Jan Chaseley

Good evening, everybody, and welcome to our webinar on urogynaecology treatments. My name is Jan, and I'm the Clinical Nurse Specialist in Continence Care here at Benenden, and I'm joined today by Consultant Gynaecologist, Mr Abhishek Gupta.

This presentation will be followed by a question-and-answer session. If you'd like to ask a question during or after the presentation, please do so by using the Q&A icon, which is at the bottom of your screen, and this can be done with or without leaving 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 at the end of this session, and I'll now hand them over to Mr Gupta. You'll hear from me again shortly.

Mr Abhishek Gupta

So, we are here today to talk about what urogynaecology is and the treatments, and hopefully you'll find the talk a bit informative about what's important to you, when to seek help, and what we can do.

What you can do at your level and what you can help seek help from the specialist nurses, and then you will also find it helpful about various resources we're going to share with you, and also if what treatment pathways are there and when to seek surgical treatment, what's the aim of surgical treatments and non-surgical treatment, so hopefully we'll cover a fair amount of what urogynaecology treatments are.

This is a bit about me. I'm a consultant gynaecologist, and my special interest is urogynaecology. My NHS base is Darent Valley Hospital. I'm a lead there, and I have done my training in the South East London rotation, and my teaching hospital, where I started the rotation, was Guys in St. Thomas's. Since then, I have done my advanced training in urogynaecology as well as benign abdominal surgeries, and I'm also an active member of European Ecology. So, the Association, which is the British Society of Urogynaecologists, and the unit in my NHS are accredited for your urogynaecology services, and we follow almost the same pathways here at Benenden as well.

Jan Chaseley

My name's Jan. As I say, I'm a Clinical Nurse Specialist in Continence Care at Benenden, and I've been in this role now for just over 15 years.

I manage the specialist nurse team. And there are four specialist nurses here at Benenden. So, we're very lucky that you have access to a really good specialist team, and we provide nurse-led clinics. And also, urodynamic assessments, which are a bit of a diagnostic test to make sure we're giving you the right treatment for your symptoms.

Mr Abhishek Gupta

So, what's included in this session? So, we'll just talk about what urogynaecology is. We will also discuss the common referrals we get. We'll discuss the bladder problems. We'll discuss urinary incontinence, which is one of the various types of incontinence. We'll also explain how an assessment of incontinence works. Then we'll talk about vaginal prolapse, and we'll also talk briefly about urinary tract infections, which do get very common, but to get referrals and also patient resources and some questions and answers. So that's the kind of session overview.

So, what is your urogynaecology? So urogynaecology is a part of gynaecology, where we are dedicated to the diagnosis and treatment of incontinence as well as pelvic female pelvic floor disorders, which are mainly incontinence, and not only incontinence, but sometimes applied. I also have other issues like urgency and frequency, which may or may not result in incontinence. It may or may not be because of prolapse of the vagina, but vaginal prolapse itself can cause other issues like discomfort, feeling bulgy, and dragging sensations. Then you have issues with rectal pain, which may or may not be related to prolapse, and bladder pain syndrome is very interesting, that is, usually, if it's not associated with endometriosis.

We try to work with urologists rather than Urogynecologist for bladder pain and pain syndrome because the urologists are the same for men and women. So, we tried to work with our fellow colleagues, urologists, about the bladder pain. And obviously, when you have a child, a child is born, especially when you have four such deliveries and other things. You have pelvic floor injuries, which can cause problems with the pelvic floor. And this is quite a big deal. And if it is said that roughly one in every one to two in 10 women will experience reportable issues with that pelvic floor, that's quite a big number. If you look, 20 to 25% of the patients who report will come forward with reportable issues with their pelvic floor. But it is also said that there are a vast number of patients who may or may not ever come forward because sometimes people don't talk about it. But if it's a problem or if you're having issues, it's better to discuss this. And if you know that there is this level of help for you to improve your quality of life,.

We all have to have our specialized training in the field of incontinence prolapse before we embark on any surgical treatments for incontinence prolapse, because it's become quite a specialized field.

Now the most common referral we get is urinary incontinence. So, either patients are referred for urgency, frequency, urge incontinence, or stress incontinence, which is a leak when you get coughs, knees, lift heavy weights during sexual intercourse, or run or jump. And this is when I say that stress is not mental stress; it is physical stress. More often than not, it's not very clear that it is urgency or frequency, which can be because of activity or stress incontinent, which is mainly weakness of the pelvic floor or at the endometriosis level. Weakness is sometimes a mixed picture. So, people do get a mix of urge incontinence, which is when you get problems of urgency, frequency, and urgent continence, as well as stress incontinence, which is physical stress. And sometimes they're a mixture of both.

Then you also get referred for pelvic floor weakness because it results in prolapse, which is basically what people typically describe as a bulge in the vagina area or a dragging sensation. Or you feel lumpy. Various patients describe it differently. I mean, commonly, people describe it as a golf ball, or some people require it as a tennis ball or something like a bulge we are feeling.

Patients get referred for recurrent UTIs, which may or may not be a result of prolapse, and we'll discuss that at the end. For bladder pain syndrome, we usually refer our patients to the urologist because they have. They have a different pathway for these patients and obviously pelvic floor injuries from post-delivery, which sometimes do occur in younger patients, which we have to see for deficient scar tissues or prolapses even after they have had a trauma to the pelvic floor, secondary forceps, or any difficult birth or a prologue labour.

So, bladder problem. So, let's talk about the bladder problems. So that is a diagram for what you describe as a female bladder. So that's a female bladder opening. You can see in the dome that these are the tubes that drain from the kidney to the bladder. Then you've got pelvic floor muscles, and it's a 2-dimensional picture, and the urethra, which is tube training from kidney to bladder. Sorry, from the bladder to the outside, which is what brings the urine out. In the middle of this, the female urethra is only 4cm long, and the bit of the uterus is in the middle. So, where you can see the pelvic floor diagram, that is, if you, if you, if I try to explain to you for my stress incontinence, what is stress incontinence? If I try to explain to you, just imagine my wrist as a bladder and the tube that drains out as a ureter and in the pelvis.

When your tummy pressure is increasing, or when you're coughing or sneezing, your tummy pressure is increasing, which is trying to squeeze that balloon, which is full of water out, and this tube, which is the ureter now, which is a 2-dimensional picture there is going through just in your vaginal area.

So mid-urethra when the pressure comes from the top. When you are coughing, sneezing, or jumping, there's pressure coming from the top trying to squeeze that balloon out, but the same pressure is coming from your urethra.

If you have enough support at the mid-urethral level, the pressure comes from the top, the pressure comes from the bottom, and that area closes, and you don't get a leak.

If you have weakness in this area, rather than closing this area, this hose pipe over the urethra just bends above. So, rather than closing it, just a bit of a bend because there's not enough support here. So, there's enough urine left for that to leak urine, and that's what causes stress incontinence. Obviously, this weakness can happen after childbirth or traumatic experiences, but it can also happen for people who have repetitive injuries. If you are constantly lifting heavy weights, if you are constantly constipated, or obviously, some people are born with weak collagen tissues, which are supported structures, and they do get weak over time, especially if you have. Sometimes we see the leak when coughing, sneezing, or experiencing stress incontinence in younger patients, especially without having children. The younger patients are in their late teens or even early twenties. And they have stress incontinence because of the weakness in the collagen tissues, which are your supporting structure, so they are basically born with the weakness. So that's that. That's what stress incontinence is.

Now the overactivity of the bladder is slightly different. So, the stress incontinence, as I explained, is coughing, sneezing, lifting heavy weights, having sexual intercourse, running, jumping, and jumping up and down.

Overactivity of the bladder is slightly different, that is, when you get a lot of urgency waterworks, frequency waterworks, and you have to go for waterworks. Often, if you can't reach us, you get a leak, and if you're referred to us for mixed-incontinence issues,.

It's not very unusual. We give you something in your bladder diary to fill in, which is what? 3 days: what you drink, what you drink, and how often you drink! Often you get urges about how often you leak, so a typical or active bladder, because your bladder is not in your control, is trying to squeeze the urine out like this. This is typical of overactive bladder patients who have urgency and frequency of waterworks. You will see they are often going for waterworks, and the amount of fluid is the amount of urine you go and drain every time you go. To work is anything between 50 and 250 miles. So low volumes and frequent urination—that is kind of a sign of an overactive bladder and planet—would really help what you drink. Often you go, and what we can do with you to improve your quality of life is all over called quality of life, and hence the first line treatment is always fluid and dietary advice. So fluid is if you're drinking a lot of caffeine.

If you're drinking a lot of alcohol, if you're drinking a lot of fizzy drinks, they all irritate the bladder, they all make your blood full very quickly, and you will have constant going for waterworks often. So, modifications to what you're drinking are very important.

Bladder retraining. So, nobody wants to leak in the pelvic area. Is it so? What happens when we are working or going out? Because we have leaks? We don't want to make ourselves embarrassed. We train our minds to keep a water tank empty all the time, so it's not very unusual that patients have trained themselves to keep going for waterworks, so that they're going for an hour to two car journeys. Whether they need it or not, they train their bladders to keep emptying, and hence, even with a little bit of fluid in, you have that cycle that you need to go forward with us. You need to go forward with work now. Bladder retraining is what Jan and his team teach patients when they want to make their bladder capacity slightly higher because constant overactivity can kill blood. Your bladder capacity is smaller, and I'll let Jen talk about it a bit more in detail. So, what is that? Do it, especially when you're in the sales space of your home.

Then the then you can train you. You know you've just been to the waterworks. Is the bladder not that full? Even if you need to go, you need to start thinking. No, this is not the time for me to go. And can I borrow 10 minutes extra? Hold the bladder more, and slowly you will see that this helps to break that loop of bad practices or bad habits you've developed of going for often and helps you to increase your capacity of blood. If that doesn't obviously work, then strengthening the pelvic floor will help. If that doesn't work, then we switch to medication. There are basically two kinds of medication for overactivity of the bladder, one of which helps to prevent the contraction of the bladder.

Which is called, that prevents the contraction of the bladder. Sorry, which helps to prevent the contraction of the bladder, which is like, or things like that, which are urodynamic clinics, and it's a good medication to start with. However, it does cause side effects like dry mouth, constipation, and palpitations, and the side effects do come before the actual effect of the medication comes in. So, if you can tolerate the side effects of the first week or week 2, then you will see whether that is good.

The results will come later on. Other medications come out of the background. It's slightly different. It doesn't prevent the contraction, but it helps to relax the blood a bit more. It doesn't have the side effects of constipation, laxity, dry mouth, or palpitations. But it's said that when you have a long medical background, you need to make sure your blood pressure is well controlled, and if the test doesn't work, then we sometimes have to give the Botox, which is to stop the involuntary contractions of your muscles. If you really have an overactive bladder, then the Botox injections do help, and they do improve the quality of life of the patients. It works really well with overactivity in the bladder. And the disadvantage is that, for one in 12 women, it relaxes the bladder so much that you are not able to empty the bladder. Well, so we teach you how to categorize yourself, to empower yourself in case that is to happen to you, and the Botox will eventually fear you. So, you'll have to have this done again anytime within 6 months to 2 years, and it's difficult to predict which patient will need it. Again, for patients who have neurological conditions like MS, the loop of the nurse becomes very active and overacts with the bladder, which is very common, and I'm one of them. And you can see this when you do a test called urodynamics. The bladder muscles are contracting like this, which is not under your control, and talking, and it's more common that we may have to resort to blood Botox if medication hasn't helped, but it happens to other patients as well. But in neurological patients, it's seen more.

So, we talked about urge incontinence. We come to the point of what Botox treatment is, and that's how it's done. So, what we do is have a look inside the bladder with a little camera, and that middle goes in. And basically, we do a 10-side injection of one ml. But it's that we start with a hundred internal new doses of Botox, but sometimes you have to increase it.

That doesn't work. Then there are two other methods of what is called posterior tibial stimulation, which is like stimulation of the nerve, which is offered privately by Jan here. And I'll let Jan talk about it a bit more. Neuromodulation is getting a bit of electrode on your back near the spine, which forms the loop to prevent your contraction of the bladder again and again. The second year of modulation we don't offer at Benenden, and I'm not sure any of the local managers at the hospital offer that as well, but sometimes operations may have to be referred to the tertiary centre for this one, and that's it. It doesn't get helped by Botox.

Now, we talked about stress incontinence. So now the stress incontinence is supported at the middle level. That's what we're talking about. So again, lifestyle modification is helpful in this. So, we have adjusted what you're going to bring to meet your needs and also reduced the weight. Because if you are smoking because we know smokers, there's enough evidence to say smokers don't ail very well after any procedure, and also, your support structures get weak with smoking, and hence, to get any optimal outcome of the bladder symptoms of smoking, it is very important. Second, if your weight is on the higher side, try to reduce your weight. There's more and more evidence to say that any incontinence procedure does work better with optimization of the weight and fewer complications. So, it's so important for the optimization of weight that, obviously, pelvic sizes do work. And even if it doesn't work in the long term, if you have any procedure or surgery for any incontinence of prolapse in the future, to reduce the chance of this happening again, pelvic floor exercises are so important.

So medical exercise is, and should be, your best friend if you start having the problem. But even if you don't have a problem now, it's better to do the pelvic exercises to prevent it from happening in the future. Then, obviously, since 2018, all the mesh surges for incontinence have been put on hold in England. So, there are three mainstays of surgical treatment for stress incontinence. The first is called bulking agents, which are popularly known as bulkamid. It's a local anaesthetic, permanent gel. So, the first diagram will show that what we do is just at the neck of the blood level. With the help of a camera. We give four site injections. It's a use of a permanent job, and it works that area up or cushions that which is shown in a second small set diagram in a sec diagram. So that's bulkamid. It's a permanent job that may need repeating. And in my practice, I only give one top-up. If it's not properly successful or if it reduces success over time,.

If it doesn't work for a second top-up, then this is not for you. It's successful in 55 to 60% of the patients. The advantage is that it is a less invasive option. It can be done with local anaesthesia. In fact, 95 to 96% of my patients get that done under local anaesthesia. So, there's no downtime. The risk is a small risk of a leading infection and a small risk of a temporary catheter, which is usually 3 to 5 days. If it's happening, it's the least invasive. But it's also the least successful. If you are a woman of childbearing age and you want to have more children, incontinence is really affecting you, or you are unfit for surgery, then I would prefer bulkamid over any major surgeries because doing the major surgery. The first shot at doing the surgery is the best shot.

If repeated surgeries don't work that well, then there are surgical options: either autologous fascial sling or colpsuspension. So autologous fascial sling is when we give an incision on your tummy. Take 7 to 8 cm of what is called a rectus sheet from your body, go through the vagina, and then poke it back again to the tummy. So basically, it forms a sling just next to the neck of the bladder, which is midyear through level sling. It supports that. It's quite an invasive surgery. 80 to 85% success rates. Hospital stays only one night in my practice. I send all the patient’s home with 7 to 10 days of catheter, and they come back after 7 to 10 days. Jan and her team take the catheter out; 90% of the patients are passing urine. Well, 80 to 85% success rate, but one in 10 patients because it's an obstructive surgery.

One in ten patients may feel that they're still having difficulty passing the urine, and we will again teach you how to catheterize.

yourselves if the need arises in the future, so that you're empowered again, and you and know that bring into me to start saying it is not as bad as it sounds. So, we do all this pre-op work before we do the operation. And sometimes it's an obstetric operation. Sometimes you plan to become overactive, and we may have to do the medication for you.

Next is what is called a suspension, where, instead of taking the sheet of your body, we go through the tummy. It can be done under. Look, laparoscopy, or open surgery again—we go behind the bone. So, behind the bone from the tummy, put the stitches next to the vagina, and put it back to the bone. So, all we are doing now is lifting your pelvic floor to keep the support again at the mid-era level, like this similar hospital stay. Similar complications to fascist things. Similar success rates exist, but colpsuspension does result in better support in the front. So, there is a slight increase in the chance of developing prolapse on the back wall of the vagina in the long term, just to keep in mind. But it's an equally good operation.

Jan Chaseley

Thank you. So, specialist nurse assessment. So if you're referred to Benenden by your GP with an issue with your bladder, whether that's overactivity, stressing continents, or something suggestive of having prolapse, you're probably going to find your first appointment is going to be with one of the specialist nurse teams, and what we will do is obviously take a full history, find out what your symptoms are, and what bothers you. We're going to test your urine just to make sure you don't have an underlining urine infection that you're not aware of.

I think, as Mr Gupta said, if you've got overactivity and you're emptying your bladder every hour, then actually, you're going to be passing quite small volumes of urine, whereas, you know, we want to try and increase that for you, but also to scan your bladder afterwards to check that that bladder is emptying out properly. And that may be a bit of a problem if you've got some prolapse. From the bladder diary that Mr Gupta talked about. We'll look at what you're drinking and advise you about restricting your caffeine intake, making sure you have an adequate intake. With overactivity. It's very common for people to say that if I'm going out, I'm not going to drink. I'm going to cut down on my intake again. That's going to put you slightly at risk of getting urine infections. So, it's really important to keep your intake, you know, between one and a half and 2 litters, and we'll give you a bit of dietary advice as well, particularly if constipation might be a problem.

We'll work with you on the bladder retraining. So, if you're emptying your bladder every hour, we'll try to get you to improve that by 5 minutes, 10 minutes, 20 minutes, or 30 minutes, and again, that's all about using your pelvic floor. If, when you've got that edge to go, you can squeeze your pelvic floor, just feel yourself. You're getting a little bit of control back in your bladder. A, and then hopefully, you know, it will just calm that. Urge down, maybe only for a couple of minutes, but sometimes that can be the difference between getting to the toilet and not having a leak.

if you've got symptoms of stress incontinence. The national guidelines call for good, structured pelvic floor exercises for at least 3 months, so we will do that with you. And then we'll just reassess at 3 months and see how you're getting on again with constipation. We'll help you with dietary advice and maybe any medications.

I think, as Mr Gupta said, you know, it's really important. If you are overweight, we'll work with you, you know, with some weight loss, maybe along with your GP, so that if you do need some surgery, we're going to have better outcomes, and we'll also give you advice about, you know, exercising if you've got stress incontinence and you're leaking. What are better exercises to do? That's probably something like swimming a little bit less, or maybe aerobics. But then, their aerobic exercise is also important to do postmenopausal for your bones. So, it's trying to sort of get that balance of what you can do to help manage your symptoms but also to help you, you know, improve your quality of life.

So that diagram there shows your pelvic floor muscle, and the pelvic floor muscle sits like a hammock of muscles, and I always think it's a much bigger muscle than people think it is.

So, we're going to sort of advice you. You know, we're going to tell you how to strengthen your pelvic floor and you do something called fast contractions, where you're just going to squeeze it up for one and relax it for one. Those false contractions are very good for stress incontinence because it's working that muscle to snatch quick with those sudden movements.

For overactivity and for prolapse. It's more about a squeeze and a hold, which are the strong contractions trying to hold on. It might only be for a couple of seconds initially, but we're going to hope that we can build on that sort of over 3–4 months with you.

And it's really important to make sure you've got the right technique. If you're holding your breath and pulling your tummy while squeezing your bottom, you're not necessarily squeezing your pelvic floor, so you know we'll do an internal vaginal assessment. Assess your pelvic floor so that you can be confident that what you are doing is the right thing.

And, as I said earlier, it'll take at least 3 months to strengthen those muscles. You know, so don't give up, and we'll be there to answer the phone. Follow ups. You have someone at the end of the phone to support you through this.

Mr Abhishek Gupta

So, before I talk about the prolapse again, just build on the pelvic floor, and quite a few patients think that they're doing Pilates, which means they're doing pelvic floor. Pilates is good exercise for yourself. But then, not only based on the pelvic floor, even if you do Pilates, you still have room to improve your pelvic flow because it's not just pelvic flow. So just something to keep in mind.

So, what is prolapse? So, we talked about incontinence. So, this is a good, two-dimensional picture. So, if you imagine, we're looking at the woman from front to back. So, the first thing you notice is the bladder, which is just behind your previous phone. There's a bladder that drains water.

Then you got behind it is the vagina, and we have that little tube that is draining bladder is called the urethra, and we talked about the mid-mitral level in the vagina. Then you had a vagina. Then you got the room neck of the room, and behind that is the back passage, or rectum. So, if the front wall is where the bladder is, and if that is prolapsing in the vagina, that's called a cystocele.

If your womb is collapsing, which is in the second diagram, you can see the womb coming down; that's called uterine prolapse, and the back wall of the vagina is prolapsing, which is now called rectocele. So that's the human anatomy. So, we just explain what prolapse is and what the causes of prolapse are. It's a weakness of your support structure. So, it's basically a hernia in your organs through the vagina, because the vagina is a hollow organ. So that's, basically, hernia. And it always happens because of a weakness, and what are the triggers or causes? Again, what is important to say is that chronic smoking will make your chest painful, so chronic coffee will cause you to prolapse, as will smokers. They do weaken, and they do have weaknesses in their supporting structures, so they are increasing the risk of having the prolapse repeated strain from chronic constipation and frequent lifting of heavy weights. Chronic cough. Obviously, all of us get older. We don't get younger, so we go; therefore, with time, the supporting structure can get weakened, and you can prolapse. A female body goes through a lot of changes with the menopause, and the menopause can affect your pelvic floor.

Traumatic childbirth. We know about vaginal birth. Does it stress your pelvic floor?

There is enough evidence to say that if you have a forceful delivery, a traumatic delivery, or a long labour, it increases your chance of prolapse. We have talked about obesity again; coming back to obesity is so important for lifestyle adjustment. Obesity can increase the chance of a prolapse. A hysterectomy is an interesting one because it depends on why it is done and for what reasons. So, if you have hysterectomy because of fibroid, heavy periods, or something else, The womb itself has support structures, and if you have a hysterectomy, then it can increase your chance of prolapse in the future. But sometimes you do a hysterectomy because the womb is prolapsing anyway. So, if you have the extract, me or prolapse, that's because your support structures have. I've already stretched or weakened. So, if your instructor is doing it for benign reasons, not for prolapse, then yes. It can increase the chance of prolapse. But if this hysterectomy is already done because of your organs, we need your support. Structure has gotten weaker, and you're getting prolapsed, which is different. So, they have various indications for a hysterectomy, and hence a start for me, too. Do prolapses cause pelvic floor weakness, and what are the indications?

Okay, so treatment prolapse. If you have mild or no symptoms, patients get referred because you can't do your GP service. You see a nurse for a smear for routine. Then look at you and say you've got a prolapse. Go and see one of the specialists.

Any woman who gives birth naturally will have some weakness in the pelvic floor because

During the delivery or passage of babies, the body and head do weaken the floor a bit, so you will have a bit of a mild experience. Prolapse. It doesn't need treatment if it's not causing you symptoms. So, prolapse only needs treatment. If it's causing problems for you and your quality of life,.

Otherwise, lifestyle changes, such as losing weight, avoiding constipation, stopping smoking, and doing pelvic floor exercises, are all you need for mild prolapse. Also, prolapse is not causing any problems with quality of life. Hormone treatment, which is mainly oestrogen, to vaginal pessaries, and sometimes you get patients who have a lot of dragging sensations. Get to examine what kind of prolapse. Hence the weak flow, but the prolapse is very small. We can't do any surgical treatment. But the lack of oestrogen, which is called menopause, is caused by vulvovaginal atrophy (VVA). That can cause a lot of symptoms that can cause a lot of dragging, a lot of discomfort, and pelvic floor exercises. A bit of oestrogen cream in the vagina really works well on this, and then pessaries. Three pessaries come in various sizes, shapes, and sizes that are like rings; they come with a stem. It's called gel. It's come in the donut size. It's not for all, where it works in around one in two patients, or 50% of the patients. It's a symptomatic correction of prolapse. Doesn't prevent prolapse from getting worse in the future. But if it's causing your problem, pessaries need to be changed every 4 to 6 months, and unless you can take capacity out yourself and put it back again, it can interfere with section intervals, and the last option is surgery.

So, the aim of surgical treatment is twofold. One is to restore your anatomy and give you a good quality of light; the second is to restore the functionality of the vaginal tissues. So, cystocele

The prolapses are still in front. What we do is open the front wall, push the bladder back in, and bring the tissues together so they are intact. Similarly, the prolapse

on the back is called. So now I'm talking about colporrhaphy, which is the third item on the list, which is rectocele to prolapse from.

On the back, you again open the back wall.

Bring the muscles together and suture them up. Let's repair the front and back prolapses of the womb. If you have the womb itself and it is prolapsing, there is the option of hysterectomy, which involves taking the womb and the neck of the womb. Both out. There are alternatives to hysterectomy that are as invasive as hysterectomy, if not more, one of which is called sacrospinous fixation.

where we stitch the neck of the womb back to a ligament or use the mesh, which is to go through the tummy and put it around the neck of the room, suspended to the bone. We don't use mesh. We don't do any mesh surgeries at Benenden. Because meshes are under high vigilance restrictions at the moment for NHS England, and also, if something.

If you have any complications from mass searches, then we can't solve it at the local level, and that you have to be deferred to a mesh centre, which is in London, so hence, in my clinical practice, I stay away from meshes, but there is an option for mesh, especially for people who are in the child-bearing age group, and if you have the hysterectomy, then you got the vault, which is on top of the vagina, which is called the vault, which is in this. In this diagram, you can see the bladder in the front. You can see the backward in the front. There's no womb, but there's a vagina. So, this call. Sometimes the vagina can come out like this, which you call vault prolapse. The vault is coming down. There are again two options. The option we offer. Here is restitching the top of the vagina with a strong to-come and called Sacro tuberous ligament, which is done through the vagina, or another option is a mesh, which again, we don't do here.

Regardless of whether you have repairs, a hysterectomy, or sickness, hospital stays usually last one night. A complete recovery will take 4 to 6 weeks. The slightest risk involved is the completion of an infection, which can happen with any surgery. Infection is common because the operation site is very close to your back wall, and there are a lot of germs in the area and poop. Getting an infection causes injury to surrounding organs. So, as you see, we operate at less than 1% risk. But there is a risk of injury, and there are three things to always keep in mind after and after prolapse surgery. Sometimes it can cause painful intercourse because of scarring. Perhaps this can come back in the future, hence my plea to keep doing pelvic floor exercises, not lifting; everybody's not getting constipated; optimize your weight. And last, but not least, if the prolapse is, if the front wall prolapses, it is called cystocele, my fist as a bladder tube running out as a urethra is kinking the urethra.

So, once I collect the prolapse, the skin in the uterus is taken care of. What you don't know is how much support you have at the mid-urethral level. So, what I'm trying to say here is after the repair of the front wall. If you've got a big prolapse, sometimes it can unmask a bit of leak or waterworks, and in literature, it can happen up to one in 20 women, but out of that, one or two may require surgical intervention later on. Something to keep in mind.

A recurrent urinary tract infection can happen. Again. We talked about menopause and prolapse. If you have diabetes, pregnancy can cause it. And obviously, if you have a weak immune system or don't drink enough, that's what can cause a recurrent urinary tract infection. Now, the very important bit for the recurring urinary tract infection is if you have a recurrent track infection if you have to go back to the GP for antibiotics after antibiotics. It's worth pushing for sending you to the lab to know what kind of bacteria or microorganisms are causing this UTI because, depending on what it is causing, they can do a sensitivity test, and therefore, we can start you in a targeted and divided manner; otherwise, just give you 3 days of antibiotics and 3 days of antibiotics again and again. It's not very helpful in the long term.

So recurrent infection, so recurrent infection. Now, what do we do? If you have been referred for a recurrent infection, we always check, and you will ensure that your unit is clear or not. We check for prolapse because if you have a big cystocele, which is a bladder prolapse, sometimes it can stop you from emptying your bladder fully, and we can do a flow test. We actually ask you to pee in a port to see how fast you pee, and then we can plot us to see how much you're keeping.

Now, if you're not emptying the blood well, it creates a reservoir, and you can't. Then you could become susceptible to infections again and again. If the patient doesn't have cystocele, then, like a lack of oestrogen, you can increase your chance of feeling an infection. So again, hormone cream in the vagina helps.

We often get a scan done for checking your kidneys and bladder, and sometimes we have to have a look inside the bladder with the camera to make sure you don't have things like stones or things like cancer. If that's all been ruled out and you keep getting infections, sometimes you do put yourself on low-dose antibiotics again, depending on what this bug was sensitive to. Sometimes we have to keep patients for 4 months, and sometimes you may have to pick patients for all their lives. If it doesn't get rid of it, occasionally for 3 months, we can use something, which is basically a urine antiseptic along with antibiotics, and very occasionally we may have to go for bladder installations that form a little coat in the bladder to prevent the risk of infection again and again.

So, these are the resources, and these are the resources for incontinence and prolapse. It's quiet. It's written with patients in mind. So, it's worth clicking on the slides that are available to you. So, you can read various options. We have summarized for you what this means. And then the British Society of Urogynaecologists, which we are all basically members of. There are patient information leaflets, which you will find very useful. The top three leaflets are also available on the website. But it will be very. You will find it useful to read through the options for each level. So, I thought it'd be a good idea for us to share these resources with you. Hand it over to Jan again.

Jan Chaseley

Lovely, thank you. So, we have a few questions. In fact, there's one quite nice question of my lady who says she's had urge incontinence but with regular pelvic floor restricting caffeine and bladder retraining that has improved a lot, but she does have a bladder prolapse and has had some recent urine infections. So, what can I do to avoid the infections, and would the oestrogen cream help?

Mr Abhishek Gupta

So oestrogen cream if you are in we don't know what your age is so we if you are menopausal then oestrogen cream can help with recurrent UTIs and again the amount of hormones which come in blood bloodstream because of local oestrogen is very little so it's very fairly very safe so almost only indication where I check with patients whether you have is if you have breast cancer then you should get it okay by your oncologist even if your mother had or anyone in your family had it it's not a contraindication so oestrogen can help but it also depends on how big is your bladder prolapse and how much is urine you're not able to empty if you got a significant grade two and above bladder prolapse and you're not able to empty the bladder well then we may have to do the correction of the bladder your prolapse to reduce your chance of infection again

Jan Chaseley

Again, ladies, I had a hysterectomy, but could this lead to a prolapse of the bladder?

Mr Abhishek Gupta

Yeah so again this is the discussion we were having depends on what are the reasons for your hysterectomy if your hysterectomy was done because of heavy periods and you had no prolapse in  past then obviously your support structures which are holding the uterus and some of the  gets disturbed with hysterectomy but if you already have prolapse and hysterectomy is done because of prolapse then usually it doesn't increase your chance of a bladder prolapse however you might notice that if you had a prolapse on the from the womb and that's get corrected different compartment then become more susceptible for prolapse because one compartment is completely sorted then other compartments do have more risk or awareness of prolapse coming down.

Jan Chaseley

There's a question about what treatments are available for a grade one cystocele, and hopefully we covered that, but I think for a grade one cystocile, we would definitely just be advising pelvic floor muscle exercises. Maybe some vaginal oestrogen is needed for lifestyle adjustment. lifestyle adjustments

Mr Abhishek Gupta

Yeah, So with a hysterectomy, are the ovaries generally left behind, and do they still carry on releasing hormones? It depends on why the hysterectomy is done, to be honest, and if your hysterectomy is done because of the uterine prolapse, we usually don't try to take the ovaries out of the vagina. It's not a common practice. Keyhole hysterectomy on your open is different, but it's for vaginal hysterectomy for prolapse. The ovaries are generally conserved because they are not connected to the uterus; they're higher and trying to take the ovaries out of the vagina does become more invasive and increases your risk of complications, and they're not And for the standard vaginectomy, which is done for prolapse, we don't usually take the ovaries out.

Jan Chaseley

Okay, a lady is asking about the PTNS, which is the percutaneous tibial nerve stimulation, which is a treatment for overactive bladder.

it's not something we do here a lot but it is it is available but it's a private self-pay treatment so basically if you imagine the tibial nerve runs from sort of your ankle up to your spine so the tibial nerve stimulation involves having a very small acupuncture needle just putting the side of your ankle it's then connected to a machine much the same as like a TENS machine and it's going to give electrical stimulation through this needle that is obviously going to travel up the needle to sort of where the tibial nerve joints at the base of the spine it's generally a course of over 12 weeks and it's quite often sort of you know nine 10 weeks before you really notice a lot of improvement so I think it's one of those things you'd need to come along have a proper discussion decide actually is that the best treatment for you or are there other things that we can manage to help with overactive bladder and if that hasn't answered your question please feel free to email in to the specialist nurses

Another question is: are there any implications if you have low back problems if you're having a sacrospinous fixation?

Mr Abhishek Gupta

No if you having sacrospinous fixation that shouldn't cause any problem with your back or disc we just have to be careful positioning you because legs are up when you're doing the operation fixation does cause sometimes and that mainly not because of your disc on the back but it's because the stitch which goes in and reattaches to either the womb or the top of the vagina that Stitch is taken on a ligament called sacral ligament which you attach your womb or the top of the vagina and behind that there runs a nerve called and hence though your operation done to the vagina sometimes you refer the pain on the right side of buttock because of the disturbance and done the nerve but it shouldn't cause any problem with your back no.

Jan Chaseley

Lovely, thank you. So, somebody here thinks that they've got vaginal atrophy. So, what's the best thing to do for vaginal atrophy?

Mr Abhishek Gupta

As I said, oestrogen, either in a pessary or a cream, is the best answer. Usually, it's started as one, either the cream or a P3, once every night for two weeks, and occasionally, if your vaginal atrophy is quite bad, it can take 3 to four weeks to reverse, so you may have to have it every night for two to three weeks, and then twice or three times per week to maintain it because once you stop, it can go back to where it started from. A lady is asking about how you would know if you have urine retention and that's again one of the things that the specialist nurses would do at your first appointment we'd probably get you to empty your bladder and then we have a machine called a bladder scanner that literally just scans over your bladder and it will pick up if you're leaving urine behind which obviously is what's called your postvoid residual and depending on if you had  prolapse or what your symptoms were you know we'd be able to help manage that hopefully with bladder retraining double voiding intermittent catheters if we if we needed to but it's one of those things where you just need to come and have a have a good assessment

Jan Chaseley

Another question is: I've had a bladder biopsy, and I have a moderate prolapse. I've lost that one. Now that I've had a bladder biopsy and I have a moderate prolapse, will that heal over time?

Mr Abhishek Gupta

I'm not sure; does that mean we've had a bladder operation? I had a bladder operation already, and there's now a bridge on the edge, where it was smooth with that and the water. I mean, honestly, that's it. This is not normally what happens after the bladder biopsy, so I'm not sure you should experience any ridges in the vagina after the blood biopsy, so it's better to get checked because the bladder biopsy and the ridge in the vagina are completely two different places, so it's better to get checked.

Jan Chaseley

Somebody who said they're trying pelvic floor muscle exercises currently through the NHS, would it be better to be treated at Benenden? I mean, we work alongside each other, don't we?

Mr Abhishek Gupta

So yes, it's it. I don't think it's better to be treated in Benenden or in the NHS. I think the treatment is almost going to be the same. It depends on the specialist unit doing your treatment, so we can't give that opinion. It's better to be treated in Benenden or at NHS. But yes, it depends on your local hospital, but we're happy to help here. Yeah, and I think sometimes it's around waiting times. A lot of people are still on an NHS waiting list, and if you haven't had an appointment, then obviously we can see you here at Benenden if you're actually already in the system and you're getting treatment. Yes, the advice is probably to stay in with that, particularly if you're not overly local to Benenden, and I work in, yes, I'm NHS as well, so the treatment is exactly the same; it's just the waiting times are different.

Jan Chaseley

Yeah, and I've got a lady here who's got some recoil after having a hysterectomy. How long should I continue doing the pelvic floor exercises?

Mr Abhishek Gupta

Generally, you know you need to maintain good structure on the pelvic floor for at least three months, and then I think it's just about reassessing. Yeah, I think so, and so 3 months is the minimum, but I think 3 to six months. The way I tell my patients is, if anybody goes to the gym and starts building up their muscles and lifting heavy weights, you won't see any difference if you go once or twice a week, and in a four-week time, you only start noticing difference after you've done it for two-three months, and I think that's where your question then comes in.

Jan Chaseley

Lovely, thank you, and as a lady who's got some prolapse with a history of breast cancer, is there any benefit to taking oestrogen?

I think you mentioned before to check with the oncologist whether it was whether your cancer was hormone receptor positive or negative, but if you have vulvovaginal atrophy, and especially if you had breast cancer so long ago

Mr Abhishek Gupta

I mean, you're 64 now from your description. You had it when you were 36 years old, so it's quite a few decades ago. Most of the oncologists will have no problem starting hormones for a short duration of six to eight weeks. They may have some issues by taking it forever, but after 8 to 10 weeks, they usually don't have any problems, especially if you had the breast cancer treatment almost 24 years ago.

Jan Chaseley

Lovely, thank you very much. I'm sorry if we didn't get around to answering all of your questions, and if you provided your name, we would answer your questions by email. Mr Gupta, can we move to the last slide? Please thank you very much. As a thank you for joining our session today, we're offering 50% off the value of your consultation and a call back from your dedicated private patient advisor. Tomorrow, you'll receive an email with a recording of this session, further information, and some updates on news and future events. We'd also be very grateful if you could please complete the survey at the end of the session to help us shape any future events. If you'd like to discuss or book a consultation, the private patient team can take your calls until 8 p.m. this evening or between 8am and 6pm Monday through Friday, using the number that's available on your screen. You can also book a consultation on the website with the discount code, and again, on the screen, a link to the book will appear once you've submitted your survey. All of our next webinars can also be found on the website on behalf of Mr Gupta and the expert team here at Benenden. I'd like to say thank you for joining us today, and we hope to hear from you all very soon. Thank you very much.