Infertility Treatments. About Infertility Treatments - Patient info

 

 

The uterus is the medical name for the womb. It includes the neck of the womb (cervix) from where the smear test is taken.
After the menopause (the change) periods stop and the womb is no longer needed for babies. As hormone levels fall at this time, the womb usually gets a bit smaller.
The womb normally sits in the pelvis which is the place between the hip bones at the bottom of the abdomen (tummy). The pelvic bones form a strong circle and have a sheet of muscles forming a hammock between them – these muscles are the pelvic floor muscles.
The pelvic floor muscles support the womb, the top of the vagina (front passage), the bladder and the rectum (back passage). If this muscle sheet is weak, the organs it supports can sag down with gravity. Having babies and getting older may weaken the pelvic floor muscles.
This sagging forms bulges into the vagina because the walls of the vagina are stretchy. This sagging is called Prolapse.
When the womb is sagging it is called Uterine Prolapse. Sometimes the womb sags so much that the neck of the womb pokes out of the vaginal opening.
Uterine prolapse can cause you to have a lump in the vagina that you can see or feel. The lump is often smaller first thing in the morning but gets bigger during the day when you are on your feet. The lump can be uncomfortable, it may get in the way of having sex or putting in tampons. If the lump pokes out, it can rub on your underwear and get sore and sometimes gets in the way of the bladder emptying properly.

Do nothing– if the prolapse (bulge) is not distressing then treatment is not necessarily needed. If, however, the prolapse permanently protrudes through the opening to the vagina and is exposed to the air, it may become dried out and eventually ulcerate. Even if it is not causing symptoms in this situation it is probably best to push it back with a ring pessary (see below) or have an operation to repair it.
Pelvic floor exercises (PFE) -The pelvic floor muscle runs from the coccyx at the back to the pubic bone at the front and off to the sides. This muscle supports your pelvic organs (uterus, vagina, bladder and rectum). Any muscle in the body needs exercise to keep it strong so that it functions properly. This is more important if that muscle has been damaged. PFE can strengthen the pelvic floor and therefore give more support to the pelvic organs. These exercises may not get rid of the prolapse but they make you more comfortable. An expert who is usually a Physiotherapist best teaches PFE. These exercises have no risk and even if surgery is required at a later date, they will help your overall chance of being more comfortable.

Types of Pessary

This usually gets rid of the dragging sensation and can improve urinary and bowel symptoms. It needs to be changed every 6-9 months and can be very popular; we can show you an example in clinic.
Other pessaries may be used if the Ring pessary is not suitable. Some couples feel that the pessary gets in the way during sexual intercourse, but many couples are not bothered by it.

  • Shelf Pessary or Gellhorn- If you are not sexually active this is a stronger pessary which can be inserted into the vagina and needs changing every 4-6 months.

There are several operations can be performed for Uterine Prolapse. Often your doctor will advise you regarding one of these operations after considering your symptoms, whether you want more children, any medical problems you may have and any treatments you may have tried before in the past. It is important that you have time in clinic to talk about this with your doctor.
The most common operation for Uterine Prolapse is a Vaginal Hysterectomy. It involves taking out the womb through the vagina so there are no cuts on your abdomen.
As the womb is removed, this operation is not suitable for women who want more children. If you have not gone through the Menopause (change) and might want more children you must discuss this with your doctor.
It may be better for you to do nothing or use a Pessary until you have had your family. The prolapse lump may get worse during pregnancy and not improve once the baby has been born. Having a prolapse does not usually stop you from having a normal delivery. Some types of Pessary can be used in pregnancy.
It is sometimes possible to do an operation for uterine prolapse but leave the womb behind. These operations use strong stitches or artificial mesh (like netting) to hold the womb up in its normal position. Your doctor can discuss these with you. They may want you to see another doctor at a different hospital where they have experience of these operations and can give you advice about them.

Anaesthetic risk – This is very small unless you have specific medical problems. This will be discussed with you.
Haemorrhage -There is a risk of bleeding with any operation. The risk from blood loss is reduced by knowing your blood group beforehand and then having blood available to give you if needed. It is rare that we have to transfuse patients after their operation. Please let your doctor know if you are taking an anti-clotting drug such as warfarin or aspirin.
Infection -There is a risk of infection at any of the wound sites. A significant infection is rare. The risk of infection is reduced by our policy of routinely giving antibiotics with major surgery.
Deep Vein Thrombosis (DVT) -This is a clot in the deep veins of the leg. The overall risk is at most 4-5% although the majority of these are without symptoms. Occasionally this clot can migrate to the lungs which can be very serious and in rare circumstances it can be fatal (less than 1% of those who get a clot). DVT can occur more often with major operations around the pelvis and the risk increases with obesity, gross varicose veins, infection, immobility and other medical problems. The risk is significantly reduced by using special stockings and injections to thin the blood (heparin).

The operation can be done with a general anaesthetic so you are asleep or using a spinal anaesthetic so you are awake but unable to feel any pain from the waist down.
Your legs are placed in stirrups (to elevate them) and the vagina and surrounding skin cleaned with antiseptic solution.
Often some local anaesthetic will be injected into the vagina even if you are asleep as it can help to make the operation easier and reduce bleeding.
A cut is made around the neck of the womb (cervix). Alongside the womb are strong ligaments (which help to hold the womb up) and the blood vessels to and from the womb. These are cut and tied off with dissolvable stitches.
The womb is taken out and sent to the laboratory so that they can look at it under a microscope and check it is a normal womb.
The hole at the top of the vagina is stitched closed with dissolvable stitches. Once it has healed, the vagina will have a smooth top.
Usually a catheter tube is passed along the urethra (water pipe) to drain the bladder. Once any swelling around the bladder has gone down, this will be removed.
Sometimes a long bandage called a ‘pack’ will be put in the vagina to press on the wound and soak up any spilled blood. This is removed the next day.
You usually stay in hospital for up to five days.
Other operations performed at the same time
Your doctor may suggest that a Vaginal Hysterectomy is all that is required to help your prolapse. However, sometimes extra operations are done at the same time as a Vaginal Hysterectomy and your doctor may advise you regarding these. You should check that you know exactly what will happen to you in the operating theatre and why any extra operations are or are not being suggested.
Removal of the ovaries – the ovaries are usually left behind during a Vaginal Hysterectomy. This is because they are quite high up in the pelvis and can be difficult to reach when taking the womb out vaginally. The ovaries are not involved in prolapse and don’t need to be taken out to treat a prolapse. If there is a special reason why you need your ovaries taking out, you should discuss this with your doctor. They may suggest leaving them behind or taking them out through your abdomen (tummy), perhaps with keyhole surgery.
Vaginal repairs – often the vaginal walls sag when the womb sags. Sometimes the front (anterior) or back (posterior) walls of the vagina sag so much that your doctor may suggest repairing them at the same time as your hysterectomy. This shouldn’t make your stay in hospital any longer and the recovery at home is much the same. However, some things are different including the risks of the operation. For example, painful intercourse (sex) is more likely if a repair is done, although it is still uncommon. You should, therefore discuss this with your doctor. They may have an extra information leaflet for you about vaginal wall repairs.
Sacrospinous fixation (SSF).If your doctor is worried that the top of the vagina will sag down as soon as the womb is out, they may suggest a SSF. This involves holding the top of the vagina up by stitching it to a strong ligament in the pelvis. It is done through a cut on the back wall of the vagina so it might be combined with a back wall repair. There is another information leaflet about the SSF operation which you should be given if you are thinking about having it done.

On return from the operating theatre you will have a fine tube (drip) in one of your arm veins with fluid running through to stop you getting dehydrated.
You may have a bandage in the vagina, called a ‘pack’ and a sanitary pad in place. This is to apply pressure to the wound to stop it oozing.
You may have a tube (catheter) draining the bladder overnight. The catheter may give you the sensation as though you need to pass urine but this is not the case.
Usually the drip, pack and catheter come out the morning after surgery or sometimes later the same day. This is not generally painful.
The day after the operation you will be encouraged to get out of bed and take short walks around the ward. This improves general wellbeing and reduces the risk of clots on the legs.
It is important that the amount of urine is measured the first couple of times you pass urine after the removal of the catheter. An ultrasound scan for your bladder may be done on the ward to make sure that you are emptying your bladder properly. If you are leaving a significant amount of urine in your bladder, you may have to have the catheter re- inserted into your bladder for a couple of days more.
You may be given injections to keep your blood thin and reduce the risk of blood clots normally once a day until you go home or longer in some cases.
The wound is not normally very painful but sometimes you may require tablets or injections for pain relief.
There will be slight vaginal bleeding like the end of a period after the operation. This may last for a few weeks.
The nurses will advise you about sick notes, certificates etc. You are usually in hospital for up to 4 days.

Mobilization is very important; using your leg muscles will reduce the risk of clots in the back of the legs (DVT), which can be very dangerous.
You are likely to feel tired and may need to rest in the daytime from time to time for a month or more, this will gradually improve.
It is important to avoid stretching the repair particularly in the first weeks after surgery. Therefore, avoid constipation and heavy lifting. The deep stitches dissolve during the first three months and the body will gradually lay down strong scar tissue over a few months.

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Do not use tampons for 6 weeks. There are stitches in the skin wound in the vagina. Any of the stitches under the skin will melt away by themselves. The surface knots of the stitches may appear on your underwear or pads after about two weeks, this is quite normal. There may be little bleeding again after about two weeks when the surface knots fall off, this is nothing to worry about.
At six weeks gradually build up your level of activity. After 3 months, you should be able to return completely to your usual level of activity.
You should be able to return to a light job after about six weeks, a busy job in 12 weeks. Avoid all unnecessary heavy lifting.
You can drive as soon as you can make an emergency stop without discomfort, generally after three weeks, but you must check this with your insurance company, as some of them insist that you should wait for six weeks.

You can start sexual relations whenever you feel comfortable enough after six weeks, so long as you have no blood loss. You will need to be gentle and may wish to use lubrication (KY jelly) as some of the internal knots could cause your partner discomfort. You may, otherwise, wish to defer sexual intercourse until all the stitches have dissolved, typically 3-4 months.
Follow up after the operation is usually six weeks to six months. This maybe at the hospital (doctor or nurse), with your GP or by telephone. Sometimes follow up is not required.

Hysterectomy is the operation to remove the womb (uterus). It may be advised for a number of reasons. This leaflet gives a brief overview of the operation. You should discuss any concerns with your doctor before you have a hysterectomy.

The female reproductive organs are made up of a womb (uterus), vagina, Fallopian tubes and ovaries. The womb is about the size of a pear. It is made of specialised muscle and lies in the pelvis between the bladder and the bowel. Hysterectomy is the removal of the womb by an operation.img7

Many women in the UK have a hysterectomy every year. Around one in five of all women have a hysterectomy. Reasons for needing a hysterectomy include the following:

• Heavy or very painful periods. In some women, day-to-day life is made difficult because of heavy periods. Sometimes the heavy bleeding can cause anaemia. There are various other treatment options for heavy periods, including tablets and an intrauterine system (Mirena® coil). If they don’t improve the problem, hysterectomy is an option for treatment.

• Fibroids. These are swellings of abnormal muscle that grow in the womb (uterus). Fibroids are common and often do not cause any symptoms. However, in some women they can cause heavy or painful periods. Some fibroids are quite large and can press on the bladder to cause urinary symptoms.

• Prolapse. This occurs when the uterus or parts of the vaginal wall drop down. This may happen after the menopause when the tissues which support the uterus tend to become thinner and weaker.

• Endometriosis. This is a condition where the cells which line the uterus are found outside the uterus in the pelvis. This can cause scarring around the uterus, and may cause the bladder or rectum to stick to the uterus or Fallopian tubes. Endometriosis may cause only mild symptoms, but some women develop painful periods, tummy (abdominal) pain or have pain during sex.

• Cancer. Hysterectomy may be advised if you develop cervical cancer, uterine cancer, ovarian cancer or cancer of the Fallopian tubes.
For most of the conditions mentioned above (apart from cancer), hysterectomy is usually considered as a last resort after other treatments have failed. The decision to have a hysterectomy should be shared between you, (your partner) and your doctor.

Before a hysterectomy, make sure that any questions or worries you have are dealt with. For example, the following three questions are common and only you or your doctor will be able to answer them:

• Are there any other alternative treatments that have not been tried?

• Are my symptoms and problems severe enough to need a hysterectomy?

• Do I still want to have children? (If you are considering hysterectomy before the menopause.)

There are different types of hysterectomy operations:

• Total hysterectomy is the operation in which your womb (uterus) and the neck of your womb (cervix) are removed. The ovaries are usually left. However, if they are removed, this is called a bilateral salpingo-oophorectomy (BSO).

• Subtotal hysterectomy involves removal of your uterus but not your cervix.

• Radical hysterectomy (also called Wertheim’s hysterectomy) involves your whole womb, cervix, Fallopian tubes and ovaries, part of the vagina and lymph glands being removed. This operation is done for cancer.
The womb may be removed either through a cut in the tummy (abdomen), usually leaving a scar in the bikini area, or through the vagina, which means you will not have a visible scar. Sometimes the hysterectomy is done by using keyhole surgery. You should discuss the way your operation is to be done with your gynaecologist.

Removing your womb (uterus) should not stop you having a good sex life after the operation. In fact, many women report an improvement in their sexual pleasure after having a hysterectomy. This may be because the reason for having a hysterectomy (pain, prolonged heavy bleeding, etc) is removed. However, some women feel that a hysterectomy impairs their sex life. In particular, some women feel that their orgasm is different after a hysterectomy. Some even have difficulty in reaching orgasm. Having a hysterectomy should not affect your sex drive (libido) unless your ovaries are also removed. Having HRT will improve this though.
You can usually begin to have sex again about six weeks after the operation. You obviously will no longer need to use any form of contraception after a hysterectomy.

You will be given painkillers for the first few days, both whilst in hospital and also to take home with you. You will be able to eat and drink within a few hours of having the operation. You are likely to have a catheter in for a couple of days or so. This is a thin tube going into your bladder, which drains urine. Some women also have a drain coming out of their wound for a day or so.
It is very common to have some light bleeding from the vagina, which can last for up to six weeks. If you have any stitches then they are usually removed between five and seven days after your operation.

This varies from person to person. Recovery is usually faster if you have had the hysterectomy through the vagina. You are likely to need to rest more than usual for a few weeks after the operation. You are likely to be recommended to do light exercise and gradually build up the amount of exercise you do. It is likely that you will be shown how to do pelvic floor exercises which are important to continue at home. Full recovery commonly takes around six to eight weeks. However, it is not unusual for women to take three months until they feel fully back to normal.
There is a small increased risk of clots in the veins of your legs following surgery (deep vein thrombosis). This risk is reduced by wearing special compression stockings (anti-embolic stockings) which will be given to you in the hospital. Some women will also need to have heparin injections in their stomach which work to make the blood less sticky and reduce the risk of a clot developing. Your doctor will explain this in more detail to you.
You should not drive until your doctor tells you that you are safe to do so after your hysterectomy. This is usually between three to eight weeks after the operation. You should not drive until you are safe to do an emergency stop. The time before you can return to work will depend on your job. You can discuss this with your doctor or gynaecologist.

Most women no longer need to have cervical screening tests after a hysterectomy. However, if you have had an operation that leaves the neck of the womb (cervix) in place, or because of cancer, you may be advised to continue having cervical screening tests. Your doctor will advise you about this.

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Heavy periods are common. In most cases no cause can be found. In some cases a cause is found such as endometriosis, fibroids and other conditions (listed below). There are a number of ways of improving heavy periods and making them more manageable. Options include medication to reduce bleeding, a type of coil placed in the womb (uterus), or an operation.

About 1 in 3 women describe their periods as heavy. However, it is often difficult to know if your periods are normal or heavy compared with other women. Some women who feel they have heavy periods actually have an average blood loss. Some women who feel they have normal periods actually have a heavy blood loss. Most of the blood loss usually occurs in the first three days with either normal or heavy periods.img5

Some medical definitions of blood loss during a period are:

• A normal period is a blood loss between 30 and 40 ml (six to eight teaspoonfuls) per month. Bleeding can last up to eight days but bleeding for five days is average.

• A heavy period is a blood loss of 80 ml or more. This is about half a teacupful or more. However, it is difficult to measure the amount of blood that you lose during a period. For practical purposes, a period is probably heavy if it causes one or more of the following:

• Flooding through to clothes or bedding.

• You need frequent changes of sanitary towels or tampons.

• You need double sanitary protection (tampons and towels).

• You pass large blood clots.

• Menorrhagia means heavy periods that recur each month. Also, that the blood loss interferes with your quality of life. For example, if it stops you doing normal activities such as going out, working or shopping. Menorrhagia can occur alone or in combination with other symptoms

This is called dysfunctional uterine bleeding and is the cause of heavy periods in 4 to 6 out of 10 cases. In this condition, the womb (uterus) and ovaries are normal. It is not a hormonal problem. Ovulation is often normal and the periods are usually regular. It is more common if you have recently started your periods or if you are approaching the menopause. At these times you may find your periods are irregular as well as heavy.
Other causes

These are less common. They include the following:

• Fibroids. These are non-cancerous (benign) growths in the muscle of the womb. They often cause no problems, but sometimes cause symptoms such as heavy periods. See separate leaflet called Fibroids for more details.

• Other conditions of the uterus, which may lead to heavy periods. For example:

• Endometriosis. See separate leaflet called Endometriosis for more details.

• Infections.

• Small fleshy lumps (called polyps).

• Cancer of the lining of the uterus (endometrial cancer) – a very rare cause. Most cases of endometrial cancer develop in women aged in their 50s or 60s.

• Hormonal problems. Periods can be irregular and sometimes heavy if you do not ovulate every month. For example, this occurs in some women with polycystic ovary syndrome. Women with an underactive thyroid gland may have heavy periods.

• The intrauterine contraceptive device (IUCD, or coil) sometimes causes heavy periods. However, a special hormone-releasing IUCD called the intrauterine system (IUS) can actually treat heavy periods (see ‘Levonorgestrel intrauterine system (LNG-IUS)’ below).

• Pelvic infections. There are different infections that can sometimes lead to heavy bleeding developing. For example, chlamydia can occasionally cause heavy bleeding. These infections can be treated with antibiotics.

• Warfarin or similar medicines interfere with blood clotting. If you take one of these medicines for other conditions, heavier periods may be a side-effect.

• Some medicines used for chemotherapy can also cause heavy periods.

• Blood clotting disorders are rare causes of heavy bleeding. Other symptoms are also likely to develop, such as easy bruising or bleeding from other parts of the body.

If you stop taking the contraceptive pill it may appear to cause heavy periods. Some women become used to the light monthly bleeds that occur whilst on the pill. Normal periods return if you stop the pill. These may appear heavier but are usually normal.

• A doctor may want to do an internal (vaginal) examination to examine your neck of the womb (cervix) and also to assess the size and shape of your womb (uterus). However, an examination is not always necessary, especially in younger women who do not have any symptoms to suggest anything other than dysfunctional uterine bleeding.

• A blood test to check for anaemia is usually performed. If you bleed heavily each month then you may not take in enough iron in your diet, needed to replace the blood that you lose. (Iron is needed to make blood cells.) This can lead to anaemia which can cause tiredness and other symptoms. Up to 2 in 3 women with recurring heavy periods develop anaemia.
If the vaginal examination is normal (as it is in most cases) and you are under the age of 40, no further tests are usually needed. The diagnosis is usually dysfunctional uterine bleeding and treatment may be started if required. Further tests may be advised for some women, especially if there is concern that there may be a cause for the heavy periods other than dysfunctional uterine bleeding. For example:

• Women over the age of 45 who develop heavy periods.

• If treatment for presumed dysfunctional uterine bleeding does not seem to help.

• Any woman in whom a doctor detects a large or abnormal uterus, or who has other symptoms which may indicate an underlying problem. For example, if you:

• Bleed between periods, or have irregular bleeding.

• Have bleeding or pain during, or just after, sex.

• Have pain apart from normal period pains.

• Have any change in your usual pattern of bleeding, particularly if you are over the age of 45.

• Have symptoms suggesting a hormonal problem or blood disorder.

If tests are advised then they may include one or more of the following:

• An ultrasound scan of your uterus. This is a painless test which uses sound waves to create images of structures inside your body. The probe of the scanner may be placed on your tummy (abdomen) to scan the uterus. A small probe is also often placed inside the vagina to scan the uterus from this angle. An ultrasound scan can usually detect any fibroids, polyps, or other changes in the structure of your uterus.

• Internal swabs. This may be done if an infection is the suspected cause of the heavy bleeding. A swab is a small ball of cotton wool on the end of a thin stick. It can be gently rubbed in various places to obtain a sample of mucus, discharge, or some cells. A swab is usually taken from the top of your vagina and also from your cervix. The samples are then sent away to the laboratory for testing.

• Endometrial sampling. This is a procedure in which a thin tube is passed into the uterus. Gentle suction is used to obtain small samples (biopsies) of the uterine lining (endometrium). This is usually done without an anaesthetic. This is more likely to be done if you are aged over 45 years, have persistent bleeding or have tried treatment without it helping. The samples are looked at under the microscope for abnormalities.

• A hysteroscopy. This is a procedure in which a doctor can look inside the uterus. A thin telescope is passed into your uterus through your cervix via the vagina. This too can often be done without an anaesthetic. Small samples can also be taken during this test.
Blood tests. These may be take if, for example, an underactive thyroid gland or a bleeding disorder is suspected.

It may be worth keeping a diary for a few periods (before and after any treatment). Your doctor may give you a chart which you can fill in. Basically, you record the number of sanitary towels or tampons that you need each day and the number of days of bleeding. Also, note if you have any flooding or interruption of normal activities. For an example of a chart given below. A diary is useful for both patient and doctor to see:

• How bad symptoms are and whether treatment is needed.

If treatment is started, whether it is helping. Some treatments take a few menstrual cycles to work fully. If you keep a diary it helps you to remember exactly how things are going.

An abnormally slow flow of urine during voiding or a sensation of incomplete emptying of the bladder.
Voiding disorders are common in women. As many as 14% of women who present at the Urogynaecology Centre with bladder symptoms were found to have voiding disorders.

Symptoms of voiding disorders include:

• Delay in initiating urination.

• Slow urinary flow.

• Sensation of incomplete emptying of bladder.

• The need to immediately re-void.

• The need to strain to void.

• Dribbling of urine after completing bladder emptying.

Additional symptoms that co-exist are urinary frequency, urgency, passing urine more than once at night, urinary incontinence, and urinary tract infection. Some patients may have associated prolapse of the womb, bladder or rectum.

There are many causes of voiding disorders in women. Some may be temporary while others may be permanent. The causes include:

• Urinary tract infection.

• Medications such as oxybutynin, detrusitol and antidepressants.

• Nerve damage such as spinal cord injury and diabetic neuropathy.

• Psychological influences such as anxiety, hysteria and depression.

• Pelvic surgery and vaginal delivery.

• Obstruction due to prolapse of the womb, impaction of stools and urethral narrowing.

• Overdistension of the bladder.

• Inability to relax the urethral sphincter during voiding.

If left unrecognized, it may predispose one to frequent urinary tract infections. In more severe case, the kidneys may be damaged due to continuous back pressure that is created by a full bladder.

Various investigations may be ordered apart from comprehensive urogynaecological and neurological examination. Uroflowmetry: It measures the rate of urine flow during voiding.

• Residual Urine Volume: It is the amount of urine remaining in the bladder after voiding. It is measured either by scan or by putting a tube into the bladder to drain out the urine.

• Cystometry: The bladder pressure is measured during voiding. It can diagnose the bladder muscle that is not contracting normally during voiding.

• Electromyography: It defects the contractions of the sphincter muscles during voiding.

• Radiology: It includes X-rays and ultrasound scan to look for tumour, diverticulum and foreign body of the bladder, or enlarged kidneys caused by voiding disorders.

• Cystoscopy: To look into the bladder and the urethra for foreign body, diverticulum or tumour.

• Prevention and early recognition: Prevention of voiding disorders is important. After pelvic or continence surgery, the use of temporary catheterisation can prevent immediate post-operative bladder overdistension. Early recognition of postnatal urinary retention and early catheterisation is crucial to early return of normal urinary function subsequently.

• Medication: Drugs may be used to treat the underlying cause of the voiding disorders. A course of antibiotics or antiseptic may be used if there is an infection. In patients with anxiety disorders, a small dose of anti-anxiety medication or sleeping tablets may help. Vaginal oestrogenpessaries may be used if atrophic changes are implicated in the voiding difficulties. Some drugs may be used to improve bladder muscle contraction.

• Clean Intermittent Self Catherisation (CISC): In CISC, the patient is taught to insert a urinary catheter under clean conditions at regular intervals. This procedure is easy to learn. The use of CISC enables many women to live normal lives with efficient bladder emptying, free from discomfort and distress. For patients not willing or unsuitable to use CISC, indwelling catheters may be used.

• Surgical treatment: In cases where the urethral opening is narrowed, it may be dilated using metal rods called Hegar dilators. However, the main disadvantage is that voiding difficulty may recur following healing and scarring of the dilated area. Often, repeated dilatations are needed. If the woman is having bladder or uterine prolapse, it should be dealt with surgically.

Voiding disorders are common in women. If left unrecognised, it may lead to permanent damage to the bladder and kidneys. Hence treatment should be started early and the causes dealt with promptly.

A prolapse occurs when there is protrusion of an organ or structure beyond its normal position. In utero-vaginal prolapse, there is descent of the uterus and/or vagina. This is a common gynaecological condition. The uterus is held in the pelvis by supporting muscles and ligaments. When these supporting structures weaken, this leads to uterine prolapse.
Prolapse of the uterus can occur on its own. It can also be associated with a protrusion of anterior (front), or posterior (back) wall of the vagina, or both. In women who have had their uterus removed, prolapse of the vagina can occur after surgery. The degree of prolapse can vary from a very mild descent of the pelvic organs, to a severe descent in which the uterus, part of the bladder and part of the rectum (back passage) protrudes through the vaginal opening.
Many women do not seek treatment because of embarrassment, or they are unaware that the condition can cause problems and that treatment is available. It is important to seek medical advice early as it can be treated.

Common factors leading to this are:

• Pregnancy & Childbirth: When there can be excessive stretching of the tissues.

• After menopause: When a relative lack of female hormones can lead to thinning and weakening of the tissues.

• Obesity.

• Lifting and moving heavy equipment.

• Chronic constipation.

• Chronic Lung disease.

• Age.

Women with a very mild degree of prolapse may not have any symptoms. However most women with significant prolapse may experience some of the followings:

• Dragging sensation or discomfort in the lower abdomen or pelvis.

• Sensation of swelling or fullness in the vagina.

• Backache.

• Vaginal discharge or bleeding.

• Difficulty in passing motion or urine.

• Urinary symptoms, which include passing urine more frequently, a sensation of incomplete emptying of the bladder or leakage of urine during coughing, sneezing and straining.

Many of the above symptoms are relieved when lying down. The symptoms are worse in the evening and better in the morning.

Certain measures can be undertaken to reduce the chances of developing utero-vaginal prolapse, or to prevent a prolapse from getting worse.

• Pelvic floor excercises.

• Avoid bearing down (pushing) before the cervix is fully dilated during labour.

• Avoid Constipation, prolonged standing, heavy lifting, straining during opening of bowels and chronic cough.

These occur only with longstanding untreated cases of moderate or severe utero-vaginal prolapse.

• Ulceration and infection of the cervical and vaginal skin.

• Bleeding from the genital tract.

• Thickening of the skin of the cervix.

• Obstruction to urine flow and retention of urine leading to back pressure effects on the kidneys.

• Urinary tract infection.

• Worsening prolapse.

Once utero-vaginal prolapse has occurred, spontaneous recovery is not possible.

There are different types of vaginal pessaries available, which can be inserted into the vagina to support the prolapse and temporarily relieve the symptoms.
This type of treatment is not a cure and is used in cases when surgery is not suitable. Every 3-6 months, a regular examination with change of pessary is required. Any aggravating factors such as chronic cough or constipation will need to be addressed.

Surgery is curative for utero-vaginal prolapse. The principles of surgery are to correct the supportive defects and restore the normal anatomy and sexual function. This may include removal of the uterus (hysterectomy) or conserving the uterus, hitching up the bladder or vagina and or uterus or bowel with repair and ‘tightening’ of the vagina. Depending on the condition, surgery may be performed either through the vagina or through the abdomen. Your doctor will be able to discuss with you and advise you on the appropriate surgery.

Urinary tract infection occurs when bacteria is present within the urinary tract in significant numbers. 20% of women aged 20 – 65 years suffer at least one attack per year. Approximately 50% of women will experience UTI at lease once during their life span.

• Passing urine more frequently than normal.

• “Burning” pain on passing urine.

• The urge of having to pass urine quickly.

• Passing blood-stained or cloudy urine or foul-smelling urine.

• Lower abdominal or loin pain.

• Fever.

If you have any of the above symptoms, it is advisable to see a doctor early.

Organisms originating from the intestines usually cause UTI. In 80 – 90% of first infections, the bacteria Escherichia coli is involved.

The occurrence of UTI varies with age and sex. The incidence of UTI is 10 times higher in adolescent girls as compared with boys and this continues throughout adult life. The following are predisposing factors:

• Diabetes mellitus.

• Foreign bodies (e.g. catheters, urinary tract stones).

• Recent instrumentation of the urinary tract (e.g. catheterisation, cystoscopy, after urodynamic studies).

• Neurological disorders or drugs that may cause incomplete emptying of the bladder.

• Co-existing diseases involving the pelvis (e.g. tumours, inflammatory bowel disease).

• Sexual activity.

If UTI is left untreated, the infection can spread upwards to the kidneys, causing infection in the kidneys and even renal failure. It can also spread via the blood stream (septicaemia) to affect the body in general, which may be fatal.

To confirm the diagnosis of UTI, a sample of your urine will be sent to the laboratory for testing. Antibiotics will usually be prescribed. You may be prescribed alternative antibiotics after the urine culture result is available. You may also be given medication to make the urine more alkaline and asked to drink more water.

It is defined as having UTI three times or more within a year. It can be due to the same species or different bacteria.

If you have recurrent UTI, further tests such renal ultrasound, intravenous pyelogram, cystoscopy, urine for tuberculosis and cytology are necessary to identify the causes and complications of recurrent UTIs.

You may also be given prophylactic antibiotics for a period of 6 months. You will be advised on good personal hygiene and other preventive measures.

Although UTI can be easily treated with antibiotics, the prevention of UTIs or the avoidance of further infection is more important.
As the source of bacteria comes from one’s own bowel, it is important to wipe yourself from front to back in order to avoid faecal contamination of the urinary tract (especially during an episode of diarrhoea) after going to the toilet.
Potential irritating vaginal deodorants and bubble baths should be avoided and a high standard of personal hygiene should be maintained at all times.
This involves washing the genital area with water during bath and especially after intercourse (as intercourse is a common predisposing factor for UTI). Voiding soon after intercourse is also encouraged.
Any vaginal / lower genital tract infection should be treated; otherwise the infection may spread to the urinary tract.
In order to prevent recurrent UTI, a minimum fluid intake of 2 litres a day is recommended (more if exercising strenuously or on hot days). Oral fluids should be increased to 3 litres or more a day if symptoms of UTI are suspected, irrespective of the degree of frequency of urine. Regular and complete bladder emptying is advisable to prevent the accumulati9on of infected urine in the bladder.

As UTI is a common occurrence in women, one should be aware of the symptoms of UTI. Early recognition and appropriate treatment is necessary to prevent complications.

Urinary incontinence is the uncontrollable leakage of urine. It is more common in the elderly, especially among women. Many women do not seek treatment because of embarrassment, or they are unaware that the condition can cause problems and that treatment is available. It is important to seek medical advice early as it can be treated

In a healthy person, the bladder stores urine and pass urine at the person’s convenience. During the storage phase, the bladder relaxes and the bladder outlet contracts. No urine leaks out. However, when the bladder and / or the bladder outlet are not functioning normally, urine may leak.

There are four types of urinary incontinence:

• Stress incontinence (SUI) – Leakage of urine when you cough, sneeze, laugh or lift something heavy.

• Overactive bladder(OAB) –passing urine many times during day and night, associated with need to rush to the toilet and unable to control leak of urine before reaching the toilet.

• Overflow incontinence – constantly dribbling of urine with sense of incomplete emptying of bladder.

• Fistula – A false connection between the bladder or ureter to the vagina.

Below are some common factors that cause urinary incontinence:

• Weak pelvic floor muscles supporting the bladder outlet.

Multiple childbirths
Menopause
Obesity

• UTI.

• Constipation.

• Sideeffects of medications.

• Nerve disorders.

Stroke
Multiple sclerosis
Dementia
Parkinsons

An initial evaluation should include an assessment of patient’s symptoms, detailed physical examination and urinalysis.
Once urinary tract infection has been excluded, it is possible to establish a working diagnosis based on the patient’s description of symptoms.

These include:

• Urine analysis – to rule out UTI.

• Urine cytology — To detect bladder tumour.

• Frequency Volume Chart — A chart of the timing and volume of output to indicate the severity of the problem. Follow-up charts are also useful to provide evidence of a response to treatment.

In cases where there is uncertainty regarding the diagnosis, more advanced investigations should be carried out.

• Urodynamics – is the mainstay of investigation and the only objective assessment method of assessing the bladder.

• Cystoscopy — To look for bladder stone, tumour or inflammation.

Urinary incontinence is not a natural process of ageing. Management will depend on the types of urinary incontinence. It can be readily treated, improved or cured with lifestyle modification, behavioural methods, medication or surgery.

Lifestyle modification:

• Drink 6-8 glasses of water daily unless your doctor has instructed otherwise.

• Limit your intake of alcohol and caffeinated drinks.

• Take a balanced diet that includes all food groups and keep within a healthy weight range.

• Include enough fluid and fibre in your diet and exercise regularly to prevent constipation that can lead to poor bladder control.

• Practise good bladder habits by regularly emptying your bladder. Holding back for too long when a bladder is full, or persistently emptying it when it is not, can both cause abnormal bladder function.

• Do pelvic floor exercises regularly to strengthen the muscles supporting the outlet of the bladder.

• Avoid precipitating factors such as obesity, chronic cough, sneezing and heavy lifting etc.
Bladder retraining:A12-week program of scheduled voiding with progressive increase in the interval between each void. This technique has shown significant improvement in the symptoms.
Medications: used to treat urinary infection, vaginal inflammation or to reduce overactivity of bladder muscles. In menopausal women, local oestrogens help to reduce urinary frequency and urgency.
Surgery:Commonly used for female stress urinary incontinence. It is offered after failed conservative treatment or have severe stress urinary incontinence. In addition, surgery is also recommended for conditions that cause voiding difficulties such as pelvic organ prolapse.
Your doctor will recommend the appropriate type of surgery.

There is a specific bladder condition causing extreme urgency, requiring the person to urinate many times in the day (frequency) and night (nocturia) in the absence of infection or other bladder pathology. They may feel pain in the lower abdomen, region above the pubis, the perineum, lower back, vulva and vagina.This condition is more common amongst women than men (female to male ratio = 9:1). The average age ranges from 42 to 53 years old. The incidence is 16 to 450/100,000 people.

Currently, experts agree that the protective layer of the bladder (GAG layer) in most PBS patients is not well developed thereby allowing toxins or irritative substances to affect the nerve receptors in the bladder, thus causing unpleasant symptoms.

As we do not fully understand the cause(s) for PBS/IC, treatment is difficult and often not optimal. Conservative treatment include instillation of various chemicals and drugs directly into the bladder to replace or replenish the GAG layer; such as chondroitin sulphate, hyaluronic acid, heparin, dimethyl sulfoxide (DMSO), or a combination of the above. Success rates range from 30% to 92%.

Oral medication such as pain killers, antihistamines, antidepressants, pentosanpolysulphate, or a combination of treatments have been used, but their success rates have been equivocal.

Some patients have worsening urinary frequency and urgency after ingestion of certain food types (usually acidic food such as oranges, tomatoes, etc.). Dietary avoidance of these foodstuffs may decrease their symptoms.

Surgery for PBS/IC is associated with a low success but high complication rate. Hence, it is not commonly practised or advocated.

Only two drugs, DMSO and pentosanpolysulphate have been approved by the US Food and Drug Association (FDA) for use in PBS/IC.

Intravesical DMSO has been used in KK Urogynaecology Centre since May 2006 with good results, with patients experiencing a reduction in their PBS symptom.

The actual cause(s) of PBS/IC is unknown. A variety of empirical treatments have been used, but no single treatment works for all patients. The best approach is sequential treatment, starting with the least toxic choices, until satisfactory relief is achieved. PBS/IC is a difficult confition to endure, and patients are helped greatly when friends, relatives, medical and nursing practitioners are supportive, kind and understanding towards their condition.

Haematuria is the presence of red blood cells in the urine. It can be visible to the naked eye (macroscopic) or only picked up during laboratory testing (microscopic).
Disease at any part of the urinary system (kidneys, ureters, bladder and urethra) can cause haematuria.

There are many medical conditions in the kidney, ureters, bladder or urethra that can result in haematuria:

1 Kidney stones, infection, glomerulonephritis (swelling of the filtering tubes within the kidney) and kidney cancers can cause haematuria

2 Stone passage along the ureters can cause intense pain in the mid and lower back that travels down into the groin, causing haematuria

3 Haematuria may also result from bladder cystitis (infection), painful bladder syndrome (PBS), bladder stones and bladder cancer

There are also other causes of haematuria not listed in the above causes, such as contamination from vaginal bleeding, medical disorders such as systemic lupus erythematosus (SLE), sickle cell anaemia, vigorous exercise, physical trauma to your body, certain foods e.g. beetroot, and medications e.g. aspirin

When you see blood in the urine, it is necessary to seek medical help. Your doctor will go through your medical history, in order to find the cause of haematuria.
The presence of urinary urgency, frequency, pain on urination (dysuria), abdominal pain or fever are useful in reaching a diagnosis. Risk factors for cancers, like smoking and certain chemical exposure can also be identified. After a physical examination, certain investigations and tests will be ordered.

• Urinanalysis (UFEME): A raised white blood cell count in the urine may indicate the presence of a urinary tract infection (UTI), which is a cause of haematuria.

• Urine culture: The urine is cultured for the types of bacteria and their antibiotic senstivities. This will allow your doctor to prescribe an appropriate antibiotic.

• Urine cytology: Cells in the urine are examined to identify the presence of cancerous (malignant) cells, which may come from anywhere along the urinary tract, which warrants immediate attention and further evaluation.

• Ultrasound of the kidneys, ureters and bladder: This ultrasound is used to visualise any abnormal growths/stones within the kidneys, ureters and bladder, assess the size of the kidneys, and abnormal swelling of the kidneys and ureters.

• Cystoscopy: This can be done under local and general anaesthesia where a camera is inserted through the urethra to look at the bladder, and biopsy samples can be taken to look for infection, inflammation, and cancerous growths.

• CT urogram: Computed tomography (CT) examines the structure of the urinary tract. Kidney stones, masses, abnormalities of the ureters and bladder can be detected.

• Urine phase contrast: This is used to visualise the red blood cells in the urine to determine the source of haematuria. Abnormal-shaped red blood cells (dysmorphic) usually implies a kidney source, whereas normal-shaped red blood cells (isomorphic) usually implies haematuria from the lower tract, e.g. bladder.

There is no specific treatment for haematuria since it is not a disease in itself. Treatment is directed at the cause of haematuria and can be discussed with your specialist doctor.

Haematuria is an alarming situation for most patients when it occurs. Do not to panic if you have haematuria. Please seek your doctor’s advice, as there are many causes for Haematuria as described above, and the treatments can vary to a great degree for the different causes of haematuria. It is therefore important to seek treatment early.

At the mention of cosmetic surgery, we instinctively think of the famed boob job and tummy tuck, perhaps because they are a ‘fix’ to women’s most ‘problematic’ areas. However, things have progressed. Today’s cosmopolitan woman is having another intimate body part fixed as well, her vagina.

Vaginoplasty (designer vagina)is both a reconstructive and cosmetic procedure for the vaginal canal and its surroundings, resulting in greater strength, contraction and control.
“Vaginoplasty is basically tightening vaginal tissues, especially after the effects of childbirth or similar trauma.

Various women feel the need to get work done on their vaginas for different reasons. Basically, vaginoplasty aims to strengthen the function of the vagina, firm up and reshape tissue for a more youthful appearance – a literal lady parts ‘face lift’.
It is also performed with the primary function of improving ones sexual gratification i.e. to allow both the man and woman receive and give more pleasure during sexual intercourse by tightening the vagina.

which is altering the fold of skin (especially the vaginal lips) surrounding the vulva. This is performed on those with congenital conditions (deformity) while aesthetic labiaplasty can be performed on those who, for personal reasons, wish to alter the appearance to look more, in their opinion, aesthetically pleasing i.e. make them smaller, with less folding, especially if they experience discomfort while wearing tight clothing.img3

“Vaginoplasty is performed under general anaesthesia. It mainly involves putting stitches around the muscles and bringing them together because they are loose and flaccid”. The stretched muscles are joined together and shortened with dissolvable stitches. Any unwanted skin is also removed. This will tighten the vaginal muscles and the surrounding soft tissues by reducing the excess vaginal lining.”

The first step to getting a vaginoplasty, however, is to gather as much information as possible. During your initial consultation with your Urogynaecologist, he will explain the procedure, the risks involved, the benefits that you can derive from the procedure, the costs, any complications that may arise due to your medical history, your suitability for the procedure, and whether you are psychologically and emotionally stable enough to go through such a procedure.
Before undergoing vaginoplasty, or any other sort of cosmetic procedure, one should have realistic expectations and understand the possibilities and limitations of the procedure. Candidates should also be fit for surgery, be in overall good health, with no previous medical conditions that may complicate the procedure, and in essence, be physically fit.
Potential complications include infections, altered sensation (could become overly sensitive or not sensitive at all), dyspareunia (pain while having sex) and scarring. Healing well and to be cleared for the resumption of normal coitus, varies from woman to woman. It could take anywhere from four to six weeks, within which the swelling and soreness should come down and the stitches will have dissolved.

Hymen restoration surgery or Hymenoplasty or Hymen repair surgery popularly known as Revirgination is the operation to get virginity back is a simple plastic surgery procedure used for reconstructing the hymen of women who need to have their virginity restored for cultural, social and ethical reasons.
Causes Preserving virginity till marriage is considered a necessity in certain countries and cultures. In conservative backgrounds and countries, virginity is a pre-requisite for marriage. Some consider virginity a gift to be given to their partner after marriage.
Hymen rupture can occur due to various strenuous physical activities such as cycling, swimming, horse riding and gymnasium. Hence women may need to undergo hymenoplasty for cultural, religious and ethical reasons. Other reasons where a woman may choose hymenoplasty are when faced with physical abuse and rape where the freedom of choice of whom she chooses to give her virginity to, has been taken away from her. Hymenoplasty might empower her emotionally.
Some other reasons where women choose hymenoplasty are when they feel their sex life is dull and want to spruce it up, since along with reconstructing the hymen it also tightens the vaginal walls.

Procedure
The surgeon stitches the edges of the remaining hymen which grows back again to the same natural hymen like earlier. The surgery also gives a feeling of the tightness of the area. If the hymeneal remnants are not big enough to be used for the reconstruction, the surgeon will reduce the opening of the vagina using a small portion of the vaginal mucous tissue. During the first intercourse, there will be a small rupture of this newly reconstructed hymen that will be very similar to the rupture of a natural hymen.
The torn edges are brought together and sutured with dissolvable sutures. It is performed under general anaesthesia or local anaesthesia and sedation. The procedure lasts from 45 minutes to an hour.

The newly constructed hymen would be same as original hymen and would break during the next intercourse as if you were a virgin.

You would able to return to work the next day. You may notice some minor blood loss during first 48-72 hours which is normal. You need to avoid strenuous activities like horse riding and sports for at least six weeks and then can resume your usual activities

The symptoms of PCOS can include:

• irregular periods or no periods at all.

• difficulty becoming pregnant (reduced fertility).

• more facial and/or body hair than usual for you (hirsutism).

• loss of hair on your head.

• rapid increase in weight, difficulty losing weight and being overweight.

• oily skin, acne .

• depression and mood swings.

The symptoms may vary from woman to woman. Some women have mild symptoms, while others are affected more severely by a wider range of symptoms.

The cause is not yet known. PCOS runs in families. If any of your relatives (mother, aunts, sisters) are affected with PCOS, your own risk of developing PCOS may be increased.
The symptoms of PCOS are related to abnormal hormone levels. Hormones are chemical messengers, which control body functions. Women with PCOS have slightly higher than normal levels of testosterone and are associated with many of the symptoms of the condition. The ovaries produce this hormone.
Insulin is a hormone, which regulates the level of glucose (a type of sugar) in the blood. In PCOS, the body may not respond to the hormone insulin (known as insulin resistance) leading to higher level of glucose in the blood. To reduce the glucose levels, your body produces more insulin. Therefore high insulin levels lead to weight gain, irregular periods, infertility and higher levels of testosterone.

Women with PCOS often have different signs and symptoms. Hence makes this condition difficultto diagnose. Therefore, it may take a while to get a diagnosis.

A diagnosis is usually made when you have any two of the following:

? irregular, infrequent periods or no periods.

? more facial or body hair than is usual for you and/or blood tests which show higher testosterone levels than normal.

img1

an ultrasound scan which shows polycystic ovaries

img2

You are at greater risk of developing the following long-term health problems if you have PCOS:
Insulin resistance and diabetes
If your blood glucose does not stay normal, this can lead to diabetes. One or two in every ten (10–20%) women with PCOS go on to develop diabetes at some time.
If you have PCOS, your risk of developing diabetes is increased further if you: are over 40 years of age
have relatives with diabetes developed diabetes during a pregnancy (known as gestational diabetes) are obese (body mass index or BMI over 30).
If you are diagnosed with diabetes, you will be given dietary advice and may be prescribed tablets or insulin injections.
High blood pressure
Women with PCOS tend to have high blood pressure, which is likely to be related to insulin resistance and being overweight, rather than the PCOS itself. High blood pressure can lead to heart problems and should be treated.
Heart disease in later life
Developing heart disease is linked to health conditions such as diabetes and high blood pressure. If you do not have these conditions, there is no clear evidence that, just because you have PCOS, you are more likely to die from heart disease than women who do not have PCOS.
If you have a high cholesterol level you may be advised to take medication (statins) to reduce the risk of heart problems. If you are trying for a baby, you should seek specialist advice about the use of statins.

Cancer
With fewer periods (less than three a year), the endometrium (lining of the womb) can thicken and this may lead to endometrial cancer in a small number of women.
There are different ways to protect the lining of the womb using the hormone progestogen. Your doctor will discuss the options with you. This may include a five-day course of progestogen tablets used every three or four months, taking a contraceptive pill or using the intrauterine contraceptive system (Mirena®). The options will depend on whether you are trying for a baby.
PCOS does not increase your chance of breast, cervical or ovarian cancer.
Depression and mood swings
The symptoms of PCOS may affect how you see yourself and how you think others see you. It can lower your self-esteem.
Snoring and daytime drowsiness
PCOS can lead to fatigue or sleepiness during the day. It is also associated with snoring.

The main ways to reduce your overall risk of long-term health problems are to:

• eat a healthy balanced diet. This should include fruit and vegetables and whole foods (such as wholemeal bread, whole grain cereals, brown rice, wholewheat pasta), lean meat, fish and chicken. You should decrease sugar, salt, caffeine and alcohol (14 units is the recommended maximum units a week for women).

• eat meals regularly especially including breakfast.

• take exercise regularly (30 minutes at least three times a week).
Your doctor or a dietician will provide you with full information on eating a healthy diet and exercise.
You should aim to keep your weight to a level, which is normal (a BMI between 19 and 25). BMI is the measurement of weight in relation to height. If you are overweight, it would be helpful to lose weight and maintain your weight at this new level. If you are obese (BMI greater than 30), discuss strategies for losing weight.

The benefits of losing weight include:

• more regular periods.

• an increased chance of becoming pregnant.

• improved mood and self-esteem .

• a lower risk of insulin resistance and developing diabetes .

• a lower risk of heart problems .

• a lower risk of cancer of the womb .

• reduction in acne and a decrease in excess hair growth over time
Have regular health checks .

Once you have a diagnosis of PCOS, you will be monitored to check for any early signs of health problems.
Women with PCOS over the age of 40 should be offered a blood sugar test once a year to check for signs of diabetes. If you are obese (BMI over 30) or have a family history of diabetes, you may be offered testing for diabetes earlier than age 40.
If you have not had a period for a long time (over 4 months), it is advisable to see your doctor. You may be offered further tests which may include an ultrasound scan.
Discuss with your doctor how often you should have your blood pressure checked and whether you should have blood tests for cholesterol levels.

There is no cure for PCOS. Medical treatments aim to manage and reduce the symptoms or consequences of having PCOS. Medication alone has not been shown to be any better than healthy lifestyle changes (weight loss and exercise).
Many women with PCOS successfully manage their symptoms and long-term health risks without medical intervention. They do this by eating a healthy diet, exercising regularly and maintaining a healthy lifestyle.

Bowel incontinence is the loss of bowel control, leading to an involuntary passage of stool. This can range from occasionally leaking a small amount of stool and passing gas, to completely losing control of bowel movements.
Urinary incontinence, a separate topic, is the inability to control the passage of urine.

Uncontrollable passage of feces; Loss of bowel control; Fecal incontinence; Incontinence – bowel

Among people over age 65, most surveys find that women experience bowel incontinence more often than men. One to three out of every 1,000 women report a loss of bowel control at least once per month.
To hold stool and maintain continence, the rectum, anus, pelvic muscles, and nervous system must function normally. You must also have the physical and mental ability to recognize and respond to the urge to have a bowel movement.

• Chronic constipation, causing the muscles of the anus and intestines to stretch and weaken, and leading to diarrhea and stool leakage (see: encopresis)

• Chronic laxative use.

• Colectomy or bowel surgery.

• Decreased awareness of sensation of rectal fullness.

• Emotional problems.

• Gynecological surgery.

• Injury to the anal muscles due to childbirth (in women).

• Nerve or muscle damage (from trauma, tumor, or radiation).

• Severe diarrhea that overwhelms the ability to control passage of stool.

• Severe hemorrhoids or rectal prolapse.

• Stress of unfamiliar environment.

You need to be assessed by aUrogynaecologist or a colorectal surgeon to establish a possible cause for your symptoms and initiate appropriate treatment.
The possible treatments that will be considered are .

Incontinence is not a hopeless situation. Proper treatment can help most people, and can often eliminate the problem.
Treating bowel incontinence should begin by identifying the cause of the incontinence. There are several ways to strengthen the anal and pelvic muscles and promote normal bowel function.

Fecal impaction is usually caused by chronic constipation. It leads to a mass of stool that partially blocks the large intestine. If constipation or fecal impaction contributes to fecal incontinence, usually laxatives and enemas are of little help. A health care provider may need to insert one or two fingers into the rectum and break the mass into smaller pieces that can pass more easily.
Take measures to prevent further fecal impaction. Add fiber to your diet to help form normal stool. Use other medications your health care provider recommends. In addition, drink enough fluids and get enough exercise to enhance normal stool consistency.

Bowel incontinence often occurs because the rectal sphincter is less able to handle large amounts of liquid stool. Often, simply changing the diet may reduce the occurrence of bowel incontinence.
Take alcohol and caffeine out of your diet, because they may cause diarrhea and incontinence in some people. Certain people develop diarrhea after eating dairy foods because they are unable to digest lactose, a sugar found in most dairy products. Some food additives such as nutmeg and sorbitol may cause diarrhea in certain people.
Adding bulk to the diet may thicken loose stool and decrease its amount. Increasing fiber (30 grams daily) from whole-wheat grains and bran adds bulk to the diet. Psyllium-containing products such as Metamucil can also add bulk to the stools.
Formula tube feedings often cause diarrhea and bowel incontinence. For diarrhea or bowel incontinence caused by tube feedings, talk to your health care provider or dietitian. The rate of the feedings may need to be changed, or bulk agents may need to be added to the formula.

In people with bowel incontinence due to diarrhea, medications such as loperamide (Imodium) may be used to control the diarrhea and improve bowel incontinence.
Other antidiarrheal medications include anti-cholinergic medications (belladonna or atropine), which reduce intestinal secretions and movement of the bowel. Opium derivatives (paregoric or codeine) or diphenoxylate (lomotil), as well as loperamide (Imodium) increase intestinal tone and decrease movement of the bowel.
Other medications used to control bowel incontinence include drugs that reduce water content in the stools (activated charcoal or Kaopectate) or that absorb fluid and add bulk to the stools (Metamucil).

With your health care provider, review all the medications you take. Certain medications can cause or increase bowel incontinence, especially in older people. These medications include:

• Antacids.

• Laxatives.

If you often have bowel incontinence, you can use special fecal collection devices to contain the stool and protect your skin from breakdown. These devices consist of a drainable pouch attached to an adhesive wafer. The wafer has a hole cut through the center, which fits over the opening to the anus.
Most people who have bowel incontinence due to a lack of sphincter control, or decreased awareness of the urge to defecate, may benefit from a bowel retraining program and exercise therapies to help restore normal muscle tone.
Special care must be taken to maintain bowel control in people who have a decreased ability to recognize the urge to defecate, or who have impaired mobility that prevents them from independently and safely using the toilet. Such people should be assisted to use the toilet after meals, and promptly helped to the toilet if they have the urge to defecate.
If toileting needs are often unanswered, a pattern of negative reinforcement may develop. In this case people no longer take the correct actions when they feel the urge to have a bowel movement
See also: Toileting safety

IPeople who have bowel incontinence that continues even with medical treatment may benefit from surgery to correct the problem. Several different options exist. The choice of surgery is based on the cause of the bowel incontinence and the persons general health.

ISphincter repair is performed on people whose anal muscle ring (sphincter) isnt working well due to injury or aging. The procedure consists of re-attaching the anal muscles to tighten the sphincter and helping the anus close more completely.

In people who have a loss of nerve function in the anal sphincter, gracilis muscle transplants may be performed to restore bowel control. The gracilis muscle is taken from the inner thigh. It is put around the sphincter to provide sphincter muscle tone.

Sometimes a fecal diversion is performed for people who are not helped by other therapies. The large intestine is attached to an opening in the abdominal wall called a colostomy. Stool passes through this opening to a special bag. You will need to use a colostomy bag to collect the stool most of the time.

Haematuria is the presence of red blood cells in the urine. It can be visible to the naked eye (macroscopic) or only picked up during laboratory testing (microscopic).
Disease at any part of the urinary system (kidneys, ureters, bladder and urethra) can cause haematuria.

There are many medical conditions in the kidney, ureters, bladder or urethra that can result in haematuria:

1 Kidney stones, infection, glomerulonephritis (swelling of the filtering tubes within the kidney) and kidney cancers can cause haematuria.

2 Stone passage along the ureters can cause intense pain in the mid and lower back that travels down into the groin, causing haematuria.

3 Haematuria may also result from bladder cystitis (infection), painful bladder syndrome (PBS), bladder stones and bladder cancer.

There are also other causes of haematuria not listed in the above causes, such as contamination from vaginal bleeding, medical disorders such as systemic lupus erythematosus (SLE), sickle cell anaemia, vigorous exercise, physical trauma to your body, certain foods e.g. beetroot, and medications e.g. aspirin.

When you see blood in the urine, it is necessary to seek medical help. Your doctor will go through your medical history, in order to find the cause of haematuria.
The presence of urinary urgency, frequency, pain on urination (dysuria), abdominal pain or fever are useful in reaching a diagnosis. Risk factors for cancers, like smoking and certain chemical exposure can also be identified. After a physical examination, certain investigations and tests will be ordered.

• Urinanalysis (UFEME): A raised white blood cell count in the urine may indicate the presence of a urinary tract infection (UTI), which is a cause of haematuria.

• Urine culture: The urine is cultured for the types of bacteria and their antibiotic senstivities. This will allow your doctor to prescribe an appropriate antibiotic .

• Urine cytology: Cells in the urine are examined to identify the presence of cancerous (malignant) cells, which may come from anywhere along the urinary tract, which warrants immediate attention and further evaluation.

• Ultrasound of the kidneys, ureters and bladder: This ultrasound is used to visualise any abnormal growths/stones within the kidneys, ureters and bladder, assess the size of the kidneys, and abnormal swelling of the kidneys and ureters.

• Cystoscopy: This can be done under local and general anaesthesia where a camera is inserted through the urethra to look at the bladder, and biopsy samples can be taken to look for infection, inflammation, and cancerous growths.

• CT urogram: Computed tomography (CT) examines the structure of the urinary tract. Kidney stones, masses, abnormalities of the ureters and bladder can be detected.

• Urine phase contrast: This is used to visualise the red blood cells in the urine to determine the source of haematuria. Abnormal-shaped red blood cells (dysmorphic) usually implies a kidney source, whereas normal-shaped red blood cells (isomorphic) usually implies haematuria from the lower tract, e.g. bladder.

There is no specific treatment for haematuria since it is not a disease in itself. Treatment is directed at the cause of haematuria and can be discussed with your specialist doctor.

Haematuria is an alarming situation for most patients when it occurs. Do not to panic if you have haematuria. Please seek your doctor’s advice, as there are many causes for haematuria as described above, and the treatments can vary to a great degree depending on the causes of haematuria. It is therefore important to seek treatment early.

 

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