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.

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!

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.

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.

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.

Endometrial Cancer

Endometrial Cancer is a cancer of the inner lining of the womb. It is the next most common cancer after the ovary but has a much better prognosis and survival rate. Endometrial cancers tend to be less aggressive and are almost always related to high and prolonged exposure to oestrogen. Which is why they are more common and typically affect women who are "fat, fair, and fifty". Late menopause, obesity predispose to endometrial cancer. The good news is that they are often detected early and when treated by surgery in the early stage have a 95% chance of 5 year survival or cure.
My patient presented at age 52 with bleeding in between her periods. Her GP had given her hormones to try and regulate her menstrual flow and stop the bleeding without success. When I saw her, an ultrasound scan of her uterus was unremarkable except that the lining of her womb was unusually thick. This raised my suspicions, and I immediately arranged to do a hysteroscopy (viewing the cavity of the womb with a telescope) and performing a biopsy. The hysterscope enabled me to view and locate a very small suspicious area on the lining. Now in the olden days, the standard procedure would be to perform a dilatation and curettage or scrapping of the womb. This small nidus would almost certainly have been missed with such a blind procedure and produced a false negative result. A biopsy of the suspicious area confirmed a stage I(a) endometrial cancer. Over the next week, I performed a total hysterectomy and bilateral salpingo-oophorectomy for my patient, taking out her womb, tubes and ovaries. No further treatment was necessary and I could confidantly tell her that she had a very good prognosis and was indeed a very lucky woman. The message to remember is to have any form of bleeding per vaginum or change in periods investigated thoroughly and not delay having your annual check-ups. A vigilant gynaecologist will pick up anything that could progress to something more sinister and not delay a cure. Avoid taking soy products (not fermented soy) as they are high in plant oestrogens, maintain a healthy weight through excercise.

Adenomyosis/ Endometriosis ( Heavy + Painful periods )

Adenomyosis is a very common condition and is very easily missed in a gynaecological examination. It is a condition in which the endometrium which lines the cavity of the womb somehow penetrates the muscle protruding into the myometrium. It can be focal ie isolated pockets in the womb or diffuse and extensive causing the whole womb to enlarge.
The most common symptoms are heavy and painful periods. This condition commonly coexists with other disorders such as fibroids, endometriosis and polyps. No one knows the cause, but it is thought to be due to an imbalance in the hormones. The pain during periods is due to the ectopic endometrial cells bleeding into the muscle of the womb and the heavy periods due to the whole surface area of the womb being enlarged.
It is typically diagnosed on ultrasound scan of the pelvis and on MRI.
I recently performed a removal of the adenomyosis on a 39 year old lady. She was single. This was unusual as adenomyosis most often affects those who have had pregnancies or previous surgery to the womb. She came with the problem of severe period pains and backache, pain radiating down to her thigh and leg. At the time of surgery, the back of the womb was filled with a large adenomyoma and the womb was stuck to her rectum and intestines at the back. She in addition had endometriotic cyst of her ovary and a polyp in the cavity of her womb. The surgery was performed through a conventional open method rather than through key-hole surgery as it would be impossible to remove the adenomyoma entirely otherwise and thereby risking a higher chance of recurrence.
Surgery would be the primary form of treatment in severe cases and very often if the patient has completed her family a hysterectomy would be recommended. In less severe cases, other forms of treatment can be tried such as Lucrin injections to induce a chemical menopause, inserting a mirena device.