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Relations the upper posterior vaginal wall forms the anterior peritoneal reflection of the pouch of Douglas how does an erectile dysfunction pump work best order for viagra plus. The middle third is separated from the rectum by pelvic fascia and the lower third abuts the perineal body erectile dysfunction treatment thailand generic 400 mg viagra plus mastercard. Anteriorly erectile dysfunction what kind of doctor generic viagra plus 400mg with visa, the upper vagina is in direct contact with the base of the bladder impotence xanax order viagra plus 400mg visa, whilst the urethra runs down the lower half in the midline to open into the vestibule; its muscles fuse with the anterior vaginal wall. Laterally, at the fornices, the vagina is related to the attachment of the cardinal ligaments. Age-relatedchanges the disappearance of maternal oestrogenic stimulation after birth causes the uterus to decrease in length by approximately one-third and in weight by approximately one-half. At puberty, however, the corpus grows much faster and the size ratio reverses; the body becomes twice the length of the cervix. After the menopause, the uterus undergoes atrophy, the mucosa becomes very thin, the glands almost disappear and the walls become less muscular. These changes affect the cervix more than the corpus, so the cervical lips disappear and the external os becomes more or less flush with the vault. Age-relatedchanges Immediately after birth, the vagina is under the influence of maternal oestrogen so the epithelium is well developed. After a couple of weeks, the effects of maternal oestrogen disappear, the pH rises to 7 and the epithelium atrophies. The vagina undergoes stretching during coitus, and especially childbirth, and the rugae tend to disappear. The Vagina the vagina is a fibromuscular tube which extends posterosuperiorly from the vestibule to the uterine cervix. It is longer in its posterior wall (approximately 9 cm) than anteriorly (approximately 7. The vaginal walls are normally in contact, except superiorly, at the vault, where they are separated by the cervix. The vault of the vagina is divided into four fornices: posterior, anterior and two lateral. The mid-vagina is a transverse slit and the lower portion has an H-shape in transverse section. Structure the skin of the vagina is firmly attached to the underlying muscle and consists of stratified squamous epithelium. The epithelium is thick and rich in glycogen, which increases in the postovulatory phase of the cycle. This pH has a protective role for the vagina in decreasing the incidence of pyogenic infection. The muscle layers consist of an outer longitudinal and inner circular layer, but these are not distinctly separate and are mostly spirally arranged and interspersed with elastic fibres. Labiamajora the labia majora are two prominent folds of skin with underlying adipose tissue bounding either side of the vaginal opening. They contain numerous sweat and sebaceous glands, and correspond to the scrotum of the male. Anteriorly, they fuse together over the symphysis pubis to form a deposition of fat, the mons pubis. From puberty onwards, the lateral aspects of the labia majora and the mons pubis are covered 5 1 Surgical anatomy with coarse hair. Labiaminora the labia minora are two small vascular folds of skin, containing sebaceous glands but devoid of adipose tissue, which lie within the labia majora. Anteriorly, they divide into two to form the prepuce and frenulum of the clitoris. They are not well developed before puberty, and atrophy after the Clitoris this is a small erectile structure, approximately 2. The body of the clitoris contains two crura, the corpora cavernosa, which are attached to the inferior border of the pubic rami. The clitoris is covered by ischiocavernosus muscle, whilst bulbospongiosus muscle inserts into its root. The clitoris has a highly developed cutaneous nerve supply and is the most sensitive organ during sexual arousal. The vestibular bulbs are two masses of erectile tissue on either side of the vaginal opening, and contain a rich plexus of veins within bulbospongiosus muscle. These glands secrete mucus, producing copious amounts during intercourse to act as a lubricant. Perinealbody this is a fibromuscular mass occupying the area between the vagina and the anal canal. Coccyx 6 the bladder which is lost during childhood but reappears during puberty, at which time hair grows. The labia minora shrink, subcutaneous fat is lost and the vaginal orifice becomes smaller. Occasionally, it is injured by high sutures near the cervix in a pelvic floor repair. The Bladder the bladder is a muscular reservoir capable of altering its size and shape depending on the amount of fluid it holds. When empty, it is the shape of a tetrahedron, with a triangular base or fundus and a superior and two inferolateral surfaces. The two inferolateral surfaces meet to form the rounded border which joins the superior surface at the apex. The base and the inferolateral surface meet at the urethral orifice to form the bladder neck. Normal bladder capacity is between 300 and 600 ml, but it can, in cases of urinary retention, contain several litres and extend as far as the umbilicus.

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It was also shown that South Asian women with polycystic ovaries had a comparable degree of insulin resistance to controls with established type 2 diabetes erectile dysfunction pump for sale 400 mg viagra plus with visa. Type 2 diabetes and insulin resistance have a high prevalence among indigenous populations in South Asia erectile dysfunction after 80 buy viagra plus 400 mg on-line, with a rising prevalence among women erectile dysfunction treatment milwaukee order 400 mg viagra plus with visa. Insulin resistance and hyperinsulinaemia are common antecedents of type 2 diabetes erectile dysfunction treatment uk buy viagra plus 400 mg otc, with a high prevalence in South Asians. Type 2 diabetes also has a familial basis, inherited as a complex genetic trait that interacts with environmental factors, chiefly nutrition, commencing from fetal life. The presence of obesity and/or type 2 diabetes worsens the degree of insulin resistance. Insulin resistance is restricted to the extrasplanchnic actions of insulin on glucose dispersal. Insulin resistance causes compensatory hypersecretion of insulin, particularly in response to glucose, so euglycaemia is usually maintained at the expense of hyperinsulinaemia. That is, they remove excess lipids from the circulation and tissues to transport them to the liver for excretion, or transfer them to other lipoprotein particles. All of the women were over 45 years of age and 770 women had been treated by wedge resection of the ovaries. There were six deaths from diabetes as an underlying or contributory cause, compared with the expected 1. Thus, despite surrogate markers for cardiovascular disease, Pierpoint et al (1998) found no increased rate of death from cardiovascular disease. The risk of developing endometrial cancer has been shown to be adversely influenced by a number of factors including obesity, long-term use of unopposed oestrogens, nulliparity and infertility. Women with endometrial carcinoma have had fewer births compared with controls, and it has also been demonstrated that infertility per se gives a relative risk of 2. Hypertension and type 2 diabetes have long been linked to endometrial cancer, with relative risks of 2. A study by Coulam et al (1983) examined the risk of developing endometrial carcinoma in a group of 1270 patients who were diagnosed with chronic anovulation syndrome. Endometrialhyperplasia Endometrial hyperplasia may be a precursor to adenocarcinoma, with cystic glandular hyperplasia progressing in perhaps 0. The rationale is that cancer of the endometrium often presents at an early stage, is well differentiated, has a low risk of metastasis, and therefore is not perceived as being life threatening, while poorly differentiated adenocarcinoma in a young woman has a worse prognosis and warrants hysterectomy. This may be because of the factors that predispose to the endometrial pathology - chronic anovulation often combined with severe obesity - or secondary to the endometrial pathology disrupting potential embryonic implantation. An 257 Homocysteine A moderately increased total plasma homocysteine (Hcy) concentration is associated with an increased risk of atherosclerosis. Hcy is an essential intermediate in the transfer of activated methyl groups from tetrahydrofolate to Sadenosylmethionine, in the synthesis of cysteine from methionine, and in the production of homocysteine thiolactone. An abnormal elevation of Hcy in plasma and urine is caused by an imbalance between Hcy production and metabolism, which can be of demographic, genetic, nutritional or metabolic aetiology, and is associated with premature vascular disease. Mild hyperhomocysteinaemia has been demonstrated to induce sustained injury to the arterial endothelial cells that accelerate the development of thrombosis and atherosclerosis. Weight reduction and regular physical exercise are recognized interventions that help to reduce insulin resistance and the metabolic syndrome. Endometrialcancer Endometrial adenocarcinoma is the second most common female genital malignancy, but only 4% of cases occur in 18 Polycystic ovary syndrome endometrial thickness of more than 10 mm in an amenorrhoeic woman warrants an artificially induced bleed, which should be followed by a repeat ultrasound scan and endometrial biopsy if the endometrium has not been shed. Another option is to consider a progestogen-secreting intrauterine system, such as the Mirena. Management of Non-Fertility Aspects of Polycystic Ovaries Psychologicalsupportandqualityoflife the symptoms typically associated with the condition have also been shown to lead to a significant reduction in healthrelated quality of life (Jones et al 2004). Health-related quality of life is a multidimensional, dynamic concept that encompasses physical, psychological and social aspects that are associated with a particular disease or its treatment. Infertility and weight issues have also been found to affect other social and psychological parameters. Infertility can cause tensions within the family, altered self-perception and problems at work. Whilst obesity worsens the symptoms, the metabolic scenario conspires against weight loss; many women experience frustration in attempts to lose weight and suffer from low-esteem and poor body image. Ovariancancer In recent years, there has been much debate about the risk of ovarian cancer in women with infertility, particularly in relation to the use of drugs to induce superovulation for assisted conception procedures. Inherently, the risk of ovarian cancer appears to be increased in women who have multiple ovulations; that is, those who are nulliparous (possibly because of infertility) with an early menarche and late menopause. Thus, it may be that inducing multiple ovulations in women with infertility will increase their risk; a hypothesis that is by no means proven. The polycystic ovary, however, is notoriously sensitive to stimulation and it is only in recent years, with the development of high-resolution transvaginal ultrasonography, that the rate of unifollicular ovulation has attained acceptable levels. The use of clomiphene citrate and gonadotrophin therapy for ovulation induction in the 1960s, 1970s and 1980s resulted in many more multiple ovulations (and indeed multiple pregnancies) than in recent times, and might therefore present with an increased rate of ovarian cancer when these women reach their 60s, the age of greatest incidence. A few studies have addressed the possibility of an association between polycystic ovaries and ovarian cancer. The results are conflicting, and generalizability is limited due to problems with the study designs. Weight loss improves the endocrine profile, the likelihood of ovulation and the likelihood of a healthy pregnancy.

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Newly formed lesions tend to be clear to red erectile dysfunction treatment in tampa order viagra plus 400 mg otc, with older lesions more deeply pigmented erectile dysfunction typical age cheap 400 mg viagra plus, with variable proportions of pale scarring and fibrosis erectile dysfunction treatment vancouver buy viagra plus canada. Shortening and thickening of uterosacral ligaments reduces uterine mobility and causes fixed retroversion impotence guilt buy viagra plus with amex. Pouch of Douglas obliteration follows involvement of rectal serosa and sometimes muscularis. They are thought not to be true cysts but invaginations of the ovarian cortex lined by typical endometriotic tissue. Endometriosis deposits are histologically similar to eutopic endometrium, but not identical. Plaques contain oestrogen, progesterone and androgen receptors, and grow in the presence of oestrogen and atrophy with androgens. Abnormal levels and function of growth factors, macrophages and proinfla mmatory cytokines have been observed in the peritoneal fluid and serum of women with endometriosis. Endometriosis may be suspected clinically with appropriate symptoms and examination findings (nodularity in pouch of Douglas or uterosacral ligaments) or radiologic evidence of endometriomas. If endometriosis is present at laparoscopy, it is recommended that it is surgically removed at the same time as diagnosis, as it is an effective treatment for endometriosisassociated subfertility and pain. First-line medical treatment is appropriate, followed by laparoscopy and surgical management if unsuccessful. Generally, excision is recommended if >=4 cm, there is pain or access to follicles is affected. It should be considered in any symptoms with a cyclical pattern, especially if it is associated with pain and/or bleeding. The phenotype develops through chronic anovulation of any aetiology and a clear sequence of events is therefore not identifiable. Hirsutism is the growth of coarse/terminal hair in amounts that are socially unacceptable to a woman. Under 5% of women (various ethnic origin) in the reproductive age group have scores over 7. This is in a non-sexual pattern and is not related to , but may be aggravated by, excess androgens. Virilism is a condition usually secondary to hyperandrogenism and is associated with one or more of clitoral hypertrophy, breast atrophy, male baldness and deepening of the voice. About 15% of women normally have terminal hair on their faces, and this tends to increase with age. Hair growth and hirsutism In the skin, plasma testosterone is converted by 5-alpha-reductase to dihydrotes tosterone, which is required for the local stimulation of vellus hair follicles to produce terminal hair. Once the hair follicle has been stimulated by androgens to produce terminal hair, the changes persist even in the absence of androgen excess. Investigations the aim is to exclude serious disease and establish the source of androgens. Natural methods Natural methods are based on avoiding sexual activity that might lead to conception at the time when the ovum can be fertilised. It is necessary to predict the time of ovulation (generally by observing changes in body temperature) and to allow for the time that the sperm can survive with fertilising potential in the female genital tract. Intercourse is prohibited until 72 hours after the rise in basal body temperature. Barrier methods Diaphragm the diaphragm lies diagonally across the cervix, vaginal vault and anterior vaginal wall (extends from posterior vaginal fornix to behind pubic bone). Types of design are arcing, coil or flat; it is manufactured from natural rubber, latex or silicone.

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If the anatomy of the pelvic side wall has been distorted erectile dysfunction symptoms causes 400 mg viagra plus for sale, this technique will almost always allow the ureter to be identified and followed within the pelvis impotent rage quotes buy 400mg viagra plus with amex. If an ovarian mass is present whey protein causes erectile dysfunction purchase 400 mg viagra plus otc, the ureter may be dissected free from the mass in this retroperitoneal plane what is an erectile dysfunction pump proven 400mg viagra plus. They lie close to the genital tract and repair of a damaged ureter is technically demanding, with results that are not always satisfactory. By recognizing when and where the ureters are at greatest risk and by adopting a safe technique, the risk of damage to the ureter should be minimized. Anatomicalrelations the urinary and genital tracts are closely related in embryological development, and their anatomy and physiology, not surprisingly, are intertwined. The ureter develops from a bud on the posterolateral border of the mesonephric duct near the cloaca, which elongates and eventually fuses with the developing kidney. The ventral portion of the cloaca develops into the urethra, bladder and lower portion of the vagina. The ureters enter the pelvis by crossing the common iliac arteries in the region of their bifurcation. American Journal of Obstetrics and Gynecology 158:536, with permission of Elsevier. If bleeding does occur, the ureter should be palpated again after replacing the clamp to ensure that it has not been included. The ureter is occasionally damaged in its course across the anterior surface of the vagina. This may occur when taking a cuff of vagina, during a vaginal hysterectomy or colposuspension. When dissecting the upper vagina, it is important to keep in the correct plane close to the vaginal wall. Stitches placed either vaginally or abdominally in this area must be in tissue that has been accurately identified. This diagram shows the dissection performed for a radical hysterectomy, but illustrates the close relationship between the ureter and the uterine artery. Repairinguretericdamage If a ureter is damaged, the presence of the contralateral kidney should be checked. If the ureter has not been cut across but merely crushed or ligated in error, and this is recognized on the table, it is acceptable to remove the ligature and insert a stent into the ureter in the hope that a stenosis will not result. In the past, gynaecologists have resorted to simply tying off the divided ureter but this is rarely justifiable now. Repair of the ureter is technically demanding and may lead to long-term complications. It is not appropriate for a gynaecologist without urological training or extensive urological experience to undertake this. In principle, an end-to-end anastomosis can be performed for ureteric damage at the pelvic brim or above. They are spatulated and the anastomosis performed using fine interrupted sutures over a Silastic stent (Figure 8. An alternative for damage at this level is to perform a uretero-ureteric anastomosis. If the damage has occurred at the level of the ureteric tunnel or lower, the safest method of repair is to reimplant of Douglas and the thumb placed laterally in front of the uterine pedicle. The ureter, which is felt as a firm cord running across the cardinal ligament, is surprisingly far lateral to the cervix if the bladder has been properly reflected and the anatomy is normal. However, adhesions, fibrosis or inadequate dissection may disrupt these relationships, causing the ureter to remain fixed near the lateral margin of the cervix. Damage to the ureter in this site is prevented by carefully reflecting the bladder and by not taking a large pedicle that includes both the uterine artery and the paracervical tissue. The author prefers to take the uterine artery relatively high, at the level of the internal os, which allows the parametrium to fall laterally, taking the ureter with it. The ureter can then be palpated again and a second pedicle taken medial to the first, to include the cardinal ligament. In most cases, damage to the ureter occurs at this site because the pedicle slips or the original ligature is not ade108 Bladder damage Repair of the bladder, however, is more straightforward and the results are very good. It is an extraperitoneal organ that is located behind the symphysis pubis and rests on the anterior part of the levator diaphragm, the anterior vaginal wall and the cervix. The trigone is at the level of the upper vagina, with the base of the bladder related to the anterior vaginal fornix and cervix. When full, the bladder rises out of the pelvis towards the level of the umbilicus and presents a hazard during abdominal incision. The bladder is also at risk in this position if it is adherent after previous surgery or during caesarean section in labour, when the lower segment of the uterus is lifted out of the pelvis, elevating the bladder with it. A cleanly cut ureter may be reanastomosed by spatulating the ends and repairing it with fine sutures over a suitable splint. The distal end of the ureter is brought through the tunnel and, after spatulating the end, is sutured to the bladder mucosa. A couple of sutures into the serosal surface anchor the ureter to the outer layer of the bladder (Figure 8. When damage has occurred higher on the pelvic side wall, the bladder can be elevated to the cut end of the ureter to allow reimplantation without tension, using either a psoas hitch or a Boari flap.

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