Samie R. Jaffrey MD, PhD

• Associate Professor of Pharmacology, Department of Pharmacology
• Cornell University Weill Medical College, New York City

http://vivo.med.cornell.edu/display/cwid-srj2003

In severe cases erectile dysfunction gnc products buy vimax 30caps, correction of hypovolemia valsartan causes erectile dysfunction buy vimax 30caps amex, electrolyte imbalance erectile dysfunction doctor san diego generic vimax 30caps on line, metabolic acidosis and blood coagulopathy have to be done psychological erectile dysfunction young vimax 30caps line. Ovarian reserve means the quantity as well as quality of the follicles present in the ovary erectile dysfunction japan generic 30caps vimax with mastercard. Poor ovarian reserve indicates poor outcome following stimulation of ovulation (p erectile dysfunction pumps review discount 30caps vimax overnight delivery. It should be started in the early follicular phase and barrier methods of contraception should be used. The side effects are due to hypoestrogenic, androgenic and metabolic changes (see Table 31. The drug should be discontinued, if the patient develops hirsutism or hoarseness of voice. Cell nucleus is the principle site of action of the steroids as opposed to the cell membranes of gonadotropins. Progestogens are classified according to their structural derivatives and progestogen content (Table 31. They are also classified according to their metabolic effects and also with the grades of progestational activity (Table 31. In presence of withdrawal bleeding, it signifies intact hypothalamo-pituitary ovarian axis and there is endogenous estrogen production. Combined estrogen and progestogen preparations are commonly used as oral contraceptives. The source of androgens in female are adrenal, ovary and peripheral adipose tissues. Pediatric and adolescent gynecology encompasses gynecologic diseases of children from birth to adolescence. It covers a spectrum of gynecological problems including congenital anomalies, problems due to infection (vulvovaginitis), precocious development, menstrual abnormalities and neoplasm. To prevent the problems of teenage pregnancy and sexually transmitted infections, contraceptive counseling has a place. Gynecologists need specific communication skill considering the psychological and developmental milestones of the girl child and the adolescent. Careful history taking reveals development of some degree of masculinizing features of the mother during pregnancy, probably due to increased adrenocortical activity. Rarely, the enlargement may be one of the manifestations of intersexuality of type, female pseudohermaphrodite. Genital Crisis: It includes spectrum of disorders noticed within few days of birth. It is due to the effect of passive estrogenic stimulation, which has passed across the placenta from the mother. The presence of the estrogen so obtained produces changes in the endometrium and other target tissues such as breasts and cervical glands. Bleeding per vaginum: It usually occurs within 10 days following birth; mostly blood stained but, at times, frank bleeding. This is due to decline in level of estrogen, which is unable to support the endometrium, resulting in withdrawal bleeding. Enlarged breasts: Due to effect of maternal estrogen and progesterone, there may be some development of duct and alveolar system of the breasts. Neonatal leucorrhea: this is due to excessive secretion of cervical mucus from the hypertrophied cervical glands under the influence of estrogen. Labial adhesion (adhesive vulvitis) is the condition when the labia minora have adhered together. Causes: Commonly, it is due to mild infection of the vulva which is favoured by lack of local defense due to absence of estrogen. The adhesions of the labia minora start from behind forward leaving a small opening at the foremost tip through which urine escapes out. Rarely, it may be a manifestation of minor form of masculinization following maternal intake of androgen during pregnancy. The mother usually, anxious about the entity, brings to the notice of the physician for not visualizing the vaginal opening. The adhesions may cause difficulty in micturition or periodic attacks of urinary tract infection. Examination reveals adhesions of labia minora obliterating the vaginal opening and, at times, even the external urethral meatus. In imperforate hymen and agenesis of vagina, the labia minora and external urethral meatus are clearly visible. Local application of estrogen ointment is also helpful Treatment: Separation of the adhesions using fingers or by a probe is almost always effective. The raw area is treated with topical application of estrogen or any other antibiotic ointment to prevent reagglutination. If it does, in spite of repeated separations, it is better to await spontaneous cure at puberty because of high-level endogenous estrogen. MuCo or HydroColpos Pathophysiology: There is imperforate hymen or a transverse vaginal septum just above the hymen. Due to excess estrogen stimulation acquired in utero from the mother, there is increased secretion of mucus or watery discharge from the cervical and uterine glands. If a large quantity of fluid is collected in the vagina, it produces hydro or mucocolpos. This is rarely met beyond 1 year of age because the uterine and vaginal transudation is not produced in sufficient quantity beyond that age. Clinical features There are usually some urinary problems to the extent of retention of urine. Vulval inspection reveals a tense bulge of the obstructing membrane which looks shiny. This influence of elevated gonadotropins can stimulate to produce ovarian follicular cysts. Chapter 32 GyneColoGiC Problems from birth to AdolesCenCe As the vaginal infection is almost always associated with vulvitis, the terminology of vulvovaginitis is appropriate. Thenonspecificorganisms(common) the infection is polymicrobial in nature and it is difficult to pinpoint any particular one responsible for infection. Skin conditions lichen sclerosus Psoriasis Eczema Sources of infection Direct contact with infected person. Indirect from foreign body, infected towel or bath 545 the offending foreign body may be detected. Investigations: Examination under anesthesia Vaginoscopy is needed to visualize the upper vagina for bleeding, foreign body or neoplasm. For better visualization, water cystoscope ( to wash away secretions, debris or blood) or laparoscope (8 mm) may be used. Bacteriological examination of the discharge either by gram stain or hanging drop preparation or culture, to identify the causative organism (see p. Blood examination for estimation of sugar in suspected cases of juvenile diabetes. Treatment: As the cause remains obscure in majority, the principles to be followed are: Vulvar hygiene-Proper wiping will reduce rectal flora in the vulvovaginal area. Symptoms Vaginal discharge: Purulent or blood-stained in the presence of foreign body. Vaginal inspection using aural speculum reveals congested epithelium with pent-up discharge. In refractory cases, estrogen locally as cream twice daily for 3 weeks is effective to improve the vaginal defense and to promote healing. Monilial infection is treated by local application of clotrimazole 1 percent cream. Specific therapy 546 textbook of GyneColoGy Prolapse of the urethral mucosa: it presents as a vascular swelling surrounding the external urethral meatus which bleeds easily. Associated systemic illness should be treated by intramuscular antibiotic therapy. It is due to excessive production of mucus from the cervical glands and increased transudation from the vaginal epithelium. Granulosa cell tumor is estrogen-producing tumor and may cause precocious puberty. Mixed germ cell tumor is highly malignant and dysgerminoma is intermediary in position, provided the capsule remains intact. Sarcoma botryoides: It should be remembered that the entity is most often present as early as 2 years of age (see p. Till then, various types of menstrual abnormalities may occur, causing concern to the young girls or their parents (see p. Hypothalamic-pituitary-ovarian (Hpo) axis dysfunction Dysfunctional uterine bleeding (see p. The bleeding may, at times, be brisk and requires varying amount of blood transfusion. Bleeding usually stops spontaneously but may, at times, require hemostatic suture. It is expected that after a certain period of time, the menstrual cycles become normal with the onset of regular ovulation. The unresponsive or problematic cases have been dealt with in appropriate chapters. HirsutisM: Hirsutism is one of the manifestations of hyperandrogenism and often causes problems to the young girls. One should not forget to elicit iatrogenic cause of hirsutism following intake of androgenic steroids, corticosteroid or synthetic progestogens. The columnar epithelium of the endocervix extends on to the ectocervix and also variable part of the vaginal fornices. Infective discharge during the period may be due to: Nonspecific infection following unhygienic use of menstrual pads or foreign body in the vagina. The others, though rare, are benign epithelial tumors, dysgerminoma, mixed germ cell tumor or androblastoma. Common symptoms are lump in the lower abdomen, acute pain abdomen or, at times, with retention of urine. Diagnosis: the diagnosis is made by abdominal, bimanual vaginal or rectal examination. Surgical therapy is needed in cases where there are symptoms, masses that fail to resolve or masses with solid or multilocular appearance on ultrasound. The surgery is usually conservative (ovariotomy or ovarian cystectomy) considering her future fertility and endocrine functions. In such a situation, the affected ovary is removed and a formal staging is done (fertility sparing surgery). A problem may arise when an apparently cystic epithelial benign ovarian tumor is removed, which ultimately proves malignant histologically. In such cases, in consultation with an oncologist, Chapter 32 GyneColoGiC Problems from birth to AdolesCenCe chemotherapy followed by relaparotomy and removal of uterus with contralateral tube and ovary may be done. Primary ovarian failure-There is lack of endogenous estrogen delayed closure of the epiphysis of long bones. There is associated unopposed action of the growth hormone from the anterior pituitary resulting in linear growth of the long bones (see p. Genital crisis is due to hyperestrogenic state and includes bleeding per vaginum, enlarged breasts and neonatal leucorrhea (see p. Labial fusion is commonly due to infection and rarely a feature of intersexuality. Vulvovaginitis in premenarchal period is mostly due to non-specific organisms and occasionally to specific gonococcal infection. Bacteriological examination should be carried out from the discharge prior to therapy. Ovarian follicular cysts are common in adolescent girls and are usually self-limiting. The neoplasm in premenarchal period is usually ovarian and, in about 25 percent, it is malignant. The common type is germ cell tumor (benign cystic teratoma, dysgerminoma, mixed germ cell tumor). The menstrual disorders in adolescent period are usually self-limiting and the hormones should not be used injudiciously. The discharge may range from what is called excess of normal to one which is a part of wide spectrum of ailments. It may be blood-stained or contaminated with urine or stool, all of which are however excluded from the discussion made below. Characteristics of normal vaginal fluid: It is watery, white in color, nonodorous with pH around 4. The symptom of excessive discharge is a subjective one with individual variation, while to declare it to be normal and not an infective one, requires clinical and laboratory investigations. The term leucorrhea should fulfil the following criteria: the excess secretion is evident from persistent vulval moistness or staining of the undergarments (brownish yellow on drying) or need to wear a vulval pad.

Alkalinization of the urine with sodium bicarbonate or acetazolamide may be justified to increase the solubility of uric acid erectile dysfunction doctors baton rouge purchase cheap vimax on-line. Specific treatment of uric acid calculi requires reducing the urine uric acid concentration with a xanthine oxidase inhibitor vascular erectile dysfunction treatment vimax 30caps without prescription, such as allopurinol or febuxostat intracorporeal injections erectile dysfunction generic vimax 30 caps on-line. These agents decrease the serum urate concentration and the urinary excretion of uric acid in the first 24 h erectile dysfunction pump rings discount vimax 30caps with mastercard, with a maximum reduction occurring within 2 weeks erectile dysfunction doctor in jacksonville fl buy vimax australia. Allopurinol is also useful in reducing the recurrence of calcium oxalate stones in gouty patients and in nongouty individuals with hyperuricemia or hyperuricaciduria erectile dysfunction help without pills quality 30caps vimax. In addition, antihyperuricemic therapy in the form of allopurinol in a single dose of 8 mg/kg is administered to reduce the amount of urate that reaches the kidney. Advances in genetics, as well as high-performance liquid chromatography and tandem mass spectrometry, have allowed for better diagnosis. Early diagnosis and appropriate therapy with allopurinol can prevent or eliminate all the problems attributable to hyperuricemia but have no effect on the behavioral or neurologic abnormalities. Myoadenylate deaMinase deFiciency Primary (inherited) and secondary (acquired) forms of myoadenylate deaminase deficiency have been described. Clinically, some may have relatively mild myopathic symptoms with exercise or other triggers, but most individuals with this defect are asymptomatic. The acquired deficiency occurs in association with a wide variety of neuromuscular disease, including muscular dystrophies, neuropathies, inflammatory myopathies, and collagen vascular diseases. Expression of the defect is similar in the two populations, as is the frequency of the heterozygous state (0. In the United States, 13% of men and 7% of women will develop a kidney stone during their lifetimes, and the prevalence is increasing throughout the industrialized world. Stone passage A stone can traverse the ureter without symptoms, but passage usually produces pain and bleeding. The pain may remain in the flank or spread downward and anteriorly toward the ipsilateral loin, testis, or vulva. A stone in the portion of the ureter within the bladder wall causes frequency, urgency, and dysuria that may be confused with urinary tract infection. Calcium, cystine, and struvite stones are all radiopaque on standard x-rays, whereas uric acid stones are radiolucent. Other syndromes Staghorn calculi types of stones Calcium salts, uric acid, cystine, and struvite are the constituents of most kidney stones in the western hemisphere (Chap. Calcium stones are more common in men; the average age of onset is the third to fourth decade. Approximately 50% of people who form a single calcium stone form another within the next 10 years, and some form multiple recurrent stones. The average rate of new stone formation in recurrent stone formers is about one stone every 3 years. Five percent of stones are struvite, whereas cystine stones are uncommon, accounting for 1% of cases in most series of nephrolithiasis. Manifestations of stones As stones grow on the surfaces of the renal papillae or within the collecting system, they do not necessarily produce symptoms. Asymptomatic stones may be discovered during the course of radiographic studies undertaken for unrelated reasons. Stones become symptomatic when they enter the ureter or occlude the ureteropelvic junction, causing pain and obstruction. They gradually fill the renal pelvis and may extend outward through the infundibula to the calyces themselves. Very large staghorn stones can have surprisingly few symptoms and may lead to the eventual loss of kidney function. Hereditary Dehydration Lesch-Nyhan syndrome Cystine stones 1 Intestinal, habit Males only Hereditary 1:1 Glucose intolerance, Alkali and obesity, hyperlipidemia allopurinol if daily urine uric acid >1000 mg Clinical diagnosis Alkali and allopurinol Uric acid stones, Alkali and allopurinol no gout if daily urine uric acid >1000 mg History, intestinal Alkali, fluids, fluid loss reversal of cause Reduced hypoxanthine- Allopurinol guanine phosphoribosyltransferase level Stone type; elevated cystine excretion Stone type Massive fluids, alkali, D-penicillamine if needed Antimicrobial agents and judicious surgery 1:1 Hereditary Struvite stones 5 1:3 Infection Values are percentages of patients who form a particular type of stone and who display each specific cause of stones. Urine calcium >300 mg/24 h (men), 250 mg/24 h (women), or 4 mg/kg per 24 h either sex. Most break loose and cause colic, but they may remain in place so that multiple papillary calcifications are found by x-ray, a condition termed nephrocalcinosis. Infection Although urinary tract infection is not a direct consequence of stone disease, it can occur after instrumentation and surgery of the urinary tract, which are used frequently in the treatment of stone disease. Stone disease and urinary tract infection can enhance their respective seriousness and interfere with treatment. Obstruction of an infected kidney by a stone may lead to sepsis and extensive damage of renal tissue, since it converts the urinary tract proximal to the obstruction in to a closed space that can become an abscess. Stones may harbor bacteria in the stone matrix, leading to recurrent urinary tract infection, and infection due to bacteria that have the enzyme urease can cause stones composed of struvite. Activity of stone disease In active disease, new stones are forming or preformed stones are growing. Sequential radiographs are needed to document the growth or appearance of new stones and ensure that passed stones are actually newly formed, not preexistent. Calcium, oxalate, and phosphate form many soluble complexes among themselves and with other substances in urine, such as citrate. Reduction in ligands such as citrate can increase ion activity and therefore supersaturation. Urine supersaturation can be increased by dehydration or by overexcretion of calcium, oxalate, phosphate, cystine, or uric acid. Urine pH is also important; phosphate and uric acid are acids that dissociate readily over the physiologic range of urine pH. Alkaline urine contains more dibasic phosphate, favoring deposits of brushite and apatite. Measurements of supersaturation in a 24-h urine sample probably underestimate the risk of precipitation. Transient dehydration, variation of urine pH, and postprandial bursts of overexcretion may cause spikes in supersaturation. Crystallization When urine supersaturation is excessive, crystals begin to nucleate. Once formed, crystal nuclei will grow in size if urine is supersaturated with respect to that crystal phase. For a kidney stone to form, crystals must be retained in the renal pelvis long enough to grow and aggregate to a clinically significant size. Recent studies have shown that common calcium oxalate kidney stones form as overgrowths on apatite plaques in the renal papillae. If the urothelium becomes damaged, the plaque is exposed to the urine, and calcium oxalate crystals form on the plaque, accumulating a clinically significant mass to form a stone. Calcium phosphate stone formers, particularly formers of brushite, do not follow this pattern. Inner medullary collecting ducts are plugged with apatite crystals, and stones form as extensions of those plugs. Unlike in calcium oxalate stone formers, renal papillae are often fibrotic and deformed. The kidneys must conserve water, but they must excrete materials that have low solubility. These two opposing requirements must be balanced during adaptation to diet, climate, and activity. The problem is mitigated to some extent by the fact that urine contains substances such as pyrophosphate, citrate, and glycoproteins that inhibit crystallization. When urine becomes supersaturated with insoluble materials, because excretion rates are excessive and/or because water conservation is extreme, crystals form and may grow and aggregate to form a stone. Supersaturation A solution in equilibrium with a solid phase is said to be saturated with respect to that substance. If the concentration of a substance in a solution is above the saturation point, the solution is said to be supersaturated and evaluation and treatMent of patients with nephrolithiasis Most patients with nephrolithiasis have remediable metabolic disorders that cause stones and can be detected by 98 chemical analyses of serum and urine. Adults with recurrent kidney stones and children with even a single kidney stone should be evaluated. A practical outpatient evaluation consists of two 24-h urine collections, with a corresponding blood sample; measurements of serum and urine calcium, uric acid, electrolytes, and creatinine, along with urine pH, volume, oxalate, and citrate should be made. Since stone risks vary with diet, activity, and environment, at least one urine collection should be made on a weekend when the patient is at home and another on a workday. When possible, the composition of kidney stones should be determined because treatment depends on stone type (Table 9-1). No matter what disorders are found, every patient should be counseled to avoid dehydration and drink copious amounts of water. The efficacy of high fluid intake was confirmed in a prospective study of first-time stone formers. Calcium stones Idiopathic hypercalciuria this condition is the most common metabolic abnormality found in patients with nephrolithiasis (Table 9-1). Idiopathic hypercalciuria is diagnosed by the presence of hypercalciuria without hypercalcemia and the absence of other systemic disorders known to affect mineral metabolism. Vitamin D overactivity through either high calcitriol levels or excess vitamin D receptor is a likely explanation for the hypercalciuria in many patients. Recent studies have shown that a polymorphism (Arg990Gly) of the calcium-sensing receptor, which leads to activation of the receptor, is more common in hypercalciuric subjects and probably contributes to higher urine calcium excretion. Hypercalciuria contributes to stone formation by raising urine saturation with respect to calcium oxalate and calcium phosphate. The specific treatment depends on the location of the stone, the extent of obstruction, the nature of the stone, the function of the affected and unaffected kidneys, the presence or absence of urinary tract infection, the progress of stone passage, and the risks of operation or anesthesia in light of the clinical state of the patient. Oral 1-adrenergic blockers relax ureteral muscle and have been shown to reduce time to stone passage and the need for surgical removal of small stones. Severe obstruction, infection, intractable pain, and serious bleeding are indications for removal of a stone. Advances in urologic technology have rendered open surgery for stones a rare event. Extracorporeal lithotripsy causes the in situ fragmentation of stones in the kidney, renal pelvis, or ureter by exposing them to shock waves. After multiple shock waves, most stones are reduced to powder that moves through the ureter in to the bladder. Percutaneous nephrolithotomy requires the passage of a nephroscope in to the renal pelvis through a small incision in the flank. Ureteroscopy generally is used for stones in the ureter, but some surgeons are now using ureteroscopy for stones in the renal pelvis as well. Hypercalciuria For many years the standard therapy for hypercalciuria was dietary calcium restriction. However, studies have shown that low-calcium diets increase the risk of incident stone formation, perhaps by reducing the amount of calcium in the intestine to bind oxalate, thereby increasing urine oxalate levels. A 5-year prospective trial compared the efficacy of a low-calcium diet to a low-protein, lowsodium, normal-calcium diet in preventing stone recurrence in male calcium stone formers. The group on the low-calcium diet had a significantly greater rate of stone relapse. In addition, hypercalciuric stone formers have reduced bone mineral density and an increased risk of fracture compared with the non-stone-forming population. In sum, low-calcium diets are of unknown efficacy in preventing stone formation and carry a long-term risk of bone disease, making low-sodium and low-protein diets a superior treatment option. If diet therapy is not sufficient to prevent stones, thiazide diuretics may be used. Thiazide diuretics lower urine calcium and are effective in preventing the formation of stones. Three 3-year randomized trials have shown a 50% decrease in stone formation in the thiazide-treated groups compared with the placebo-treated controls. The drug effect requires slight contraction of the extracellular fluid volume, and high dietary NaCl intake reduces its therapeutic effect. Thiazide-induced hypokalemia should be treated aggressively since hypokalemia will reduce urine citrate, an important inhibitor of calcium crystallization. Hyperuricosuria About 20% of calcium oxalate stone formers are hyperuricosuric, primarily because of an excessive intake of purine from meat and fish. The mechanism of stone formation probably involves salting out calcium oxalate by urate. The alternative is allopurinol, which has been shown to be effective in a randomized, controlled trial. Primary hyperparathyroidism stones in this situation is uncertain, and thiazide treatment is a reasonable alternative. In treating patients with alkali, it is prudent to monitor changes in urine citrate and pH. If urine pH increases without an increase in citrate, calcium phosphate supersaturation will increase and stone disease may worsen.

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A high resolution camera and color monitor is required for both the surgeon and the assistants erectile dysfunction doctors in sri lanka vimax 30caps sale. Light source: Xenon or mercury halide can provide high intensity light sources for excellent illumination erectile dysfunction doctor brisbane buy vimax 30 caps cheap. Telescope inserted within the diagnostic sheath erectile dysfunction medications list generic vimax 30caps free shipping, is gradually inserted through the cervical canal while the light is on erectile dysfunction age 16 vimax 30caps fast delivery. Uterine cavity is evaluated throughly with a closer view at fundus doctor for erectile dysfunction in kolkata buy vimax online now, lateral impotence after prostatectomy vimax 30caps on-line, anterior, posterior walls and the tubal ostia. Operative procedures-are carried out under general anesthesia or regional anesthesia (spinal or epidural). A special catheter is passed through the tubal ostium up to the interstitial part of the tube. The distension media flowing through the tube spreads the infection in the peritoneal cavity. Cardiopulmonary disorders are at higher risk of anesthesia as hysteroscopy carries its own risk of gas embolism, fluid overload and pulmonary oedema (see p. There would be no further regeneration of endometrium as the basal layer of endometrium as well as the basal and spiral arterioles are destroyed. Procedure: Endometrial resection is done from cornu to cornu (fundus) and all the walls. Myometrium is desiccated through contact coagulation for 30-40 seconds to control bleeding. Hematometro and pyometers-may occur due to infection after hysteroscopic surgery with cervical stenosis. In gynecology as much as 80 percent of operations can be performed endoscopically with the use of either a laparoscope or a hysteroscope. During laparoscopy, the magnification of the object depends upon the distance of the laparoscope from the object. Before any procedure is undertaken, contraindications must be carefully excluded (Table 35. Informed consent should include the permission for open surgery if necessity arises. Hemostasis during laparoscopic surgery can be achieved using electrocoagulation (monopolar/bipolar), laser coagulation, ligatures, sutures(extracorporeal/intra-corporeal), enseal, harmonic scalpel or by stapler and clips. Complications of laparoscopy may be due to the procedure itself or due to anesthesia (see p. The distending media commonly used in hysteroscopy is normal saline or glycine (1. Complications include fluid overload, pulmonary edema, and injury to genital or abdominal organs or electrosurgical injuries (see p. Ability to self renew (undergoing numerous cell divisions) maintaining the undifferentiated state. Totipotent Stem Cells are produced by first few divisions of the fertilized egg cell. Totipotent stem cells (from the morula) can differentiate in to embryonic and extraembryonic cell types. These cells can differentiate on tissues derived from any of the three germ layers including fetal tissues (placenta, umbilical cord, amnion, amniotic fluid cells). Multipotent Stem Cells can differentiate in to various tissues originating from a single germ layer (mesenchymal cells or hemopoietic stem cells that produce red blood cells, white blood cells, platelets). It is the major concern about the oncogenic potential of pleuripotent stell cells (embryonic stem cells). Multipotent Stem Cells can be obtained from several fetal tissues (following medical termination of pregnancy or at birth). This is aimed to restore and regenerate rhabdomyosphincter muscle content and function. Acellular natural or synthetic biomaterials are used as an implant which becomes incorporated through ingrowth of cells from the adjacent native host cells of the bladder. The biomaterials used are: Small intestinal submucosa and bladder-derived acellular matrix. Reports are available indicating possibility of creating full thickness bladder wall. Biomaterials should have good biocompatibility and appropriate biomechanical and biochemical properties. Autologous cells (from vaginal biopsy) can be expanded and functional vagina can be reconstructed for a woman with vaginal agenesis. The purpose is to generate new muscles/tissues which can perform in an integrated manner with the existing tissues to provide mechanical support to the pelvic organs. Hybrid biomaterials (synthetic and naturally-derived polymers) may be fabricated to restore pelvic floor However, till date it is essential to understand its known limitations, putative benefits and the unknown risks. Procedure For cervical cells-Projected end of the spatula goes within the external os. Gradings are total five: Normal, infective, suspicious, few malignant cells and plenty of malignant cells (p. Abnormalities may be nuclear enlargement in size and shape, irregularity in outline, multinucleation and hyperchromasia. The typical changes are: Perinuclear halo, nuclear irregularity, hyperchromasia and multinucleation. The valves are to retract the anterior and posterior vaginal wall so as to have a good look to the cervix. It is the histological observation where part or whole of thickness of cervical squamous epithelium is replaced by cells with varying degree of atypia. To use as a tourniquet in myomectomy operation as an alternative to myomectomy clamp. What are the different menstrual abnormalities that can manifest with retention of urine No menstrual abnormality Impacted ovarian tumor, cervical fibroid or ovarian mass. Management of injury to bladder during operation: Bladder mucosa is apposed with 3-0 delayed absorbable suture (Vicryl) as a continuous layer. Self-assessment What are the urinary complications following abdominal hysterectomy Common causes of retention of urine due to pelvic tumour or retroverted gravid uterus (p. Usually the anterior lip is held but in some conditions, the posterior lip is to be held. Self-assessment Normal position of the uterus and length of the uterocervical canal (p. To detect evidence of ovulation - by seeing the secretory changes in the endometrium (see p. As such, it minimizes trauma to the uterine wall if accidentally caught and also it has got no crushing effect on the conceptus. The common symptoms are: genital organs protruding out of the vaginal opening, difficulties in walking, sitting, urination or defecation. Procedure: Cervix is occluded with the instrument and methylene blue dye is injected in to the uterine cavity through the fundus using a syringe and a needle. To give traction in a big uterus (multiple fibroid) requiring hysterectomy while the clamps are placed. It curtails the blood supply to the uterus temporarily, thereby minimizing the blood loss during operation. Simultaneous, bilateral clamping of the infundibulopelvic ligaments by rubber guarded sponge holding forceps may be employed. The instrument is placed at the level of internal os with the concavity fitting with the convexity of the symphysis pubis. The round ligaments of both sides are included inside the clamp to prevent slipping of the instrument and preventing the uterus from falling back. The drugs instilled are dexamethasone 4 mg with gentamicin 80 mg in 10 mL normal saline. Diagnostic laparoscopy and dye test; sonohysterosalpingography and insufflation test (p. Mention the different sites where the clamps are placed in total abdominal hysterectomy (p. To inspect the suture lines after completion of vaginal plastic operations by retracting the anterior or posterior vaginal wall. Conservative treatments include: (i) To avoid aggravating factors (obesity, chronic cough, constipation). Mention the different sites where the clamps are placed during vaginal hysterectomy (p. To expose the field of operation widely (no assistant is needed for manual retraction). To catch-hold the needle, the needle should be caught at the junction of anterior 2/3rd and posterior 1/3rd. Plain or non-toothed use To hold soft tissues like peritoneal margins during suturing. To cut the mucous coat in vaginal plastic operation and to cut tissues during surgery. What is wound dehiscence: When the separation of the layers of abdominal wound is up to the peritoneum - it is called a complete dehiscence. Predisposing factors are malnutrition, infection, cough due to chronic lung disease or abdominal distension. The bowel is cleansed thoroughly with warm normal saline and placed back in the abdominal cavity. Self-assessment How the antiseptic cleaning in abdominal or vaginal operation is done in the operation table prior to draping (see p. Antibiotic (broad spectrum) is started and modified according to the culture and sensitivity report. Freezing produces cellular dehydration by crystallization of intracellular water and ultimately death of cells occur. The veress needle consists of a spring loaded blunt perforated trocar within a sharp cannula. The common site of puncture is through a small incision made in the lower rim of the umbilicus (see p. Advantages and disadvantages of laparoscopic sterilization operation over conventional methods (p. Electrodes (coagulating roller ball electrode) Self-assessment Indications of hysteroscopy (p. The broad end lies in the posterior fornix, the narrow end behind the symphysis pubis and the concavity is directed upwards. It is done initially by the doctor/nurse and later on by the patient herself once she is taught about the procedure. In every follow up visit, patient is asked about any symptoms like: vaginal bleeding, pain, offensive discharge and voiding difficulty. Vaginal discharge, bad odor, vaginal erosion, ulceration, pessary incarceration, forgotten pessary rarely vaginal cancer (rare). Disinfection: It is done by any one of the methods: Immersing instruments in (i) boiling water for 20 minutes (ii) 2% glutaraldehyde (Cidex) solution for 20 minutes or (iii) 0. Cleaning: Instruments are disassembled and washed on all surfaces in running (preferably warm) water. SutureS the suture materials used in a particular surgical step depend on the strength of the tissues to be sutured and the time required for the wound to regain its strength. Chromic catgut is degraded by proteolytic enzymes of white blood cells (inflammatory cells) slowly. Chromic catgut loses half of its tensile strength by 10 days and maintains some strength up to 21 days. It is a foreign protein and initiates strong inflammatory response and loses half of its tensile strength by 1 year. Synthetic Dexon: Dexon (polyglycolic acid) is a copolymer of glycolic acid and is degraded by hydrolysis with minimal inflammation. Posterior surface is identified by: Attachment of ovarian ligament with or without ovary. Cut margin of the posterior peritoneum which is densely attached and placed at a lower level than the cut edge of the anterior peritoneum. Uterine tubes: Tubular structures with abdominal ostium surrounded by fimbriae and mesosalpinx. If the uterine tube is not mounted, even then the specimen is likely to be ovarian as there is no other pelvic organs resembling it, exception being a parovarian cyst.

The posterior lip of the amputated cervix is covered by the vaginal flap using a Sturmdorff suture (vide erectile dysfunction protocol real reviews order vimax uk. Principles of the operation in prolapse y Removal of the uterus through vaginal route erectile dysfunction doctors tucson az 30 caps vimax with mastercard. The ends of the ligature are passed through the cervical canal and are taken out laterally on either side of new posterior fornix erectile dysfunction cvs vimax 30caps on line. The vault prolapse in such cases may be effectively repaired transvaginally maintaining the same principle of repair of enterocele along with anterior colporrhaphy and colpoperineorrhaphy (see p erectile dysfunction causes of discount 30 caps vimax otc. Sometimes erectile dysfunction treatment for diabetes purchase 30 caps vimax amex, it may require suspension of the vault with the anterior sacral ligament in front of 3rd sacral vertebra (sacral colpopexy) transabdominally using nonabsorbable sutures such as Teflon or Mersilene mesh impotence gels trusted vimax 30caps. The structures are cut as close to the uterus and replaced by ligature (Vicryl No. The fundus is now brought out through the anterior pouch by a pair of Allis tissue forceps. The third clamp includes - round ligament, fallopian tube, mesosalpinx and ligament of the ovary. The sutures of the pedicle containing the uterosacral and Mackenrodt ligaments are passed through the vault crosswise and are to be held temporarily. As in anterior colporrhaphy, the pubocervical fascia is approximated and fixed to the uppermost tied broad ligament pedicles to close the hiatus. Redundant portions of the vaginal flaps are excised and the margins approximated by interrupted sutures (Vicryl No. Crosswise passed sutures of the lowermost pedicles are now tied, thus fixing the ligaments with the vaginal cuff. Cardinal and uterosacral ligaments to the vaginal cuff is useful to prevent vault prolapse. Chapter 15 DisplaCement of the UterUs Colpocleisis (cases following hysterectomy). The principle steps of the operation are: Denudation of rectangular vaginal flap from the anterior and posterior vaginal walls. A vertical incision is made on the posterior peritoneum over the sacral hollow while the rectosigmoid is pulled up laterally. Lateral angles of the vagina are identified and grasped with Allis tissue forceps. The other ends are fixed to the anterior longitudinal ligament in front of 3rd sacral vertebra with proper tension. Laparoscopic sacrocolpopexy is found to be effe-ctive with similar result to open sacrocolpopexy. Successive purse string absorbable sutures are placed from above downwards to appose the vaginal walls. It is a simple, safe and effective operation for a woman who is no longer interested in coital function. Sacrospinous colpopexy: the sacrospinous ligament is attached medially to the sacrum and coccyx and laterally to the ischial spine. Complications: Injury to the rectum, pelvic vessels (internal pudendal, inferior gluteal), stress urinary incontinence, gluteal pain (pudendal or sciatic nerve injury). Abdominal approach Vault suspension (Sacral colpopexy): Principle of the operation is to suspen the vaginal vault to be anterior longitudinal ligament in front of the 3rd sacral vertebra. Strips of rectus sheath of either side passed extraperitoneally are stitched to the anterior surface of the cervix by silk. Principle steps of the operation A transverse abdominal incision is made through the skin and fat. Bladder peritoneum is dissected off and the uterine isthmus is exposed mobilizing the bladder. The medial ends of the facial strips are now brought down between the leaves of the broad ligament to this site of uterine isthmus. The free edges of the facial strips are now fixed at the uterine isthmus with a sturdy bite using silk. It is due to imperfect hemostasis at operation or due to slipping of the ligature. Along with the resuscitative procedures, the patient is to be brought to the operation theater. Under anesthesia, the suture sites in the vagina, both anterior and posterior are explored and hemostatic sutures are given. The vagina should be packed tightly with dry roller gauze which should be removed after 24 hours without anesthesia. If the hemorrhage is brisk, along with resuscitative procedures, the patient is to be brought to the operation theater and under general anesthesia, the vagina is explored. If only generalized oozing is found, tight intravaginal pack using dry roller gauze is enough. If bleeding point is visible, hemostatic sutures should be given followed by vaginal packing. Instead of fascial strips, currently non-absorbable (Marlex or Gore-Tex) tape is used for this purpose. To know much details and variations of all the operations, the readers are requested to consult books of operative gynecology. Some synthetic (polygalactin) and all biological materials (fascia lata, dermis, rectus seath) are absorbable. Graft augments fibroblast proliferation and collagen tissue formation as they have pores. Absorbable mesh or grafts are less likely to cause complications but failure rates are high. In contrast, nonabsorabable mesh has low failure rate but higher rate of complications. Suitable cases for mesh surgery are: Symptomatic anterior/posterior vaginal wall prolapse, recurrent prolapse, prolapse due to congenital connective tissue disorder. Complications are: Mesh erosion, dyspareunia, vaginal pain, chronic sepsis, discharge, urinary incontinence and fistula formation. Contraindications: Atrophic tissues, active pelvic infection, uncontrolled diabetes, obesity, smoking and history of pelvic radiation. Trauma - the bladder in anterior colporrhaphy or rectum in perineorrhaphy may be injured. Additional complications include: Chapter 15 DisplaCement of the UterUs Immediate y Vault cellulitis y Pelvic abscess y Thrombophlebitis (see p. Causes Incomplete obstetric inversion unnoticed or left uncared following failure to reduce for a variable period of 4 weeks or more. Per vaginum: (a) the cervical rim is felt high up in incomplete variety but not felt in complete one. Rectal examination: Rectoabdominal examination is more informative to note the fundal depression or displacement of the uterus. Sound test: Demonstration of shortness or absence of uterine cavity using an uterine sound is reasonably confirmative. Senile inversion following high amputation of the Types: Two types are described in chronic inversion. Maternity Hospital, Osmania Medical College, Hyderabad] Treatment General measures: the patients are usually anemic. Preservation or removal of the uterus is determined by such factors like age, parity, associated complicating factors. It is a sound policy to remove the tumor by shelling from its capsule rather than dividing the pedicle in such cases. The diagnostic difficulty is much when inversion is secondary to a fibroid polyp or sarcoma and the inversion is incomplete, filling the vagina. A portion is to be removed from the tumor mass for histological examination to differentiate between a simple fibroid or sarcoma. In fibroid polyp - the uterus is in normal position and the uterine sound can be passed in to the uterine cavity. The important risk factors for prolapse is history of vaginal birth and age of the woman. Important support structures of uterus are the cardinal, uterosacral, pubocervical ligaments, endopelvic fascia, levator ani muscle (pubococcygeus, iliococcygeus, levator plate) and the perineal body. Prolapse is due to a combination of injury to the neuromuscular as well as supporting structures. Etiology of genital prolapse includes the anatomical factors, as well as the different clinical factors (p. Cystocele and urethrocele are more common with a gynecoid pelvis than with android or anthropoid types. Secondary vault prolapse is more following vaginal hysterectomy than abdominal one. Predominant urinary complaints in genital prolapse are difficulty in passing urine, incomplete evacuation, frequency, stress incontinence and rarely retention. Uterine prolapse may be confused with congenital elongation of the cervix, chronic uterine inversion and fibroid polyp. Degree of urine prolapse: 1st degree: Uterus descends from its anatomical position but external uterine os remains in the vagina; 2nd degree: External os protrudes outside the vaging but uterine body remains inside; 3rd degree: Uterine body descends outside the vaginal introitus (procidentia). Prolapse must be documented in terms of anterior or posterior vaginal wall and the uterine descent (Table 15. Pessary treatment may be indicated in early pregnancy, puerperium, patient unfit for surgery or while the patients are waiting for operation. The type of surgery for an individual woman depends on her age, parity, reproductive and sexual function and also the type and degree of prolapse (Table 15. Colpocleisis is an easy, safe and effective method for a woman who is no longer interested in coital function. When an enterocele is present, the sac should be dissected high up and ligated at its neck to prevent recurrence. External McCall suture is placed at a higher level than the internal McCall Contd. Vicryl (1-0) suture is passed through the left posterior vaginal wall, peritoneum, pararectal fascia (uterosacral ligament) and it is then carried over in front of the sigmoid colon to include the similar points on the right hand side. Chronic inversion may be confused with fibroid polyp, uterine prolapse, fungating cervical malignancy or prolapsed hypertrophied ulcerated cervix. Secondary infertility indicates previous pregnancy but failure to conceive subsequently. Fecundability is defined as the probability of achieving a pregnancy within one menstrual cycle. Physiological consiDeration Due to anovulation, infertility is the rule prior to puberty and after menopause. But it should be remembered that the girl may be pregnant even before menarche and pregnancy is possible within few months of menopause. Despite the fact that the patient is amenorrheic during lactation, ovulation and conception can occur. Factors Essential for Conception Healthy spermatozoa should be deposited high in the vagina at or near the cervix (male factor). The spermatozoa should undergo changes (capacitation, acrosome reaction) and acquire motility (cervical factor). The motile spermatozoa should ascend through the cervix in to the uterine cavity and the fallopian tubes. The fallopian tubes should be patent and the oocyte should be picked up by the fimbriated end of the tube (tubal factor). The remaining 10 percent, is unexplained, in spite of thorough investigations with modern technical knowhow. It is also strange that 4 out of 10 patients of unexplained category become pregnant within 3 years without having any specific treatment. It is also emphasized that the relative subfertility of one partner may sometimes be counterbalanced by the high fertility of the other. Congenital - Undescended testes: the hormone secretion remains unaffected, but the spermatogenesis is depressed. Varicocele probably interferes with the cooling mechanism or increases catecholamine concentration. However, no definite association between varicoceles and infertility has been established. Bacterial or viral infection of the seminal vesicle or prostate depresses the sperm count. Alcohol inhibits spermatogenesis either by suppressing Leydig cell synthesis of testosterone or possibly by suppressing gonadotropin levels. Gene deletion have been detected in the long-arm of Y chromosome (Yq) for patients with severe oligospermia and azoospermia. Obstruction of the efferent ducts: the efferent ducts may be obstructed by infection like tubercular, gonococcal or by surgical trauma (herniorrhaphy) following vasectomy. Sperm abnormality: Loss of sperm motility (asthenozoospermia), abnormal sperm morphology (roundheaded sperm, teratozoospermia) are the important factors. Errors in the seminal fluid y Unusually high or low volume of ejaculate y Low fructose content y High prostaglandin content y Undue viscosity.