NEW CONCEPTS AND TECHNIQUESand pursuing a career in urogynaecology

N J NwabineliConsultant in Obstetrics, Gynaecology and

UrogynaecologySouth Tyneside NHS Foundation Trust

Greetings from Tyneside

Urogynaecology is all about the pelvic floor

Urogynaecology is all about the pelvic floor

UrologistG

ynae

colo

gist

Colo

rect

al

Urogynaecology

Female Pelvic Medicine Female Urology

Pelvic Floor Muscles

Pelvic Floor Fascia

THE PELVIC FLOOR MUSCLES -An extraordinary multi-tasker!

Pelvic Floor Dysfunction

UrologistG

ynae

colo

gist

Colo

rect

al

Can affect anyone or combination of all 3 organs passing through it.Dysfunction can be caused by the muscles and nerves of the pelvic floor.

Pelvic Floor DysfunctionAnterior compartment

Too active Urinary Retention

Under active Urinary Incontinence

Pelvic Floor DysfunctionMiddle compartment

Too active Vaginsmus

Under active Pelvic Organ Prolapse

Pelvic Floor DysfunctionPosterior compartment

Too active Constipation – obstructed defaecation

Under active Flatus – Fecal incontinence

Pelvic Floor DysfunctionChronic pelvic pain

• Muscles in spasms

• Hyperaesthesia of nerves – PBS, etc.

Urinary ProblemsDefinitions

Problem PAST PRESENT

Urinary Retention Symptoms, signsCatheterisation

Symptoms, signsBladder Ultrasound

Incontinence Symptoms and signs only

Symptoms, signs and Urodynamics

Urodynamics

Urodynamics

Treatment of True or Urodynamic Stress Incontinence

• Anterior Repair• MMK (1949)• Burch Colposuspension (1970’s)• Stamey’s and similar procedures• Mid urethral tapes/slings (mid 1990’s)• Bulking agents (mid 1990’s)

Tension Free Vaginal TapeDown upSide to side

Tension Free Vaginal TapeDown up

Tension Free Vaginal TapeSide to side (TVT-O, TOT)

Bulking agents

Treatment of Urge Urinary Incontinence

• Life style modification

• Anti-cholinergics

• Beta sympathomimetics (Mirabegron)

• Botox

• Neuro-modulation (PTNS, SNS)

• Complex surgery

Neuro-modulationPTNS SNS

Anal Incontinence and Obstructed defaecation

Anal Manometry

Anal Incontinence and Obstructed defaecation

Trans-anal ultrasound

Dynamic coloproctography

Bulking of anal supports

Pelvic Organ ProlapseTreatment

Pelvic Organ Prolapse

Treatment – Traditional repair

Pelvic Organ ProlapseTreatment – Mesh repair

Pelvic Organ ProlapseHystero sacro-colpopexy

Pelvic Floor Dysfunction The Future

Shift in paradigm of our approachAnatomy of supports• Fresh cadaveric dissections• Trans perineal ultrasound• MRI – staticSupports in action• Dynamic MRI• Bio mechanical modelling

Fresh cadaveric specimens

Perineal Ultrasound

Static MRI

Dynamic MRI

John De Lancey

Must pelvic floor dysfunction occur? Can we prevent it?

• Inherited collagen• Aging• Childbirth• Other trauma

If we can not prevent PFD – can we mitigate the effects?

• How are tissues damaged?

• What changes occur in structure and function?

• How can we adapt treatments that take these factors into consideration?

• Comparison with car accidents

Pursuing a career in Urogynaecology

• What to consider? – Is there a demand?(Population will get older)

• What are the demographics of PFD in Nigeria compared to UK?

Pursuing a career in Urogynaecology

Personal recommendations

Start where you are and build your skills into urogynaeecology incrementally without switching off obstetrics

Be prepared to learn and to change as you go along

Ensure you are first of all a good doctor before aspiring to be a good Uro-gynaecologist

Pursuing a career in Urogynaecology

You will be dealing with women whose problemsare not life threatening but of Quality of Life - Therefore be prepared to negotiate

Be patient and thorough in the learning of your anatomy as your chosen area involves risks to several organs.

Maintain an enquiring mind as the specialty evolves

Remain humble – we do not know it all yet and because we are mending broken parts, we have to sometimes accept that we have not gotten it right.