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Scenario 2: A 16-year-old girl accompanied by her mother presents to the hospital very concerned with regards to the appearance of her left labia as her best friend pointed out to her that it was abnormally enlarged erectile dysfunction medication cialis order extra super avana with american express. In this scenario thorough and accurate history of symptoms and assessment of the Gillick competence of the patient is crucial. It is important that patient is able to give consent and is capable of expressing her own free will. In younger adolescent women, influence by their peer groups and parental concerns can affect their judgement. Therefore some of these cases may have to be counselled in collaboration with a psychologist. This procedure should not be carried out in women younger than 18 years of age because the shape of their external genitalia is still changing during puberty. Reinforce and highlight that there will be developmental changes in hormones, fat and pubic hair distribution. Explain that a great interpersonal variability in the shape and appearance of the external genitalia exists (according to one paper the width varied from 7 mm to 50 mm). They may not realize that hormonal changes during puberty result in growth of genitals in such a way that the inner labia mostly become longer than the outer labia. Therefore in some cases patients may interpret the results of these normal physiological changes as abnormal and may feel insecure, uncomfortable and bothered by the shape of their genitals. This results in women becoming more aware of their protruding labia, which in vast majority of the cases is probably anatomically normal. If complaints are of sexual dysfunction then it is important to highlight that reducing the labia may not improve sexual function unless it is specifically related to the labia rubbing or catching during intercourse. If there are any psychosexual issues they must be addressed and appropriate counselling should be arranged. Make sure that patient does not suffer from depression, anxiety or body dysmorphic disorder which can be common in teenagers. They should completely understand what the procedure entails and be fully aware of the risks and complications of the surgery. Counselling must include the risks of haemorrhage or infection which can result in premature breakdown of the sutures causing a poor cosmetic result. However ultimately in this case surgery should not be performed due to the risk of additional operations later on because of the growth of the other labia due to normal development. Scenario 3: A 50-year-old lady presents with complaints regarding the appearance of her bilateral labia majora and labia minora especially since childbirth and menopause. She feels that her labia minora are excessively large and cause discomfort especially when she cycles.

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Take details of difficulties in conception low testosterone erectile dysfunction treatment extra super avana 260 mg amex, episodes of pelvic infections, endometriosis, cysts, fibroids and surgery. Drug use/misuse, auto-immune, endocrine, neurological, urological and gastrointestinal conditions may be relevant and need recording. For example, long-term antibiotics use predisposes women to yeast infection, which may cause pain. Interestingly, some studies suggest low doses of ethinylestradiol in premenopausal women were more likely to develop vulvodynia. History taking Women rarely present with dyspareunia symptoms alone, it is often an accompanying symptom that has to be raised in closed or direct questioning. If the patient volunteers pain with intercourse as her primary problem, it is a good sign that further information can be obtained. As well as her pain, she may feel embarrassment, guilt, loss of self-esteem, frustration, depression and anxiety. It can be difficult for patients to discuss sexual matters with someone they barely know, so creating an understanding, professional atmosphere during consultation can enhance openness and confidence. She should feel unhurried and at ease, with no more people in the consultation room than necessary. Patients should not be asked straightaway if they are having difficulties with sexual intercourse unless they raise it early on. Once it is established that dyspareunia is a problem, start with more systematic questioning. Be flexible and cover further areas only if the consultation appears to be going well. Have you had pain since the first time you had intercourse or did it develop later on With patients complaining of dyspareunia the clinician must be even more aware of the range of causes and adapt the examination, particularly with patients in whom a psychosexual causation is suspected. An element of prior sexual abuse may accompany the symptomatology, which may make the examination painful for the patient and uninformative for the doctor. It could even damage the professional relationship and so impede management strategies. The patient must be told that the examination is to identify the cause of the pain and may be uncomfortable but can be stopped at any time. This may be difficult to organise but if the patient is made aware of the delays this may cause she may decide to continue.

Diseases

• Acrorenoocular syndrome
• BAER
• Oculocerebral hypopigmentation syndrome type Preus
• Skeleto cardiac syndrome with thrombocytopenia
• Neuroendocrine tumor
• Vitamn B12 responsive methylmalonicaciduria
• Sandhoff disease
• Pentosuria
• M?llerian duct abnormalities galactosemia
• Fetal brain disruption sequence

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In fact erectile dysfunction gene therapy treatment extra super avana 260 mg visa, there is no in vivo or in vitro evidence that endometrial cells in peritoneal fluid can attach or invade peritoneal surfaces. This theory also fails to account for why endometriosis can be found at distant sites, in pre-pubertal girls and in men. However, a similarity has been observed between ectopic endometrial lesions and the basalis layer of uterine endometrium, supporting the possibility of retrograde menstruation providing a route for endometrial stem cells to extrauterine structures. This Coelomic Metaplasia Theory suggests endometriosis develops from metaplastic transformation of cells lining the visceral/abdominal peritoneum into endometrium. The trigger for metaplasia is an undetermined stimulus, potentially hormonal, infectious, or environmental. Proponents of this theory believe spread to distant sites may occur through lymphatic or haematogenous spread, or iatrogenically during surgery. Given the shared embryological origin of pelvic, abdominal and thoracic tissues, this theory offers reasonable explanation for endometriosis. However, ageing tissues also undergo metaplasia, therefore increased incidence of endometriosis should also occur with increasing age. Risk factors and genetics There are several risk factors associated with endometriosis (Box 1). The current trend towards earlier menarche and delayed age of childbirth lead to increased number of ovulations and menstrual cycles; with regular menstrual flows increasing the risk of endometriosis. Endometriosis may vary with ethnicity, with higher prevalence amongst Asian women and lower incidence among African women, when compared to Caucasians. These ethnic variations indicate the significance of genetic and environmental risk factors. This postulates that if the basis of endometriosis is an alteration of genital tract structures during organogenesis, it should be possible to see misplaced endometrial tissue outside the uterine cavity of female human foetuses at autopsy. This 11% correlates well with the reported adult prevalence of endometriosis and the fact that low recurrence rates exist after complete surgical excision of endometriosis. The cervix can also be laterally displaced if there is unilateral uterosacral thickening/shortening. Suspicion of severe disease should be raised if the uterus is immobile or very retroverted. Diagnosis the gold standard the leading investigation to confirm endometriosis is a diagnostic laparoscopy. The operation report should describe the size, macroscopic appearance, location and depth of infiltration for all lesions. Images should be taken to facilitate optimal record keeping, patient education and referral to an endometriosis specialist where required. While endometriosis is considered a histological diagnosis, biopsies are rarely necessary during diagnostic procedures. Surgical experience is key in ensuring a correct diagnosis of endometriosis from visual inspection alone, with reported sensitivity of 94e97% and specificity of 77e85%. If endometriosis is identified, which requires surgical management and has greater operative risk, patients should be fully counselled and re-listed at a later date.

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The reasons why vulvodynia may develop remain unclear erectile dysfunction what is it generic extra super avana 260 mg with visa, but recurrent vulval inflammation may be a factor. Vestibular neuronal proliferation has also been demonstrated in patients with vestibulodynia so it is possible that vulvodynia is a chronic pain syndrome where there are an excess of dysfunctional vulval skin nociceptors. It has long been assumed that inflammatory pain can lead to neuropathic pain, but this has never been proven in vulvodynia. Recent animal studies, however, have confirmed that an allodynia response can be generated in the vulva secondary to repeated attacks of vulvovaginal candidiasis independent of tissue inflammation. After three attacks of treated vulvovaginal candidiasis, 40% of mice tested showed a sustained allodynia response. The vulval skin of mice examined after treatment for vulvovaginal candidiasis demonstrated neuronal proliferation in the absence of inflammation. In humans some studies have shown an increase in the intraepithelial nerve fibre density among women with provoked pain which fits into the inflammatory to neuropathic pain model. The message is clear, early diagnosis and appropriate treatment of vulval symptoms is crucial to prevent both peripheral and central nervous system processes becoming established to produce a chronic pain syndrome. Other more subtle cases are recurrent candidiasis and idiopathic vulval fissuring. Vulval fissuring is either due to a dermatological problem of the skin eg eczema or idiopathic. Idiopathic fissuring is often an overlooked cause of sexual pain and patients can demonstrate quite dramatic splitting at the fourchette after sex. One common mistake is that clinicians give a diagnosis of vulvodynia too early in a consultation with a vulvodynia patient leading to premature discussion of treatments (information giving) without adequate clinical information. This might include questions on the degree, site, radiation and nature of the pain. There are many means of objectively assessing pain levels including asking the patient to score the pain out of 10 and standardised questionnaires (eg Brief Pain Inventory). Patients with sexual pain should have an adequate sexual history taken asking specifically about the presence of vaginal lubrication, vaginismus and sexual avoidance. Not infrequently vulvodynia can lead to secondary psychosexual problems such as avoidance, phobia of touch, loss of libido and vaginismus (see below). Recognition of this as the main problem for the patient is crucial so that treatment can focus on sexual rehabilitation either through self-management (increasing communication with partners, use of lubricant and vaginal dilators) or with a psychosexual counsellor. The differential diagnosis of vulval pain There is a wide differential diagnosis of women presenting with vulval pain. With the exception of vulvodynia, the majority of conditions listed in Table 1 present with a clinically obvious lesion.

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Opportunities for questions should also be given and comprehensive patient information leaflets provided erectile dysfunction at the age of 21 buy 260 mg extra super avana. Female sterilization may be performed via the hysteroscopic or laparoscopic routes. The mechanism of action is to irreversibly occlude the fallopian tubes to prevent fertilization occurring. A pregnancy test will only be reliably negative 3 weeks after any episode of unprotected sex so encouraging a reliable form of contraception before the procedure is essential. Sterilization in the follicular phase of a normal menstrual cycle reduces the risk of an undetected implanted pregnancy occurring prior to or just after the procedure. Although the risks of the operation are small, women need to be fully informed to obtain valid consent. Minor complications include infection and/or bruising to the small skin wounds, shoulder tip pain, laceration to the cervix and uterine perforation (from the uterine manipulator). Anaesthetic risk should be mentioned and the overall risk of death from laparoscopic sterilization is 3e8 per 100,000. At the time of consent they should be informed that the lifetime failure rate of sterilization is 1 in 200, which is lower than some reversible alternatives. Female sterilization is more popular than vasectomy despite the higher rate of operative complications and failure. In fact vasectomy has now overtaken female sterilization in popularity with 16% of males between ages of 16 and 45 being sterilized compared with 8% of females (2009 figures). Sterilization can be undertaken at caesarean section, at termination of pregnancy or as an elective procedure. Female sterilization using culdoscopy via the vaginal route is no longer a recommended technique due to an increased risk of infection. After introducing the laparoscope through the umbilical port and checking for injuries, a second port is inserted suprapubically under direct vision. Diathermy to the tubes is discouraged due to the increased risks of bowel injury (either direct or indirect thermal injury) and ectopic pregnancy. After occlusion, topical local anaesthetic should be applied to the fallopian tubes via the laparoscope to reduce post-operative pain secondary to necrosis of the tube. The ports should then be withdrawn under direct vision, checking for haemostasis and re-checking for injuries. If sterilization is performed via mini-laparotomy or at the time of caesarean section, surgical occlusive methods are usually preferred. The Pomeroy technique involves tying the base of a loop of tube and then excising the loop e the ends of the tubes then pull apart as the sutures absorb. This technique can be modified by separating a small section of the tube and ligating the ends. Women should be advised to have someone with them for the following 24 hours and then can usually return to work after 3e7 days.

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Conditions such as von Willebrand disease and immune thrombocytopenic purpura should be excluded in any girl with severe menorrhagia refractory to simple treatments erectile dysfunction hormonal causes purchase extra super avana 260 mg with amex. Abstract Adolescent gynaecology is increasingly recognized as an area in which specific knowledge and expertise is required to ensure that patients achieve the best outcome. Gynaecological problems in adolescents are common, and although serious pathology is rare, distress and discomfort can be significant. Adolescent girls are under greater pressure than ever before, particularly in terms of examination performance; they find menstrual dysfunction particularly difficult to manage. Careful and sympathetic assessment is crucial, and simple treatment remedies may be all that is required. However, complex and rare medical conditions can also occur and must not be missed. Early detection and appropriate treatment will ensure the best possible outcomes in terms of sexual function and potential fertility. Treatment Approximately one in 10 adolescent girls, requires some form of treatment for heavy periods. Cyclical progesterone is the most widely used regime, although its efficacy is poorly established. In order to be effective, progesterone does need to be given for a full 21 days each month rather than just during the luteal phase as has traditionally been prescribed. The administration of luteal phase progesterone will make the cycle regular but can make periods heavier. Norethisterone is the most potent of progestogens and as such provides the best cycle control. However, it is also the most androgenic and side-effects such as acne and hirsutism may deter continuing treatment. A combination of cyclical progesterone and a prostaglandin synthetase inhibitor such as mefenamic acid is frequently recommended and seems to be effective. It has been demonstrated objectively to reduce blood loss and is safe if used within current guidelines in girls in whom there are no contraindicating factors. However, there is no evidence that recommending the combined oral contraceptive for menstrual dysfunction brings forward the sexual debut. There is also no evidence that the combined oral contraceptive interferes with sexual development or affects final height and can therefore be safely prescribed in a menstruating adolescent. This may be due to an underlying medical problem, for example systemic lupus erythematosus or a personal or close family history of venous thromboembolism.

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The studies that have been carried out that include pregnancy as an endpoint suggest that there may be an increase in the likelihood of pre-term delivery erectile dysfunction causes cancer buy discount extra super avana on line, miscarriage, abnormal placentation and postpartum haemorrhage and that these complications occur more frequently than after myomectomy. In addition, the problem with the trials is that sub-fertility often has a multiple causes and many women included are over 35 years of age when fertility tends to decrease naturally. Many women who have uterine fibroids do conceive and it is unclear as to how much impact the position of the fibroids has on outcome as mentioned above. Progesterone receptor modulators also act very quickly and bleeding is lessened within the first week of use. Endometrial effects the progesterone receptor modulators induce an unusual appearance of the endometrium. It is associated with an endometrial antiproliferative effect in non-human primates in the presence of follicular phase oestradiol levels. Hyperplasia does not appear to occur with short term use in spite of follicular phase oestrogen levels. Endometrial morphology is described in a way that differs from the normal menstrual cycle. There are profound changes and this may be associated with the efficacy since blood vessels appear to be thickened rather than thin walled and friable as occurs with progestagens when administered alone. Currently it limits the use to the short term as it is possible that, like oestrogen, the development of abnormal changes increases with duration of use. Development of asoprisnil was suspended for this reason although that of ulipristal is ongoing. Fibroid size Progesterone receptor modulators have a modest effect on size with a decrease of up to 26%. This means it is unlikely to be effective where fibroid size is the principal presenting complaint. Assessment of symptoms associated with fibroids reveals that progesterone receptor modulators are effective and the improvement in the menstrual problems is associated with improved quality of life. Clinical trials have recently been reported and given widespread publicity and it is likely their use will increase. When developed further, ulipristal and others like it are likely to be very popular agents for use by women who wish to have conservative treatment for their uterine fibroids. Levonorgestrel secreting intrauterine system this is a very effective method of treating heavy menstrual bleeding in women with a normal uterine cavity or where there are small fibroids. Evidence suggests that it is unlikely to be of value with those who have an enlarged uterus and is often expelled during the menses. It has little or no impact on fibroid size and works by making the endometrium very thin.

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In pregnancy a modified perioperative approach is required due to increased risk of potential surgical and anaesthetic complications secondary to physiological maternal adaptations erectile dysfunction prescription medications generic 260 mg extra super avana mastercard. These changes include increased swelling of the upper airways, reduced gastric emptying, gastroesophageal sphincter relaxation, tidal volume increase, reduced blood pressure due to uterine compression of the inferior vena cava, and an increased thrombotic tendency. Preoperative thromboprophylaxis, hydration and gastro-oesophageal reflux prophylaxis (H2 antagonists) are recommended to reduce complications. Maternal surgical complications in pregnancy include miscarriage, anaesthetic risks. When the surgical procedure involves removal of the corpus luteum before 7e9 weeks of gestation, progesterone supplementation is recommended to reduce the miscarriage risk. Laparotomy has been the mainstay of surgical treatment for ovarian masses in pregnancy. A midline skin incision is recommended to facilitate exposure due to presence of the gravid uterus. The decision to perform cystectomy or oophorectomy is based on the size of the cyst, the degree of suspicion of malignancy, vascular compromise and the appearance of the contra-lateral ovary. Salpingo-oophorectomy is the procedure most commonly performed in such cases, although de-torsion of the ovary, cystectomy and adnexal fixation could be considered in carefully selected cases. However, concerns include uterine trauma during the insertion of Verres needle or trocars, decrease in the uterine blood flow due to raised intra-abdominal pressure and absorption of carbon dioxide by the fetus. Laparoscopic procedures performed using an open entry technique and port site placement under direct vision can theoretically reduce the risk of injury to the gravid uterus and are recommended. Women diagnosed with cysts during pregnancy should have antenatal discussion about potential management if a caesarean section is performed for obstetric reasons. In this case, emergency surgery was indicated as the clinical presentation with sudden onset of pain with associated nausea and vomiting was highly suspicious of ovarian torsion. The risk of surgery had to be balanced against the risk of delaying surgery: conservative management could have resulted in ovarian infarction, haemorrhage or peritonitis, which may have lead to an increased morbidity and miscarriage rate. Case 3 A 35-year-old woman was referred to the emergency gynaecology service complaining of lower abdominal pain. Her past medical history was unremarkable and she reported no previous sexually transmitted infections or pelvic inflammatory disease. Examination revealed mild tenderness and a palpable mass in the lower abdomen but no signs of peritonism. The patient was treated with broad-spectrum antibiotics for suspected pelvic infection.

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Prophylactic ureteric stenting should be considered if difficult dissection is anticipated erectile dysfunction treatment fort lauderdale extra super avana 260 mg low price, which can aid ureteric identification in addition to allowing conservative management of minor ureteric injuries. Surgical techniques and equipment Laparoscopic procedures the use of minimal access procedures has expanded and is now common in the surgical management of benign and malignant disease. With improving laparoscopic equipment and surgical skill, intra-operative complication rates should be minimized. The use of electrocoagulation and laser vaporization can also lead to unintended thermal damage, which may present as a delayed injury. Laparoscopic complications are usually related to abdominal entry, when damage to major blood vessels, bowel and omentum can occur. The ideal entry point is at the umbilicus, where the aponeurosis is adherent to the peritoneum. This is also the ideal site to introduce the primary trochar in the majority of patients, unless significant adhesions from previous surgery are anticipated or the patient is markedly obese or very thin. Trendelenberg position is best avoided when introducing the pneumoperitoneum and during primary trochar insertion, as it distorts the insertion angle, increases the risk of vascular injury and can move the bowel up and out of the pelvis towards the umbilicus. Pelvic vessels are most at risk from insertion of secondary ports, although direct visualization to control entry helps reduce this. The inferior epigastric vessels are most at risk with insertion of lateral ports and these vessels should be visualized with the laparoscope before they are sited. If vessel damage occurs they may bleed during the procedure and limit visualization, in addition to generating significant blood loss, which can be easily underestimated. The port cannula may also tamponade the vessels so that bleeding occurs only after its removal. Port sites should therefore be inspected after gas release and instrument removal, to check for delayed bleeding at the end of the procedure. The final port should be removed with the laparoscope still in place, after release of the pneumoperitoneum, to prevent bowel loops or omentum herniating into the wound. Endoscopic devices Both minimal access and open surgery has been enhanced by the use of increasingly sophisticated devices. Some of these are being superseded by energy devices using a variety of strategies. Simple monopolar diathermy has an inherent risk of complications at the point of use due to relatively wide thermal spread as the tissues surrounding the application site are in circuit. Also the phenomenon of arcing can occur to surrounding tissues and to unshielded instruments the patient population also has an increasing likelihood of having an indwelling electronic device such as pacemakers and nerve stimulators which may be affected by this. Bipolar devices such as scissors and forceps are safer and more precise but can still cause thermal injury if used injudiciously. The use of "intelligent" electrocautery sealing and cutting devices with minimal thermal spread makes more precise and bloodless surgery possible.

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It was later abandoned due to the associated morbidity and recurrence of symptoms erectile dysfunction 50 years old cheap 260 mg extra super avana free shipping. A large clinical series has reported significant improvement in most of their patients with symptomatic relief lasting for about 23 months. The standardisation of terminology of lower urinary tract function: report from the standardisation sub-committee of the international continence society. Diagnostic criteria, classification, and nomenclature of painful bladder syndrome/interstitial cystitis: an essic proposal. Long term outcome of patients with interstitial cystitis treated with low dose cyclosporine A. Bladder surface glycosaminoglycan: efficient mechanism of environmental adaptation. Long term efficacy and tolerability of pentosan polysulfate sodium in the treatment of painful bladder syndrome. Its aetiology and pathogenesis is largely unknown although mast cells and destruction of the glycosaminoglycan layer in the bladder are thought to play an essential role. Symptoms of a vaginal bulge or protrusion, pelvic heaviness, bladder, bowel and sexual dysfunction are often associated with the problem. Conservative approaches to the treatment of prolapse are often used in cases of mild to moderate prolapse; for those who wish to have more children; the frail or those unwilling to undergo surgery; and those awaiting surgery. This article describes the conservative methods available to women presenting with pelvic organ prolapse including lifestyle advice, pelvic floor muscle training and vaginal pessaries. Lifestyle advice Lifestyle interventions include weight loss, reducing exacerbating activities. These interventions seek to avoid exacerbation of the prolapse by decreasing intra-abdominal pressure. Effectiveness of lifestyle advice the extent to which any of these lifestyle changes are effective in managing prolapse is unknown as there have been few randomised controlled trials of lifestyle interventions in this population. One randomised controlled trial has compared a weight loss programme with a control group receiving an educational programme in overweight and obese women with urinary incontinence and found no difference in prolapse symptom bother between groups after six months. Further trials in women where prolapse is their main presenting problem are however needed to evaluate this hypothesis further. Studies have also reported an association between constipation and symptoms of prolapse but there is no evidence to support a causal relationship: prolapse, particularly prolapse of the posterior vaginal wall, may lead to problems with evacuation, but conversely constipation can cause straining which contributes to the development of prolapse. This lack of correlation between the presence (or extent) of prolapse symptoms and the anatomical severity has been noted by several authors in the literature. For example, some women with prolapse extending beyond the hymen may report no symptoms, whilst others with mild prolapse have very bothersome symptoms. This highlights the importance of recording Keywords conservative management; lifestyle advice; pelvic floor muscle training; pelvic organ prolapse; pessary Introduction Pelvic organ prolapse is a common female condition. Conservative treatment is generally considered for women with a mild degree of prolapse, those who wish to have more children, the frail or those unwilling to undergo surgery. Conservative approaches can also be used prior to surgery, for example as an adjunct, or as an interim measure.

Fraser, 46 years: Corticosteroids have also been shown to reduce bowel obstruction in patients with advanced ovarian cancer and have a low rate of adverse effects. However, of the few underpowered studies conducted only one has shown benefit and better data are needed. Pseudoprecocious puberty can occur with McCuneeAlbright syndrome, in which an isolated ovarian functional cyst is associated with skin pigmentation and polyostotic fibrous dysplasia. They have an important role in picking up ova and transporting ova, sperms, and the embryos.

Hernando, 29 years: Opportunities for questions should also be given and comprehensive patient information leaflets provided. While it has been shown that hysterectomy is a clinically highly effective intervention in terms of cure and improvement in quality of life, its cost, with regard to both the method/route as well as alternative treatments, has to be considered. Transverse incisions are better cosmetically, less painful and indeed may be 30 times stronger than midline incisions. In addition it can cause mild gastrointestinal disturbances, dry skin and decreased libido.

Jack, 27 years: A diagnostic laparoscopy was performed due to the clinical suspicion of ovarian cyst torsion. A continuous running balance between the inflow and outflow should be maintained during the surgery. Once again a full assessment should be undertaken including full history, examination and investigations including biochemical profile and imaging if intestinal obstruction is suspected. Salpingo-oophorectomy is the procedure most commonly performed in such cases, although de-torsion of the ovary, cystectomy and adnexal fixation could be considered in carefully selected cases.

Kulak, 42 years: Dyspareunia was less frequent following sacrocolpopexy (16%) compared with sacrospinous fixation (36%). The uterus is emptied using a plastic suction cannula and blunt surgical instruments. Most vulval malignant melanoma arise in the clitoris (31%) and labia majora (27%). It is unclear how this information would alter prognosis and whether it can guide the use of adjuvant therapies.

Marik, 60 years: Hemorrhage from the mucosa of the renal pelvis may be produced by its sharp edges and blood may cover the stone making it to appear black. Potential complications include post-operative voiding dysfunction caused by autonomic nerve damage. The distribution and end result of this plexitis is variable and may be modified by the host response or the etiologic stimulus. The defence argued that even if the surgeon had failed to warn the patient of the risk of cauda equina syndrome, there was no evidence that, had she been given this warning, Miss Chester would never have had the operation.