKxmAMFaN892W/" width="293" /></a>periurethral mass</div><div style="text-align: left;"><br /></div></div><div class="separator" style="clear: both; text-align: justify;">The differential diagnosis of suchs massess include;</div><div class="separator" style="clear: both; text-align: justify;"><ul><li>Urethral Diverticulum ( 84%)</li><li>Peri-urethral leiomyoma (7%)</li><li>Periurethal vagianl cyst/ Gartner's cyst (6%) or remnant of mullerian duct cyst</li><li>Skene's gland cyst or abcess</li><li>Retention cyst</li><li>Urethral Prolapse</li><li>Urethral Caruncle</li><li>Ectopic Ureterocele </li><li>Inguinal/Femoral Hernia</li><li>Benign tumours- angiomyoblastoma, fibromas, warts</li><li>Malignancies</li></ul><div>The diagnosis is usually clinical, and some case we may need to do some imaging studies to see the nature & extent of the lesions. The suggested imaging studies include perineal Ultrasound, Ct Scan/ MRI, Urethroscopy/cystoscopy, micturating cystogram and double balloon urethrogram.</div><div><br /></div><div>The management options will depends on the diagnosis. If small & asymptomatic, usually can be managed as conservatively. Aspiration of the cyst content can be done , but usually the cyst reoccurs. The suggested surgery include endoscopic re-roofing, trans-urethral incision, Marsupialization of the diverticulum or cyst, cystectomy of the cyst wall in cases of gartner's or skene gland cyst. Diverticulectomy in case of urethral diverticulum with grafting in some case. In some case excision of the lesions</div><div><br /></div><div>Below are some of my personal collection of cases & how l managed them:</div><div><br /></div><div><b><span style="color: red;">Case 1</span></b>. 36 year old Para 2 with urinary incontinence & passing pus discharge urethral meatus. on examination noted tender, fluctuant mass, below urethral meatus. On pressing/milking the mass, pus & urine discharge noted coming from the urethral meatus. The diagnosis of Urethral Diverticulum was made. Marsupialization was carried out. This will create a small suburethral fistula and allow the secretion to escape & thus facilitates the closure & healing of the fistula tract that communicates into the urethra. Based on my experience, this is very effective & simple operation.</div></div><p></p><blockquote style="border: none; margin: 0px 0px 0px 40px; padding: 0px;"><p></p><p></p><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiojs4Y5mCYIKeQp2TIV-lBFn57IqUk51NAGN9st3-uekd2rXi03S5JoED6JzvYEF5T_rAK2Rdr8IVSfANHQGlPFFgXx-LzQIo5LTIoERS8aGVJs1aqtEiMCqPoTisin8ut8b4gpO-svn95/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="415" data-original-width="368" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiojs4Y5mCYIKeQp2TIV-lBFn57IqUk51NAGN9st3-uekd2rXi03S5JoED6JzvYEF5T_rAK2Rdr8IVSfANHQGlPFFgXx-LzQIo5LTIoERS8aGVJs1aqtEiMCqPoTisin8ut8b4gpO-svn95/w239-h240/image.png" width="239" /></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTLJ-T_186i6hTm7_811Y0Ggatw5DzAfWOZcreClro1Z_fY9mrVdsMLGV6chAZEB7K7zHC96xveNsJaRtAeM7CfqsZlycSWyvPXUJusEgMdngsQ15_l5GH4lY5kyZjQ6paBmZI5d1zB4-h/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="411" data-original-width="416" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTLJ-T_186i6hTm7_811Y0Ggatw5DzAfWOZcreClro1Z_fY9mrVdsMLGV6chAZEB7K7zHC96xveNsJaRtAeM7CfqsZlycSWyvPXUJusEgMdngsQ15_l5GH4lY5kyZjQ6paBmZI5d1zB4-h/" width="243" /></a></div></div><p></p><p></p></blockquote><p></p><p></p><div class="separator" style="clear: both; text-align: center;">suburethral abscess</div><br /><b><span style="color: red;">Case 2.</span></b> 32 year old patient presented with periurethral mass for 3 months. Initially the mass was small 3x 2 cm. Over few mass it become 8x8 cm. It was infected & rubbery in nature. Patient also had difficulty in passing urine. EUA & excision of the mass was carried out. The histology was consistent with para-urethral angiomyofibroblastoma. This case was published in Australia & New Zealand Continence Journal Vol 10, No 1, March 2004. The patient recovered very will with no recurrence. This condition is Benign tumour. <p></p><p><img alt="" data-original-height="284" data-original-width="312" height="183" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh5o3FkWSDEoMM1U1y29es0cbQROUfpBjvHS0wNWxThbOu1UxQ2uD0gOKLkvkzg5KIAnoPIgg520MN8pPvUmNsRjIfNGoqSr8vkjBd7CnRFpP6dAB3sqti3prjRKu6zL5R8fykqr4-3vCao/w202-h183/image.png" width="202" /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7suqToRmm-xyfLcUNSP6CU7h_HOUTZkpeh5Vj3HJgzrNbD6bCAPjuSNCNJHA-kOmQpwUB__uJPgqLr48SNIJieXN_BMo-E_mdV06OsHX0ZICPmU9YBub-JeV73StgPGVXMu3n0hxvkvAq/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="280" data-original-width="318" height="191" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7suqToRmm-xyfLcUNSP6CU7h_HOUTZkpeh5Vj3HJgzrNbD6bCAPjuSNCNJHA-kOmQpwUB__uJPgqLr48SNIJieXN_BMo-E_mdV06OsHX0ZICPmU9YBub-JeV73StgPGVXMu3n0hxvkvAq/w217-h191/image.png" width="217" /></a></p><p></p><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7suqToRmm-xyfLcUNSP6CU7h_HOUTZkpeh5Vj3HJgzrNbD6bCAPjuSNCNJHA-kOmQpwUB__uJPgqLr48SNIJieXN_BMo-E_mdV06OsHX0ZICPmU9YBub-JeV73StgPGVXMu3n0hxvkvAq/" style="margin-left: 1em; margin-right: 1em;"></a></div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh5o3FkWSDEoMM1U1y29es0cbQROUfpBjvHS0wNWxThbOu1UxQ2uD0gOKLkvkzg5KIAnoPIgg520MN8pPvUmNsRjIfNGoqSr8vkjBd7CnRFpP6dAB3sqti3prjRKu6zL5R8fykqr4-3vCao/" style="margin-left: 1em; margin-right: 1em;"><br /></a><div class="separator" style="clear: both; text-align: left;"><img alt="" data-original-height="280" data-original-width="316" height="217" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjKO-WG5anALM1FUwhDB4rU9Ia-4Vr4vQIGL8GIBc1R4_9D1tyUUDrQAVgT9RF6pTPDdCdChyHOiBFxcfBla9cRrAPEFBSiR9leBPHvaIfiCekVsaAiVaNsHtVOOgzrRERWCH-OQhAR0OAn/w211-h217/image.png" width="211" /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPtYBZboCJtV7tjF19kqW8sB8XaY5sICVFuZWePMocrsFFGDZ0c-U6w1KN_QOSWvAa3J816r4oXv-IfCZs3zyRGozngGOAMGKySy30LAw_9iP_V4Xpi-2oTHXD9roRyv87YFmXz3G1WmV-/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="280" data-original-width="362" height="214" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPtYBZboCJtV7tjF19kqW8sB8XaY5sICVFuZWePMocrsFFGDZ0c-U6w1KN_QOSWvAa3J816r4oXv-IfCZs3zyRGozngGOAMGKySy30LAw_9iP_V4Xpi-2oTHXD9roRyv87YFmXz3G1WmV-/w219-h214/image.png" width="219" /></a></div></div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjKO-WG5anALM1FUwhDB4rU9Ia-4Vr4vQIGL8GIBc1R4_9D1tyUUDrQAVgT9RF6pTPDdCdChyHOiBFxcfBla9cRrAPEFBSiR9leBPHvaIfiCekVsaAiVaNsHtVOOgzrRERWCH-OQhAR0OAn/" style="margin-left: 1em; margin-right: 1em;"><br /></a><b><span style="color: red;">Case 3.</span></b> 29 year old Para1, noted cystic swelling around urethral meatus after delivery. On examination there was a cystic, transparent mass around 6 o clock below the urethral meatus. It was non tender mass. Mobile & cystic in nature. The options for such cases are neddle aspiration (but the recurrence rates are high), cystectomy, & marsupialization. In this case complete cystectomy was done. paraurethral or vaginal cyst develop as result of local irritation, inflammation or sequential blockage of vaginal or paraurethral glands. If infected the develop into abscess.<p></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEguKz1Zla1emrcujhPhm6oenlyK-yUDfLFM6I5O8wtGrH2t8HZcILLY4A4gLV_hDWMcUCVO-BQPt0w1n0beNK1cHQXZZN6dMEB3cox3VL6mHwBnq0c_DPKDT0Z3tIv-E3iiIroZgDMGszVn/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="2048" data-original-width="1536" height="262" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEguKz1Zla1emrcujhPhm6oenlyK-yUDfLFM6I5O8wtGrH2t8HZcILLY4A4gLV_hDWMcUCVO-BQPt0w1n0beNK1cHQXZZN6dMEB3cox3VL6mHwBnq0c_DPKDT0Z3tIv-E3iiIroZgDMGszVn/w191-h262/suburethral+abcess.jpg" width="191" /></a><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dwVzz2HOvutmU5K-BOdM7LLmW1Nxt0gCpU_724Z5xleYgpE9SSOAQATdO-npXFhvqkLre32_AtvbSfBOohMiw' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: justify;"><span style="color: red;"><b>Case 4.</b></span> 56 year old para 5 lady, presented with progressively enlarging mass on the left side of vagina. On examination the was 18 x 12 cm cystic mass noted. The mass was multiloculated & cystic. CT Scan showed cystic mass with no intra pelvic extension. A dignosis of <span style="text-align: justify;"> </span><span style="text-align: justify;">vagianl cyst/ Gartner's cyst or remnant of mullerian duct cyst was made. EUA and drainage was carried out. Serous like material removed and complete cystectomy and labioplasty was carried out. Vaginal wall cyst/ Gartner/ Mullerian remnant cyst occurs in 0.5-1% of patients. Mostly asymptomatic & unreported. An evaluation should include upper genito-urinary tract assessment to rule out any extension of the mass/cyst and other genito-urinary tract abnormalities. US/CT scan/MRI is the imaging modality of choice. If the is no concomitant abnormality of extension, than a cystectomy or marsupialization is surfice.</span></div><div class="separator" style="clear: both; text-align: justify;"><span style="text-align: justify;"><br /></span></div><div class="separator" style="clear: both; text-align: justify;"><span style="text-align: justify;"><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: center;"><img alt="" data-original-height="470" data-original-width="408" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8_Sx56G8FvPEK3uN_YOxkySEqvuY4U0FXZZv8-HPq_iz1PTXqZmRvI9-rmskRPVB3TTMq26OU6OsfaaAk9jRT-bHosGK4Oyn2PwcXMosTEUcgOaRjla1-4mFUEfOR51FVq-u_0oqPsKBB/" width="208" /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIVWgvDWsuAau3cnVo_yIxbDGgwtgskD-rw4NvyFZVYOGsn-TXdEhnAY8W_xwX10mri-GsdyMewWXGNfVBFHRdJemuvvDjXHxZvXJITS5adne1qWuVTvdB3zSwm1VDeLENNDF5v9IAMyxK/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="435" data-original-width="375" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIVWgvDWsuAau3cnVo_yIxbDGgwtgskD-rw4NvyFZVYOGsn-TXdEhnAY8W_xwX10mri-GsdyMewWXGNfVBFHRdJemuvvDjXHxZvXJITS5adne1qWuVTvdB3zSwm1VDeLENNDF5v9IAMyxK/" width="207" /></a></div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8_Sx56G8FvPEK3uN_YOxkySEqvuY4U0FXZZv8-HPq_iz1PTXqZmRvI9-rmskRPVB3TTMq26OU6OsfaaAk9jRT-bHosGK4Oyn2PwcXMosTEUcgOaRjla1-4mFUEfOR51FVq-u_0oqPsKBB/" style="margin-left: 1em; margin-right: 1em;"><br /></a></div><b><span style="color: red;">Case 5</span></b>. 44 year old para 5 presented with recurrent left side tender vaginal mass. The mass typically present during pregnancy & subside after delivery. After the last childbirth, the mass persisted and become very tender & painful. </span>Transabdominal ultrasound revealed a longitudinal mass from left vaginal
wall extending to pouch of douglas. The mass was mixed in echogenicity. CT scan of abdomen reported as cystic mass anterior to the sacrum extending
to lower part of vagina with possible differential diagnosis as (rectal
duplication cyst or cystic sacrococcygeal teratoma or ischiorectal cystic
lesion/abscess.). A diagnostic laparoscopy was carried out, which revealed left ischiorectal
fossa abscess Therefore, 300cc of pus
and caseous material drained through vagina. Pus culture and sensitivity grew
B-hemolytic non A/B steptococcus. Otherwise, swab AFB, all other infective screening
were negative. The fasting blood sugar was 4.8mmol/l. Sigmoidoscopy and Colonoscopy was essentially
normal. This time a large marsupialization was done & the abscess was drained. Since than the mass/abscess did recurred. She remain asymptomatic until now.</div><div class="separator" style="clear: both; text-align: justify;"><br /></div><div class="separator" style="clear: both; text-align: justify;"><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhU9fJY2OygdQ2o_MJ4ALevKmtq9s3ilKL0WE2GV2tsL2o-cFRZJMROmghQGwsHjBoCXzygtF5h0QHtgHE4x9NX9yklCVV31xLPnCJ4zKDpA5oe9Gu9ID28pTMAyMR2KMZF0ApybthLsu0N/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="183" data-original-width="220" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhU9fJY2OygdQ2o_MJ4ALevKmtq9s3ilKL0WE2GV2tsL2o-cFRZJMROmghQGwsHjBoCXzygtF5h0QHtgHE4x9NX9yklCVV31xLPnCJ4zKDpA5oe9Gu9ID28pTMAyMR2KMZF0ApybthLsu0N/w242-h240/image.png" width="242" /></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiD1ZqBvht_GA0WcJ9TVtTQ-qlmYa06MZ5pvttwyZn8K4R62IcDK3wsst3wzDqym9-Y4d7BvWhcsFE4kLsgAAxOgWIx6vIAlV9FuEXx0ZsJgrVaGZEVwvjD30MbAAarmQf6tOhRqXTzNhc0/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="203" data-original-width="301" height="231" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiD1ZqBvht_GA0WcJ9TVtTQ-qlmYa06MZ5pvttwyZn8K4R62IcDK3wsst3wzDqym9-Y4d7BvWhcsFE4kLsgAAxOgWIx6vIAlV9FuEXx0ZsJgrVaGZEVwvjD30MbAAarmQf6tOhRqXTzNhc0/w244-h231/image.png" width="244" /></a></div><br /></div><div class="separator" style="clear: both; text-align: justify;"><div class="separator" style="clear: both; text-align: center;"></div><b><span style="color: red;">Case 6.</span></b> 68 year old patient postmenapausal for 20 year, presented with painful micturition and vaginal soreness. On assessment, there was a growth at the external urethral meatus. The common diagnosis for such conditions are Caruncle or urethral prolapse. In this case this patient had a urethral prolapse. Treatment for caruncle or prolapse is usually topical estrogen application. In some case caruncle/prolapse can be infected. in such cases antibiotics may be indicated. Surgical options includes cauterization for the caruncle or prolapse. In some cases of prolapse, circumferential excision of the prolapse and approximation of the urethro-vagina margins can be carried out.<br /><div style="text-align: left;"><br /><br /></div></div><div class="separator" style="clear: both; text-align: justify;"><span style="text-align: justify;"><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: left;"><img alt="" data-original-height="478" data-original-width="359" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiRQe3tiQXTGaoul3ErEd7kctHc9UczmOw91hrZUEkKLrIjt8jmpOEA8LUpfVooo1OGeevDZf24m-1v9PnHGwURUO6FtwNgwpPJyMOpsLK3WvOIAbsyKS1oL4do_b4gAX_9O5C-liNXTQSK/w206-h240/image.png" width="206" /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitnjW6daqXMERVCD0C_G23facjjdiFR3t6_8szAqrIgxI0eTBr7GnDShpzQxCJ5MWRF4QLoEvy8bsXJh_Iik9nj4i_iKjkTjnqB_JN10x6b6vIVx2kn3x9bvq2WwNk8OWco5X9zJ6aBpBG/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="512" data-original-width="416" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitnjW6daqXMERVCD0C_G23facjjdiFR3t6_8szAqrIgxI0eTBr7GnDShpzQxCJ5MWRF4QLoEvy8bsXJh_Iik9nj4i_iKjkTjnqB_JN10x6b6vIVx2kn3x9bvq2WwNk8OWco5X9zJ6aBpBG/w235-h240/image.png" width="235" /></a></div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiRQe3tiQXTGaoul3ErEd7kctHc9UczmOw91hrZUEkKLrIjt8jmpOEA8LUpfVooo1OGeevDZf24m-1v9PnHGwURUO6FtwNgwpPJyMOpsLK3WvOIAbsyKS1oL4do_b4gAX_9O5C-liNXTQSK/" style="margin-left: 1em; margin-right: 1em;"><br /></a></div><b><span style="color: red;">Case 7</span></b>. 58 year old, presented with urinary obstruction & pv bleeding. </span></div><div class="separator" style="clear: both; text-align: left;"><span style="text-align: justify;"><br /></span></div><div class="separator" style="clear: both; text-align: justify;"><span style="text-align: justify;"><div class="separator" style="clear: both; text-align: justify;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHovC-UT7vA39lcX47l6OUjUUjMamzP6xnaDB-iEerkyCCelsfC2td6S2lNnufMyGkeVKOizxXDoRje8FI-R8Vjy0XAbrtms1V5V_TlyZU6R98LC0ufKlH2kZiCyg4VA8xqef9Zot_QHJ-/" style="margin-left: 1em; margin-right: 1em; text-align: left;"><img alt="" data-original-height="469" data-original-width="352" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHovC-UT7vA39lcX47l6OUjUUjMamzP6xnaDB-iEerkyCCelsfC2td6S2lNnufMyGkeVKOizxXDoRje8FI-R8Vjy0XAbrtms1V5V_TlyZU6R98LC0ufKlH2kZiCyg4VA8xqef9Zot_QHJ-/w245-h240/image.png" width="245" /></a></div></span></div><div class="separator" style="clear: both; text-align: justify;"><span style="text-align: justify;">On Examination, noted friable mass periurethrally. Biosy was consistent with sq cell ca stage 4. Patient was referred for radiotherapy. Malignancy at peri- urethral region is very rare. Prognosis is usually poor.</span></div><div class="separator" style="clear: both; text-align: justify;"><span style="text-align: justify;"><br /></span></div><div class="separator" style="clear: both; text-align: justify;"><span style="text-align: justify;"><b><span style="color: red;">Case 8.</span></b> This is a 15 year old girl, presented with continuous urine leakage from young. No proper previous evaluation. On examination, there was continuous leakage & wetness at periurethral region. CTU was carried out, revealed an ectopic ureter from right kidney extending to the periurethral region. Patient was referred to our paediatric surgeon, who subsequently ligated the ectopic ureter. Patient was symptom free after this procedure.</span></div><div class="separator" style="clear: both; text-align: justify;"><span style="text-align: justify;"><br /></span></div><div class="separator" style="clear: both; text-align: justify;"><span style="text-align: justify;"><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiuBQgtrOBNDM-3YpmsahzUnyrpsjN49vQSfM92A1DVw6jygU9869q8RO5OuM4rRJw0Po3HQDFh7GoJMY-nbLXgPrlE3dtpykuvg8Bt-h2I_KyKcHdBceYhN2KPWr-LkLpvhCIylvyRaOMo/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="429" data-original-width="289" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiuBQgtrOBNDM-3YpmsahzUnyrpsjN49vQSfM92A1DVw6jygU9869q8RO5OuM4rRJw0Po3HQDFh7GoJMY-nbLXgPrlE3dtpykuvg8Bt-h2I_KyKcHdBceYhN2KPWr-LkLpvhCIylvyRaOMo/w255-h240/image.png" width="255" /></a></div><br /><div style="text-align: left;"><b><span style="color: red;">Case 9</span></b>. A 6 year old child presented with difficulty in pass urine & para peri-urethrally. The mass was firm in consistency & non tender. It was reducible. An inguinal hernia was suspected. This patient referred to paediatric surgeons. The finding confirm reducible inguinal hernia with omentum</div><div class="separator" style="clear: both; text-align: justify;"><span style="text-align: justify;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: left;"><img alt="" data-original-height="446" data-original-width="334" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh11uSo55AgoX_tMKd-xPRD7MkiE66zSZsXhIuQUow67mQtxln70uLrmozb5uXMoP3PD1wTwQjCa1Vw-P2sfXTsJ16R1oaG6-RyOPWLNqf2UWs7K4CY4qLHjvStvLZiB0Z_t45Ki0ymR_e8/w233-h240/image.png" width="233" /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhc8rvfM4ugMqqd7yxhIB7ObJIfGgPbLahWpU6M9KOjXJXNUmF-UPQ5YZNsMByl_cMUdwRgfa7kU-5pwzQEVkXegS4-0SuEaucazTFs_s37ItsBKeWVOhXEHipvDLHiquHSL_4knrCrf9bW/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="384" data-original-width="377" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhc8rvfM4ugMqqd7yxhIB7ObJIfGgPbLahWpU6M9KOjXJXNUmF-UPQ5YZNsMByl_cMUdwRgfa7kU-5pwzQEVkXegS4-0SuEaucazTFs_s37ItsBKeWVOhXEHipvDLHiquHSL_4knrCrf9bW/" width="236" /></a></div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh11uSo55AgoX_tMKd-xPRD7MkiE66zSZsXhIuQUow67mQtxln70uLrmozb5uXMoP3PD1wTwQjCa1Vw-P2sfXTsJ16R1oaG6-RyOPWLNqf2UWs7K4CY4qLHjvStvLZiB0Z_t45Ki0ymR_e8/" style="margin-left: 1em; margin-right: 1em;"><br /></a></div><b><span style="color: red;">Case 10.</span></b> A 58 year old patient presented with large mass, protruding from the vulval region. It was there for nearly 20 year. it was slow growing mass. On examination there was a firm & pedunculated mass on the left labia. It was non tender and mobile. US & CT scan did not show any extension or pelvic mass, Uterus & ovaries was normal, Labial Fibroma was diagnosed. Patient underwent excision with much problem. Histology was consistent with fibroma<br /><div style="text-align: left;"><br /></div></span></div><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: left;"><img alt="" data-original-height="375" data-original-width="336" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhsD8KQizhCbI8966XEOfQbZoFySKQY_U9wbDDiWdtDN8LHdziAOeKhQFqgIJP8zyOtOKBI8auaSCih0kIkL_xjjqSt0YPdrUe4nwSDBMfwftK09aAk9WWoOXRua0yDjHovP7iHLfDV9h__/" width="215" /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi3RSrEuiMR_DE2Yq9uICluTk8mM6cZkAW8dYtsnKZbZ18ecNKTx2l8LTHxOBRvInwQKQr21fvGOb643BndepVWobD_15tRRNhntcW0NFhAHsQkjqvK2DoZiAzgE_wNWnntBciaCB2Joqj-/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="2048" data-original-width="1536" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi3RSrEuiMR_DE2Yq9uICluTk8mM6cZkAW8dYtsnKZbZ18ecNKTx2l8LTHxOBRvInwQKQr21fvGOb643BndepVWobD_15tRRNhntcW0NFhAHsQkjqvK2DoZiAzgE_wNWnntBciaCB2Joqj-/w231-h240/IMG_0300.JPG" width="231" /></a></div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhsD8KQizhCbI8966XEOfQbZoFySKQY_U9wbDDiWdtDN8LHdziAOeKhQFqgIJP8zyOtOKBI8auaSCih0kIkL_xjjqSt0YPdrUe4nwSDBMfwftK09aAk9WWoOXRua0yDjHovP7iHLfDV9h__/" style="margin-left: 1em; margin-right: 1em;"><br /></a></div><b><span style="color: red;">Case 11.</span></b> 65 year old para 5 presented with right side periurethral mass. the mas was firm & tender on pressure. Patient also had voiding difficulty. On examination there was a firm mass in the right upper labia and extending to lower abdomen. it was not reducible. A CT scan revealed a possible ovarian mass with omentum. A diagnosis of ovarian hernia was diagnosed. EUA & exploration was carried out, It turn of as ovarian fibroma prolapsing through the inguinal canal. Right Salphingo-oopherectomy & hernia repair was carried together with surgical team. Patient recovered well. Histology consistent with ovarian fibroma.<div><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: left;"><img alt="" data-original-height="2048" data-original-width="1536" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-kf6311THlbxa-aGVbrcXHcXSctX9md_UBSR0Tm_H7_OldwfP899BzXAmfonGoeOJC2yqh_uhvziaNvc3Jcz7eexzFYiMBIUOA7A8PRcWQ1DRaWLQ_ofhj6EQsjsbq4UIz0fdOa2n2Zsc/w239-h240/social+2019+510.JPG" width="239" /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyP1zWOAJkrzdwFR-kSLYFnJr86dbFTa6WMWhalSF_e9txI7AcanXTavdHmHKEvE0X1V0Rv_SgY_Gf2UGN5vqV1f6VTVy6ZoJQJf2O38tg0fb7RPZAivTNg77lS2-2a934LT1pMU0Azi5D/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="2048" data-original-width="1536" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyP1zWOAJkrzdwFR-kSLYFnJr86dbFTa6WMWhalSF_e9txI7AcanXTavdHmHKEvE0X1V0Rv_SgY_Gf2UGN5vqV1f6VTVy6ZoJQJf2O38tg0fb7RPZAivTNg77lS2-2a934LT1pMU0Azi5D/" width="180" /></a></div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-kf6311THlbxa-aGVbrcXHcXSctX9md_UBSR0Tm_H7_OldwfP899BzXAmfonGoeOJC2yqh_uhvziaNvc3Jcz7eexzFYiMBIUOA7A8PRcWQ1DRaWLQ_ofhj6EQsjsbq4UIz0fdOa2n2Zsc/" style="margin-left: 1em; margin-right: 1em;"><br /></a></div><br />Other Mass that I have seen in my practice:</div><div><br /></div><div><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDR1_kDQqaa03SzKZG_0tk7we3uofDVRYc6_zKeekTZQKO6nO_jy6tN8kRIVqZZdOShp_8PiGWWBy6JBtDnjCfiNQlnkoKm9Nvwv7xpOX9NAukuiJ5Gmh-EmC5FqEQRfZt5WhrF1cSds5i/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="2048" data-original-width="1536" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDR1_kDQqaa03SzKZG_0tk7we3uofDVRYc6_zKeekTZQKO6nO_jy6tN8kRIVqZZdOShp_8PiGWWBy6JBtDnjCfiNQlnkoKm9Nvwv7xpOX9NAukuiJ5Gmh-EmC5FqEQRfZt5WhrF1cSds5i/w193-h240/160.JPG" width="193" /></a>Recurrent mass at upper left labial. First excision biopsy was leiomyoma. came back again after 5 years, the second Excision Biopsy can as Leiomyosarcoma. She was subsequently referred for wider excision and chemotherapy with gynae-oncologist.</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2IqYeko9hi4wmN5jJnSnaa4HIKPILm0t-IM43qbI8M_ccBzv6u-9SaH8k3-I7wl4-dzbixmpQq54FwGXrv8RyXRvSOVJS-y8MFhyphenhyphenDcWYQ9lNYYYikAxsWqvKtNyK3sxhfrPiGanZh5jEP/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1008" data-original-width="490" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2IqYeko9hi4wmN5jJnSnaa4HIKPILm0t-IM43qbI8M_ccBzv6u-9SaH8k3-I7wl4-dzbixmpQq54FwGXrv8RyXRvSOVJS-y8MFhyphenhyphenDcWYQ9lNYYYikAxsWqvKtNyK3sxhfrPiGanZh5jEP/w205-h240/ABMD0865.JPG" width="205" /></a>This patient presented as fungating grown & wary lesions. Biopsy & excision of the warty growth reveal Hyperkeratosis. Manged with local & systemic steroids. No under dermatology.</div><div class="separator" style="clear: both; text-align: left;"><br /></div></div><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsvlmlVjfQ2Mav3vj9b9Ned1Wa1Zw_zrX8L14VwuUFx7Gq-vSdeNaNm46ZUxXQqsUwjoDnGnZyFvDFKUqe5U-PET1zSzn6G5bF1_L0z-pi161Uvq0ZsXaV07JlngEIKgAaIRt0AIvpsJeq/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1080" data-original-width="810" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsvlmlVjfQ2Mav3vj9b9Ned1Wa1Zw_zrX8L14VwuUFx7Gq-vSdeNaNm46ZUxXQqsUwjoDnGnZyFvDFKUqe5U-PET1zSzn6G5bF1_L0z-pi161Uvq0ZsXaV07JlngEIKgAaIRt0AIvpsJeq/w240-h240/SEPTEMBER+1306.JPG" width="240" /></a>Hypertrophic clitoris. Patient planned for clitroplasty</div><br /><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgaMQ9ce-WOptbSzUI8zt7hgB_W3qMidXWrmV8FYoireWGgymb2w-bZ_CJqgYM607lblZBgswPPwiuDl_y6_rY3Vp-i17Zcx7yGuNLiakcw4VWBCfMTXIPKHkqs4ZnaymViAhRLA4L6yqhj/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="2048" data-original-width="1536" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgaMQ9ce-WOptbSzUI8zt7hgB_W3qMidXWrmV8FYoireWGgymb2w-bZ_CJqgYM607lblZBgswPPwiuDl_y6_rY3Vp-i17Zcx7yGuNLiakcw4VWBCfMTXIPKHkqs4ZnaymViAhRLA4L6yqhj/w234-h240/IMG_8788.JPG" width="234" /></a> Genital Wart. Excision & cauterization of the wart carried out. Followed by application of imiquimod cream.</div><div class="separator" style="clear: both; text-align: left;"><br /></div><br /><div><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1Qx8WnrdDr5IX2vfCPff1ZPwr4pllo0YBR_8gSmtGzopDQXdLr1LRsUp041xm8KRrqhtSRQni0eT9zPYeYZyYjrrPJsLNOsUkjkaEf8UdLUazFyEwfqyMhfPi9IUV3S40IK6dl04_5GdW/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1536" data-original-width="2048" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1Qx8WnrdDr5IX2vfCPff1ZPwr4pllo0YBR_8gSmtGzopDQXdLr1LRsUp041xm8KRrqhtSRQni0eT9zPYeYZyYjrrPJsLNOsUkjkaEf8UdLUazFyEwfqyMhfPi9IUV3S40IK6dl04_5GdW/" width="320" /></a>Chronic Ulceration & necrotic mass. Biopsy revealed sq cell ca, Wide excision & radiotherapy carried out.</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFYmCR8NyLX24X9g-zhA0DfUBCS-EwuUvcIVZ4pBWNlQ6oYOoIYMi035RyF1blrF4Cgyg4IsC0Saam3BEY5wzz8fDguD2Sih-LzMUofqSrEAPorG8HLPo0xJSZ0KCG9s-_FVQvx6eSsz2x/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="2048" data-original-width="1536" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFYmCR8NyLX24X9g-zhA0DfUBCS-EwuUvcIVZ4pBWNlQ6oYOoIYMi035RyF1blrF4Cgyg4IsC0Saam3BEY5wzz8fDguD2Sih-LzMUofqSrEAPorG8HLPo0xJSZ0KCG9s-_FVQvx6eSsz2x/w272-h240/IMG_0937.JPG" width="272" /></a> Recurrent Paget's Disease . Now on remission & intermittent Imiquimod cream treatment.</div></div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxnE1FloxeSHmViDDp-5fmHkUH6fBZZK3dyGOMyhO9PlQ7g9IaDSVHvocSUaQGxYE9LTHM4CIKLKo0HMrttwwjCHF7N3ESW8AUQO7SZv0Q_ay1ALRUdl1VfrwRGCU_KmXRL4-m2x8C-DTG/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1536" data-original-width="2048" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxnE1FloxeSHmViDDp-5fmHkUH6fBZZK3dyGOMyhO9PlQ7g9IaDSVHvocSUaQGxYE9LTHM4CIKLKo0HMrttwwjCHF7N3ESW8AUQO7SZv0Q_ay1ALRUdl1VfrwRGCU_KmXRL4-m2x8C-DTG/" width="320" /></a>Excessive Lichen sclerosis. Excision biopsy and local Steroid treatment given, recover very well.</div><br /><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgenTQ76ioWaIqx1clKSQH3FdK817Kk-kfsrhMFBy8OA4TF2iC6N8NT0yCFA4_d5OpQzFQISBd_YYhVkB_IjMawgH96axgfDZW4dPwxPEUElWPsAw6-PWGNzT7o7PygoSEBWgy1gQCrBHkb/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="395" data-original-width="416" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgenTQ76ioWaIqx1clKSQH3FdK817Kk-kfsrhMFBy8OA4TF2iC6N8NT0yCFA4_d5OpQzFQISBd_YYhVkB_IjMawgH96axgfDZW4dPwxPEUElWPsAw6-PWGNzT7o7PygoSEBWgy1gQCrBHkb/" width="253" /></a> A baby with Ambiguous genitalia. given to paediatric surgeon to manage</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: left;"><img alt="" data-original-height="1536" data-original-width="2048" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-xvfz-s_RKD3_SoCEGMQyt-bTU3ZAtklHu9EB-dRR3bdxFhYrpxttGafXNR601-u7Od7dp2cbGdff6mxIYVSRB5Kf3uhmA8u4Y_-5Zhv0wH77nHvIgibUCDSayTQ2PfkivGaQKI9pJCA_/w241-h240/vaginal+vericosity.JPG" width="241" /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiGSyoR0G5A7GkDp5SS9TxAxCgAA6GVGVBg6suxuTteLOoz1Hy0wv6DjhqMB4OTy0ihGFNK0iL4vB7jqtJ7Auzr2P4yFUNGayN8-9cmk0SWHMwFtuxTqAIj2GyqKQdHWBPCeprhK9nw2aAQ/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="200" data-original-width="198" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiGSyoR0G5A7GkDp5SS9TxAxCgAA6GVGVBg6suxuTteLOoz1Hy0wv6DjhqMB4OTy0ihGFNK0iL4vB7jqtJ7Auzr2P4yFUNGayN8-9cmk0SWHMwFtuxTqAIj2GyqKQdHWBPCeprhK9nw2aAQ/" width="238" /></a></div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-xvfz-s_RKD3_SoCEGMQyt-bTU3ZAtklHu9EB-dRR3bdxFhYrpxttGafXNR601-u7Od7dp2cbGdff6mxIYVSRB5Kf3uhmA8u4Y_-5Zhv0wH77nHvIgibUCDSayTQ2PfkivGaQKI9pJCA_/" style="margin-left: 1em; margin-right: 1em;"><br /></a></div><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3rIDsRtGptJyXyriX9IOCyofYjbjK8H5daCrz_bkLGK14gPYXA5bNPBbMxvZKoyrJ8vYdGVvJMRgI8OqBpf-sBZXwhuTLwXHe4wLzvmDKUS9bhdasVOtRhwaZTFGYBGcZR8VNVslu_2zg/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="2048" data-original-width="1536" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3rIDsRtGptJyXyriX9IOCyofYjbjK8H5daCrz_bkLGK14gPYXA5bNPBbMxvZKoyrJ8vYdGVvJMRgI8OqBpf-sBZXwhuTLwXHe4wLzvmDKUS9bhdasVOtRhwaZTFGYBGcZR8VNVslu_2zg/" width="180" /></a> Case of Vulva Varicosity before & after ligation of the feeding vessels ( by Plastic Surgeon) newer modality is sclerotherapy and embolization technique by Interventional radiologist.</div><div><br /></div>In Summary, In most case proper history & examination is sufficient to make a diagnosis. In some case we may want to take a biopsy before treatment or we can do an excision biopsy which is diagnostic and therapeutic, in which the lesion is removed at the same setting. We also may need some imaging modality like US/CT Scan or MRI or CTU / cystoscopy to assess the extend of peri-urethral, perineal or vaginal masses. These imaging will give us some idea about the relationship of such mass with the surrounding areas. This information is important to plan our definitive surgical plan.</div></div><div><br /></div><div>All the photos were taken and displayed with patients permission.</div><div>Like to thank the owners of the drawings/ pictures as these photos were taken taken from google images. They were displayed here purely for teaching purpose only. </div>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-11630706302794260892021-06-15T18:22:00.000-07:002021-06-15T18:22:19.161-07:00Malaysian Urogynaecology Mission to Vientiane, Laos<p><span style="text-align: justify;">A team of Malaysian
urogynaecologists participated in a mission to Vientiane, Laos on the
invitation of the officials from the Ministry of Health, Laos & The
Obstetrics & Gynaecology society Of LOAS</span><span style="text-align: justify;">
</span><span style="text-align: justify;">. This team comprised Dato Dr Aruku Naidu ( Team Leader from Hospital Raja Permaisuri Bainun, Ipoh), Dr Ng Poh Yin (Senior consultant
urogynaecologist of Hospital Kuala Lumpur), Prof Lim Pei Shan (consultant
urogynaecologist </span><span style="text-align: justify;"> </span><span style="text-align: justify;">from Hospital
Universiti Kebangsaan Malaysia), Dr Ida Liliwaty Latar (consultant
urogynaecologist from Pusat Perubatan Universiti Malaya), Dr Tan Gaik Imm
(urogynaecology fellow from Hospital Pulau Pinang), Sr Tan Lee Khan (Hospital
Kuala Lumpur) Sr Lee Fong Hoo (Hospital Kuala Lumpur). This mission was
partially sponsored by the Obstetrics and Gynaecology Society Malaysia (OGSM), with
the support of The Malaysian Urogynaecology Society (MUGS).</span><span style="text-align: center;"> </span></p><p align="center" class="MsoNormal" style="text-align: center;"><!--[endif]--><!--[if gte vml 1]><v:shapetype
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in Vientiane on 28</span><sup style="text-align: justify;">th</sup><span style="text-align: justify;"> October and proceeded to work soon after
arriving. The mission was held at the Women and Neonate Hospital Vientiane. This
was the first and only Maternal & New born Hospital in Laos. </span><span style="text-align: justify;"> </span><span style="text-align: justify;">After a quick tour of the hospital premises
and facilities, the team proceeded to assess women with urogynaecological
problems, who had been screened beforehand by the local hospital doctors. Out
of 10 women was reviewed, but only 3 patients were identified for surgical
intervention, including 2 women with advanced Stage 4 pelvic organ prolapse and
1 patient with </span><span style="text-align: justify;"> </span><span style="text-align: justify;">3</span><sup style="text-align: justify;">rd</sup><span style="text-align: justify;"> degree
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<p class=MsoNormal><span lang=EN-GB style='font-size:10.0pt;line-height:
115%'>O & G clinic at Vientaine women’s Hospital<o:p></o:p></span></p>
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</v:shape><![endif]--><!--[if !vml]--></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi6Jj8rn8v9VB0Dm-3xJWw1kg200LfjDB4ZhqCadyXo9utrs7uSMqeFDM3BqL9F90coLwS4JjpbWDZ-97RfxeMYydMJxblEJiuPNPEhSx6X4wMZPhH-mVuxspzrGP6OQbbShuxjYAo2fhec/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="270" data-original-width="360" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi6Jj8rn8v9VB0Dm-3xJWw1kg200LfjDB4ZhqCadyXo9utrs7uSMqeFDM3BqL9F90coLwS4JjpbWDZ-97RfxeMYydMJxblEJiuPNPEhSx6X4wMZPhH-mVuxspzrGP6OQbbShuxjYAo2fhec/" width="320" /></a></div><p></p><p class="MsoNormal" style="tab-stops: 425.25pt; text-align: justify;"><span lang="EN-GB">The following day, the Malaysian team conducted the Obstetric Anal
Sphincter Injury (OASIS) Workshop for the benefit of the local obstetric
specialist and registrars. This workshop was attended by 60<span style="color: red;"> </span>participants. They were junior doctors and specialist
from all over Laos. The workshop comprised lectures delivered by the mission urogynaecologists.
The topics discussed include pelvic and anal sphincter anatomy, risk factors
and prevention of OASIS, and methods of repair of OASIS. The lectures were
delivered with the help of a local translator. The afternoon was spent on a
hands-on workshop using life animal models & life porcine specimen. The
participants had the invaluable opportunity to practise their skills in the
repair of the anal sphincter tears on sow perineum. <o:p></o:p></span></p><p class="MsoNormal"><!--[if gte vml 1]><v:shape id="Text_x0020_Box_x0020_14"
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<p class=MsoNormal><span lang=EN-GB>Prof LimPS & Dr Ida Waty delivering
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</v:shape><![endif]--><!--[if !vml]--></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgaWnBoER5Ap0Q4rlTZuectX1T34NpT8TNkCxco7a8TzEHRRwARTGJsJIwHPqNuMqooWw4UNNhDF57jgZ-PqMAhUrnBj3Lftm48fDPaPrxA7BhMdAvjuAjZeQWWRmXWVytajRyh0TxnacoQ/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="300" data-original-width="400" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgaWnBoER5Ap0Q4rlTZuectX1T34NpT8TNkCxco7a8TzEHRRwARTGJsJIwHPqNuMqooWw4UNNhDF57jgZ-PqMAhUrnBj3Lftm48fDPaPrxA7BhMdAvjuAjZeQWWRmXWVytajRyh0TxnacoQ/" width="320" /></a></div><br /><div style="text-align: center;"><br /></div><div><span style="text-align: justify;">On the 31 October 2017, the team performed pelvic reconstructive
surgeries on the 3 patients who had been identified and prepared for surgery.
Two teams of Dr Ng/ Dr Ida and Dr Aruku/ Dr Lim performed the surgeries which
included vaginal hysterectomy, pelvic floor repair, McCall culdoplasty and
perineal body reconstruction. The aim of the surgical workshop was not only to
offer symptom relief to the patients but also to demonstrate surgical
techniques and train the Laotian doctors in repair methods, and this was aptly
demonstrated by the team. The nursing team of Sr Tan and Sr Hoo were also able
to educate the local nurses on the proper technique to safely assist and
sterilize equipment for the operation.</span><p></p><p class="MsoNormal"><!--[if gte vml 1]><v:shape id="Text_x0020_Box_x0020_27"
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<p class=MsoNormal><span lang=EN-GB style='font-size:10.0pt;line-height:
115%'>Doctors & staff of Vientaine Women & Neonate Hospital <o:p></o:p></span></p>
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<p class=MsoNormal><span lang=EN-GB>Sr Tan Lee Khan & Sr Lee Fong Hoo (
HKL) helping in the surgeries</span><span lang=EN-GB style='font-size:10.0pt;
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</v:shape><![endif]--><!--[if !vml]--></p><p class="MsoNormal"><span style="text-align: justify;">On the final day of the mission, the team visited the hospital to conduct
a post operative ward round to ensure that the patients were on the road to an
uncomplicated recovery. We found that the 3 patients were nursed in the
recovery area of the operating theatre. Although somewhat uncomfortable for the
patients, this enabled them to have better monitoring in the critical post
operative period due to logistic reasons in the local setting. All 3 patients
were recovering well, and we educated the local registrars about post operative
management for urogynecology patients, which included pain relief, prevention
of thromboembolism, catheter care and the trial of void protocol and follow up.
As with the common problems with mission such as this, the importance of post
operative care cannot be overemphasized as the team cannot be present onsite
throughout the entire recovery period and also to assess patients in the
immediate and short term post operative period, which would be the ideal
situation. We however ensured that the local doctors would be able to contact
the operating team for advice should the need arise so as not to compromise
patient care.</span></p><p class="MsoNormal"><!--[if gte vml 1]><v:shape id="Text_x0020_Box_x0020_34"
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<p class=MsoNormal><span lang=EN-GB style='font-size:10.0pt;line-height:
115%'>The Team doing post op review the following morning after surgery<o:p></o:p></span></p>
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</v:shape><![endif]--><!--[if !vml]--><span style="height: 34px; margin-left: 15px; margin-top: 275px; mso-ignore: vglayout; position: absolute; width: 406px; z-index: 251689984;"><br /></span><!--[endif]--><!--[if gte vml 1]><v:shape id="Picture_x0020_21"
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</v:shape><![endif]--><!--[if !vml]--></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiwUIIJaOUXwu6mP1FE0SUlW8mtDrz7ZejXrGyZsdz6C31lsO5Sb0CF5Up8gIbu5ZsD3Ayvgf3MDO3_8V-aLYd6EDlJ_ArxgndDjhAdqNRl4ZSUUbUJ1kWwdUPjA4X2TnM7ixVG3voLXTAb/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="451" data-original-width="602" height="289" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiwUIIJaOUXwu6mP1FE0SUlW8mtDrz7ZejXrGyZsdz6C31lsO5Sb0CF5Up8gIbu5ZsD3Ayvgf3MDO3_8V-aLYd6EDlJ_ArxgndDjhAdqNRl4ZSUUbUJ1kWwdUPjA4X2TnM7ixVG3voLXTAb/w515-h289/image.png" width="515" /></a></div><br /><span style="text-align: justify;">Overall it was a very successful inaugural mission to Vientiane for
both the Malaysian and Laotian teams. We were able to build networks and learn
from one another. It was enlightening to experience working in a different
country’s settings with challenging logistics, manpower, experience and equipment.
We hope to assist our foreign counterparts in setting up and running an
organized urogynaecology service by periodical missions over the coming years
and hope to foster goodwill and better friendships for future collaboration
within the Asia-Pacific region.</span><p></p><p class="MsoNormal"><span style="text-align: justify;">Last but not least, the Malaysian urogynaecology Mission Team likes
to thank all the team players for their valuable support either morally or
physically. A very big thanks to OGSM for the timely partial financial support
to make this event a successful event. </span> </p></div>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-64275027398568511942021-06-10T19:41:00.001-07:002021-06-10T19:41:32.009-07:00Prevention of Vault prolapse during hysterectomy (PHVP)<p style="text-align: left;"><span style="font-family: "Times New Roman", serif; font-size: 12pt; line-height: 115%; text-align: justify;">Prevention of vault prolapsed, needs some
understanding on pelvic organ support system. </span><span lang="EN-SG" style="font-family: "Times New Roman", serif; font-size: 12pt; line-height: 115%; text-align: justify;">De Lancey’s 3 Levels of Pelvic Support ( Delancey JOL: Am J Obstet
Gynecol 166: 1717, 1992 )</span><span style="font-family: "Times New Roman", serif; font-size: 12pt; line-height: 115%; text-align: justify;"> is one of the
essential components in preventing PHVP. The method & techniques’ for
prevention depends on the type of hysterectomy carried out ( Abdominal as well as Vaginal). If the Abdominal
Hysterectomy, one can Re-anchor uterosacral ligament pedicles to vaginal vault
during vault closure / pelvic peritonisation or pericervical tissues ( Level B evidence), Moscowitz sutures (Circumferential sutures to
obliterate a deep cul-de-sac) & Halban cul-de-sac closure are some other
procedures to prevent PHVP. When doing vaginal hysterectomy, one can do </span><span lang="EN-SG" style="font-family: "Times New Roman", serif; font-size: 12pt; line-height: 115%; text-align: justify;">peritoneal closure of the
cul-de-sac, a vaginal Moschowitz operation, McCall’s culdoplasty. However The
authors found significantly fewer cases of posterior-apical vaginal prolapse
(stage 2) at three years following the
McCall’s culdoplasty 2/32 (6%) than with either peritoneal closure 13/33 (39%) or
the vaginal Moschowitz procedure 10/33
(30%) (p=.004)* (Stephen H Cruikshank,
Am J 427 Obstet Gynecol 1999;180:859-65). Therefore McCall Culdoplasty at the
time of vaginal hysterectomy is effective in preventing subsequent PHVP (Level
B evidence). Sacrospinous ligament fixation (SSF) & abdominal sacral
colpopexy are not recommended for the prevention of prolapse at the time of hysterectomy for non-related disease (Level C). SSF can be added to a post
vaginal hysterectomy and McCall culdoplasty if the cuff (point C) is ≥ Stage 2
to prevent vault prolapse. Subtotal hysterectomy is not recommended for the
prevention of PHVP (Level A). In cases of total Laparoscopic hysterectomy (TLH).
The only study evaluating 22 laparoscopic uterosacral ligament suspension in
comparison to 96 vaginal uterosacral ligament suspension retrospectively found
no significant difference in recurrent apical prolapse (6% in the vaginal group
vs 0% in the laparoscopic group. This study identified no statistical
significance in the ureteral compromise
recognized intraoperatively 4% in the vaginal group, 0% in the laparoscopic
group (Rardin CR, Erekson EA, Sung VW, Ward RM, Myers DL. Comparison of
laparoscopic and vaginal.Uterosacral colpopexy at the time of vaginal
hysterectomy's J Reprod Med 2009: 54: 273-80). Of course there are other
confounding factors involved in the success in preventing the PHVP which
include surgeon factor, patient factors, materials & techniques used.</span></p><p style="text-align: left;"><span lang="EN-SG" style="font-family: "Times New Roman", serif; font-size: 12pt; line-height: 115%; text-align: justify;">Below is AN technique which is the modification of Mc Culdoplasty to address vault prolapse after Vaginal Hysterectomy. </span></p><p style="text-align: left;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgKST2fu0WvZ-Uqxw7MaJCbROSAMCGvvTpbkYMQT2SmVOyM2TuMfmXOzOz5NB-rL2uWSshE3qAlmZu1d5xnSiCxlMIZuFrOUMmrxKigRoWM5lvbDWPN_VFnXBIVq4Sy5X8PNH3oZcusrzSe/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="550" data-original-width="617" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgKST2fu0WvZ-Uqxw7MaJCbROSAMCGvvTpbkYMQT2SmVOyM2TuMfmXOzOz5NB-rL2uWSshE3qAlmZu1d5xnSiCxlMIZuFrOUMmrxKigRoWM5lvbDWPN_VFnXBIVq4Sy5X8PNH3oZcusrzSe/w282-h240/image.png" width="282" /></a></div><span lang="EN-SG" style="font-family: "Times New Roman", serif; font-size: 12pt; line-height: 115%; text-align: justify;"><div style="text-align: center;"><span style="font-size: 12pt;"><br /></span></div><div style="text-align: center;"><span style="font-size: 12pt;">DE LANCEY'S 3 LEVEL PELVIC SUPPORTS</span></div></span><p></p><p style="text-align: center;"><span lang="EN-SG" style="font-family: "Times New Roman", serif; font-size: 12pt; line-height: 115%; text-align: justify;"><br /></span></p><p style="text-align: left;"> <b> METHODS OF PREVENTION OF PHVP</b></p><p style="text-align: left;"><b> <span style="color: red;"> Abdominal Hysterectomy</span></b></p><p style="text-align: left;"></p><ul style="text-align: left;"><li><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: justify;">Peritonisation of pelvis- transfixing anterior leaf of peritoneum, round ligament, ovarian ligaments, uterosacral ligaments and vaginal wall of vault. This is repeated on both sides.</div></div></li></ul><p></p><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg71oG3oUpJ-M8SXoMJp6FTx42K_8xSwL5HKjQHqx5M0cFpdXsjFk7fneROqKtIi5s-1B2uIbG09O7x_aUUt4W9xuV9wGdZ2WAEqk8XV2fzo0GquhlN_kOHSnWw9ZMBnjrMfbnrExTXbFQh/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="569" data-original-width="524" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg71oG3oUpJ-M8SXoMJp6FTx42K_8xSwL5HKjQHqx5M0cFpdXsjFk7fneROqKtIi5s-1B2uIbG09O7x_aUUt4W9xuV9wGdZ2WAEqk8XV2fzo0GquhlN_kOHSnWw9ZMBnjrMfbnrExTXbFQh/w250-h240/image.png" width="250" /></a></div><br /><div style="text-align: left;"><ul style="text-align: left;"><li>Richardson's cuff angle closure, in-cooperating broad ligaments, uterosacral ligament & vaginal vault ( most gynaecologist do this during abdominal hysterectomy)</li></ul></div></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiuu_30ewFvRrz8asgTz_KFrTrZZyY695NbndEmFQCbYeaJ9BRtuZou5aYQ6RHirBfd9m1Ogg-zDfkWl3TS7Infu2-m9GJvtYd4ySYEEQp77Va0FA0bgEJE0lTvj_3aNfG-7lVl9cC_Qpaw/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="459" data-original-width="408" height="257" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiuu_30ewFvRrz8asgTz_KFrTrZZyY695NbndEmFQCbYeaJ9BRtuZou5aYQ6RHirBfd9m1Ogg-zDfkWl3TS7Infu2-m9GJvtYd4ySYEEQp77Va0FA0bgEJE0lTvj_3aNfG-7lVl9cC_Qpaw/w269-h257/image.png" width="269" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><ul><li style="text-align: left;">Moschowitz Suturing ( usually done if there concurrent enterocele)</li></ul></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgUf9MV1dAuRrO0gfZqpE60rLsBock3V_JrQVDka0jiyQ9xI-jLBtxjLZqvh_TxF-9UbIVZsJCIStZ37zzGrUF9WDgXDkMWSByQEUq9eGUL5vIRMZe-O_6PgUd6V_mG1phPsEa0X4t51tSJ/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="457" data-original-width="444" height="272" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgUf9MV1dAuRrO0gfZqpE60rLsBock3V_JrQVDka0jiyQ9xI-jLBtxjLZqvh_TxF-9UbIVZsJCIStZ37zzGrUF9WDgXDkMWSByQEUq9eGUL5vIRMZe-O_6PgUd6V_mG1phPsEa0X4t51tSJ/w281-h272/image.png" width="281" /></a></div><br /><ul><li style="text-align: left;">Halbans Cul do sac closure ( Done if there is concurrent enterocele)</li></ul></div><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8a9Vlv30z0b40gsGmC5C205-XpZph0wUgEOVHjDSyb6mCIiwyPrUvskTZIGZrTzqoSmoq6fE-2c8wGF678GHkw3eSL5wGow-CbfWY8AiZV8fGa_YeMk63WK_P5YJ5zQNUM_-OPEdDjoYt/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="430" data-original-width="432" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8a9Vlv30z0b40gsGmC5C205-XpZph0wUgEOVHjDSyb6mCIiwyPrUvskTZIGZrTzqoSmoq6fE-2c8wGF678GHkw3eSL5wGow-CbfWY8AiZV8fGa_YeMk63WK_P5YJ5zQNUM_-OPEdDjoYt/w287-h240/image.png" width="287" /></a></div><br /><b><span style="color: red;">Abdominal / Total Laparoscopic Hysterectomy</span></b></div><div class="separator" style="clear: both; text-align: center;"><b><span style="color: red;"><br /></span></b></div><ul><li style="text-align: left;">Pericervical And Uterosacral plication ( most laparoscopic surgeons do this technique at the time of TLH</li></ul></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsXRXwMI8jxxOEEY0zbXjPXiK9KstaYRDtCBzCB5TeoIJWYHltPs85Vz6W2zkAv7IqSK6jnz0X_tFTrs1jDQepV6ohcoxEHxsCpxbl0MEztQcbrQzCAAyIP11i0QUWrGx86JNpeIUVeHH9/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="390" data-original-width="552" height="246" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsXRXwMI8jxxOEEY0zbXjPXiK9KstaYRDtCBzCB5TeoIJWYHltPs85Vz6W2zkAv7IqSK6jnz0X_tFTrs1jDQepV6ohcoxEHxsCpxbl0MEztQcbrQzCAAyIP11i0QUWrGx86JNpeIUVeHH9/w320-h246/image.png" width="320" /></a></div><br /><p></p><div class="separator" style="clear: both; text-align: center;"><span style="color: red;"><b>Vaginal Hysterectomy / LAVH</b></span></div><div class="separator" style="clear: both; text-align: left;"><ul style="text-align: left;"><li>Mc Call Culdoplasty ( very effective operation, has small risk of ureteric injury esp with regards to high suture placement)</li></ul></div><div style="text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYpgGOfpKkltohE3swRUJLt2-349pRq32ufBjrRqZL_ZfDvUZugYgjmJITsg9ZTF8SksFUNTg-qzYTcJ6ybewpbT1i9gbwDPLNb3AfDbAbDLYjuluJrGgknUN0Kz1if7wJaMr7Z5_VPT3Y/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="477" data-original-width="656" height="233" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYpgGOfpKkltohE3swRUJLt2-349pRq32ufBjrRqZL_ZfDvUZugYgjmJITsg9ZTF8SksFUNTg-qzYTcJ6ybewpbT1i9gbwDPLNb3AfDbAbDLYjuluJrGgknUN0Kz1if7wJaMr7Z5_VPT3Y/w330-h233/image.png" width="330" /></a></div><br /><ul><li style="text-align: left;">Vaginal approach Moschowitz ( most vaginal surgeon like this technique, in cooperating all the ligaments-round, ovarian and uterosacral ligaments and in-cooperating them as purse string closure )</li></ul><div style="text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjY0fpuQldh8Vcr-DKaYepWA3b0ZDvRvt0lrVTxDUpdxIj_in3E0_O78a391ei0RpyDibvlFpG16vi_v1ACndm0qvTDFeCBEW-2DwuG5cjxgEGwLcHG8c0OM0gcwzzTGG_YCFlO3Qnib-No/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="358" data-original-width="546" height="221" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjY0fpuQldh8Vcr-DKaYepWA3b0ZDvRvt0lrVTxDUpdxIj_in3E0_O78a391ei0RpyDibvlFpG16vi_v1ACndm0qvTDFeCBEW-2DwuG5cjxgEGwLcHG8c0OM0gcwzzTGG_YCFlO3Qnib-No/w370-h221/image.png" width="370" /></a></div><br /><ul><li style="text-align: left;">AN (Aruku Naidu) modified Mc Call ( In-cooperation of low-mid uterosacral and anchored to vaginal vault ipsilaterally and brought to centre) = provide goo vault support & reduce post vaginal skin bleeding</li></ul><div style="text-align: center;"><div class="separator" style="clear: both; text-align: right;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhFU9U8eH7CHCs2X9f1F49d22g2nMK5tEFjDw48ZVT0fpqruL9nZhoR8iN_P4INBZ4HAfi6I9yfFLCh9-J3T_ETznQYc8J_-XBllUwH8C0XpQYB-a0WQAFG198MMel63pLiAKp3wYx3WSbx/" style="margin-left: 1em; margin-right: 1em;"></a><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhFU9U8eH7CHCs2X9f1F49d22g2nMK5tEFjDw48ZVT0fpqruL9nZhoR8iN_P4INBZ4HAfi6I9yfFLCh9-J3T_ETznQYc8J_-XBllUwH8C0XpQYB-a0WQAFG198MMel63pLiAKp3wYx3WSbx/" style="margin-left: 1em; margin-right: 1em;"></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPsKfyylNMGnZBCHBM64dCTfxfCd8A_Ef-ZAVJRYLX9hjF0uQKobMBDZXhp2RJ6HY3VusVaukHhXB654wytQ_SCb0-dLOrcn-NzmsynQ9HmcgIpA63ukQACJ5p9iJq1LOK-Tm4Ro1vd2xL/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="527" data-original-width="432" height="227" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPsKfyylNMGnZBCHBM64dCTfxfCd8A_Ef-ZAVJRYLX9hjF0uQKobMBDZXhp2RJ6HY3VusVaukHhXB654wytQ_SCb0-dLOrcn-NzmsynQ9HmcgIpA63ukQACJ5p9iJq1LOK-Tm4Ro1vd2xL/w255-h227/image.png" width="255" /></a> <img alt="" data-original-height="529" data-original-width="402" height="227" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhFU9U8eH7CHCs2X9f1F49d22g2nMK5tEFjDw48ZVT0fpqruL9nZhoR8iN_P4INBZ4HAfi6I9yfFLCh9-J3T_ETznQYc8J_-XBllUwH8C0XpQYB-a0WQAFG198MMel63pLiAKp3wYx3WSbx/w232-h227/image.png" width="232" /></div><br /></div><br /><div style="text-align: left;"><div class="separator" style="clear: both; text-align: center;"><object class="BLOG_video_class" contentid="" height="266" id="BLOG_video-" width="320"></object></div><br />The above are some of the technique, which can be used to prevent vault prolapse during hysterectomy after abdominal, laparoscopic or vaginal approach.</div><div style="text-align: left;"><br /></div><div style="text-align: left;">Credits to all the authors of the pictures, which was taken from internet/ google images.</div><div style="text-align: left;">Consent has been obtained for the video clip on AN technique from the patient</div><div style="text-align: left;">The above picture & video are purely for teaching junior doctors.</div></div></div></div>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-41056960056829696632021-06-10T00:48:00.001-07:002021-06-10T00:57:57.732-07:00REPAIR OF VAGINAL APICAL SUPPORT DEFECTS<p><span style="text-align: justify;">Apical support defects can occur
alone but usually one or more of the following segmental prolapses coexist:</span></p><p style="text-indent: 0px;"><span style="text-align: justify; text-indent: -0.25in;"> </span><span style="font-family: Symbol; text-align: justify; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-align: justify; text-indent: -0.25in;">Uterine prolapse when a uterus is in place</span></p><p class="MsoNormal" style="margin-left: 39pt; mso-list: l3 level1 lfo1; tab-stops: list 39.0pt; text-align: justify; text-indent: -0.25in;"><o:p></o:p></p>
<p class="MsoNormal" style="margin-left: 39pt; mso-list: l3 level1 lfo1; tab-stops: list 39.0pt; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7pt "Times New Roman";"> </span></span></span>vaginal vault prolapse is reserved to apical
support defect when a hysterectomy was performed previously<o:p></o:p></p>
<p class="MsoNormal" style="margin-left: 39pt; mso-list: l3 level1 lfo1; tab-stops: list 39.0pt; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7pt "Times New Roman";"> </span></span></span>Cystocele<o:p></o:p></p>
<p class="MsoNormal" style="margin-left: 39pt; mso-list: l3 level1 lfo1; tab-stops: list 39.0pt; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]-->Rectocele<o:p></o:p></p>
<p class="MsoNormal" style="margin-left: 39pt; mso-list: l3 level1 lfo1; tab-stops: list 39.0pt; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7pt "Times New Roman";"> </span></span></span><!--[endif]-->Enterocele<o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">These defects should be
recognized prior to surgery and their repair carried out at the same time.</p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">Several surgical procedures have
been described for the correction of apical support defects. The repair can be
performed transvaginally, transabdominally, or laparoscopically. Surgical
procedures available include as day care procedure include:<o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;"><u><span style="color: red;">Abdominal Appraoch</span></u></p><p class="MsoNormal" style="text-align: justify;"><b> Abdominal sacral colpopexy (Open/ laparoscopic)</b></p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">This approach is usually
preferred when a preservation of cervical length to allow sexual intercourse is
desired or when vaginal approach failed. The bladder, rectum and ureters
can be directly visualized; hence the chances of injury to these structures is
minimized. This procedure aims at supporting
the vaginal apex to the sacral promontory using a synthetic or facial bridge.</p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">Procedure:</p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;"><o:p> </o:p><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="text-indent: -0.25in;">The patient is in frog-leg like position with a
foley catheter inside the bladder.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="text-indent: -0.25in;"> </span><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="text-indent: -0.25in;">Three port or single port technique can be
employed.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="text-indent: -0.25in;"> </span><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="text-indent: -0.25in;">The peritoneal cavity is entered and the bowel
is displaced out of the field.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="text-indent: -0.25in;"> </span><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="text-indent: -0.25in;">A sponge stick introduced into the vagina is
helpful in identification of the vagina. The peritoneum overlying the vagina is
then dissected of the vaginal wall.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="text-indent: -0.25in;"> </span><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.25in;">A synthetic graft polypropelene mesh are used
are sutured to the vaginal apex using permanent suture material using 3/0
daflon or prolene sutures. </span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; text-indent: -0.25in;"> ·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="text-indent: -0.25in;">The peritoneum covering over the sacrum is
opened from the sacral promontory to the level of S3. Permanent sutures are
passed through the periosteum of the sacral promontory, alternatively protex
tagger/ bone anchors can be used to fix the free end of the graft.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="text-indent: -0.25in;"> </span><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.25in;"> </span><span style="text-indent: -0.25in;">Once the
sutures are tied, the vaginal apex is approximated to the sacral promontory.
The graft material should be tension free. </span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; text-indent: -0.25in;"> ·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="text-indent: -0.25in;">The peritoneum is then closed with absorbable
suture material.</span></p>
<p class="MsoNormal" style="text-align: justify;">Complications</p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="text-indent: -0.25in;">Injuries to bowels, bladder, ureter, and vessels</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="text-indent: -0.25in;">Bleeding</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="text-indent: -0.25in;">Infection</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="text-indent: -0.25in;">Mesh related complication like erosion,
irritations to bowels</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="text-indent: -0.25in;">Chronic pelvic pain, defecation pain</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> H</span></span><span style="text-indent: -0.25in;">erniation</span></p><p class="MsoNormal" style="text-align: justify;"><u><span style="color: red;">Vaginal Apparoach</span></u></p>
<p class="MsoNormal" style="text-align: justify;"><b>Vaginal sacrospinous fixation (
TVSSF)</b></p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">This procedure aims at suspension
of vaginal apex to the sacrospinous ligament (SSL) or the
coccygeous-sacrospinous ligament that extend from the ischial spine to the
lower portion of the sacrum and coccyx.</p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">The surgeon should be aware of
the close proximity of the pudendal nerve and vessels running directly
posterior to the ischial spine and the sciatic nerve that runs superior and
laterally to the ligament.</p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">Procedure:</p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.25in;">The patient is put in the dorsal lithotomy
position. </span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.25in;">The ischial spine and sacrospinous ligament
should be identified by palpation before surgery begins.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.25in;">The apex of the vagina is grasped and fully
retracted out of the vagina to evaluate the extent of the defect. Stay sutures
are put to mark the apex of the vagina and then the apex is reduced to verify
its relationship to the SSL. At times, the vagina is too short to reach the SSL
so that the fixation is dependant on the sutures connecting the two structures
(vaginal apex and SSL).</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.25in;">Cystocele repair, +/- bladder neck suspension or
a sling procedure, if needed, is usually performed at this point. </span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="text-indent: -0.25in;">A midline longitudinal posterior vaginal wall
incision is performed from the vaginal intoitus to 2cm caudal to the vaginal
apex previously marked.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.25in;">An enterocele sac, when present, should be
dissected free from the posterior vaginal wall and reduced as discussed
separately (see enterocele repair).</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.25in;">The plane between rectocele and posterior
vaginal wall is developed as in any rectocele repair, this dissection is
extended, however, usually on the right side of the patient, to the perirectal
space. </span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="text-indent: -0.25in;">The perirectal space at the level of the ischial
spine is entered by blunt and sharp dissection of the fibroareolar tissue
medial to the rectum until the SSL can be palpated. </span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; text-indent: -0.25in;"><span style="mso-list: Ignore;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span></span><span style="text-indent: -0.25in;">The SSL is further dissected clean.
Briesky-Navratil retractors (long straight retractors) are used by the
assistant to allow easy approach to the deeply situated SSL and medial
retraction of the rectum. A Deschamps ligature carrier and a nerve hook or a
Miya hook ligature carrier are traditionally used to pass 2 sutures through the
SSL 3-4 cm medial to the ischial spine, 1 cm apart. Passing the sutures more
laterally can cause injury to the underlying pudendal nerve and internal
pudendal vessels which course posteriorly to the ischial spine. Other
commercially available kits ( Capio applicators) for passing the sutures are also available. An
Allis or a Babcock clamp can be used to hold the SSL, during this sometimes difficult
to perform step. </span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; text-indent: -0.25in;"><span style="mso-list: Ignore;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span></span><span style="text-indent: -0.25in;">The sutures are then passed through vaginal
apex. A pulley stitch can be used so that the knot is buried between the
vaginal wall and the SSL. </span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; text-indent: -0.25in;"><span style="mso-list: Ignore;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span></span><span style="text-indent: -0.25in;">The vaginal apex incision is closed. Only then,
the stitches passed through the SSL and the vaginal apex are tied so that the
vaginal apex is approximated to the SSL. Tying these sutures beforehand will
cause difficulty in closing the vaginal apex. </span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; text-indent: -0.25in;"><span style="mso-list: Ignore;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span></span><!--[endif]--><span style="text-indent: -0.25in;">The posterior vaginal wall is closed as in
posterior colporraphy.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; text-indent: -24px;">·</span><span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; text-indent: -24px;"> </span><span style="text-indent: -0.25in;">Check cystoscopy & PR are performed to exclude any injuries to the bladder or bowels</span></p><p class="MsoNormal" style="text-align: justify;"><span style="text-indent: -0.25in;">This are two main appoach to support in my practice, there are other options like Uterosacral ligament plication and others</span> </p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj9iiwglEGqTI4iVYphYeOaPUozrGVmpE_6lDmhYQeuPYoYhL2ETXzLgKtORSUyoXoKFYowVGqh6jmHkrCjachDgHxUCXkabAYouYSZJyo3RfzsWY2TwgVXok4gh_w45ZxolSE6PWkyCWpp/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1536" data-original-width="2048" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj9iiwglEGqTI4iVYphYeOaPUozrGVmpE_6lDmhYQeuPYoYhL2ETXzLgKtORSUyoXoKFYowVGqh6jmHkrCjachDgHxUCXkabAYouYSZJyo3RfzsWY2TwgVXok4gh_w45ZxolSE6PWkyCWpp/" width="320" /></a></div><p></p><p class="MsoNormal" style="text-align: justify;"> </p>
<p class="MsoNormal" style="text-align: justify;"><o:p> </o:p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtKIr760jhL-qv-HMNVsllfOgEFLONXID2JHTsyjZx5jM46-a-bFczz14CeAdB6tLfbpKy_Q7hvi9FKiBujstaKY9ILaLeBi01xvdShHHom6wuOGeRczVqYn6JJWpEdgXH4k1HfBhk9Ob1/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1536" data-original-width="2048" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtKIr760jhL-qv-HMNVsllfOgEFLONXID2JHTsyjZx5jM46-a-bFczz14CeAdB6tLfbpKy_Q7hvi9FKiBujstaKY9ILaLeBi01xvdShHHom6wuOGeRczVqYn6JJWpEdgXH4k1HfBhk9Ob1/" width="320" /></a></div><br /><p></p>
<p class="MsoNormal" style="text-align: justify;"><o:p> The above are perrecatal dissection & placement of sutures to SSL and vault</o:p></p><p class="MsoNormal" style="text-align: justify;"><o:p style="text-align: left;"> </o:p><span style="text-align: left;">Consent Has been Taken from Patient to publish this Pictures ( For Teaching Purpose)</span></p>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-60615618720724669772021-06-09T19:32:00.004-07:002021-06-09T19:32:58.427-07:00VAGINAL PESSARIES FOR PELVIC ORGAN PROLAPSE<p style="text-align: justify;">V<span style="font-family: Arial, sans-serif; font-size: 10pt; text-align: justify;">aginal pessary is a device used in conservative
management of pelvic organ prolapse (POP) or urinary incontinence. Vaginal
pessary is placed in the vagina to provide support and prevent pelvic organ
prolapse. Continence pessaries act by providing mechanical support to the
urethra. In the pass, various materials had been used which include: Pomegranate
soaked in vinegar, fruits, mould, cotton etc. Modern vaginal pessaries are made
of silicone as it is inert, does not absorb secretions and resistant to
degradation by the majority of the antiseptics. </span><span style="font-family: Arial, sans-serif; font-size: 10pt;">Patients satisfaction rate ranges 70-92%. </span><span style="font-family: Arial, sans-serif; font-size: 10pt;"> </span></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Types
of pessaries</span></b><span style="font-family: Arial, sans-serif; font-size: 10pt;"> </span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l3 level1 lfo2; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">There
different sizes, shapes and configurations.<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l3 level1 lfo2; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Mainly
two basic mechanisms: supportive and/or space occupying<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l3 level1 lfo2; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Space
occupying pessaries preclude sexual intercourse<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l3 level1 lfo2; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Commonly
used vaginal pessaries: Ring, Gellhorn , Hodge, Cube and Donut <o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l3 level1 lfo2; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Continence
pessary: usually equipped with a knob which should be placed in the midline
under the urethra. For example: incontinence ring pessary, ring pessary with
knob, and incontinence dish pessary Mar-land pessary and Uresta pessary are
incontinence pessary which are unique in the design.<o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: normal; text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhrH4s6K3kdrQ83xbb-YvWFNmvQyMzrmbVCjfBMDVw71a_4JsRo3vbQHyJGAjk4_s3RCR7V0Ib4XRd4BCLUndTTKWQKL0kA-gjDGnSdPrCedhj8QxAWU22QJpeWHhhQbbreOTNxtxYunevJ/s633/support+pessary.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="424" data-original-width="633" height="208" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhrH4s6K3kdrQ83xbb-YvWFNmvQyMzrmbVCjfBMDVw71a_4JsRo3vbQHyJGAjk4_s3RCR7V0Ib4XRd4BCLUndTTKWQKL0kA-gjDGnSdPrCedhj8QxAWU22QJpeWHhhQbbreOTNxtxYunevJ/w311-h208/support+pessary.png" width="311" /></a></div><br /><o:p><br /></o:p><p></p><p class="MsoNormal" style="line-height: normal; text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p><br /></o:p></span></p><p class="MsoNormal" style="line-height: normal; text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-WMHaQ2AnTgrIKxcJ72biS4RUDgafiuzbMKL9xTuyFPI4ZS0Zyda4kluor8soe5wTQrAhkcxv2SvconiiwBkRXZGOFqx9GwG71qlg8VXtOflCpmiwtPm4FdaFIXqxiduoCPDd88jqlF53/s629/incontinence+pessary.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="426" data-original-width="629" height="208" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-WMHaQ2AnTgrIKxcJ72biS4RUDgafiuzbMKL9xTuyFPI4ZS0Zyda4kluor8soe5wTQrAhkcxv2SvconiiwBkRXZGOFqx9GwG71qlg8VXtOflCpmiwtPm4FdaFIXqxiduoCPDd88jqlF53/w307-h208/incontinence+pessary.png" width="307" /></a></div><p></p><p class="MsoNormal" style="line-height: normal; text-align: justify;"><span style="font-family: Arial, sans-serif; font-size: 10pt;"><o:p> </o:p></span><b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Indications</span></b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> </o:p></span><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Symptomatic
pelvic organ prolapse or stress urinary incontinence</span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l2 level1 lfo3; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">In
frail elderly with multiple co-morbid and not fit for surgery<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l2 level1 lfo3; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">In
women prefer conservative management<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l2 level1 lfo3; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">In
women with prolapse in pregnancy or awaiting surgery for temporary support<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l2 level1 lfo3; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Temporary
use for diagnostic purposes: to demonstrate occult stress incontinence along
with POP, to determine whether surgery would alleviate vague symptoms such as
backache/dragging pain</span></p><p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l2 level1 lfo3; text-align: justify; text-indent: -.25in;"><b style="text-indent: -0.25in;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Pessary
selection</span></b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> </o:p></span></b><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Ring
pessary is commonly used as first choice due to its easy insertion and removal.</span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l1 level1 lfo4; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Ring
pessary can be used in most of the stages of POP.<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l1 level1 lfo4; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">In
concurrent stress incontinence, ring pessary with knob can be used<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l1 level1 lfo4; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">If
failed fitting of ring pessary or advanced POP, a Gellhorn, cube or donut pessary
can be used.</span></p><p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l1 level1 lfo4; text-align: justify; text-indent: -.25in;"><span style="font-family: Arial, sans-serif; font-size: 10pt;"><b>Procedure</b></span><b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> </o:p></span></b></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l4 level1 lfo1; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">This
is usually done as out-patient setting<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l4 level1 lfo1; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Can
be inserted on supine or lithotomy position, the severity of prolapse, type of
prolapsed will help in the choice of pessary<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l4 level1 lfo1; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Often
the correct fitting is trial and error. However, the size of pessary can be estimated
by measuring the distance between the symphysis pubis and posterior fornix.<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l4 level1 lfo1; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Following
insertion, the patients are instructed to perform Valsava, maneuvers to confirm
fitting.<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l4 level1 lfo1; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Ability
to void without difficulty should be checked before sending home.<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l4 level1 lfo1; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Patients
or caregivers can be thought to remove and insert the pessaries. This is
usually permissible in ring pessary or cube pessary. <o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l4 level1 lfo1; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Follow
up period between 2-3 months to clean and re-insertion if patient is unable to
do it. An interval follow-up of 6-12 months is acceptable if the patients are
able to manage themselves.</span></p><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; margin-left: 1em; margin-right: 1em; text-align: center;"><br /></div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXyVWBQ9n8hkaI6NhL_AFOipeWL5W-JNX17-15PxmnuX5SUKyi0FqJT21dHhL0ZGGNW3ZjI42YslyIfNA0_EuFN7KCXdmnhqXzM-PoRQacru7fKC2hATrTUMs7-VlDBA2SXAeqTnetaZ9f/" style="margin-left: 1em; margin-right: 1em;"><br /><span style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="326" data-original-width="394" height="174" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXyVWBQ9n8hkaI6NhL_AFOipeWL5W-JNX17-15PxmnuX5SUKyi0FqJT21dHhL0ZGGNW3ZjI42YslyIfNA0_EuFN7KCXdmnhqXzM-PoRQacru7fKC2hATrTUMs7-VlDBA2SXAeqTnetaZ9f/w263-h174/measuring+size+of+pessary.jpg" width="263" /></span></a></div><br /><br /><p></p><p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l4 level1 lfo1; text-align: justify; text-indent: -.25in;"><b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 115%;"><br /></span></b></p><p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l4 level1 lfo1; text-align: justify; text-indent: -.25in;"><b></b></p><div class="separator" style="clear: both; text-align: center;"><b><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgFO3TZZu324qXyPEc4U5TExKJOTRyE1VHKOxmfq0INam6J9tOvE2r6UOLddYdYljwiIYRSrH_ARmVGxj2SjF00e3nzCENDy38oyQ-i9d7Nd9KRF3_bIzlsZRfiN60xiAK3vdGJ-m1ObBk2/s167/inserting+pessary.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="127" data-original-width="167" height="204" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgFO3TZZu324qXyPEc4U5TExKJOTRyE1VHKOxmfq0INam6J9tOvE2r6UOLddYdYljwiIYRSrH_ARmVGxj2SjF00e3nzCENDy38oyQ-i9d7Nd9KRF3_bIzlsZRfiN60xiAK3vdGJ-m1ObBk2/w274-h204/inserting+pessary.png" width="274" /></a></b></div><p></p><p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l4 level1 lfo1; text-align: justify; text-indent: -.25in;"><b style="text-indent: -0.25in;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 115%;">Complications</span></b></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l5 level1 lfo5; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Minor
complications include: vaginal discharge, odor, bleeding, abrasion<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l5 level1 lfo5; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Erosion
or ulceration of the vagina wall, particularly if the pessary is left
unattended for long periods of time. It can be managed by a short period of
rest and use of topical oestrogen.<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l5 level1 lfo5; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Concurrent
use of topical oestrogen may reduce the incidence of erosion and ulceration.<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l5 level1 lfo5; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Decreased
efficacy over time, a larger pessary may be necessary. Though an improvement of
POP-Q stage had been reported. <o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l5 level1 lfo5; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Impaction
of pessary, fistula formation especially in neglected cases<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l5 level1 lfo5; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Vaginal
cancer has been reported in long term use<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l5 level1 lfo5; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Proper
patient education and counseling are essential to minimize neglected cases</span><span style="font-family: Arial, sans-serif; font-size: 10pt;"> </span></p><p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l5 level1 lfo5; text-align: justify; text-indent: -.25in;"><span style="font-family: Arial, sans-serif; font-size: 10pt;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgc49O7EDXeXGvD4YeMlfQHejj561_QpqR2-tTXwplaRgmtZuvKOwgGgHzMsI5MWw_199eINuJnhvpc79JmJd-fZFaNPNw1F9LTEQ73wa0TGy_n5ayGdzkIbf1GDs3cg6RquML1dxHFWHbT/s2048/struck+ring+pessary.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1536" height="188" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgc49O7EDXeXGvD4YeMlfQHejj561_QpqR2-tTXwplaRgmtZuvKOwgGgHzMsI5MWw_199eINuJnhvpc79JmJd-fZFaNPNw1F9LTEQ73wa0TGy_n5ayGdzkIbf1GDs3cg6RquML1dxHFWHbT/w215-h188/struck+ring+pessary.JPG" width="215" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p>
<p class="MsoNoSpacing" style="text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Factors
predicting success or failure of fitting<o:p></o:p></span></b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> </o:p></span><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">The
likelihood of successful fitting ranges from 74%-94%</span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l0 level1 lfo6; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Some
women may need a second fitting<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="margin-left: .5in; mso-list: l0 level1 lfo6; text-align: justify; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">Prior
hysterectomy, short vaginal length (<6cm), wide introitus (≥ 4 fingers
breath), large posterior prolapse and poor perineal support may give a higher
failure of fitting<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> </o:p></span></p><p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p>Consent & permission has been obtained from patients to use the pictures for teaching purposes</o:p></span></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> </o:p></span><b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">References</span></b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> 1. </o:p></span><span style="font-family: Arial, sans-serif; font-size: 10pt;">Scott Miller D. Contemporary use of the
pessary. Gynecol Obstet 1991; 39: 1-12</span></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> 2. </o:p></span><span style="font-family: Arial, sans-serif; font-size: 10pt;">Baydock SA, Farrell SA. Chapter 5. Selection
of pessaries for pelvic organ prolapse. Pessaries in clinical practice. 32-45</span><span style="font-family: Arial, sans-serif; font-size: 10pt;"> </span></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">3. Farrell SA. Pessaries for the management of
stress urinary incontinence. J Obstet Gynaecol Can. 2001; 23: 1184-1189<o:p></o:p></span></p><p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: Arial, sans-serif;"><span style="font-size: 13.3333px;">4. </span></span><span style="font-family: Arial, sans-serif; font-size: 10pt;">Cundiff GW, Weidner AC, Visco AG, Bump RC,
Addison WA. A survey of pessary use be members of the American Urogynecology
Society. Obstet Gynecol 2000; 95(6): 931-935</span></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> 5. </o:p></span><span style="font-family: Arial, sans-serif; font-size: 10pt;">Baydock SA. Chapter 2. Pessaries for pelvic
organ prolapse: The evidence. Pessaries in clinical practice 10-16</span></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> 6. </o:p></span><span style="font-family: Arial, sans-serif; font-size: 10pt;">Amir-Khalkhali B, Farrel SA. Chapter 6
Selection of pessaries for urinary incontinence. Pessaries in clinical practice
46-53</span></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> 7. </o:p></span><span style="font-family: Arial, sans-serif; font-size: 10pt;">Schraub A, Sun XS, Maingon P et al. Cervical
and vaginal cancer associated with pessary use. Cancer 1992; 69(10): 2505-2509</span></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> 8. </o:p></span><span style="font-family: Arial, sans-serif; font-size: 10pt;">Handa VL, Jones M. Do pessaries prevent the
progression of pelvic organ prolapse? Int Urogynecol J 2002; 13: 349-352</span></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> 9. </o:p></span><span style="font-family: Arial, sans-serif; font-size: 10pt;">Wu V, Farrel SA, Baskett TF, Flowerdew G. A
simplified protocol for pessary management. Obstet Gynecol 1997; 90: 990-994</span></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> 10. </o:p></span><span style="font-family: Arial, sans-serif; font-size: 10pt;">Clemons JL, Anguilar VC, Tillinghast TA,
Jackson ND, Myers DL. Risk factors associated with an unsuccessful pessary
fitting trial in women with pelvic organ prolapse. Am J Obstet Gynecol 2004;
190: 345-350</span></p>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-21882836487534081562021-06-09T17:40:00.000-07:002021-06-09T17:40:00.849-07:00COLPOCLEISIS: VAGINAL OBLITERATIVE PROCEDURE<p><span style="font-family: Arial, sans-serif; font-size: 10pt; text-align: justify; text-indent: -27.35pt;">Colpocleisis is a vaginal obliteration
procedure for treatment of advanced pelvic </span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-align: justify; text-indent: -27.35pt;">organ prolapsed (POP) or Global pelvic floor failure
(GPFF). Obliteration of the vagina is a surgical option for patients
with advanced symptomatic POP who are not engaging in vaginal intercourse.</span></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: Arial, sans-serif; font-size: 10pt;">Colpoclesis can be divided into <b>total
(complete) </b>colpoclesis or <b>partial (Le Fort)</b> colpocleisis.</span></p><p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: Arial, sans-serif; font-size: 10pt;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjO7yV-w7hcYv5zVK7XNrBR6kuFuNCX8fbPAPlHaz3mEP2vqMjjyagZE2yU_KjvbJH9YoKQwk_MsQWKsLqBKmf_0K7CnDIPr6MZjaUp99SqIcOR39T1l0g2woTFTR_EEy-RZCvkkb8QhlLp/s2048/556.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1536" height="270" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjO7yV-w7hcYv5zVK7XNrBR6kuFuNCX8fbPAPlHaz3mEP2vqMjjyagZE2yU_KjvbJH9YoKQwk_MsQWKsLqBKmf_0K7CnDIPr6MZjaUp99SqIcOR39T1l0g2woTFTR_EEy-RZCvkkb8QhlLp/w202-h270/556.JPG" width="202" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><span style="font-size: 10pt; text-align: justify;">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, pudendal blocks, intravenous
sedation or regional anaesthesia.</span></div><p></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: Arial, sans-serif; font-size: 10pt;">It
has</span><span style="font-family: Arial, sans-serif; font-size: 10pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 10pt;">relatively good success rate</span><span style="font-family: Arial, sans-serif; font-size: 10pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 10pt;">of between 85-100% patients claim to be
satisfied or very satisfied with the sugery.</span></p>
<p class="MsoNormal" style="text-align: justify;"><b><span style="font-family: Arial, sans-serif; font-size: 10pt;">Indications:</span></b></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Advanced pelvic organ prolapsed/
Global Pelvic Floor Failure </span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Medical unfit patients/ patients
with comorbidity</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Frail elderly patients</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Patient request simpler operation</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Patient who could not stand long
surgery</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Sexually not active/ disinterested
in maintain sexual function</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Unsuccessful trial of vaginal pessaries
or surgeries</span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;"> </span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;"> </span><b style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Advantage:</b></p>
<p class="MsoNormal" style="text-align: justify;"><span style="color: black; font-size: 10.0pt; mso-fareast-font-family: +mn-ea;"><o:p> </o:p></span><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;"> ·</span><span style="font-size: 10pt; text-indent: -0.25in;"> </span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Shorter operating time, takes half the time of vaginal hysterectomy</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;"> ·</span><span style="font-size: 10pt; text-indent: -0.25in;"> </span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Minimal
blood loss and complications</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;"> ·</span><span style="font-size: 10pt; text-indent: -0.25in;"> </span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Excellent cure rates or success rate</span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="color: black; font-size: 10.0pt; mso-fareast-font-family: +mn-ea;"><o:p> </o:p></span><b><span style="font-family: Arial, sans-serif; font-size: 10pt;">Disadvantage: </span></b></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Recurrence of Pelvic organ prolapse</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Injuries to bladder/ rectum</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Unable to perform sexual
intercourse</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">If uterus still in situ as in Le
Fort operation, there is a remote possibility of cervical or endometrial carcinoma.</span></p>
<p class="MsoNormal" style="text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: +mn-ea;">A.<span style="mso-spacerun: yes;">
</span>Partial Colpocleisis ( Le Fort):</span></b><span style="font-family: Arial, sans-serif; font-size: 10pt;"> </span></p>
<p class="MsoNormal" style="tab-stops: list .5in; text-align: justify;"><span style="color: black; font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: +mn-ea;">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.<o:p></o:p></span></p>
<p class="MsoNormal" style="tab-stops: list .5in; text-align: justify;"><b><span style="font-family: Arial, sans-serif; font-size: 10pt;">Procedure:</span></b></p>
<p class="MsoNormal" style="text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-size: 10.0pt; mso-fareast-font-family: +mn-ea;"><o:p> </o:p></span></b><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Can be done under local, iv
sedation, pudendal block or regional anesthesia</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">The rectangular epithelial areas on
the anterior and posterior vaginal wall are denuded.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">The denuded epithelial areas are
then sutured to each other with the uterus reduced to a proximal position </span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;"> so
that the anterior rectal wall and the base of the perivesical fascia around the
bladder base are fused.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Approximating the opposing walls of
the vagina prevents descent of the uterus and practically obliterates </span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;"> the </span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">vagina.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">The rectangular areas are designed
so that a continuous lumen from the vaginal apex on both sides of </span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;"> the </span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">obliterated space will persist. This lumen serves to drain vaginal and uterine
secretions.</span></p>
<p class="MsoListParagraphCxSpMiddle" style="text-align: justify;"><b><span style="font-family: Arial, sans-serif; font-size: 10pt;">B. Total Colpoclesis (Complete
Colpectomy):</span></b></p><p class="MsoListParagraphCxSpMiddle" style="text-align: justify;"><span style="font-family: Arial, sans-serif; font-size: 10pt;">Total
colpocleisis can be performed in post-hysterectomised vaginal vault prolapse
patients or after a vaginal hysterectomy. This procedure was first described by
DeLancey and Morley.</span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="color: black; font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: +mn-ea;"><o:p> </o:p></span><b><span style="font-family: Arial, sans-serif; font-size: 10pt;">Procedure:</span></b></p>
<p class="MsoNormal" style="tab-stops: list .5in; text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-size: 10.0pt; mso-fareast-font-family: +mn-ea;"><o:p> </o:p></span></b><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">The vaginal mucosa is completely
excised from the base of the prolase by a circumscribing incision. </span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;"> </span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;"> Subsequently
the vaginal skin is denuded. </span></p><p class="MsoNormal" style="tab-stops: list .5in; text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">A series of purse-string sutures
are placed so that the vaginal fascial and muscular layers are inverted cephalad. </span></p><p class="MsoNormal" style="tab-stops: list .5in; text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">The vagina is completely
obliterated. </span></p><p class="MsoNormal" style="tab-stops: list .5in; text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">This can be followed by standard
Kelly’s placation, Levator ani plication or perineorhaphy</span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="color: black; font-size: 10.0pt; mso-fareast-font-family: +mn-ea;"><o:p> </o:p></span><b><span style="font-family: Arial, sans-serif; font-size: 10pt;">Complications:</span></b></p>
<p class="MsoNormal" style="text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: +mn-ea;"><o:p> </o:p></span></b><b><span style="font-family: Arial, sans-serif; font-size: 10pt;">Immediate/ Intermediate:</span></b></p>
<p class="MsoNormal" style="text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: +mn-ea;"><o:p> </o:p></span></b><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">De novo urinary incontinence in 27%</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-size: 10pt; text-indent: -0.25in;"><span style="font-family: Arial, sans-serif;"> </span></span><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Persistent stress urinary
incontinence in 28% patients</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-size: 10pt; text-indent: -0.25in;"><span style="font-family: Arial, sans-serif;"> </span></span><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Transient Ureteral occlusion in 10%
patients</span></p>
<p class="MsoNormal" style="text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: +mn-ea;"><o:p> </o:p></span></b><b><span style="font-family: Arial, sans-serif; font-size: 10pt;">Late/delayed:</span></b></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Risk of injuries to bladder or
rectum</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Infection</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">De Nova or persistence of
stress urinary incontinence (25-30%)</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Vaginal Evisceration ( very rarely)</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Symbol; font-size: 10pt; text-indent: -0.25in;">·<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Post operative regret of</span><span style="font-size: 10pt; text-indent: -0.25in;"> l</span><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">oss of sexual function in 5% of patients</span></p><p class="MsoNormal" style="text-align: justify;"></p><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen="" class="BLOG_video_class" height="266" src="https://www.youtube.com/embed/ExQq30qbbJE" width="409" youtube-src-id="ExQq30qbbJE"></iframe></div><br /><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;"><br /></span><p></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;"><br /></span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: Arial, sans-serif; font-size: 10pt; text-indent: -0.25in;">Consent & permission has been taken to publish this pictures & video from the patients for the purpose of teaching junior doctors)</span></p><p class="MsoNormal" style="text-align: justify;"><b><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">References:</span></b></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;">1. Denehy TR, Choe JY, Greori CA et al. Modified
Le Fort Partial Colpoclesis with Kelly urethral placation and posterior
colpoperineoplasty in medically compromised elderly. Am J Obstet Gynaecol 1995;
173(6): 1697-1702.<o:p></o:p></span></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> 2. </o:p></span><span style="font-family: Arial, sans-serif; font-size: 10pt;">Le Fort L. Nouveau precede pour ia guerison
du prolapsus uterin. Bull Gen Therp. 1877; 92:337-346</span></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p>3. </o:p></span><span style="font-family: Arial, sans-serif; font-size: 10pt;">DeLancey Jo, Morley GW. Total colpocleisis
for vaginal eversion. Am J Obstet Gynaecol, 1997;176(6): 12278-1235.</span></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> 4. </o:p></span><span style="font-family: Arial, sans-serif; font-size: 10pt;">FitzGerald MP, Brubaker L. Colpoclesis and
urinary incontinence. Am J obstet Gynaecol, 2003;189(5): 1241-1244.</span></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> 5. </o:p></span><span style="font-family: Arial, sans-serif; font-size: 10pt;">Von Pechmann WS, Mutone M, Fyffe J et al. Total
Colpocleisis with high levator plication for the treatment of advance pelvic
organ prolapsed. Am J Obstet Gynaecol, 2003;189(1): 121-126</span></p>
<p class="MsoNoSpacing" style="text-align: justify;"><span style="font-family: "Arial","sans-serif"; font-size: 10.0pt;"><o:p> 6. </o:p></span><span style="font-family: Arial, sans-serif; font-size: 10pt;">Ubachs JM, Van santé TJ, Schellekens LA.
Partial colpocleisis by a modification of Le Fort’s operation. Obstet Gynaecol,
1973; 42(3): 415-420</span></p>
<p class="MsoNormal"><span style="mso-bidi-font-size: 10.0pt;"><o:p> </o:p></span></p>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-21284662819102789652021-06-08T16:29:00.004-07:002021-06-10T00:54:58.389-07:00Prevention of OASIS<p><span style="font-family: Cambria, serif; font-size: 12pt; text-align: justify;">Predicting
OASIS and tears in individual women is inaccurate and midwifery practices can
do little to prevent them. </span></p><p><span style="font-family: Cambria, serif; font-size: 12pt; text-align: justify;"></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: Cambria, serif; font-size: 12pt; text-align: justify;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiV0LbnwNlexyPbazGKorhOcXxdgkCNVxFNGIORUgRyJI2h2yrsF9R9cGd56gMtJbZKLwrAd3OgDhfIi-a4p49hbxzeFuQ47Fr-HwyrWmv1ScBaA77otJ-313rZjW-ISHEpRlikx0YFylp4/s2048/social+2019+777.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1536" data-original-width="2048" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiV0LbnwNlexyPbazGKorhOcXxdgkCNVxFNGIORUgRyJI2h2yrsF9R9cGd56gMtJbZKLwrAd3OgDhfIi-a4p49hbxzeFuQ47Fr-HwyrWmv1ScBaA77otJ-313rZjW-ISHEpRlikx0YFylp4/s320/social+2019+777.JPG" width="320" /></a></span></div><span style="font-family: Cambria, serif; font-size: 12pt; text-align: justify;"><br /><div class="separator" style="clear: both; text-align: center;"><span style="font-family: Wingdings; font-size: 12pt; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings; text-align: justify; text-indent: -0.25in;">§<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin; text-align: justify; text-indent: -0.25in;">Clinicians need to be aware of
the risk factors for obstetric anal sphincter injuries (OASIS) (Grade D)</span></div></span><p></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l2 level1 lfo1; tab-stops: list .5in; text-align: justify; text-indent: -0.25in;"><span style="font-family: Wingdings; font-size: 12pt; text-indent: -0.25in;">§<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span style="font-family: Cambria, serif; font-size: 12pt; text-indent: -0.25in;">Elective / low thresh-hold for
LSCS in patients with the following risk factor/s:</span></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l1 level2 lfo3; tab-stops: list 1.0in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">•<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Nulliparity <o:p></o:p></span></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l1 level2 lfo3; tab-stops: list 1.0in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">•<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Macrosomia of more than 4kg<o:p></o:p></span></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l1 level2 lfo3; tab-stops: list 1.0in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">•<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Gestational
diabetes mellitus (GDM) <o:p></o:p></span></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l1 level2 lfo3; tab-stops: list 1.0in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">•<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Prolonged
1st stage of labour (7-to-10 interval >3hours) <o:p></o:p></span></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l1 level2 lfo3; tab-stops: list 1.0in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">•<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Prolonged
active 2nd stage of labour >60 mins)<o:p></o:p></span></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l1 level2 lfo3; tab-stops: list 1.0in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">•<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">No/poor
descent during instrumental delivery<o:p></o:p></span></p><p class="MsoNoSpacing" style="margin-left: 1in; mso-list: l1 level2 lfo3; tab-stops: list 1.0in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">•<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">High head
(not visible on parting vagina, PA & VE)<o:p></o:p></span></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l2 level1 lfo1; tab-stops: list .5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Wingdings; font-size: 12pt; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;">§<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Encourage epidural analgesia<o:p></o:p></span></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l2 level1 lfo1; tab-stops: list .5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Wingdings; font-size: 12pt; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;">§<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><!--[endif]--><b><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Perineal protection at crowning
can be protective, control delivery of the head may prevent burst injuries.</span><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ansi-language: EN-MY; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"> </span></b><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><b> (Grade C) PINCHING TECHNIQUE</b><o:p></o:p></span></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l2 level1 lfo1; tab-stops: list .5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Wingdings; font-size: 12pt; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;">§<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Left hand slowing down the
delivery of the head, the head is flexed and the right hand protecting the
perineum (Pinching Technique as in Finish Intervention Trial). <o:p></o:p></span></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l2 level1 lfo1; tab-stops: list .5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Wingdings; font-size: 12pt; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;">§<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Clinicians should explain to
women that the evidence for the protective effect of episiotomy is conflicting.
( Grade C)<o:p></o:p></span></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l2 level1 lfo1; tab-stops: list .5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Wingdings; font-size: 12pt; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;">§<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><b><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">If an episiotomy is warranted
than, a </span><span lang="EN-MY" style="font-family: "Cambria","serif"; font-size: 12pt; mso-ansi-language: EN-MY; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">medio-lateral episiotomy (60 degree angulation) has been shown to reduce
OASIS.</span></b><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><o:p></o:p></span></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l2 level1 lfo1; tab-stops: list .5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Wingdings; font-size: 12pt; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;">§<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><!--[endif]--><span lang="EN-MY" style="font-family: "Cambria","serif"; font-size: 12pt; mso-ansi-language: EN-MY; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Early
extension of episiotomy should be performed to avoid further damage</span><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"><o:p></o:p></span></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l2 level1 lfo1; tab-stops: list .5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Wingdings; font-size: 12pt; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;">§<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><!--[endif]--><span lang="EN-MY" style="font-family: "Cambria","serif"; font-size: 12pt; mso-ansi-language: EN-MY; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Forcible
delivery should be avoided, it should be
replaced with</span><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"> vacuum delivery
by use the Kiwi cup for OT & OP positions<o:p></o:p></span></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo2; tab-stops: list .5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Wingdings; font-size: 12pt; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;">§<span style="font-family: "Times New Roman"; font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><!--[endif]--><span lang="EN-MY" style="font-family: "Cambria","serif"; font-size: 12pt; mso-ansi-language: EN-MY; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Delivery
the head should be in between contraction. The m</span><span style="font-family: "Cambria","serif"; font-size: 12pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">other should not push vigorously when head is
crowning (communicate). <o:p></o:p></span></p><p class="MsoNoSpacing" style="margin-left: 0.5in; mso-list: l0 level1 lfo2; tab-stops: list .5in; text-align: justify; text-indent: -0.25in;"><span lang="EN-MY" style="font-family: Cambria, serif; font-size: 12pt; line-height: 115%; text-align: left; text-indent: -0.25in;"><span style="font-family: Wingdings; text-align: justify;">§ </span>Do take care during the delivery of the shoulder,</span><span lang="EN-MY" style="font-family: Cambria, serif; font-size: 12pt; line-height: 115%; text-align: left; text-indent: -0.25in;"> </span><span style="font-family: Cambria, serif; font-size: 12pt; line-height: 115%; text-align: left; text-indent: -0.25in;">continue
to protect the perineum (midwife/assistant) during delivery of the head &
shoulders</span></p><p><br /></p><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dwhyojnwVFawMYtvXMY_sPz7Yo69Yl0iyDB6-bJLpSxrd-MvqLEUzIhy9RsHECRMm7y6ow6vXCS411aTcJW9A' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div>The above is video demonstrating how to perform a 60 degrees episiotomy & how to do the perineal protection using PINCHING TECHNIQUE<br /><div class="separator" style="clear: both; text-align: center;"><br /></div>Consent Has been Taken from Patient to publish this video ( For Teaching Purpose)<p></p><div>Reference : RCOG Greentop guidelines No 29. June 2015</div><div> Justine RL , Episiotomy & repair. Medscape April 2021</div>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-13808160901851263212021-06-07T18:59:00.000-07:002021-06-07T18:59:11.991-07:00Spontaneous and complete uterine scar rupture occurred 26 days after caesarean section: A case report<p> Kartina Ariffin, Jumaida Abu Bakar, Aruku Naidu</p><p><o:p> D</o:p>epartment of
obstetrics & Gynaecology, Hospital Raja Permaisuri Bainun, Ipoh, Perak,
Malaysia</p>
<p class="MsoNoSpacing"><b>Abstract:</b></p>
<p class="MsoNormal" style="text-align: justify;">Caesarean section rates have
increased worldwide. Following this, the rate of uterine scar dehiscence or
rupture is also increased in pregnancy. Rupture of lower uterine segment
incision at post-partum is extremely rare clinical condition. We present a 25
year old patient at day 26 post caesarean section, presented with lower
abdominal pain with copious vaginal discharge. The examination was
unremarkable. On Pelvic ultrasound and Computerized Tomography, an anterior hyperechoic
mass with fat attenuation with the mass was visible, measuring 3.3x 7.2x 7.7cm
, an anterior uterine wall defect was also noted.<span style="mso-spacerun: yes;"> </span>The patient underwent an exploratory
laparotomy. There was a spontaneous and com<span lang="EN-MY" style="mso-ansi-language: EN-MY;">plete rupture of the lower uterine segment with omentum enclosing the
defect. </span>The debris, clot & fluids were evacuated, followed by repair
of the defects in 2 layers with polyglactin suture material size 1. The
patient’s post-operative recovery was uneventful. In conclusion, the diagnosis
of post-partum caesarean scar dehiscence or rupture is difficult clinically,
but radiological modality is essential to establish the diagnosis. As this
patient is young, primiparous and with future reproduction function in mind, an
exploratory laparotomy was performed as it is both diagnostic & therapeutic
in this rare case. <span lang="EN-MY" style="mso-ansi-language: EN-MY;"><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span lang="EN-MY" style="mso-ansi-language: EN-MY;">Key words</span></b><span lang="EN-MY" style="mso-ansi-language: EN-MY;">: post- partum, caesarean scar,
rupture uterus<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span lang="EN-MY" style="mso-ansi-language: EN-MY;">Introduction<o:p></o:p></span></b></p>
<p class="MsoNormal" style="text-align: justify;"><span lang="EN-MY" style="mso-ansi-language: EN-MY;">The post-partum lower abdominal pain and per
vaginal discharge is common presentation in patients after caesarean section or
childbirth. The common cause is urinary tract infection, endomyometritis and
retained placenta. Spontaneous caesarean scar dehiscence or rupture at
post-partum is unusual and difficult to diagnose clinically. Radiological
modality is a usual tool to help in the diagnosis. Scar dehiscence or rupture
not only can be missed but can be potentially life-threatening in her
subsequent pregnancy if not address properly. Preoperative diagnosis is usually
difficult, thus exploratory laparotomy is both diagnostic and therapeutic for
this rare condition. We report a case of spontaneous and complete rupture of a
caesarean scar at day 26 post-partum.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span lang="EN-MY" style="mso-ansi-language: EN-MY;">Case Report:<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;">The patient was a 25-year-old
primiparous woman who underwent emergency caesarean section for deep transverse
arrest. The course of her pregnancy had been normal and uneventful. She had no
significant medical or surgical history. The labour was spontaneous and progress
smoothly until she reach the second stage. The second was prolonged for 1 and half
hours with OS fully. Caesarean section was decided as there was large caput
& it was not suitable for instrumental delivery. Her caesarean section
operation was complicated with bilateral extended uterine tear, the tears was extended
and involved the broad ligaments. These tears were repaired in two layers using
polyglactin suture size 1. The uterine incision was also sutured in two layers
using the same material by a specialist. There were no active bleeding. The
abdomen was closed in layers.<o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">She was clinically stable, with
normal vital signs throughout her hospital stay and was discharged well on day
2 post-operative day. She was perfectly well during her post-delivery visits. On
the Day 26 postpartum, she presented with lower abdominal pain and foul smelling
lochia/discharge. She had no fever, any evidence of sepsis or any excessive per
vaginal bleeding. <o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">On examination, she was afebrile,
her blood pressure was 104/62mmHg, pulse rate was 100bpm and abdomen was soft,
but mild tender on palpation. Uterus was contracted well at 16 weeks. Vaginal
examination revealed copious amount of yellowish vaginal discharge, and
draining from the OS. A pelvic ultrasound showed irregular and hyperechoic mass
above the uterine incision. The mass appeared like haematoma measuring 4.1x 6.7x7.0cm.
Computerized Tomography was carried out, which also reported the same finding
and a possibility of caesarean scar rupture with blood or abscess collection. An
anterior hyperechoic mass with fat attenuation with the mass was visible,
measuring 3.3x 7.2x 7.7cm. The bladder wall was separate and well defined. The hemoglobin
concentration was 10.9 g/L, the total white blood cell was 9.0x 10<sup>9</sup>
/L. The high vaginal swab was no growth detected. <span style="mso-spacerun: yes;"> </span>Histology report suggest acute on chronic inflammation
with granulation tissue formation.<o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">As the patient was young and
primiparous, a decision was made to perform an exploratory laparotomy and
repair of the ruptured uterine defect.<span style="mso-spacerun: yes;">
</span>The patient & her husband was adequately counseled prior to the operation.
At laparotomy, there was minimal pus in peritoneum. The omentum was adhered to
anterior uterine wall. The omentum was released from the scar. There was a complete
scar rupture of the lower segment uterine incision. The margins of the incision
were unhealthy, with some collection of blood and pus. The scar was debrided
until a fresh layer of uterine wall. The uterine cavity was normal. The bladder
wall was intact.<o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">Uterine defect margins were
refashioned and approximated in 2 layers with continuous closure and
interrupted suture respectively using polyglactin suture material size 1. Thorough
abdominal lavage done and abdominal drain was inserted. The integrity of the bladder
and ureters was confirmed prior abdominal closure. Her blood pressure remained
stable throughout the surgery.<o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">The patient’s postoperative
course was uneventful and she received broad spectrum antibiotics for 14 days.
She was discharged well on the 3rd day postoperative day and remained well
thereafter. She was reviewed 6 weeks after the laparotomy. The abdominal wound
has healed well. A repeat pelvic Ultrasound reveal well define uterine margins.<o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">Ultrasound picture:<o:p></o:p></p><p class="MsoNormal" style="text-align: justify;"></p><p class="MsoNormal" style="text-align: justify;">Intraoperative picture<o:p></o:p></p><p class="MsoNormal" style="text-align: justify;"><br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRXTqboZmTgsZ6jpEF6ylxM2fHEUADOTsV4LpSzFN4pYHCa1i59e3kzmldZ53HjQZQ9jexl973P1WwVco74Uxn8OeHdEIX1Yxvv9hixmcqhxvFjJXbSFWpyNVMIzW7sGOEnWE9YV3RWtXQ/" style="margin-left: 1em; margin-right: 1em;"></a><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRXTqboZmTgsZ6jpEF6ylxM2fHEUADOTsV4LpSzFN4pYHCa1i59e3kzmldZ53HjQZQ9jexl973P1WwVco74Uxn8OeHdEIX1Yxvv9hixmcqhxvFjJXbSFWpyNVMIzW7sGOEnWE9YV3RWtXQ/" style="margin-left: 1em; margin-right: 1em;"></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi3YoUoKXZNEdm0SD8BiEiIx2k7kzAymPL8K2kWwZf7ONT1N9aykZKyc_xC_jTWHDq1HhDm7vHeTvEGEqN7ib2YCAbi2PkEW9u9u7jpFjpgKrYt3IImCe-60WKZUy-FtL72O5fZZx8h04w-/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="220" data-original-width="298" height="236" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi3YoUoKXZNEdm0SD8BiEiIx2k7kzAymPL8K2kWwZf7ONT1N9aykZKyc_xC_jTWHDq1HhDm7vHeTvEGEqN7ib2YCAbi2PkEW9u9u7jpFjpgKrYt3IImCe-60WKZUy-FtL72O5fZZx8h04w-/" width="320" /></a></div><br /><img alt="" data-original-height="226" data-original-width="306" height="236" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRXTqboZmTgsZ6jpEF6ylxM2fHEUADOTsV4LpSzFN4pYHCa1i59e3kzmldZ53HjQZQ9jexl973P1WwVco74Uxn8OeHdEIX1Yxvv9hixmcqhxvFjJXbSFWpyNVMIzW7sGOEnWE9YV3RWtXQ/" width="320" /></div><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><p class="MsoNormal" style="text-align: justify;"><b style="mso-bidi-font-weight: normal;">Discussion<o:p></o:p></b></p>
<p class="MsoNormal" style="text-align: justify;">Abdominal pain and per vaginal
discharge after post caesarean delivery is a common complaint. <span lang="EN-MY" style="mso-ansi-language: EN-MY;">The common causes for such symptoms
are urinary tract infection, endomyometritis and retained placenta</span>
However, pain secondary to uterine dehiscence or rupture are a rare clinical
condition. The incidence of post-partum uterine scar dehiscence or rupture is
between 0.6% - 3.8%<sup>1</sup>. Delayed presentation of caesarean scar rupture
up until 6 weeks postpartum period has been reported in literature<sup>2</sup>.
Postpartum scar dehiscence or rupture can present as secondary post-partum
hemorrhage, localized or generalized pain and peritonitis, sepsis or even
shock. In our case, the presenting complaint was only tenderness at the lower
abdomen associated with copious vaginal discharge, which may suggested a
possibility of endomyometritis. This case report shows that it is important to
have high index of suspicion to exclude uterine dehiscence or rupture in
patients who present with localized tenderness or even pelvic haematoma or abscess.
Risk factors for lower segment uterine incision rupture during the post-partum
period are advance age, multiparity, diabetes, immune compromised, wound infection
and hematoma. In our case, we postulated that the extended tear may have led to
haematoma and subsequently developed infection that caused tissue necrosis and
scar dehiscence. This was evident by presence of copious vaginal discharge vaginally.
Among other factor that is associated with poor wound healing is malnutrition.
The body mass index of the patient during booking was 16. Whether this has a
direct relationship with uterine dehiscence, is unknown.<o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">Ultrasound is the commonly used
imaging modality to help with the diagnosis. On ultrasonography, the uterine
incision site may show full thickness defect, some hypoechoiec area along the
uterine incision line or in some cases some blood or abscess collection
anterior to the incision site. Other imaging modality that we can use to aid in
our diagnosis is computed tomography (CT) an magnetic resonance imaging ( MRI).
An MRI with a heavily T2 weighted image may show a bright fluid filled tract<sup>3</sup>.
However, the clinical usefulness using this modality in acute setting needs to
be defined.<o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">Management of these patient’s
will depend on the clinical situation taking into account the haemodynamic
stability, the severity of infection and patient future reproductive potentials.
The management includes conservative or surgical management. In conservative
management, broad spectrum antibiotics should be considered and long term
follow is need. Patient uterine integrity is difficult to test if this patients
plan for further pregnancies and deliveries. In those patients who are
unstable, exploratory laparotomy is recommended. Option between refashioning of
the edges of the uterine incision or hysterectomy should depend on the
intraoperative findings and patient future needs. In our case, the scar margins
was intact, hence re-suturing of the incision site was carried out. If the
edges are necrotic and irregular, hysterectomy may be considered.<o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">The consequence of this
complication for a future pregnancy remains unknown. Mode of delivery in next
pregnancy is preferably a repeat caesarean section. For our patient, we have
recommended for an elective caesarean delivery at around 37 weeks.<span style="mso-spacerun: yes;"> </span><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;"><b style="mso-bidi-font-weight: normal;">Disclosure<o:p></o:p></b></p>
<p class="MsoNormal" style="text-align: justify;">None of the authors has anything
to disclose <o:p></o:p></p><p class="MsoNormal" style="text-align: justify;">Consent Taken from Patient to use the pictures & publish this article</p>
<p class="MsoNormal" style="text-align: justify;"><b style="mso-bidi-font-weight: normal;">References:<o:p></o:p></b></p>
<p class="MsoNormal" style="text-align: justify;">1. El-Agwany AS et al.
Conservative management of infected post partum uterine dehiscence after <span style="mso-spacerun: yes;"> </span>c<span style="mso-spacerun: yes;"> </span>cesarean
section. J Med Ultrasound. 2018;<b style="mso-bidi-font-weight: normal;">26</b>(1):59.
doi:10.4103/jmu.jmu_5_18.<o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">2. Wagner MS, Bédard MJ.
Postpartum Uterine Wound Dehiscence: A Case Report. J Obstet Gynaecol Canada.
2006;28(8):713–5.doi:10.1016/s1701-2163(16)32236-8<o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">3. Jastrow N, Chaillet N, Roberge
S, Morency AM, Lacasse Y, Bujold E. Sonographic lower uterine segment thickness
and risk of uterine scar defect: a systemic review. J Obstet Gynaecol Can 2010;<b style="mso-bidi-font-weight: normal;">32</b>:321-7<o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">4.<span style="mso-spacerun: yes;"> </span>Sengupta Dhar R, Misra R. Postpartum uterine
wound dehiscence leading to secondary PPH: Unusual sequelae. Case Rep Obstet
Gynecol 2012;2012:<b style="mso-bidi-font-weight: normal;">154685.<o:p></o:p></b></p>
<p class="MsoNormal" style="text-align: justify;"><o:p> </o:p></p><br /><p></p>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-7925830973879774012021-06-07T18:46:00.004-07:002021-06-07T18:48:50.853-07:00Algorithm for Management Of Urinary Incontinence In Women<p style="text-align: center;"></p><div style="clear: both; text-align: justify;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEin4WPp7qh_LjJY91QsSyTCSAkDOtq5iGgG_lFUJ8xq1Kernfdl2EsPpl7aEJvdIhOU_Zn7YZUkiH93ug5LTnPcJJMYVuSy824R1AG8Ik180yaFfNV9ORaOa0yrw2vQdy6jBQ4Ep0dv35gq/s640/IMG_0742.jpg" style="margin-left: 1em; margin-right: 1em;"><strike><img border="0" data-original-height="640" data-original-width="550" height="667" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEin4WPp7qh_LjJY91QsSyTCSAkDOtq5iGgG_lFUJ8xq1Kernfdl2EsPpl7aEJvdIhOU_Zn7YZUkiH93ug5LTnPcJJMYVuSy824R1AG8Ik180yaFfNV9ORaOa0yrw2vQdy6jBQ4Ep0dv35gq/w532-h667/IMG_0742.jpg" width="532" /></strike></a></div><br /><div><br /></div><div><table cellpadding="0" cellspacing="0" style="width: 100%px;"><tbody><tr><td><div>
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<p align="center" class="MsoNormal" style="text-align: center;"><b><span style="font-size: 14pt; line-height: 115%;"> </span></b></p></div><p style="text-align: center;"><span></span></p><div style="text-align: left;"><div class="separator" style="clear: both; text-align: center;"><br /></div><br /></div><span face="Calibri, sans-serif" style="font-size: 14pt;"></span><p></p>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-38234368181699090162021-05-18T01:04:00.001-07:002021-05-26T19:20:30.868-07:00Management of Urinary Incontinence in Women ( GP GUIDE)<blockquote style="text-align: left;"><p>A. Definition and Epidemiology</p></blockquote><p> B. Classification of Urinary Incontinence</p><blockquote style="text-align: left;"><p>C. Making the diagnosis (History/ Physical & pelvic Assessment/Investigation)</p><p>D. Red flags and Referral<span style="white-space: pre;"> </span></p><p>E. Treatment option for Primary Care Givers</p><p><b><span style="color: red;">A. Definition and Epidemiology</span></b></p><p style="text-align: justify;">Urinary incontinence (UI) has been defined the by International Continence Society (ICS) as involuntary loss of urine which is objectively demonstrable and is a social and hygienic problem1. Urinary incontinence is the most common chronic medical disorder in women, accounting for about 35% of all chronic medical conditions, much more common than hypertension (25%), depression (20%) and diabetes (8%) (2). The most common causes for urinary incontinence in women are urinary stress incontinence, urge incontinence, mixed urinary incontinence & overflow incontinence. Urine loss through other than the urethra is extra-urethral incontinence, e.g. congenital, fistula (3).</p><p style="text-align: justify;">Prevalence data varies considerably with the definition of urinary incontinence and population base or studies. European and American epidemiological studies reported the prevalence to be between 10-40%. An Australian based study showed that every 1 in 4 women suffers from urinary incontinence(4). In a study in Malaysia, among young nulliparous women, the prevalence of Lower Urinary Tract Symptoms (LUTS) was 52.7% (5). </p><p style="text-align: justify;"><span style="text-align: left;">Urinary incontinence has a significant impact on the quality of life. A wide range of women (8-58%) who suffer urinary incontinence reported some degree of interference with their physical, psychological, and social lives. The impact of urinary incontinence on the quality of life includes social isolation, and depression. Many of them suffer in silence and do not seek help (6,7).</span></p><p><b><span style="color: red;">B. Classification of Urinary Incontinence </span></b></p><p style="text-align: justify;">For simplicity the UI in women are divided in four categories.</p><p style="text-align: justify;"><b>SUI</b>: (25-45 %) of UI usually seen in younger women can be due to childbirth trauma (urethral hypermobility), congenital weakness, previous surgery, radiation (intrinsic sphincter deficiency, ISD). Usually it is easy to diagnose this condition; patients usually have urine leakage on valsalva/ exersion/ cough/sneezing /physical activity7. The urine leakage can be demonstrable on lying down, at the time of pelvic examination. We can also ask patients to stand on covered sheet and ask them to bend forward and do some valsalva/cough vigorously few times. Presence of urine leakage on the cover sheet indicates a positive stress test. Patients must not empty the bladder before this test (there must be at least 150mls in bladder before doing this test) (1,2,7).</p><p style="text-align: justify;"><b>Urge Incontinence</b>: (9-31 %) Idiopathic in most cases, nervous system disorders like multiple sclerosis, diabetes, genital syndrome of menopause (GSM)/ atrophic vaginitis, constipation/ impaction stool, urinary stones, cancer or cystitis are some of the common causes for UI. In patients with Urge incontinence, most patients will have Frequency (F), Urgency (U) with or without incontinence and Nocturia (N): “FUN” symptoms (1,2,7)</p><p style="text-align: justify;"><b>Mixed UI</b>: (20-30%) In cases of mixed incontinence, the patients normally have mixed symptoms of stress incontinence and urge incontinence. In managing such patients the GP’s need to find out which is the predominant symptom and treat the most troubling symptom first (3,7). </p><p><b>Overflow Incontinence</b>: Occurs in 5-7% of cases. This is usually due to chronic retention which can be the result of local factors like urethral stricture/ stenosis, vaginal or peri-urethral mass or obstruction and in some case any pelvic organ prolapse may also cause obstruction or kinking effect on the urethra. The systemic factors are like brain (CNS) mass or lesions, cognitive disorders/impairments, spinal trauma, spinal disc problems, medications, CNS surgery and tumours (1,2,7).</p><p><b><span style="color: red;">C. Making the diagnosis (History/ Physical & pelvic Assessment/Investigation)</span></b></p><p>A thorough assessment is required to make an accurate diagnosis. This includes history-taking, physical examination and some relevant investigations. </p><p><b>1. History taking </b></p><p style="text-align: justify;">The assessment of urinary incontinence (UI) involves taking a detailed history regarding the duration and nature of UI. Understanding the symptoms allows appropriate questions to be asked, and this is crucial to differentiate the types of urinary incontinence.</p><p style="text-align: justify;">- Stress urinary incontinence: Urine leak on exertion, like coughing, sneezing, laughing or doing certain physical activity that causes increase intra-abdominal pressure.</p><p style="text-align: justify;">- Urge urinary incontinence: Urine leak associated with urgency (women may have urgency and wet themselves before reaching the toilet)</p><p style="text-align: justify;">- Urgency: A strong desire to pass urine, in which the patient finds it hard to differ urination.</p></blockquote><p> <span style="text-align: justify;">- Frequency: Urinating more than 8 times /day during the day time.</span></p><blockquote style="text-align: left;"><p style="text-align: justify;">- Nocturia: Urinating more than once after going to bed. </p><p style="text-align: justify;">- Overflow incontinence: Patient may present with difficulty to initiate micturition, some may need to strain to void, poor or disruptive flow of urine & incomplete voiding.</p><p style="text-align: justify;">- Mixed urinary incontinence: The presence of both stress & Urge urinary incontinence.</p><p style="text-align: justify;">In addition:</p><p>-<span style="white-space: pre;"> </span>Fluid intake history</p><p>-<span style="white-space: pre;"> </span>Symptoms suggestive of utero-vaginal prolapse, bowel symptoms & sexual history</p><p>-<span style="white-space: pre;"> </span>Past obstetric history including the number deliveries, the weight of the babies and any episiotomy or instrumental vaginal deliveries. </p></blockquote><blockquote style="text-align: left;"><p>-<span style="white-space: pre;"> </span>Past surgical history, e.g. incontinence surgery, caesarean section, pelvic organ prolapse repair and hysterectomy</p><p>-<span style="white-space: pre;"> </span>Patient general health or medical problems like COAD, asthma, mental status/cognitive disorders and any neurological condition</p><p>-<span style="white-space: pre;"> </span>Drug history, as some medications may contribute to UI, such as diuretics, some anti-depression, anti-psychotic, alpha & beta-adrenergic blockers & agonist.</p><p><br /></p><p><b>2. Physical examination: </b></p><p style="text-align: justify;">- In patients with UI, it’s essential to perform an abdominal and pelvic examination/assessment (7,8). Neurological assessment may need to be done in certain indicated cases.</p><p style="text-align: justify;">- Abdominal examination: look for old surgical scars which may indicate prior hysterectomy or incontinence surgery; also feel for any pelvic masses or distended bladder</p><p style="text-align: justify;">- Pelvic assessment: look at the external genitalia, any prolapse, vaginal discharge and signs of atrophy of the vulvo-vaginal. Speculum and bimanual examination will provide some information on the stage of prolapse if any, the size of uterus and any pelvic masses.</p><p style="text-align: justify;">- Cough/stress test: This simple test can be done on lying or standing. The patient must not pass urine before the test. Ask patients to cough or perform valsalva manoeuvre a few times. Any urine leakage may indicate the patient has stress urinary incontinence (SUI).</p><p style="text-align: justify;">- In some cases, a gentle stroke on the urethral or bladder base may induce spontaneous urinary leakage. This may suggest overactive bladder/ urge incontinence.</p><p style="text-align: justify;">- Neurological examination: Look for any upper motor or lower motor lesions or disorders. Pay more attention to the nerve distribution of S2-4. These nerves can be assessed by assessing the lower limb motor function & reflex responses, testing the perineal and perianal sensation/ tone.</p><p><b>3. Investigations</b></p><p style="text-align: justify;">- Bladder diary: This basic investigation tool is also known as Frequency Volume Chart (F/Q Chart). It is simple and patients can easily complete it. Patients are required to list down all the type and volume of fluid intake and output. They also need to record any events like urgency, urinary leakage and condition associated with the urine leak. By looking at the pattern of fluid intake and urine output, the GP’s can assess if the patients are consuming too much or too little fluids. They can also detect the presence of urinary frequency and nocturia. The presence of urgency and urge incontinence may indicate urge incontinence.</p><p style="text-align: justify;">- Urine analysis and culture: This may rule out any evidence of urinary tract infection (UTI) as the cause for the UI. If there is a presence of significant hematuria, the patient may require further evaluation.</p><p style="text-align: justify;">- Pelvic/Bladder Ultrasound: A pelvic ultrasound can exclude any pelvic masses, can assess the bladder volume and post-void residual urine (PVR). Overflow urinary incontinence can easily be diagnosed if a woman has urinary incontinence and ultrasound showed a distended bladder high PVR, more than 100mls after micturition (7,8).</p><p style="text-align: justify;"><br /></p><p><span style="color: red;">D. Assessment to rule out RED flag cases and referrals</span></p><p style="text-align: justify;">- Presence of RED flag markers may indicate some serious pathology & these patients need further evaluation. The Red flag markers including recurrent UTI, painful bladder syndrome, distended bladder, presence of hematuria, passing out urinary stones, presence of a visible vaginal prolapse, neurological deficits and etc. It is advisable to refer such patients to the respective specialty. </p><p style="text-align: justify;">- If no improvement in 6-8 weeks, a referral can be made to the community continence service/ urogynaecologist or urologist for further assessment, conservative or supportive treatment, and in some cases surgery may be indicated</p><p style="text-align: justify;"><span style="color: red;">E. Treatment option for Primary Care Givers</span></p><p style="text-align: justify;">Management of urinary incontinence encompasses detail history taking, doing proper general & pelvic assessment and doing appropriate investigation. In most cases the diagnosis can be established if we follow the sequence of investigation as mention above. Once the diagnosis is establish than we can focus on managing them based on the diagnosis (7,8). </p><p style="text-align: justify;">1. <b>The initial treatment</b> in any of the urinary incontinence is behavioral modification or life style intervention. </p><p style="text-align: justify;">-<span style="white-space: pre;"> </span>Patient should be advised to consume about 2-litres (6-8 cups) a day. The change in fluid intake is adjusted based on the bladder dairy (9).</p><p style="text-align: justify;">-<span style="white-space: pre;"> </span> In older/geriatric patients, there is a strong correlation between evening fluid intake and nocturia. In such cases, patients are advised to avoid any fluid intake 2 hours before going to bed. </p><p style="text-align: justify;">-<span style="white-space: pre;"> </span>Avoid ‘just in case’ voiding patterns or habits</p><p style="text-align: justify;">-<span style="white-space: pre;"> </span>They should be taught on proper toiletry hygiene </p><p style="text-align: justify;">-<span style="white-space: pre;"> </span>Proper technique to pass urine (lean forward technique), passing urine with feet flat on the floor and elbows resting on knees (10,11). </p><p style="text-align: justify;">-<span style="white-space: pre;"> </span>Patients are also advice to avoid bladder irritants like caffeinated drinks & alcohol. Patients are encouraged to consume cranberry/ spirulina juice or tablets as some studies consider them as bladder friendly.(12)</p><p style="text-align: justify;">-<span style="white-space: pre;"> </span>Other interventions include reducing weight, reduction in excessive physical activity, avoidance of constipation/straining and cessation of smoking (13). </p><p style="text-align: justify;">-<span style="white-space: pre;"> </span>Patients who are post-menopausal and have symptoms of GSM are advised to apply topical estrogen. </p></blockquote><blockquote style="text-align: left;"><p style="text-align: justify;">2.<b> Pelvic floor exercise (PFE</b>): The pelvic floor exercises are aimed at strengthening the pelvic floor muscles. The PFE can be taught to patients at the time of pelvic assessment or referred to the physiotherapist to help with the exercises. The exercises should be done with three to four sets of about 8-10 slow pelvic contractions, sustained for 8-10 seconds and repeated 3-4 times per week. The PFE is performed for 6 weeks to 3 months. The short term improvement & cure rate are quoted from 65-75%. PFE is effective for stress as well as mixed urinary incontinence (14). </p><p style="text-align: justify;">3. <b>Bladder Retraining</b>: Is a behavioral modification technique which can be taught to patients at GP setting. The aim of bladder retraining is to increase the capacity of the bladder until it can hold the normal amount of urine (300 – 500 mls). By stretching the bladder, patients can reduce visits to the toilet to 5-7 times during the day and 0-1 time at night. Patients can be taught about proper bladder care, technique to increase the void internal in cases of urgency, urge incontinence and overactive bladder. Patients are advised to delay the void interval from 15-30min initially and gradually increase the intervals to 3-4 hours. They are also taught how to defer the void sensation with various distractive techniques. The distractive techniques include in-curving of the 1st toes, squeezing the pelvic muscle, mental distraction at the time of urge and others (15).</p><p style="text-align: justify;">4. <b>Estrogen Therapy</b>: Application of topical estrogen has been shown be effective in reducing vaginal & bladder irrigative symptoms. Meta-analysis by Fantl & Sultana in 1994 has shown that it is more effective for urge incontinence, recurrent urinary tract infection than stress incontinence (16,17). </p><p style="text-align: justify;">5.<b> Pharmacological therapy</b>: </p><p style="text-align: justify;">- There is no effective medical treatment for stress incontinence. Alpha- adrenergic agonists & duloxetine are some of the drugs used for SUI. These drugs did not get US FDA approval for usage in SUI.</p><p style="text-align: justify;">- For urge incontinence/ overactive bladder symptoms: </p><p style="text-align: justify;">The commonly used drugs are anticholinergic or antimuscarinic drugs. These drugs are contraindicated in patients with narrow-angle glaucoma and cardiac arrhythmia. Patients also need to be counseled about the common side effects which include dry mouth, constipation, tachycardia and transient blurring of vision. Antimuscarinic drugs that are commonly used are oxybutynin, tolterodine, solifenacin, derifenacin and others. Mirabegron is a beta –adrenergic agonist that acts on beta-3 receptors in the detrusor muscles and increase the bladder capacity (18,19,20). Use of medical therapy is ONLY recommended after the first line / initial treatment fails.</p><p style="text-align: justify;">- When using medical therapy, there must be a clear indication. Patient must be adequately counselled with regards to the indication, side effects, contraindications, duration of treatment and the benefits of this treatment</p><p style="text-align: justify;">- Initial medical treatment is started with low dose & long acting drugs, patient must be review 6-8 weeks to assess the side effects & effectiveness of this treatment. Doses can be adjusted depending on patients’ response. Bladder dairy can be of use to assess the symptoms & effectiveness of the treatment (20).</p><p style="text-align: justify;"><span style="color: red;">F. Devices & other no pharmacological therapy</span></p><p style="text-align: justify;">- In patient with genuine stress incontinence (SUI), one can try incontinence pessaries/occlusive devices. Some form of training is required before GP’s can try these pessaries or occlusive devices.( 21)</p><p style="text-align: justify;">- Electrical stimulation (percutaneous tibial nerve stimulation) can be tried for urge UI. A weekly stimulation for 3 months followed by monthly stimulation has shown similar effect as antimuscarinics medication (21).</p><p style="text-align: justify;">- For patients with obstructive bladder symptoms secondary to prolapse, one can insert a vaginal pessary to release the pressure / kinking effect. Application of pessary or devices needs practice & some training.</p><p style="text-align: justify;">- If there is an over-distended bladder without any obstructive pathology, one can insert an indwelling catheter to empty the bladder before sending to specialist hospitals.</p><p><br /></p><p><span style="color: red;">References</span></p></blockquote><p></p><ol style="text-align: left;"><li><span style="text-align: justify;"> </span><span style="text-align: justify; text-indent: -32pt;">Hayden BT, de Ridder D, Freeman RM at
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forward improve micturation? J Obs Gynaecol. 2000;20(6):628–9.</span></li><li style="text-align: justify;"><span style="text-indent: -32pt;">Jepson RG, Craig JC. A systematic review
of the evidence for cranberries and blueberries in UTI prevention. Mol Nutr
Food Res. 2007;51(6):738–45.</span></li><li style="text-align: justify;"><span style="text-indent: -32pt;">Subak LL, Whitcomb E, Sheh H et al.
Weight loss: a novel and effective treatment for urinary incontinence. J Urol.
2005;174:190–5.</span></li><li style="text-align: justify;"><span style="text-align: left; text-indent: -32pt;">Hay-Smith EJ, Bo K, Berhmans LC. Pelvic
floor exercise training for urinary incontinence in women. Cochrane Database
Syst Rev. 2003;(1):CD001407.</span></li><li style="text-align: justify;"><span style="text-align: left; text-indent: -32pt;">Wallace, Roe B, Williams K, Palmer M.
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of overactive bladder: systematic review. BMJ. 2003;326:841.</span></li><li style="text-align: justify;"><span style="text-align: left; text-indent: -32pt;">Nabi H, Cody JD, Ellis G, Hay-Smith J.
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<p align="center" class="MsoNoSpacing" style="text-align: center;"><br /></p></div></td></tr></tbody></table></v:textbox></v:rect></p>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0Ipoh, Perak, Malaysia4.597479 101.090106-28.455603865155815 65.93385600000002 37.650561865155815 136.246356tag:blogger.com,1999:blog-1041229983825909936.post-85399084817653329112013-10-07T00:41:00.005-07:002013-10-07T01:11:50.239-07:00Three cases of paraurethral angiofibroblastoma<!--[if !mso]>
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<h2>
<a href="http://www.blogger.com/blogger.g?blogID=1041229983825909936" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"></a><a href="http://www.blogger.com/blogger.g?blogID=1041229983825909936" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"></a><a href="http://www.blogger.com/blogger.g?blogID=1041229983825909936" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"></a><a href="http://www.blogger.com/blogger.g?blogID=1041229983825909936" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"></a>
Three case reports of angiofibroblastoma.</h2>
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<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Case 1</span></b></span></div>
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<a href="http://www.blogger.com/blogger.g?blogID=1041229983825909936" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"></a><a href="http://www.blogger.com/blogger.g?blogID=1041229983825909936" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"></a><span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">A
32 year old lady presented with an asymptomatic, but gradually enlarging
vaginal lump over 3 months. On examination, there was a small 3x2 cm rubbery
tissue mass arising from the left paraurethral region. An examination under
anesthesia and excisional biopsy was thus organized. However she defaulted on
her surgery due to anxiety, and failed to attend her follow up appointment. Six
months later she returned complaining od pain and bleeding on voinding. On examination,
the solitary paraurethral lump had noe enlarged to a size 8x8x4 cm, amd had
become ulcerated and infected ( figure 1). There was no associated inguinal
lymphaadenopathy. Due to the pain and voiding difficulties, an examination
under anesthesia, cystoscopy and excision of the mass was promptly carried out.
Intraoperatively, the tumour was found to be localized to the paraurethral
regionand had not invaded into the urethra or bladder. It was found that the
tumour was well circumscribed and was able to be ‘shelled out’ relatively
easily. The patient did not require any indwelling catheter post operatively
and subsequently made an uneventful recovery ( figure 2). Histopathology
confirmed the mass to be a benign angiofibroblastoma.</span></span></div>
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<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";"></span><span style="font-family: "Times New Roman","serif";"></span></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhleO5VYr6L2a4pl5x2tNVVmr8H4jF9mrrQtT5oQzyDsv6_dXUxG76o4gNLtYS-mYpiZh_rmnE5WNLYJgbWo_7WoCroyIAvJrO8wjgs5UmipqKAL6RNEfNOaHHlzX-l4qO7hjseinO1Gkp8/s1600/Angiomyofibroblastoma+1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhleO5VYr6L2a4pl5x2tNVVmr8H4jF9mrrQtT5oQzyDsv6_dXUxG76o4gNLtYS-mYpiZh_rmnE5WNLYJgbWo_7WoCroyIAvJrO8wjgs5UmipqKAL6RNEfNOaHHlzX-l4qO7hjseinO1Gkp8/s320/Angiomyofibroblastoma+1.jpg" width="320" /></a></div>
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<b><span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Case 2.</span></span></b></div>
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<span style="font-size: small;">A 42 year old Para
2+1, This patient initially presented on
9.10.2008 because she noticed a mass per vaginal which had been present for 2
years, it was reducible but protruded back out immediately. The mass was firm,
nodular and mobile, measuring 4x3 cm. The mass progressive got bigger and
causing voiding dysfunction. An
examination under anesthesia was carried out on 226.2009. An indwelling
catheter was inserted to assist in the surgery. The mass was very close to the
urethra and has distorted the anatomy of the urethra. The mass was easily
enucleated. The estimated blood loss was 100mls. There were no
intraoperative complications. The catheter was kept for three days. The
histology was consistent with suburethral angiofibroblastoma (4x3cm). </span></div>
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<br />
<br />
<b><span style="font-size: small;">Case 3.</span></b></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;">This a 65 year old lady Para 6,
presented with elongated and firm mass near the urethral meatus. The mass was
initially small but over six year its size has increased and causing pain and
difficulty in walking. She also has difficulty in micturation. She has to move
the elongated mass to one side. On examination there was a 7x4x4 cm elongated
mass with the tip of the distal part of the mass appeared fungating and
necrosing. The proximal part of the mass had a 4cm stock/ base. She underwent
examination under anaesthesia and excision of the mass. The surgery was
straight forward. Check cystoscopy was normal. The histology was consistent
with Angiomyofibroblasroma.</span><br />
<br />
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</div>
<div class="MsoNormal">
<span style="font-size: small;"></span></div>
<div class="MsoNormal">
<b><span style="font-size: small;">Discussion</span></b></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;">Angiomyofibroblastoma is a rare
mesenchymal tumour of the female genital tract that was only first described in
1992(1). This tumour is predominately found in the vulval region, bu can also
arise from the vagina, clitoris, labia majora and perineum. Unusual cases
involving the male scrotal and inguinal regions have been reported 9(1). They
have been reported in women from the age of 23-86 (mean 45.8) years. They
usually appears as a painless lump that may have been present for a few weeks
or up to 13 years. Clincally, this tumour can be mistaken for a bartholin gland
cyst, skene’s gland cyst, urethral diverticulum or Gardner duct cyst.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;">Angiomyofibroblastoma is a slow
growing tumour that is usually well circumscribed, and has a soft rubbery
consistency with a bulging, pink, section surface. Histologically, this tumour
is composed of two components: the blood vessels and stromal cells. It shows
alternating hypercellular and hypicellular oedematous ares, in which numerous
thin walled, small to medium sized vessels are irregularly distributed
throughout. The tumour cells show immune reaction for vimentin and desmin and ,
more recently, it was noted to be muscle specificactin-positive or Alfa-smooth
muscle actin-positive (2,3,4). It is typically benign in nature. Only one case
of a malignant transformation of an angiomyofibroblastoma ( ‘angiomyofibrosarcoma’)
has been reported(3).</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;">Angiomyofibroblasroma may have
been reported as an aggressive angiomyxoma. Unlike Angiomyofibroblasroma,
aggressive angiomyxoma affects deeper tissues with infiltrative margins, and
tends to recur (4). The pathogenesis of Angiomyofibroblasromais still unclear,
although it has been proposed that it may originated from an immature
mesenchymal cell in the sub epithetial myxoid zone of the lower female genital
tract, or in perivascular areas. The outcome in these patients were good, and
is always favorable with simple excision of the tumour mass.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small;"><b>References</b> </span></div>
<div class="MsoListParagraphCxSpFirst" style="text-align: justify; text-indent: -0.25in;">
<ol>
<li><span style="font-size: small;"><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Fetchers
CDM, Tsang WY, Fisher C, lee KC & Chan JK. Angiomyofibroblasromaof the
vulva. A benign neoplasm distinct from aggressive angiomyxoma. Am J Surg Patho
1992; 16;373-82.</span></li>
</ol>
</div>
<div class="MsoListParagraphCxSpMiddle" style="text-align: justify; text-indent: -0.25in;">
<ol>
<li><span style="font-size: small;"><span style="font-family: "Times New Roman";">2. </span><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Hiroshi
K, Noriomi M, Yoshikazu S, Masanori M, Taiji T & Takashi s.
Angiomyofibroblasroma of the female urethra. Int J Urol 1999; 6:268-270</span></li>
</ol>
</div>
<div class="MsoListParagraphCxSpMiddle" style="text-align: justify; text-indent: -0.25in;">
<ol>
<li><span style="font-size: small;">3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> N</span>ielsen
GP,Young RH, Dickersin GR & Rosenberg AE. Angiomyofibroblasromaof the vulva
with sarcomatous transformation (‘Angiomyofibrosarcoma)’. Am J surg Pathol
1997;30:3-10</span></li>
</ol>
</div>
<div class="MsoListParagraphCxSpMiddle" style="text-align: justify; text-indent: -0.25in;">
<ol>
<li><span style="font-size: small;">4.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Steeper
TA & Rosai J. Aggressive angiomyxoma of the female pelvis and perineium.
Report of nine cases of a distinctive type of gynaecologis soft-tissue
neoplasma. Am J Surg Pathol 1983; 7:463-465.</span></li>
</ol>
</div>
<div class="MsoListParagraphCxSpMiddle" style="text-align: justify; text-indent: -0.25in;">
<ol>
<li><span style="font-size: small;">5.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span>Fukunaga
M, Nomura K, Matsumoto K, Doi K, Endo Y & Ushigome S. Vulval
Angiomyofibroblasroma: Clinicopathological analyisi of six cases. Am J clin
Pathol 1997; 6:45-51</span></li>
</ol>
</div>
<div class="MsoListParagraphCxSpLast" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="margin-left: 0.25in; text-align: justify;">
<br /></div>
Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-70171192426454378262013-10-07T00:22:00.001-07:002013-10-07T00:28:54.900-07:00VAGINAL DISCHARGE:NOTES FOR PMC STUDENTS<!--[if gte mso 9]><xml>
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<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 16.0pt; line-height: 115%;"> Vaginal
Discharge</span></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Vaginal
discharge is a common presenting symptom in any physician’s office. Vaginal
discharge may be physiological or pathological. Although abnormal vaginal
discharge often prompts women to seek screening for sexually transmitted infections
(STIs), vaginal discharge is poorly predictive of the presence of an STI.<sup>1</sup>Clinicians
need to be aware of emerging epidemiological data, the different presentations
of vaginal discharge, and how to approach their management so that the symptom
can be treated according to its aetiology.<sup>2</sup></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Vaginal
discharge is a common gynaecological condition among women of childbearing age
that frequently requires care. It derives from physiological secretion of
cervical and Bartholin’s glands and desquamation of vaginal epithelial cells
resulting from bacterial action in the vagina.<sup>3</sup></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;">The
amount of mucus produced by the cervical glands varies throughout the menstrual
cycle. Vaginal discharge that suddenly differs in colour, odour, or
consistency, or significantly increases or decreases in amount, may indicate an
underlying problem like an infection.<sup>4 </sup>Increased amount of vaginal
discharge can be due to emotional stress, ovulation, pregnancy or sexual
excitement. </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 16.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;">Aetilogy</span></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;">Physiological
Discharge</span></b></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;">Many
women have what they perceive as an abnormal vaginal discharge at some point in
their lives, but usually it is just a normal physiological discharge. This is a
white or clear, non-offensive discharge that varies with the menstrual cycle. </span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">The
quality and quantity of vaginal discharge may alter in the same woman in cycles
and over time. Factors that can influence physiological discharge are:-</span></div>
<br />
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Age</span><br />
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l2 level1 lfo2; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Prepubertal</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l2 level1 lfo2; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Reproductive </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l2 level1 lfo2; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Pregnancy</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l2 level1 lfo2; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Hormonal contraceptions</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l2 level1 lfo2; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Menopause </span></div>
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Local
facors</span><br />
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l2 level1 lfo2; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Semen</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l2 level1 lfo2; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Personal hygiene and
habits</span></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: .75in; mso-add-space: auto; mso-list: l2 level1 lfo2; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Menstruation </span></div>
<div class="MsoNormal" style="text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%; mso-bidi-font-size: 12.0pt;">Pathological Discharge</span></b></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Pathological
vaginal discharge can be further divided by specific age groups which are
prepubertal group, reproductive group and menopause group.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Common
causes of pathological vaginal discharge for each age group are:-</span></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Prepubertal</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 154.05pt;" valign="top" width="205"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Reproductive</span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 154.05pt;" valign="top" width="205"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Menopause</span></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="border-bottom: none; border-left: solid windowtext 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 154.0pt;" valign="top" width="205"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: center;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Nonspecific bacterial vaginitis</span></div>
</td>
<td style="border-right: solid windowtext 1.0pt; border: none; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 154.05pt;" valign="top" width="205"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: center;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Foreign bodies (ex: IUCD, tampon,
condom)</span></div>
</td>
<td style="border-right: solid windowtext 1.0pt; border: none; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 154.05pt;" valign="top" width="205"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: center;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Cervical or endometrial carcinoma</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="border-bottom: none; border-left: solid windowtext 1.0pt; border-right: solid windowtext 1.0pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 154.0pt;" valign="top" width="205"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: center;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Foreign bodies</span></div>
</td>
<td style="border-right: solid windowtext 1.0pt; border: none; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 154.05pt;" valign="top" width="205"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: center;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Allergic to local irritant</span></div>
</td>
<td style="border-right: solid windowtext 1.0pt; border: none; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 154.05pt;" valign="top" width="205"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: center;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Actropic vaginitis</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 154.0pt;" valign="top" width="205"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: center;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Sexual abuse</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 154.05pt;" valign="top" width="205"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: center;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Infections</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 154.05pt;" valign="top" width="205"><div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: center;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">FB (ex: vaginal pessary)</span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Common
causes of infections:-</span></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Candidiasis: Acute
vulvovaginal candidiasis / recurrent vulvovaginal candidiasis</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Bacterial vaginosis</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Trichomoniasis</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Chlamydia trachomatis</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Neisseria gonorrhoea</span></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Pelvic inflammatory
disease</span></div>
<div class="MsoNormal" style="text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Principles of management</span></b></div>
<br />
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">History<sup>5</sup></span><br />
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Characteristics of the
discharge - Onset, duration, colour, odour, consistency.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Any associated symptoms
- Itch, dyspareunia, abdominal pain, abnormal vaginal bleeding or pyrexia is
more likely to indicate sexually transmitted infection. </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Sexual history - Is
patient at increased risk of sexually transmitted infection (age <25 years,
new sexual partner or more than one sexual partner in past year, previous sexually
transmitted infection)</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Contraceptive use</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Pregnancy</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Concurrent medications
and previous treatments</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Medical conditions such
as diabetes, immunocompromised state.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Non-infective causes of
discharge such as allergic reaction, known cervical ectopy or polyps, genital
tract malignancy, foreign body (such as tampons).</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; text-align: justify;">
<br /></div>
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Examination<sup>5</sup></span><br />
<br />
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Abdominal palpation for
tenderness or mass.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Inspect the vulva for
discharge, erythema, ulcers, other lesions or skin changes.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Bimanual pelvic
examination for adnexal or uterine tenderness or mass, and for cervical motion
tenderness (this can indicate pelvic inflammatory disease).</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Speculum examination to
inspect vaginal walls, cervix, and characteristics of discharge. </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Take endocervical swabs
if there is risk of sexually transmitted. </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -.25in;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">High vaginal swabs are
of limited diagnostic value except in pregnancy, post-instrumentation, failed
treatment, recurrent symptoms, or to confirm candidiasis.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: .75in; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Bacterial Vaginosis</span></b><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"></span></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Bacterial
vaginosis is the most common cause of infective vaginal discharge. It causes
profuse and fishy smelling discharge without itch or soreness. This condition
is characterised by an overgrowth of anaerobic bacteria and occurs and remits
spontaneously. Asymptomatic bacterial vaginosis in non-pregnant women does not
require treatment. The condition is associated with poor pregnancy outcomes,
endometritis after miscarriage, and pelvic inflammatory disease. Antibiotics
are the mainstay of therapy for bacterial vaginosis. Medications include
metronidazole, clindamycin, and metronidazole vaginal gel. </span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Vulvovaginal Candidiasis</span></b></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">The
prevalence of asymptomatic carriage of Candida in women is 10%. Symptoms are
vulval itch and soreness and thick white non-offensive discharge. There is no
evidence that combined oral contraceptives cause candidiasis. Asymptomatic
vulvovaginal candidiasis does not need treatment. Vulvovaginal candidiasis can
be acute or recurrent. Recurrent vulvovaginal candidiasis diagnosed when there are
4 or more episodes of VVC in 1 year.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Chlamydia Trachomatis</span></b></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Chlamydia
trachomatis is the most common sexually transmitted infection caused by a
bacterium. Chlamydia can cause a purulent vaginal discharge, but it is
asymptomatic in 80% of women. It was thought that 10-40% of untreated
chlamydial infections will result in pelvic inflammatory disease. This has
recently been challenged by a large observational study, which reported that
only 5.6% of women developed this disease,<sup>6</sup> and by a small prospective
study that reported an even lower rate of 1%.<sup>7</sup> Chlamydia is treated
with either single dose of Azithromycin or twice daily dose of Doxycycline.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Neisseria gonorrhoea</span></b></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Neisseria
gonorrhoea may present with a purulent vaginal discharge but is asymptomatic in
up to 50% of women. Major symptoms include vaginal discharge, dysuria,
intermenstrual bleeding, dyspareunia and mild lower abdominal pain. The true
prevalence and epidemiology in the general community is not known. Gonorrhoea
may be complicated by pelvic inflammatory disease.Culture is the most common
diagnostic test for gonorrhoea, followed by the deoxyribonucleic acid (DNA)
probe, and then the polymerase chain reaction (PCR) assay and ligand chain
reaction (LCR). </span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Trichomonasvaginalis</span></b></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Trichomonasvaginalis
can cause an offensive yellow vaginal discharge, which is often profuse and
frothy, along with associated symptoms of vulval itch and soreness, dysuria,
and superficial dyspareunia, but many patients are asymptomatic. The true
prevalence and epidemiology in the general community is not known. Usually an
oral antibiotic called metronidazole (Flagyl) is given to treat trichomoniasis.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Persistent Vaginal Discharge</span></b></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">It
would be difficult to proceed further for women who complain of persistent
vaginal discharge with repeated negative STI screen results. When minimal discharge
is evident, it is worth discussing again personal hygiene practices and
douching, the basis for physiological discharge, and inquiring whether there
are psychosexual difficulties as a result of the patient's continued symptoms.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">If
use of spermicides and lubricants are contributing to symptoms, alternative
contraception choices should be discussed. An extensive cervical ectropion can
cause heavy mucoid discharge. After the menopause, atrophic vaginal changes may
predispose women to infective vaginitis. Intravaginal oestrogen replacement,
with pessaries or cream, gradually improves the condition of the vaginal
epithelium and reduces the susceptibility to infection.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Underlying
gynaecological disease must be considered in all women with unexplained
persistent vaginal discharge. Gynaecological neoplasms, such as benign
endocervical and endometrial polyps, can present with vaginal discharge, and malignancy
needs to be excluded.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%; mso-bidi-font-size: 12.0pt;">Conclusion</span></b></div>
<div class="MsoNormal" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Many
women self-diagnose and self-treat episodes of vaginal infection with over the
counter treatments. Some women may subsequently present with history of
recurrence and never having had this diagnosis confirmed by any microbiological
tests. It is important to confirm the diagnosis and to ensure a full sexual
health screen has been done to exclude concurrent infection. Management of
vaginal discharge requires an empathic approach with reassurance and psychological
support as necessary.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Reference</span></b></div>
<br />
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Vaginal
discharge—causes, diagnosis, and treatment</span>
<br />
<div class="MsoListParagraphCxSpMiddle" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"> BMJ
2004; 328 doi: http://dx.doi.org/10.1136/bmj.328.7451.1306 (Published 27 May
2004)</span></div>
<br />
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Vaginal
discharge</span>
<br />
<div class="MsoListParagraphCxSpMiddle" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"> BMJ.
2007 December 1; 335(7630): 1147–1151. doi:<span style="mso-spacerun: yes;">
</span>10.1136/bmj.39378.633287.80 PMCID: </span></div>
<div class="MsoListParagraphCxSpMiddle" style="text-align: justify;">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"> PMC2099568 Clinical Review</span></div>
<br />
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Pathological
Vaginal Discharge among Pregnant Women: Pattern of Occurrence and Association
in a </span><br />
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"> Population-Based SurveyTânia Maria M. V. da Fonseca,1 Juraci A. Cesar,2
Raúl A. Mendoza-Sassi,2 </span><br />
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"> and Elisabeth B. Schmidt3</span><br />
<br />
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;">Source: Vaginal discharge |
University of Maryland Medical Centerhttp://umm.edu/health/medical</span><br />
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;"> /ency/articles/vaginal-discharge#ixzz2foJJk45j</span><br />
<br />
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;">Abnormal vaginal discharge</span>
<br />
<div class="MsoListParagraphCxSpMiddle">
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;"> BMJ 2013; 347 doi:
http://dx.doi.org/10.1136/bmj.f4975 (Published 13 August 2013) </span></div>
<br />
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;">Low N, Egger M, Sterne JA, Harbord R, Ibrahim F,
Lindblom B, et al. Incidence of severe </span><br />
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;"> reproductive tract complications
associated with diagnosed genital chlamydial infection: the Uppsala </span><br />
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;"> women's
cohort study. Sex Transm Infect 2006;82:212-8.</span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;"></span><br />
<br />
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;">Morré SA, van den Brule AJC, Rozendaal L, Boeke AJ,
Voorhorst FJ, de Blok S, et al. The natural </span><br />
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;"> course of asymptomatic Chlamydia
trachomatis infections: 45% clearance and no development of </span><br />
<span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;"> clinical PID after
one-year follow up. Int J STD AIDS 2002;13(suppl 2):12-8.</span><span lang="EN-SG" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-SG;"></span>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-63836121576383963722013-04-02T16:55:00.001-07:002013-04-02T16:55:15.010-07:00MRCOG/MOG PRACTICE QUESTION 2<b>QUESTION 2</b><br />
<br />
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A 58 year-old woman has had a TAHBSO 3 years earlier for
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Examination reveals a vault prolapse and a moderate cystocoele.</div>
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<br /></div>
<div style="text-align: justify;">
</div>
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How would you manage her? (<b style="mso-bidi-font-weight: normal;">Key word here is MANAGE; which would include history, examination,
investigation, treatment)</b></div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
</div>
<div class="MsoNormalCxSpMiddle" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">a)<span style="font: 7.0pt "Times New Roman";"> </span></span></span>History</div>
<div style="text-align: justify;">
</div>
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Clarify nature of symptoms, worse with standing/ standing,
relieved by lying down</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
Effects on quality of life</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
Urinary symptoms- any incontinence, incomplete voiding,
voiding difficulties (symptoms likely to be related to prolapse)</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
Bowel symptoms- incontinence, difficulty emptying rectum (<b style="mso-bidi-font-weight: normal;">URINARY AND BOWEL symptoms comes hand in
hand)</b></div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
Sexual history and desire to retain sexual function</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
Previous gynecological history especially on the hysterectomy/
prolapse surgery</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
</div>
<div class="MsoNormalCxSpMiddle" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b)<span style="font: 7.0pt "Times New Roman";"> </span></span></span>Examination</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
BMI</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
Any abdominal mass</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
Speculum examination; using the objective assessment of
prolapse with POP-Q</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
Access for SUI after <b style="mso-bidi-font-weight: normal;">reducing
prolapse with full bladder</b></div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
Pelvic examination (the Bimanual- to assess for pelvic mass)</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
</div>
<div class="MsoNormalCxSpMiddle" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">c)<span style="font: 7.0pt "Times New Roman";"> </span></span></span>Investigations</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify;">
Relevant blood investigations eg
FBC, Renal Profile, pre-operative work up</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="margin-left: 0.5in; text-align: justify;">
<br /></div>
<div style="text-align: justify;">
</div>
<div class="MsoNormalCxSpMiddle" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">d)<span style="font: 7.0pt "Times New Roman";"> </span></span></span>Treatment
options</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
<b style="mso-bidi-font-weight: normal;">Non-surgical options</b></div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
-Pelvic floor exercise – no evidence for efficacy, used in
women whom wants to avoid surgery but maintain sexual function, unlikely to be
effective</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
- Pessaries- ring/shelf (with the ring, likely to be
expelled in women with deficient perineum/perineal body. With shelf pessary,
sexual intercourse may not be possible). Should be reserved for women who are
unfit/decline surgery or while awaiting surgery. Need to be changed every 6-9
months.</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
<b style="mso-bidi-font-weight: normal;">Surgical options</b></div>
<div style="text-align: justify;">
</div>
<div class="MsoNormalCxSpMiddle" style="margin-left: 0.75in; text-align: justify; text-indent: -0.25in;">
<span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Abdominal sacro-colpopexy- effective, evidence
proven, major surgery for a relatively healthy women but may require the
additional vaginal procedure if woman has anterior/posterior vaginal wall
prolapse</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormalCxSpMiddle" style="margin-left: 0.75in; text-align: justify; text-indent: -0.25in;">
<span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Sacrospinous ligament fixation – vaginal
procedure with lower morbidity and suitable for women who are unfit for
laparotomy. Failure rate higher than abdominal route. Allows simultaneous
vaginal wall repair.</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormalCxSpMiddle" style="margin-left: 0.75in; text-align: justify; text-indent: -0.25in;">
<span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Laparoscopic sacro-colpopexy may be undertaken
if expertise is available</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormalCxSpMiddle" style="margin-left: 0.75in; text-align: justify; text-indent: -0.25in;">
<span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Colpocleisis may be offered for frail women who
do not wish to retain sexual function.</div>
<div style="text-align: justify;">
</div>
<div class="MsoNormalCxSpMiddle" style="margin-left: 0.75in; text-align: justify; text-indent: -0.25in;">
<span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><b style="mso-bidi-font-weight: normal;">Mesh-
controversial and probably should not be mentioned in an exam answer as the
only evidence for it would be anterior repair.</b></div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
</div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-48655353249567112112013-04-02T16:53:00.003-07:002013-04-02T16:53:44.225-07:00MRCOG/MOG PRACTICE QUESTIONS 2013<!--[if gte mso 9]><xml>
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<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: 11.0pt;"><b>QUESTION 1. </b></span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: 11pt;">A <b style="mso-bidi-font-weight: normal;">65 year</b> old otherwise <b style="mso-bidi-font-weight: normal;">healthy
woman</b> presents with incontinence of urine on coughing, sneezing and
laughing.</span></div>
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<span style="font-size: 11.0pt;">a)What important aspects in
history will influence your subsequent management? <b style="mso-bidi-font-weight: normal;">8 marks</b></span></div>
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<span style="font-size: 11.0pt;">b)What <b style="mso-bidi-font-weight: normal;">investigations </b>would you perform and how would you <b style="mso-bidi-font-weight: normal;">manage</b> her?<b style="mso-bidi-font-weight: normal;">12 Marks</b></span></div>
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<span style="font-size: 11.0pt;">a)</span></div>
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<span style="font-size: 11.0pt;">History</span></div>
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<span style="font-size: 11.0pt;">-severity of incontinence and
the impact on <b style="mso-bidi-font-weight: normal;">quality of life</b>
(QOL)*IMPORTANT</span></div>
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<span style="font-size: 11.0pt;">-other urinary symptoms;
urgency, urge urinary incontinence, frequency, nocturia</span></div>
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</div>
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<span style="font-size: 11.0pt;">-symptoms of voiding
dysfunction; dribbling, hesitancy, poor stream, strain to void</span></div>
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<span style="font-size: 11.0pt;">-UTI symptoms; dysuria,
haematuria, frequency</span></div>
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<span style="font-size: 11.0pt;">-Presence of bladder pain and
prolapse symptoms</span></div>
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<span style="font-size: 11.0pt;">-Bowel symptoms-
constipation, incontinence of faeces</span></div>
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</div>
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<span style="font-size: 11.0pt;">-Past obstetric history
including date of last delivery and reproductive intentions</span></div>
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<span style="font-size: 11.0pt;">-Fluid intake, caffeine,
alcohol</span></div>
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<span style="font-size: 11.0pt;">-Previous treatment for
incontinence including surgery</span></div>
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<span style="font-size: 11.0pt;">b)</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 11.0pt;">Key point here is ‘healthy woman’</span></b></div>
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<span style="font-size: 11.0pt;">Investigations</span></div>
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<span style="font-size: 11.0pt;">Urine dipstick</span></div>
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</div>
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<span style="font-size: 11.0pt;">Mid stream urine for culture</span></div>
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</div>
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<span style="font-size: 11.0pt;">Bladder diary/ Frequency
volume chart</span></div>
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</div>
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<span style="font-size: 11.0pt;">Multichannel urodynamics only
if conservative treatment has failed or if surgery is being considered or
before surgery if there is clinical suspicion of DO/ previous surgery for SUI
or anterior compartment prolapse/ symptoms of voiding dysfunction</span></div>
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<span style="font-size: 11.0pt;">Management include an
examination (BMI, abdominal and pelvic examination; pelvic mass, palpable
bladder; Check for presence of prolapse; Demonstrate SUI with <b style="mso-bidi-font-weight: normal;">moderately full bladder, </b>150mls)</span></div>
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<u><span style="font-size: 11.0pt;">Conservative</span></u></div>
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</div>
<ul style="margin-top: 0in; text-align: justify;" type="disc">
<li class="MsoNormal"><span style="font-size: 11.0pt;">Life style intervention: reduce weight, quit smoking, reduce/avoid
risk factors, control medical disorders like asthma</span></li>
<li class="MsoNormal"><span style="font-size: 11.0pt;">Application of oestrogen cream/gels-controversial, there are some
evidence that has shown , reduction in all type of incontinece</span></li>
<li class="MsoNormal"><span style="font-size: 11.0pt;">First line treatment should be supervised pelvic floor exercise/
muscle training (PFMT) lasting at least 3 months, there good evidence
shown significant reduction in the incontinence esp. GSI ( 65-70%)</span></li>
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<ul style="margin-top: 0in; text-align: justify;" type="disc">
<li class="MsoNormal"><span style="font-size: 11.0pt;">Duloxetine should not be used as first line treatment or should
not be routinely used as a second-line treatment for SUI. (NICE
guidelines)</span></li>
</ul>
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<u><span style="font-size: 11.0pt;">Surgical options</span></u><span style="font-size: 11.0pt;"> if conservative treatment failed;</span></div>
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<span style="font-size: 11.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-size: 11.0pt;">retropubic
mid-urethral tape ( Subject. & Object cure rate 85-95%)</span></div>
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</div>
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<span style="font-size: 11.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-size: 11.0pt;">open
colposuspension (Subject. & Object cure rate 85-95%)</span></div>
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</div>
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<span style="font-size: 11.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-size: 11.0pt;">TOT</span></div>
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</div>
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<span style="font-size: 11.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-size: 11.0pt;">Intramural
bulking agents</span></div>
<div style="text-align: justify;">
</div>
<div class="MsoNormalCxSpMiddle" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: 11.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-size: 11.0pt;">Artificial
urinary sphincter</span></div>
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</div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: 11.0pt;">Not recommended for SUI;</span></div>
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</div>
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<span style="font-size: 11.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-size: 11.0pt;">Routine use of lap
colposuspension</span></div>
<div style="text-align: justify;">
</div>
<div class="MsoNormalCxSpMiddle" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: 11.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-size: 11.0pt;">Anterior
colporrhapy, needle suspensions, paravaginal defect repair, MMK procedure</span></div>
<div style="text-align: justify;">
</div>
<div class="MsoNormalCxSpMiddle" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;">
<span style="font-size: 11.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-size: 11pt;">Autologous fat
and PTFE as intramural bulking agents </span></div>
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</div>
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<br /></div>
Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-68361111949009163042012-10-18T18:31:00.007-07:002021-06-10T01:03:56.636-07:00Pelvic floor excercise<h2 style="margin-bottom: 0pt; text-align: center; text-justify: inter-ideograph;"><span face="arial, helvetica, sans-serif" style="font-size: x-large;"><u>PELVIC FLOOR EXCERCISE</u></span></h2>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4iH2q9gDdFARiGyxdIh-5LotpBsMYEX5VVbp-fovv53BIW7RNJHnMFsEPnAvqTC0s7TYPHZ7eBQFgmcBnL3AV6qUdYGkijjUTT_OIru_SojGYovpZVacIcaoiwWh5KLAnvXuh6jJnK0Kz/s1600/kegel+exercise.gif" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="196" nea="true" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4iH2q9gDdFARiGyxdIh-5LotpBsMYEX5VVbp-fovv53BIW7RNJHnMFsEPnAvqTC0s7TYPHZ7eBQFgmcBnL3AV6qUdYGkijjUTT_OIru_SojGYovpZVacIcaoiwWh5KLAnvXuh6jJnK0Kz/s400/kegel+exercise.gif" width="400" /></a></div>
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<b><span style="color: black;">Kegel Exercise</span></b></div>
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<span style="color: black;">First published in 1948 by </span><span style="font-size: 13.5pt;"><a href="http://en.wikipedia.org/wiki/Arnold_Kegel"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: black; font-size: 12pt;">Dr. Arnold Kegel</span></a></span><span style="color: black;">, a pelvic floor exercise, more commonly called a Kegel exercise, consists of repeatedly contracting and relaxing the muscles that form part of the pelvic floor</span><span style="color: black;">, now sometimes colloquially referred to as the "Kegel muscles". Dr. Kegel attempted to develop diverse exercise for the injured women’s pelvic muscle due to childbirth or natural urinary incontinence.</span></div>
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<b><span style="color: black;">Introduction</span></b></div>
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<span style="color: black;">The aim of Kegel exercises is to improve muscle tone</span><span style="color: black;">by strengthening the pubococcygeus muscle</span><span style="color: black;">of the pelvic floor</span><span style="color: black;">. Kegel is a popular prescribed exercise for pregnant</span><span style="font-size: 13.5pt;"><a href="http://en.wikipedia.org/wiki/Pregnant"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: black; font-size: 12pt;"> </span></a></span><span style="color: black;">women to prepare the pelvic floor</span><span style="color: black;">for physiological stresses of the later stages of pragnancy </span><span style="color: black;">and childbirth</span><span style="color: black;">. Kegel exercises are said to be good for treating vaginal prolapse</span><span style="font-size: 13.5pt;"> </span><span style="color: black;">and preventing </span><span style="font-size: 13.5pt;"><a href="http://en.wikipedia.org/wiki/Kegel_exercise#cite_note-7"></a></span><span style="color: black;">in women and for treating prostate </span><span style="color: black;">pain and swelling resulting from benign prostatic hyperplasis </span><span style="color: black;">(BPH) and prostitis </span><span style="color: black;">in men. Kegel exercises may be beneficial in treating urinary incontinence </span><span style="color: black;">in both men and women.</span><span style="font-size: 13.5pt;"><span style="color: black; font-size: 12pt;"> </span></span><span style="color: black;">Kegel exercises may also increase sexual gratification and aid in reducing prematue ejeculation</span><span style="color: black;">.</span><span style="font-size: 13.5pt;"><span style="color: black; font-size: 12pt;"> T</span>here are</span><span style="color: black;"> many actions performed by Kegel muscles include holding in urine and avoiding defecation. Reproducing this type of muscle action can strengthen the Kegel muscles. The action of slowing or stopping the flow of urine may be used as a test of correct pelvic floor exercise technique but should not be practiced as a regular exercise to avoid urinary retention<b> </b></span></div>
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<b><span style="color: black;">Indications:</span></b></div>
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<a href="http://www.blogger.com/null" name="Urinary_incontinence"></a><b>1. Urinary incontinence </b>- <span style="color: black;">The consequences of weakened pelvic floor muscles may include urinary or bowel incontinence, which may be helped by therapeutic strengthening of these muscles. M</span><a href="http://en.wikipedia.org/wiki/Meta-analysis"><span style="color: black;">eta-analysis </span></a><span style="color: black;">of </span><a href="http://en.wikipedia.org/wiki/Randomized_controlled_trials"><span style="color: black;">randomized controlled trials </span></a><span style="color: black;">by the </span><a href="http://en.wikipedia.org/wiki/Cochrane_Collaboration"><span style="color: black;">Cochrane Collaboration </span></a><span style="color: black;">concluded that "PFMT (Pelvic floor muscle training) should be the first-line conservative programs for women with stress, urge, or mixed, urinary incontinence.</span></div>
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2. Pelvic prolapse - The exercises are also often used to help prevent prolapse of pelvic organs. A meta-analysis of rabdomised controlled trials by the <a href="http://en.wikipedia.org/wiki/Cochrane_Collaboration">Cochrane Collaboration</a> concluded that "(there is now some evidence available indicating a positive effect of PFMT for prolapse symptoms and severity.)''</div>
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<b><span style="color: black;">Steps:</span></b></div>
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<span style="color: black;">Here’s how to do your Kegels to strengthen your pelvic floor: Lie or sit down, whichever you prefer. You may use a pillow as a wedge under the small of your back if you like.<b><br /></b>Find the muscle you identified earlier and clench it, then relax. Clench again, than relax. And so on. One clench-and-relax constitutes a repetition, and both sides of the repetition both the clenching and the unclenching are equally important.<b><br style="mso-special-character: line-break;" /></b><o:p></o:p></span></div>
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<span style="color: black;">You may find it difficult to do Kegels at first if your muscles are very weak. But each repetition really will increase the strength of the muscles, and in time, doing your Kegels will become easier guaranteed. </span></div>
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<span style="color: black; mso-bidi-font-weight: bold; mso-fareast-font-family: 'Times New Roman';"><span style="mso-list: Ignore;">1.<span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant-caps: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="color: black;">Tighten the muscle and hold for 10 seconds, relax for 10 seconds. Do 10 repetitions to strengthen your slow-twitch pelvic floor muscles.</span></div>
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<span style="mso-fareast-font-family: 'Times New Roman';"><span style="mso-list: Ignore;">2.<span style="font-family: "times new roman"; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant-caps: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="color: black;"><span style="mso-spacerun: yes;"> </span>Tighten and hold for two seconds, relax for two seconds. Do 10 repetitions to strengthen the fast-twitch fiber muscles. The two different basic Kegel exercises differ only in timing, not in the process. <b><br style="mso-special-character: line-break;" /></b></span></div>
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<b><span style="color: black;">Effect of Kegel Exercise</span></b></div>
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<span style="color: black;">1. At the last month of pregnancy, the fetus goes down and the head puts pressure upon of the perineal region, which causes a pain. Kegel Exercise helps to mitigate the pain by strengthening the perineal region.</span></div>
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<span style="color: black;">2. In case of training the ability of moving the pelvic floor musclefreely though Kegel exercise during the period of pregnancy, it is possible to put pressure upon the exact region at the time of childbirth. This helps to shorten the childbirth time.</span></div>
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<span style="color: black;">3. At the time of giving birth, it is possible to prevent the tear of perineal region by applying the power to the region slowly. If not Kegel exercise, sudden application of power to the region may cause the tear of weak perineal region.</span></div>
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<span style="color: black;">4. After childbirth, urinary incontinence may be occurred due to the relaxation of muscle under the bladder or the rupture of the nerve cell or muscle. In ordinary time, cough, sneezing or laughing may cause incontinence. Kegel Exercise is useful to settle such problems economically.</span></div>
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<span style="color: black;">5. In case of taking a long time in natural childbirth, the fecal incontinence may be occurred. Kegel Exercise helps to return such the anus muscle to the normal state.</span></div>
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<span style="color: black;">6. With steady exercises, it is possible to strengthen the vaginal muscle and regenerate the injured cell due to childbirth by promoting blood circulation around the vagina.</span></div>
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<span style="color: black;">7. This exercise helps to reduce the risk of hemorrhoids caused by constipation during the period of pregnancy or after childbirth.<o:p></o:p></span></div>
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<span style="color: black;">8. By recovering the elastic force of the vaginal muscle, which is weakened after childbirth, it helps to increase sexual gratification and feel orgasm intensively.</span></div>
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<b><span style="color: black;">A study by Cammu et al.</span></b><span style="color: black;">, comprising a 10-year follow-up of women after pelvic floor muscle exercise for stress incontinence, concluded that when pelvic floor muscle training is initially successful there is a 66% chance that the favorable results will persist for at least 10 years.</span></div>
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<span style="color: black;">The trials suggest that the treatment effect (especially self reported cure/improvement) might be greater in women with stress urinary incontinence participating in a supervised PFMT programme for at least three months. It also seems that the effectiveness of PFMT does not decrease with age: in trials with</span> <span style="color: black;">stress urinary incontinent older women it appeared that results for both primary and secondary outcome.</span></div>
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<b><span style="color: black;">Conclusion</span></b></div>
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<span style="color: black;">There is evidence for the widespread recommendation that pelvic floor muscle exercise helps women</span> <span style="color: black;">with all types of urinary incontinence. However, the treatment is most beneficial in women with stress</span> <span style="color: black;">urinary incontinence alone,</span></div><div style="margin-bottom: 0pt; text-align: justify; text-justify: inter-ideograph;"><span style="color: black;"><br /></span></div><div style="margin-bottom: 0pt; text-align: justify; text-justify: inter-ideograph;"><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dzILd9NnOTXyk3JuYXXt-bkvvJ-vCcHtDcwsId0-JGla2vnQ71MyFaOSlCvnPQqTNTXD8yeYWQoRQOrl2vpOA' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div><br /><span style="color: black;"><br /></span></div><div style="margin-bottom: 0pt; text-align: justify; text-justify: inter-ideograph;"><span style="color: black;"><br /></span></div><div style="margin-bottom: 0pt; text-align: justify; text-justify: inter-ideograph;"><span style="color: black;"><span style="text-align: left;">Consent Has been Taken from Patient to publish this video ( For Teaching Purpose)</span></span></div>
Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-4932280090930824522012-08-08T23:59:00.002-07:002020-08-15T07:04:15.591-07:00Consent for urogynae pts<div class="MsoNormal" style="margin: 0in -21.2pt 10pt 0in;">
<span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%; mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;"><span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<v:shapetype coordsize="21600,21600" id="_x0000_t202" o:spt="202" path="m,l,21600r21600,l21600,xe"><v:stroke joinstyle="miter"></v:stroke><v:path gradientshapeok="t" o:connecttype="rect"></v:path></v:shapetype><span style="font-family: Arial, Helvetica, sans-serif;"><span style="line-height: 115%; mso-ansi-language: #0400; mso-bidi-font-family: Calibri;">Consent</span><span style="line-height: 115%; mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;"> of</span><span style="line-height: 115%; mso-ansi-language: #0400; mso-bidi-font-family: Calibri;"> Patient</span><span style="line-height: 115%; mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;">’s</span><span style="line-height: 115%; mso-ansi-language: #0400; mso-bidi-font-family: Calibri;"> agreement </span><span style="line-height: 115%; mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;">for Urogynaecology & Gynaecological </span></span></h2>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="line-height: 115%; mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;">I</span><span style="line-height: 115%; mso-ansi-language: #0400; mso-bidi-font-family: Calibri;">nvestigation</span><span style="line-height: 115%; mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;">, T</span><span style="line-height: 115%; mso-ansi-language: #0400; mso-bidi-font-family: Calibri;">reatment</span><span style="line-height: 115%; mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;"> & Surgery</span></span></h2>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%; mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;">Name:---------------------------------- MRN/IC NO:-----------------------------------------</span></b></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="line-height: 115%; mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;"><o:p> </o:p></span><b style="mso-bidi-font-weight: normal;"><u><span style="mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;">Name of proposed procedure:<o:p></o:p></span></u></b></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;"><strong>SUBURETHRAL SLING AND CYSTOSCOPY WITH/WITHOUT PELVIC</strong></span></span><span style="font-family: Arial, Helvetica, sans-serif;"><span style="mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;"><strong>FLOOR </strong></span></span><span style="font-family: Arial, Helvetica, sans-serif;"><span style="mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;"><strong>REPAIR FOR PROLAPSE<o:p></o:p></strong></span></span></div>
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<v:rect id="_x0000_s1044" style="height: 15pt; margin-left: 10pt; margin-top: 7.7pt; position: absolute; width: 13.25pt; z-index: 251665920;"><strong><span style="font-family: Arial, Helvetica, sans-serif;"></span></strong></v:rect><strong><span style="font-family: Arial, Helvetica, sans-serif;"><span style="mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;">VAGINAL HYSTERECTOMY WITH/ WITHOUT PELVIC FLOOR </span></span></strong><strong><span style="font-family: Arial, Helvetica, sans-serif;"><span style="mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;">REPAIR FOR PROLAPSE</span></span></strong></div>
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<span style="mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;"></span><v:rect id="_x0000_s1045" style="height: 14.85pt; margin-left: 10pt; margin-top: 6.45pt; position: absolute; width: 13.25pt; z-index: 251666944;"><strong><span style="font-family: Arial, Helvetica, sans-serif;"></span></strong></v:rect><span style="mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;"><strong><span style="font-family: Arial, Helvetica, sans-serif;"><span style="mso-spacerun: yes;"></span>VAGINAL OR ABDOMINAL VAULT SUPPORT OPERATION WITH/ WITHOUT PELVIC FLOOR REPAIR</span></strong></span></div>
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<span style="mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;"></span><v:rect id="_x0000_s1046" style="height: 14.85pt; margin-left: 10pt; margin-top: 7.7pt; position: absolute; width: 13.25pt; z-index: 251667968;"><strong><span style="font-family: Arial, Helvetica, sans-serif;"></span></strong></v:rect><span style="mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;"><strong><span style="font-family: Arial, Helvetica, sans-serif;"><span style="mso-spacerun: yes;"></span>OTHER UROGYNAECOLOGY PROCEDURES:____________________________________________________</span></strong></span></div>
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<span style="mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;"><span style="font-family: Arial, Helvetica, sans-serif;"><strong>HER GYNAECOLOGICAL PROCEDURES:_________________</strong>___________________________________</span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;"><o:p> </o:p></span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: EN-US; mso-bidi-font-family: Calibri;"><span style="font-size: x-small;">A. <u>Statement of health profession: </u></span></span></b></span><span style="mso-ansi-language: EN-US;"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">I have explained the procedure to the patient. In particular, I have explained<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">1. <u>The intended benefits:</u><span style="mso-spacerun: yes;"> </span>(tick where applicable)<o:p></o:p></span></span></span></div>
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt 43.5pt; mso-list: l0 level1 lfo1; tab-stops: list 0in; text-indent: -0.25in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="EN-MY" style="mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">To improve or resolve the symptoms of ‘stress urinary incontinence’ and ‘prolapse‘<o:p></o:p></span></span></span></div>
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt 43.5pt; mso-list: l0 level1 lfo1; tab-stops: list 0in; text-indent: -0.25in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="EN-MY" style="mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">To remove uterus to overcome uterine related pathalogy<o:p></o:p></span></span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="EN-MY" style="mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">Others (please specify) ________________________________________________________</span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">2.<u> Possible serious risks:<o:p></o:p></u></span></span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="EN-MY" style="mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">Damage to the bladder and/or Ureter and/or long term disturbance to the bladder function<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">inapproximately 2% of cases<o:p></o:p></span></span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="EN-MY" style="mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">Damage to bowel in approximately in 1% cases<o:p></o:p></span></span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="DE" style="mso-ansi-language: DE; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="DE" style="mso-ansi-language: DE;">Haemorrhage requiring blodd transfusion <span style="mso-spacerun: yes;"> </span>in about 2-3% cases<o:p></o:p></span></span></span></div>
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt 46.5pt; mso-list: l1 level1 lfo2; tab-stops: list 0in; text-indent: -0.25in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="EN-MY" style="mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">Return to the operating theatre for additional stitches or to control bleeding or for open surgery<o:p></o:p></span></span></span></div>
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt 46.5pt; mso-list: l1 level1 lfo2; tab-stops: list 0in; text-indent: -0.25in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="EN-MY" style="mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">Pelvic abscess/infection approximately in 1% cases<o:p></o:p></span></span></span></div>
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt 46.5pt; mso-list: l1 level1 lfo2; tab-stops: list 0in; text-indent: -0.25in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="EN-MY" style="mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">Venous thrombosis or pulmonary embolism <span style="mso-spacerun: yes;"> </span>approximately in 1% patients<o:p></o:p></span></span></span></div>
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt 46.5pt; mso-list: l1 level1 lfo2; tab-stops: list 0in; text-indent: -0.25in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="EN-MY" style="mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">Dyspareunia ( painful sexual intercourse)<o:p></o:p></span></span></span></div>
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt 46.5pt; mso-list: l1 level1 lfo2; tab-stops: list 0in; text-indent: -0.25in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="EN-MY" style="mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">Failure to achieve the desired results or recurrence of prolapse or urinary incontinence <o:p></o:p></span></span></span></div>
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt 46.5pt; mso-list: l1 level1 lfo2; tab-stops: list 0in; text-indent: -0.25in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="EN-MY" style="mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">Sling complications eg. Erosions, mesh protrusion in about <span style="mso-spacerun: yes;"> </span>0.7%<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">3.<u>Possible frequently occurring risks:<o:p></o:p></u></span></span></span></div>
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt 46.5pt; mso-list: l3 level1 lfo4; tab-stops: list 0in; text-indent: -0.25in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="EN-MY" style="mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">Urinary retention in about 3% of patients, may need excision of the tape if unable to void properly<o:p></o:p></span></span></span></div>
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt 46.5pt; mso-list: l3 level1 lfo4; tab-stops: list 0in; text-indent: -0.25in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="EN-MY" style="mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">Vaginal bleeding, discharge or infection<o:p></o:p></span></span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="EN-MY" style="mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">Frequency of micturition, nocturia and urgency in about 7% of patients<o:p></o:p></span></span></span></div>
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt 46.5pt; mso-list: l3 level1 lfo4; tab-stops: list 0in; text-indent: -0.25in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="DE" style="mso-ansi-language: DE; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">Wound infection – up to</span><span lang="DE" style="mso-ansi-language: DE;"> 15% especially in patients with risk factors<o:p></o:p></span></span></span></div>
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt 46.5pt; mso-list: l3 level1 lfo4; tab-stops: list 0in; text-indent: -0.25in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="DE" style="mso-ansi-language: DE; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="DE" style="mso-ansi-language: DE;">Pain, may require analgesics<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">4.<u> Any extra emergency procedures which may become necessary during the procedure:<o:p></o:p></u></span></span></span></div>
<div class="MsoNoSpacing" style="margin: 0in 0in 0pt 48.75pt; mso-list: l2 level1 lfo3; tab-stops: list 0in; text-align: justify; text-indent: -0.25in;">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="EN-MY" style="mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">Blood transfusion – may be required in approximately 2 in every 1000 women undergoing this procedure<o:p></o:p></span></span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="EN-MY" style="mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">Removal of ovaries for unsuspected disease during the surgery<o:p></o:p></span></span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="EN-MY" style="mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-MY">Conversion to abdominal approach due to anticipated difficulties or to undertake repair of any injury to bladder ,ureter, bowel or major blood vessels in approximately 4%- 8% cases<o:p></o:p></span></span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span lang="DE" style="mso-ansi-language: DE; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">§<span style="font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="DE" style="mso-ansi-language: DE;">Other procedures (please specify) ___________________<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">I have explained that in obese women those with underlying medical problems or who have had previous surgery (ex: Caesarean section), the quoted risks may be higher.<br style="mso-special-character: line-break;" /><br style="mso-special-character: line-break;" /><o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">I have also discuss the benefits and risks of any available treatments including physiotherapy, ring pressary insertion and also option of no treatment<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">Signature:_____________________________________<span style="mso-spacerun: yes;"> </span>Date:_____________________<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">DR ARUKU NAIDU MD(UKM) FRCOG(UK) CU(JCU)<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">Consultant Urogynaecologist<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">Signature of patient: ____________________________<span style="mso-tab-count: 1;"> </span><span style="mso-spacerun: yes;"> </span>Date:_____________________<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span style="mso-spacerun: yes;"> </span>Patients Name:_________________________________<o:p></o:p></span></span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><b style="mso-bidi-font-weight: normal;"><span lang="EN-MY">B. <u>Statement of interpreter (</u></span></b><span lang="EN-MY">where appropriate)<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">I have interpreted the information above to the patient to the best of my ability and in a way which I believe she can understand.<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">Signature:_____________________ Name:_______________________________ Date:______________<o:p></o:p></span></span></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">C. <u>Statement of patient<o:p></o:p></u></span></span></span></b></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">Please read this form carefully. You must also read the front page carefully which describes the benefits and risks of the proposed treatment. if you have any questions, please ask us as we are here to help you. You have the right to change your mind at any time, including after you signed this form.<o:p></o:p></span></span></span></div>
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<v:rect id="_x0000_s1028" strokeweight=".26mm" style="height: 7.15pt; left: 0px; margin-left: 435.45pt; margin-top: 2.1pt; mso-wrap-style: none; position: absolute; text-align: left; v-text-anchor: middle; width: 7.15pt; z-index: 251649536;"><v:fill color2="black"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"></span></v:fill></v:rect><v:rect id="_x0000_s1027" strokeweight=".26mm" style="height: 7.15pt; left: 0px; margin-left: 383.5pt; margin-top: 2.1pt; mso-wrap-style: none; position: absolute; text-align: left; v-text-anchor: middle; width: 7.15pt; z-index: 251648512;"><v:fill color2="black"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"></span></v:fill></v:rect><span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">1.<span style="mso-spacerun: yes;"> </span>I have read the previous sheet and understood the benefits<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> Y</span>ES<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>NO<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span style="mso-spacerun: yes;"> </span>and the risks of the proposed treatment or surgery<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small; mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<v:rect id="_x0000_s1030" strokeweight=".26mm" style="height: 7.15pt; left: 0px; margin-left: 435.95pt; margin-top: 1.9pt; mso-wrap-style: none; position: absolute; text-align: left; v-text-anchor: middle; width: 7.15pt; z-index: 251651584;"><v:fill color2="black"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"></span></v:fill></v:rect><v:rect id="_x0000_s1029" strokeweight=".26mm" style="height: 7.15pt; left: 0px; margin-left: 383.5pt; margin-top: 1.9pt; mso-wrap-style: none; position: absolute; text-align: left; v-text-anchor: middle; width: 7.15pt; z-index: 251650560;"><v:fill color2="black"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"></span></v:fill></v:rect><span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">2.<span style="mso-spacerun: yes;"> </span>I agree to the procedure described by the doctor<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>YES<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>NO<o:p></o:p></span></span></span></div>
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<v:rect id="_x0000_s1032" strokeweight=".26mm" style="height: 7.15pt; left: 0px; margin-left: 436.95pt; margin-top: 1.75pt; mso-wrap-style: none; position: absolute; text-align: left; v-text-anchor: middle; width: 7.15pt; z-index: 251653632;"><v:fill color2="black"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"></span></v:fill></v:rect><v:rect id="_x0000_s1031" strokeweight=".26mm" style="height: 7.15pt; left: 0px; margin-left: 385pt; margin-top: 1.75pt; mso-wrap-style: none; position: absolute; text-align: left; v-text-anchor: middle; width: 7.15pt; z-index: 251652608;"><v:fill color2="black"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"></span></v:fill></v:rect><span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">3.<span style="mso-spacerun: yes;"> </span>I understand that you cannot give me a guarantee that a particular person<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>YES<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>NO<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span style="mso-spacerun: yes;"> </span>will perform the procedure. The person will, however has the <o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span style="mso-spacerun: yes;"> </span>appropriate experience to perform the surgery.<o:p></o:p></span></span></span></div>
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<v:rect id="_x0000_s1034" strokeweight=".26mm" style="height: 7.15pt; left: 0px; margin-left: 435.95pt; margin-top: 2.1pt; mso-wrap-style: none; position: absolute; text-align: left; v-text-anchor: middle; width: 7.15pt; z-index: 251655680;"><v:fill color2="black"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"></span></v:fill></v:rect><v:rect id="_x0000_s1033" strokeweight=".26mm" style="flip: x; height: 7.15pt; left: 0px; margin-left: 386.05pt; margin-top: 2.1pt; mso-wrap-style: none; position: absolute; text-align: left; v-text-anchor: middle; width: 7.15pt; z-index: 251654656;"><v:fill color2="black"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"></span></v:fill></v:rect><span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">4.<span style="mso-spacerun: yes;"> </span>I understand that I have the opportunity to discuss the details of anaesthesia<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>YES<span style="mso-spacerun: yes;"> </span>NO<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span style="mso-spacerun: yes;"> </span>with an anaesthetist before the procedure, unless the urgency of my situation <o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span style="mso-spacerun: yes;"> </span>prevents this.<o:p></o:p></span></span></span></div>
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<v:rect id="_x0000_s1039" strokeweight=".26mm" style="height: 7.15pt; left: 0px; margin-left: 436.45pt; margin-top: 2.1pt; mso-wrap-style: none; position: absolute; text-align: left; v-text-anchor: middle; width: 7.15pt; z-index: 251660800;"><v:fill color2="black"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"></span></v:fill></v:rect><v:rect id="_x0000_s1037" strokeweight=".26mm" style="height: 7.15pt; left: 0px; margin-left: 386.05pt; margin-top: 2.1pt; mso-wrap-style: none; position: absolute; text-align: left; v-text-anchor: middle; width: 7.15pt; z-index: 251658752;"><v:fill color2="black"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"></span></v:fill></v:rect><span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">5.<span style="mso-spacerun: yes;"> </span>I understand that any procedure in addition to those described on this<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>YES<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>NO<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span style="mso-spacerun: yes;"> </span>form will only be carried out if it is necessary to save my life or to prevent serious<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span style="mso-spacerun: yes;"> </span>harm(complications) to my health<o:p></o:p></span></span></span></div>
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<v:rect id="_x0000_s1040" strokeweight=".26mm" style="height: 7.15pt; left: 0px; margin-left: 438.85pt; margin-top: 2.1pt; mso-wrap-style: none; position: absolute; text-align: left; v-text-anchor: middle; width: 7.15pt; z-index: 251661824;"><v:fill color2="black"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"></span></v:fill></v:rect><v:rect id="_x0000_s1036" strokeweight=".26mm" style="height: 7.15pt; left: 0px; margin-left: 386.05pt; margin-top: 2.1pt; mso-wrap-style: none; position: absolute; text-align: left; v-text-anchor: middle; width: 7.15pt; z-index: 251657728;"><v:fill color2="black"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"></span></v:fill></v:rect><span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">6.<span style="mso-spacerun: yes;"> </span>I have been told about the additional procedures which may become necessary<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> YE</span>S<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>NO<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span style="mso-spacerun: yes;"> </span>during my treatment<o:p></o:p></span></span></span></div>
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<v:rect id="_x0000_s1041" strokeweight=".26mm" style="height: 7.15pt; left: 0px; margin-left: 438.85pt; margin-top: 2.1pt; mso-wrap-style: none; position: absolute; text-align: left; v-text-anchor: middle; width: 7.15pt; z-index: 251662848;"><v:fill color2="black"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"></span></v:fill></v:rect><v:rect id="_x0000_s1035" strokeweight=".26mm" style="height: 7.15pt; left: 0px; margin-left: 386.05pt; margin-top: 2.1pt; mso-wrap-style: none; position: absolute; text-align: left; v-text-anchor: middle; width: 7.15pt; z-index: 251656704;"><v:fill color2="black"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"></span></v:fill></v:rect><span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">7.<span style="mso-spacerun: yes;"> </span>I have been given a patient information leaflet<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>YES<span style="mso-spacerun: yes;"> </span>NO<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span></span></div>
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<v:rect id="_x0000_s1042" strokeweight=".26mm" style="height: 7.15pt; left: 0px; margin-left: 439.35pt; margin-top: 1.2pt; mso-wrap-style: none; position: absolute; text-align: left; v-text-anchor: middle; width: 7.15pt; z-index: 251663872;"><v:fill color2="black"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"></span></v:fill></v:rect><v:rect id="_x0000_s1038" strokeweight=".26mm" style="height: 7.15pt; left: 0px; margin-left: 387.55pt; margin-top: 3.75pt; mso-wrap-style: none; position: absolute; text-align: left; v-text-anchor: middle; width: 7.15pt; z-index: 251659776;"><v:fill color2="black"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"></span></v:fill></v:rect><span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">8.<span style="mso-spacerun: yes;"> </span>I have listed below procedures which I do not wish to be carried out<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>YES<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>NO <o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span style="mso-spacerun: yes;"> </span>without further discussion<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><span style="mso-spacerun: yes;"> </span>___________________________________________________________________________</span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small; mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">Signature:_____________________ Name:_________________________ Date:______________<o:p></o:p></span></span></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">D. <u>Witness<o:p></o:p></u></span></span></span></b></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">A witness should sign below if she/he has witnessed the patient's signature above. Parents or guardians should sign below behalf of patients under the age if legal consent (18 years and above)<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">Signature:_____________________ Name:_________________________ Date:______________<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">Relationship to patient: __________________<o:p></o:p></span></span></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">E. <u>Confirmation of consent<o:p></o:p></u></span></span></span></b></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">This section to be completed when the patient admitted for a procedure has sign the form in advance. On behalf of the team treating the patient, I have confirmed with the patient that she has no further questions and wishes the procedure to go ahead.<o:p></o:p></span></span></span></div>
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<span lang="EN-MY"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;">Signature:_____________________ Name:_________________________ Date:______________<o:p></o:p></span></span></span></div>
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Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-75027200439428901452012-07-12T17:50:00.006-07:002020-08-15T07:05:12.047-07:00Drugs In The Management of Incontinence<div align="center" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><u><span style="font-size: x-large;">Drugs In The Management of Incontinence</span></u></b></div>
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<span style="font-size: 14pt;">Drugs commonly used for the management of female urinary incontinence can be categorized into the following categories:-</span><br />
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<span style="font-size: 14pt;"><span style="mso-list: Ignore;">1.<span style="font-family: "Times New Roman";"> </span></span></span><span style="font-size: 14pt;">Drugs for overactive Bladder ( OAB)</span></div>
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<span style="font-size: 14pt;"><span style="mso-list: Ignore;">2.<span style="font-family: "Times New Roman";"> </span></span></span><span style="font-size: 14pt;">Drugs for Hypocontractile Bladder</span></div>
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<span style="font-size: 14pt;"><span style="mso-list: Ignore;">3.<span style="font-family: "Times New Roman";"> </span></span></span><span style="font-size: 14pt;">Drugs for Stress Urinary Incontinence</span></div>
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<span style="font-size: 14pt;">4. Drugs Acting Outside The Urinary Tract</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt;"><span style="mso-list: Ignore;">1.<span style="font-family: "Times New Roman";"> </span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt;">Detrusor Overactivity ( OAB)</span></b></div>
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<span style="font-size: 14pt;">The mainstay of treatment should be behavioural and pelvic floor therapy. When these therapies are ineffective then pharmacological therapy should be added. These pharmacological therapies include:</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt;">Anticholinergic Drugs</span></b></div>
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<span style="font-size: 14pt;">The drugs of choice are the antimuscarinic drugs. Drugs that are available in Malaysia are:– oxybutynin 2.5-5mg bd/tds (Ditropan ®), Tolteridine 4mg daily ( Detrusitol ®), Fesoteradine (4 and 8 mg), solifenacin 5-10mg daily ( Vesicare ®), Trospium 20mg ( Spasmolyt ®) and Propantheline Bromide 15md-30mg bd/tds.</span></div>
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<span style="font-size: 14pt;">This drugs has side effects of parasympathetic blokage like: the complaint of dry mouth which may lead to the undesirable tendency to drink more. It may also cause drowsiness, tachycardia , constipation and blurred vision. It is therefore contraindicated in patients with acute angle glaucoma and cardiac arrythmia.</span></div>
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<span style="font-size: 14pt;">In patients with neurogenic detrusor overactivity (detrusor hyper-reflexia) the dosages of these drugs can be increased till the desired inhibition of detrusor contraction is achieved or until intolerable side effects occur.<span style="mso-spacerun: yes;"> </span>In some cases, oxybutynin can also be instilled directly into the bladder (5mg tablet crushed into 30mls of saline, instilled 3 times per day and retained for 30 minutes each time) </span></div>
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<span style="font-size: 14pt;">Oxybutynin has the advantage that it can be used in children above the ages of 5 but must be used with caution in the elderly and in those with heart disease. Both drugs are contraindicated in pregnancy, with breast feeding, in patients with glaucoma and myasthenia gravis. Toleradine and fesoteradine newer antimuscarinic agents which as efficacious as oxybutynin and higher tolerability rate among patients.</span> </div>
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<span style="font-size: 14pt;">Other quarternary ammonium compounds with antimuscarinic activities include propantheline (Pro-Banthine ®), emepromium and hyoscyamine (Buscopan®). However these drugs are limited by their unpredictable pharmacokinetics and are not commonly used for detrusor overactivity.</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt;">Tricyclic Antidepressants</span></b></div>
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<span style="font-size: 14pt;">Tricyclic antidepressants have both anticholinergic and alpha adrenergic effects. These drugs are useful for detrusor overactivity and will at the same time increase the urethral sphincter tone. Their central sedative effect is also an advantage especially in patients who are unduly anxious. Imipramine<span style="mso-spacerun: yes;"> </span>(25mg od-tds) is usually used. The dose can be increased by 2.5mg/ week until the desired effects are seen or until intolerable side effects occur. Abrupt cessation of the drug must be avoided because of its rebound tendency. side-effects include hepatic dysfunction, mania, cardivascular events.</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt;">Flavoxates</span></b></div>
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<span style="font-size: 14pt;">Flavoxates (Genurin®, Urispas ®) has no appreciable anticholinergic effects but has anti spasmodic activity on the smooth muscles of the urogenital tract. They also have local analgesics effects and are suitable for symptomatic relief of symptoms of irritable bladder syndrome ie cystitis. High doses (400mg tds) can be used for detrusor overactivity. Side effects are few but can cause drowsiness and must be used with caution in patients with glaucoma and obstructive uropathy. </span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt;">Other Drugs</span></b></div>
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<span style="font-size: 14pt;">Other drugs that can be used for detrusor hyperactivity include intravesical capsaisin (substance P antagonist), beta adrenalgic agonists (terbutaline), calcium channel blockers (nifedipine : Adalat®) have been reported with limited success. These drugs are best considered as adjunct to first line therapy. </span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt;"><span style="mso-list: Ignore;">2.<span style="font-family: "Times New Roman";"> </span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt;">Detrusor Hypocontractility</span></b></div>
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<span style="font-size: 14pt;">Poor detrusor contractility leads to high residual volume and can lead to overflow incontinence. Treatment is directed at improving bladder emptying.</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt;">Parasympathomimetic Agents</span></b></div>
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<span style="font-size: 14pt;">These are the agents of choice for improving detrusor contractions. Bethanechol chloride (Urecholine®) was the main agent of choice but is not available locally. The alternative is the cholinesterase inhibitor Ubretid ®. This drug can be given with an initial loading dose of 5 to 10mg followed by 5 mg every other day. It should not be used in patients with circulatory insufficiency and bronchial asthma. </span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt;"><span style="mso-list: Ignore;">3.<span style="font-family: "Times New Roman";"> </span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt;"> Stress Urinary Incontinence and Uretheric Sphincter Incompetence</span></b></div>
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<span style="font-size: 14pt;">For the management of Urethreric sphincter incompetency and strees urinary incontinence: pelvic floor exercises, vaginal devices, injectables and<span style="mso-spacerun: yes;"> </span>surgery has always been considered the main modality of treatment. However several types of pharmacological agents have been found to be of some benefits. There are alpha adrenalgic receptors on the bladder neck and on the smooth muscle portion of the external urethral spincter and alpha adrenalgic agonists appear to increase the tone of these smooth muscles at the bladder neck. Other pharmacological agents include the Serotonin Norepinephrine Reuptake Inhibitors. </span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt;">Alpha adrenalgic agonist</span></b></div>
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<span style="font-size: 14pt;">Drugs available include epinephrine, pseudoephedrine and phenylpropanolamine. These are commonly found in cough mixtures and nasal decongestants. They should be viewed as adjunct treatment to the other established modalities of treatment for urethric sphincter incompetence.</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt;">Serotonin Norepinephrine Reuptake Inhibitor (SNRI)</span></b></div>
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<span style="font-size: 14pt;">Duloxetine hydrochloride (Cymbalta ®, Yentreve®) is a drug that primarily targets major depressive disorders and pain related to diabetic peripheral neuropathy. It is now found to be effective in the management of stress urinary incontinence. Using 40mg twice daily, the drug has been proven to reduce incontinence episodes by up to 50% in most individuals. Side effects include nausea, fatigue, dry mouth and insomnia. This drug is not available locally and currently not popular simply because it is expensive and for it's long term usage. Availability of sling ( SUS) operation with good results further retards it's usage.</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt;"><span style="mso-list: Ignore;">4.<span style="font-family: "Times New Roman";"> </span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt;">Drugs Acting Outside The Urinary Tract</span></b></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt;">Oestrogens</span></b></div>
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<span style="font-size: 14pt;">Topical and oral oestrogens have been noted to exert a trophic effect on the uroepithelium of the urethra and trigone. It is therefore useful in the incontinent women when the urethral mucosal seal in defective. It does not appear to have any effect with incontinence secondary to bladder neck hypermobility. oestraogen ( oestradiol valerate 0.5gm biweekly for 2 months does help in older women with urogenital atrophy (UGA)</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 14pt;">Anti-diuretic Hormone (ADH)</span></b></div>
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<span style="font-size: 14pt;">Desmopressin (Minirin dDAVP®) is a synthetic vasopressin that increases distal renal tubules reabsorbtion of water. It is effective in the treatment of enuresis where a deficiency of nocturnal ADH is present. It is also useful in the elderly patient with nocturia. It can be taken orally in doses of between 0.2 to 0.4mg at night and at these doses, there will be between 8 to 20 hours of antidiuresis. Its use is contraindicated in those patients with unstable angina and cardiac failure.</span><br />
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<span style="font-size: large;"><strong>Dr Aruku Naidu MD FRCOG CU</strong></span><br />
<br /></div>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-58638019041897636072012-07-01T23:07:00.002-07:002012-07-01T23:12:43.219-07:00What are Urodynamics?<div align="center" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: center;">
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<span lang="EN-AU"><span style="font-family: Arial;">Urodynamics means the study of pressure and flow in the bladder and the tube through which you pass urine, the urethra.<span style="mso-spacerun: yes;"> </span>These investigations show what is happening when the bladder is filling and emptying.<span style="mso-spacerun: yes;"> </span>If you’ve been booked for urodynamic studies you will have been experiencing bladder or prolapse problems and Dr Aruku has decided that you need to have these tests done to accurately diagnose and determine the treatment options.</span></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-AU" style="font-family: "Arial", "sans-serif"; font-size: 12pt; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 10.0pt;">When Do You Need Urodynamics?</span></b></div>
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<span lang="EN-AU" style="font-family: "Arial", "sans-serif"; font-size: 12pt; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 10.0pt;">Not everyone with bladder problems needs urodynamic studies.<span style="mso-spacerun: yes;"> </span>They’re most useful where:</span></div>
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<span lang="EN-AU" style="font-family: Symbol; font-size: 12pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 10.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-family: "Times New Roman";"> </span></span></span><span lang="EN-AU" style="font-family: "Arial", "sans-serif"; font-size: 12pt; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 10.0pt;">There may be a mixture of symptoms, or uncertain symptoms</span></div>
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<span lang="EN-AU" style="font-family: Symbol; font-size: 12pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 10.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font-family: "Times New Roman";"> </span></span></span><span lang="EN-AU" style="font-family: "Arial", "sans-serif"; font-size: 12pt; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 10.0pt;">After surgery for bladder or prolapse repairs.</span></div>
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<span lang="EN-AU" style="font-size: 12pt; mso-bidi-font-size: 10.0pt;"><span style="font-family: Arial;">Urinary symptoms like incontinence (leakage of urine), frequency, dribbling etc. do not accurately tell the doctor what may be wrong with you.<span style="mso-spacerun: yes;"> </span>Urodynamics forms part of a total assessment of your bladder problem and will help us make an accurate diagnosis so that you get the right treatment options explained to you.<span style="mso-spacerun: yes;"> </span>It may even avoid unnecessary surgery.<span style="mso-spacerun: yes;"> </span>Also it guides the surgeon as to what may happen to your bladder or bowel after surgery.</span></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-AU" style="font-family: "Arial", "sans-serif"; font-size: 12pt; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 10.0pt;">What is involved?</span></b></div>
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<span lang="EN-AU" style="font-family: "Arial", "sans-serif"; font-size: 12pt; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 10.0pt;">Please attend with a comfortably full bladder.<span style="mso-spacerun: yes;"> </span>When you arrive you’ll be asked to pass urine, in private, into a toilet or commode.<span style="mso-spacerun: yes;"> </span>You’ll be asked to change into a dressing gown and lie down on a couch.<span style="mso-spacerun: yes;"> </span>The doctor will examine your bladder through a fine scope called a flexible cystoscope.<span style="mso-spacerun: yes;"> </span>Then fine hollow tubes will be passed into your vagina and bladder.<span style="mso-spacerun: yes;"> </span>These tubes are attached to a chart recorder that monitors the pressure in your bladder and abdomen.</span></div>
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<span lang="EN-AU" style="font-size: 12pt; mso-bidi-font-size: 10.0pt;"><span style="font-family: Arial;">The bladder will gradually be filled with fluid.<span style="mso-spacerun: yes;"> </span>You’ll need to indicate to us what sensations you feel eg. Normal desire to pass urine and urgency. During the filling of your bladder you will be asked to cough every so often.<span style="mso-spacerun: yes;"> </span>Once the bladder is full we will get you to stand and cough again and do some easy exercises like heel bounces.<span style="mso-spacerun: yes;"> </span>After this you’ll be asked to pass urine into a special receptacle, which will record rate of flow of urine.<span style="mso-spacerun: yes;"> </span>The staff will usually be able to let you do this in private.<span style="mso-spacerun: yes;"> </span>The tubes will then be removed and the procedure is complete.</span></span></div>
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<span lang="EN-AU"><span style="font-family: Arial;">While the procedure is taking place, the recording device records a graph of what your bladder is doing.<span style="mso-spacerun: yes;"> </span>Your test results will be discussed with you by the doctor and treatment options explained.<span style="mso-spacerun: yes;"> </span>The procedure should take between 20 and 30 minutes.<span style="mso-spacerun: yes;"> </span>Try not to worry –everything will be fully explained to you both before and during the procedure and every effort will be made to ensure a minimum of discomfort and maximum privacy</span></span></div>
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<span lang="EN-AU" style="font-family: "Arial", "sans-serif"; font-size: 12pt; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 10.0pt;"><strong>Do I Need to Prepare for the Investigations?</strong></span></div>
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<span lang="EN-AU" style="font-family: "Arial", "sans-serif"; font-size: 12pt; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 10.0pt;">Yes.<span style="mso-spacerun: yes;"> </span>Please attend clinic with a comfortably full bladder.<span style="mso-spacerun: yes;"> </span>If you have a urine infection please contact us so that another appointment can be made for you.</span></div>
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<span lang="EN-AU" style="font-size: 12pt; mso-bidi-font-size: 10.0pt;">Afterwards:</span></h4>
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<span lang="EN-AU" style="font-family: "Arial", "sans-serif"; font-size: 12pt; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 10.0pt;">Most people have no problems after the procedure is performed. You should drink plenty of fluids for the remainder of the day.<span style="mso-spacerun: yes;"> </span>There will be a small amount of irritation caused by catheters, this should subside in 24-48 hours.<span style="mso-spacerun: yes;"> </span>If you do experience burning or stinging when passing urine we suggest you purchase a packet of ural sachets from your local pharmacy. If discomfort persists after 48 hours please contact your local doctor or Dr Aruku’s clinic.</span></div>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0tag:blogger.com,1999:blog-1041229983825909936.post-16664196178803918742012-05-02T20:08:00.002-07:002012-05-02T20:09:27.944-07:00TRIP TO DOWN UNDER<h2 align="center" class="MsoNormal" style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; margin: 0in 0in 0pt; text-align: center;">
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<span style="font-family: "Arial", "sans-serif";">In May 2003 JPA (Jabatan Perkhidmatan Awam), offered the first ever scholarship to pursue fellowship in Urogynaecology.<span style="mso-spacerun: yes;"> </span>Following few contacts and recommendations, I manage to secure an urogynaecology and pelvic reconstructive surgery fellowship training programme with Professor Ajay Rane a well known professor in urogynaecology from James Cook University (JCU), <place w:st="on"><city w:st="on">Townsville</city>, <state w:st="on">Queensland</state> <country-region w:st="on">Australia</country-region></place>.</span></div>
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<span style="font-family: "Arial", "sans-serif";">Little is known about JCU and Townsville. My first reaction was to look up in the world atlas and search the wed site, to see where this place is? Townsville is the “capital city” of the northern <state w:st="on"><place w:st="on">Queensland</place></state>, with a population of about 150,000 people along with it twin city Thuringowa, and it make up the largest city in tropical <state w:st="on"><place w:st="on">Queensland</place></state>. Townsville got the name from <city w:st="on"><place w:st="on">Sidney</place></city> businessman Robert Townsville, who sponsored the establishment of a port in 1864. </span></div>
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<span style="font-family: "Arial", "sans-serif";">The excitement turned to horror, especially when I was trying to gain entry into <country-region w:st="on"><place w:st="on">Australia</place></country-region>. There are various levels of screening and protocols to follow before getting a visa. It took almost 4 months to obtain entry permission. There are also various levels of bureaucracy in obtaining medical registration with the <state w:st="on"><place w:st="on">Queensland</place></state> medical board. </span></div>
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<span style="font-family: "Arial", "sans-serif";">After the long wait, it was time to travel. The flight took 7 plus hours and further 11/2 hours from <city w:st="on"><place w:st="on">Brisbane</place></city> as Townsville is situated about 1300kms north of <city w:st="on"><place w:st="on">Brisbane</place></city>. Townsville is quite and peaceful town. The weather was extremely hot ranging between 32 to 38 degrees. However the weather became very pleasant between Mac to September (winter months). We (with family) managed to settle down quickly and the training and posting commenced smoothly.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixEdMRVaQELNPKFZEktrAypFbm0spYzWl4fwsPGQ3PzE-eW__1u0SO51N9plQf21XFWER7cL1UmNOJ387LVA68TuLlW3A6yOoh6syCb2fVRW-ZecKF29wGFYekSP8RNQAlUCfxC3_bT_Rp/s1600/Townsville+Hospital.jpg" imageanchor="1" style="clear: right; cssfloat: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="240" mea="true" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixEdMRVaQELNPKFZEktrAypFbm0spYzWl4fwsPGQ3PzE-eW__1u0SO51N9plQf21XFWER7cL1UmNOJ387LVA68TuLlW3A6yOoh6syCb2fVRW-ZecKF29wGFYekSP8RNQAlUCfxC3_bT_Rp/s320/Townsville+Hospital.jpg" width="320" /></a><span style="font-family: "Arial", "sans-serif";">Adapting to the new environment and system did not take very long as the team in the urogynaecology department was very helpful. The real work started after the Christmas and New Year break. The urogynaecology and pelvic reconstructive department in Townsville is the first subspecialist services in the <place w:st="on">North Queensland</place> and this unit covers a wide area as up to the <state w:st="on"><place w:st="on">Northern Territory</place></state>.<span style="mso-spacerun: yes;"> </span>Our referrals are mainly from general practitioners and occasionally from the O & G specialist.</span></div>
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<span style="font-family: "Arial", "sans-serif";">Prof. Rane and this team of one senior lecturer (Dr Christopher Barry), 2 fellows in urogynaecology, and a bladder nurse (Audrey Corstiaans) and other allied staff is well known not only in <country-region w:st="on"><place w:st="on">Australia</place></country-region> but also in the world of Urogynaecology as a centre of excellence. The centre carries out various multicentre trials in urogynaecology. It is also the first centre to invent and publish about Perigee, a device invented to correct the anterior wall prolepses using transobturator route. I was lucky to be part of the team when this procedure was introduced and to date numerous abstracts and papers has been published with regards to this product.</span></div>
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<span style="font-family: "Arial", "sans-serif";">The urogynaecology department is a very busy unit, with almost 95% of their work concentrated on incontinence and pelvic reconstruction. We were involved in 3 and half days of Clinics, urodynamics & surgery in both the public (<place w:st="on"><placename w:st="on">Townsville</placename> <placetype w:st="on">Hospital</placetype></place>) as well as the private hospital (Mater’s Hospital) and Townsville Day surgery Unit. The other days are allocated for research. </span></div>
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<span style="font-family: "Arial", "sans-serif";">There was so much going on at the same time. During my one-year sting, we managed to organize a North Queensland Urogynae and Pelvic reconstructive surgery conference. Prof. Bob Schull a well-known pelvic surgeon attended the conference from <state w:st="on"><place w:st="on">Texas</place></state>, <country-region w:st="on"><place w:st="on">United States</place></country-region>. We also carried out nearly 6 trials or studies. Some of the studies are still on going. We also presented few papers in the IUGA/ICS conference in <city w:st="on"><place w:st="on">Paris</place></city>. Apart from that we also published few papers pertaining to urogynaecology.<span style="mso-spacerun: yes;"> </span></span></div>
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<span style="font-family: "Arial", "sans-serif";">Life was hard initially especially with regards to research as being a clinician for so long. As time goes by it has become part of work and it was interesting. There were ample operating opportunities to learn new surgeries in Uogyanecology and pelvic reconstruction.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCZQWSMLHQmbghIhctjcKQBkMb_T_bsBrdGCOQIZOx-1ZyRGrxrrvIQ8iK1JAabGB4zuNsG-Q_SN7PvVHTCCSGj8d8qtzXW4ejFgyFrncFBlAi-bm8fC7z2xXHAGrUII5DohkxyNB_P7-U/s1600/Ajay+Rane.jpg" imageanchor="1" style="clear: right; cssfloat: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="240" mea="true" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCZQWSMLHQmbghIhctjcKQBkMb_T_bsBrdGCOQIZOx-1ZyRGrxrrvIQ8iK1JAabGB4zuNsG-Q_SN7PvVHTCCSGj8d8qtzXW4ejFgyFrncFBlAi-bm8fC7z2xXHAGrUII5DohkxyNB_P7-U/s320/Ajay+Rane.jpg" width="320" /></a><span style="font-family: "Arial", "sans-serif";">Training aside, the weekends were completely free and we had great time visited the surrounding areas. Schools are fantastic; children had stress free schooling with minimal exams and homework. Quality of life was certainly fantastic as there was ample time to spend with the family. Townsville has few exciting places to visit; this includes the Billabong Sanctuary, where you can see and play with Australian wide-life.<span style="mso-spacerun: yes;"> </span>The Reef Headquarters’, the largest reef aquarium world is in Townsville. The <place w:st="on">Great Barrier Reef</place> and the <city w:st="on"><place w:st="on">Cairns</place></city> tourist town are only about 350kms north of Townsville.</span></div>
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<span style="font-family: Arial;">Work, research and pleasure as an urogynaecology fellow in Townsville/JCU quickly elapse and it was time to set back to the routine and hassle bustle of Malaysian life. The knowledge and experience gained during this short sting is there to stay in my memory for a long time.<span style="mso-spacerun: yes;"> </span>I wish l could one day follow the foot steps of my “GURU’ Prof. A Rane, to establish a vibrant and active Urogynae and pelvic reconstructive unit (<place w:st="on"><placename w:st="on">Pelvic</placename> <placename w:st="on">Health</placename> <placetype w:st="on">Center</placetype></place>) in <country-region w:st="on"><place w:st="on">Malaysia</place></country-region>. </span></div>
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<span style="font-size: small;"><span style="font-family: "Arial", "sans-serif"; font-weight: normal;">Back in <country-region w:st="on"><place w:st="on">Malaysia</place></country-region>, with the help of Dr Mukudan, head of O & G department. I have the opportunity to start the first Pelvic Health Unit in <place w:st="on"><placename w:st="on">Ipoh</placename> <placetype w:st="on">Hospital</placetype></place>. The response was tremendous. We can see that there is so much work in urogynaecology and pelvic reconstruction in Perak alone. These poor patients were suffering in silence for so long, no where to turn to or they were provided with substandard advice and treatment. To start</span><span style="font-family: "Arial", "sans-serif";"> </span><span style="font-family: "Arial", "sans-serif"; font-weight: normal;">with we introduce the Pelvic Health Concept which basically teaches public how to take care the pelvic structures. </span></span></h1>
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<span style="font-family: Arial;"><city w:st="on"><place w:st="on">Ipoh</place></city> hospital is the first public hospital to set up the Pelvic Health Unit (urogynaecology and pelvic reconstructive unit) under the department of obstetrics and gynaecology. The first line of management is to educate patients about good bladder habits, such as posture during micturation, avoidance of bladder irritants, pelvic floor exercises and maintenance of good general health. Our unit has started the “Beat The Bladder Blues” campaign to create awareness among care providers and public and how to seek advice with regards to their bladder or prolapse problem.</span></div>
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<span style="font-family: "Arial", "sans-serif";">We in the Pelvic Health Unit, Department of O & G. Ipoh Hospital, welcome your referrals and support. We are contactable at<span style="mso-spacerun: yes;"> </span>05-2085089( urogynaecology Clinic, Ipoh Hospital), 05-2408777( Sessional clinic Ipoh specialist hospital) and email: <a href="mailto:aruku64@yahoo.com.au">aruku64@yahoo.com.au</a>.</span> <a href="mailto:aruku1964@gmail.com">aruku1964@gmail.com</a></div>
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<br /></div>Dato' Dr Aruku Naiduhttp://www.blogger.com/profile/12654923018445435921noreply@blogger.com0