By Y. Kalesch. Spring Hill College. 2019.

One study reported a 38% rate of new-onset fecal incontinence after this approach [56] discount levitra soft 20mg mastercard. Rates of constipation were 63% preoperatively and 33% postoperatively purchase levitra soft 20mg on-line, while difficulty in evacuation decreased from 92% to 27% cheap levitra soft uk. However, rates of dyspareunia were found to be 28% preoperatively and 44% postoperatively, in which the authors attributed to the transvaginal portion of the operation [93]. Previously, retrospective reviews suggested equivalence between transanal and transvaginal rectocele repairs [56,94]; however, current evidence appears to suggest transvaginal repair is superior to the transanal approach. In a survival analysis, a 50% rectocele recurrence rate was noted over a mean 6-year time frame [92]. They excluded patients with other symptomatic prolapse or compromised anal sphincter function as evidenced by colon transit study. At 12 months follow-up, 14 (93%) patients in the vaginal group and 11 (73%) in the transanal group reported improvement in symptoms (p = 0. The need to digitally assist rectal emptying decreased significantly in both groups, from 11 to 1 (73%–7%) for the vaginal group and from 10 to 4 (66%–27%) for the transanal group (p = 0. A 27% improvement rate in dyspareunia was noted; none of the patients developed de novo dyspareunia. The Cochrane review on surgery for pelvic organ prolapse identified three studies comparing transvaginal and transanal rectocele repairs. After review, patients who underwent transvaginal repair were found to have fewer subjective and objective findings of recurrent prolapse. Therefore, with the current evidence available, transvaginal correction of the posterior compartment appears to be superior over a transanal approach in the prevention of recurrent rectocele [58]. Rectocele repair is a common surgical procedure and occurs in approximately half of the patients undergoing prolapse repair. A thorough history and physical examination is paramount before considering surgical or nonsurgical interventions. The use of pelvic floor imaging may complement the clinical assessment of the pelvic floor, but its use needs to be further studied and defined prior to advocating its routine use. Numerous surgical techniques and materials exist for repairing the posterior compartment. These surgical decisions should be made based on the current evidence and the surgeon’s experience. Predicting the number of women who will undergo incontinence and prolapse surgery, 2010 to 2050. Progression and remission of pelvic organ prolapse: A longitudinal study of menopausal women. The rectovaginal septum revisited: Its relationship to rectocele and its importance in rectocele repair. Morphometric properties of the posterior vaginal wall in women with pelvic organ prolapse. Protecting the pelvic floor: Obstetric management to prevent incontinence and pelvic organ prolapse. Preserving the pelvic floor and perineum during childbirth—Elective caesarean section? Female pelvic organ prolapse: Diagnostic contribution of dynamic cystoproctography and comparison with physical examination. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Magnetic resonance imaging of pelvic organ prolapse: Comparing pubococcygeal and midpubic lines with clinical staging. A systematic review of clinical studies on dynamic magnetic resonance imaging of pelvic organ prolapse: The use of reference lines and anatomical landmarks. Dynamic cystoproctography: A unifying diagnostic approach to pelvic floor and anorectal dysfunction. Evacuation proctography: An investigation of rectal expulsion in 20 subjects without defecatory disturbance. Evacuation proctography (defecography): An aid to the investigation of pelvic floor disorders. Dynamic magnetic resonance imaging for grading pelvic organ prolapse according to the international continence society classification: Which line should be used? Dynamic magnetic resonance imaging to quantify pelvic organ prolapse: Reliability of assessment and correlation with clinical findings and pelvic floor symptoms. Dynamic transperineal ultrasound in the diagnosis of pelvic floor disorders: Pilot study. Ultrasound assessment of pelvic organ prolapse: The relationship between prolapse severity and symptoms. Selection criteria for anterior rectal wall repair in symptomatic rectocele and anterior rectal wall prolapse. Patient satisfaction and changes in prolapse and urinary symptoms in women who were fitted successfully with a pessary for pelvic organ prolapse. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Randomized, controlled trial shows biofeedback to be superior to alternative treatments for patients with pelvic floor dyssynergia-type constipation. Bowel symptoms 1 year after surgery for prolapse: Further analysis of a randomized trial of rectocele repair. Disordered colorectal motility in intractable constipation following hysterectomy. Sexual function and vaginal anatomy in women before and after surgery for pelvic organ prolapse and urinary incontinence. Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles. Midline rectovaginal fascial plication for repair of rectocele and obstructed defecation. Evaluation of the fascial technique for surgical repair of isolated posterior vaginal wall prolapse. Rectocele repair: A randomized trial of three surgical techniques including graft augmentation. Transperineal repair of symptomatic rectocele with marlex mesh: A clinical, physiological and radiologic assessment of treatment. PelviSoft BioMesh augmentation of rectocele repair: The initial clinical experience in 35 patients. Functional and anatomical outcome of anterior and posterior vaginal prolapse repair with prolene mesh.

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The accelerated postmenopausal loss is largely due to the loss of estrogen buy levitra soft 20mg on-line, which has antiresorptive actions cheap levitra soft 20 mg fast delivery. This results in an accelerated phase of bone resorption and loss of trabecular bone levitra soft 20 mg online. The rapid fall in bone density immediately after the menopause has triggered a wide range of strategies to prevent osteoporosis over the last 30 years [30]. There is much debate about when to start preventative treatment as long-term treatments have potential adverse effects and are costly. Prevention of osteoporosis remains a lifelong strategy even if for some or most of that time no specific treatment is used. A detailed description of all the treatments and their potential role can be found elsewhere [30,31,36]. The mean age of women in this study was 63 years, but when the data were reanalyzed for those women under the age of 60, no harmful effect was found; indeed there was a suggestion of a beneficial effect [44]. Dementia Decline in cognitive function inevitably occurs with age, but once this interferes substantially with social or occupational functioning, it becomes dementia. The incidence of dementia, of which Alzheimer’s disease is the commonest form, is increasing and doubles every 5 years after the age of 65 [47]. Alzheimer’s disease is more common in women than men, and estrogen receptors are widespread in the central and peripheral nervous systems facilitating autonomic regulation and cognitive function. However, the evidence for a role of estrogen and menopause in the pathophysiology of cognitive decline and dementia is conflicting and may depend on age and timing of intervention. During the menopause in two midlife studies, 36%–62% of women reported memory changes [48,49], but natural menopause does not seem to be associated with objective loss of memory [50]. However, early surgical menopause is associated with an increased risk of dementia in later life, as well as other neurological problems [51]. A meta-analysis of postmenopausal estrogen use around the time of the menopause suggested that it may improve cognitive function and reduce the risk of Alzheimer’s disease [52]. However for other women, the menopause can be a difficult time and there are a variety of treatment options available. For most women, menopausal symptoms are relatively short lived and will settle within a few years, but for some they will go on much longer and longer-term treatment may be needed. The menopause is a hormonal milestone and provides an opportunity to establish firm strategies for the prevention of the long-term disorders outlined earlier. Lifestyle Dealing with the effects of the menopause should incorporate a holistic approach. It is an ideal time to encourage lifestyle changes that can build for a healthy future and help maximize health potential. For many women, the menopause can be a time of uncertainty and may be the first time they’ve sought professional help for themselves for many years. Smoking is associated with an earlier menopause and an increased risk of cardiovascular disease, lung cancer, and osteoporosis. Smoking cessation leads to a steady reduction in all the increased risks and should be encouraged as part of a health promotion strategy. Diet Body weight increases on average 1 kg/year around menopause, although this does not seem to be a direct effect of the menopause itself [54]. In addition, there are metabolic changes and changes in body fat distribution with body fat shifting from the hips and thighs (gynecoid) to a more android distribution (abdomen) [55]. Thus, it is particularly important that women going through menopause eat sensibly and try and avoid excessive weight gain. A recommended diet should be rich in fruit and vegetables, whole grain and high-fiber foods, oily fish twice a week, saturated fat intake less than 10%, cholesterol less than 300 mg/day, alcohol intake no more than 1 unit/day, and sodium to 1 tsp/day [56]. For women with obesity problems, entering the menopause specialist dietary advice may be helpful. Exercise 956 Regular physical activity has positive effects on a variety of conditions and physical activity can be effectively used to reduce vasomotor symptoms [58] possibly by an effect on endorphins. Regular exercise, even of relatively low intensity, can be beneficial to cardiovascular health [59]. Exercise also has a key role to play in the maintenance of bone health; not only does regular weight-bearing exercise help to conserve bone density in the hip and spine, it also helps to maintain muscle strength, joint flexibility, and overall balance, all factors that will reduce the risk of falls and subsequent fracture [60]. Alternative and Complementary Therapies A wide variety of nonhormonal prescription drugs, complementary and alternative medicines, are used to improve menopausal symptoms. Some of the licensed preparations such as clonidine, venlafaxine, and gabapentin have short-term randomized trials demonstrating their efficacy [61], but robust evidence for the efficacy and safety of most of the complementary and alternative products or methods is notably lacking [61]. In our own clinic, we identified that up to 40% of women were taking additional over-the-counter supplements for their menopausal symptoms and 10% were taking more than four different products concurrently [63]. These products are currently unregulated in the United Kingdom, and while the majority are likely to be harmless, a number of serious and potentially fatal interactions have been reported between herbal supplements and standard medications [64]. By contrast, the use of phytoestrogens, plant substances with similar activity to estrogen, and black cohosh appear to have some beneficial effects on menopausal symptoms [61]. Estrogen is the principal hormone and can be given either alone or in combination with progestogen, which should be given to all nonhysterectomized women. Estrogen There are a variety of different types of estrogen available, which can be given at varying doses and by different routes [66]. For the vast majority of women, the type and route of administration are not important, and provided an adequate dose of estrogen is given, it is likely to be effective. However, there are some women who do not show an appropriate response and adjustment to a different type of estrogen may be helpful. The appropriate dose depends on age and severity of symptoms, but as with any treatment, the lowest effective dose should be used. Different routes of estrogen administration have different pharmacokinetic profiles. However, oral estrogens, because of their first-pass effect, have potentially greater beneficial effects on lipids and lipoproteins and glucose and insulin metabolism [66,71], so women with hypercholesterolemia or hypertriglyceridemia may benefit more from oral estrogens. For the vast majority of patients, the route of administration is not important provided adequate estrogen levels are achieved. Nonoral routes tend to be more expensive, and for those women who need a progestogen, there can be logistical problems administering the progestogen component simultaneously. They can be given either cyclically, mimicking the natural 28-day cycle and resulting in a regular withdrawal bleed, or continuously to prevent any bleeding, so-called “no-bleed” treatment. The latter is usually recommended for women who are clearly postmenopausal, while the former is usually prescribed for women who are perimenopausal. While this has potential advantages in limiting withdrawal bleeds to 4/year, it carries an increased risk of breakthrough bleeding and potential endometrial abnormalities if continued long term [74]. Side effects are common, particularly in the first few months, and these may vary depending on the type and dose of progestogen used. Switching from one type of progestogen to another or changing the route of administration can alleviate side effects in many cases. However, all progestogens are not necessarily equal [66] particularly in their possible cardiovascular [75] and breast [76] effects.

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A systematic review of clinical studies on hereditary factors in pelvic organ prolapse purchase online levitra soft. Incontinence and pelvic organ prolapse in parous/nulliparous pairs of identical twins levitra soft 20mg discount. A review of the epidemiology and pathophysiology of pelvic floor dysfunction: Do racial differences matter? Is antenatal bladder neck mobility a risk factor for postpartum stress incontinence? Conservative management of persistent postnatal urinary and faecal incontinence: Randomised controlled trial discount 20mg levitra soft with amex. Levator ani trauma after childbirth, from stretch injury to avulsion: Review of the 137 literature. Effects of prolonged second stage, method of birth, timing of caesarean section and other obstetric risk factors on postnatal urinary incontinence: An Australian nulliparous cohort study. Pudendal nerve damage during labour: Prospective study before and after childbirth. The role of pudendal nerve damage in the aetiology of genuine stress incontinence in women. Cesarean section: Does it really prevent the development of postpartum stress urinary incontinence? Exclusive caesarean section delivery and subsequent urinary and faecal incontinence: A 12-year longitudinal study. The prevalence of urinary incontinence 20 years after childbirth: A national cohort study in singleton primiparae after vaginal or caesarean delivery. Risks of stress urinary incontinence and pelvic organ prolapse surgery in relation to mode of childbirth. Prediction models for postpartum urinary and fecal incontinence in primiparous women. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Pelvic floor muscle training during pregnancy to prevent urinary incontinence: A single-blind randomized controlled trial. Promoting urinary continence in women after delivery: Randomised controlled trial. A randomized controlled trial of pelvic floor muscle exercises to treat postnatal urinary incontinence. Effect of postpartum pelvic floor muscle training in prevention and treatment of urinary incontinence: A one-year follow up. Postpartum pelvic floor muscle training and pelvic organ prolapse–a randomized trial of primiparous women. Postpartum pelvic floor muscle training and urinary incontinence: A randomized controlled trial. Randomised controlled trial of conservative management of postnatal urinary and faecal incontinence: Six year follow up. The long-term effectiveness of antenatal pelvic floor muscle training: Eight-year follow up of a randomised controlled trial. Pelvic floor muscle training in the prevention and treatment of urinary incontinence in women— What is the evidence? Risk of new-onset urinary incontinence after forceps and vacuum delivery in primiparous women. The prevalence of occult obstetric anal sphincter injury following childbirth— Literature review. A multicenter interventional program to reduce the incidence of anal sphincter tears. Obstetrical anal sphincter laceration and anal incontinence 5–10 years after childbirth. Outcomes from medium term follow-up of patients with third and fourth degree perineal tears. Risk of recurrence and subsequent delivery after obstetric anal sphincter injuries. Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: Time trends and risk factors. Third degree obstetric anal sphincter tears: Risk factors and outcome of primary repair. Third degree obstetric perineal tears: Risk factors and the preventive role of mediolateral episiotomy. Does midline episiotomy increase the risk of third-and fourth-degree lacerations in operative vaginal deliveries? Faecal incontinence 20 years after one birth: a comparison between vaginal delivery and caesarean section. Cutting a mediolateral episiotomy at the correct angle: Evaluation of a new device, the Episcissors-60. Incidence of obstetric anal sphincter injuries after training to protect the perineum: cohort study. Perineal techniques during the second stage of labour for reducing perineal trauma. A randomized prospective trial of the obstetric forceps versus the M-cup vacuum extractor. Risk factors for third-degree and fourth-degree perineal lacerations in forceps and vacuum deliveries. Effect of second vaginal delivery on anorectal physiology and faecal continence: A prospective study. Risk factors for primary and subsequent anal sphincter lacerations: A comparison of cohorts by parity and prior mode of delivery. Risk factors for female anal incontinence: New insight through the Evanston- Northwestern twin sisters study. Urinary incontinence and hysterectomy in a large prospective cohort study in American women. Supravaginal uterine amputation v hysterectomy with reference to subjective bladder symptoms and incontinence. A randomized comparison of total or supracervical hysterectomy: Surgical complications and clinical outcomes. Randomised controlled trial of total compared with subtotal hysterectomy with one-year follow up results. Tension-free vaginal tape versus colposuspension for primary urodynamic stress incontinence: 5-year follow up. Seven-year follow-up of the tension-free vaginal tape procedure for treatment of urinary incontinence. Prevalence of persistent and de novo overactive bladder symptoms after the tension-free vaginal tape. Transobturator and retropubic tape procedures in stress urinary incontinence: A systematic review and meta-analysis of effectiveness and complications. A randomized comparison of transobturator tape and Burch colposuspension in the treatment of female stress urinary incontinence.

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It is not known whether the specific anatomical areas of the urethra or pelvic floor (sphincter urethra levitra soft 20 mg low price, compressor urethra best buy levitra soft, urethrovaginal sphincter buy discount levitra soft 20 mg, bulbocavernosus, anal sphincter, levator complex) act in unison, individually, or at all in detrusor 391 inhibition in normal subjects. Therefore, the central and peripheral nervous systems mediate bladder control through complex voluntary pathways and reflex arcs. Central efferent control of the bladder smooth musculature is mediated by afferent activity from the detrusor musculature and bladder mucosa (facilitatory) and the reflex and voluntary contractions of the pelvic floor and sphincter musculature (inhibitory). The underactive bladder: Traditional concepts of detrusor underactivity have focused on either efferent innervation or myogenic dysfunction. By contrast, contemporary views emphasize the importance of the neural control mechanisms, particularly the afferent system, which can fail to potentiate detrusor contraction, leading to premature termination of the voiding reflex. To void efficiently, a feedforward mechanism by which urinary flow in the urethra helps to enhance and maintain adequate contractile function of the bladder until the bladder is empty is required. Sensory information is fed back to the motor system at several levels of control between the end organ and brain cortex. These sensors themselves can be damaged, for example, through an effect of ageing or ischemia. In addition, impairment of innervation can lead to decreased information transfer via either the sensory or motor nerves. A functional disruption of higher central nervous regulatory systems can lead to functional abnormal voiding [44]. During the initial phase of bladder emptying, the pelvic floor and external sphincter relax in order to decrease urethral resistance and facilitate low pressure flow. In addition, this relaxation decreases the reflex inhibition of bladder contractility. Relaxation is followed by a detrusor contraction, which continues until voiding is completed. When emptying failure is secondary to bladder dysfunction, it may be a result of either detrusor smooth muscle pathology or insufficient neural stimulation of the detrusor. Insufficient neural stimulation may occur at the neuromuscular level (pharmacological), with nerve impairment (neuropathy), or with alterations in central control of micturition (conus medullaris, spinal column, or brain). The impairment of detrusor contractility by the absence of pelvic floor relaxation is evident in spinal cord disease (failure to empty following adequate sphincterotomy in the spinal cord patient due to incomplete detrusor contractions) and Parkinsonism (failure to empty secondary to pelvic floor bradykinesia). Mixed–combined disorders: Disorders of the bladder and outlet during storage and emptying may occur alone and in combination. In addition, the elderly females or patients with neurological diseases may demonstrate detrusor overactivity (hyperreflexia) with impaired contractility (poorly sustained contraction). Sensory disorders: Afferent neurons from the bladder and urethra are of major importance during both the storage and emptying phases, both initiating the voiding reflex and sustaining the voiding drive during bladder emptying. Somatic activity may inhibit the emptying reflex by voluntary contraction of the external sphincter or pelvic floor—and although not established in humans, may provide inhibitory activity during bladder filling. Traditional classification systems have focused on motor rather than sensory activity. Disorders of bladder and bladder outlet sensation may result from central or peripheral denervation, from psychological causes, or from pharmacological agents such as pain medications. The role of decreased sensation in the function of the pelvic floor and the interaction between the pelvic floor and bladder with relation to the sensory pathway on the micturition reflexes await further investigation. The pudendal nerve is responsible for the innervation of pelvic floor structures as well as of the genital skin, urethral mucosa, and anal canal. Proprioceptive information of the periurethral musculature and sensory innervation of the levator ani muscles are also mediated by the pudendal branches. Increased sensation or pain attributed to the bladder is a major clinical challenge. The symptoms of urinary frequency, urinary urgency, and suprapubic pressure often result in diagnostic evaluations and therapy for bladder disorders, even in the absence of definitive findings of mucosal or smooth muscle abnormality. Pain that may originate from fascial, muscular, or neurological etiologies within the pelvic floor should be included in the differential diagnosis of the patient with urethral or bladder syndromes. Traditionally, sensory signaling in the urinary bladder has been largely attributed to direct activation of bladder afferents. There is substantive evidence that sensory systems can be influenced by 392 nonneuronal cells, such as the urothelium, which are able to respond to various types of stimuli that can include physiological, psychological, and disease-related factors. The corresponding release of chemical mediators (through activation of a number of receptors/ion channels) can initiate signaling mechanisms between and within urothelial cells, as well as other cell types within the bladder wall including bladder nerves. However, the mechanisms underlying how various cell types in the bladder wall respond to normal filling and emptying and are challenged by a variety of stressors (physical and chemical) are still not well understood. Alterations or defects in signaling mechanisms are likely to contribute to the pathophysiology of bladder disease with symptoms including urinary urgency, increased voiding frequency, and pain [45]. These systems can be clearly illustrated with the functional areas of the bladder and outlet on the vertical and axis the functions of filling/storage and voiding/emptying on the horizontal. The reader is encouraged to incorporate these systems into their own clinical algorithms and critique and modify them based on additional evidence or “opinion. The standardisation of terminology of lower urinary tract function: Report from the standardisation sub-committee of the international continence society. Analysis of the standardisation of terminology of lower urinary tract dysfunction: Report from the standardisation sub-committee of the International Continence Society. Pelvic floor muscle function and urethral closure mechanism in young nullipara subjects with and without stress incontinence symptoms. Female stress, urge, and mixed urinary incontinence are associated with a chronic and progressive pelvic floor/vaginal neuromuscular disorder: An investigation of 317 healthy and incontinent women using vaginal surface electromyography. Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work? Standardization of terminology of pelvic floor muscle function and dysfunction: Report from the pelvic floor clinical assessment group of the International Continence Society. An integral theory and its method for the diagnosis and management of female urinary incontinence. An anatomical classification—A new paradigm for management of urinary dysfunction in the female. Resting and stress urethral pressures as a clinical guide to the mechanism of continence in the female patient. Structural support of the urethra as it relates to stress urinary incontinence: The hammock hypothesis. Stress urinary incontinence: Relative importance of urethral support and urethral closure pressure. The sensory bladder (1): An update on the different sensations described in the lower urinary tract and the physiological mechanisms behind them. These techniques are not ideal and do not routinely lead to physiological recovery of the affected organ or organs. This has led scientists in the field of regenerative medicine to apply the principles of cell transplantation, materials science, and bioengineering to construct biological substitutes that may eventually improve the quality of life for these patients. The field of regenerative medicine encompasses various areas of technology such as tissue engineering and cloning. Tissue engineering combines the principles of cell transplantation, materials science, and bioengineering to develop new biological substitutes that may restore and maintain normal organ function. Tissue engineering strategies generally fall into two categories: the use of acellular matrices that allow the body’s own regenerative systems and serve as scaffolds on which to direct new tissue growth and the use of matrices with cells.