Masaryk University Schol of Medicine and Brno University Hospital Department of Obstetrics and Gynecology Head: Prof. Pavel Ventruba, DrSc.,MBA General Medicine Obstetrics and Gynecology Seminary 2017 – 2018 – Autumn Semester UROGYNECOLOGY as. MUDr. A. Ivan Belkov 2018 – 2019 General medicine - autumn semester Logo logo_mu UROGYNECOLOGY Gynekologicko - porodnická klinika Masarykovy univerzity a FN Brno Přednosta: prof. MUDr. Pavel Ventruba, DrSc., MBA UROGYNECOLOGY ? UROGYNECOLOGY : nManagement of urine incontinence n n nMain topic: n* Diagnosis and therapy of urine n incontinence n* Inflamation of lower urinary tract n* Reconstrution of pelvic floor n n URINE INCONTINENCE nDefinition: nUncontroled leakage of urine nNot desease, but a complex n of patological and n functional disturbances n n 2 1 nIncidence of urine incontinence : n n about 14 % women above age 30. n nIn postmenopausal age incrised n urine incontinence by more than 50 % n in women population n Factors leads to UI n nChildbearing ( 4000g) nChronic intraabdominal presure nObstetric operations n ( vakuumextractor,forceps ) nRecidive inflamation of urine nLoss of the ligamenta elasticity n n n PEPA1U Theory of incontinence Risk factors of incontinence: nRestrictid mobility nDrugs with diuretic efect nSmoking nIncrised number of childbirth nBabies weight more than 4000g nHigh BMI nDiabetes mellitus nStroke nEnuresis nocturna in childhood n n Clasification of incontinence nstress incontinence nurgent incontinence n - motoric n - sensoric nmixed incontinence nneurological incontinence nextrauretral incontinence Stress incontinence: nLeak by incriesed intraabdominal pressure (cough,sneezeing,runnig e.c.) nby hypermobility of uretra nby hypotonia of uretra nICS definition ( International Continence Society) n leak by incriesed vesical pressure over n uretral presure without contraction of detrusor n n Urge incontinence : nLeakage conectit with strong desire n (functional disturbance) nCause- incrised irritation of bladder wall nPatofyziology- caused by incriesed senzoric impulzy from receptors located in bladder wall or less inhibition of micturition reflex Overactiv Bladder(OAB) n obrazekx836 obrazekx837 Symptoms of Urge incontinence: n n polakisuria (8x) n nocturia (2x) n imperativ desire to void n psychologic disposition n ncause: neurological, idiopatic,stenotic n uretra n n Mixed incontinence : nLeakage caused by incrised irritation of bladder wall and anatomic changes n of bladder and uretra Incontinence caused by neurological deseases : nLeakage of urine by degenerativ deseases of CNS : n - Morbus Parkinson n - Sclerosis multiplex nOr after injury of spine and spinal cord n n Extrauretral incontinence n nHypospadia n (hereditary defect) nFistula n (vesicovaginalis,uretrovaginalis) n n n Diagnosis of incontinence: nhistory ngynecologic examination ndiagnostic test´s nultrasound ncystoscopie nurodynamic examination n Q - typ test : 4 Cystoscopic pictures obrazekx838 Urodynamic unite : obrazekx839 1. Cystometrie : nmesurements of relation between volume of bladder and intravesical presure nwe do: n - intravesical pressure (Pves) n - abdominal pressure (Pabd) n - detrusor presure (Pdet) = Pves – Pabd n - firs sensation,normal desire and strong n desire to void n - maximal cystometric volume n n 30 2.Uretral pressure profile : n nParameters: n - maximal uretral presure (Pura, max) n n - maximal uretral close profile (MUCP) n n - functional lengh of uretra (FUL) n 32a Mesurement of UP : C:\FNProjects\moukova\4.jpg Uroflow : C:\FNProjects\moukova\5.jpg Therapy of urge incontinence npsychoprofylaxy nDaily pelvic floor muscle excercise nBladder drill n n Farmakoterapie : nparasympatolytika (Oxyphenon, Spasmex,Toviaz ) nspasmolytika ( Ditropan, Cystrin ) nanticholinergica ( Vezicare ) n nsympatomimetika ( Gutron ) nsympatolytika ( Xantral ) nbetablokátory Ca 2+ kanálů ( Isoptin ) n nantidepresiva ( Melipramin ) n ninhibitory syntézy prostaglandinů ( Indren ) nantiparkinsonika ( Parlodel ) nestrogeny ( Ovestin, Ortho-Gynest ) Therapy of SIU: nExcercises – contraction and relaxation of specific pelvic floor muscles nElektrostimulation – positiv influence on the muscles contractions nPeessaries and devices for non-surgical treatment Vaginal conusis C:\FNProjects\moukova\6.jpg Vaginal devices : nThe effectiveness of devices are small and short nRecomandit only in cases where the operativ treatment is contraidicated nUretral occlusive devices,intrauretral devices Frank´s cubic pessary: C:\FNProjects\moukova\7.jpg obrazekx830 Uretral prothesis: C:\FNProjects\moukova\8.jpg Uretral suction cap: C:\FNProjects\moukova\9.jpg History of operative treatment of SUI BAKER a BROWN 1864 GIORDANO 1907 KELLY 1913 STOECKEL 1920 MARSHAL - MARCHETTI - KRANTZ 1949 BURCH 1961 PEREYRA 1958 STAMEY 1971 RICHARDSON 1981 ULMSTEN 1996 Operative treatment of SUI: nURETROPEXE - TVT n (tension free vaginal tape) n n nKOLPOSUSPENSION sec. BURCH n- n TVT retropubic: C:\FNProjects\moukova\12.jpg Kolposuspenze sec. Burch: 5 No prolapse obrazekx826 obrazekx828 Rectocele Cystocele obrazekx829 09i Komplet síťky a pásky na současné řešení cystocele a inkontinence Komplet síťky a pásky na současné řešení prolapsu a inkontinence 09g Sacrokolpopexis obrazekx832 Fistula vesicovaginalis C:\FNProjects\moukova\13.jpg END