Jan Chaseley

Good evening, everybody. We're just waiting a few moments for everybody to join.

Welcome to our webinar on urinary incontinence and pelvic organ prolapse. My name is Jan, and I'm the Clinical Nurse, Specialist in Continence Care here at Benenden, and I'm joined tonight by our presenter, Mr Abhi Gupta Consultant Urogynaecologist.

This presentation will be followed by a question and answer session. If you'd like to ask any questions during or after the presentation, you can do so by using the Q&A icon, which is at the bottom of your screen, and this can be done with or without giving your name.

Please note that this session is being recorded. If you do provide your name.

If you would like to book a consultation, we'll provide details for that at the end of the session.

Mr Abhishek Gupta

Good evening, everyone. My name is Abhishek Gupta. I'm one of the Consultant Gynaecologists, and I'm a Urogynecologist. I did my training in South East London. So I started training from guys in St Thomas's and then rotated in South East London.

And during the process of my training in gynaecology I did my specialized training, incontinence, and prolapse. And also I have special interest in doing keyhole surgery and in my NHS base in Darent Valley Hospital, and I have started also offering robotic surgery in Darent Valley Hospital last year.

I'm an active member of British Society of Urogynaecology. I was for six years in their governance committee, and I also am a member of Royal College of Obstetrics and Gynaecology, and a member of a British Irish Association of Robotic Surgeons. So that's me.

Jan Chaseley

Thank you and I'm Jan. I've been working in Urogynaecology for at least 20 years now, and I manage the specialist nurse team here at Benenden, and we're really lucky we have four specialist Urogynae urology nurses here we run. Nurse led clinics that I'll tell you a little bit more about later, and we also offer Urodynamic assessments.

Mr Abhishek Gupta

So in this this session, what we have tried to include is a what urogynaecology is, then what or active bladder is, what stress incontinence then import, and I wouldn't. I can't stress enough that the incontinence, prolapse and issues with pelvic floor and waterworks
as it is joined up approach with the specialized nurses, and they're so important for assessment, so important for your primary treatment.

And also once we, if you do have to have any surgery, it's so important for the post-op care and all the investigation that nurses do.

Then we'll talk about a bit of a pelvic organ prolapse, and we will also point you about where you can access some resources which you can read, and then, if you have any questions you can post it on, and then we'll try to take as many questions as possible towards the end of our session.

So what is urogynaecology? So that's an area of gynaecology where we dedicate in treating pelvic floor dysfunction, which is mainly urine. Incontinence, prolapses. The common referrals we get is incontinence, prolapse, some patients come with recurrent urinary tract infection, some people have pain when the bladder is full.

Then also the injuries of childbirth which can cause various issues, and obviously for us to practice in urogynaecology, we should have gone through the specialized training in this area before we become consultants, and then we practice.

So it's quite a governed field. So people doing urogynaecology, which is prolapse incontinence. They have to have specialized training.

We all have our. We all associated with British Society of Urogynaecology, so all our operations and their outcomes should be recorded in the database, and any patient who's having any surgery with us should be discussed in our central multi safety meeting before we offer surgery.

So it's quite a regulated area now, more so after the mesh debacle which happened and the report came out in 2019. So it's quite regulated and quite specialized area now.

So these are the common referrals we get. So obviously, you can guess that we get a lot of bladder problems. Then we also get fair referrals for vaginal prolapses. Then UTI’s bladder pain and post childbirth injuries.

I'll talk a bit more about how, let Jan talk about a bit of more healthy bladder.

Jan Chaseley

Lovely. Thank you. A lot of the things we talk about in the nurse led clinics. We talk about healthy bladder. So actually, what is a healthy bladder?

So basically, you should be drinking between one and a half and two litres a day with no more, maybe than two to three caffeinated drinks.

If you're drinking that amount, you should be emptying your bladder about seven to eight times during the day, roughly around every three hours, nighttime symptoms.

So, Nocturia. As you get older, you're going to be getting up a little bit more at night. But ideally it shouldn't be any more than once. So if you're looking at that and thinking, oh, I go to the toilet more often than that. It may be you would benefit from a specialist nurse assessment.

On the right hand side of the screen. You've got like the colours of urine. So your urine should be straw coloured, it should be infection free. So if you have an infection, it will be cloudy, may have a little bit of an odour.

So you want your urine to be straw coloured if it's darker. That's suggesting that you're not drinking enough. And again, that's going to put you at risk of urine infections.

So first and foremost, now we'll talk about the urinary issues. So one common thing we get is urgency of waterworks or people needing to go to waterworks often, and also complaining that they get up in the night few times to empty the bladder.

Now this is called frequency urgency, and getting up in the night is called Nocturia. So these are the common presentation which we get and what happens to typically patients who have got overactivity of the bladder.

What we means with overactivity is if a normal bladder. If you feel that you need to go for urge to go for passing urine, then, in a normal circumstances, if it's not too full you can hold. You will find obviously a toilet nearby, and once you find a safe space where you can empty the bladder, your nervous system kicks in you, relax your pelvic floor, and then you empty the bladder.

The people who have an overactive bladder typically the bladder is trying to contract without their will against their will. So once the bladder starts to contract, you feel that sense of contraction, and even if you want to relax those bladder, you're not able to, and hence you keep rushing to the toilet all the time because the bladder is doing this for you.

Also sometimes the bladder contraction. If you imagine the balloon, if the bladder contraction goes if the balloon squeezes completely, then even if you don't want if you want to hold this urine. The balloon is squeezing that water out, and then your pelvic floor will not be able to hold, or your bladder sphincter will not be able to hold, and you start leaking.

This is called urge incontinence, which we say is a symptom of overactive bladder. Now, why, this happens most of the time we don't know why the overactivity of the bladder has happened, and we have seen overactive bladder at all the ages.

However, it is more prominent. As people get older, so they have less. Your bladder holds a bit lesser that becomes more overactive, and then you can go for frequency and urgency waterworks often.

Sometimes, if you have recurrent urinary tract infections that can cause your bladder to become more active, not so much in female, more so in more male. But if there is any blockage which makes you not go for waterworks that well like, if you have got a massive prolapse, then you may notice that your overactivity of the bladder is more and some neurological conditions.

For example, if you have an MS then there is a nerve loop which kicks in and the nerve is constantly asking your bladder to contract and you leak.

You will also find that the patients, or anyone who drinks a lot of caffeinated drink, smoking, or take fizzy drinks and alcohol that can irritate the bladder quite a bit, and that may make you go. You often feel full, and you often make often need to go for waterworks often.

So that's kind of a lot of things which causes over activity of the bladder. And it typically presents with symptoms of obviously, as I said, urgency so need to rush for the toilet.

You can get more often you may have to go for waterworks, and sometimes you leak, because if it's contract, your bladder is contracted so much that your balloon can't hold then you leak, and sometimes you'll have to get up at night a few times, which is called Nocturia.

Typical overactive bladder patients who got overactivity of the bladder, which kind of some really affects their quality of life usually have small volumes of water, so when they go for passing urine they only pass a small amount because the bladder is full with a small amount, and the bladder is constantly in that situation.

So small amount of water goes in. You pass small amount of water, and more often that's typical of overactive bladder, and sometimes you get a lock and key effect. You need to go for waterworks. You put the key in the house and you start leaking. That's a typical symptoms of overactive bladder. You find sound of water. If you're doing washings, putting your hand in the water, and you suddenly have the reflex which makes your bladder contract. So that's again typical overactive bladder.

So these are kind of tell the sign of typical overactive bladder, causing you urgency, noise, incontinence.

So what are the management options? It's all about quality of life. So nothing we're going to discuss today, which is anything else but the quality of life and it's important for caffeine reduction. So if you drink a lot of caffeine, the coffee make it decaffeinated. Healthy intake of fluid is 1.5 to two litres if you're getting up quite few times in the night, but you take a cup of tea or cup of coffee before you go to bed or a glass of wine before you go to bed. Then you will get up in the night.

It's well known that as we all go older, we do have a more sensitivity, and we go to toilet. We wake up in the night for going to toilet hence the food management is so important. If this is causing you a problem and having you less sleep and getting your sleep disturbed, or getting your day to day life.

So fluid management is very important. Pelvic floor muscle exercises is again very important. It helps you to hold your bladder longer. It also helps to manage your symptoms and your reflexes.

As we've talked about Nocturia, which is getting up in the night. If you feel that you're not emptying the bladder well, sometimes you empty the bladder. Then then you get up, and five min later you empty it again, so that you know that you are emptying the bladder well, completely, so that when you're going out, you know you're going out with a complete empty bladder and obviously, if you have tendency to constipation, then straining is not good for your pelvic floor.

And obviously, if the first stage treatment, which is bladder retraining, which is well, Jan and her team teaches patients how to hold the blood a bit longer, bit longer, bit longer, especially when you are at home. So you don't have a fear of leaking in public and that helps to improve your capacity of the bladder longer, and also reduces how many times you go for waterworks.

If those things don't work, then we go into the next step of treating your symptoms with medication or getting more specialized test.

So what are the medications which we can offer? So one is called anticholinergic, so there are two main medications which are used in overactive bladder. One is called anticholinergics, and one is commonly called Mirabegrin, Betmiga. So anticholinergics have got various trait name Oxybutanin, Tolterodine, Solifenacin.

So what they do is they work on a receptor on the bladder to prevent the contraction. So this medication prevent the contraction of the bladder and the Betmiga Mirabegrin works slightly differently. It helps to relax the bladder, so one is preventing the contraction. One is relaxing the bladder. Hence the side effect profile is different.

So the Anticholinergic medication can give you a lot of drama because they're the same receptors which are used to produce mucus. It can give you palpitation, and because it reduces the contraction, sometimes it can also give you a lot of constipation.

So that's the common side effects people get with Anticholinergic. With Betmiga it is better tolerated because it's got less of side effect because it works with relaxation of the muscles.

So if patients come with urgency frequency Nocturia first step is to go and get your fluid management, so you'll be given a blood diary. You'll go and see Jan and team to assess your pelvic floor, I mean, we assess in the clinic, and then Jan and Mary and the team will assess the pelvic floor as well go through the bladder, retraining fluid management, and we may trial the medication for you as well.

If your symptoms get better, we do nothing and if your symptoms don't get better. Then we do a specialized test called urodynamics, which we'll talk in a minute, which is a physiological test of how your bladder is functioning, and then we go with more invasive treatment.

So the more invasive treatment for overactive bladder which the one we offer at Benenden is called Botox treatment. So what Botox does is. It's a very simple procedure. We have a quick look inside the bladder with the camera and give an injection of Botox in the bladder.

The little picture on the slide is to say how the Botox is given. It's spread over the bladder. So what it does is it relaxes the muscles quite well. So patients who really their quality of life is suffering because of overactive bladder. They have to keep going to toilet, they keep having urge, they keep leaking once they've exhausted the medication option. If they don't get better, then Botox is really help with their quality of life.

The only two flip side with Botox is, it needs repeating. So every six months to two years you will find that the symptoms coming back, and we may have to repeat it. Second with a Botox, sometimes your bladder relaxes so much that you're not able to empty the bladder well, so one in 12 women we have to teach how to catheterize or Jan and team teach us how to catheterize the patients in case the need arises after the procedure. That's the flip side with Botox.

The other two options. One is called percutaneous tibial nerve stimulation, which is called PTNS. It is like stimulating the nerves by doing a slightly equivalent to acupuncture, which also can help with your bladder symptoms. At least, it's less invasive.

And Jan does offer PTNS here. Second, neuromodulation is slightly more invasive where they put a little electrode on your back which then regulates the bladder contraction and reduces your chance of urgency and bladder contraction.

PTNS is a good option. But the PTNS is at the moment of level only in the tertiary centre, and for that the patient will have to refer to tertiary centre like UCLH to get the PTNS option for a nerve modulator to put on the spines on the back.

Did I miss anything?

Jan Chaseley

No, that's fine.

Mr Abhishek Gupta

Okay. So the other thing which we get with incontinence is stress incontinence, and quite often we get mixed pictures. Patient may have both overactive as well as stress. So quite often we get sometimes mixed picture. So stress incontinence slightly different.

Now, what is stress incontinence? If you imagine you got bladder, which I'm again saying is a balloon, because bladder is like a balloon. It's full of water. Now, if you imagine my wrist as a balloon, and the tube returns water out, it's like a urethra.

Now, when you cough, sneeze, laugh, run, trampoline, shout, or do any exercise which increases the tummy pressure, and, as you can see on our slide as well. When the tummy pressure increases, the pressure is going on this balloon to get you to leak urine, because that's the same pressure, coughing, coughing, sneezing, running, so the balloon is trying to obviously leak.

But when you had good muscles in the vaginal area just at the neck of the bladder, the same pressure comes from the top to the urethra, and same pressure is counter. Pressure is through the vagina. So with the receptor, with your pressure from the top pressure from the bottom. The tube which drains water out can close, and hence you don't leak.

When you don't have much support at the neck of the bladder level, the tube which drains water out, which is called urethra, doesn't. When you cough, sneeze or lift water, it doesn't close, it just kinks because there's no counter support at the vaginal level.

So the host pipe doesn't close, it just kinks. So you've got enough space for urine to leak. And that's where the stress incontinence happens in a patient. And what are the risk factors for stress incontinence?

Obviously, anything which has a trauma to pelvic floor can cause can cause stress, incontinence so obviously vaginal deliveries, and more than vaginal deliveries. If you have instrumental delivery like forceps or ventures delivery, they do cause a lot of trauma to pelvic floor.

Then menopause. Okay, so when the woman body hits menopause, the menopause itself doesn't cause stress incontinence, but it can cause a weakness in the vaginal area and the support tissue, and then it can lead to have an increased symptom of urine incontinence.

Obesity. If you've got a lot of weight you carry around the middle, it will put a lot of pressure on the pelvic floor. It does causes increased leak, and it does reduce your success rate of any surgical. If you offer any surgical correction, obesity does cause, reduce your success rate and increase your complication. So it's so important to manage weight before we attempt any incontinence surgeries in future for getting you the best outcomes.

Age, as we unfortunately all of us grow older, we don't go younger, and with age, the supportive structures do fell, and it can cause more susceptibility of leakage.

Smoking, and chronic cough. They can do two things. One, it does weaken your pelvic floor. If you keep coughing, you do weaken your pelvic floor because the excess goes to the pelvic floor.

Smokers tend to have more weak pelvic floor, or any muscle tissue or connected tissues, and even if you have a surgery, the smokers heal up much, don't heal up that well, as the non-smokers, so smoking cessation is so important. And obviously, if you got neurological disorder, and the last which is prostatectomy doesn't hold us. But this is for more for male than female.

So this kind of issues are more pertaining and genetic, plays a part on a certain cohort as well, because the collagen, which is a tissue which holds, or your connective tissue. Some of the collagen deficiency can be genetically linked, and that can also make you more susceptible for both prolapse as well as incontinence.

So what is the treatment of stress incontinence? So, first and foremost, the treatment of stress incontinence is again pelvic floor exercises so reduction of smoking, or preferably stopping.

Pelvic floor exercises and managing your weight. This is the really first line treatment of any urinary issue or a prolapse issue you have.

Now it's all about quality of life, how often you leak, how is that quality of life is different and remember, it's about your quality of life. It's not about your neighbour quality of life, it's not about your sisters quality of life or your mums quality of life, because everybody's quality of life is different.

If a young woman who's 30 years old have got two children who go trampoline with those kids and leak, her quality of life is is disturbed because of. She wants to do more activity with their children than someone who don't do that much of activity but leak very less, but they can manage their leakage without it affecting quality of life. So everybody's quality of life is different.

It's is the prolapse and content. What is it causing to you. And what is this stopping you doing so. It's all about quality of life. So once the pelvic floor exercises, we have done weight loss, we have recommended. Things have not worked, it's affecting quality of life. Then we default again to the test of Urodynamics, which we'll talk in a minute.

When the Urodynamic is done. It's called three purposes. Urodynamic test. One is to give us the diagnosis so differentiate whether you've got stress incontinence. You've got overactive bladder because treatment are different or you've got mixed picture. How is your bladder? What is your capacity of the bladder? How you're emptying the bladder?

It helps us to counsel so diagnosis, capacity, and how well you're emptying the bladder. That's the three things which this test tells us and then we can plan your treatment.

So if we have now, you got stress incontinence we have exhausted. This is now affecting quality of life. Pelvic exercises have not worked. Then what are our options. So now we're going to the three options we have for stress incontinence.

One is called bulkamid which is a urethral bulking agent. It's a local anaesthetic procedure, and I'll talk to you more about in my next slide. And there are two surgical options. One is called autologous fascia sling surgery, and last, is a colposuspension surgery. So two surgical options and one bulkamid which is a least invasive option of, and it can be done in local anaesthetic.

So what is bulkamid and how do we do it. So bulk commit is a procedure where we it can be done local anaesthetic. Obviously you have a choice of general anaesthetic if you want to. But majority of my patients tolerate this procedure very well with local anaesthetic. So what we do is in our ambulatory care unit. We give you local anaesthetic injection on the very just next to urethra in the vagina, and with this camera at the neck of the blood level you can see foresight. We put this injectables, which is a permanent gel. What it does, it gives you support at the neck of the blood level and reduces the leaking.

So the advantage is, it's the least invasive option, and it's a permanent gel, and sometimes you may have to repeat it, and when you have to repeat it, I only repeat it once or top it up. It works around 60% of the patients. 60% of the patients. It's all about quality of life. As I was saying.

60% of patients feels that quality of life is better. There's not much downtime with this procedure. So you can go home same day, and you can go into the normal activities pretty much from same day or next day.

What we tell patients to do is we ask them to avoid sexual intercourse for around three to four weeks and a high impact strenuous exercises after that procedure. Otherwise you are allowed to do everything. So it's a least invasive option. But it works on around 60% of the patients and may need a top up or repeating once, if we have to do it.

The rest two surgeries, one called autologous fascia sling. So what this does is. It's a major surgery. It's 80-85% successful where we give a incision. Take something called a rectus sheath out of your body, go through the vagina and again stitch it up, so that holds and forms a hammock just near your neck of the bladder, or through the vagina, and it for the support there. So this called rectus fascia sling.

It works well, 80-85% success rate. But it is also major operation which requires six to eight weeks recovery period at hospital stay of one to 10 days and sometimes the bladder, sometimes, after the procedure, you feel that you're not emptying the bladder very well, and it can happen in roughly around one in 10 patients. And we do teach you how to catheterize yourself before we do this operation, just in case the need arises.

The last option is called colposuspension, which is again a very good surgery, is 80-85% success rate, and what we do again, rather than taking any tissue out from your body, we give a little incision. Go deep in the vagina, do the stitches next to the neck of the bladder, but through here and hook it to the bone there. So it lifts the pelvic floor up like this.

Again, 80-85% success rate and since six to eight week recovery period in our, we still teach you how to categorize yourself in case need arises. But in our experience from the patients we're seeing less issues with the catheters, with colposuspension than fascia slings and colposuspension can be done open. It can be done keyhole, and in my NHS base I do it robotically, which, because this this place, which is the pelvic just behind your pubic bone, is quite a small, narrow place to operate on, so robot does give you a better vision, but we do offer it routinely here, open.

So it's a colposuspension. So that's the three options you have for stress, incontinence, bulkamid, fascia sling and colposuspension.

Jan Chaseley

Lovely. Thank you. So just going to talk a little bit about Specialist Nurse assessment. So if you're listening to this, and you're thinking I might have those symptoms, or am I doing my pelvic floor correctly. You can get an appointment just directly with us. You don't necessarily need to have seen a consultant first and a lot of the time. If your GP referral is mentioning incontinence or mild prolapse, you probably are going to see us as a first line, anyway, before we refer on to the consultants.

So we're going to sort of take up a history. We want to know a little bit, your background, your medical history. But we want to know about your symptoms and what bothers you. And I think, as Mr Gupta was saying, it's all about individual quality of life. It's not for me to say you've got a large prolapse, or you've got stress incontinence. It's what bothers you. And that's what we're going to focus on.

We're going to test your urine to make sure you haven't got an infection, and we'll just do a small bladder scan to check that. You are emptying your bladder properly.

We'll get you to fill in a bladder diary before you come along and that's going to be for three days you record what you drink, and then you measure and record how much urine you’re passing. So if you've got something like overactive bladder, you might be emptying your bladder quite frequently with small volumes.

If you've got stress incontinence, you may have good, nice, regular emptying every sort of three, four h, but they're going to be ticks on there for when you're leaking, and we'll give you advice about your drinking, so that might be restricting on your coffee, restricting your intake if you're drinking sort of more than about the two litres, maybe two and a half, you know, if you're exercising or you're being more active.

And one of the key things there, particularly from overactive bladder point of view, is looking at the bladder retraining. And what happens with your bladder, as Mr Gupta said, you get that first sensation that your bladder's filling, but that doesn't always mean that you need to go then.

That's just your bladder saying I'm filling. I might need to go in a minute, so you've got time to finish the ironing, and then you can go afterwards with overactivity. You lose that, or I'll go in a minute, and it's I have to go, and I have to go now. So we'll work with you on actually, how can we retrain your bladder, how can we extend that interval of how often you're going, and the key thing for whether it's stress, incontinence, prolapse, overactive bladder is going to be about pelvic floor exercises.

We'll assess your pelvic floor. So that's going to involve just a little vaginal assessment, because that's the only way that we're going to know that you're doing your pelvic floor properly. We don't want to give you exercises, and you've gone away and not done them quite right, and we haven't improved your symptoms.

We'll look at your bowel management as well. If constipation is an issue, difficulty emptying might be an issue. If you've got a rectocele, Mr Gupta will talk about that in a while we'll help you with weight loss, and we'll give you advice about the exercises that you can be doing, particularly to things like pilates that can also help with pelvic floor muscle strength.

As we've said, one of the sort of key things for all of this is going to be pelvic floor exercises. So with pelvic floor exercises, you do strong contractions, you do false contractions, and I think the key thing to remember is it's going to take at least three months to strengthen up your pelvic floor muscle. There can be that tendency to do them for a month. Things aren't really a lot better, so you can give up.

You absolutely have to carry on with them. In most people you will get some improvement. It might only be slight, and it might not be enough to give you an improvement significantly in your quality of life, and you might then need further interventions. But actually, then, that's going to get you in good stead, you know, to recover from your surgery.

So to strengthen your pelvic floor muscles, it's about squeezing the muscles underneath, gently squeezing as if you feel you're trying to stop passing wind and also squeezing to feel you're trying to stop emptying your bladder, passing urine. And what you do is you squeeze that muscle up for a count of one, and you relax it for a count of one.

That's what you call the fast contractions. Not fast, really quickly. Make sure you feel you've squeezed for one relaxed for one and do 10 of those two, three times a day. They're very good, or that's the main exercise for the stress incontinence.

The strong contractions squeezing and holding that you're going to need those if you're trying to work on your bladder retraining, you're going to need those to give you support for prolapse, and that's about squeezing and holding and it may be that actually, you can only squeeze and hold that for three or four seconds, but that's fine. Do that, relax it down, try and repeat it five times. Do that two or three times during the day.

Really importantly, when you're doing pelvic floor exercises, don't hold your breath, don't tighten your stomach. All of the work should be going underneath. So what you're trying to feel is almost like a slight lifting feeling in the vagina.

Thank you.

So Mr Gupta mentioned urodynamic study, which is a bit of a pressure test on your bladder. So if we've done all of the conservative interventions and you're still symptomatic, we'll do this.

A urodynamic study involves having a little catheter put into your bladder attached to a bag of fluid that's going to fill your bladder up artificially. You have all normal sensations. So you might be saying, oh actually I've got a lot of urgency now, or if you get stress incontinence, we'll have you coughing at the end to try to make you leak, but it's going to give us a graph print out, and it's going to give us a diagnosis.

It's going to show have you got stable bladder or have you got an overactive bladder when you cough are you leaking. So we're going to sort of give a report of everything we've got from the test which helps as a diagnostic tool for Mr Gupta.

Mr Abhishek Gupta

So if we've gone down the route of urodynamics, which is a kind of as Jan was saying it takes. You have to put a catheter in the bladder, a small catheter in black passage to see how your bladder is actually behaving. That means the conservative options and the medical treatment has not worked. So now the whole idea is to get the diagnosis confirmed and so see how your physiologically your bladder is working. And then we're thinking about going down the route of invasive treatment.

So there's no other role for urodynamics done to get the diagnosis when we started thinking about doing something more invasive.

So I think we covered the incontinence topic a bit. Now we'll try to cover some prolapse as well so what is basically the prolapse. So hopefully, my cursor moves so you can see. So it's a two damaged picture.

So we're looking at the woman from front to back. So first thing you notice is a bladder which drains water out, which is called urethra, and when we were looking at the slide to bulk commit. We were putting bulkamid somewhere there. So this is bladder neck of the bladder urethra that's vagina, that's womb that's neck of the womb, and that's the back wall, back passage. So that is human anatomy.

And the prolapse is basically herniation of your organ through the vagina and herniation happened because of the weakness of the support structure. So when the support structure weak, it gets herniated. So the support structure here are the ligaments which hold the womb, the support structure here, for the bladder is the fascia.

Here this is the lavatory muscle, which is again a support structure, and then you've got support structure here for the bowel, which is again called fascia and the lavatory muscles. So anything which can cause the weakness of tissues that can cause you to have prolapse.

And then again, as we were discussing the incontinence, some things are overlapping, like trauma from a childbirth, instrumental delivery, chronic cough lifting heavy weights, previous pelvic surgery, age, previous hysterectomy can cause weakness in the tissues. Then we talked about obesity. We talked about smoking.

Again, we talked about genetic causes, where we genetic causes, which is where the collagen tissues are weak, like a syndrome, or something else where you are born with the congenitally weak tissues, and that can increase your susceptibility of prolapse and incontinence. So this is what usually causes the prolapse. But prolapse can happen on patients who are never given birth as well with age and with connective tissue disorder, it can happen.

So that's the normal anatomy we were talking about. That's the bladder womb, vagina urethra, back wall and anus.

So what are the. There are three compartments in the vaginal area. The front wall is front, wall, middle, and the back wall. So when the bladder starts to descend into the vagina, which is the weakness of this front wall. Then this is called Cystocele, where the bladder is coming down, and and obviously I'll just ask you to have a look here, what's happening with the urethra, it's getting kinked so this can present its bulge.

So people do present bulge. They find it very difficult to empty. Sometimes they find if it's a big sister cell, you can find it difficult to empty the bladder. You find that you have slow flow and slow flow, and you find it difficult to empty, because, rather than going urine going here, it goes here so you might have to double void to completely empty this.

And sometimes, if you're not emptying the bladder well with a significant cystocele, you can also present with recurrent urinary tract infection, because it acts as a reservoir.

Similarly, if it goes on the back wall, it's called rectocele, which is the prolapse on the back wall of the vagina, which is the bowel pushing in it can again present this bulge uncomfortable feeling, and also sometimes it doesn't cause you constipation.

But if the bowel is full, and you are unable to empty. Sometimes you might have to splint or push through the vagina which creates a little pocket here, so you're not able to empty the bowel. Well, sometimes you can splint to empty the bowel and the middle compartment the womb can come down, which usually presents as a discomfort, and pressure and the pulse.

And if patients had hysterectomy, you still have the top of the vagina, and the top vagina can come out, which is called vault prolapse. So these are the common causes of the common prolapse. The front wall is cystocele, back wall, rectocele. Middle is either a womb prolapse, or the prolapse of the top of the vagina.

The prolapse and discomfort usually gets better if you're resting, so if you're at the night, and you're resting, and you're sleeping, and you don't have a discomfort, and if you're on your feet for a long time, and you feel your prolapse is worse towards the end of the day. That's gravity. So typically prolapse presents like this.

Again, having a bit of prolapse after childbirth is common. So you might go to your GP. For a smear test, and the GP says, or GP practice a specialist tells you you've got a bit of prolapse, but if it's not causing you any problem, you're not feeling dragging, you're not feeling bulge. You're emptying your bladder. Well, you've emptying your bowel fairly well, then, that prolapse doesn't need specialized treatment.

All it needs is a pelvic floor exercises because it's all about quality of life. So never do an operation on a prolapse. If it's not affecting quality of life, thinking it may get worse in future, because a it may never get worse in future, and all prolapse treatment has one to three in 10, chance of perhaps just coming back and doing the first time around. And prolapse operation is always the best, having a repeat operation increases, complication reduces your success rate. Hence the quality of life discussions come in very important.

So what is the treatment for pelvic organ prolapse? The treatment of pelvic organ. Prolapse is all about quality of life. So as we discussed first the pelvic exercises and the lifestyle changes with weight, loss, cessation of smoking, doing pelvic exercises, avoid lifting heavy weight, avoiding constipation is so important. If that helps your quality of life, we don't have to do anything else. If that doesn't help. Then we go next step.

Hormonal treatments don't sort your problem of prolapse out, and it's not the systemic hormone doesn't help with prolapse.

The only thing which can help with prolapse, and it takes your symptoms away is a condition called vaginal atrophy, which is lack of oestrogen in the vaginal area. When the skin loses a lot of water and becomes very thin, and it can get a lot of dragging and a lot of feeling of discomfort.

And obviously, if you're having pelvic exercises, or even having surgery reversing vulva, vaginal atrophy does help to make you feel comfortable, reduce the risk of infection, helps you to heal better and helps you to do better. Pelvic floor exercises. It does make your skin and your condition better, and it can be helped by taking local oestrogen, not systemic oestrogen, not through the oral, not through patches.

Cream, or a pessary via vagina, which is a small dose of hormone which works vaginally, the amount which comes in your bloodstream is little, so it doesn't give you any side effects, but works really well.

And then, before the surgical option, there is an option of pessaries device which comes in various shapes and forms, which is like a ring or a donut or gel horn. So what pessaries does? It goes in the vagina, and all it does is to support the prolapse. It's not a cure for prolapse, it's just, and it doesn't prevent it getting worse. All it does is to hold that in place for you to get better symptomatic correction of prolapse.

The advantage is, it's a it's less invasive. So you don't have to have an operation. The disadvantages that it needs to be changed every four to six months and it can give you pressure sensation. It does give you some vaginal discharge and last, but not the least, the pastries work only on 50% of patients.

So it only works in one in two patients. It doesn't work for everyone.

And as I said, it needs to be changed every four to six months, and then surgery. What is the aim for the so what is what are the aim of surgery? Surgical aim is again to improve your quality of life.

So obviously the prolapse. If you've got bulge restoration of the organ where they are. So if the bulge is the main issue, we need to operate to make the bulge better. If you're having discomfort, it is to make the discomfort better it also, sexual activity is very important people, if it's causing problem with sexual activity.

Get better if you're not emptying your bowel well, and you have to digitize through the vagina to empty or splint to improve that. That's your symptom control, or how quality of life improvement if you're not emptying your bladder well, then we do the procedure to get your bladder well, and it depends on where you have got the prolapse.

So if you've got a frontal prolapse where the bladder is coming down, you open this area, push the bladder back in, bring the tissues together and suture this up, we also, if your bowel is coming, we do the same for here, and if the top of the vagina is coming down, sorry if the womb is coming down. Then, obviously one of the options which are age old option is a vaginal hysterectomy works really well.

And sometimes the alternative vaginal hysterectomy is to restitch the neck of the womb, which is called sacrospinous fixation, which is same process, same operation, which we can also offer. If you already had a hysterectomy. The top of the vagina is coming down, and the last option for the womb prolapse, or the top of the vagina prolapse is something called sacrohysteropexy, which is use of a mesh and that is done to the tummy.

We at Benenden don't do any mesh surgeries, and the mesh is an option. So it depends on where you are prolapse wise, and hence we do.

The operation is usually irrespective. Whatever you get done, one to two nights in hospital stay, complete recovery takes six weeks or so, whatever the stitches we use dissolve themselves and as I was talking in my talk there is a chance the prolapse can come back.

Also sometimes you can get pain during intercourse, which is called dyspareunia, because scar tissue usually settles on its own. Occasionally we may have to divide the scar tissue, and in my previous slide, where I showed you that when you have a cystocele your urethra is kinked. You're not able to empty the bladder valve at this level here.

So if I correct the cystocele, that kink is gone, so it straightens your urethra, so sometimes, after repair, it can unmask an underlying problem of leak of waterworks because the kink is causing it. So once we correct it, it can unmask a bit of leak of waterworks and if it does happen, we may have to do further treatment.

So there are pros and cons of every surgery. So hence, if it's affecting quality of life, have the prolapse, and if the choice you want for surgery, then it's a good time to have the surgery because you want to improve your quality of life.

These are some resources. What I would recommend that you go into a British Society of Urogynaecology website. You can Google it up British Society of Urogynaecology, which is called BSUG. And there is a section for patient information. And you'll get a lot of resources where you can read about operation as well as different options, we have touch base, and the physiology of what production contents means. So it's a good resource in one place, which is British Society of uroynecology, and then patient information. You just have to Google. You'll go to the page, and you can read all of this literature.

Jan Chaseley

Lovely. Thank you, Mr Gupta. I'm going to leave this slide up that talks to you about consultations. But we're now going to go to some questions and answers. So I've got a bit of a double question. Here is incontinence common during menopause, and would HRT help?

Mr Abhishek Gupta

I think some of these we have covered in our discussions. Yeah. So obviously as time goes, when we go older, the connective tissues do get weaker and with lack of hormones, the connective tissues even become more weaker. So yes, the menopause and age can have a contribution to urinary incontinence, but obviously systemic HRT if you start early. Systemic HRT is when you take a patch, or oral, or a gel.

If you start early then it does can improve your connective tissues. But if you have not started just after going into menopause, then there is no evidence that after five years or six years of menopause a HRT. Systemic HRT will work.

However, the local vaginal oestrogen can still help and work, and it's less it's got less side effects as well.

Jan Chaseley

Thank you. I'm fit and healthy, but I discovered I had a prolapse. After a long walk. It went back after I rested, so should I be concerned, and should I try to do less?

Mr Abhishek Gupta

Yeah. So as I was talking about the prolapses do get worse towards the end of the day, especially when you're on your feet for a long time because of the effect of gravity, and it's all about quality of life.

So if you're if the walking or running is a good form of exercises, and if that is really important for you, and that is important for your quality of life, I wouldn't say that necessarily you have to do less of that if it was a day when you did a huge 20 miles walk which was not common for you, and you don't do it often, and that's not your quality of life. Then yeah, you can change your quality of life and see whether it helps you.

But if it's come down with a normal walking or normal long walk which you like to do. Then that is, that is where I'm saying that is affecting your personal quality of life, and then you should be get seen, and we should and would like to try to say to help you.

Jan Chaseley

Yeah and if you try bulkamid and it doesn't work, could you be worse off?

Mr Abhishek Gupta

No, it usually either works or doesn't work. So even if you have the bulkamid, it doesn't work. You can be suitable for any major surgeries in future. I haven't seen bulkamid causing any issues to patients up to now.

Jan Chaseley

Lovely, thank you. And a question. Once I've started to pass urine I can't stop. Can this be improved with pelvic floor exercises? I think. Yeah, absolutely. We can definitely work on your on your pelvic floor.

A lady has said on our description. In the beginning we mentioned acupuncture for stress incontinence. That would be the PTNS and the tibial nerve stimulation, that's for your overactive bladder, which is something that is offered at Benenden but not the acupuncture isn't for the stress incontinence

A lady put on here that. Actually, she's doing pelvic floor exercises. But she has a tense pelvic floor and pelvic floor exercises don't really help. So again, I think a specialist nurse appointment. We can look at pelvic floor relaxation, pelvic floor massage. So if that's something you're interested in, you could come and see the specialist nurses or come to see Mr Gupta just for a consultation.

Mr Abhishek Gupta

It's also important to see that you're doing it well. So I think pelvic floor exercise is one of those where it's easier said than done. So it's good to know whether you've been able to contract those muscles, and sometimes people overdo it as well with the wrong way which doesn't help.

It's always wise to see a specialized physio see one of the continence specialists to see what's going on

Jan Chaseley

What's going on. And again a bit about exercise.

Can I do aqua aerobics, yoga and Pilates with a vaginal prolapse?

We would definitely say, yes, you can do all of those. I think the things to avoid. If you have prolapse is going to be doing things like squats. Don't do abdominal crunches, so don't do things like a rowing machine. Be cautious on cross trainers, but otherwise, say a lot of exercises will help to support your pelvic floor as well.

What is the stage four prolapse?

Mr Abhishek Gupta

So there are four stages of the prolapse. One is the so if you look into the whole vaginal length when the prolapse starts to come down to vaginal length and reach the 50% of vagina, but not coming out of your body. That's stage one when it's reached the 50%. But just started to coming out of your body or vaginal opening from there to there is stage two when it starts to come out of your body stage three, and when in a crude way, when everything has come out, it's stage four.

Jan Chaseley

Thank you. I have prolapse. I have prolapse, don't want surgery, but haven't been offered pessaries. It may just be you need to go back to your GP. Or some GPs don't fit pessaries. So again, I think, coming for a consultation and some advice here at Benenden would be.

Mr Abhishek Gupta

It also depends on your how's your muscles of that area. Because, as I said, pessaries only work on 50% of the patients. So if your pelvic floor muscles are quite weak, and sometimes some of the prolapses are not suitable for pessaries device. So when we examine, we get a bit of idea whether this prolapse with the pessaries will work on you or not, so it will be only after examination. One can give an opinion that the best three can be tried or not.

Jan Chaseley

And can you use vaginal HRT premenopause?

Mr Abhishek Gupta

You can. But at the end of the day. If you're not going into menopause, you shouldn't have any issues with vulvovaginal atrophy or lack of hormones in the vaginal area. So if you're getting regular periods and not got into menopause.

You should have enough of your own oestrogen to not cause lack of oestrogen in the vaginal area. Sometimes we have to, if it's too much of vaginal dryness, whereas usually we examine you to make sure there's nothing else going on before we recommend that to be done, and is a vaginal hysterectomy suitable for all patients, including elderly.

I think if I think nowadays, with advances in anaesthetic and post-op care, if the womb is coming down, and you're fairly okay with your fitness for surgery. Then we do offer vaginal hysterectomy for different age group as well as for 80 plus.

We have even in we have done quite significant numbers of vaginal hysterectomy on patients who are 80 plus. Obviously, if you require any post-operative care for high dependency unit or ITU, because of a lot of comorbidities, then it can still be done. But we will like to do it in a place where you have an facility rather than in Benenden. But routinely, we do offer 80 plus patients if they want hysterectomy to be done.

Jan Chaseley

Yeah, does it help to use, it says here a vaginal tens machine so obviously like pelvic floor muscle stimulators?

I mean, I think there is a place for those. I think you need a really good assessment of your pelvic floor with a specialist nurse first and it's you doing the exercises. That's really important. But if you're using sort of a pelvic floor at the stimulator machine, it would be doing a pelvic floor exercises alongside. It's not going to be an alternative, or I don't think it's a quick fix.

A lady's mentioning that she's got urgency with no control. So that's suggestive of possibly symptoms of overactive bladder. So yes, just speak to your GP.

Mr Abhishek Gupta

Sorry.

Jan Chaseley

I was just going to say sometimes GPs will just prescribe medication as a first line.

Mr Abhishek Gupta

And if you are, if you are listening, if you don't hopefully, don't drink too much of caffeine, because he drinks alcohol, and also you might, if you have to go more often to the waterworks and have this urgency in leak, then yes by all means do this lifestyle adjustment, and then get your GP to prescribe the medication. And obviously, if things don't get better, we're very happy to see you and try to help.

Jan Chaseley

Yeah. Yeah. And if you have a prolapse. Should you avoid lifting things?

Mr Abhishek Gupta

Yeah, lifting heavy weight is not good, because even after the operation, lifting heavy weights because the excess for when you lift heavy weight the excess goes through the pelvic floor and can increase your chance of having a reoccurrence of prolapse. So it's a jerky, very heavy moment we're talking about, but lighter hoovers, lighter laundry baskets or lighter shopping. That's absolutely fine.

Jan Chaseley

Thank you.

A question about can pelvic floor exercises stop a prolapse going from stage two to stage three.

Mr Abhishek Gupta

Yeah, I mean, after it's gone past stage two. It's very difficult for pelvic floor exercise to bring it back. But yes, if good pelvic floor exercises can help for making it not worse in future. Yeah. So that's one of the really important thing which you can help yourself with pelvic floor exercises. Absolutely. Yes.

Jan Chaseley

I've been told I have a retroverted uterus. Is that significant in terms of bladder prolapse or any prolapse.

Mr Abhishek Gupta

Not at all. One in four women are born with a retroverted uterus, and it doesn't make any difference to anything.

Jan Chaseley

Lovely, thank you very, thank you very much.

So lovely. Thank you for attending this webinar. I'm really sorry if we didn't answer all of your questions, and there has been some that we haven't managed to answer. But if you provided your name, we will answer via email.

Move to the last slide. Thank you.

Lovely. Thank you. So as a thank you for joining this session tonight, we're offering you 50% off the value of a consultation for a limited period.

You will get a call back from a dedicated Private Patient Advisor and an email with a recording of their webinar treatment information and loyalty reward points.

We'll also give you updates on new and future events.

We would also be grateful if you could complete the survey at the end of the session to help us shape future events.

If you would like to discuss or book a consultation either with Mr Gupta or with the Specialist Nurses, our private patient team can take your take your call until 8pm this evening, and the number is there on the screen, or, if not Monday, to Friday, between 8am and 6pm.

We have a number of upcoming webinars, including acid reflux, cataract, surgery, and orthopaedics. So please feel free to sign up to anything that you find interesting.

So on behalf of Mr Gupta and the team here at Benenden, I'd like to say, thank you for joining us today, and we hope to hear from you very soon. Thank you very much, bye bye.

Mr Abhishek Gupta

Thank you.