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Hello, everyone and welcome to our first event this week. Er, today we have Sarah Farrell joining us and she's gonna be chatting about Euro gynecology. Um, as always, pop your questions in the chat. Sarah will actually take all your questions at the end. All right, so please pop them in the chat, leave them in the chat and we'll work through them right at the end. Uh, as always, this is, this will come with a feedback form and an attendance certificate. All right. So I'm gonna hand it straight over to Sara now over to you, Sarah. Thank you. Um, hello everyone. My name is Sarah Farrell and as you said, I'm a consultant, your gynecologist and gynecologist at Sulfur Royal, um, which is situated in Manchester England. So, um, I'm also a lead for Uro Gyne. So, um, the objectives of today is basically just tell you a little bit about what urogynecology is, what kind of patients we see kind of a little bit about our setting here. Um, how to take a good Uro gyne history, how to examine a Uro gyne patient, what kind of investigations we go for and, um, sort of common uro gynecological conditions um as well as some of the conditions that come together with uro gyne conditions and how to manage them. Um when to involve other specialties like urology and colorectal and geriatrics, et cetera and how we consent for Uro Gyne procedures um in the UK and then we'll have a question and answer sessions. Um So Uro Gyne has many definitions. Um It's basically a subspecialty of gynecology that you train at the end of your S and Gyne training. Um You then choose your gynecology and you do a two year just concentrating urogynecology. Um We all have to be members of the British Society of Urogynecologists and they say that I consult a urogynecologist like myself. Um I should have had specialist training, which I have. Um And there's a module that you get signed off for, for various things, operations and so on. Um I have to do three Uro Gyne sessions per week minimum and that including in a full day of operating. Um Then I do a lot of urodynamics. Um We do a lot of Uro gyne clinics um then invasive procedures in outpatients like Botox and VCO it. Um And on top of that, the multidisciplinary team meetings, which are extremely important. And on top of that job, um you obviously do teaching like this. Um we also teach Uro gyne nurses um and medical students as well as other Uro Gyne trainees. So um a little bit about um who our patients are. So sulfa roil is a really big hospital um in the heart of Manchester. It's got over 7000 people who work there. It's a really nice hospital. I quite like it. Um And we have a very large catchment area. Most of our patients are Caucasian um white woman. Um but we also get a lot of Asian Pakistani and Indian Bangladeshi background who live in the outer skits of Manchester. Um So we serve quite a mix really, but most of our patients are um working class um social class five. Um We get GP referrals and that's how we see our patients. So they come to us either as urgent um which is not really the case in urogynecology because it's a noncancer specialty. Um and we triage them. So we go through all the incoming referrals and we see who we can get them to see. Um So the ones that are slightly complex are seen by your Gyne consultant like myself um or they're seen by a patients assessing them and they can do almost everything um except for operating, of course. Um And they see whether the patient can have a pessary, for example, before they see you, we also get them seen by physiotherapy straight away sometimes or we get them seen in a pessary clinic. Um They're all seen in gyne outpatient setting. Um And sometimes we get referrals from our gyne consultant colleagues who are not so confident in um sorting out problems in prolapse patients incontinence patients. So we also see patients from them. We also get a lot of external referrals. Um There are certain U gyne operations that not all hospitals do and we do quite a lot of specialist incontinence surgery. So we get referrals from places like ultra um as far as Blackpool um which is good. So clinical history, so demographic is very, very important. So you need to know where is your patient from? Um I always ask, you know, obviously, if they look Caucasian white, then you don't need to ask. Um But if their ethnic minorities is very important, you need to also make sure that they can speak English. Um If not, we've got a telephone interpreter which I really do not like. Um it's ideal to have a face to face interpreter. Um We use a interpreter. Um We know and if you happen to speak the same language as the patient, um it's a bit of a gray area. Um But we encourage not to, um we're encouraged even if you speak the same language as a patient, not to speak your own language, it's better to get an interpreter. Um It's more because some people say there's an imbalance of power. There, some people say it's because um the nurse, for example, in the room cannot vouch for what you have said or not said. Um I'm not sure whether I agree with that or not. Um But it's a bit of a gray area medicine in general. So presenting complaints. Um the most important things, you know, you just ask your Gyne questions like urinary incontinence. Um Do you leak, um Do you have any fecal incontinence, um symptoms of prolapse any problems when you wee um any problems on intercourse, any pain, anything gets in the way, so very much. Um in late terms, and we've got to put it to them. Any pain um needing to digitate is an extremely important um question. So you need to ask, do you have to put your finger in the vagina to be able to empty your bladder? Do you have to put your finger in the back passage to empty your feces? So that is an extremely important question. Do you have to squat for example, to finish uh weighing or finish pooing? Um So it's really important that you give the patient time to talk. So what I normally say is um a uro gynecologist, I deal with incontinence and prolapse. Can you tell me about why you're here today? Um And then stop talking and give them a minute just to tell you as much as they want. Um Normally because patients have been waiting in, in our trust over a year to see us, they have a lot of things to say, which is fine, but you have to kind of filter through that and see what's important to you if they're going on and on and on about multiple symptoms and you can't quite get your head around everything that's going on. I normally just stop them and say, can I just stop you? I just want to know the three most important symptoms. I do care about all the other things that are going on in your life. But just tell me the three things that are bothering you the most. And you'd be surprised they come up with almost three things that they mentioned before. So it's really important because then I put them in ranking in my documentation. Then I know which one to target history presenting complaint is extremely important. So, constipation is obviously very important to us. Chronic cough. Is that why they've got a prolapse is that the reason their surgery failed or is likely to fail if you operate on them? Um, menopause is very important because sometimes the symptoms of menopause are masking the symptoms of a U Gyne problem or vice versa. So if you correct one, the other one will correct itself. Use of pads. So you need to know what kind of pads you use? Did they use any at all? Um That's a really important question for me because if somebody says I'm leaking all the time, but I don't need to wear a pad, you kind of think, well, how much are you leaking? Is that vaginal discharge that you're feeling or is it proper urine. And if you're leaking a lot of urine, you should really be wearing a pad. So that is a very important question. What kind of pad is it a panty liner or is a proper tenner lady as we call in the UK? And is it soaked or not? But sometimes they change it just for hygiene reason, but it's actually not soaked. And how often are you changing it? Um Past medical history, obviously, with women is really important. We need to know how many babies they've had mode of delivery is extremely important if you're going to operate on them. If you operate on someone who's had five Cesarean sections, you need to think about the scarring and the risk of damage to bowel and bladder birth weight is extremely important. How big weigh your um baby? So we had a patient this morning whose last baby was 14 lbs, which is about six. I think that's about 5.56 kg. So that's obviously going to do some damage to your pelvic floor, prolonged second stage, um which is the stage of pushing of the baby out. So you need to ask about that. How long were you pushing for? So anything over two hours is considered a prolonged sometimes they say I didn't push at all really, I only push for about five minutes. That's also important because if they push the baby all out in one go, obviously, that will damage the pelvic floor. And so what kind of tears did you have? Did you just tear naturally? Were you sutured in the room or were you taken into theater where it was an extensive tear? Had it gone into the back passage? So these things are very important. Recurrent uti is extremely important because you need to correct that before you move on to anything. Um, and you have to also investigate for, um, red flags diverticular disease. Obviously, very important. Anything to do with the bowel renal disease, hypertension, particularly important with uh when you prescribe a medication, diabetes is important because that means they might be retaining urine, they might be getting recur urinary tract infections and some of the medications that you give will affect uh diabetes, thyroid dysfunction is extremely important. Thyroid has a function on everything, especially in women. So if they've got, um for example, lichen sclerosis will get worse if their thyroid is not, um in range constipation is worse with thyroid weight gain. So all of these very, very important medication interactions also important cancers. You need to know if they've had any pelvic radiotherapy or operations. Obviously, if they're undergoing any cancers, for example, breast cancer, you need to think about it because if you're going to give them HRT, what kind of h ty can you give if they've got breast cancer, endometriosis important again, for pelvic pain and kind of the kind of pain that they're going to have postop operation because people with endometriosis due to prolonged disease have got disturbed pain pathways. And so that's something to think about obesity. Obviously, um, ears Danlos syndrome, it's important because they get pelvic laxity and they've got poor pelvic floor. Um and then bed wetting as a child. So if you wet the bed as a child, you're more likely to have urinary urgency as an adult. So, surgical history, um Cesareans, like I said, any surgery, particularly hysterectomy, you know, obviously, you want to know if there's a wound there. If there's a cervix there, what's coming down? Is it the womb or cervix? If either of those have gone, then it's obviously just a bulge coming down continence surgery including mesh. So if you're dealing with mesh, you've got to be very, very careful, you've got to scan them, um, to see where the mesh is, you've got to do a cystoscopy. You need to make sure that their symptoms are not caused by mesh in the bladder or in the bowel. Um, so we do basic investigations in our hospital and then we send them to Saint Mary's Hospital at Manchester Ro Infirmary, which is a registered mesh center. Um We don't take mesh out, they do prolapse surgery. So any prolapse surgery you need to know because if you're going to do repeat prolapse surgery, it needs to be discussed at a regional MDT and you need to be a little bit careful as to why it's failed. Um, if it's failed, then it's got a higher chance of failing. Again, bowel surgery is important. Obviously, smears and treatment to cervix. Extremely important. I recently had a patient who I did a vagina hysterectomy on. Um, this patient was actually put on the list by one of my other colleagues. I had not seen the patient before we do what we call pooled lists since COVID just to get through the Gyne operating backlog. So I hadn't actually examined this patient myself and she was on my list when I went to, examined her and try to do the hysterectomy. There was no cervix at all. Um So basically that she had that much treatment to the cervix that there was a, what I thought was the OS was a pimple. I managed to do the Hysterectomy that way. So you need to be very careful if they've had cervical treatment before drug history. Anticholinergics are very important because they make you retain urine. Also, they make your urinary urgency better. So you need to know, have they tried anticholinergics before? Then? There's no point in giving that again. HRT is extremely important because it's very good for women. Um And we encourage it and if they're not on some form of HRT, we, we tend to encourage them to go on HRT at least vaginal hormone um like vaginal estrogen neuropathic opioids, again, same effect on urinary retention and um and pain uh while they're taking pain medication. Anti hypertensive is extremely important because, um, a lot of medication we give has an effect on BP. Anti diuretics makes you go to, to the toilet a lot. So they need to know what they're taking and when they're taking it, are they taking it in the afternoon? In which case, not pain wise, long term steroids make your tissues go a little rubbish. Um, so that why they've got a prolapse. Um And obviously, if they're immunosuppressed, you need to worry about their operating on them. Um, social history, alcohol and smoking. Um, obviously sexually active. That's the most important question. Are they sexually active? And how important is that to them? Because some of the operations we do will affect sexual function. So we need to know, um and some of the pessaries we use, most of them are not compatible if you're sexually active. What's the kind of support they have at home? So we operate at Rochdale Infirmary, which is our kind of sister hospital, but is an elective standalone unit in the middle of Rochdale. Um, you operate there by yourself, um, sometimes with no gynecologist or general surgeon in the building. So you need to be very careful about who you choose to operate there. If anything happens, they need to be transferred out, they have a nurse led um overnight stay, but it's mainly for social reasons. So you need to be very careful about if you're operating on someone in Rosh and you're sending home home on the same day, which is what we do with all of our operating except incontinence, operating. We send them all home on the same day who they have at home. Um, are they able to get support care? Responsibility is very important if somebody says I've got a 90 year old mother who's 12, 12, 13 stone and I've got to pick her up and put her in a wheelchair four times a day. You need to think about if that's going to obviously affect their prolapse and it's going to affect their success rate. Occupation is very important. So, if they're a body builder, if um they work in a warehouse or they're lifting a lot of heavy stuff is extremely important. Exercise really important. So, ask about whether they um they lift weights. I had a patient who was a professional rower. Um And obviously with the rowing because he put in your whole weight um into the pelvic floor and there, there's a lot of bal salva maneuver. Um So she had a really bad prolapse. So you need to ask about that and you need to counsel them. You know, we set to this day that we carry on growing like that. Obviously, your prolapse is gonna come back. Um So there's some counseling um there as well, then others um try therapies, pessaries and pelvic physiotherapy, which we very much like um stress incontinence. Pessaries like a femia comp to form um supersized tampons. So these are very good. So you get them to put a tampon when they're going, walking or exercising or running and it works really well for stress, incontinence, cognitive behavioral therapy is very, very good for almost everything we do recommend it, but it's very hard to get hold up on the NHS. And obviously the most important thing, ideas, ideas concerns expectation. What do you think is causing your prolapse? What are you worried about? Is it symptoms? Um Some of my patients just say I don't care about the symptoms. I'm just worried it's gonna get worse or it's my whole organ is gonna fall out and you have to reassure them that their insides are not gonna fall out. It's very rare for that to happen. It's unlikely to get worse over time. It's not going to turn cancerous. Sometimes they just want to hear that. Um, an expectation. What do you expect from the consultation today? Um They might just turn on and say I just want the vagina not to be as dry. I want to be sexually active. I just want to leak a little bit less or if they come to you and say I want everything fixed. Um, and you turn back time 25 years. So you just need to know. Um, so urinary incontinence, um very simple, but you have to make sure you ask about everything. So do you leak or not leak? How often do you go to the toilet? When do you leak? So that's a very important question. Do you leak just before you get to the toilet or do you leak when you get to the toilet and you sit down? So of that change in position, how often do you leak? What makes you leak? And what makes things better? Um, is it key in the latch incontinence? So this is quite interesting when they're out and they think I'm gonna go home now, I'm go and use the toilet when they put the key in the latch, they start leaking. Um And that's a sign of urgency, toilet mapping. So wherever they're going, they're thinking, where's the toilets? Um first void of the morning is very important. Do they leak on the first void? Um So that could be a sign of stress incontinence because as they get up from bed, um do they leak small amounts, large amounts again? Very important. You have to find out what kind of leak they have is it stress? So, um changing position, coughing, sneezing any sort of increase in the intraabdominal pressure or urge. Um So you just leak without any uh reason or both, which can happen. Um You asked about some other things like postural, um like I said, bed wetting, insensible losses. Do you wake up in the middle of the night and uh you've soak through the mattress without even knowing about it and you leak on intercourse. Flow is very important. Do you, does it take a while for your week to come or when it comes? Is it a good flow or do you have to strain to push it out? Um As soon as you finish, do you feel like you've got to go again? Do you have to put your fingers in the vagina? Do you have to change position to be able to finish your week? Nocturia? Extremely important. So, twice or less is normal. Um So in anyone over the age of 50 more, twice is normal. So anything more than that, we consider abnormal, but they have to be sleep on either side of that urination. Um So symptoms of prolapse, very important, dragging, feeling, feeling of a bod back pain. And can they reduce that again? Can you push it back when you push it back? How long does it stay back? Fluid intake? And type is extremely important? Um So you need to know um what kind of things um they're drinking. So any caffeine fizzy citrus drinks, food, how much they're drinking? So, any more than 1500 meals, including what's in your food, um is too much and other symptoms, pain dysuria. So fluids um input output. So I'm I'm sure you can Google this. Um So it's a bladder chart when you put in Google it comes up with. Um So you do it over three days. Um So you tell them to get two drugs and one is for drinking and one is for peeing and tell them not to get them mixed up. Um It has happened before. Um So you get them to literally measure out what they pee out. Um So they write, for example, I woke up at 7 a.m. peed 400 mils and then they write when they leak. Um So when they went to the toilet, it was 100 mils leaked beforehand or leaked afterwards. Um When I'd cough, sneeze. So you kind of get a, get an objective description of what they're saying to you. Um And it's really, really important. It's one of the best things we use. Um And it gives you a lot of information. First void is the most important that first void in the morning is really good to know how much is in that jug when they pee in the morning because that shows the capacity of the bladder. Um So then we've got caffeine fizzy drinks, um alcohol, citrus food, spicy food, all of that. They need to avoid normal daily intake. 1200 above normal frequency is less than seven nighttime output. You shouldn't really be peeing out more than 400 meals in the night, less than three times at night as we talked about nocturnal polyuria. So if you think that your patient is peeing out a lot, you can actually measure that. Um And anything more than 3 33% of their full intake, then that's abnormal maximum void should be less than 500 mils. Typical void is around 250 mils. Um So like I said, clinical history, you then need to figure out does your patient have incontinence or prolapse or both? And which one is the bothersome? So you treat that one first, other causes, for example, is she going through the menopause? That's why she's leaking genital urinary symptoms. Um Has she got recurrent uti I? That's why she's leaking. Has she got frequency or she got bladder pain syndrome, which I will go through later. So based of questionnaires, I'm just trying to see whether I can um show you the, the questionnaire. So we are part of the British Society of your Gynecology. Um So I pay them a certain amount of money per year and they keep a register. Um And they basically keep a tab on us really. So any patients that you see, you've got to put on that, we suck. You put their names NHS number, hospital number and date of birth, you've got to get the patient's consent form for that. Um They sign a consent form, they say it's fine. Um And I normally tell the patient it's a database. Um It keeps a tab on us rather than you. It's just so that they can see who we treat and are we treating them well. And according to guidelines, um and B has got its own questionnaire. So they've got a vaginal symptom questionnaire, um where it basically goes through uh 10 questions about quality of life. Um And it gives a score, for example, how much is your quality of life affected 1 to 10? Um And in terms of um effect on sexual life, um how much you're leaking, do you have to put the prolapse back, that sort of thing? So it gives you a score at the end. So you get an idea and objective measure of how the patient is and then when you operate on them or you treat them, you bring them back to the clinic and you get them to fill out the questionnaire again. Um So I just, I could just show you um one of these, I, I think I had it on here actually. Uh If you could see. Um So I'll just show you an example if I can be able to see that. Yeah. Yeah, fine. So that's for example, a a bladder chart there. And then, so that's the bladder diary, for example, um how much they drank? Um What kind of volume? This is just what I found on the internet. We have exactly the same one. Um And then you can, this is a vaginal symptom questionnaire from cell. Um So you write the patient's number there. Um And you get a score um for example, up to four and then you calculate that at the end and it gives you a cumulative score and you put that in your um So there, so you get a total vaginal symptom score um and you get sexual matters um score there and then quality of life. So you put that all in b um database um and it's very, very good um and just going to see, OK, so um Uroflow um so this is these are all the things that we do before we even see the patient in clinic um or sometimes during the clinic. So I always have one of these machines in my clinic room. Um A uroflow is basically a special toilet where the patient sits on it and they pee into a pot. The pot is on a weighing scale. Um I try to get uh the best explanation. Basically, it measures um the weight of the urine coming down and it measures it per time. So it gives you a graph of urine flow in mils per second. So it's very, very important piece of information. So that's exactly what we've got in our clinic room, which is a chair um with a little machine and it gives you this kind of printout. So it tells you how long the patient took to void. So for example, that's a normal voiding pattern. Um It's a little bit prolonged because it took that patient about 45 2nd to finish their void. Um which is, you know, it should really be voiding time shouldn't be any more than 30 seconds because we are um mammals and we are prey. So the way our body is designed is you should finish your void. For example, when you're in the jungle, you should finish your void under 30 seconds. Otherwise you get eaten by a lion, that sort of thing. So that, that's where that 30 seconds come from. That animals tend to finish their void within 30 seconds, um, flow time. Um So 17 seconds, for example, that's normal, voiding time. Um And then we've got time to peak flow. We don't care about that as much peak flow is really important. So how much they manage to um get that um bladder contraction behind it to be able to produce that nice speed of flow. So that's really, really important. It gives you an idea of the function of the bladder muscle. Um So there is 19.8 milliseconds. So anything above 15 is normal, anything over 25 you're slightly worried about whether they're pushing against an obstruction. Um That's more common in men. OK. So, voiding dysfunction, uh like I said, that was a really nice bell shaped graft and that's what we're expecting. If you see an intermittent one, it might be because there's prolapse and it's coming and going. Um So that's interrupting the flow again. We're not too worried about that as long as they finish all of their we within that, it doesn't matter if it's intermittent and if it's prolonged, sometimes we think whether they've got bladder hypo activity, um does the patient reduce the prolapse the void? So if the patient says I normally put my fingers in the vagina to be able to finish my wi then I always say to them, please do whatever you do in your own home to, to produce your urine. So I normally leave the room and they can do what they want because you want to get that real life presentation of what's going on normal range. Like I said, more than 15 mils, abnormal flow, prolonged or intermittent. And then afterwards we have a scan machine and we scan them, we just scan them over the tummy. Um And it should be less than 50 mils really left in the um in the bladder. That depends how much they pass. If they pass 500 mils, then less than 200 is normal. Um But if they past 100 mils, then I don't want any more than 50 left over. Um Ideally, um some people say that low is not valid unless you've voided 150 mils. That isn't true. Um It's still valid. It's just that the studies that they did was on void of 150 mils. So post void retention is very, very important. You have to think if your patient has weed 100 males and is retaining 200 anything over 200 you have to start to worry um because you need to um offer them, for example, intermittent self catheterization after you've ruled out other causes because you shouldn't be retaining that much. It can damage your kidneys, it can give you urinary tract infections. So I had one patient that we never got to the bottom of why she was retaining urine. Um So we did a cystoscopy, there was nothing in the bladder. She didn't have a prolapse. Um, so then I went down the route of, I checked her thyroid function, um, diabetes, vitamin B 12 deficiency. I went through all of her medication. She was on gabapentin, but that was the only reason I could think as to why. But other than that, we never got to the bottom of that. Um So we then test that urine. Ok. So that's really, again, an extremely important part of your consultation if they can't produce urine. Um, I normally make them wait around, um, till I've seen a few more patients get them to drink lots of water. Um, and then do the whole thing again. I don't tend to let my patients go until they've given me urine. Um, so glucose. Um, I don't worry too much about it. If they're di diabetic, then we know why. If they're not diabetic, then I'll just get them to get it repeated by the GP. And if it's still there, then the GP can, uh, investigate if they have blood that this is really important. Um If they've got blood and urine dip, everybody panics and sends them or you might have bla bladder cancer, you need to go for a cystoscopy urgently. It's not quite like that. Um So if they have blood on the urine, we normally send that urine sample to the lab called microscopy. So, non visible hematuria, which is um basically uh microscopic hematuria doesn't mean urine dipstick positive for blood. It means when you sent up for microscopy, it showed under the microscope that they have more than three or more red blood cells on that screen. Um And with that, the chance of cancer is 3%. No, that's why I sent to the lab and then I'll wait for them to get back to me. And if they say no, there was no blood, then you can test it again at six months. Ok? Make sure that there is no blood. If they do have um blood on the microscopy, then you need, you can think about whether you want to send them to um cystoscopy. If they have more than 10, send them if they're over 50. Um um if they're over 50 send them or if they have risk factors, we have a 25 year old who smokes, send them if they have no risk factors. And if they're under the age of 50 you can always repeat it as six months. Um in terms of nitrite glucoside protein, um the nice guidelines is very vague about this. It's quite hard to get your head around. Basically, it says consider antibiotics, it's up to you. So, my patients, if they are symptomatic, I treat them ok. Even if they don't have um, anything on their urine dip. If they're symptomatic of a uti I, I treat them. Whereas, um, the nice guideline says send them issue and consider treating if they're asymptomatic but they're nitro is or leukocytes positive. If they're nitro is positive, I always treat them. Um But if they're leukocytes positive depends if they're leukocyte positive. Nitro is negative asymptomatic. I might wait for the MS S to come back and consider antibiotics. Um If they're symptomatic, like I said, I always treat them if they've got protein, consider renal ultrasound because there might be something wrong with their kidneys on examination. Now, this is the kind of thing very important. So um in our Uro Gyne clinic, we have a I I make like a Uro Gyne examination kit. So we have a kidney dish, we have a pop Q stick. So you can see that one on your screen. Mine is not quite the actual branded pop Q stick. I just ordered some tongue depressors and um me and my colleagues sit there and we're not doing anything um and mark them 1 to 10. Um And we have some Ky jelly um and a sin speculum as you can see over there and these are the things we use. I use a lithotomy chair. Um You can either use a lithotomy chair, but the actual um guidance in Uro Gyne is to always examine your patient at left lateral position in Valsalva. So ideally is valsalva maneuver. So either get them to cough, um or you get them to bear down. They really can't do either of those I've had patients where they can't produce a cough um or they can't quite um understand what that means by pushing out. I get them to hold their hands really tight and pull on that and then I get them to clench their teeth and that sometimes just relaxes um the bottom. Um But yeah, I use a lithotomy chair just because if I'm going to operate on them, that's the position they're going to be in the operating room. So it's easy for me to see whether it's operable or not and don't ever forget the abdomen. So you need to check for masses. Um and any scars. Is there a cancer that's pushing down? Hence causing the prolapse and never forget the abdomen. Um Body mass index, extremely important. I don't know where you are. But unfortunately, in the UK, we hardly see anybody with a BMI less than 30. Um So that's kind of that our norm. Um Uro Gyne kid, like I said, we use infections. So always look for things that come with Uro Gyne problemss. So most of our ladies are older ladies. So they have vaginal atrophy. They've had a few Children, episiotomy scars. Their perineum is deficient. Have they got anal pathology? Um Have they got urethra pathology when they cough? Do they leak on you? Um Lichen sclerosis obviously look for. So, examination, uh pain is not something to be discarded. It's very important um that you, first of all explain you exactly what you're going to do. We had a case where a patient um complained and it went really high up actually that she said she consented to speculum, but she never consented to a bimanual or a Uro Gyne exam. Um So you need to be very careful. So you need to tell them I'm going to use this, which is your speculum with some gel and I'm gonna take some measurements. I'm going to put my fingers in the vagina and I'm gonna ask you to be in an unusual position. It, I'm gonna last for a couple of minutes at any point. If you feel uncomfortable, just say the word stop. And I think that that has been working for me for the last few years. Um Pain again, like I said, do not ignore it. It's extremely important because if they have pain on you just examining, you need to think about. Is there a disturbed pain pathway here that you're gonna operate on? Are they gonna be uh a candidate for chronic pain? Why do they have pain? Is that something you need to correct before pop Q I will go through that. Um So that's an objective way of measuring uh a very subjective prolapse. Um Urethral hypermobility is extremely important, quite difficult to examine. So you just get them to cough and you can see the underneath the urethra if you could imagine a band or a hammock under the urethra that comes out if that comes out, that means they've got urethral hypermobility. Um Always look at the cervix. If they've got one, you don't want to miss a cervical cancer. Um by manual, like I said, to assess the size of the uterus. Very important. If you're gonna do a vaginal hysterectomy, make sure the uterus is not too big that you're gonna be able to get it vaginally. Um Oxford grading score, obviously, that's for pelvic floor. Um So it goes 1 to 55 being very strong and one being barely anything. So most of my patients fall in the 223 category digital rectum exam if needed. So this is pop two. Now, um it's quite difficult to get your head around. Um Only 40% of us actually use this. Um I know how to use it because it was the only way I learned from the beginning when I was a trainee on campus. That's how I learned. But um a lot of my colleagues and a lot of my older colleagues don't use it at all. So I wouldn't get too bogged down with this. But the way I describe it, it works for me because I can imagine if somebody says to you a, a which is the front bit of the front wall is plus three, for example, then I know that they mean, the cyst sealed, the bladder is coming down to three centimeters below the level of the. Hi. I can imagine that in my head. Whereas if somebody says to me, to me, grade three prolapse, what does that mean? But if someone says his cervix is at plus five, I know that the cervix is five centimeters below the level of the hymen or if they say posterior wall is minus five, then I know that there is no prolapse because it's minus five. Ok. Um PB obviously is a per in your body really important. That's from the for today that, um, that's important to know if they've had previous surgery. Sorry. Um, and then genital hiatus is very important. That's from the urethra to the poster hymenal ring. That's important if you're gonna do a vaginal hysterectomy. Um I would want to know that because if you're telling me that's one centimeter, I wouldn't even be able to move your fingers in to be able to get this um, uterus. Ok. Um So, like I said, only used by 40% of us difficult to learn. Um, when I was starting to learn it, when I was a trainee, I used this pop Q tool um on the American Society of Uro Gyne and it, and it saved my skin quite a few times. So this is what the normal pop QE is. The bladder is three centimeters above level of the hymen cervix is five centimeters above the level total vaginal length. The vagina is 10 centimeters long, perineal body, three Genis, two posterior wall, three centimeters above the hymen. So if you ever have this in your exam three is a normal number. Um And then the others are quite easy to get your head around. I just wanted to show you if I can get the, the pelvic. Um If I'll show you the tool, it's really very, very good. Um I've always really enjoyed um using it when I was a trainee and you basically can put anything in there and it tells you um of what kind of pub Q it is. And I used to use this to cheat a lot. Um I don't need to use it anymore. Um I'm grateful to say, but for example, you can go on the website and you can use this for free. Um So choose a prolapse. For example, if somebody tells you they've got um you try and stage three. OK. What does that mean? So that means as you can see the uterus is hanging outside of the body. Um So a a which is the anterior wall is plus two. So that's, that's the hymenal edge. So A A is plus two. So that means that look, the bladder wall is coming down ok to two centimeters below the level of the hymen. Uh B is the back part of the bladder. That's the bit that's coming down. Um Cervix is four centimeters. Cervix is here. So it's four centimeters below the level of the hymen genital hiatus is that whole thing is five, perineal body is one centimeter T bl is um 10 and then A P is two and two. So the posterior wall is two centimeters below the level of the hymen. Ok. Sorry, just bear with me. Where was I? Ok. Ok. So criteria for a referral to UDS. So UDS is um called Urodynamic studies. Ok. Um So this is a special, again, it's a special study that you uh put a catheter in the bladder and a catheter in the rectum and you hook it up to a machine and it's very clever and it tells you whether they have urinary urgency. Is there something wrong with the bladder or not? And that's really important to know because if you're going to offer somebody Botox BMI surgery and you haven't corrected what's wrong with the bladder, then you make things worse. So, when do we refer for urodynamics? If anybody has had treatment and nothing is working, you've got to say, have I got the wrong end of the stick here? If you're going to do any procedure on them. So with Botox and surgery, um, for incontinence, nice guidelines if they need to have uds. But for VOLTA it, we do us in our unit. Um, just because we consider that relatively invasive. So you don't have to have any necessarily black and white reason to do UTS, but it's better to do it than not to do it if you know what I mean? Um, prolapse with urinary symptoms. Some places, anyone who's got urinary symptoms and happens to have a prolapse, they do uds on that is a really good practice. But unfortunately, we don't have the slots and the manpower to do that complex symptoms. Again, some people that you just don't know what's going on, um I bring them back for uds. It's actually quite a good thing because your gyne appointments are 30 minutes. Uds is an hour. So you get to know your patient very well. Um So I sometimes just bring them back for that reason just to have another look to have another chat just to see what's going on. Suspected voiding disorder. Definitely uds. Is there something wrong with the bladder previous unsuccessful incontinence surgery? What's happened? Um, why has it failed? Um, and a neurogenic bladder disorder. So anyone with MS Parkinson's stroke, quite bad diabetes, I tend to bring them for urodynamics. So, hemodynamics, um, that essentially what they look like. Um, so I do them in a sitting position, you examine them beforehand because sometimes you have to reduce the prolapse. So you put something inside the vagina to be able to do your study. Um You put a sterile cast in the bladder and a normal cast in the rectum. You don't have to have sterile gloves for that. Obviously. Um It measures the pressure in the abdomen, the rectum one and it measures the pressure in the bladder. Um, the bladder pressure, which comes from the detrusor pressure is actually a complete um calculation. It doesn't actually exist. So that's abdominal pressure, minus the bladder pressure. So this is this is something that I created for myself. Um Just so that I know all the values I didn't know them off my heart. So I created this for myself. So you're right. How much you put in them? For example, we put normal saline into the bladder at 50 mils per minute. If you've got a little old lady put it at 25 because that itself putting the, a lot of uh water into the bladder can cause urgency, abdominal catheter either in the vagina vagina erection, make sure your pressures are all OK. Um And then position that filling you then say to them the way I describe it is um Tell me what's your favorite shop in Salford? It's normally TK Maxx or Aldi. Um So they say I'm an Aldi, I'm looking around, I'm like, OK, so you're in your favorite aisle. You've got your basket in your hand. Um, so tell me when you feel that, oh, I might, I might need a wi or is it that I need a wie, that I first sensation? So when they tell you that you mark it on the, on the graph, on the computer and then you say to them, so tell me when you feel like, oh, well, I, I really want to know where the toilets are and that's your first desire. And then you say to them, tell me when you would put your basket down in the middle of the aisle and run to the toilet and that's your strong desire. And then we'll see how much we can fill them maximum capacity and then we get them to stand up. Um And this is a very um degrading process for both the patient and the practitioner involved. So you've got to warn them about that. So what normally happens? A patient stands up and stands on an ino sheet, you sit down or you kneel um and you hold the tissue in your hand and put it between their legs and you get them to jump up and down. And if you, if they leak on your hand, then that's stress incontinence. Um And if they don't leak, then it's unlikely they have stress incontinence. Sometimes you can't produce their symptoms in the clinic. That's something to be wary of because it's an artificial um setting. So for example, this is a normal one. Ok. So there is no leak here uh with coughing. So if you get them to cough every two minutes just to make sure the test is running. Ok. Our machine is very temperamental. So I get them to cough every minute because I'm worried about the machine um playing up. But so for example, here there's no leak. Um and there's no rise. You see that flat line that I'm not too sure what that is, but I'm not too worried about that. So that is a flat line. That means that the calculation from that to that is essentially baseline zero. There's no rise in detrusor pressure. Her bladder is stable. And then at the end, obviously, she, she causes this massive detrusor contraction, which is a good thing to be able to empty her bladder. So that's normal. This one is a stress incontinence, it leaks during cough. But again, it's essentially normal like the normal trace. But the only thing is she leaks on the cuff. But otherwise, it's a, it looks like a normal trace. A very uh stable bladder pressures are good, but she's leaking every time she coughs. This is the true overactivity as you can see. So there is the bladder pressure is going up, the abdominal pressure is not going up and there's a mass of detrusor contraction for no reason. Ok. Sometimes they leak just after a cough. So you need to be careful that if the increase in pressure is just after a cough. That's actually the true over activity, not stress. So then you make a diagnosis. Um Is it the truth over activity? But they're not leaking, they choose over activity. They're leaking. They've got stress incontinence, they've got stress incontinence and the truth overactivity. They've got the truth of activity but they're not leaking and they're not feeling it. So you don't need to do anything about that sensory urgency without the they're feeling the urgency, but the trace is fine. So, um urodynamics is, is really quite difficult. It takes years to master, but once you're in the room and you can judge what's happening. Um That's why we recommend that we do all of our own urodynamics. So for example, that wouldn't like to send my patient to another person to do the urodynamics and give me the result because I wasn't in the room. Ok. So criteria for other investigations, this is really important. So, cystoscopy, um some recurrent uti s, you send them for a camera test. Um So we do all of these as outpatient. Um I'll go through which ones you send for a camera test. If they've had mesh surgery, you need to be careful because you need to make sure it's not mesh in the bladder. Um, renal stones. So, if they've had any history of stones, I send them um for um renal ultrasound because our worry is that the stones are causing the urgency protein urea renal ultrasound, defecating procto gram. So this is a bit of a gray area. There is no absolute guidelines on who you send for procto gram. But for me, if they need to digitate, if they need to put their hand into the rectum to empty the feces, I need to send them for an um procto gram just to make sure they don't have intussusception um which is very different to a prolapse. So prolapse is um basically the muscle is giving way. So the rectum is coming in the vagina. But with intussusception is rectum is going into the, it's not going into the vagina, it's going to prolapses into the rectum. Um and that you cannot correct with surgery, pelvic MRI I've ordered before to see if there's any mesh anywhere. Um And the transvaginal ultrasound, I like um I because I use it to assess the size of the uterus prior to vaginal hysterectomy. If I've got a young patient, I always make sure that the uterus is not too big before embarking on a vagina hysterectomy. Uh The last thing you want is urine ro there by yourself and you can't get that uterus out of the vagina um kind of a referral to other specialists. So us and urologists work very, very closely together. So they refer patients first, we refer patients to them. We work on MDT colorectal. I like to involve my colorectal colleagues quite a lot. So I discuss a sort of fecal incontinence, intussusception, irritable bowel disease, um, sorry, inflammatory bowel disease. I discuss with colorectal team. Um, it would be really good if you have a colorectal pelvic floor surgeon on your MDT. I happen to be married to a colorectal pelvic floor surgeon, which is very handy. But if you don't have one at home, then it's a good idea to get one on your MD T. Um, clinical psychologist. Um, so anything related to mesh pain, that sort of thing. I refer to clinical psychologist, pain specialist, menopause specialist. If you're lucky to have one in your year, we don't have one. So we do all of our own menopause. Um endocrine extremely important. So if they've got thyroid dysfunction, things like that, I do like to, you know, get um endocrine involved. Dermatology is important if they've got refractory lichen sclerosis, it's nice to get them involved. And geriatrician very important. We used to have one on our NDT. So if you can get any of these people on your multidisciplinary team meeting, even if it's once every six months, then you can collect all your cases and discuss it at that one setting, urinary incontinence or how we gonna treat it. Obviously conservative is always good. So, weight loss, if they've got BMI over 30 none of my patients listen to me when I tell them to lose weight, but you got to say it um over 35 we have a um better life. I think it's called, um, where you send them for, um, some kind of weight loss program, um, which we have in SULFA, which is very, very good smoking cessation, obviously. Um, fluid modification, like I said, 1200 mils of water, um, try and avoid tea, coffee. Um, and if you go to do that practice what you preach. So, um, I quite like diet Coke and coffee myself. But when the patients coming in, I try to kind of hide my mug behind my laptop and I tell them that it's decaf but, you know, don't, don't have your diet cokes flying around when the patient comes, um, pads. Um, if they can always just carry on with pads and we do have a funding, um, procedure in place for that in Salford. Bladder retraining is really important. So that's one of the first things we do. We send them for bladder retraining. If you don't have that in your department, it's quite easy to get a lot of information online. The other thing is, for example, you say to them if you feel like you need a wee, but you've just been to the toilet, you're in a restaurant or you're in somebody's house and you're sitting down and you feel like, oh, gosh, I need to go to the toilet again. You know, you don't need to because there's nothing in your bladder. You just tell them that it's going to pass and I promise you, it will pass, but you need to persevere. So you get them to kind of hold their tummy and bend forward and that increased pressure in the abdomen and the perineum would um resolve the urge. So you just get them to do that and sit and count back from 10. And that normally resolves it or if they're outside. Um I tell them to sit and puts their bum on a sharp edge of a table. Um, and that normally resolves that urge, um, by putting a bit of perineal pressure, it works the same as, for example, when you see toddlers and they need, they need a weed, they kind of put their hand on their perineum and that's what they're trying to do to stop their, um, the urge pelvic floor exercise is extremely important. Um, and we'll do that through our physio public toilet app. We have that in the UK. Um, and it's free. So, you know, where all the public toilets are and NHS Squeezy app, it's extremely good. So it's two lbs 99 and it, and it's, um, through the nice guidelines and it basically tells you how to do your exercises. It sets reminders for you. It's very good. I normally tell them to download that app after they've been to our physio. Um, if they've got stress incontinence. Um, one of the other things that works really well for conservative management is we use these, um, pessaries quite a lot. So II I, if they're young and they don't want to use a pessary, I understand. So, um, we normally tell them to use them like an oversized tampon, an extra large one, during exercise and that apparently works very well because it keeps the urethra um same principle for the F MA or conform. These are available on the NHS. Um And our patients like them a lot. Um You can use them up to 16 hours a day and you just take them out and wash them and put them back in medical vaginal estrogen. Um You've got to be careful with peanut allergy. Um If you're going to give them estradiol cream, but we use Vagifem or ragiv. So, Vagifem is quite expensive. It's environmentally not very friendly because it comes with each tablet comes with a single applicator. Vax is an applicator and you put the tablet in and then you wash your applicator. You have to use that at night for six weeks and then twice a week for life. It rejuvenates your bladder urothelium, um and urethra. Um So it works very well for stress incontinence. You can use it in breast cancer patients. Uh even if they're on Tamoxifen, but aromatase inhibitors, there is some um concern regarding their safety, but if they've finished their treatment with aromatase inhibitors, um like letrozole, then you can put them on Vagifem, not a problem at all. Um DULoxetine, um we don't tend to use it. It doesn't have um very good reputation because of the amount of side effects it gives you surgical. So then, so for example, nice guideline says you have to offer surgery first before bulking agents. But the nice guideline was prior to BMI, which is a certain brand of a bulking agent, which works really well. So we tend to offer bulking not first, but we kind of encourage them to try it because this is less invasive than having an operation. And we always say that, um, if bulking doesn't work, you can always have the operation. Um, so the surgery is in the form of the mesh, for example, the tape, um, which I'm sure you all must have heard of. Um, there is a mass mesh scandal in Scotland and the UK and is banned in Scotland, but it's not quite banned in the UK. Having said that it's under such high, um, litigation and vigilance at the moment that one of my patients wanted a mesh tape. Um, our unit didn't agree to put it in and I couldn't get anyone in the region to put it in either. So, even if your patient wants mesh, it's going to be difficult for somebody to agree to put it in, in the first place due to his risk of complications. Um, but we used to put them into everybody back in the day. Um, then auto specialist slings open or lab call po and then surgery MDT, like I said, is really important and A B data base urethral bulking ages. So this is a very short procedure. It works quite well. Um, you basically to put three incisions into the urethra, as you can see, that's the kind of image you can get down there like a little pillow on the side there on your cystoscopy. It's a little bit fiddly. Um, but it's good to do. Um, and it's essentially 97.5% water. It's exactly the same as lip for this. It's the same agent. So it's meant to be permanent, but mainly top ups. Um Most of our patients, one of our patients has gone 3 to 4 years um without needing a top up, which is good. Um, risks are very, very small. Um We've never really had anybody with any, any complications afterwards, which is good. The complications that are documented. I've never seen them in real life. So granulomas migration, never seen them, never seen UTI with them. Either success rate is over 80% but can go down to 60% at two years. Like I said, the filler might move or loses its effect. I'm not sure whether it's weight gain and people never get thinner, they just get bigger. Um And some people say whether it's cost effective because if you're going to repeat it and repeat it and repeat it. Um So that's that operation for stress incontinence, not um, log conscious thing is something that we do in our unit. We like it. Um You only stay one night overnight because you don't actually go inside the peritoneal cavity. You stay on the outside. So you cut the skin like a Cesarean. Um You get to the sheath, you, you get a really nice strip of the sheath and you close it back up, close the sheath back up. So there's a small risk of hernia because obviously you've taken one centimeter away of the sheath, you bring it down, you put it on two hooks and then you cut the vagina, you put the hooks, um, under the pubic bone around the bladder. Um, risk of bladder injury is quite high. Some people say the risk of bladder damage 10 to 20%. Um, I have personally damaged the bladder twice with, um, fascia sling for whatever reason. I it's just when you put the hooks, it's, it's blind. So it's quite difficult if they've had previous surgery. Um, you can damage the bladder. So you need to warn them about that. But if you damage the bladder, um, you do a cystoscopy, you can see a hook, you take it out. Um, you try again and hopefully you don't do it again. Um, and then you just leave the catheter in for 10 days, um, and then remove it in 10 days and then it's normally, ok. Um, so I'm just gonna see if I can show you this um this video, I'm not sure. Uh If I can, if it comes up for you guys, um It's quite good. So it just shows if I just show you the, so if I show you here, so that's the thing as well. I would. So, yeah, so that's the way OK, we divide the skin and subcutaneous tissues. The big one is I the muscles of the work of the discussion and then the got you. So right, the took off for pass of the thing three and the P session, this is secured by using an suture therapy. But we, we kind of at this point, she's got tissue. So that was basically what that was. Um it just goes through the sling and then you take it, excuse me, make sure it's not too tight. Um And we use absorbable sutures because it's the scarring that would eventually cause the um um tension and then at the top, you, you kind of um tie the, the two ends on the top of the tummy together again, not too um not too tight and then just suture the skin and then suture the vagina a bit and then hopefully not damage the bladder in the meantime, um open or uh lab close. So we do a lot of open. It works very, very well. Um So again, it's similar uh entry to the fascist thing. You go on the, the triangle of Breus and you get your um iliopectineal ligament, which is also known as the Cooper's ligament and you just stitch it to either side of the bladder into the vagina and, and suspend the, the bladder and it works very well. Same efficacy. Um, depends who's, you know, you have to decide to a certain extent which one will be a better candidate for which one, but also patient's preference. Ok. So urinary urgency. So these are the posters that we've got in our uh department and we have it behind the in the toilets just where when, when you sit down um to have a wee is right and your eye contact there. Um and I give them to my patients. So like I said, on the left side, the yellow bit try not to have a lot of those in your uh in your room when the patient comes in modified fluid intake, bladder training, like I said, vagina and estrogen um first line um like I said, estrogen restores the integrity of the bladder tissue. Um and it works very, very well. 10 microgram once at night, that's for six weeks to build up your levels and then twice a week. Urinary urgency. Uh so to treat urinary urgency, you can attack it at various points. So you've got the spinal cord S two to S four, the preganglionic parasympathetic nerve, then the postganglionic parasympathetic nerve. So if you do the spinal cord, one, you can have S MS modulator put in and then you can have um then the postganglionic um you've got the anticholinergics, obviously, for example, Solifenacin um works very well. You can increase it to 10 mg. Um You have to warn them about side effects, which is dry mouth constipation, blurred vision, tell them it takes a few weeks, but the side effects tend to wear off, but at least four weeks to work if they have side effects or you're worried about the patient's cognition, you can try ones that don't cross the blood brain barrier. Like my very old patients, I've given tamsulosin or uh Feidin oxybutynin. You have to be careful with um anticholinergic side effects and effect on cognition. You have to avoid it in over 65 but it works really well for genital symptoms of menopause. So if you have a young patient, oxybutynin is a good option and it comes as a patch as well. Um beta receptor agonist. So that's myogram. Um And it basically relaxes the bladder. Um And you can start at 25 mg, you have to be very careful with BP. Um You have to check it out one week, a normal BP, women tend to have smaller vessels, so they have to have a lower BP than men. So really, uh if their BP is over 100 and 40/85 I don't start mybe make sure you measure the BP in the clinic desmopressin. If they've got nocturn polyuria, we can give them desmopressin. Um So again, things that are more invasive. So if none of that has worked, you take them to your MDT and if the MDT comes back and says, try this, try that and sometimes they say try bladder Botox. Um So that's basically the picture. Here you go in with a cystoscopy. It's really easy. You put um uh like a little catheter in with a needle at the end, you put 100 units of Botox. Only the Botox brand on unfortunately, is licensed by night for some reason. Um It's the only one that's mentioned in night. So you can just put um so for example, you can put nine points in the bladder. I put nine points, but I know some of my colleagues just put the whole thing in one go in one area. Um And it works just as well. Um You have to be, be careful so that you're not too superficial and you're not too, too deep because otherwise you're going to be on the bladder. Um So it, it takes a, a few sessions just to learn it. Sacral neuromodulation is very good. We do it at SFOR so you do have a trial period where you, you put it uh under dr anesthetic. You put a device that stimulates um the S 234, the S3 is the most important. Nobody really knows how it works. Um But it's apparently stimulation. Um that works. Um If they, if they climb Botox and the SNS, then you can offer them uh percutaneous tibial nerve stimulation. It works the same as um SNS really, it's quite labor intensive. You need to have the staff for it. Which, which is why we don't offer it at some point, we don't really have the staff for that sort of thing. It's for 30 minutes a week for eight weeks. Um The patient needs to have the time to come and sit for half an hour every week, for six, for 6 to 8 weeks. Um um And you have to have the staff recurrent uti. OK. So this is something that you see a lot in your Gyne clinic. The definition is two or more in six months or three or more in a year, identified trigger factors. For example, if this just happens after intercourse, give him a single dose of antibiotic or apply Vaseline to the urethra risk factors, diabetes. Obviously, Parkinson's anything that causes urinary retention, urinary incontinence, cystocele renal disease. Um And then you've got self-care. So I love the manos. Um We give one g twice a day and one g, three times a day if they have an active infection. Um one g twice a day is prophylactic dose. You can get it from herbal shops. Um Cranberry juice, which obviously, we all know about Hiprex. We also give again, this is a nonantibiotic we're trying on estrogen. We love it, we give it, um, antibiotics obviously and be at six months. Who do we refer now to urology? If you've treated them and they're not getting treated, then you refer to urology. Is there something going on? Is there a cancer in there or something? Um, if they have, if they're over the age of 60 whether you should refer them anyway, because of the risk of cancer if they're over 60 they've got microscopic hematuria and dysuria or raised blood cells, refer them if obviously got Frank Hema, refer them any history of bladder stones, kidney stones, symptoms of fistula or obstruction, we refer them. So they're quite um common sense really prolapse just quickly, I'll just go through this. So prolapse. If you see it, even if you see that, please don't mention it unless the patient mentions it. We get a lot of inappropriate referrals from GPS or other specialties saying that this lady has a prolapse and the patient comes here really distressed. I didn't know how a prolapse I wanted gone. And you say to them you didn't know. No, my GP told me. So we're not really grateful for the GP telling them that. So please don't say anything unless it's bothering the patient. Ok. Um So you have to know with prolapse ideas, concerns expectation. Again, if you didn't know it was there and it wasn't bothering you, you don't need to hear anything about it. Um Options are do nothing um pessaries, which we have a huge range of pessaries. Um The ring is actually not on there, but the ring is essentially that without that support, it's the only one that you can really use um with intercourse. Um Then that's the cube again. Um You can use that with intercourse as well. You take it out. Um We, we use these quite a lot, we like these, these are called Gellhorn. Um And then physio if it's not gone, uh more than one centimeter below the level of the hymen, if it's more than one centimeter below the level of the hymen, it's left the pelvic floor, there's no use sexual activity, um Conservative management again. Um Like I said, physio, pessary, the puppy trial, we give them a ring pessary and they change it at home themselves every six months. Colonic irrigation is another one. So if they've got a rectal prolapse, some of the rectal surgeons give colonic irrigation before o before operation on them surgical management. So front floor cystocele anti repair go through the pros and cons. We do as they case, we follow them up the next day. The physio rings them, see how they are. I see them at 3 to 4 months in my clinic. I examine them and um hopefully tell them there's no prolapse. If there is a prolapse, I don't say anything until it's, unless it's bothering them. 30% recurrence rate. 10%. The nervous stress incontinence extremely important to tell them because what happens is when they cough at the moment, the cystocele comes out and blocks the urine. If you take that away and they cough, urine will leak dyspnea, rectocele, constipation, diagnose and manage roll of procto gram. Like I mentioned before, when to involve colorectal surgeons, poster repair, 30% recurrence may not correct the constipation. You try prola. So there's various different options. You've got vaginal hysterectomy Manchester repair. You take the, just the cervix away. We don't tend to really do it. They love it in places like um, Denmark, sacrospinous Hisle. So I've uh offered one of my patients that this week. So if the, if the uterus is very, very small, um then, um, you don't have to remove the, the, uh the uterus so you can just stitch it to the sacrospinous. Um You can also do sacro colpopexy with mesh, um then vault prolapse afterwards. They can come back through with the vault prolapse. They can offer them sacro spinous fixation. You can offer them colpocleisis. If they're elderly, then do not ever want to be sexually active again and you basically close up the vagina. Um, all done as their case is under general anesthetic. We don't use a pack, we don't use a catheter. Um This is Rochdale for me. This is a lovely little hospital. Uh, but if you have complications there, you need them transferred out just a little bit about constipation. Um you need to be careful of red flags. So if they've got change in bowel habit, weight loss, if you feel a mass, obviously, you refer the Eat Well guide is a really good guidance on how to avoid constipation. So it's concentrated on Mediterranean diet, high fiber diet. You need to build up 10 g a week. Not, don't just start on 30 g a day. Um, exercise there sti potty. I want to show you a video which is really interesting uh Publix toilet app which I described to you before. First line treatment is bulking laxatives like fiber gel. Then second line osmotic like macro which I quite like macro. I give it to a lot of my patients. Third line is lactulose. Um And then fourth line is uh bid and glycerin supposits if you need, consider that medication. Is it caused by, by that? I always check my patient's thyroid function. Hb A one C um use these um neurological conditions, obviously comes from the history structural, always check the rectum just a few things about bladder pain syndrome. Um So it used to be called interstitial cystitis and painful bladder syndrome. It's um an exclusion. Uh diagnosis of exclusion is, is not really a diagnosis that you first make. Um it's more than six weeks duration of unpleasant cation related to the bladder. It's associated with a lot of other painful things. Um like endometriosis, fibromyalgia. They normally I've had the past history of chlamydia, you have to fill out a diary of symptoms and bladder symptoms. Um when you examine them, you check for tenderness. Um but you also, as, as I said, you di it's a diagnosis of exclusion. So you check everything for everything else and then you send them for cystoscopy again to exclude it, not diagnose it. Um And then you finally say they've got bladder pain syndrome. Um you get them to know their body. So you do a food diary, bladder diary, um avoid uh caffeine manage stress, refer to the pain team. Uh Medical management, amitriptyline works very well. Um cystoscopy works very well. Um And we also give um hy which is sodium hyo eight which is the same as intravesical hyaluronic acid. Um We consider SNS in um in very refractory cases and oral cycloSPORINE pain. I've never had to do a cystectomy in somebody who's uh who's got bladder pain syndrome with vaginal atrophy. You will see it in almost all of your elderly patients. So conservative management, it's a nonhormonal. We love the SVM gel uh which is available on the NHS is a nice combination of oils and minerals and is nonhormonal. So it's repellent. So it's silk. Uh we acidify the vagina with lactobacilli. So when they've done a recent study where they've compared the vaginas of 20 year olds versus postmenopausal postmenopausal have got a lot less lactobacilli non estrogen treatment. So, I've given one of my patients Ospemifene because she's got a very strong history of breast cancer and did not want vaginal estrogen under any circumstances. Um There is a steroid called prasterone that's recently on the market. It's vaginal and it works quite well. Um We talked about uh vaginal estrogen, HRT, triple negative breast cancer. Ok. To have it. Obviously, if they've had double mastectomy and they've had estrogen receptor positive, it's not gonna come back as it. So we do give estrogen. Um Again, it's a joint decision. We have had patients that take systemic HRT with a history of estrogen receptor, breast cancer. Um C BT hypnosis laser, uh I would avoid it. Um There is no evidence for it and there is some evidence that it doesn't work probiotics. Uh They love it in some countries and I think we're a little bit behind on that. So we should really be taking probiotics, vulvodynia. Uh So this is provoked or unprovoked. Again, you can use vs uh yes. S vagal moisturizer, vagina, estrogen, amitriptyline, gabapentin C BT, low libido. Again, these are all the things that go hand in hand with your uro gyne consultation. So, also known as Hypoactive Sexual Desire disorder, we just call it low libido. So first line is HRT, if that doesn't work, we use a lot of testosterone in our clinic. We quite like it. Um You can use Tial as well and third line is C BT uh MDT and consenting. Um So we had an MDT. This morning we are five uro gynecologists, um, one urologist. Um We have pelvic floor physio, we have a specialist nurse, we have a pessary nurse. Um and occasionally we have other intelligent people join us, which really helps. It's once a month. Um We discuss everything. Um We have any complex patients we discuss and anyone who obviously needs an operation. Um and some people say that you have to modify risk factors prior to offering any operations. So BMI I smoking, chronic cough, constipation occupation, I don't know how we can modify that, but these are things to discuss. Um So I use procedures, specific consent forms. Um So these are the, these are consent forms that I made myself with a combination of B CD and RC. So for example, this one is anterior repair plus or minus plus three repair. So it tells you specifically is to improve the symptoms of your prolapse. What did I offer? And I always take, I've offered no treatment, do nothing physio pessaries. And these are the risks. And then I hear like for example, specific risks to if I'm gonna do separate spin fixation, I write Buttock pain here. Um Again, I've got one for vaginal hysterectomy. Very similar, but it's very good because on here I can then as a reminder to myself that I've offered everything. So no treatment, physio, pessary, colpocleisis, sacra hyster Sacrospinous Hyp at Manchester Repet um and our follow up appointment uh, when I see them, I do the misa questionnaire again to check for any granulation tissue, for any sutures. The sutures can stay up to six months. Um, don't forget that any absorbable sutures. So don't take them out any infections and that's it. I'm just going to see, um, there was one video that I really wanted to show you guys and that is squatty potty. So, um, this is something that I recommend all my patients uh to squat once they when they having a poo. So I just wanted you to have a look at those quite good video. Fine. So I'm just going to stop sharing now and never have I seen so many videos. Like I actually that last one reminded me when I watched when I let the books out. It was like right enough, sorry, I'm sorry, I'm sorry, I feel like I've talked to everyone to death. Uh I, I felt like I felt responsible for all of the uy I just put in as much as possible. It took me like a while but uh so I just wanted to give as much as possible. So I'm sorry about that. If it took a while, it's fine. We do have some questions though. So do you need to take a drink before we start? No, no, I've got my coffee which is decaf brilliant, brilliant, right? OK. So we have some questions going back to probably the beginning of your talk. Uh it was uh quarter past two. This question was put in. Do you have electronic history sheets that has questions programmed in? Yes. So we have pa um but unfortunately we don't use that as sulfur because it's quite expensive. Um And believe it or not, most of our patients um cannot use um smart devices. So it's an online thing, but we do have it at Manchester Roll in February. So we get them to sit down before their um clinic and they go on a and um and they do it online and then we get a printout. So yes, it's ep pa eak brilliant. Next question. Did stopping gabapentin cause the symptoms to improve? Um I don't know because she said no to stopping it. So I don't know, she uses it for fibromyalgia. So she said absolutely not. So I don't know. I, I, yeah, I'm, I'm assuming it would do, but I don't know. Ok. Um Do you routinely do urodynamic studies for patients with incontinence? No. Um not at all. So, um it's only for patients with complex symptoms, patients that you've tried medical management, medical and conservative and it hasn't worked pa any patient that is going to have anything invasive must have urodynamics. So that's Botox uh BMI stress incontinence surgery. But for prolapse uh surgery you don't need um Urodynamics. Perfect. Do you use the pop Q app? Is that the one that you showed us? Yeah, perfect. Ok. Which is treated first in patients with both stress incontinence and do. Ok. So, um, it's, I normally treat theo quite aggressively. Um, if you treat the most of the time, um, the stress incontinence also settles because it kind of overlaps bladder modification. Um, if they have less in their bladder, it's less, less likely to leak on stress incontinence. And also some of the things that we do for stress incontinence, for example, um, BCA, it, then you've got, um, stress incontinence surgery, um, then it can cause urinary retention. So we don't want them to have any bladder problems. So I do treat the urgency quite aggressively first. Perfect. That's it for questions. Does anyone else have any questions? They want to pop in the chat? And then we have, uh, two. Thank yous one. You've given a great lecture. Thanks doctor. And thank you a very useful refresher. Ok, good. So, does anyone have anything else they want to ask just before Farrell gets on with her day? I'm not doing anything in and I'll probably have to feed the cat because he's been trying to get the, the door down and he's, he's putting his little pole under the door. I call it ac A T scanner pets. A, I have a dog that can open the door and it's just like, no, no, no, no, mine's not that clever yet. It's only give him time. Yeah. So I don't think there's any more questions So basically the me form will be coming to you or in your inbox already, please fill out and I will pass that feedback on to Sarah as well and er, this er, talk will be on catch up too. Ok? So we're gonna say goodbye now and hopefully we'll see you at the next six months. Ok? Thank you. Thank you. Bye everyone.