new concepts and techniques and pursuing a career in urogynaecology n j nwabineli consultant in...
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NEW CONCEPTS AND TECHNIQUESand pursuing a career in urogynaecology
N J NwabineliConsultant in Obstetrics, Gynaecology and
UrogynaecologySouth Tyneside NHS Foundation Trust
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Greetings from Tyneside
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Urogynaecology is all about the pelvic floor
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Urogynaecology is all about the pelvic floor
UrologistG
ynae
colo
gist
Colo
rect
al
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Urogynaecology
Female Pelvic Medicine Female Urology
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Pelvic Floor Muscles
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Pelvic Floor Fascia
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THE PELVIC FLOOR MUSCLES -An extraordinary multi-tasker!
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Pelvic Floor Dysfunction
UrologistG
ynae
colo
gist
Colo
rect
al
Can affect anyone or combination of all 3 organs passing through it.Dysfunction can be caused by the muscles and nerves of the pelvic floor.
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Pelvic Floor DysfunctionAnterior compartment
Too active Urinary Retention
Under active Urinary Incontinence
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Pelvic Floor DysfunctionMiddle compartment
Too active Vaginsmus
Under active Pelvic Organ Prolapse
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Pelvic Floor DysfunctionPosterior compartment
Too active Constipation – obstructed defaecation
Under active Flatus – Fecal incontinence
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Pelvic Floor DysfunctionChronic pelvic pain
• Muscles in spasms
• Hyperaesthesia of nerves – PBS, etc.
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Urinary ProblemsDefinitions
Problem PAST PRESENT
Urinary Retention Symptoms, signsCatheterisation
Symptoms, signsBladder Ultrasound
Incontinence Symptoms and signs only
Symptoms, signs and Urodynamics
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Urodynamics
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Urodynamics
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Treatment of True or Urodynamic Stress Incontinence
• Anterior Repair• MMK (1949)• Burch Colposuspension (1970’s)• Stamey’s and similar procedures• Mid urethral tapes/slings (mid 1990’s)• Bulking agents (mid 1990’s)
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Tension Free Vaginal TapeDown upSide to side
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Tension Free Vaginal TapeDown up
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Tension Free Vaginal TapeSide to side (TVT-O, TOT)
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Bulking agents
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Treatment of Urge Urinary Incontinence
• Life style modification
• Anti-cholinergics
• Beta sympathomimetics (Mirabegron)
• Botox
• Neuro-modulation (PTNS, SNS)
• Complex surgery
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Neuro-modulationPTNS SNS
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Anal Incontinence and Obstructed defaecation
Anal Manometry
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Anal Incontinence and Obstructed defaecation
Trans-anal ultrasound
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Dynamic coloproctography
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Bulking of anal supports
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Pelvic Organ ProlapseTreatment
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Pelvic Organ Prolapse
Treatment – Traditional repair
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Pelvic Organ ProlapseTreatment – Mesh repair
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Pelvic Organ ProlapseHystero sacro-colpopexy
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Pelvic Floor Dysfunction The Future
Shift in paradigm of our approachAnatomy of supports• Fresh cadaveric dissections• Trans perineal ultrasound• MRI – staticSupports in action• Dynamic MRI• Bio mechanical modelling
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Fresh cadaveric specimens
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Perineal Ultrasound
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Static MRI
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Dynamic MRI
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John De Lancey
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Must pelvic floor dysfunction occur? Can we prevent it?
• Inherited collagen• Aging• Childbirth• Other trauma
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If we can not prevent PFD – can we mitigate the effects?
• How are tissues damaged?
• What changes occur in structure and function?
• How can we adapt treatments that take these factors into consideration?
• Comparison with car accidents
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Pursuing a career in Urogynaecology
• What to consider? – Is there a demand?(Population will get older)
• What are the demographics of PFD in Nigeria compared to UK?
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Pursuing a career in Urogynaecology
Personal recommendations
Start where you are and build your skills into urogynaeecology incrementally without switching off obstetrics
Be prepared to learn and to change as you go along
Ensure you are first of all a good doctor before aspiring to be a good Uro-gynaecologist
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Pursuing a career in Urogynaecology
You will be dealing with women whose problemsare not life threatening but of Quality of Life - Therefore be prepared to negotiate
Be patient and thorough in the learning of your anatomy as your chosen area involves risks to several organs.
Maintain an enquiring mind as the specialty evolves
Remain humble – we do not know it all yet and because we are mending broken parts, we have to sometimes accept that we have not gotten it right.