Jan Chaseley

Once again, good evening, and a very warm welcome to the webinar this evening, which will be on urinary incontinence and pelvic organ prolapse. My name's Jan, I'm the Clinical Nurse Specialist in Continence Care here at Benenden, and I'm joined today by the expert speaker, Mr Abhishek Gupta, Consultant Urogynecologist.

Tonight's session will begin with a presentation from Mr Gupta and myself, followed by a live question and answer session.

If you have any questions at any point, please feel free to submit them using the Q&A icon, which you'll find at the bottom of your screen. You're welcome to ask these anonymously or include your name.

Just a reminder that this session is being recorded, so any names shared may be visible in the recording.

To help us get through as many questions as possible at the end, please keep your questions brief.

If you're interested in booking a consultation, we'll share relevant details at the end of the session. I'd now like to hand over to Mr Gupta.

Mr Abhishek Gupta

Good evening, everyone. So my name is Abhishek Gupta. I'm a Consultant Gynaecologist and a Urogynecologist. So, I trained in London and Southeast.

I completed my specialist training in 2012, and then I joined, Dartford and Gravesend NHS Trust in 2012 as a Gynaecologist. Obviously, I am a Urogynecologist, and I also do minimal access surgery.

And from last year, I have started doing robotic surgeries as well, so I'm a robotically trained surgeon. I did my training in this region, as I said, and I've got a I've done my advanced training in urogynaecology, as well as laparoscopy upon surgery.

Obviously, I am a member of British Society of Urogynecologist and Royal College of Optional Gynaecology, and from last year, I'm also a member of British-Irish Robotic, gynaecology surgery, BRACs as well.

So that's me, and I have been working in Benenden Hospital since 2012, end of 2012, so I've been here for the last 12 years as a consultant, and Now, I'd like Jan to introduce herself.

Jan Chaseley

Thank you, Abhi. So I'm Jan, I'm the Clinical Nurse Specialist in Continence Care here at Benenden. I've got probably over 20 years' experience now in urogynaecology nursing, and I manage the specialist nurse team here at Benenden, and we're very lucky we have four, clinical nurse specialists that can all help to manage your symptoms.

We run nurse-led clinics and we also offer urodynamics, which is a diagnostic test.

Along with Mr Gupta, we run multidisciplinary team meetings to discuss your symptoms, your case, to make sure we're giving you the right treatment at the right time.

Mr Abhishek Gupta

Thanks, Jan.

So what our webinar is, to give you an overview of what incontinence prolapse is about, where you can seek the help, what are the common things we do, how do we provide the help for you, and what you can do to help yourself as well.

What are so we basically want to give you as much I'm, as much knowledge as possible to empower you to seek help, or even to know your own body and see whether what's, and that will empower you to know what's going on, and seek help, or help self-benefit as well with self-help strategies.

So, we'll give an overview of what urogynaecology is, what overactive bladder means, what stress incontinence means.

Jan will talk about nurse assessment, because it's so important to work in a team, especially for urogynaecology, because Surgery is not the only option you have. It's not lots before and after surgery.

You I'm sure everyone has learned about the issues meshes went through, and the negative publicity the meshes got for incontinence, and then they were stopped in 2019, 18, 19 time. It was not the tape which caused problem, which is which is for incontinence.

Is the way the tape was implemented, and unregulated putting the tape was a problem, because half of the patients may not need a tape. They needed a multidisciplinary team to work with them to get them better.

So, it is so important, and it's a recognition everywhere that urogynaecology is a team-based approach, where specialist nurses, specialist physiotherapist.

and as specialist consultants, they work together to bring the best outcome a woman deserves for incontinence prolapse, because it's quite personal to you.

It does affect people's confidence in more than one way, and there is a need for a multidisciplinary way of working to make it happen and make it better.

Then we'll talk about prolapses, and then I'll also tell you about various resources you can, look at yourself, because when you put on Google and all that, you get a lot of unregulated, lot of unregulated, media-proven, things as well, which we don't know whether they are valid or not, whether they're logical or not, but I'll give you some resources which we recommend you can go down and tap to endeavour to help you to have a bit more knowledge, and evidence-based knowledge.

Then we'll try to answer as many questions as possible in the short time we have today.

So, what is urogynaecology? So, it's a subspecialty of urogynaecology, which helps with, basically, female pelvic floor dysfunctions.

It can range from anything which causes urinary incontinence, or symptoms of urinary incontinence, vaginal prolapses. Recurrent UTIs can be from a mixed bunch of falls between sometimes urology and urogynaecology, because it can be related to upper tract as well, like, kidneys and ureter, but lower tract, which is bladder and the vaginal issues, then recurrent UTIs also comes under us.

Bladder pain syndrome, and obviously pelvic floor injuries post-childbirth, because a lot of trauma has happened when you have a vaginal delivery, or especially when you have prolonged labour, or instrumental delivery, like forceps or vaginal delivery, so trauma has happened. So these are main areas where we come in with specialization where we can help And that's what urogynaecology encompasses.

So, what are the common referrals we see in our area? So, as you can imagine, we see a lot of problems with bladder problems, which can range from people requiring frequency, urgency waterworks, they need to go often, their frequency, this affects their quality of life, and They may leak, which may be involuntary, involuntary. We'll talk in a minute what all that means.

Obviously, the prolapse, which can have symptoms as well, and recurrent UTI, bladder pain, and as we said, pelvic floor injuries after childbirth.

So let's start talking about the issues for first range of referrals, where the bladder referrals, which are quite common to us, where we get patients referred for, urgency, frequency, have to rush into rush for waterworks, or you leak, or you might have to wear a pad.

So often, the incontinence can be either urge incontinence, which is with urgency, stress incontinence, which is unprovoked with no urgency, but you're doing an activity, which is, like, coughing, sneezing, lifting weights, jogging, sexual intercourse.

Sneezing, so anything which increases your tummy pressure, or a jerky movement, that leaks, that stress incontinence.

However, a lot of incontinence are a mixed picture, so sometimes you can have urgency waterworks and stress incontinence, both.

Patients who have shown stress incontinence without no overactivity of the bladder, they may also present with overactive bladder.

So it's so important for us to understand, because when patients are leaking, involuntary, nobody wants to leak in front of strangers or any places, because that's embarrassing.

So what our natural reaction is to help ourselves to keep our bladder empty so we train our minds to keep going for toilet, to keep our bladder empty all the time, and then we think that we are visiting often, but it's actually our nature, because we don't want to be leaking, and that may be stress incontinence.

Sometimes that's where Jan and her team are very good in finding out from your bladder diaries and everything else whether you have only a component of stress incontinence, mixed picture, or you've got urgency. So I'll talk one by one and hope it will be helpful.

So what is an overactive bladder? So, overactive bladder is a bladder which is not in your control, so it's involuntary. So, bladder is if you imagine my face as my hand as a balloon.

And it's full of water. That's your bladder. So, in the normal circumstances, when you have a bladder around 300, 350mls of fluid in the bladder, you want to go for a wee. You usually, find you can hold it, you find a look when you find the toilet where you go in, relax, and then you tell your mind, now I'm in a safe place when I have to start emptying my bladder. So the bladder then contracts.

That happens when you relax yourself and give this give that signal to your mind that now I can start weeing. And then the bladder contracts, and then you wee.

However, with patients with overactive bladder, your bladder is constantly doing this. So there's slightly this balloon is not in your control, the balloon is getting this contraction, and that's called detector contraction. Hence, you keep going this urgency and frequency.

So you want to go for waterwork often, and often the patients who have really an overactive bladder, which is contracting like that, you will have, peculiarly small amount of urine you pass, and often.

So you the problem is you're not able to hold the urine well too much, and when bladder sometimes then becomes like this, the contraction becomes more powerful.

Then you start leaking. So that is an overactive bladder, and as I said, the symptoms are urgency, which is you need to go, you need to go, and often you will have some kind of symptoms like when you're putting your hand for washing. So you touch water, or sound of water may make you go and rush.

Often what we call is a lock and key, that you reach home, you want to go for waterworks, you're rushing, you put the key on the lock, and you start leaking. So these are kind of cues for us that the bladder can be overactive.

Obviously, sometimes you have to get up in the night for overactive bladder. However, sometimes the nighttime getting up can be normal, because after a certain age the physiology of the bladder does make you get up a couple of times in the night.

So, these are kind of overactivity bladder that can happen, as I was describing about the age, but sometimes it can be nerve-related as well, and you can find a table overactivity of bladder with patients who have got MS, for example. But overactivity can happen on its own without any cause.

Jan Chaseley

So, looking at managing overactive bladder, particularly if you come to the specialist nurses and we're treating you, you know, as your first appointment, Mr Gupta mentioned about filling in a bladder diary, and that's really important.

You'll measure your intake and your output for three days, and you'll measure how often you pass urine, and what, more importantly, I think, what the voided volumes are, how much you're passing, so we can see, are you going very frequently with small amounts, can your bladder hold on.

But if you're treating overactive bladder, we always look at your You're drinking. Keep your drinking between one. five and two litres, that's all you need to be drinking in a day.

Look at how much caffeine you're having. So, caffeine's a bit of a diuretic, so it will make your kidneys make more urine, but it's quite irritant to this bladder. It will set this sort of twitchy bladder off, and give you more urgency and frequency.

We would normally say two caffeine drinks in a day would be fine. Otherwise, look at decaffeinated, look at fruit herbal teas, look at other substitutes.

We'll work with you on a program of bladder retraining, so if you're emptying your bladder every hour, we'll try and get you to stretch that an hour and a quarter, an hour and a half, because you should be emptying your bladder you know, around about that three hours, if you haven't got bladder symptoms.

Pelvic floor muscle exercises, I'll talk about those again a little bit later on, but they're key, and often squeezing a strong squeeze of that pelvic floor muscle can help you when you have that awful urgency to just momentarily calm that bladder down, and that might be the difference between getting from where you are to the toilet without having a leak.

If you have bothersome nighttime symptoms, we'd say have your last drink a good, sort of, two hours before bed, so around eight o'clock if you go to bed around 10 and try and make that not a caffeinated drink. Have decaf, have a milky drink, Horlicks, avoid the hot chocolates again, because you're going to have, caffeine in that.

If we know that you're maybe not emptying your bladder completely efficiently, sometimes we get you to double void before you go to bed, and that's just around emptying your bladder as normal, cleaning your teeth, getting ready for bed, emptying again 15 minutes later before you go to bed, and that can sometimes help with the nighttime symptoms.

We're gonna we're gonna look at what's going on with your bowels. If you suffer with constipation, a full bowel's gonna put pressure onto your bladder, so do we need to, you know, advise any medication, help you with that?

And then again, we'll review medications that you're taking, you know, are you on some blood pressure tablets and diuretic that's actually giving these some of these symptoms? And then, obviously, we'd then discuss that with Mr Gupta, and maybe advice to your GP to review some medication.

Mr Abhishek Gupta

While we're on the subject of medication you might be in, you especially when you're getting up in the night.

Often it's worth checking with your GP what medications you are on. Very often, because it's a very common medication people are on, Nifedipine or Amlodipine. Amlodipine are calcium channel blockers, and they can make you go up these are mainly hypertension medications, but they will they have increased risk of you getting up in the night few times.

The normal bladder is fine, but if you're on medication which will make you get up in the night, then you might like to review these medications.

So now, with what we call as fluid management, training yourself, pelvic floor exercises, if your symptoms are still ongoing, then we that's the time when we start, thinking about putting the medications on. So, there are two kinds of oral medications which we can try before we do anything invasive.

So one is called anticholinergic, and we just put the names of the medication, which are there, Oxybutynin, Solifenacin, tolerated the different kind of anticholinergics. So, what anticholinergics does, it prevents the contraction. That's the method of working, it prevents the contraction.

Now, they work on the same receptor as you have for your salivary glands, you have for your gut, so sometimes they have side effects, which are, like, constipation. You can have a lot of dry mouth, then not good medication if you've got glaucoma.

But if you can tolerate the side effects, then the normal effect of, whether it's helping or not comes in play. So it takes three to four weeks to start showing the effect.

Betmiga, which is Myrbetriq, is a slightly different drug. It works on a slightly different receptor, so anticholinergic prevents the contraction. Myrbetriq helps to relax the bladder. So they are working as slightly different, different receptors. Myrbetriq has got lesser side effects, Than, anticholinergics.

It doesn't give you that constipation, dry mouth kind of side effects. It's the only thing which we need to be careful. If you've got uncontrolled hypertension. So you've got uncontrolled hypertension, or you've got, cardiac rhythm problem, then we have to be kind of careful with Betmiga. otherwise, it's safer. Especially for elderly population, it's got, long use of anticholinergics are associated with dementia. However, Betmiga doesn't have that problem.

Then, if this doesn't work, then we do a specialized test called a urodynamic test, which we try to do it. Not necessarily has to be, but that's we try to do it to establish the treatment establish the diagnosis to make sure we have not got it wrong, and Jan will talk about urodynamics in a minute. And then we got Then we're going on to slightly, invasive treatment for, overactive bladder.

One is PTNS, which is percutaneous tibial nerve stimulation, and now recently, which we haven't evaluated, but there is a company which is coming with transcutaneous nerve stimulation, which is easier, probably, for patients to use.

And that, what it does, is it stimulates the nerve, and it helps to relax your bladder, to make to reduce the contraction often.

And then we So, the PTNS is usually offered by Jan and her team, privately.

Botox is a medical treatment where what we do is we have a look inside the bladder with the camera, and we inject around we start with 100 international units of Botox on the bladder. For overactive bladder, where patients' quality of life is really affected, Botox works really well.

Patients do, within two or three weeks, patients' quality of life are much better. They're not going for that often, they're not having a lot of urgency. The only two flip side of Botox is, one, it keeps needing to be repeated. So every six months to a year, it will need to be repeated. And the second is, you sometimes the bladder does become so relaxed, because the whole idea of Botox is to slightly paralyze the bladder and relax it, that you're not able to empty the bladder well. Well, and hence, we or Jan's team, teaches all the patients who wants to have the Botox, how to catheterize themselves. It does sound more horrible than what it is. Once you've been taught and empowered, it's not actually that bad. And it only  one in 12 women who are requiring Botox will require the intermittent catheterization. So, 11 out of 12 times, you won't need it, but we'll teach you before we do the Botox. And then, the last option is sectoral neuromodulation, where they put a little electrode on the back, with a transducer, and that creates a reflex to stop your bladder contracting, overactive bladder contracting.

Unfortunately, sacral neuromodulation is only done in sub tertiary centres, and the only one I know which is functioning at the moment, where it's been done, is in London. So we don't have any local centres where the sacral neuromodulation is actually offered, which I know of.

So, let's talk about the other component which I was talking about, stress incontinence. So, all incontinence has to be involuntary, because if you're voluntarily leaking, then it's your weak, not leaking. So stress incontinence is involuntary, so what happens is when you cough, sneeze, now my hand, again, I'm showing you this hand. So if that's a balloon, your balloon is stable, but there's a tube which drains water out, which is called urethra. So when you cough, sneeze, lift weight, a lot of pressure goes on the tummy, which is trying to press on your balloon like this, which is And as long as you've got a good support just below your urethra, Then, you will North Lake.

But if you have weakness in that area, then the urethra, which is a tube you can see there, doesn't close very well, and then there is still space left for it to start leaking.

Now, various risk factors, and that's all part of the pelvic floor, one risk factor is vaginal deliveries, especially if you have instrumental deliveries, and that causes weakness of that area.

Menopause, so woman body goes through a lot of trauma, and menopause is one of it, and menopause does cause weakness of the tissues there. If you are overweight, it's so important for weight to be addressed first. Smoking, chronic cough, really doesn't help.

Because it will make your pelvic floor really weak, and even if you want to do any operations or any surgery to help, you don't heal that very well. And some neurological disorder and can cause that as well.

So what are the treatment of stress incontinence? First is the life lifestyle treatment, which is the structured pelvic floor exercises, where Jan and her team comes in. So you need to see specialist nurse or specialist physiotherapists do pelvic floor exercises. If you're overweight, lose weight.

If that doesn't help, then we can go a step further. And there are three recognized treatments, so after the mesh has been stopped, there are three recognized treatments.

Which we can offer, and we offer all three at Benenden Hospital. One is urethral bulking agent, which is called Bulkamid. It's a local anaesthetic procedure. It can be it's done in outpatient, it's done in local anaesthetic, it's a use of a permanent gel.

It works in around 55-60% of the patients, and it's all about quality of life. So it's not about you leaking or not leaking. Is this affecting your quality of life?

So if your quality of life is affected, and everybody's quality of life is very different. Some people's quality of life, when you've got young children, you're going for trampoline with your children, or go running with your children, and you leak. That's your quality of life.

Other people somebody in want to play tennis, and they're leaking that during playing tennis. That's their quality of life. So, what affects your quality of life? So, therefore, we success of our operations, we deem is how well it has improved your quality of life.

So, when we do Bulkamid, which is a which is a small injectable procedure, which works in around 55-60% of the patients.

It's local anaesthetic It's a permanent gel. It it's we haven't seen any long-term issues with Bulkamid. There's a small risk of bleeding infection, risk of a temporary catheter, and if you end up with a catheter, it's usually a few days.

But we haven't seen any either it works or doesn't work. Sometimes you have to give a top-up, and I'll explain you in the next slide, because we've got a little slide for bulkamid, to say where it goes and why it needs a top-up.

And the next two surgeries are quite a major surgery. One is called autologous fascist link, another is called corpus suspension. The both surgeries are major surgeries, and the whole idea of giving to doing this surgery is to give a support at the neck of the bladder level, which is your urethra. So through the vagina, that's the support we want to give. So when the bladder pressure increases, your urethra is well supported, and you don't leak.

So these are two major surges. The success rate around 80%, so unfortunately, none of them are 100% successful, but they're around 80% success.

When we look at our data, or our results, we do get more than 180% success rates with our surgeries.

But they are major surgeries, and they require six to eight weeks recovery period. They do require quite a bit of an engagement from us and you to make sure that you understand the procedure, you're ready for the procedure, and any issues post-operatively, we can manage. So they are quite major surgeries, but they do help with quality of life.

If we optimize you, Reduce your BMI, or weight. Make sure you stop smoking, and you've tried pelvic flows, and if things are not better then the operations do help, and then we can go around and doing them.

So I'll quickly talk about bulk commit, because Major operations, we've we can talk about them later, or you can ask me the questions, and I'll try to answer.

So, bulkamid is a procedure. So, we have a look. This is a camera which goes in with a little injection or needle which goes in, and it's just at the neck of the bladder level. So, this is a local anaesthetic injections we give on the site, then we put a camera inside the urethra.

Just at the neck of the bladder level, there's a two-dimensional picture, unfortunately, but if you look at the hollow organ, hollow tube, four-dimensional, one, two, three, four, four sites.

One, two, three, four, four sites, I give these injectables. The whole idea is to make that cushions to reduce your chances of leaking, and give that area a bit more support.

Sometimes this, The cushions do become flatter, and therefore sometimes we'll have to give a top-up to get more optimal correction of the stress incontinence.

And as I said, even with the cushions, sometimes it is not enough support, and it doesn't work. And then we may have to give further treatment.

Jan Chaseley

Thank you. So talking about Specialist Nurse assessment, so if you're referred here to Benenden, with any of the things we're talking about, incontinence, prolapse, quite often your first appointment and assessment will be with one of the specialist nurses.

So what we're going to do is we're going to take a history. We want to know a little bit about, you know, what your symptoms are. Is it bladder related? Is it a prolapse? Have you had children? Difficult deliveries? What is going on?

We're always going to test your urine, because we want to rule out urine infection, or find out if you get recurrent infections.

And then, quite often, we'll scan over your bladder, something called a residual scan, that will then tell us how well your bladder is emptying, because if you've got some incomplete bladder emptying going on, that could be the cause of the symptoms.

As I said earlier, we're going to look at your fluid intake, we're going to work on the bladder retraining, as I say, structured pelvic floor muscle exercises are the key, whether it's stress incontinence, whether it's overactive bladder.

Bowel management, again, managing constipation. If you're overweight, we'll help you with, you know, with weight loss, with dietary advice, and we'll also advise you about, you know, exercises that you can do alongside, sort of, your pelvic floor. Pilates is very good for core strength, but you might want to avoid high-impact exercises. Too much, sort of, squatting and weights might be aggravating your symptoms.

So, while we're talking about an overactive bladder, we've said, you know, one and a half to two litres in a day. You don't need to be drinking loads. You might need an extra 500ml of water if you're doing an exercise class, a lot of gardening, you know, in the hot weather. Restrict your caffeine to two to three drinks during the day.

And ideally, you know, you should be emptying your bladder every three hours, and at night, not all once.

It's really important, I think, looking at the colour of urine on the right-hand side of your screen, not that you probably normally, you know, look, but pay attention. If your urine is down the bottom end, you know, it's quite orangey, it's quite yellow, it's suggesting that maybe you're a little bit dehydrated. That might be because you get a lot of urgency and frequency, and you're trying to manage that by not drinking, but that sort of concentrated urine, that will irritate in your bladder, and it won't it'll still make you need to go as much, you'll just be passing smaller volumes, you'll be more at risk of urine infections.

And pelvic floor exercises, we thought this was an ideal opportunity to just talk about those.

As you can see in the diagram, the green, it's green turquoise, is your pelvic floor. So your pelvic floor swings across and it is like a hammock of muscle, swings from your pubic bone at the front across to the base of your spine. So imagine it as a really large muscle. It's not just something small, which is why it's so important.

So, to strengthen your pelvic floor muscles, we tend to do what we call fast contractions and what we call strong contractions. And to do a pelvic floor contraction, you gently squeeze at the back passage, so you feel you're trying to stop passing wind.

And you also want to feel you then carry that squeeze forward to the front, so you'll feel you're squeezing to stop having a wee. But what you're trying to feel by doing both of those is like a lifting, a pulling up in the vagina.

So, fast contractions are where you would squeeze up for a count of one, relax for a count of one, up for a count of one, relax for a count of one, and we would normally advise doing 10 of those at least three times during the day. Very good for stress incontinence, because it's working that muscle to snatch in quick with those sudden movements.

The strong contraction's more about building that strength and support, so you're going to need that if you've got prolapse to help to improve the support. If you've got urgency and you want to try and squeeze and hold on with your bladder, and we advise squeezing and holding that muscle, and you may only be able to hold for three or four seconds to start with. That's absolutely fine. Quite often, we'll start a hold for five, Relax for five and just do five of them, and build that up as your, you know, as that muscle strengthens.

Really important when you're doing them, don't hold your breath, don't pull your tummy in. So if you stand in front of a full-length mirror, you squeeze your pelvic floor, you should still look exactly the same, but you should be feeling that lifting in the vagina. And it takes at least three months to strengthen up your pelvic floor, so when you start doing them, if you don't think they're working, don't give up. You know, really work at them and give them at least three months.

So, if we've done all of these things, and actually you've still got bothersome symptoms, the stress incontinence, the overactive bladder, we can offer something called a urodynamics test.

And it's basically a pressure test on your bladder. We'll get you to empty your bladder into a commode that measures urine, which will tell us what your normal flow's like. Again, we'll scan your bladder, and then by putting a little catheter into your bladder, we're going to fill your bladder up artificially. So your bladder's going to fill artificially, you'll have all the normal sensations, and you'll tell us when you get an urge to go.

If you're leaking, we'll stand you up. If you normally leak with coughing and sneezing, we'll get you to cough. If it's with exercise, we'll do star jumps, bending down. And what we're looking at is, is your bladder muscle nice and steady all the way through the test.

Or is it giving little contractions, which is that overactivity? Or if in the test, when you're coughing, you leak, then that's sort of that diagnosis of stress incontinence, and all of that information is key then, you know, for Mr Gupta and the team to make sure we're giving you the right treatment.

Mr Abhishek Gupta

Thanks, Jan. So, as Jan said, for pelvic floor exercises, don't give up, because it takes three months to start showing a real good effect on you, because when you go to gym and start Or if you have gone to the gym, or see anyone exercising, you don't miss you don't build up any of your muscles by going to gym twice in a week.

You build up your muscles when you have done it for at least six weeks to three months. Then you'll see the changes in your body. Pelvic flows are same. Easier said than done. But if you don't if you do it religiously and regularly, you'll get the results.

Similarly, urodynamic test has got three per it's got three phases. One is three things to see. One is to show what is your bladder capacity.

If your bladder has a very small capacity, your bladder is a big capacity, and if it's a small capacity, what is the issue? Is it the contraction, or is it just you're quite nervous, or what are the reasons that you're not able to fill that properly?

Second, whether you've got overactive bladder, which is urgency, which we talked about, or you've got stress incontinence, or you've got a mixture of both.

Third how well you empty the bladder. Do you leave the urine behind? What how fast you empty the bladder? Because that will determine whether we will, A, teach you how to empty this properly, B if we give any treatment to you, then how likelihood is you going to get a problem emptying your bladder in future, once the treatment is done?

Because When we're talking about Bulkamid, we're talking about fascination, carpal suspension surgeries, there's a level of obstruction on your blood and neck. So it will give us idea about how well you're empty in the first place. So these are three main things which pick up with urodynamic tests, which is a physiological test of your bladder function.

So we'll talk about some, prolapse as well, and as we discussed about the prolapse is a weakness in pelvic floor, which causes the bladder to come down. So if you imagine so this picture, just to understand this picture, I'm really sorry, we don't have the pointer today, so there was a bit of pointed where you should see.

But if you see this picture, it's a two-dimensional picture, so we're looking at women from front to back. From, so, first thing you notice, behind that little ovoid thing is your pubic bone. So, behind that, the first hollow organ you see is bladder and a tube which drains water out, which is called urethra.

Behind that is the vagina, and the top of that is the womb, neck of the womb, and behind that is the back passage. So that's the human anatomy. Bladder, vagina, back passage, and the top of that is the womb.

So that's what you're looking at. Now, if you see your the vagina area is a hollow organ, and that itself is anatomically a hollow organ where the hernia of the organs can take place, if your supporting tissue in front, back, or the middle has failed. So there are three compartments in the vagina. Front where, where the bladder is resting on the vagina.

Top, where the womb is located, or where if you had a hysterectomy, it's the top of the vagina, and the back wall, where the bowel is resting. So there are three compartments, front, middle, and the back. So that's your anatomy.

So, any prolapse is basically a hernia of your organ through the vagina and because the vagina is a hollow organ, it becomes susceptible for herniation to take place.

So that's what prolapse means. The prolapse, again, in urogynaecology, everything is about quality of life and the only preventive strategy is pelvic floor exercises, blood retraining, not lifting heavy weights, not getting constipated, life adjustment, like smoking cessation, improvement of BMI, those are the only preventive strategies you have.

You we never do a prolapse surgery just because it may get worse in future. Because A, prolapses may not get worse in future, B, there is no guarantee of operation, and the prolapse will not come back. So it's all about quality of life. If the prolapse is affecting quality of life now.

We do the treatment. Prevention is in your hands. Not in surgical hands. So, that's where the preventive strategies come in.

So what causes prolapse? So, anything which can weaken your pelvic floor, which can cause. So, repeated straining, so if you're constipated and you keep straining, it's not going good for pelvic floor. If you keep lifting heavy weights, not good for pelvic floor. Chronic cough not good. Menopause. As I was saying, that women's body do go through a lot of trauma after menopause, and the tissues do become weak.

Childbirth, another trauma. previous surgeries in pelvis area, Unfortunately, as we go all go older, we our tissues go weaker, and unfortunately, we do all go older. Hysterectomy, Can predispose you for and this we're talking about hysterectomy done for heavy periods, or fibroids, or that reasons, rather than for prolapses, because once you do the hysterectomy for prolapse the supporting organs have already failed.

So these are the when you don't have prolapse and you had a hysterectomy, then hysterectomy can also increase your chance of prolapse coming. And then, we have talked about obesity quite a bit.

So, again, this is a good picture to describe your own anatomy, because sometimes this is this is where it is, so you have now known bladder, urethra, that's what I was talking about, from front to back, vagina, uterus, back passage, and the, anus.

So, what is sister cell? Cystocele is a prolapse of your bladder through the vagina. So, if you look into the front compartment of the bladder, in this particular picture, you can see the bladder now herniating into vaginal canal, and that's called sister cell, yeah?

Now, in this compartment, you can see the back wall bulging in, which is called rectocele. So, while we are in these pictures, I'll just briefly talk about how these patients usually present to us. So, the sister cell, which is the bladder prolapse in the front wall, can present to us with a bulge. All the prolapses can present a bulge.

Uncomfortable feeling. Usually, the prolapse gets worse later on the day. So, when you're on your feet for a long time, you'll feel that your prolapse is getting worse.

If you feel that you're lying down, and you're feeling a lot of discomfort in the vaginal area, and the pain, and all that, probably that's not the prolapse, there's something else going on. Because prolapse Typically, prolapse symptoms get thicker when you're lying down. It's purely the gravity. If you're on your feet for a long time, it gets worse. So, bulge can happen with both Cystocele rectocele, discomfort can happen with both Cystocele  rectocele, and the Cystocele can present if you're not emptying the blood out that well, or you have typically what is called post-micturition dribble. So you feel you have emptied, you get them, and you feel that you need to empty more. So that's can happen with Cystocele. Similarly with rectocele, because there if you can see, there's a little pouch created for where the arrow is.

Where your rectum is rectocele is going, or the prolapse is going.

So when you're emptying the bowel, it creates a little pouch, and you can see your bulge getting worse when you're trying to empty your bowel. And then sometimes you may have to gently digitate or hold your perineum, or sometimes, in a crude way, you may have to push through the vagina to get that in place to empty the bowel better. So these are the common symptoms patients present with.

This is where the womb is coming down. So that's called uterine prolapse. So this is now middle compartment has come down, which is wound prolapse, but you can see it's also dragging the front wall and the back wall. And this is the prolapse of the middle compartment. Not often we see one compartment prolapse.

Sometimes you see this double compartment prolapse, and sometimes you see all the three compartments. Not unusual, because the pelvic floor is the pelvic floor. And how it will affect your which compartment is difficult to say, but sometimes you get one compartment, two compartments, and sometimes all three compartments. Not unusual to get three compartment prolapse.

And then, sometimes you had when you have a hysterectomy, the top of the vagina, which is labelled as a vaginal cuff, that can come down, and that's called wolf prolapse.

So, now we'll talk about the treatment of pelvic organ prolapse, but the aim of any prolapse treatment, again, I'm going back to the same thing, is quality of life.

So, one is to make you feel better. So, if it's dragging sensation, you're getting the pulse you're getting, you're not emptying the bladder well.

not emptying the bowel well to get your symptoms better, to get your quality of life better. That's the aim of prolapse surgery, and sometimes to restore the function. So if you're not able to have sexual intercourse because everything is hanging down, or you're not able to put a tempo in the vagina because it's it is obstructing than to restore the function. So there are two things. One is to improve your quality of life by your physical symptoms, and second, the functions of the vaginal canal. And that's the two main principles of any prolapse treatment.

I'll talk to, I would hand over to Jan if she wants to talk a bit about pessary and pelvic floor exercises, that's it.

Jan Chaseley

Yeah, absolutely. So, yeah, I think pelvic floor exercises, we've talked about that. Hormone treatment. So vaginal oestrogen can actually be a bit of a game changer, I think. And that can either be a little pessary, something like VagiFem pessaries, or a cream, estriol cream. Very low dose of oestrogen. I think people worry, particularly if they' have not had HRT, they worry about having oestrogen. It's an incredibly, incredibly low dose of oestrogen, because you're putting it exactly where it needs to go. You generally use it every day for two weeks, and then just twice weekly. But if those vaginal tissues are prolapsing, it's suggesting they're thin because they're losing oestrogen. So along with the pelvic floor, it's all going to plump those tissues up, give more support, and sometimes That may be all the treatment that you need.

Mr Abhishek Gupta

Sometimes the patients, when they have discomfort, dragging sensation, then you may get there's a condition called vulva vaginal atrophy, which is lack of oestrogen in the vaginal area, and it really helps. And even if you want to do any press release or a surgical treatment, it is so important to build up those skin.

It's a low-dose oestrogen, it's vaginal, so amount which comes in your bloodstream is minimal. So, when we recommend then it is very safe. The only time you have to be careful is if you had any history of breast cancer.

And not family history of breast cancer, if you had a breast cancer, and that too depends on how long ago you had a breast cancer. So, if you had a long time ago, we can also always give it a cautious oestrogen, and you can give it for short duration that really helps.

Then vaginal pessaries, they have various types of pessaries. Ring, that is ring with support, they're also called shelf.

The whole idea is it goes in the vagina, and it supports. It's, again, not preventative of prolapse getting worse. It is only to support that area. It needs to be changed every four to six months, or at least now we've got new pessaries which are silicon pessaries, which can last for a longer time. So what we need to see in six months' time, to take it out, make sure it's not forming ulcers in the vagina, still the same size is good for you, and then wash it and reinsert.

The pessaries work only in 50% of the patients, so it only works in one in two patients.

The primary reason doesn't work. Sometimes the vaginal, shape It's not suitable for a pesty device. Sometimes your muscles are not strong enough to hold it in place.

So therefore and sometimes you get a lot of vaginal discharge, so it's a discontinuation. Or it presses on blood, and you start leaking. So, but therefore, it doesn't work in everyone. It works in 50% of patients, and it needs to be changed, or at least looked at in every six months.

If you're sexually active then usually only the ring pessaries or the ring pessaries with support can help. Other pessaries don't work very well, because we have to teach you how to take the pessaries out and reinsert yourself, so we'll have to empower you to do it. Other pessaries are very difficult for you to manage it yourself, and then you need a specialist, people like us, to help. But these pessaries.

You can have sexual intercourse as long as we explain you how to also train you how you can help to remove the pessaries and reinsert yourself.

The last option is surgical options. So, surgical options are, again, as I said, is either to make you better, so to get the anatomical correction, and improve the functionality.

So, for a womb prolapse, when the womb is coming down, so in this particular picture, the womb is already out, and it's showing where the stitches can be. So, if the womb is coming down, then The operation vaginal hysterectomy is an option, and there are alternatives for vaginal hysterectomy, which is one is called sacrospinous fixation, where we stitch the neck of the womb with a strong ligament called sacrospinous ligament, or, or something called a sacrohystopexy, which is used for mesh.

Which is done through the tummy. In Benenden, we don't offer mesh operations. And For prolapse of cystocele, which is front wall prolapse or back wall prolapse, you do a repair, which is where we open the front wall, push the bladder back in, bring your tissues together, suture it up, do the same on the back of the vagina.

Hospital stay is usually, one night. Complete recovery will take six to eight weeks, depending on how many compartment prolapse surgeries you had. Risk, bleeding infection, which can happen with any surgery, because we operate so near to bowel, bladder, tube draining bladder called ureter. There's a very small risk, less than 1% risk of injury. If anything happens, then we do a keyhole surgery cut in the tummy.

to correct this up. Prolapses can come back, so make sure you don't lift heavy weights, don't get constipation, because prolapses can come back.

And as I was saying to you, that BSUG, which is British Society Bureau of Gynaecology. If you go into BSUG website and go into patient information leaflets.

You will have tremendous resource to read through, and all the nice guidelines and all that are there. So these are And there are a lot of patient decision aids and patient leaflets. So these are leaflets which are being written and made for patients in the mind. So it's written for you as a patient, so that you understand it better.

So, if you want to go and have some resources to read, I would recommend that you go to British Society of Urogynaecology website, go into patient decision Patient Leaflets, and then you'll open, and there will be a lot of resources for you to read. And they will have a lot of informative, information there for you to access.

I think we are ready for a question.

Jan Chaseley

Yes, lovely, thank you, Mr Gupta.

Thank you for joining us and sending in some questions. One question is, at an initial assessment, are you able to diagnose a prolapse just by a physical examination, or would I need any further tests?

Mr Abhishek Gupta

So it really depends on your symptoms and your findings. So, if your symptoms are predominantly prolapse-related, we usually can diagnose in the first  initial assessment and examination. There are there are rare things not rare, but there are few occasions when it's difficult to assess during the first consultation. If you are using the pessaries yourself.

And, sorry, if you're on pessaries or anything, and you want to have surgical correction of prolapse.

And you've been using pest trees for quite some time. When the pest-free comes out, your prolapse doesn't straight away come down. It takes some time for prolapse to come to, come down. Therefore, we may not be able to diagnose that well, and we may have to examine you without pest-free after two or three weeks.

Second, if your prolapse gets worse towards the end of the day, and your appointment is first thing in the morning.

And you sometimes you don't find that kind of prolapse, and then we may have to examine you in standing position, or the sims position, to find out, or sometimes we may have to give you another appointment for us to come and assess your pelvic floor again. However, majority of cases, we can we can Diagnose the prolapse, and give you the treatment plan, even in the first visit, majority of majority of times.

Jan Chaseley

Lovely, thank you.

Sorry, I'm just going back up to an earlier question.

If you're in your 80s with urinary incontinence, is it something that you have to put up with as part of the aging process?

No, that would be my answer. The answer will be no.

Mr Abhishek Gupta

Yeah, you shouldn't be putting up with it, because At the end of the day.

It's about quality of life. And at the end of the day, frankly, age is a number. If what it prevents you doing, that's the most important thing.

You may be the most fit 80 years old who goes to gym and leaking, and you need treatment and just because you got 80 years old should not stop you seeking help.

An assessment of what we can offer and what we can't offer and have a very realistic and professional discussion with the healthcare professional. But putting up with a leak, I wouldn't say It's the right thing, if it's affecting quality of life professionally.

Jan Chaseley

Definitely. It may just be, as I say, assessing pelvic floor. You talked about the bulkamid, the bulking agents can often be, you know, a good starting point.

A lady who's got prolapse wants to know, if it's fine to have a pessary, even though she's had lumbar surgery.

Mr Abhishek Gupta

So, if you have a lumbar surgery, you can definitely have, or you've got spinal surgery, you can definitely have the pessary, but obviously.

A, if the prolapse is affecting you, and I can see from your description, it affects you when you go to the gym, and you have the operation on your back.

Pessaries can help, and we can definitely try to put it in. However, as I said, not all prolapses are suitable for a pessary device, because sometimes you had a previous surgery, it really depends on if you have any pelvic floor to hold it, and if you have a very low rectocele, i.e. just at the opening, your muscles are not strong enough to keep the pessaries in properly.

So, it will depend on the assessment, but of course, it can be tried, but We have to individualize the care, depending on how fit it will be for you. But we can have that assessment and certainly try it.

Jan Chaseley

Thank you. And a question, are the equipment advertised for pelvic floor any good, and do they work?

I'm not a great fan of the gadgets that you can buy. I think the important thing is you doing your pelvic floor exercises and knowing that you're doing them properly. I think if the pelvic floor is not overly strong, there may be a place for some of the machines that give a little bit of electrical stimulation, but I think I think sometimes they need to be used with caution, and I don't think they're a quick fix. It's you doing your exercises that's gonna help. Do you agree with that, Mr Gupta?

Mr Abhishek Gupta

Yeah, I think so.

Jan Chaseley

Yeah, and there's also a question about, getting an appointment with the continence care team, so you can do that by contacting the private patient advisors, and you can book a direct appointment with any of the specialist nurses.

We'd love to see you and assess you and help you with your symptoms.

A question about, is oestrogen cream good for your pelvic floor if you've got urgency?

Mr Abhishek Gupta

Yeah, so if you're if you're into your menopause, and it will be good to see someone, a specialist.

Or even your GP should be able to assess whether there is something called vulvovaginal atrophy, which is lack of hormones in the vaginal area. And if you're menopausal and you get sense of urgency, sometimes you may not have overactive bladder, but you do get slight inflammation because of lack of hormones in the vaginal area, and what I was describing as vulva vaginal atrophy can cause urgency.

So, once you have an assessment, I think oestrogen cream will be very sensible to start once the assessment has been done and this assessment can be done by your general practitioner or specialist nurse at your practice as well, just for starting the oestrogen cream.

Jan Chaseley

Definitely and somebody's made, just an observation, really, that they're waiting to be seen by a gynaecologist, and obviously the wait in the NHS is a long time, and there's information there on the screen, and there's a discounted price for listening to this webinar. So if you wanted to come along to see Mr Gupta or one of the team, we'd be able to, you know, assess you and help you.

Just a question, actually, about using vaginal, the pessaries, the support pessaries, is it safe to have one for the long term?

Mr Abhishek Gupta

There is there is no, issue with using the long-term pessaries, as long as this is reviewed every six months. So, as we said, we need to make sure that this is still fit for you? Does it pessary need to be changed, or it can be washed and reinserted? And is this pessaries giving any ulcers or any trauma to the vaginal tissues? That needs to be assessed every six months later. As long as that's getting assessed and you're happy with it, it can be used for long-term without a problem.

Jan Chaseley

Lovely. Thank you, Mr Gupta. So thank you again for your questions, and I'm really sorry if we haven't managed to answer those, and we will try and answer and reply to you.

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Mr Abhishek Gupta

Thank you.