ObsNGyn - Urogynecology and Mics Topics Atf
ObsNGyn - Urogynecology and Mics Topics Atf
ObsNGyn - Urogynecology and Mics Topics Atf
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✓ Pubocervical ligament
✓ Round ligaments(false support)
✓ Uterosacral ligament
✓ Cardinal ligament also called as Transverse cervical ligament: Mackenrodt ligament.
Note: Broad Ligament: Sheet of peritoneum (double layer) extends from side of uterus
to lateral pelvic wall, no support.
Kegel’s Exercise: can strengthen the voluntary muscle, (pelvic diaphragm), no role in
strengthening ligaments.
Level Defect
Level 1 ✓ Uterosacral ligaments ✓ Uterovaginal prolapse.
✓ Cardinal ligaments ✓ Enterocele
✓ Pubocervical Ligament ✓ Vault Prolapse
CAUSES OF PROLAPSE
Contributory factors:
Grading of Prolapse:
✓ Jeffcoat’s classification
✓ Malpas classification
✓ Shaw’s classification
First degree: The cervix descents into the vagina but above the level of introitus.
Fourth degree: The entire uterus is outside the introitus. Also called as
PROCIDENTIA.
✓ Standardized system
✓ Reference point hymen
Clinical features:
✓ Post-menopausal women
✓ Vault/ post hysterectomy prolapse
✓ Multiparous young women
✓ Nulliparous
Post-menopausal women
Anterior Colporrhaphy
Posterior Colporrhaphy
Urogynecology & miscellanous topics P a g e 4 | 17
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Perineo-raphy
Enterocele repair:
1. Moschowitz repair
2. Halbans repair Previously
3. Mac Culls culdoplasty: it also helps to suspend the vaginal vault to uterosacral
ligaments
Q. Post-menopausal woman who is v.v high risk, recent history of M.I, Anesthesia is
C/I, what can we do? Pessaries
Indication of pessary:
1. Anesthesia is C/I
2. Pregnancy
Pessary should be removed at-18 weeks and recheck if required bcz mostly
spontaneous reduction happens after 2 nd trimester.
Steps:
1. Preliminary D and C
2. Amputation of the cervix
3. Suturing of Mackenrodt ligaments in the front of the
cervix
4. Anterior colporrhaphy if required
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5. Colpo-perineorrhaphy if required
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Surgica l trea tm e nt o f SU I :
The various operations done for genuine stress incontinence (GSI) are as follows:
1. Kelly’s plication:
2. Needle suspension
surgeries.
Starney’s Pereyra’s
3. Colposuspension:
Ureteropubic Urethropexy
Disadvantage:
TVT:
✓ Most of the times these fistulae present with continuous dribbling of urine.
✓ If it’s a large fistula, then the bladder will not fill.
✓ If fistula is small: she can hold urine or pass urine
normally but she is always wet.
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Case 1:
Case 2:
P/S examination: Pooling of urine but we can’t see feel a fistulous opening.
Procedure:
✓ A catheter is introduced into the bladder through the urethra and bladder is
filled with methylene blue dye.
✓ The vaginal cavity is packed with three sterile cotton swabs.
✓ The swabs are removed after some time and eva luated for staining
Results:
✓ If there is a VVF present, the methylene blue dye stains the uppermost swab.
✓ If the lowermost swab gets stained, the leak is from the urethra --> urethrovaginal
fistula
✓ If the swabs do not take up the stain, but get wet with u rine, the leak is from the
ureter-->ureterovaginal fistula
• No. of fistula
• Exact location
• Proximity of fistula to ureter.
Fig: 32.47
Note:
3. Intraabdominal repairs:
✓ V. large fistulas
✓ Failed vaginal repair
✓ Fistula very near to ureter
✓ Urinary continence +
✓ Menouria Youssef syndrome
H Y ST ERECT O MY :
Routes:
1. Abdominal: for larger uterus, >12 -week size
2. Vaginal
3. Laparoscopic
4. Laparoscopic assisted Vaginal
5. Robotic
✓ Vaginal and Laparoscopic route: Shorter hospital stay, earlier recovery,
Noincision, Lesser post pain, earlier ambulation.
✓ These are the Advantages over abdominal route.
To remove tubes and ovaries with the specimen: Clamp is applied at the
infundubulopelvic ligament, round ligament is cut separately.
Vaginal Hysterectomy:
Types of Hysterectomy
✓ Type: 2
✓ Type:3
Complications of Hysterectomy:
a. Immediate complications:
✓ Haemorrhage: m/c
✓ Injuring to adjacent structure: Bladder injury -1%, chances of ureter injury are
lesser, bowel injuries.
b. Delayed complications:
✓ Post-operative complications: Fever, Infection: Pelvic infection, wound
infection, urinary tract infection, post -operative vault infection (lead to
persistent bleeding or discharge PV)
✓ 2-4 months later: there can be vault prolapse.
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Ureter Injuries:
✓ Most common location: Danger area - 1.5 cm lateral to cervix, crossing of uterine
artery over ureter
✓ Risk of ureteric injuries is more with Radical
types of hysterectomy.
✓ Risk of ureteric injuries is more with abdominal
hysterectomy than vaginal.
✓ 2nd m/c site of ureteric injuries: crossing of
ureter over the bifurcation of the common iliac
artery, while clamping the infundubulo pelvic
ligament.
Hymen
✓ Membrane covered by epithelium on both sides.
✓ Usually ruptures during childhood
✓ Only remnants remain after childbirth: c/a carunculaemyriteformes.
✓ Hymen has got nothing to do with virginity.
Nerve supply:
Function of gland:
Note: Any histology form of malignancy can arise from Bartho lin gland.
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Bartholin’s gland cyst
Treatment:
Bartholin’s cyst:
TOC: Marsupialization,
Notes:
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