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Thursday, 25 September 2014

Bladder Prolapse

These two weeks were unusual in that I operated on two similar cases in which both ladies were postmenopausal and suddenly presented with a lump appearing in their vagina, one after carrying extra heavy objects and the other after a bout of a persistent cough. Examination of both showed similar pathology in that their bladder had prolapsed into their vagina through a weakness in the tissues supporting the bladder wall.
 This problem is quite common and very often ignored by older women who pass it off as part of ageing and think nothing of it until it either causes pain, becomes uncomfortable or the protrusion is out of the vagina and starts to rub against her underwear.
Closer examination showed that these were defects not only in the bladder wall but also of the rectum. Tears in the tissue of the bladder wall and tissues surrounding the rectum during vaginal childbirth very often contribute to this condition, and it starts to show up when the hormone levels fall as a result of menopause causing the tissues to weaken even more. The exception is the young woman in their 20's or 30's with this problem which is then caused by an inherent defect in the collagen tissues of the supporting structures of the pelvic organs.
After much discussion of the alternatives, it was decided to do a formal repair of the defects under anaesthesia. Mesh implantation was discussed with the patients but due to the incidence of long term complications with mesh it was decided to do a traditional repair of the bladder wall and a tight closure of the musculature of the pelvic floor to prevent a recurrence.
Both women have recovered well and are they will no doubt be able to continue their active lifestyles after this such as going to the gym, resuming golf and tennis and household chores.

Monday, 4 August 2014

Incontinence...Stress or Urge

A problem not many women want to complain about and keep to themselves. It often comes out only on routine questioning of a patient or if there is an associated problem such as prolapse. Unfortunately it is a very common problem especially in older women who have had many or difficult vaginal deliveries. With age the collagen tissues that support the bladder neck become weak and cannot hold the urine when she coughs, sneezes or does physical activity such as jogging. This is pure stress incontinence. I recently had a patient who had stress incontinence but was too embarrassed to bring up this problem even though it had affected her lifestyle so that she had to give up her favourite excercise of jogging. Each time she went out she had to wear pads and was always aware that there was a smell of urine about her.
Urge incontinence presents differently. The patient will feel the urge to constantly go to toilet but very often will not be able to get there in time and will leak urine. After voiding she may feel the urge to go again. This is not due to a weakened bladder neck but an overly sensitive bladder.
Both urge and stress incontinence may co-exist to complicate matters as in my recent patient.
It was my job to firstly determine which of the two was the predominant symptom that was causing her more distress and then to deal with the problem.
In my patients case it was the stress incontinence that needed attention. She was counselled about the various methods of treating stress incontinence and eventually opted for a sling operation. To date she has been free of her stress incontinence and has happily resumed her favourite excercise of jogging!

Thursday, 31 July 2014

Chronic fungal infections

This is the most common condition that a gynaecologist like myself sees almost on a daily basis. The most common and unfortunately one of the most difficult to eradicate. Chronic recurrent fungal infection can however be controlled. It depends on how motivated a patient is. There are many naturopathic treatments that have been advocated but most results with 'candida and parasite cleansing diets are anecdotal and not proven. Why is it so difficult to control ..because it is a condition that is related to the bodies immune system of which a great is not known about. We do know that the parasite lives as a commensal in parts of the body just as other harmless bacteria. In some patients there is a greater abundance of these yeast spores and when during times of stress as in chronic illness, pregnancy or when taking antibiotics, the yeast spores multiply and cause infections which present as vaginal itch and discharge.
Certain measures taken can help to reduce the chances of recurrence such as reducing sugar intake, carbohydrates, taking antibiotics, maintaining a healthy lifestyle of sufficient rest, sleep and excercise.
Taking probiotics may very well help if the correct probiotic is taken. There have been some advocates of probiotic vaccines as opposed to oral probiotics, however their value has not been proven.
The take home message is to treat the fungal infection vigorously in the early stages. If not with each subsequent infection it becomes more difficult to treat with medication and takes longer to resolve with a higher chance of recurrence. There are many medical treatment regimes for controlling and preventing recurrent chronic fungal infections. It is important to see a gynaecologist for a proper workup and appropriate treament. Self medication is very common for fungal infections but sometimes the diagnosis of the vaginal discharge or itch may be wrong and therefore treatment inappropriate.