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By J. Jack. University of Massachusetts at Amherst. 2018.

Failure to recognize concomitant detrusor overactivity and / or Clinical Indications for voiding dysfunction may also Urodynamics Investigations affect the outcome of appropriate There are many etiological factors surgery 50 mg caverta free shipping. Certainly the most Table 1 lists the most important common problems are urodynamic indications for urodynamic studies discount caverta 100mg. Medico – legal cases must be emphasized that many 14 Clinical Diagnosis versus History, clinical examination and basic tests urodynamic diagnosis Over the past 35 years there have In the ongoing search for an uncomplicated and cost – effective been ongoing discussions in the approach to the pre – operative literature on how best to evaluate evaluation of a patient for patients with incontinence. The accuracy of history alone Most of the early papers looked In summary the addition of other clinical parameters and simple at the discriminatory value of a pure history of either stress offce tests do enhance the sensitivity of a history. In summary, it is clear In South Africa, Urogynaecology as from the majority of studies that a subspeciality is still in its infancy. The symptom of stress incontinence may be very sensitive, and this is an area which urgently but is so nonspecifc as to render it requires development, particularly of little diagnostic value. Medical practice is increasingly History is best used as a guide to becoming dogged by litigation and the subsequent evaluation process and to serve as a measure of practitioners have to be able to disease severity. They are often also run by staff who are not properly trained to provide good quality results and interpretation. It is these practitioners who should be at the forefront of attempts to develop mechanisms which are aimed a providing the best possible service for their patients. Where a Gynaecological surgical intervention is planned, Examination the responsible surgeon should determine exactly what may It is impossible to perform an be required at operation – so adequate urogynaecological that the appropriate consent examination without using a can be obtained and the correct Sims speculum and in some intervention planned. The vulva and vagina are inspected for any The women’s mobility and general lesions, atrophy or excoriation. The woman is then asked to cough or valsalva while the clinician observes for any stress Neurological incontinence. She is then asked to turn onto her left side and the examination Sims speculum is used to inspect the anterior and posterior vaginal The spinal segments S2,3. It is imperative be assessed by testing the tone, that the middle compartment is strength and sensation in the 17 also adequately assessed for any Grade I: Descent halfway to the uterine or vaginal vault descent. It does are not adequately explained by not give a quantitative impression the fndings at examination, it may of the severity of the prolapse. This length, perineal body size or the is accomplished by asking her to length of the urogenital hiatus. She is then asked these issues and it supercedes the to cough again in the standing previous systems used to describe position. The new objective assessment allows a clear and unambiguous description of prolapse, facilitating Classifcation and better objective assessment, management and surgical grading of prolapse comparison. The most commonly used Terms used in the past such as for grading system is the Baden- example small, medium or large, Walker halfway system which cystocoele or rectcoele, are no grades prolapse as follows: longer applicable. Six specifc vaginal sites (points Aa, Ba, C, D, Bp and Ap) and the vaginal length (tvl) are assessed using centimeters of measurement from the introitus. They gh, pb, and tvl measurements will always represent the extent of prolapse, have a positive value be it above the introitis ( ie All measurements, except for tvl, are made negative) or below the introitis ( ie while patient is bearing down positive) 20 Point Aa Point Bp If an imaginary small man walked Again, this point describes more from the introitis up the anterior extensive prolapse beyond the vaginal wall and made a mark once 3 cm mark of Ap similar to Ba. This point is therefore for example, is 7cm above the never more than 3 and represents introitis, this point is then -7, if it is the bottom 3cm of the vagina. Point Ba Point D This point describes additional This describes the descent of the prolapse of the anterior vaginal posterior fornix again similar to wall that goes beyond the frst the cervix. It can therefore be Total vaginal Length greater than the +3 described for This is the measurement of point Aa. It is usually Because it essentially defnes more measured with the marked spatula extensive prolapse, when there inserted to its maximum into the is no prolapse, by convention we vagina. Urogenital hiatus Point Ap The measuring spatula is placed Again our imaginary man makes anteroposteriorly along the the 3cm trip up the posterior wall introitis and measures from the where he marks off point Ap. The diagnosis in women two separate catheters are used with urinary incontinence based for flling and pressure recording. There is a large intra-abdominal pressure (Pabd) overlap between symptoms and and this pressure could therefore examination and urodynamic also be obtained by inserting the fndings.

Changes in the O2-Hb dissociation curve: Shift to the right: Occur when there is decreased affinity of Hb for O2 (see figure order 100mg caverta overnight delivery. Increases in temperature also cause right shift cheap caverta 50 mg amex, and facilitate unloading of oxygen in the tissues. This decrease in affinity causes right shift and facilitates unloading of oxygen in the tissues. This facilitates O2 delivery to the tissues as adaptive mechanism 252 Figure 69 A. By the time blood reaches the venous end of the capillaries Hb is conveniently in its deoxygenated form (i. There is a useful + reciprocal relationship between the buffering of H by deoxyhemoglobin and the Bohr + effect. Thus the H generated from the tissue Co2 causes hemoglobin to release O2 + more readily to the tissues. The frequency of normal, involuntary breathing is controlled by three groups of neurons or brainstem centers. Afferent (sensory) information reaches the medullary inspiratory center Via central and peripheral chemoreceptors and via 259 mechanoreceptor. Efferent (motor) information is sent from inspiratory center to the phrenic nerve, which innervates the diaphram. Inspiration is shortened by inhibition of inspiratory center via the pneumotaxic center (see below) • Expiratory center (see figure 68) is located in the ventral respiratory neurons and is responsible primarily for expiration. Since expiration is normally a passive process, these neurons are inactive during quite breathing. However, during exercise when expiration becomes active, this center is activated • Apneustic Center. Apneusis is an abnormal breathing pattern with prolonged inspiratory gasps, followed by brief expiratory movement. Stimulation of apneustic center in the lower pons excites the inspiratory center in the medulla, prolonging the contraction of the phrenic nerve. Normal breathing rhythm persists in the absence of these centers Cerebral cortex: Commands from the cerebral cortex can temporarily override automatic brainstem centers. The decrease in PaCo2 will produce unconsciousness and person revert to normal breathing pattern. Central chemoreceptors: They are located in the brain stem (ventral surface of medulla) and are important for minute-to-minute control of breathing. Other receptors: Lung stretch receptors: These are mechanoreceptor in smooth muscle of the airways. Joint and muscle receptors: They are located in joints and muscles and detect movement of limbs. Instruction is given to the inspiratory centers to increase breathing rate Irritant receptors: Their location is between epithelial cells lining the airway. They are stimulated by noxious chemicals and particles The response is reflex constriction of bronchial smooth muscles and increase in breathing rate J- Receptors (Juxtacapillery receptors): These receptors are found in the alveolar walls (thus near capillaries). The stimulus is engorgement of pulmonary capillaries with blood and increase in interstitial fluid volume. The response is increase in breathing rate For example, in left heart failure blood “backs up” in pulmonary circulation, and J receptors mediate change in breathing pattern including rapid shallow breathing and dyspnea (difficulty in breathing) General and Cellular nonrespiratory lung function Filtration: filter out small blood clots (small pulmonary emboli) Immunologic: bronchial secretion contains Immuno globulin ( IgA ) Alveolar macrophages are phagocytic and remove bacteria and small particles inhaled by lungs. Macrophages also function in attraction of polymorpho nuclear leukocytes, release Vasoactive and chemo tactic substances. In less severe degree it results: (1) Depressed mental activity, sometimes culminating in coma. As a result, or O2 is extracted from the blood to support the oxidative metabolism of the tissues. Examples - Respiratory depression due to drug overdose (barbiturate poisoning) - Severe weakness of the muscles that support respiration e.

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The posterior aspect of following characteristics: the malleolus is grooved for the passage of the tendons of peroneus • The flattened upper end of the tibiaathe tibial plateauacomprises longus and brevis caverta 100mg low cost. The lateral malleolus projects further downwards medial and lateral tibial condyles for articulation with the respective than the medial malleolus discount 50 mg caverta amex. The patella • The intercondylar area is the space between the tibial condyles on • The ligamentum patellae, which is attached to the apex of the patella which can be seen two projectionsathe medial and lateral intercondy- and the tibial tuberosity, is the true insertion of the quadriceps and the lar tubercles. This arrange- The horns of the lateral meniscus are attached close to either side of the ment constitutes the extensor mechanism. It has anterior, medial and lat- • The posterior surface of the patella is smooth and covered with articu- eral borders and posterior, lateral and medial surfaces. It is divided into a large lateral and a smaller medial facet • The anterior border and medial surface of the shaft are subcutaneous for articulation with the femoral condyles. The osteology of the lower limb 93 42 The arteries of the lower limb Superficial epigastric Superficial (to abdominal wall) circumflex Femoral iliac Superficial external pudendal Deep external pudendal Femoral nerve Femoral sheath Femoral vein Lateral circumflex Profunda femoris Medial circumflex Plantar metatarsal artery Anastomosis Perforating Deep plantar arch with dorsal arteries artery Medial Lateral plantar plantar artery artery Gap in adductor magnus Flexor digitorum Abductor accessorius Popliteal hallucis Genicular arteries Soleus arch to knee joint Posterior tibial Fig. Tibialis • Course: the femoral artery commences as a continuation of the ex- anterior and extensor digitorum longus flank the artery throughout its ternal iliac artery behind the inguinal ligament at the mid-inguinal point. Extensor hallucis In the groin the femoral vein lies immediately medial to the artery and longus commences on the lateral side but crosses the artery to lie both are enclosed in the femoral sheath. The femoral artery dorsum of the foot to the level of the base of the metatarsals and then descends the thigh to pass under sartorius and then through the adductor between the two heads of the first dorsal interosseous muscle to gain (Hunter’s) canal to become the popliteal artery. Prior to passing to • Branches: the sole it gives off the 1st dorsal metatarsal branch and via an arcuate • Branches in the upper part of the femoral triangleafour branch the three remaining dorsal metatarsal branches (Fig. Near its origin it gives rise The posterior tibial artery to medial and lateral circumflex femoral branches. These con- • Course: the posterior tibial artery arises as a terminal branch of the tribute to the trochanteric and cruciate anastomoses (see below). It is accompanied by its venae comitantes and supplies The profunda descends deep to adductor longus in the medial com- the flexor compartment of the leg. These circle the femur posteriorly perforating, and supplying, all The artery ultimately passes behind the medial malleolus to divide into muscles in their path. The profunda and perforating branches ulti- medial and lateral plantar arteries under the flexor retinaculum. The mately anastomose with the genicular branches of the popliteal latter branches gain access to the sole deep to abductor hallucis. Posterior to the medial malleolus the structures which can be identifiedafrom front to backaare: tibialis posterior, flexor digitorum The trochanteric anastomosis longus, posterior tibial artery and venae comitantes, the tibial nerve and This arterial anastomosis is formed by branches from the medial and flexor hallucis longus. It lies close to the trochanteric fossa and pro- • Peroneal arteryathis artery usually arises from the posterior tibial vides branches that ascend the femoral neck beneath the retinacular artery approximately 2. It ends by dividing into a The cruciate anastomosis perforating branch that pierces the interosseous membrane and a This anastomosis constitutes a collateral supply. The deep branch runs • Course: the femoral artery continues as the popliteal artery as it between the 3rd and 4th muscle layers of the sole to continue as the passes through the hiatus in adductor magnus to enter the popliteal deep plantar arch which is completed by the termination of the space. The arch gives rise to plantar metatarsal the capsule of the knee joint and then on the fascia overlying popliteus branches which supply the toes (Fig. In the fossa it is the deepest structure, ren- sends branches which join with the plantar metatarsal branches of dering it difficult to feel its pulsations. Atheroma causes narrowing of the peripheral arteries with a con- • Branches: muscular, sural and five genicular arteries are given off. When symptoms are intolerable, pain is present at The anterior tibial artery rest or ischaemic ulceration has occurred, arterial reconstruction is • Course: the anterior tibial artery passes anteriorly from its origin, required. Disease which is limited in extent may be suitable for inter- membrane giving off muscular branches to the extensor compartment ventional procedures such as percutaneous transluminal angioplasty of the leg. The arteries of the lower limb 95 43 The veins and lymphatics of the lower limb From lower abdomen Inguinal lymph nodes From perineum and gluteal region Vein linking great and small saphenous veins Great saphenous vein Popliteal lymph nodes Short saphenous vein Fig. The arrows indicate the direction of lymph flow Superficial epigastric Inguinal ligament Femoral Pubic tubercle artery Edge of saphenous opening Superficial Femoral vein circumflex Deep fascia of thigh iliac Superficial external pudendal Great saphenous vein Fig. Failure of this ‘muscle pump’ to work efficiently, towards becoming varicose and consequently often require surgery. It passes anterior to the medial malleolus, Varicose veins along the anteromedial aspect of the calf (with the saphenous nerve), These are classified as: migrates posteriorly to a handbreadth behind patella at the knee and • Primary: due to inherent valve dysfunction.

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Intrapleural and alveolar pressure are given in reference to atmospheric pressure Rest caverta 50mg without prescription. Intrapleural pressure is negative (~ -5cmH2O) because opposing forces of lungs trying to collapse and chest wall trying to expand creates negative pressure in intrapleural space 100 mg caverta otc. The expanding force on the 238 lungs and airways at rest is + 5cmH2O (alveolar or airway pressure minus intraplural pressure) Inspiration. The reason is as lung volume increases, elastic recoil strength of lungs increases. The two effects together cause intrapleural pressure to be more negative (~ -8cmH2O). Alveolar pressure becomes positive (higher than atmospheric) because the elastic forces of the lung compress air in the alveoli. Following expiration, volume in the lung decreases and intrapleural pressure returns to its resting volume (i. Refers to energy expended to: • Expand elastic tissues of chest wall and lungs (compliance work) • Overcome viscosity of inelastic structures of chest wall and lungs (tissue resistance work). Alveolar gas exchange Gas exchange in the respiratory system refers to diffusion of oxygen and carbon dioxide in the lungs and in the peripheral tissues. Oxygen is transferred from alveolar gas into pulmonary capillary blood and, ultimately it is delivered to the tissues, where it diffuses from systemic capillary blood into the cells. Carbon dioxide is delivered from the tissues 239 to venous blood, (to pulmonary capillary blood), and is transferred to alveolar gas to be expired. Dalton’s law of partial pressure states that each gas contributes to the total pressure in direct proportion to its relative concentration. Henry’s law states that the actual concentration of dissolved gas in a liquid is equal to the partial pressure of the gas in contact with the liquid multiplied by the solubility coefficient of the gas in that particular liquid. Rate of transfer by diffusion is directly proportional to driving force, diffusion coefficient and surface area available for diffusion, but inversely proportional to thickness of membrane barrier. Total gas concentration in solution = dissolved gas + bound gas + modified gas Dissolved gas: For a given partial pressure, the higher the solubility of gas the higher the concentration in solution. PaO2 (practical pressure of O2 is arterial system) is slightly less than 100 mmHg because of physiological shunt. Physiologic shunt refers to the fraction of pulmonary blood flow that bypasses the alveoli, therefore is not arterialized. If shunt is small, then A-a is small (normal), If abnormal, A-a difference increases. Exactly opposite events occur in the pulmonary capillaries 246 Oxygen transport in the blood: O2 is carried in the blood in two forms. Each subunit contains heme moiety which is iron-binding porphyrin and polypeptide chain (either α or β). Adult Hb (HbA) has α2 β2 (2 of subunits have α chain and 2 have β chain) Each subunit can bind one molecule of O2, a total of 4 molecules of O2 for 1 molecule of Hb. For Hb subunits to bind O2, the iron in heme moieties must 2+) be in ferrous state (Fe Variants of Hb molecule: 3+ Methemoglobin- This is when iron molecule is in ferric (Fe ) state thus doesn’t bind O2. This is a Congenital variant Fetal Hb (HbF): In fetal Hb, the two β chains are replaced by ϒ chains (ϒ2 α2) HbF has higher affinity for O2 than HbA, facilitating O2 movement from mother to fetus. This Hb is replaced with HbA within the first year of life HbS: This is abnormal Hb, where α is normal, but β is abnormal. O2-Hb dissociation curve: Each molecule of Hb binds to 4 molecules of O2, which is 100% saturation. If 3 molecules of O2 bind - 75% saturation If 2 “ “ “ “ - 50% “ if 1 “ “ “ “ - 25% “ 248 Figure 67. Binding first molecule of O2 to a heme group increases the affinity for the second O2 molecule, the second to the third. The graph shown in figure 68 corresponds to 100% saturation and (affinity of Hg for O2 highest). Due to positive coaperativity, affinity of Hb for O2 is the highest, which corresponds to flat portion of curve (figure 68). Changes in the O2-Hb dissociation curve: Shift to the right: Occur when there is decreased affinity of Hb for O2 (see figure. Increases in temperature also cause right shift, and facilitate unloading of oxygen in the tissues. This decrease in affinity causes right shift and facilitates unloading of oxygen in the tissues.

In addition to improving cosmetic appearance buy 100 mg caverta visa, pelvic reconstruction strives to cure incontinence and voiding dysfunction cheap caverta 50 mg without prescription, and improve bowel and sexual function. Anterior compartment pelvic reconstruction is for repairing a prolapsed bladder; posterior compartment pelvic reconstruction is for repairing a prolapsed rectum; apical compartment pelvic reconstruction is for repairing prolapsed small intestine. The anesthesiologist will discuss these options with you to help you determine what type of anesthesia is best for you. Vaginal discharge (often bloody), is also typical for several weeks following surgery and it is therefore recommended that you wear a pad. Prior to being discharged, you will be given typed instructions and a prescription for antibiotics and a pain medication. It is important to complete the prescription for antibiotics to help avoid a urinary tract or pelvic infection. Underlying contributing factors include childbirth (in particular, traumatic vaginal deliveries of large babies), menopause, hysterectomy, aging and any condition causing a chronic increase in abdominal pressure such as cough, asthma, and constipation. The intrinsic factor, intrinsic sphincteric defciency, is a weakness of the urethral sphincter muscles. The extrinsic factor, urethral hypermobility, is an acquired laxity in the tissue support of the urethra that allows urethral descent with increases in abdominal pressure. The current procedure represents an evolution of surgical technique that has merit because of its effectiveness, durability, relative simplicity, and need for only tiny incisions. The sling procedure works by providing support and a “backboard” to the urethra such that with “stress” maneuvers such as coughing and sneezing, the urethra can be compressed against the sling to provide continence. The stitches used to repair the vagina and pubic or groin region will dissolve on their own and do not require removal. Sub-urethral refers to the placement of the sling beneath the urethra, the tubular channel that leads from the bladder to the urinary opening. Sling refers to the “hammock” that provides urethral support and that allows compression of the urethra with stress maneuvers. Urgency incontinence is a sudden urge to urinate with the inability to make it to the bathroom on time. Essentially, a piece of surgical mesh is sutured to the uterine cervix, and the other end of the mesh is attached to one of the hardy pelvic ligaments. This results in the re-establishment of uterine support and a return of the uterus to its normal anatomical position. Hysterectomy is the surgical removal of the uterus, a procedure that can often be performed vaginally by your gynecologist. If high grade uterine prolapse coexists with bladder and urethral prolapse, the gynecologist and urologist will collaborate to repair all aspects of the prolapse. Siegel earned a bachelor of science degree magna cum laude from Syracuse University, Syracuse, New York, in 1977, and a medical degree from the Chicago Medical School, Chicago, Illinois, in 1981, where he was elected to the Alpha Omega Alpha Honor Medical Society. He completed a two-year residency in general surgery at the North Shore University Hospital, Manhasset, New York, an affliate of Cornell University School of Medicine. Siegel then went on to undertake residency training in urology at the University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, from 1983 to 1987. Siegel completed a fellowship in incontinence, urodynamics, and reconstructive and female urology at the University of California School of Medicine, Los Angeles, California, under the direction of Dr. He is a member of the American Urological Association, the New York section of the American Urological Association, the American Medical Association, the Society for Urodynamics and Female Urology, the American Uro- Gynecological Society, and the International Continence Society. Siegel has authored chapters in urology textbooks including Current Operative Urology and Interstitial Cystitis, and has published articles in numerous professional journals including Urology, Journal of Urology, Urologic Clinics of North America, Postgraduate Medicine, Neuro-Urology and Urodynamics, and International Urogynecology Journal. He has presented papers at professional meetings for many medical societies including the Philadelphia Urological Society, the American Academy of Pediatrics, and the American Urological Association, both nationally and internationally. Siegel is a urological surgeon at Hackensack University Medical Center, and is the Director of The Center for Continence Care. He is very involved in the training of urology residents at the University of Medicine and Dentistry of New Jersey where he is a Clinical Assistant Professor of Urology. He is the author of Finding Your Own Fountain of Youth – The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity. Im aging t ultrasound • transvaginal ultrasound provides enhanced details of structures located near the apex of the vagina; i. Classification of Contraceptive M ethods Type Description Effectiveness Surgical Sterilization (tubal ligation) 99. Pedunculated subserosal Subserosal Intram ural Subm ucosal Cervical Pedunculated subm ucosal Figure 10.

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