Download METHODICAL INSTRUCTIONS

MINISTRY OF PUBLIC HEALTH OF UKRAINE
NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY, VINNYTSYA
CHAIR OF OBSTETRICS AND GYNECOLOGY №1
METHODICAL INSTRUCTIONS
for practical lesson
« Endometriosis. Pelvic floor dysfunction, uterovaginal prolapse. Abnormal
development of the genital tract. Urinary incontinence»
MODULE 4: Obstetrics and gynecology
TOPIC 11
I. Scientific and methodical grounds of the theme
Recently the problem of endometriosis has become especially actual due to the
increase of frequency of this pathology, implementation of modern diagnostic and
therapeutic methods in to practice that’s why the aim of the practical lecture is the
study of etiopathogenesis of endometriosis, methods of its diagnostic and treatment
II. Aim:
A student must know:
1. Classification of endometriosis of female genitalia .
2. Main clinic symptoms for endometriosis of female genitalia.
3. Methods of diagnosis of endometriosis of female genitalia.
4. Main principles of therapy of endometriosis of female genitalia.
5. Indications for surgery of endometriosis of female genitalia.
6. Possible developmental anomalies of uterine tubes, ovaries.
7. Clinic, diagnosis and treatment infantilism.
A student should be able to:
1. Collect general and specific gynecologic anamnesis.
2. Make up a plan of examination and treatment of endometriosis.
III. Recommendations to the student
ENDOMETRIOSIS
Endometriosis involves deposits of endometrium outside the uterine cavity.
Its manifestations are very variable and often bear no relation to the extent of the
disease.
Pathology
The gross appearance shows ectopic deposits which can very in number from a
few in one locality to large numbers distributed over the pelvic organs and
peritoneum.
The commonest sites of these deposits are:
The commonest appearance of a typical lesion is that of a round protruding vesicle
which shows a succession of colours from blue to black to brown. The variation in
colour is due to haemorrhage with subsequent breakdown of the haemoglobin.
Ultimately the area of haemorrhage heals by the formation of scar tissue. The
result is a puckered area on the peritoneum. Commonly however the haemorrhage
results in adhesion to surrounding structures. These adhesions are more apt to form
between fixed structures such as the broad ligament, ovary, sigmoid colon or the
posterior surfaces of the vagina and cervix.
The ectopic deposits of endometrial tissue vary in size from pin-point to 5
mm or more. It is these larger deposits which tend to rupture leading to adhesions.
These adhesions over the ovary can lead to the formation of quite large
haemorrhagic cysts due to continued bleeding from deposits, the blood being
unable to escape. Investigation has shown that many lesions do not have a 'typical'
appearance. The following is a list of other appearances which have been
described. White, slightly raised opacities due to retro-peritoneal deposits. Red
flame-like or vascular swellings, more common in the broad ligament or uterosacral ligament. Small excrescences like the surface of normal endometrium.
Adhesions under the ovary or between the ovary and the ovarian fossa
peritoneum. Cafe-au-lait patches often in the Pouch of Douglas, broad ligament or
peritoneal surface of the bladder. Peritoneal defects on utero-sacral ligament or
broad ligament. Areas of petechiae or hypervascularisation usually on the bladder
and the broad ligament.
Secondary pathology
This is due to the adhesions between the endometriotic deposits and adjacent
organs. In long-standing cases the pelvic cavity is obliterated by these adhesions.
Retroversion of the uterus can be produced.
Clinical findings
The incidence of endometriosis has been estimated at 3 to 7% of women but the
true incidence is unknown. Quite often deposits are found incidentally in women
who have no symptoms of endometriosis and are undergoing laparoscopy or
laparotomy for some other condition. In addition, as indicated in the section on
pathology, many peritoneal changes now known to be due to endometriosis were
undiagnosed in the past.
The prevalence of endometriosis peaks between the ages of 30 and 45 years. Since
ectopic endometrium is stimulated by the same ovarian steroid hormones as the
endometrium lining the uterine cavity, endometriosis is almost never found outside
the reproductive years.
Symptomatology
A. Pain affects more than 80% of women with endometriotic deposits. The
pain tends to begin premenstrually reaching a peak during menstruation and
subsiding slowly.
The character of pain may vary as does its apparent origin. It may be
generalised throughout the abdomen and pelvis like the pain of severe
dysmenorrhoea. Alternatively, pain may be localised to a particular site within the
pelvis. Deep dyspareunia affects around 40% of women with endometriosis.
B. Menstrual disturbance. Menstrual disturbance affects around 20% of
women with endometriosis. It may take the form of premenstrual 'spotting',
menorrhagia or infrequent periods. Lesions in the wall of the bladder may result in
'menstrual haematuria'.
C. Infertility. Endometriosis is found more commonly in women undergoing
investigation for infertility than in the 'normal' population. It is not clear which
condition arises first. Approximately 30% of patients with endometriosis complain
of infertility. When endometriosis is extensive, and both fallopian tubes are
occluded, the mechanism by which endometriosis prevents conception is obvious.
However, milder forms of endometriosis are also associated with subfertility, and
here the pathophysiology is less clear. The most likely mechanism appears to be
that immunological factors within the peritoneal cavity inhibit normal gamete
function, thus reducing fertilisation rates.
Physical examination
Endometriosis cannot be diagnosed by physical examination alone. However,
enlargement of the ovaries, fixed retroversion of the uterus and tender nodules
within the pelvis may each raise the suspicion of the disease. Endometriosis should
always be considered when patients have symptoms referable to the pelvic cavity.
Laparoscopy
Laparoscopic examination is the only way of making a positive diagnosis. The
lesions can be seen and their number and location estimated. Endometriosis of long
standing may be very difficult to diagnose due to obliteration of the pelvic cavity
by adhesions. Histological confirmation must be obtained if feasible.
Imaging techniques
Ultrasound, computerised tomography and magnetic resonance imaging may
suggest the presence of endometriosis (e.g. by the demonstration of a particular
type of ovarian cyst) but are by themselves insufficiently reliable to make the
diagnosis.
Differential diagnosis
Due to the mixture of symptoms and the variation in appearance of the pelvic
structures, conditions such as pelvic inflammatory disease and tumours of the
ovary and bowel must be considered and eliminated.
Histogenesis. There are three theories.
Retrograde spill of menstrual debris through the tubes. Retrograde
menstruation takes place in most women, but it is unclear why some women
should develop endometriosis while others are unaffected.
Metaplasia of embryonic cells. These are derived from the primitive coelom
and may remain in and around the pelvis and differentiate into Mullerian duct
tissue.
Emboli of endometrial tissue may travel by lymphatics or blood vessels and
become established in various sites.
The first of these theories is most favoured.
TREATMENT. Medical treatment. Any treatment must be aimed at treating
symptoms. Since ovarian hormones are responsible for growth and activity in
endometrium many medical therapies are designed to reduce ovarian steroid
production or oppose their action.
1. Progestogens
Progestogens in a relatively high dose (e.g. medroxyprogesterone acetate 10
mg tid) induce decidualisation, and sometimes resorption of ectopic endometrium.
Side effects include weight gain, bloating and irregular vaginal bleeding.
2. Combined contraceptive pill
The combined oral contraceptive pill also induces decidualisation of ectopic
endometrium. It may be given continuously for up to 3 months.
3. Danazol
Danazol is a steroid hormone closely related to testosterone, which inhibits
pituitary
gonadotrophins,
is
anti-oestrogenic,
anti-progestational,
slightly
androgenic and anabolic. The dose of danazol given can be titrated to the patient's
symptoms up to a maximum of 800 mg daily. If danazol can be tolerated,
symptoms and objective signs of disease can be alleviated in the majority of
patients. However, androgenic side effects including amenorrhoea, weight gain,
acne, hirsutism and deepening of the voice may limit acceptability of the drug.
4. Gestrinone
Gestrinone is a derivative of 19-nortestosterone. It has slight androgenic
activity and is markedly anti-oestrogenic and anti-progestogenic. It interacts with
the pituitary steroid receptors and decreases gonadotrophic secretion resulting in
diminished follicular growth and anovulation. A bi-weekly oral dose of 2.5 to
5.0mg for 6 months induces amenorrhoea, disappearance of pain and regression of
the endometrial deposits. Side effects include weight gain, acne, seborrhoea and
mild hirsutism.
Gonadotrophic releasing hormone analogues (GnRH analogue)
GnRH analogues are administered by depot injection or nasal spray. Their mode
of action is shown above. Although these drugs are generally effective in treating
symptoms, menopausal side effects, in particular bone loss, may preclude long
term use. In the future, use of 'add back' regimens which include small
supplementary doses of oestrogen may prove to be effective in treating the
symptoms of endometriosis without the complications of total oestrogen
deprivation.
Conclusion
As with medical therapies for other conditions, the optimum treatment is
dictated by the side effect profile which is most acceptable to the patient. None of
the drug treatments described will prevent recurrence of endometriosis once
therapy has been stopped, although there may be a period of some months between
stopping treatment and the re-emergence of symptoms. No medical treatment has
been shown to improve subsequent fertility. Notwithstanding, none of the above,
with the exception of the combined pill, is a proper contraceptive agent and
patients should be advised to use barrier contraception to avoid the potential
teratogenic effects of drugs such as danazol if they are at risk" of becoming
pregnant.
Surgical treatment
Where infertility is not a problem radical surgery to remove both ovaries is
said to be a lasting cure for endometriosis, since it removes the oestrogenic
stimulus to endometrial growth. In many cases the patient wishes relief from pain
but also desires to retain the possibility of future pregnancy. In these circumstances
only conservative surgery can be employed.
The intentions in conservative surgery are:
 To ablate as many endometrial deposits in the pelvic cavity as possible.
 To restructure the pelvic anatomy by destroying adhesions which interfere
with ovarian and tubal function.
 To destroy endometrial deposits in the ovaries.
 To deal with sensory nerve pathways.
In view of the many vital structures such as the bladder, rectum, colon and ureters
in close proximity to each other, conventional open surgery is not always feasible.
Laser surgery under laparoscopy, with its almost microscopic accuracy, may be
employed. Endometrial deposits and adhesions can be vaporised easily without
damaging tissue outside a radius of a fraction of a millimetre from the target.
Similarly the laser destruction of ovarian lesions can be carried out without
destroying any of the functional tissue.
The question of dealing with sensory nerve pathways is difficult to answer.
Severe pain is a feature of a number of gynaecological conditions, especially those
related to malignancy. Elsewhere in this book operative techniques are described
which involve interfering with sensory conductivity centrally, i.e. at the spinal cord
level. Recently, a local operative procedure, paracervical uterine denervation, has
been recommended. This consists of vaporising the utero-sacral ligaments by laser
at their attachment to the posterior aspect of the cervix where the sensory fibres
emerge from the uterus. Two difficulties are associated with this procedure. First,
the ureters must be avoided and, secondly, veins lying lateral to the ligaments must
not be injured. Unfortunately severe pain is often associated with severe
endometriosis and adhesions may make the operation very difficult.
Reports in the literature record complete relief from pain in 50% of patients
followed for more than a year and another 41% obtained moderate relief.
IV. Control questions and tasks
1. Frequency of endometriosis pathology.
2. Classification of endometriosis.
3. Laboratory methods of endometriosis diagnosis.
4. Conservative methods of treatment.
5. Surgical methods of treatment.
I. Scientific and methodical grounds of the theme
In born anomalies of genitalia development appear in 0,23-0,9% of women.
Anomalities of female genitalia include inborn disorders of anatomical structure of
genitals, in the form of incomplete organogenesis, deviation of size, shape,
proportions, symmetry, topography, presence of formations, noncharacteristic to
the female organism in postnatal period.
II. Aim:
A student must know:
1. Etiology of development anomalies of female organism.
2.Terminology, used characterize development anomalies of female genitalia
or their separate parts..
3. Ways of formation of female genitalia during embryogenesis.
4. Developmental anomalies of hymen, vulva and vagina, diagnostic methods
and treatment.
5. Classification of developmental anomalies of uterus, their diagnostics and
treatment.
6. Possible developmental anomalies of uterine tubes, ovaries.
7. Clinic, diagnosis and treatment infantilism.
A student should be able to:
1. Collect general and specific gynecologic anamnesis.
2. Make up a plan of examination and treatment
of different forms
of developmental anomalies.
III. Recommendations to the student
DEVELOPMENT OF FEMALE GENITALIA IN PRENATAL PERIOD
On the 3-4th weeks of embryo development on internal surface of primary
kidney a gonad germ is generated. Primary gonad has an indifferent structure
(identical for both genders) and consists of celomic epithelium cells (external
layer), mesenchyme (internal medullar layer) and gamete cells — gonocytes.
Sexual differentiation of indifferent glands is induced by sexual chromosomes. Ychromosome presence determines testicle development, and X-chromosome
presence determines ovarian development.
External genitals of fetus also goes through the different stages of
development. They are germinated on the 6-7th weeks of the development in the
form of genital prominence and urethral fissure, bordered by urethral and
labioscrotal folds.
Forming of masculine sexual glands begins from the 7th week, and masculine
genitals — from the 8th week of fetal development.
Differentiation of female reproductive system takes place in later terms.
Forming of female-type gonads begins from 8-10th week of pregnancy. Presence
of 2 X-chromosomes in a zygote is necessary for ovarian development. A gene
inducing ovarian development is localized in long shoulder of X-chromosome.
Under its influence gonocytes are transformed into ovogonies, then — into
ovocytes, around which the primary granulous cells are generated from
mesenchymal cells. They are situated in the cortex of sexual gland and intensively
reproduce themselves by means of mitotic division. On the 5th month of
embryonal development a number of primary follicles reaches 4 mln., till the birth
time of a girl their amount is reduced to 1 mln. The ovary is morphologically
formed.
Internal genitalia — uterine tubes, body, uterine cervix, upper 1/3 of vagina
are formed from paramesonephral ducts. Process starts on the 5-6th and finishes to
18th week of pregnancy. From upper one-third of paramesonephral ducts uterine
tubes are formed. Lower and middle parts uniting together form a body and uterine
cervix. Lower department of paramesonephral ducts forms the upper one-third of
vagina, lower 2/3 are formed from urino-genital sinus
Common organ cavity is formed to 21-22 week of gestation. The rest of
mesonephral channels are preserved as paraovophorone, epiovophorone and
Gartner's passages on the lateral walls of vagina. External female genitals are
formed since the 17th week of gestation. At first major labia are formed from
labioscrotal folds, from urethral folds minor labia are generated. Clitoris is formed
from genital prominence
DEVELOPMENT ANOMALIES OF EXTERNAL GENITALIA
Most frequently defects of external genitalia development are common at
androgeny and adrenogenital syndrome. These defects of external genitalia
development are manifestations of genital glands development violations and they
will be discussed in the corresponding chapter
UTERINE AND VAGINAI DEVELOPMENT ANOMALIES
Genitalia formation in female fetus takes place during the first months of
gestation from the middle embryonic layer (mesenchyme). From the same layer the
organs of urinary system are generated, that's why the uterine and vaginal
anomalies can be combined with urinary organs anomalies.
The ovaries are formed on the first weeks of gestation from indifferent
(identical for both genders) genital gland. On the third month of gestation their
differentiation starts. The ovaries dislocate down and draw into the small pelvis.
Uterus, uterine tubes and vagina are developed from mesodermal germs
(Muller's ducts). One uterine tube, a half of uterus and vagina are generated from
each of them. The middle and lower third of these ducts are united on the second
month of gestation, forming the external organ contour, but on all the length uterus
and vagina are parted by membrane. During the 3rd month of fetal development
this membrane is dissolved, uterine cavity and vagina are generated. Uterine tubes
are formed from the upper parts of Muller's ducts that didn't join.
External genitalia are generated from urino-genital sinus.
If during the act of sexual organs forming harmful factors, specifically
medicinal ones (uncontrolled medicines reception), would affect a pregnant
woman, a differentiation process of the genitals can be broken. Agenesy is the
absence of the organ and even of its rudiment. Aplasia is the absence of the organ's
part. Atresia is underdevelopment in the result of the prenatal cause.
Proceeding from mechanism of genitalia forming, such variants of uterine and
vaginal development defects are possible:
Both mesonephral ducts are formed properly, but they are not joined together
along the whole length. A full uterus and vagina doubling (uterus didelfus) is
generated: the patient has two vaginas divided by a thin membrane. Uterine cervix
opens into each vagina. There are two uteruses (unicornous), in each uterus there is
one tube and one ovary. Both uteruses can function. In the patients with such
pathology pregnancy loss is more frequent. In most cases one half of sexual
apparatus is developed better than the other one.
Both mesonephral ducts are formed properly, but their uniting takes place
only at any interval. Other parts of uterus and vagina are divided by a membrane.
There can be following variants: membrane in vagina (vagina septa); presence of
one vagina, into which two uterine cervices open (uterus bicornus bicollis);
membrane in uterine cavity (uterus septa), two-horned uterus (uterus bicornus);
saddle-like uterus (uterus arcuatus). At such anomalies genitals can function
normally, pregnancy can occur, but frequently pregnancy loss takes place. When
there is a saddle-like uterus the irregular fetus positions are usually diagnosed.
One of Muller's ducts develops properly, and the other one does not develop
at all. Vagina, single-horn uterus with one ovary and one tube is formed (uterus
unicornus). In such patient one should inspect urinary system, because such defect
correlates with the absence of kidney on the affected side. Unicornous uterus can
function, menstrual function is usually for the type of hypomenstrual syndrome.
The woman can become pregnant, however there exists high frequency of
pregnancy loss on the early terms.
One of the mesodermal ducts develops properly, the other—insufficiently. The
uterus with rudimentary horn is formed. These cavities can be joined, that's why
pregnancy in rudimentary horn is possible. It develops as ectopic pregnancy.
During its interruption a considerable bleeding takes place (horn rupture) that's
why the surgical intervention is necessary. At presence of closed cavity of
rudimentary horn during menstruation blood can deposit inside, that needs the
removal of the horn.
If uterine development anomalies are combined with underdevelopment of
genitals it is followed by violation of menstrual cycle, infertility.
Diagnosis is made after examination of external genitals, uterine cervix
examination in specula, bimanual examination. Ultrasound examination, sounding,
hysterosal-pingography
or
contrasting
sonography
(contrasting
substance
"Echovist" is used) are necessary for specification of diagnosis.
Treatment of the development anomalies is surgical. Doubling of uterus and
vagina, which does not disturb woman's sexual and reproductive functions, doesn't
need intervention. Operative treatment is necessary at presence of ectopic
pregnancy or agglomeration of menstrual blood in rudimentary horn. Membranes
in vagina are usually diagnosed during pregnancy or delivery; if they prevent
child's birth, they are lanced.
Absence of vagina (aplasia vagina) is a serious defect, which makes
impossible the realization of menstrual, sexual and reproductive functions. It
develops primarily (in fetus) or secondly in the result of healing after the carried
difficult inflammatory processes in babyhood (smallpox, diphtheria, scarlet fever).
It can rarely appear in women after serious labour traumas.
Treatment is only surgical. It is a plastic operation with vagina formation
from allotment of sigmoid bowel, recently allopl'asty is common.
Gynatresy — violation of genital channel permeability in some of its
departments. Most frequently atresia of hymen, vagina and uterine cervix are
present.
Primary gynatresy develops in fetus in the result of embryonic development
defects. Secondary gynatresy (acquired) develops in the result of inflammatory
processes, carried in childhood. In mature age vaginal atresia can occur in the
result of labour traumas, uterine cervix atresia after diathermocoagulation, atresia
of uterine cavity or adhesion in it after surplus uterine curretage because of
abortion.
Primary atresia of hymen ought to be diagnosed by medical personnel or by
girl's mother still in newborn period. Then all the further complications can be
avoided. If gynatresy is not found in time, then with the beginning of the first
menses blood begins to accumulate in vagina, straining it (haematocolpos). Girls
complain of pain. After finishing of such "latent menses blood gemolizes, liquid
part of it is absorbed, volume is decreased, pain stops until the following menses
begin. If the patient does not apply for medical help, then blood, accumulating
more and more, gathers in the uterine cavity (haematometra), and in the uterine
tubes (haematosalpinx).
Diagnosis consists of examination of external genitals, during which one can
see obstructed hymen and blood, that has accumulated behind it. During the rectal
examination one can palpate tumorous formation in allotment of vagina, uterus and
uterine tubes.
Treatment. Surgical incision of hymen is necessary. Hymen is crosswise
incised. Thick, brown-colored blood is removed from vagina. In order to prevent
secondary atresia they put several stitches in dissection edges.
Prognosis depends on the interna diagnostics of disease. At long illness
duration and development of haematometra and haematosalpinx later a woman can
have problems with pregnancy. Destructive process in uterine tubes leads to their
occlusion. Endometriosis of internal genitals develops frequently.
ABNORMALITES OF OVARIAN DEVELOPMENT
Hermaphroditism is a presence of signs of both sexes in one person. True
hermaphroditism is presence of genital glands of both sexes in one person on
condition of their simultaneous functioning. Such defects are almost not found in
practice, because children, sexual glands of which contain simultaneously the
tissue of ovary and testicle, are born with other different defects, and die during the
first days of their life.
False hermaphroditism (pseudoandrogeny) is a defect, at which the structure
of external genitalia does not correspond to the character of sexual gland. Human
sex is determined by chromosome set, according to which genital glands are
developed. At false female hermaphroditism internal genitals and sexual glands are
female (ovaries), and external sexual organs are developed like the male ones —
clitoris is enlarged and looks like penis, major labia are hypertrophied and look
like scrotum. Sometimes after the birth such children's sex is mistakenly
determined and parents begin to bring a girl up as a boy. That's why in case of
child birth with anomaly of genitals development it is necessary to carry out
careful examination, including the genetic one.
At false male hermaphroditism genital glands are male (testicles), and
structure of sexual organs looks like the female ones.
The congenital adrenogenital syndrome is the disease that develops by
reason of adrenal glands cortical layer hyperfunction. It is followed by increasing
in fetal organism of female sex sexual hormones (androgens) and causes the
formation of female genitals according to the masculine type. It is very important
to determine correctly the child's sex at birth.
Clinic. In such girl the period of puberty begins at the age of 6-7 and it is
followed by virilization signs (appearance of masculine secondary sexual signs) —
hair growth, forming of skeleton and body building according to masculine type.
Children are of a low height, lower extremities are short because of the early
epiphisar cartilage closing. At postpubertal form, when the disease starts after the
period of the puberty beginning, amenorrhea or oligomenorrhea are found in girls.
Breasts, uterus and ovaries do not develop. Later the woman suffers from the
primary infertility.
Treatment is prescribed by an obstetrician-gynecologist together with
endocrinologist. Medicines of glucocorticoid hormones (Prednizolone, Cortisone,
Dexametasone) are prescribed to decrease androgens production by adrenal glands.
Owing to this the gonadotropic pituitary function increases, ovarian stimulation
and production of own estrogens begins.
Ovarian absence — two or one — happens rarely, predominantly in fetuses
having other severe development defects.
Ovarian hypoplasy is the insufficient development of ovaries frequently
combined with uterine underdevelopment. Clinically it is manifested as
hypomenstrual syndrome.
The gonads' dysgenesia (the Shereshevsky-Terner syndrome) is the disease,
associated with chromosome abnormalities (one X-chromosome is absent) that
causes ovarian tissue underdevelopment. The ovaries are represented by
connective tissue, their function is absent.
Diagnosis. These patients are of low hight (not higher 130-145 cm). Body
weight after birth is low even at interm pregnancy. During examination a short
neck with wing-like folds from ears to shoulders, wide shoulders and tubby thorax
are typical. The external eyes' corners are drawn down, palate is high, that's why
these patients have special timbre of voice. Psychic development is normal, sexual
orientation is female, but in the puberty period secondary sexual signs develop not
enough.
During gynecological examination highly expressed signs of genital
infantilism are found. External genitalia are underdeveloped, there is a severe
vagina, uterine and ovarian hypoplasia. Genetic examination, that confirm the
chromosome anomaly has a great importance for specification of diagnosis. Tests
of functional diagnostics give a picture of the expressed lowering or practical
absence of hormones, the basal temperature is permanently low, "fern" and
"pupils" symptoms are absent. There is 50% of parabasal cells during
colpocytological investigation.
Treatment at prepuberty age is directed on the growth stimulation. After 1517 years of age replacement therapy with hormones is prescribed: they are
estrogens for 6-9 months, after this the cyclic therapy with Estrogens and
Progesterone is indicated. Such treatment leads to development of secondary
sexual signs, uterine cyclic bleedins initate.
Polycystic ovarian disease (the Stein-Leventhal's syndrome). This is a
genetically predisposed disease, pathogenesis of which is a violation of sexual
hormones synthesis in ovaries in the result of insufficiency of enzyme systems.
Excess amount of androgens is produced.
Clinically this disease is characterized by excessive hairiness (hirsutism), by
hypomenstrual syndrome or by amenorrhea and infertility. Well-developed
secondary sexual signs and enlarged two-sided ovaries are found during the
examination. During US-onografy the presence of a great deal of follicular cysts,
that is a cause of ovarian enlargement is revealed. Excess androgen stimulation
causes thickening of albuminous ovarian envelope, that's why ovulation does not
come, and follicles, do not burst, transform into cysts.
Treatment of disease can be conservative (hormonal therapy) or operative
(wedge-shaped ovarian resection).
You can get more detailed information about the Shereshevsky-Turner
syndrome and the Stein-Leventhal's syndrome from the chapter "Menstrual
function disorders".
DELAYED PUBERTY
Underdevelopment or absence of the secondary sexual signs at the age of 1314 and lack of menses at the age of 15-16 should be considered as delay of sexual
development (DSD).
There are central and ovarian form of delayed puberty. It depends on the
primary link of disease pathogenesis. At central genesis the ovarian insufficiency
comes secondary in the result of insufficient gonadotropine stimulation. At primary
lesion of gonads a secretion of gonadotropic hormones is raised. It is caused by the
lack of inhibiting influence of sexual hormones on pituitary.
Central form of delayed puberty is most frequently caused by such factors,
as infectious-toxic diseases (rheumatism, viral influenza, chronic tonsillitis,
tuberculosis), stress situations, excessive physical loading. These factors, acting in
the child age, give rise to functional immaturity of hypothalamic structures that are
responsible for sexual development, functional regulation of reproductive system is
disturbed. The lesion level at central form can be different. To genetically
predisposed forms delayed puberty at Lorenz-Munne-Barde-Bidle's syndrome is
refered. Delay of sexual maturity develops in patients with hypopituitarism of
organic origin.
Delay of sexual development of ovarian genesis most frequently appears in
patients with genetic defects. Hereditary factor is present in 2/3 of patients.
Damage of ovaries happens still in pre-natal period, damage degree of fetal ovaries
depends on the duration of pathogenic factor action such as taking of medicines
especially hormonal ones by mother, infectious mother's diseases, etc. In childhood
epidemic parotitis and measles most frequently cause ovarian insufficiency.
Clinically a delay of sexual development is expressed by that or other degree
of sexual (genital) infantilism.
Genital infantilism is a such state, when in reproductive age women
anatomic and associated with them functional peculiarities of genitalia, typical for
child organism, are preserved.
Diagnosis. External examination of women reveals low hight, frail body
building, small breasts. Hairiness on pubis is weakly developed, major labia don't
cover the minor ones. Vagina is narrow, vaults are not expressed. Uterus is small,
2/3 of it is the cervix, 1/3 is the body. Taking into consideration such anatomic
peculiarity, the expressed uterine bend to front — sharp-angle anteflexion
frequently occurs. Uterine cavity length is always shorter than the norm (6 cm and
less). There are three degrees of uterine underdevelopment for cavity lenght. They
are:
 I degree — 7- cm
 II degree — 5-3,5 cm
 III degree — less then 3,5 cm
Uterine tubes are long and sinuous, ovaries are considerably smaller as
compared with the
Functional changes are closely connected with the structural ones. Menses in
such women start lately at the age of 15-16. Primary amenorrhea can appear in the
result of considerable underdevelopment. Amount of discharge is insignificant,
menses duration is 1-2 days (hypomenstrualsyndrome). Sometimes menses comes
not monthly, and is more rarely. Menses are followed by strong pain (algodysmenorrhea), that is connected with uterine structure. At expressed ovarian
underdevelopment and considerable lowering of their function, sexual desire is
absent in women. If hormonal background is moderately altered, sexual function is
preserved.
Women with hypoplastic uterus can't become pregnant (primary infertility)
for a long time after marriage. If pregnancy comes, it can be ectopic (because of
uterine tubes' structure), or it interrupts in early terms, because insufficient amount
of hormones does not provide normal pregnancy development. Such interruptions
of pregnancy in patients with genital infantilism can occur several times (regular
abortions), but pregnancy and associated with it intensive hormones secretion
always has positive influence on the patient's organism, for it contributes to uterine
development.
Treatment of such patients should be complex and includes restorative
therapy, physiotherapy, prescribing small doses of hormones for ovarian function
stimulation. Going in for sports, sanatorium-health-resort cure, gynecological
massage are also recommended. The earlier the cure begins, the greater are the
chances for success.
At central genesis of disease Prephisone (25-50 AU i/m) is indicated during
the first phase of menstrual cycle (at amenorrhea the first cycle day is considered
the first day of cure) daily, 8-10 days. Then Choriogonine (2500-3000 AU i/m) is
prescribed during the 12, 14, 15, 16, 18th cycle day. Clostylbept (Clomiphen) —
50 mg per day from 5th till 9th cycle day, then Microfolline — 0,05 nig 2 times per
day till 12-14th cycle day are also indicated. Treatment with Clomiphen and
estrogens takes 2-3 months, then synthetic Progestines in cyclic mode during 2
courses with 7-days intervals are taken. For better hormones' reception folic acid
(0,06g per day) in first phase, in ovulation period and second phase — Thymidine
— 25-50 mg per day and vitamin E 50-100 mg per day are prescribed.
INCORRECT UTERINE POSITIONS
Physiological uterine position is considered to its situation in the center of
small pelvis on identical distance from symphysis, sacrum and lateral walls of
pelvis. Uterine fundus is situated beneath the plane of inlet, external cervical os is
on the level of ishial spines (linea interspinalis).
This situation is provided by sustaining fixative and suspentive apparatus of
uterus. Uterine and vaginal own tone, the tone of frontal abdominal wall,
diaphragm and muscles of pelvic floor have a great importance.
Uterine position is uterine relation to the leading pelvis axis. Uterus is able to
displace as for its normal position. This displacement can be physiological (uterus
goes back to its previous position) or pathological and fixed. For such conditions
uterus is immovably fixed to pelvis walls or adjacent organs by adhesions or
tumor.
Anteposition — uterine displacement considering to leading axis to front.
Retroposition — uterine displacement backwards.
Lateroposition — (dextro- et sinistropositio) displacement of uterus to
correspond side.
Physiological retroposition of uterus happens at repletion of urinary bladder
Anteposition appears at full rectum
Pathological uterine displacement happens at tumors presence or pus
accumulation
Then uterus replaces to the healthy side. After operative
interventions or after the carried inflammatory process with formation of
adhesions, a connective cicatrix tissue drags uterus into this side. Uterine
movability is limited or absent
Inclination of uterus (versio uteri) is a relation of vertical uterine axis to
horizontal plane. Inclination of uterus to front (anteversio), aside (lateroversio),
and also backwards (retroversio) are distinguished.
Causes of pathological uterine inclinations may be the tumors of genital
organs (only uterine body is displaced, and cervix remains in its place) and
insufficiency of uterine ligaments.
Uterine flexion (flexio uteri) is the relation of uterine body to its cervix.
Normally between uterine body and cervix there exists an obtuse angle (for about
120°), opened forward (anteflexio). If the angle is less than 120°, such anteflexion
refers to the sharp one (it is found at genital infantilism).
Uterine flexion to back (retroflexio), to the right (lateroversio dextra), or to
the left (lateroversio sinistra) is pathological. Retroflexion is mobile and fixed.
Fixation happens at accretion of uterus with parietal peritoneum.
Combination of retroversion and retroflexion is called uterine retrodeviation.
Retroflexion and uterine retrodeviation are followed by aching dull pain in lower
abdomen, painful menses (algodysmenorrhea) and infertility. Uterine cervix
erosions and endocervicites can develop in the result of blood supply violation and
blood stagnation. Sometimes patients complain of frequent and painful urination.
There can be a delay of evacuation and pain during it. These phenomena
sometimes can be eliminated owing to uterine reposition. Aged women with
retrodeviation can have uterine and vaginal prolapse often.
UTERINE DESCENSE AND PROLAPSE
Prolapse is a single pathological process based on a tight anatomic tie
between uterus, vagina, ovaries, urinary bladder and rectum. Depending on the
stage of this process, uterine descense and prolapse are distinquished.
The vaginal walls descense—vaginal wall has lost its tone, they are descent
and do not leave the borders of vagina's introitus.
The vaginal walls prolapse — vaginal walls are beneath the introitus of
vagina.
Degrees of uterine displacement:
 I degree — vaginal part of uterine cervix is found lower, then sciatic
spines (linea interspinalis), however it stays inside of pudendal cleft
borders even during the exerting (uterine descense)
 II degree — external cervical os goes beyond the borders of pudendal
cleft, it is found beneath vaginal introitus, and uterine body is above it
(incomplete uterine prolapse)
 III degree — all the uterine and vaginal walls are found outside of
pudendal cleft (complete prolapse)
Etiology and pathogenesis. Multiple deliveries, vaginal and perineum
ruptures during the previous delivery, constipations, weight lifting, hard work can
cause weakening or violation of the supportive, fixative and suspentive apparatus
of the uterine structure and uterine displacement. More frequently descense and
prolapse of uterus develops in women after 50 years in connection with the
beginning of age atrophy of sexual organs and ligament apparatus.
Clinic. Uterine descense and prolapse is a long process. Woman complain of
dragging pain in lower abdomen and in sacrum region, frequent urination, urine
incontinence, that appears during the smallest physical loads — cough, quick
motions. Later a tumorous formation — uterine cervix with external cervical os
appears from vagina. Menorrhage is possible if woman menstruates. Sexual life is
possible after uterine reposition. Woman can become pregnant. During the first
months of pregnancy cases of its spontaneous interrupting are common. After the
12th week of gestation uterus stops to prolapse because of its largeness, after
delivery the prolapse appears again.
Together with the anterior vaginal wall urinary bladder wall discences and
prolapses. Cystocele is formed. Descense and prolapse of posterior vaginal wall
causes formation of rectum hernia (rectocele).
At complete uterine prolapse, its body together with cervix is found beneath
the introitus of vagina. Vagina is turned out by the mucous membrane. Elongation
of the cervix develops frequently.
Mucous membrane of vagina thins or thickens and dries out. Secondary
trophic changes can develop — trophic (decubital) ulcers on cervix and vaginal
walls, polyps near the external os are common. Histologically microcirculation
impairment, hyper- and parakeratosis, inflammatory infiltration, sclerotic changes
are found.
Changes in urinary system can also appear. Patients complain of frequent
urination and urine incontinence. At urine analysis bacteriuria is found. During
chromocystoscopy trabecularity and cavities in mucous of urinary bladder, ureters
dyslocation, cystitis, lowering of sphincters' tone are revealed. During excretory
urography atony and dilation of ureters are present. At US examination
nephroptosis, dilation of kidney are observed. Changes in this system are caused
by violation of the blood circulation and position of urinary bladder, ureters and
associated with this urine outflow.
Diagnosis is not of a special difficulty because prolapse is found during
inspection of external genitalia. It is important to determine whether it is a
complete or incomplete prolapse. Doctor takes the prolapsed organs with index and
forefingers on the level of vaginal introitus. If uterine body is palpated between
them, then the prolapse is incomplete. If fingers close behind the uterine fundus —
this is the complete uterine prolapse. Perineum inspection is necessary to find scars
and to estimate the functional state of pelvic muscles.
Treatment. Method of treatment for each patient is individually selected. It
depends on the age, general patient's state, presence of menstrual and sexual
functions.
Conservative treatment is indicated for women at small descense of uterus, in
reproductive age or for emaciated patients, the age or general state of which does
not allow to use a surgical intervention. Medic ally-protective regimen with
exclusion of physical loads is of great importance. Medical physical training,
directed to the strengthening of abdominal press and pelvic floor muscles, rational
feeding for constipation prevention should be recommended.
Orthopedic method is in introduction of special devices into vagina for
support of uterus in its place (rubber rings). Great attention is paid to hygiene of
genitals during pessaries usage, taking them out regularly and sterilizing by
boiling.
Conservative treatment consist also of the treatment of trophic ulcers and
vaginitis, that develop in such patients rather frequently. Doctor prescribes cure.
Midwife or medical sister can fulfil it. Vaginal walls, that have prolapsed and
uterine cervix are processed with antiseptic solutions (Potassium permanganate,
Furacillin, Hydrogenium peroxide, Chlorhexidin bigluconate). After processing of
the prolapsed tissues, they are dried up by a sterile gauze serviette. On decubital
ulcer's surface ointment or liniment with antiseptics are applied, a surface is
covered by sterile serviette, and the uterine is replaced into vagina. Then a tampon
with aseptic remedy is inserted, tampon size depends on the vaginal size. After
elimination of inflammatory process and vaginitis for acceleration of tissue
regeneration on the region of decubital ulcer there can be applied an ointment with
Solcoseril, Apilac, Methyluracil, Propoceum. Such procedures are hold daily
during 1-2 weeks to complete ulcer epithelization. If ulcer is not healed up to that
time, then biopsy for differential diagnostics with cervix cancer is made.
Aged women which have used vaginal pessaries undergo careful supervision
by a doctor of female dyspansery, a midwife, and a medical assistant. Their long
usage can cause bedsores on the uterine cervix and vagina.
Acute urine delay appears if tissues that have prolapsed squeeze. Urine should
be let out by catheter, and patient should be hospitalized. During catheterization a
catheter is directed not upwards to symphysis but on the contrary downwards,
because urethra which is connected with anterior wall of vagina changes its usual
location.
Surgical treatment is the most radical method. The main aim of cure is
restoring of pelvic floor muscles integrity, creation of uterine support, and also
renewing of normal structure and function of uterine ligaments.
Basic methods of surgical interventions are:
 the plastyc of frontal vaginal wall (anterior colporrhaphy), the plastyc
of posterior vaginal wall and perineum (posterior colporrhaphy,
colpoperineo-rrhaphy) — the plastyc of pelvic floor and perineum is
made
 shortening of round uterine ligaments (is used in women of
reproductive age);
 ventrofixation — uterus is fixed to the anterior abdominal wall (is
combined with frontal and posterior plastics of vagina)
 amputation of the cervix by Shturmdorf is made at uterine cervix
pathology
In senile age at complete uterine prolapse in combination with concomitant
pathology (uterine tumors etc), vaginal hysterectomy through vagina is made. This
operation is combined with the plastic of posterior vaginal wall and levatoroplastics.
Obligatory condition for surgical intervention is the complete healing of
decubital ulcers, absence of inflammatory process in vagina.
Prevention of uterine and vaginal walls descense and prolapse is necessary in
medical and social aspects. It is important for woman to do physical exercises, to
go in for sport, to train abdominal press and pelvic floor muscles. During delivery
it is necessary to diagnose interm and to restore perineal muscles in their rupture.
Doctor and midwife of postnatal department have to take careful tendance for
seams, to watch closely for the regimen and women's conduct in postnatal period,
not to allow woman with perineum ruptures to get up and to sit down prematurely.
Uterine inversion
Uterine inversion is a state, in some causes of which uterine fundus is pressed
inside. So serous membrane is inside, and mucous one is outside. In this case the
ovaries get inside this formation, their blood supply violates. The stagnant
phenomena and uterine edema develop.
There are two forms of uterine inversion: puerperal (postnatal) and
oncogenetic (caused by a tumor). The mechanism of puerperal inversion was
described in obstetrics course.
The oncogenetic uterine inversion is caused by the case of protruding myoma
placed on a short pedicle.
Clinically the oncogenetic uterine inversion is followed by extending strong
pain low in the abdomen like delivery. A fibromatous node, that is situated in
uterine cavity, more frequently near its fundus, descends into lower segment, is
perceived by it as a foreign body, and uterus begins to push it out. Uterine cervix is
dilated, node appears outside, but a pedicle stem does not allow it to be born.
Node's and uterine blood supply is disturbed, node necrosis is developed.
Hysterectomy is the treatment of oncogenetic uterine inversions. An attempt
to remove the node through the uterine cervix is dangerous because of uterine
perforation possibility, if nodes pedicle is short and wide.
The uterine torsion
The uterine torsion (torsio uteri) is turning of uterine body around vertical
axis. It happens extraordinarily rarely. Uterine and ovarian tumors, adhesions
process in small pelvis are the main causes of uterine torsion.
TRAUMAS OF FEMALE GENITALS
Damages of external genitals can be as contusion, haematoma, hypodermic
effusions of blood, that ordinary are accompained by damage of skin. More often
these damages appear as a result of trauma such as falls and blows. In the village
hornblows of domestic animals are observed. These traumas can be followed by
lacerated wounds which ordinary penetrating deeply into tissues, sometimes vagina
and even rectum can be damaged. In case of heavy traumas of urethra, urinary
bladder, and also pelvis bone can be damaged. In case of damage of vagina trauma
can penetrate into abdominal cavity. Ruptures of lateral walls of vagina are very
dangerous because vaginal branches of uterine arteries pass in this area.
Clinically trauma is characterised by pain and haematoma of blue to purple
colour in damaged place. In case of severe internal bleeding a picture of
hemorrhagic shock develops. Bleeding can be followed by anaemia. In case of
clitoris rupture bleeding can be especially massive. Sometimes inserting of foreign
objects into genital organs can happen. Especially frequently it happens in girls
before 10 years. Adult women can introduce catheters, sounds and other objects
into uterus with aim of pregnancy interruption. In such cases frequently uterus
perforation, bleeding can appear, that's why the woman applies for medical care. If
there is no damage of genital organs, presence of foreign body causes
inflammatory process. Purulent excretions from vagina, sometimes with blood
admixtures appear. Foreign body in adults can be found due to speculum
examination. For children one should use cautious rectal research and
vaginoscopy.
Diagnosis is based on examination. If there is suspicion on trauma of adjacent
organs catheterization of urinary bladder, cystoscopy is made. US can be useful for
diagnostics of foreign bodies in vagina.
Treatment. Traumatized tissues are sutured. In case of haematoma it is incised,
bleeding vessels are knitted and drained. If it is necessary hemotransfusion is
performed. Uterine cervix, vaginal, uterine ruptures, associated with labor act, are
described in obstetrics course.
Micturition requires coordination of several physiological processes. Somatic and
autonomic nerves carry bladder volume input to the spinal cord and motor output
innervating the detrusor, sphincter, and bladder musculature is adjusted
accordingly. The cerebral cortex exerts a predominantly inhibitory influence,
whereas the brainstem facilitates urination by coordinating urethral sphincter
relaxation and detrusor muscle contraction. As the bladder fills, sympathetic tone
contributes to closure of the bladder neck and relaxation of the dome of the bladder
and inhibits parasympathetic tone. At the same time, somatic innervation maintains
tone in the pelvic floor musculature as well as the striated periurethral muscles.
When urination occurs, sympathetic and somatic tones in the bladder and
periurethral muscles diminish, resulting in decreased urethral resistance.
Cholinergic parasympathetic tone increases resulting in bladder contraction. Urine
flow results when bladder pressure exceeds urethral resistance. Normal bladder
capacity is 300-500 mL, and the first urge to void generally occurs between
bladder volumes of 150 and 300 mL.
Incontinence occurs when micturition physiology, functional toileting ability, or
both have been disrupted. The underlying pathology varies among the different
types of incontinence:
Stress incontinence
Stress incontinence is characterized by urine leakage associated with increased
abdominal pressure from laughing, sneezing, coughing, climbing stairs, or other
physical stressors on the abdominal cavity and, thus, the bladder.
Two main causes of stress incontinence exist. The major cause is impaired urethral
support from pelvic floor muscle weakness. The less common cause is an intrinsic
sphincter deficiency usually secondary to pelvic surgeries. In either case, urethral
sphincter function is impaired, resulting in urine loss at lower than usual abdominal
pressures.
Urge incontinence
Urge incontinence is a result of uninhibited bladder contraction from detrusor
hyperactivity. This hyperactivity can be caused by abnormalities of the CNS
inhibitory pathway such as strokes or cervical stenosis. Other causes are bladder
inflammation from infection, stones, or neoplasms. Urge incontinence is
characterized by a sudden strong desire to pass urine that is difficult to suppress
leading to involuntary urine loss. It usually entails urgency, frequency, or nocturia.
These symptoms are often referred to as the overactive bladder syndrome (OAB).
Some individuals may have a pure sensory abnormality where they exhibit urinary
frequency and urgency without urine loss. This is often referred to as overactive
bladder dry. Elderly persons frequently experience urinary loss without the
sensation of urge, but the underlying mechanism of detrusor hyperactivity is still
the same.
Mixed incontinence
Mixed incontinence is the coexistence of stress and urge incontinence. Although it
is generally defined as detrusor overactivity and impaired urethral function, the
actual pathophysiology of mixed urinary incontinence is still being investigated.
Mixed urinary incontinence is characterized by involuntary loss of urine associated
with urgency as well as exertion, cough, sneeze, or any effort that increases intraabdominal pressure. This is the most common type of incontinence in women.
Overflow incontinence
The major contributing factor to overflow incontinence is incomplete bladder
emptying secondary to impaired detrusor contractility or bladder outlet obstruction.
Factors involved in the development of overflow incontinence are physical
obstruction such as pelvic organ prolapse and enlarged prostate, and neurological
abnormalities, such as spinal cord injuries. It is also commonly associated with
bladder neuropathy that occurs in the setting of diabetes mellitus. Patients often
complain of continuous small-volume leakage associated with weak urinary
stream, dribbling, hesitancy, frequency, and nocturia. Other less frequent causes of
urinary incontinence include trauma from pelvic fracture, complications of
urologic procedures, and fistulas. In the pediatric population, it includes enuresis
and congenital abnormalities of the genitourinary system. Older adults can have
transient incontinence from medication, decreased mobility, and fecal impaction.
Functional incontinence
Functional incontinence is seen in patients with normal voiding systems but who
have difficulty reaching the toilet because of physical or psychological
impediments. Patients often present with recent symptom onset and have a good
prognosis for cure if the cause is identified and treated. Functional incontinence is
often secondary to reversible causes of urinary incontinence, as discussed later.
Cotton swab test
This examination evaluates urethral mobility. Place a sterile cotton swab through
the urethra into the bladder. Pull the swab back until resistance is met, which
indicates entry into the urethra. At this point, ask the patient to strain maximally. A
change of angle greater than 30 degrees indicates urethral hypermobility. A
positive finding does not confer a specific diagnosis, and older women have a high
false-negative rate.
Stress testing
This test evaluates stress-induced leakage when the bladder is full. Ask the patient
to cough forcefully or strain vigorously. Instantaneous urine leak is highly
suggestive of stress incontinence, whereas delayed leakage is suggestive of stressinduced detrusor overactivity. This test is very sensitive but can be misleading in
inhibited patients and in those with low bladder volume.
Treatment for urinary incontinence depends on the type of incontinence, the
severity of your problem and the underlying cause. Your doctor will recommend
the approaches best suited to your condition. A combination of treatments may be
needed. In most cases, your doctor will suggest the least invasive treatments first,
so you'll try behavioral techniques and physical therapy first and move on to other
options only if these techniques fail.
Behavioral techniques
Behavioral techniques and lifestyle changes work well for certain types of urinary
incontinence. They may be the only treatment you need.
Bladder training. Your doctor may recommend bladder training — alone or in
combination with other therapies — to control urge and other types of
incontinence. Bladder training involves learning to delay urination after you get the
urge to go. You may start by trying to hold off for 10 minutes every time you feel
an urge to urinate. The goal is to lengthen the time between trips to the toilet until
you're urinating every two to four hours. Bladder training may also involve double
voiding — urinating, then waiting a few minutes and trying again. This exercise
can help you learn to empty your bladder more completely to avoid overflow
incontinence. In addition, bladder training may involve learning to control urges to
urinate. When you feel the urge to urinate, you're instructed to relax — breathe
slowly and deeply — or to distract yourself with an activity.
Scheduled toilet trips. This means timed urination — going to the toilet according
to the clock rather than waiting for the need to go. Following this technique, you
go to the toilet on a routine, planned basis — usually every two to four hours.
Fluid and diet management. In some cases, you can simply modify your daily
habits to regain control of your bladder. You may need to cut back on or avoid
alcohol, caffeine or acidic foods. Reducing liquid consumption, losing weight or
increasing physical activity are other lifestyle changes that can eliminate the
problem.
Physical therapy
Pelvic floor muscle exercises. These exercises strengthen your urinary sphincter
and pelvic floor muscles — the muscles that help control urination. Your doctor
may recommend that you do these exercises frequently. They are especially
effective for stress incontinence, but may also help urge incontinence. To do
pelvic floor muscle exercises (Kegel exercises), imagine that you're trying to stop
your urine flow. Squeeze the muscles you would use to stop urinating and hold for
a count of three and repeat. With Kegel exercises, it can be difficult to know
whether you're contracting the right muscles and in the right manner. In general, if
you sense a pulling-up feeling when you squeeze, you're using the right muscles.
Men may feel their penises pull in slightly toward their bodies. To double-check
that you're contracting the right muscles, try the exercises in front of a mirror. Your
abdominal, buttock or leg muscles shouldn't tighten if you're isolating the muscles
of the pelvic floor. If you're still not sure whether you're contracting the right
muscles, ask your doctor for help. Your doctor may suggest you work with a
physical therapist or try biofeedback techniques to help you identify and contract
the right muscles. Your doctor may also suggest vaginal cones, which are weights
that help women strengthen the pelvic floor.
Electrical stimulation. In this procedure, electrodes are temporarily inserted into
your rectum or vagina to stimulate and strengthen pelvic floor muscles. Gentle
electrical stimulation can be effective for stress incontinence and urge
incontinence, but it takes several months and multiple treatments to work.
Medications
Often, medications are used in conjunction with behavioral techniques. Drugs
commonly used to treat incontinence include:
Anticholinergics. These prescription medications calm an overactive bladder, so
they may be helpful for urge incontinence. Several drugs fall under this category,
including oxybutynin (Ditropan), tolterodine (Detrol), darifenacin (Enablex),
fesoterodine (Toviaz), solifenacin (Vesicare) and trospium (Sanctura). Possible
side effects of these medications include dry mouth, constipation, blurred vision
and flushing.
Topical estrogen. Applying low-dose, topical estrogen in the form of a vaginal
cream, ring or patch may help tone and rejuvenate tissues in the urethra and
vaginal areas. This may reduce some of the symptoms of incontinence.
Imipramine. Imipramine (Tofranil) is a tricyclic antidepressant that may be used to
treat mixed — urge and stress — incontinence.
Duloxetine. The antidepressant medication duloxetine (Cymbalta) is sometimes
used to treat stress incontinence.
Medical devices
Several medical devices are available to help treat incontinence. They're designed
specifically for women and include:
Urethral insert. This small tampon-like disposable device inserted into the urethra
acts as a plug to prevent leakage. It's usually used to prevent incontinence during a
specific activity, but it may be worn throughout the day. Urethral inserts aren't
meant to be worn 24 hours a day. They are available by prescription and may work
best for women who have predictable incontinence during certain activities, such
as playing tennis. The device is inserted before the activity and removed before
urination.
Pessary (PES-uh-re). Your doctor may prescribe a pessary — a stiff ring that you
insert into your vagina and wear all day. The device helps hold up your bladder,
which lies near the vagina, to prevent urine leakage. You need to regularly remove
the device to clean it. You may benefit from a pessary if you have incontinence
due to a dropped (prolapsed) bladder or uterus.
Interventional therapies
Bulking material injections. Bulking agents are materials, such as carbon-coated
zirconium
beads
(Durasphere),
calcium
hydroxylapatite
(Coaptite)
or
polydimethylsiloxane (Macroplastique), that are injected into tissue surrounding
the urethra. This helps keep the urethra closed and reduce urine leakage. The
procedure — usually done in a doctor's office — requires minimal anesthesia and
takes about five minutes. The downside is that repeat injections are usually needed.
Botulinum toxin type A. Injections of onabotulinumtoxinA (Botox) into the
bladder muscle may benefit people who have an overactive bladder. Researchers
have found this to be a promising therapy, but the Food and Drug Administration
(FDA) has not yet approved this drug for incontinence. These injections may cause
urinary retention that's severe enough to require self-catheterization. In addition,
repeat injections are needed every six to nine months.
Nerve stimulators. Sacral nerve stimulators can help control your bladder function.
The device,which resembles a pacemaker, is implanted under the skin in your
buttock. A wire from the device is connected to a sacral nerve — an important
nerve in bladder control that runs from your lower spinal cord to your bladder.
Through the wire, the device emits painless electrical pulses that stimulate the
nerve and help control the bladder. Another device, the tibial nerve stimulator, is
approved for treating overactive bladder symptoms. Instead of directly stimulating
the sacral nerve, this device uses an electrode placed underneath the skin to deliver
electrical pulses to the tibial nerve in the ankle. These pulses then travel along the
tibial nerve to the sacral nerve, where they help control overactive bladder
symptoms.
Surgery
If other treatments aren't working, several surgical procedures have been
developed to fix problems that cause urinary incontinence.
Some of the commonly used procedures include:
Sling procedures. A sling procedure uses strips of your body's tissue, synthetic
material or mesh to create a pelvic sling or hammock around your bladder neck
and urethra. The sling helps keep the urethra closed, especially when you cough or
sneeze. There are many types of slings, including tension-free, adjustable and
conventional.
Bladder neck suspension. This procedure is designed to provide support to your
urethra and bladder neck — an area of thickened muscle where the bladder
connects to the urethra. It involves an abdominal incision, so it's done using
general or spinal anesthesia.
Artificial urinary sphincter. This small device is particularly helpful for men who
have weakened urinary sphincters from treatment of prostate cancer or an enlarged
prostate gland. Shaped like a doughnut, the device is implanted around the neck of
your bladder. The fluid-filled ring keeps your urinary sphincter shut tight until
you're ready to urinate. To urinate, you press a valve implanted under your skin
that causes the ring to deflate and allows urine from your bladder to flow.
Absorbent pads and catheters
If medical treatments can't completely eliminate your incontinence — or you need
help until a treatment starts to take effect — you can try products that help ease the
discomfort and inconvenience of leaking urine.
Pads and protective garments. Various absorbent pads are available to help you
manage urine loss. Most products are no more bulky than normal underwear, and
you can wear them easily under everyday clothing. Men who have problems with
dribbles of urine can use a drip collector — a small pocket of absorbent padding
that's worn over the penis and held in place by closefitting underwear. Men and
women can wear adult diapers, pads or panty liners, which can be purchased at
drugstores, supermarkets and medical supply stores.
Catheter. If you're incontinent because your bladder doesn't empty properly, your
doctor may recommend that you learn to insert a soft tube (catheter) into your
urethra several times a day to drain your bladder (self-intermittent catheterization).
This should give you more control of your leakage, especially if you have overflow
incontinence. You'll be instructed on how to clean these catheters for safe reuse.
IV. Control questions and tasks
1. What is suspensive apparatus of the uterus?
2. What is fixative apparatus of the uterus?
3. What is supportive apparatus of the uterus?
4. Classification positional anomalies of female genitalia in woman.
5. Main causes of irregular positions of internal genitalia in woman.
6. What clinical symptoms occur at positional anomalies of female
genitalia in woman?
7. Prevention of irregular positions of female genitalia.
8. Etiology, clinic, diagnosis, treatment of vulva and vagina injuries.
9. Etiology, clinic, diagnosis, treatment of uterine cervix and uterus injuries.
V. List of recommended literature
1. Danforth’s Obstetric and gynaecology.-Seventh edition.-1994.-P.887-905
2. Gynecology.- Stephan Khmil, Zina Kuchma, Lesya Romanchuk.-2003.P.81-101
3. Gynaecology illustrated. David McKay Hart, Jane Norman.-Fifth Edition.2000.-P.233-252