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Monday, 16 September 2013

Lax Perineum or Loose Vagina

When my patients tell me that they don't feel the same below after delivery of a baby, especially after a few babies, I understand what they mean. The sensation of a lax or loose vagina is manifest in several ways. There may be a feeling of heaviness below, loss of sexual sensation during intercourse, leakage of urine especially when exerting pressure such as coughing or during running, loss of control in defaecation or constipation. Sometimes it is the husband who will say that the wife feels loose during intercourse. Vaginal deliveries can result in a lax perineum and prolapse of the vagina and uterus. It usually occurs when the babies tend to be big or the delivery is assisted. During delivery, the tissues that support the vaginal wall known as the fascia which is made up mainly of collagen tissue may be torn, and although not visible can result in weakening of the vaginal wall. As a result, the bladder and rectum may protrude into the vagina, and the uterus may descend into the vaginal introitus. Kegel excercises and physiotherapy have a minimal effect in improving vaginal prolapse although there is no harm in trying these as the first line management of prolapse. Surgery can be performed with a lazer or by conventional surgery to repair and tighten the vaginal opening. This can be done as a day procedure in some cases. Where prolapse is more severe, repair can be aided with a mesh which is inserted underneath the vaginal mucosa for added support. The most recent advances involve a soft polypropylene mesh developed by AMS known as `Elevate' and these may be used for both front and back wall of the vagina as well as prolapse of the top of the vagina.

Sunday, 15 September 2013

Large fibroid and Urine Retention

One of the effects of fibroids is urine retention. I had a patient recently with increasing difficulty with passing urine over several months. Eventually she ended up in the emergency unit with acute retention of urine and had to have her bladder catheterised. If the fibroid is in the back of the uterus and large, the entire uterus is pulled backwards. This results in the urethra ( the passage through which a woman passes urine ) being stretched and `thinned out' eventually blocking the passage of urine. My patient had an 8cm fibroid in addition there were other smaller fibroids which were also causing her heavy periods. Removal of the fibroids gave her instant relief from this problem. Not all fibroids need be removed but if fibroids are causing symptoms or are significantly large then surgery is indicated. Although medication is able to shrink fibroids, it is generally used to reduce it to a size that it can be taken out through a laparoscope. In the case of my patient, the acute nature of the fibroid meant that she could not wait for medical treatment to take effect and therefore had it removed through a conventional incision.