Vaginal Surgeries
Vaginal Hysterectomy
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What is Vaginal Hysterectomy?

A vaginal hysterectomy is an operation to remove your womb (uterus) through your vagina.

You will meet the gynaecologist (a doctor who specialises in women’s reproductive health) carrying out your procedure to discuss your care. It may differ from what is described here as it will be designed to meet your individual needs.

A hysterectomy is a treatment option for a number of conditions that affect the female reproductive system, these may include the following.

  • Pelvic organ prolapsed. This is when your womb, rectum or bladder drops out of position into your vagina.
  • Irregular or heavy menstrual bleeding, but only if other treatments haven’t worked.
  • Fibroids (non-cancerous growths of muscle and fibrous tissue in your womb) that are painful, cause bleeding or are very enlarged.
  • Cancer of your womb.
  • Endometriosis. A condition in which cells that usually line your womb grow elsewhere in your abdomen.
  • Adenomyosis. This is a benign condition in which cells that usually line your womb grow in the womb muscle causing painful, heavy periods.

A vaginal hysterectomy involves removing your womb through your vagina. You may or may not also have your ovaries removed, depending on why you’re having a hysterectomy. Your ovaries produce oestrogen so if you have them removed, you will immediately go through the menopause. There is some evidence to show that having your fallopian tubes removed during a hysterectomy may reduce your risk of ovarian cancer, even if your ovaries aren’t removed.

After a hysterectomy, you will no longer have periods or be able to become pregnant. It’s important to discuss this with your gynaecologist before the operation.

Bartholin cyst Removal
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What is a Bartholin cyst?

A Bartholin's cyst, or Bartholin's duct cyst occurs when the duct of the Bartholin's gland is blocked, resulting in the development of a fluid-filled cyst. Even though it may sometimes be caused by an infection, a Bartholin's cysts is not an infection.

The Bartholin's glands, also known as the major vestibular glands, are a pair of glands between the vagina and the vulva that produce lubrication (mucus-like fluid) when stimulated. Along with the lesser vestibular glands, they aid in sexual intercourse by reducing friction. The lubricating fluid goes from the Bartholin's glands down tiny tubes (ducts) which are about 0.8 inches (2cm) long into the lower part of the entrance to the vagina.

If there is blockage in these ducts the lubricant accumulates, they expand and a cyst is formed - a Bartholin's cyst. When the cyst is formed there is a risk of infection in the area, and a subsequent abscess.

According to the National Health Service (NHS), UK, about 1 in every 50 British women is affected at some time in their lives. A woman is more likely to have this type of cyst when she is young and sexually active, has not yet become pregnant, or has just had one pregnancy. Any cyst-like symptoms or lumps in the vulval area later on in life, for example during the menopause, should be reported to a doctor and checked for cancer

Cysts can range in size from that of a lentil to a golf ball. Although Bartholin's cysts are not sexually transmitted, gonorrhea (a sexually transmitted disease) is a common cause.

Thomas Bartholin (1616-1680), a Danish physician, mathematician and theologian, was the first person to describe these glands, hence their name. He was best known for his work in the discovery of the lymphatic system in humans.

Hymenoplasty
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What is Hymenoplasty?

More and more women are seeking Hymenoplasty, or reconstruction of the hymen, for a variety of reasons. Hymenoplasty is actually the surgical repair of the hymen, a membrane that partially closes the opening of the vagina. In many cultures and religions, an intact hymen is traditionally taken to indicate a mark of virginity.

Due to reasons other than intercourse, such as vigorous exercise or tampon insertion, the hymen becomes torn or ruptured. Under such circumstances, many women want their hymen reconstructed, which can be accomplished through a Hymenoplasty.

Dr. Jitendra and his caring, professional staff understand the discreet nature of the need for this type of surgery and, as always, all information will remain strictly confidential. We offer a sensitive, professional approach to the procedure, and during the initial consultation, there will be a female nurse present to help our patients feel more comfortable and secure.

Plastic surgeries Related to vaginal Opening
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What Is a Plastic surgeries Related to vaginal Opening ?

Plastic surgery of the vaginal opening is mostly due to a sense of laxity or its excessive size. The reasons are mostly the subjective feelings of women resulting from the appearance of their genitals.

In many cases these feelings are justified, resulting from a congenital defect of the vaginal opening. Vaginoplasty, a surgical intervention in the area of the vaginal opening and (according to the needs and situation) the adjacent part of the vagina and perineum, is performed mostly in women with acquired deformation of the external genitals after giving birth. This may be a vaginal birth with extensive perineal injury or poorly healed episiotomy.
In addition to aesthetic objections, the clients suffer from pain during sexual intercourse and, in extreme cases the refusal of painful sexual intercourse. In this case, the problem is both aesthetic and functional. The same situation may also result from poor postnatal care and possible infection at the site of an episiotomy.
Another group of women requiring this surgery are older women with reduced elasticity of the submucosa where aging, hormonal causes, an inborn disposition where the vaginal entrance is significantly open, provides a less than satisfactory sexual experience for both partners. It may be a cause of frequent infections in the vagina or urethra which cause discomfort while walking, sitting, etc.

It is often necessary to combine this treatment with front and back vaginoplasty that addresses the release of submucosa and thus feel of a “too loose vagina.”
Depending on the type of deformation of the vaginal opening and the nature of the difficulties, the surgeon chooses the optimal procedure. Excess tissue of the vaginal mucosa or skin folds of the vaginal opening and perineum skin are sharply dissected away and the edges of sections are carefully adapted – sewn with absorbable sutures, usually in two layers.

The surgery is performed under general anaesthesia and lasts for approximately 60 to 90 minutes. Duration of hospital stay is 3 nights and period of sick leave is at least 14 days. Required sexual abstinence is around 6 weeks.

Post Coital Tear
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What Is a Post Coital Tear ?

The presence of blood after having sex is a little disconcerting. However, post-coital bleeding is not always a cause for concern. Read on to learn more about the causes of post-coital bleeding.

How is post-coital bleeding related to menstruation?

Post-coital bleeding can occur if you are menstruating during the time of intercourse. In this case, it is not a cause for concern, as bleeding during menstruation is normal. Post-coital bleeding might also occur seven to 10 days after you finish menstruating. This occurs if the pressure from intercourse dislodges any remaining menstrual blood, which is then expelled during and after intercourse.

How is post-coital bleeding related to sexual position?

Certain positions allow an excess of pressure on the uterine wall, thereby dislodging leftover menstrual blood. Doggy-style is especially prone to producing extra pressure deep inside the vagina. Any position where the vagina is positioned downward may also induce excess blood to be dislodged due to gravity. Anal intercourse induces bleeding, because the anus tends to be tighter than the vagina.

Hymenal tear (fresh / old)
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What Is a Hymenal tear (fresh / old)?

The hymen is a thin piece of mucousal tissue that surrounds and partially covers the vaginal opening (also called the introitus).1 Every hymen is shaped differently: some are thin and elastic, while others are thicker and less stretchy. The evolutionary purpose of the hymen is unknown, but one theory says that the hymen is there “to protect the vaginal opening and the areas immediately surrounding the introitus during a female's early developing years.”1 An intact hymen typically has a small opening (or openings) that allow for the passage of menstrual blood and other fluids. The hymen oftentimes, though not always, rips or tears the first time a female engages in penetrative intercourse, which may cause some temporary bleeding and slight discomfort. The hymen can stretch and/or tear as a result of various other sexual behaviors, such as the insertion of multiple fingers or a sex toy into the vagina, and nonsexual activities such as gymnastics (doing “the splits”), horseback riding, or engaging in other physical activities. Some women may not be aware when their hymen tears, especially if it does not occur during sexual activity, because it may or may not cause bleeding or discomfort.1 The hymen is often attributed important cultural significance in certain communities because of its association with a woman's virginity; however, it can easily be torn through nonsexual behaviors. Its presence is a poor and unreliable indicator of one’s virginity. The hymen has been and continues to be a source of extreme concern in many cultures, and even now, many myths regarding the presence of the hymen exist due to ancient cultural traditions and a lack of scientific knowledge.

Structures of the Hymen

The shape and structure of the hymen varies from female to female. The picture below shows the most common configurations.

· An annular hymen has only one opening (seen top left).

· A septate hymen has two openings separated by a thin band of tissue. In rare cases, the hymen may have several very small openings (seen bottom left).

· An imperforate hymen has no opening at all (seen bottom right).

·There also exists the microperforate hymen (not shown), which has one very small hole. Females with a microperforate hymen often have difficulty inserting a finger or a tampon.

Ovarian Cyst
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What is the ovary and what are ovarian cysts?

The ovary is one of a pair of reproductive glands in women that are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of a walnut. The ovaries produce eggs (ova) and female hormones estrogen and progesterone. The ovaries are the main source of female hormones, which control the development of female body characteristics such as the breasts, body shape, and body hair. They also regulate the menstrual cycle and pregnancy. Ovarian cysts are closed, sac-like structures within an ovary that contain a liquid, gaseous, or semisolid substance. "Cyst" is merely a general term for a fluid-filled structure, which may or may not represent a tumor or neoplasm (new growth). If it is a tumor, it may be benign or malignant. The ovary is also referred to as the female gonad.

What causes ovarian cysts?

Ovarian cysts form for numerous reasons. The most common type is a follicular cyst,which results from the growth of a follicle. A follicle is the normal fluid-filled sac that contains an egg. Follicular cysts form when the follicle grows larger than normal during the menstrual cycle and does not open to release the egg. Usually, follicular cysts resolve spontaneously over the course of days to months. Cysts can contain blood (hemorrhagic cysts) from leakage of blood into the egg sac.

Another type of ovarian cyst that is related to the menstrual cycle is a corpus luteum cyst. The corpus luteum is an area of tissue within the ovary that occurs after an egg has been released from a follicle. If a pregnancy doesn't occur, the corpus luteum usually breaks down and disappears. It may, however,fill with fluid or blood and persist as a cyst on the ovary. Usually, this cyst is found on only one side, produces no symptomsand resolves spontaneously.

Endometriosis is a condition in which cells that normally grow inside as a lining of the uterus (womb), instead grow outside of the uterus in other locations. The ovary is a common site for endometriosis. When endometriosis involves the ovary, the area of endometrial tissue may grow and bleed over time, forming a blood-filled cyst with red- or brown-colored contents called an endometrioma, sometimes referred to as a chocolate cyst or endometrioma. The condition known as polycystic ovarian syndrome (PCOS) is characterized by the presence of multiple small cysts within both ovaries. PCOS is associated with a number of hormonal problems and is the most common cause of infertility in women.

OS Tightening
OS Tightening

What is an Ectopic Pregnancy?

If a fertilized egg implants outside the uterus, it's called an ectopic pregnancy. About 1 in 50 pregnancies is ectopic. There's no way to transplant an ectopic (literally, "out of place") pregnancy into your uterus, so ending the pregnancy is the only option.

While there are some risk factors, an ectopic pregnancy can happen to anyone. And, because it's potentially dangerous for you, it's important to recognize the early signs and get treatment as soon as possible.

How does it happen?

After conception, the fertilized egg travels down one of your fallopian tubes on its way to your uterus. If the tube is damaged or blocked and fails to propel the egg toward your womb, the egg may become implanted in the tube and continue to develop there.

Because the vast majority of ectopic pregnancies occur in a fallopian tube, they're often called "tubal" pregnancies. Much less often, an egg implants in an ovary, in the cervix, directly in the abdomen, or even in a c-section scar.

It's also possible for a woman to have one embryo normally implanted in her uterus and another implanted in her tube or elsewhere. This is called a heterotopic pregnancy, and it's pretty rare, occurring in only 1 in 4,000 pregnancies.

If an ectopic pregnancy isn't recognized and treated, the embryo could grow until the fallopian tube ruptures, resulting in severe abdominal pain and bleeding. This can cause permanent damage to the tube or loss of the tube, and if it involves very heavy internal bleeding that's not treated promptly, it can even lead to death. That's why early diagnosis, treatment, and follow-up care are so important.

Anterior Cystocele (Bladder) and Posterior Repair
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Anterior Cystocele Bladder Posterior Repair

A patient's anterior vaginal wall, and with it her bladder, may bulge towards her introitus when she coughs or strains (cystocele). The same thing can happen to her rectum (rectocele). If her cervix descends more than a little at the same time, she needs a Manchester repair or a vaginal hysterectomy, or if you cannot do this or refer her for it, Le Fort's operation (20.11), or ventrisuspension (20.10). An anterior and particularly posterior repair are more difficult than these two procedures, but they are much more satisfactory, so learn to do them if you can.

An anterior colporrhaphy mobilizes her bladder, returns it to its normal place, and fixes it there. Cut through the tissues joining her cervix and her bladder, so as to expose the peritoneum of her uterovesical pouch, and then suture the fascia on either side, so as to make a supporting buttress from her urethra to her cervix.

A posterior colporrhaphy, reduces her gaping introitus, reconstitutes her perineal body, reinforces her pelvic diaphragm by approximating her levator ani muscles, corrects her rectocele and eliminates the hernia of her pouch of Douglas. You can feel the levator ani muscles of a normal nullip 5 cm from her introitus. The key sutures in this operation bring her levator ani muscles together in this position.

Fig. 20-12 COLPORRHAPHY[md]ONE. Anterior colporrhaphy: A, incise the patient's anterior vaginal wall. B, mobilize her cystocele. C, mobilize her cystocele from her cervix. D, insert the tightening suture as far laterally as you can. E, the obliteration of her cystocele is complete. F, remove her redundant vaginal wall.

Posterior colporrhaphy: G, excise an ellipse of skin at the junction of her vagina and perineum. H, mobilize her posterior vaginal wall. I, separate her rectocele from her posterior vaginal wall.

COLPORRHAPHY If possible, refer the patient for both these operations, otherwise proceed as follows. If she is postmenopausal, give her a course of oestradiol before starting.

ANTERIOR COLPORRHAPHY [s7](anterior repair)INDICATIONS. (1) Prolapse of her anterior vaginal wall which troubles her, especially if she has to push it back to micturate, provided there is little or no descent of her uterus. Preferably wait until childbearing is ended, because a prolapse may recur after pregnancy. She can be pre- or postmenopausal.

CONTRAINDICATIONS. (1) Ascites. (2) A severe chronic cough.

EXAMINATION. Lay her on her side in the left lateral position. Insert a Sims' speculum posteriorly and ask her to cough and strain downwards. Her cystocele will then show its full size and the degree of uterine descent. If her cervix comes down to her vulva, she is not suitable for an anterior repair alone. Refer her for a Manchester repair, or if this is impossible, consider doing le Fort's operation, or ventrisuspension. These are mainly for third degree prolapse (when the cervix is at the introitus or lower).

Urinary Incontinence Related Surgery
Urinary Incontinence Related Surgery Urinary Incontinence Related Surgery

Urinary Incontinence Related Surgery

Bladder control is a common problem in America affecting over 15 million men and women. The prevalence is much greater in women than in men, and older women are more often afflicted than younger women. Regardless of gender or age, incontinence of urine has significant impact on both quality of life and cost of living. Many affected persons suffer from depression and social isolation. Fortunately, with continued advances in medical science, noninvasive procedures and effective drugs are available to many patients. Continue reading to learn more about available treatment options that you can discuss with your urologist.

What can be expected under normal conditions?

The urinary tract is similar to a plumbing system, with special pipes that allow water and salts to flow through them. The urinary tract includes the two kidneys, the two ureters, the bladder and the urethra. The kidneys act as a filtration system for the blood, cleansing it of poisonous materials and retaining valuable sugars, salts and minerals. Urine, the waste product of the filtration, is produced in the kidney and flows through two 10 to 12 inch long tubes called the ureters, which connect the kidneys to the bladder. The ureters are about one quarter of an inch in diameter and their muscular walls contract to make waves of movement that force the urine into the bladder. The bladder is expandable and stores the urine until it can be conveniently disposed of. It has one-way flap valves that allow unimpeded urinary flow into the bladder but prevents urine from flowing backward (vesicoureteral reflux) into the ureters and kidneys. When the bladder contracts it passes urine into a tubular structure, called the urethra, which transports the waste out of the body.

Urinary incontinence surgery is more invasive and has a higher risk of complications than do many other therapies, but it can also provide a long-term solution in severe cases.

The surgical options available to you depend on the type of urinary incontinence you have. Most options for urinary incontinence surgery treat stress incontinence. However, low-risk surgical alternatives are available for other bladder problems, including overactive bladder — also called urge incontinence or urgency-frequency syndrome.

Septum Resection and Polypectomy
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Fertility Treatment

Artificial Insemination simply imitates the natural reproduction process, inside the uterus, making it easier for the sperm to reach the right place at the time when the ovulation takes place. Artificial Insemination is used when sperm have problems reaching the uterus, either because there is a blockage or because of low sperm count or quality. When Artificial Insemination is done with the partner’s sperm, it is known as Artificial Insemination with partner sperm (AIH). When we cannot obtain sufficient sperm from the partner, or when there is no male partner, we look for an anonymous donor. This is what we call Artificial Insemination with donor sperm (AID). This technique is relatively straightforward and gives very good results. However, sometimes things are not so easy and we have to turn to In Vitro Fertilisation.

In Vitro Fertilisation involves fertilising an egg with a sperm outside the uterus, in the laboratory. If the woman’s eggs are in good condition they are harvested and, using an extremely fine needle, a sperm is injected into each egg to fertilise it. This is what we call Intracytoplasmic Sperm Injection, or ICSI. Once it is fertilised, the egg becomes a pre-embryo and is placed in the uterus to continue developing. When we suspect that sperm may be damaged in some way, we need to see things close up so we can select the healthiest ones. This procedure is known as Intracytoplasmic Morphologically-selected Sperm Injection, or IMSI. The same as for Artificial Insemination, for In Vitro fertilisation, semen can be provided either by the partner or by an anonymous donor. It may be that the woman is not producing eggs or that her eggs are not fit for use, in this case, eggs of an anonymous donor can de used and, as before, they are fertilised with sperm from either her partner or a donor before being placed in the uterus to continue developing. With this technique, 6 out of every 10 women fulfill their dream of becoming a mother.

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