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Richardson described transverse defects trazodone causes erectile dysfunction order sildenafil, midline defects impotence treatment devices order sildenafil us, and defects involving isolated loss of integrity of the pubourethral ligaments. Transverse defects were said to occur when the "pubocervical" fascia separated from its insertion around the cervix, whereas midline defects represented an anteroposterior separation of the fascia between the bladder and vagina. There have been few systematic or comprehensive descriptions of anterior vaginal prolapse based on physical findings and correlated with findings at surgery to provide objective evidence for any of these theories of pathological anatomy. In a study of 71 women with anterior vaginal wall prolapse and stress incontinence who underwent retropubic operations, DeLancey [9] described paravaginal defects in 87% 1249 on the left and 89% on the right. The pubococcygeal muscle was visibly abnormal with localized or generalized atrophy in over half of the women. Improvements in pelvic imaging are leading to a greater understanding of normal pelvic anatomy and the structural and functional abnormalities associated with prolapse. Various measurements can be made that may be associated with anterior vaginal prolapse or urinary incontinence, such as the urethrovesical angle, descent of the bladder base, the quality of the levator muscles, and the relationship between the vagina and its lateral and apical connective tissue attachments. Lateral or paravaginal defects occur when there is a separation of the pubocervical fascia from the arcus tendineus fasciae pelvis, midline defects occur secondary to attenuation of fascia supporting the bladder base, and transverse defects occur when the pubocervical fascia separates from the vaginal cuff or uterosacral ligaments. The anterior vaginal wall and endopelvic fascia function as a sling or hammock for support of the urethra (u). The paravaginal detachment (arrow) is seen at the level of the urethrovesical junction. Some features of pathophysiology may overlap, such as loss of anterior vaginal support with bladder-base descent and urethral hypermobility; other features, such as sphincteric dysfunction, may occur independent of vaginal and urethral support. The reconstructive surgeon must determine the specific sites of damage for each patient, with the ultimate goal of restoring both anatomy and function. Patients with anterior vaginal prolapse complain of symptoms directly related to vaginal protrusion or 1251 of associated symptoms such as urinary incontinence or voiding difficulty. Symptoms related to prolapse may include the sensation of a vaginal mass or bulge, pelvic pressure, low back pain, and sexual difficulty. Stress urinary incontinence commonly occurs in association with anterior vaginal prolapse. Women may require vaginal pressure or manual replacement of the prolapse in order to accomplish voiding, or they may relate a history of urinary incontinence that has since resolved with worsening of their prolapse. This can occur with urethral kinking and obstruction to urinary flow; women in this situation are at risk for incomplete bladder emptying and recurrent or persistent urinary tract infections and for the development of de novo stress incontinence after the prolapse is repaired. Physical Examination the physical examination should be conducted with the patient in the lithotomy position as for a routine pelvic examination. If physical findings do not correspond to symptoms or if the maximum extent of the prolapse cannot be confirmed, the woman is reexamined in the standing position. The genitalia are inspected, and if no displacement is apparent, the labia are gently spread to expose the vestibule and hymen. The integrity of the perineal body is evaluated, and the approximate size of all prolapsed parts is assessed. A retractor or Sims speculum can be used to depress the posterior vagina to aid in visualizing the anterior vagina. After the resting examination, the patient is instructed to strain down forcefully or to cough vigorously. During this maneuver, the order of descent of the pelvic organs is noted, as is the relationship of the pelvic organs at the peak of straining. It may be possible to differentiate lateral defects, identified as detachment or effacement of the lateral vaginal sulci, from central defects, seen as midline protrusion but with preservation of the lateral sulci, by using a curved forceps placed in the anterolateral vaginal sulci directed toward the ischial spine. Bulging of the anterior vaginal wall in the midline between the forceps blades implies a midline defect; blunting or descent of the vaginal fornices on either side with straining suggests lateral paravaginal defects. Studies have shown that the physical examination technique to detect paravaginal defects is not particularly reliable or accurate. Less than two-thirds of women believed to have a paravaginal defect on physical examination were confirmed to possess the same at surgery.
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Mucosal prolapse does not involve all wall layers; only the mucosa protrudes erectile dysfunction pills at gnc order sildenafil us, and here too the affected area is usually the anterior rectal wall erectile dysfunction pills from china cheap sildenafil on line. The incidence among adults gradually increases with age and reaches a second peak in women during the seventh decade of life. The incidence is markedly higher in women than men with a female-to-male ratio of approximately 9:1 [8]. Risk factors include chronic constipation, obesity, connective tissue or muscle weakness, and in women vaginal delivery and multiparity. In 1912, the Hungarian surgeon, Alexis Victor Moschcowitz, developed the sliding hernia theory [9]: the hernial orifice is situated in the anal canal at the pelvic floor; the hernial sac is the anterior rectal wall. The theory is supported by typical concomitant features such as an elongated sigmoid colon, a mobile mesorectum, lax lateral ligaments, and pelvic floor weakness. Today, the hernia is considered to be the consequence rather than the cause of the disease. Rectorectal invagination is thus considered to mark the onset of the disease, the earliest phase in the development of complete rectal prolapse. The emergence of cineradiography first enabled Broden and Snellman to radiographically substantiate this theory in the 1960s [10]. This is in keeping with the conical highpressure zone radiographically detected by Shafik et al. This zone resembling a bottleneck may be regarded as the starting point of invagination. In addition, various neurological changes have also been linked with rectal prolapse [12,13]. In contrast to stenosis, this is a dynamic effect that is augmented by straining during defecation and thus leads to functional stenosis. This typically causes severe defecation disorders that may also be designated as obstructed defecation. Due to secondary pelvic floor and sphincter damage, incontinence usually becomes a predominant problem 1443 later in the course of the disease. However, functional stenosis during defecation can cause abdominal complaints, defecation disorders, a sensation of bulging in the rectum, and thus a feeling of incomplete evacuation. Those affected may have frequent or prolonged defecation times or require digital support during defecation. In Grade 2, many patients additionally experience soiling and mild incontinence symptoms. Patients can touch the prolapsed intestine during defecation and push it back in place. Patients often have a considerably reduced quality of life and markedly restricted social life [8]. Fecal incontinence leads to fear of embarrassing situations in everyday life and thus results in social isolation. Prolapse is 1444 classified as Grade 3 if present at rest and as Grade 2 if the rectum protrudes only during straining maneuvers [14]. Rectoscopy, Manometry, Endosonography Rectoscopy, manometry, endosonography, and coloscopy are used as complementary measures. They can indicate the extent of prolapse and possibly exclude concomitant diseases [2,16]. Rectoscopic signs may include mechanical irritation of the mucosa and ulcerations (ulcus simplex, typically on the anterior rectal wall). Endosonography can demonstrate alterations or injuries in the anal sphincter, and coloscopy can exclude important differential diagnoses like cancer. Diagnostic Imaging Cinedefecography is performed to detect Grade 1 rectal prolapse (intussusception) [2,16]. It consists of dietary measures to promote bowel regularity (high-fiber food, plenty of fluids), laxatives, stool softeners, pelvic floor exercises, and biofeedback [14]. Nevertheless, the indication is always dependent on the clinical symptoms and the success of conservative therapy. Intussusception (Grade 1 rectal prolapse) without clinical symptoms may be an incidental imaging finding and is not an indication for therapy [17].
Abdominal Sacral Colpopexy (Colpoperineopexy) An abdominal approach may be utilized for the correction of a rectocele when accompanied by apical prolapse erectile dysfunction treatment electrical 75 mg sildenafil sale. This may be performed through an open incision or laparoscopically with or without robotic assistance erectile dysfunction gel sildenafil 50mg on line. Identification of the right ureter is confirmed prior to opening the pelvic peritoneum. The peritoneum is opened in a vertical fashion from the sacral promontory to the pelvic cul-de-sac along the lateral border of the right colon and medial to the right ureter. With the aid of an end-to-end anastomosis sizer placed in the vagina and the rectum, the rectovaginal space is identified and entered sharply. This is an avascular space and if one is in the correct plane, limited bleeding should occur. Following this, dissection of the bladder off the anterior vaginal wall is performed to the level of the bladder neck. Finally, the mesh is affixed to the anterior longitudinal ligament with two separate sutures of No. Of note, this procedure may also be combined with a vaginal approach to further correct a distal rectocele. One study revealed an improvement from 100% to 88% cure rate for constipation in 24 patients that were prospectively followed and evaluated pre- and postoperatively with standardized questionnaires, defecography, colon transit studies, anorectal manometry, and electrophysiology. This study also showed improvement in symptoms of vaginal bulge from 21% preoperatively to 4% postoperatively. In comparison, two studies showed a modest improvement (<50%) [56] or an increase [60] in the constipation rate (from 22% to 33% after a mean follow-up of 52 months). Reasons suggested for these observations include (1) unselective approach used in offering surgical treatment for persistent constipation [69], (2) retrospective analysis of the data [1], and (3) the possibility that patients with a pathologic transit study might have a less favorable outcome with respect to constipation [55,59]. In addition, the study by Kahn and Stanton showed an increase in rates of incomplete bowel emptying and fecal incontinence (4% preoperatively vs. All bowel function parameters showed improvement with overall patient satisfaction of 97% [61]. Bowel evacuation scores improved by 42% and continence by 37% based on a validated questionnaire given pre- and postoperatively [62]. Both subjective and objective outcomes 1295 following repair of the posterior compartment vary due to the various surgical procedures that routinely accompany rectocele repair, making the ability to compare and contrast the current studies difficult. Preoperatively, there was no difference in dyspareunia in both groups, but postoperatively, the prevalence of dyspareunia was significantly lower in the group without posterior repair [63]. De novo dyspareunia rates after levatorplasty have been reported to range from 12. The postoperative introital calibers in patients with or without dyspareunia were not different. The reasons for the unexpectedly high rate of dyspareunia in that study are unclear. Site-Specific Rectocele Repair the surgical outcomes after a defect-specific rectocele repair are summarized in Table 84. In addition, the lack of a standardized definition of constipation contributes to the difference in constipation rates seen in the literature after rectocele repair.
Diseases
- Motor neuro-ophthalmic disorders
- Phacomatosis pigmentovascularis
- Ulna hypoplasia mental retardation
- Pes planus
- Facio digito genital syndrome recessive form
- Albinism ocular late onset sensorineural deafness
- Johnston Aarons Schelley syndrome
- Adrenal macropolyadenomatosis
- Situs inversus viscerum-cardiopathy
The treatment of any genital sexual pain disorder involves the multidisciplinary team approach erectile dysfunction causes prostate discount sildenafil 75 mg without prescription, and this is especially true for the disabling condition of vestibulodynia impotence xanax purchase sildenafil 75 mg without prescription. Patient management includes education and support, especially regarding avoidance of contacts and practice of healthy vulval hygiene, pelvic floor physical therapy treatment, management of concomitant depression, and management of any associated neurological, dermatological, gynecological, orthopedic, or urological conditions. Symptoms include vaginal dryness, dyspareunia, itching, burning upon palpation of the vestibule. On 1025 physical exam, the vulva may appear atrophic and resorbed, the clitoris can be shrunken, and the telltale sign of hormonally mediated vestibulodynia is an inflamed and painful vestibule and periurethral glands. The hormonally depleted vagina typically has lost the rugae, has a pale complexion, has a lack of lubricating substance, and will bleed with minimal contact. On wet mount, the microscopic examination reveals parabasal cells and increased white blood cells. Important, however, is to address the testosterone receptors within the vestibule as this tissue is derived from the endoderm compared with the estrogen-rich ectoderm of the vulva and the vagina-derived mesoderm. The typical presentation of burning and itching symptoms can be so intense as to severely interfere with sexual activity, day-today activities, and even sleep. If the scarring of lichen sclerosis involves the perianal area, the patient may also complain of perianal fissuring and painful defecation. The diagnosis of lichen sclerosis is suspected by physical examination showing a white color genital, vulval, and vestibular tissue with paleness, loss of pigmentation, and characteristic "cigarette paper" wrinkling. Classically, the genital tissue changes do not involve the inside of the vagina, and if they involve the perianal area, there is a traditional "figure of eight" extension. The lichen sclerosis condition commonly involves the vestibule with associated labia minora atrophy and the vaginal introitus with loss of elasticity and narrowing [44]. Failure to respond may require more specialist gynecological, dermatological, or plastics support. All vestibular mucosal tissue has been removed, laterally and posteriorly, with reconstruction including the posterior vaginal flap advancement. The typical presentation is genital, vulval, and vestibular tissue with paleness, loss of pigmentation, and characteristic "cigarette paper" wrinkling. Lichen sclerosis commonly involves the vestibule with associated labia minora atrophy and the vaginal introitus with loss of elasticity and narrowing. Lichen Planus Lichen planus is another chronic genital dermatitis condition, which is likely to have a pathophysiology related to varied altered immunological disorders, and as a result, the presenting symptoms may vary widely. Lichen planus may occur secondary to drugs, such as antihypertensives, diuretics, oral hypoglycemics, and nonsteroidal anti-inflammatory agents. One presentation is primarily associated with itching and does not result in scarring. Overall, patient complaints may include severe vulval itching, pain, burning, and irritation similar to lichen sclerosis. Some types of lichen planus, unlike lichen sclerosis, may involve the vaginal mucosa. The pruritic type of lichen planus is associated with a purple color and multiple papules and plaques on 1027 the vulva and vestibule. The erosive type is associated with vestibular ulcers, scarring, clitoris and labia minora atrophy, and occasionally destruction of the vagina has been reported [44]. Similar to lichen sclerosus, biopsy proven disease with lichen planus is treated similarly with a topical steroid, clobetasol 0. For long-term use consider intermittent application, such as treatment on Monday, Wednesday and Friday, or switch to a low potency steroid. If there is concern about recurrent yeast infections prescribe oral fluconazole 150 mg weekly for suppression. Bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis vaginitis are the most common causes of vaginal discharge in premenopausal women. When these conditions have been excluded, other causes of vaginal discharge must be considered in the differential diagnosis of women with vaginal complaints. Most investigators believe that it is primarily an inflammatory vaginitis of noninfectious etiology, with secondary bacterial microbiota disruption [71].
