Fitsari 'dan Duniya. An African (Hausa) praise song about vesicovaginal fistulas

The vesicovaginal fistula from prolonged obstructed labor is a condition that is no longer seen in the affluent, industrialized world, yet it continues to exist in epidemic proportions in sub-Saharan Africa, where several million women are estimated to suffer from this condition. The unremitting urinary incontinence that is produced by a fistula causes these women to become social outcasts. The problem is particularly acute in Nigeria, where the Federal Ministry of Women's Affairs estimates that there may be as many as 800,000 unrepaired fistula cases. Because of the social stigma attached to their condition, fistula victims have often been subjected to major psychosocial trauma. Finding ways to help such patients reintegrate into social networks is an important part of their treatment. When fistula patients meet one another, they realize that they are not alone in their suffering. This article describes the use of a "praise song" by a group of Nigerian fistula patients as a vehicle for building group identity as part of a "sisterhood of suffering." A transcription and translation of a Hausa praise song about vesicovaginal fistulas is presented, along with a commentary on the text that sheds new light on a problem that is unfamiliar to most Western obstetrician-gynecologists.

Thomas Addis Emmet, the vesicovaginal fistula, and the origins of reconstructive gynecologic surgery

Thomas Addis Emmet (1828-1919), the foremost pupil of J. Marion Sims and his successor as chief surgeon at The Woman's Hospital in New York City, was probably the pre-eminent American gynecological surgeon of the last quarter of the 19th century. Among his many achievements were the first critical study of vescovaginal fistula repair, authorship of the first modern scientific textbook of gynecology, the invention of numerous special surgical instruments, pioneering the use of surgical scissors in vaginal operations, and the development of "staged" procedures for surgical reconstruction of the vagina. He was an active writer, a renowned collector of American historical documents and memorabilia, a devout Catholic and a steadfast Irish patriot. This article reviews his life and contributions to gynecologic surgery.

Pharmaceutical sales representatives and the doctor/patient relationship

As marketing efforts by drug companies become more aggressive, physicians are being asked to provide clinical "preceptorships" to pharmaceutical sales representatives. During a "preceptorship" of this type, the company representative spends a day with the physician seeing patients "as an educational experience," and the physician receives an "honorarium" from the drug company in return. We explore the implications of this practice. First, we examine the nature of the doctor/patient relationship and the fiduciary obligations incumbent upon physicians in their role as healers. Second, we examine four interlocking ethical principles-nonmaleficence, beneficence, respect for patient autonomy, and justice-that should govern doctor/patient encounters. Third, we critique several hypothetical scenarios involving individuals who might put forth a claim to enter the doctor/patient relationship (ie, a pharmacist, a social scientist, the husband of the patient, and a pharmaceutical sales representative). We conclude that the practice of providing clinical "preceptorships" to pharmaceutical sales representatives is unjustifiable, is unethical, and should not be permitted.

Urinary incontinence in pregnancy and the puerperium: a prospective study

OBJECTIVE

Pregnancy and childbirth are commonly thought to be associated with the development of urinary incontinence and lower urinary tract symptoms. The purpose of this study was to assess the relationship, if any, between pregnancy and the development of lower urinary tract symptoms.

STUDY DESIGN

A prospective study of lower urinary tract symptoms was carried out in a cohort of pregnant women who answered a series of symptom questionnaires and kept a 24-hour bladder chart on which frequency of urination and volumes voided were recorded throughout pregnancy and for 8 weeks after birth.

RESULTS

A total of 123 women participated in the study. Mean daily urine output (P =.01) and the mean number of voids per day (P =.01) increased with gestational age and declined after delivery. Episodes of urinary incontinence peaked in the third trimester and improved after birth (P =.001). White women had higher mean voided volumes and fewer voiding episodes than did black women. Ingestion of caffeine was associated with smaller voided volumes and greater frequency of urination.

CONCLUSION

Pregnancy is associated with an increase in urinary incontinence. This phenomenon decreases in the puerperium. Pregnancy and childbirth trauma are important factors in the development of urinary incontinence among women. These findings warrant further investigation.

Birth trauma and the pelvic floor: lessons from the developing world

Urinary incontinence, fecal incontinence, and pelvic organ prolapse are common stigmatizing conditions that afflict women far more often than they afflict men. It has been suggested that childbirth is the most likely factor to explain this great epidemiologic discrepancy between the sexes. Because the widespread availability of high-quality obstetric care through-out the industrialized world has led to precipitous drops in maternal mortality during the 20th century, many of the pathophysiologic mechanisms by which such injuries might arise are not as obvious as they were in times past. It is suggested that by looking at obstetric complications in the developing world, where the natural history of unrelieved obstructed labor is most obvious, it may be possible to shed new light on the pathophysiology of childbirth injury and its relationship to incontinence and prolapse. The spectrum of childbirth injuries resulting from obstructed labor in developing countries is surveyed, and the potential relevance of these findings to the more subtle forms of pelvic floor dysfunction seen in Western women is discussed.

Dead mothers and injured wives: the social context of maternal morbidity and mortality among the Hausa of northern Nigeria

Northern Nigeria has a maternal mortality ratio greater than 1,000 maternal deaths per 100,000 live births. Serious maternal morbidity (for example, vesico-vaginal fistula) is also common. Among the most important factors contributing to this tragic situation are: an Islamic culture that undervalues women; a perceived social need for women's reproductive capacities to be under strict male control; the practice of purdah (wife seclusion), which restricts women's access to medical care; almost universal female illiteracy; marriage at an early age and pregnancy often occurring before maternal pelvic growth is complete; a high rate of obstructed labor; directly harmful traditional medical beliefs and practices; inadequate facilities to deal with obstetric emergencies; a deteriorating economy; and a political culture marked by rampant corruption and inefficiency. The convergence of all of these factors has resulted in one of the worst records of female reproductive health existing anywhere in the world.

Stress incontinence diagnosed without multichannel urodynamic studies

OBJECTIVE

To determine if the clinical diagnosis of stress urinary incontinence made on the basis of simple criteria correlates with the diagnosis of genuine stress incontinence as determined by provocative multichannel urodynamic testing.

METHODS

The charts of 652 women who presented for clinical evaluation of a variety of lower urinary tract complaints were reviewed if they met all of the following criteria: 1) a predominant complaint of stress incontinence, 2) positive cough stress-test results, 3) postvoid residual urine volume no more than 50 mL, 4) a functional bladder capacity of at least 400 mL as determined by a completed 24-hour frequency-volume chart, and 5) a full multichannel urodynamic evaluation. Seventy-four patients met all these criteria. The clinical diagnosis of stress incontinence was based on the presence of factors 1-4; this diagnosis then was compared with the results of provocative multichannel urodynamic testing.

RESULTS

Genuine stress incontinence was confirmed in 72 (97%) of 74 patients meeting the aforementioned clinical criteria. In one patient, detrusor instability alone was demonstrated during urodynamic testing. In 11 patients with genuine stress incontinence (15%), an element of detrusor instability was also present at the time of urodynamic testing. One patient had normal urodynamic study findings, with no incontinence demonstrated.

CONCLUSION

Rigorously defined clinical criteria are highly reliable in predicting the presence of genuine stress incontinence at the time of urodynamic testing. Because of the potential implications of this finding for clinical practice, further investigation is warranted.

Stress urinary incontinence due to prescription medications: alpha-blockers and angiotensin converting enzyme inhibitors

BACKGROUND

Several antihypertensive medications affect lower urinary tract function and may cause urinary incontinence.

CASE

A 59-year-old woman on doxazosin mesylate for control of her hypertension presented with stress urinary incontinence. Because this drug is known to cause loss of urethral tone leading to stress incontinence in some patients, she was switched to enalapril maleate, an angiotensin converting enzyme inhibitor. Her incontinence improved on the new medication, but she developed a persistent dry cough that continued to cause episodic stress incontinence. Because a persistent cough is a known side effect of angiotensin converting enzyme inhibitors, her medication was changed to a calcium channel blocker, amlodipine besylate. Her cough resolved, and her stress incontinence was no longer a clinical problem.

CONCLUSION

Gynecologists should be aware of the unexpected side effects of medications on the lower urinary tract.

Intraligamentous nerves as a potential source of pain after sacrospinous ligament fixation of the vaginal apex

The aim of the study was to investigate the histology of the sacrospinous ligament to determine whether nerve fibers exist within the substance of the sacropinous ligament itself. Six sacrospinous ligaments were removed from 4 fixed female cadavers. Representative segments were taken from the lateral (ischial), middle and medial (sacral) portions of these specimens, sectioned by microtome, mounted, and stained with hematoxylin and eosin dyes. The fixed and stained sections were then examined using light microscopy. Nerve tissue was found to be concentrated in the medial portions of the sacrospinous ligaments, but nerves were found in all segments of the ligament. It was concluded that, nervous tissue is present and widely distributed within the body of the sacrospinous ligament. A wide variety of sizes and thicknesses are also demonstrated, suggesting a variety of functions, including possible pain reception. This fact should be taken into consideration when planning operative procedures for pelvic prolapse.

Use of a pedicled rectus abdominis muscle flap sling in the treatment of complicated stress urinary incontinence

OBJECTIVE

A pedicled rectus muscle flap sling in the treatment of complicated stress urinary incontinence was evaluated.

STUDY DESIGN

Thirty-two women underwent a combined vaginal and abdominal sling operation for stress incontinence with a pedicled muscle flap developed from the rectus abdominis muscle. All operations were performed jointly by the same two surgeons. The procedure involved transecting one rectus abdominis muscle just above its first tendinous intersection and isolating the muscle as a flap on its inferior vascular pedicle. The muscle flap was then swung beneath the urethra and bladder neck, pulled into the retropubic space on the contralateral side, and sewn to the obturator internus fascia or to Cooper's ligament. All patients undergoing the procedure had demonstrable stress incontinence on physical examination and underwent preoperative fluoroscopic video urodynamics. The diagnosis of complicated stress incontinence was based on the presence of one or more of the following factors: previous failed antiincontinence surgery (33 operations in 22 patients, average 1.5 operations), open vesical neck on fluoroscopy (14 patients), urethral closure pressure < or = 30 cm H2O by the Brown-Wickham technique (16 patients), or massive vaginal prolapse and demonstrable stress incontinence with the prolapse reduced and the urethra supported in a normal position (16 patients). Follow-up ranged from 2 to 13 months (average 6 months). Surgical outcome was assessed by physical examination and a detailed telephone interview conducted by a physician who was not involved in the operations.

RESULTS

Twenty-eight patients (87.5%) were satisfied with the results of the operation. There were four surgical failures (12.5%). Stress incontinence persisted in three patients after surgery, and one patient who had mixed incontinence before surgery was cured of stress incontinence but continued to have significant urinary leakage as a result of detrusor overactivity. There appears to be less voiding dysfunction with this technique than with other sling procedures for stress incontinence.

CONCLUSIONS

The sling procedure with a rectus abdominis muscle flap appears to be a viable surgical technique in the treatment of complicated stress incontinence. Further study is needed to assess the long-term results of this operation and to evaluate its proper place in reconstructive pelvic surgery.

Ritual meaning in surgery

The term "ritual" is used in medicine primarily in a negative way. In a surgical context, it is usually used to refer to slavish, unthinking devotion to technique or method, or to unnecessary surgical procedures that have outlived their usefulness. But there is another aspect of ritual that has received far too little attention from medical writers: ritual in its anthropologic sense as a form of stylized behavior that serves as a vehicle for the transmission of meaning. Because a surgical operation is a structured process that takes place within a given social context, it can be analyzed as a "rite of passage" that helps move the patient from "illness" to "health." Understanding the ritual aspects of surgical operations can help deepen the doctor-patient relationship and improve the quality of care given to surgical patients.

Obstructed labor injury complex: obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world

Prolonged obstructed labor may produce injuries to multiple organ systems. The best known, and most common, of these injuries is obstetric fistula formation. When obstructed labor is unrelieved, the presenting fetal part is impacted against the soft tissues of the pelvis and a widespread ischemic vascular injury develops that results in tissue necrosis and subsequent fistula formation. Unlike the postsurgical vesicovaginal fistula, however, which is usually the result of focal trauma to otherwise healthy tissues, the obstetric fistula is the result of a "field injury" to a broad area. The field injury that is produced by prolonged obstructed labor may result in multiple birth-related injuries in addition to (or instead of) a vesicovaginal fistula. Focusing simply on the "hole" between the bladder and the vagina ignores the multifaceted nature of the injury that many of these patients have sustained. These injuries may include total urethral loss, stress incontinence, hydroureteronephrosis, renal failure, rectovaginal fistula formation, rectal atresia, anal sphincter incompetence, cervical destruction, amenorrhea, pelvic inflammatory disease, secondary infertility, vaginal stenosis, osteitis pubis, and foot-drop. In addition to their physical injuries, women who have experienced prolonged obstructed labor often develop serious social problems, including divorce, exclusion from religious activities, separation from their families, worsening poverty, malnutrition, and almost unendurable suffering. Isolated almost exclusively to the developing world, particularly Africa, this problem has not received the international attention that it deserves, from either a medical or a social standpoint.

The epidemiology of genitourinary fistulae in Kumasi, Ghana, 1977-1992

The aim of the study was to determine the clinical epidemiology of genitourinary fistulae as seen at Komfo Anokye Teaching Hospital in Kumasi, Ghana. A retrospective study was carried out from the hospital records and operative reports of all patients with genitourinary fistulae seen at Komfo Anokye Teaching Hospital between January 1977 and December 1992. Patient age, parity, type of fistula and cause of fistula were abstracted from the medical records. There were 164 cases of genitourinary fistula managed during the study period. There were 150 fistulae due to obstetric causes (91, 5%), the vast majority of which were due to prolonged obstructed labor (121 cases, 73.8% of all fistulae), with a minority related to complications of lower-segment cesarean section (14 cases, 8.5% of all fistulae). In 5 cases (3.1%) patients developed a rectovaginal fistula owing to perineal tears and prolonged obstructed labor. During this time period there were 157,449 deliveries, giving an obstetric fistula rate of 1 fistula per 1000 deliveries. Obstetric fistulae were most common at the extremes of reproductive age and parity Fourteen additional fistulae (8.5% of all cases) were due to gynecologic causes, most commonly from surgical injury occurring at the time of abdominal hysterectomy for leiomyomata uteri (12 cases, 7.3% of all fistulae). It was concluded that in Kumasi, Ghana, obstetric trauma from prolonged obstructed labor is the most common cause of genitourinary fistula formation. Such fistulae occur in older multiparous women as well in young primigravidae. Obstructed labour can, and does, occur in women who have previously undergone uneventful vaginal delivery. Birth attendants should be aware of that fact. Prompt referral for obstetric intervention should be made in obstructed labor, irrespective of the age and parity of the patient.

Voiding function after Burch colposuspension for stress incontinence

OBJECTIVE

To evaluate changes in voiding function before and after Burch colposuspension for genuine stress incontinence.

STUDY DESIGN

Full urodynamic evaluations were performed before and three months after surgery on 21 patients undergoing Burch colposuspension for genuine stress incontinence. Sixteen patients underwent the Burch procedure alone and five underwent an abdominal sacral colpopexy for vaginal vault prolapse in addition to the Burch procedure. The preoperative and postoperative urodynamic studies were compared with each other to see what changes in voiding function had occurred as the result of surgery.

RESULTS

Statistical analysis of the differences between the preoperative, and postoperative urodynamic studies using blocked analysis of variance showed dramatic decreases in both instrumented and noninstrumented peak and mean urine flow rates and an increase in detrusor pressure at peak urinary flow during voiding. A substantial but not statistically significant increase in mean residual urine was found after surgery in patients who underwent the Burch procedure alone. There were no statistically significant differences in these parameters in patients undergoing the Burch procedure combined with abdominal sacral colpopexy. Using the criteria of a flow rate of < 12 mL/sec in association with a voiding detrusor pressure > 50 cm H2O, five patients undergoing the Burch procedure alone had evidence of postoperative outflow obstruction. Three women with complete vaginal vault prolapse had functional outlet obstruction before surgery, and another three women had postoperative outlet obstruction following the combined Burch procedure and sacral colpopexy.

CONCLUSIONS

Burch colposuspension produced significant changes in postoperative voiding function three months after surgery, and outflow obstruction induced by surgery appeared to be a significant potential complication. Renewed attention should be devoted to the development of durable but nonobstructive operations for the surgical cure of genuine stress incontinence.

Are vaginal and rectal pressures equivalent approximations of one another for the purpose of performing subtracted cystometry?

OBJECTIVE

To determine if rectal and vaginal pressures are clinically equivalent to one another for the purpose of calculating subtracted detrusor pressure during routine filling cystometry and pressure-flow voiding studies.

METHODS

A total of 140 consecutive filling and voiding cystometrograms were performed at separate sessions on 127 female patients undergoing routine clinical cystometry for a variety of clinical indications, usually urinary incontinence. In all cases, intravaginal as well as intrarectal pressures were measured simultaneously using microtip transducer pressure catheters, and two subtracted detrusor pressures were calculated throughout each study. Rectal and vaginal pressure measurements from the same patient were compared with the patient in the supine position with an empty bladder, in the erect position with a full bladder, and in the sitting position during voiding at the point of maximum urinary flow.

RESULTS

The mean pressures were similar in all cases. Although there was no statistical difference in the mean differences between the rectal and vaginal pressures in the supine-empty position (P = .5528), significant differences were noted between them in the erect-full and sitting-voiding positions (P = .0016 and P = .0033, respectively). Linear regression analysis of the data obtained in each position was carried out, plotting vaginal pressure on the x axis and rectal pressure on the y axis. The corresponding r values for each position were 0.431 for the supine-empty position, 0.547 for the erect-full position, and 0.478 for the sitting-voiding position, indicating poor correlation between pressures in individual patients. In nine patients (6.5%) with significant vaginal relaxation and large cystoceles, a steady rise in vaginal pressure was noted during bladder filling. In six patients (4.4%), one or more spontaneous vaginal contractions were noted during the course of the study, whereas in 68 (48.9%), spontaneous rectal contractions were present. Of the 68 cases where spontaneous rectal contractions were noted, these contractions faded away in 53 cases (77.9%) as the study progressed.

CONCLUSIONS

Rectal pressure and vaginal pressure are not the same during filling and voiding cystometry. Although they are reasonable approximations of each other for most qualitative clinical diagnostic purposes, potentially significant differences in subtracted detrusor pressure may occur, depending on which pressure is used as the approximation of intra-abdominal pressure. This may affect clinical management decisions in individual patients. The technique used for approximating abdominal pressure must be stated clearly in any report or publication dealing with subtracted cystometry.

Simple bladder filling with a cough stress test compared with subtracted cystometry for the diagnosis of urinary incontinence

OBJECTIVE

Our purpose was to compare the diagnostic efficacy of observing urine loss during simple bladder filling (without pressure measurement) and a cough stress test, with multichannel subtracted cystometry.

STUDY DESIGN

The urodynamic records of 77 women complaining of urinary incontinence were reviewed. All women had undergone a full evaluation that included a standardized history and physical examination, urinalysis and urine culture, uroflowmetry with measurement of postvoid residual urine, a cough stress test performed during and after simple retrograde bladder filling, and multichannel subtracted cystometry. The results of simple bladder filling and the cough stress test were recorded as "urge incontinence," "stress incontinence,"mixed incontinence," or "incontinence not demonstrated." The subtracted cystometrogram was then performed, and the urodynamic diagnoses were recorded as "detrusor instability," "genuine stress incontinence," "mixed incontinence," or "incontinence not demonstrated." The records were reviewed, and the results of simple bladder filling with a cough stress test were compared with those obtained by subtracted multichannel provocative cystometry.

RESULTS

With the subtracted multichannel cystometrogram used as the "gold standard" for diagnosis, the demonstration of "urge incontinence" during simple bladder filling had a sensitivity of 64% and a specificity of 86.8% for the demonstration of detrusor instability during cystometry, with a positive predictive value of 83.3% and a negative predictive value of 70.2%. The demonstration of "stress incontinence" during simple bladder filling had a sensitivity of 88.1% and a specificity of 77.1% for the demonstration of "genuine" stress incontinence during cystometry, with a positive predictive value of 82% and a negative predictive value of 84.4%.

CONCLUSIONS

The demonstration of urge incontinence during simple bladder filling is a reliable predictor of detrusor instability, but its absence is less reliable in excluding detrusor overactivity as a cause of urinary incontinence. Similarly, the clinical demonstration of stress incontinence during simple bladder filling is predictive of the presence of "genuine" stress incontinence during subtracted multichannel provocative cystometry. The inability to demonstrate stress incontinence during simple bladder filling is highly correlated with the absence of "genuine" stress incontinence during complex urodynamic testing. Simple bladder filling is a reliable method of diagnosing urinary incontinence. In many cases it can replace complex urodynamic testing, particularly if the proposed treatment for the condition carries a low level of risk, and is helpful in selecting patients who need more extensive evaluation.

Clinical features of urinary incontinence and urogenital prolapse in a black inner-city population

OBJECTIVE

Our purpose was to describe the clinical features and urodynamic findings of a black female inner-city population with urinary incontinence and uterovaginal prolapse.

STUDY DESIGN

A retrospective review of the urogynecoloy records of 159 black female patients was performed.

RESULTS

Genital prolapse was common. A cystocele was identified in 116 patients, a rectocele in 88 patients, and uterine or vaginal vault prolapse in 41 patients. Subtracted multichannel cystometry revealed detrusor overactivity in 58 patients, genuine stress incontinence in 44 patients, and mixed incontinence in 30 patients. Sixteen patients had normal urodynamic studies. The presence of a cystocele and the physical sign of stress incontinence at initial examination were found equally in patients with genuine stress incontinence, detrusor instability, and mixed incontinence at cystometry. There was no correlation between other commonly associated clinical factors (such as age, parity, and obesity) and the urodynamic diagnosis.

CONCLUSIONS

Many of the factors commonly assumed to predispose women to the development of incontinence and prolapse may not apply to the black inner-city population. Urodynamic testing to establish the correct diagnosis is required, because the correlation between symptoms, physical examination, and urodynamic findings is relatively poor in this population.

Randomized double-blind trial of terodiline in the treatment of urge incontinence in women

OBJECTIVE

To evaluate the effects of terodiline in women with urge incontinence.

METHODS

After a 2-week run-in period, 93 women with urinary frequency and urge incontinence were randomized to either placebo or terodiline, 25 mg twice daily, in a double-blind study for 4 weeks. Symptoms were evaluated using daily frequency-volume charts to record voiding frequency, number of incontinent episodes, absorbent pad use, and quality of life.

RESULTS

The terodiline group showed a 70% decrease in the mean (+/- standard deviation) number of incontinent episodes per week (15.8 +/- 24, decreasing to 4.9 +/- 11.9; P < .01), which persisted throughout the study period. The placebo group achieved a 9% reduction in the mean number of incontinent episodes (13.0 +/- 11.3, decreasing to 11.9 +/- 16; P < .05) only in the final week of treatment. Side effects, especially anticholinergic side effects, were more common in the terodiline group, but resulted in only one dropout. Both the treated and placebo groups improved in daytime frequency and quality-of-life indices.

CONCLUSION

Terodiline is well tolerated and effective in reducing urge incontinent episodes in women.

Urodynamic characteristics of women with complete posthysterectomy vaginal vault prolapse

OBJECTIVES

To review the symptoms and lower urinary tract function in women with posthysterectomy vaginal vault prolapse.

METHODS

A retrospective review was carried out of the urodynamic records of 19 women with posthysterectomy vaginal vault prolapse who had been evaluated in the Bladder Function Laboratory of the Department of Obstetrics and Gynecology at Duke University Medical Center.

RESULTS

A full urodynamic evaluation was carried out on 19 women who had had a hysterectomy and who had subsequently experienced complete prolapse of the vaginal vault. Vaginal eversion produced massive distortion of the lower urinary tract and was associated with complex symptoms. Among the cystometric findings in these patients was an early average first desire to void (94 mL) and a reduced average cystometric capacity (370 mL). Symptoms of voiding difficulty were common. During noninstrumented uroflowmetry, the average peak and mean flow rates were reduced in these women (16.5 mL/s and 8.1 mL/s, respectively), suggestive of functional obstruction of the outlet due to the prolapse. Pressure-flow voiding studies showed a reduced peak flow rate (11 mL/s) with an increased detrusor pressure at peak flow (50 cm H2O), also indicative of functional obstruction. All women underwent urethrocystoscopy, and no patient had a urethral stricture or urethral stenosis. Although symptoms of urgency (79%) and urge incontinence (63%) were common, detrusor instability was confirmed by urodynamic studies in only 3 women (16%), suggesting that urge-related symptoms in these women may often be due to anatomic distortion of the lower urinary tract rather than to detrusor overactivity. "Genuine" stress incontinence was documented in only 2 women (11%) during cystometry; however, when these patients were examined with full bladders with their prolapses reduced and returned to a normal anatomic position with a single-bladed speculum, the physical sign of stress incontinence was demonstrated in all 9 women (47%) who had a complaint of stress incontinence. This suggests that massive vaginal prolapse may mask an incompetent continence mechanism, which may then be revealed after surgical repair of the prolapse.

CONCLUSIONS

Women with posthysterectomy vaginal vault prolapse present complicated reconstructive problems for the pelvic surgeon. The same pathophysiological process may produce both voiding dysfunction and stress incontinence. These patients should be evaluated carefully before surgical repair is undertaken. Stress incontinence may not be demonstrated in these patients unless they are examined with a full bladder with their prolapse carefully reduced to a normal anatomic position. Women who demonstrate stress incontinence with the vaginal prolapse reduced and the urethra supported normally should be suspected of having "type III" incontinence (demonstrable stress incontinence in the presence of normal urethral support). Women with these findings may require a suburethral sling procedure if they are to remain continent after correction of posthysterectomy vaginal vault eversion.

Bladder neck mobility and the outcome of surgery for genuine stress urinary incontinence. A logistic regression analysis of lateral bead-chain cystourethrograms

Bladder neck position, as determined by preoperative and postoperative resting and straining lateral bead-chain cystourethrograms, was analyzed by logistic regression analysis in 94 women undergoing 98 operations for genuine stress incontinence. A total of 384 roentgenograms were analyzed in an attempt to build a model that would predict the likelihood of surgical success in a given patient based on the preoperative films and explain a successful surgical outcome based on the characteristics of the postoperative films. The most important predictors of success were the number of previous incontinence operations, a large distance between the bladder neck and the pubic symphysis at rest, and increased mobility of the bladder neck before surgery. Successful surgery appeared to be related most closely to decreasing mobility of a previously hypermobile bladder neck.

A technique for modified McCall culdeplasty at the time of abdominal hysterectomy

A technique has been described for performing a modified form of the McCall culdeplasty at the time of abdominal hysterectomy. The use of such techniques during abdominal, as well as vaginal, hysterectomy, should help decrease the incidence of posthysterectomy vaginal vault prolapse and enterocele formation.

One hundred unstable bladders

OBJECTIVE

To investigate the correlation between presenting symptoms and cystometric data in patients with urodynamically proven detrusor instability.

METHODS

A retrospective review was conducted of standardized urodynamic data bases and cystometrograms from the gynecologic urodynamics laboratories at Duke University Medical Center, Durham, North Carolina, and Grady Memorial Hospital, Atlanta, Georgia.

RESULTS

Of the 100 patients reviewed, 86% complained of urge incontinence and 78% complained of urinary urgency; however, 76% also complained of stress incontinence. Statistical evaluation of symptoms by analysis of variance showed no significant correlations between the symptoms of urinary frequency and urgency and any of the cystometric indices. Patients with motor urge incontinence had significantly smaller mean cystometric bladder capacities than patients without this complaint (299.9 +/- 132.5 versus 553.6 +/- 173.6 mL; P < .01). One-third (34) of the patients had mixed incontinence due to genuine stress incontinence as well as detrusor instability. Compared with patients suffering from detrusor instability alone, patients with mixed incontinence had significantly larger cystometric bladder capacities (396.0 +/- 172.9 versus 308.1 +/- 154.8 mL; P < .02) and a lower amplitude of the maximum detrusor contraction (38.8 +/- 21.7 versus 49.9 +/- 25.1 cm H2O; P < .04).

CONCLUSIONS

Women with detrusor instability represent a diverse population with a wide variety of symptoms and urodynamic findings. Patients with mixed incontinence may represent a subpopulation distinct from those with pure detrusor instability. Further research that attempts to describe other discrete subpopulations of patients with detrusor instability may improve our understanding of this troublesome clinical problem.

Medical management of pelvic relaxation

Although most gynecologists consider surgery to be the treatment of choice for pelvic relaxation, there are many non-surgical forms of therapy for this problem and conditions which it may produce, such as urinary incontinence. This review highlights the importance of properly diagnosing co-existent factors which may complicate a patient's condition, and reviews therapies which may relieve her discomfort without surgery. These options include manipulation of concurrent medical factors, estrogen therapy, pelvic muscle rehabilitation through exercise and electrical stimulation, prompted voiding regimens, and the use of supportive pessaries.

The treatment of urinary incontinence with electrical stimulation in nursing home patients: a pilot study

OBJECTIVES

To test the effectiveness of electrical stimulation in the treatment of urinary incontinence in female nursing home patients.

SETTING

A community long term care facility.

PARTICIPANTS

Nine unselected female nursing home patients with urinary incontinence. All patients were moderately to severely cognitively impaired. By bedside cystometry, six patients had involuntary detrusor contractions while two had inconclusive results.

INTERVENTION

Participants were treated with electrical stimulation for 8 weeks using the Microgyn II device. A current with a frequency of 20 hertz and a pulse width of 1 millisecond was delivered repeatedly for 2 seconds on, 4 seconds off for 15 seconds twice a week.

MEASUREMENTS

The number of every-2-hour wet episodes during a 48-hour period (Wet) was recorded by a blinded observer at baseline and after 4 and 8 weeks of treatment. We evaluated the overall effect of electrical stimulation by averaging the Wet at 4 and 8 weeks for each patient and comparing it to Wet at baseline.

MAIN RESULTS

The mean +/- standard deviation of intensity of electrical stimulation was 12 +/- 5 milliamps. Mean Wet at baseline was 11.8 +/- 4.2. For all patients mean Wet increased by 2.3 +/- 3.2, P = 0.07. Analysis of patients with documented involuntary detrusor contractions showed a mean increase in Wet of 2.6 +/- 3.6, P = 0.16. The volume of fluid at which an involuntary contraction occurred during cystometry showed a mean increase of 48.3 +/- 52.6 mL, P = 0.07 after 8 weeks of treatment.

CONCLUSIONS

Electrical stimulation is well tolerated in elderly nursing home patients. However, it was ineffective in improving urinary incontinence. In fact, there was a tendency for the treatment to worsen the incontinence.

Reproductive hormone levels in gynecologic oncology patients undergoing surgical castration after spontaneous menopause

The endocrine function of the ovary after menopause is perhaps less well understood than at any other time in the female life cycle. To evaluate the hormonal function of the ovary further at this stage of life, reproductive hormone levels were measured in 11 postmenopausal women admitted to the gynecologic oncology service for pelvic surgery which would involve bilateral oophorectomy. Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels, along with estradiol, testosterone, dehydroepiandrosterone sulfate (DHEA-S), and androstenedione levels, were measured preoperatively, on Postoperative Days 1 and 4, and at 6 weeks following surgery. Testosterone and androstenedione levels fell by half in these patients, whereas estradiol levels were unaffected. LH and FSH showed a fall in the immediate postoperative period, with a subsequent return to baseline levels by 6 weeks after surgery. DHEA-S levels were unaffected by surgery. There are no discernible differences in subjective menopausal symptoms postoperatively in postmenopausal women undergoing bilateral oophorectomy compared to their preoperative state. The data show that the long-held but inadequately proven thesis that postmenopausal oophorectomy dramatically reduces androgen levels is in fact true. This is further evidence that the postmenopausal ovary is an important source of potent and potentially aromatizable androgens.

The Pyridium pad test for diagnosing urinary incontinence. A comparative study of asymptomatic and incontinent women

Eighteen women with urodynamically proven genuine stress incontinence awaiting surgery and 23 normal, asymptomatic, continent female volunteers took part in a study to compare the accuracy of a qualitative pad test with a quantitative pad-weighing test in detecting urine loss. Each woman took 600 mg of phenazopyridine hydrochloride (Pyridium, Parke-Davis) in three equally divided doses over 18-24 hours and then underwent a standardized, one-hour pad test as described by the International Continence Society. The Pyridium pad test was regarded as positive if there was any orange staining on the pad. The quantitative pad-weighing test was considered positive if there was a weight gain of 1.0 g or more at the end of the one-hour test period. All 18 patients with genuine stress incontinence had positive Pyridium pad tests, and all had pad weight gains of greater than or equal to 1.0 g (mean, 16.5). The maximum pad weight gain in the asymptomatic, continent volunteers was 0.7 g (mean, 0.1), and none was aware of any urinary leakage during the test; however, 12 (52%) had positive Pyridium pad tests. The Pyridium pad test appears 100% sensitive in detecting urine loss in symptomatic women with genuine stress incontinence, but it has a high false-positive rate in healthy, asymptomatic, continent women. If pad-weighing tests are done, the addition of Pyridium generally will not be useful, and if Pyridium is used by itself, the results may be misleading.

The management of detrusor instability

Detrusor instability is a urodynamic diagnosis made when the detrusor is shown objectively to contract, spontaneously or on provocation, during the filling phase of a cystometrogram while the patient is attempting to inhibit micturition. It often is responsible for symptoms of urgency, frequency, nocturia, urge incontinence, and nocturnal enuresis, but is not synonymous with any of them. Furthermore, it may be responsible for urinary incontinence which appears to be simple stress incontinence, and should be excluded before an operation for genuine stress incontinence is undertaken. Patients with mixed incontinence should have their detrusor instability treated before an attempt at surgical correction of stress incontinence is made. A number of therapeutic options exist for the unstable bladder. The simplest is bladder drill. My own preference is to start patients on bladder drill in conjunction with oxybutynin chloride 5 mg orally three times daily, with the plan of weaning them off the medication if possible in 3-6 months. Propantheline bromide in dosages of 15-30 mg orally four times daily also appears to be effective. Imipramine, in dosages of 25-50 mg orally twice daily, or up to 75 or 100 mg orally at night also may be helpful, especially if the patient suffers from nocturia or nocturnal enuresis. The effects of imipramine appear to be additive to those of other drugs, and this makes it a useful adjunct in therapy. Emepronium bromide and flavoxate hydrochloride appear to be less useful pharmacologic agents. The expected addition within the next few years of terodiline hydrochloride to the drugs available in the United States is likely to improve significantly our ability to treat detrusor instability. The use of prostaglandin synthetase inhibitors in women with perimenstrual exacerbations of their symptoms may be useful on a case-by-case basis. Patients who do not experience improvement with behavioral intervention and pharmacologic treatment may be candidates for electric stimulation therapy or surgery. The efficacy of electric stimulation therapy is diminished in many cases by poor patient acceptance. The most effective surgical treatment for refractory detrusor instability appears to be augmentation cystoplasty, which should be attempted only by a trained reconstructive urologist, and which should be reserved for the most refractory and difficult cases.

Prazosin-induced stress incontinence

A case of genuine stress incontinence due to prazosin, a common antihypertensive drug, is presented. Prazosin exerts its antihypertensive effects through vasodilatation caused by selective blockade of postsynaptic alpha-1 adrenergic receptors. As an alpha-blocker, it also exerts a significant relaxant effect on the bladder neck and urethra. The patient's clinical course is described and correlated with initial urodynamic studies while on prazosin and subsequent studies while taking verapamil. Her incontinence resolved with the change of medication. The restoration of continence was accompanied by a substantial rise in maximum urethral pressure, maximum urethral closure pressure, and functional urethral length. Patients who present with stress incontinence while taking prazosin should change their antihypertensive medication before considering surgery, because their incontinence may resolve spontaneously with a change in drug therapy.

Failed abdominal sacral colpopexy: observations and recommendations

Abdominal sacral colpopexy provides effective surgical management of the vagina that has prolapsed after hysterectomy. Recurrences of prolapse after this operation are rare. Three patients are presented who did exhibit recurrent prolapse necessitating another operation. In two patients, the synthetic mesh used for colpopexy had separated from the vagina. In the remaining patient, the posterior vaginal wall had ruptured distal to the attachment of mesh to the vagina. In each patient, the mesh had become completely interpenetrated by tissue. We believe that failures can be minimized by suturing the suspensory mesh to the vagina over as extended an area as possible. Reasons for this belief are addressed, and techniques for achieving such an attachment are described. A meticulous culdoplasty beneath the suspensory mesh is also considered important, as is the use of permanent sutures placed through the full thickness of the vagina in attaching the mesh.

Transvesical phenol injection of pelvic nerve plexuses in females with refractory urge incontinence

A series of 28 female patients with urge incontinence refractory to other forms of treatment underwent a total of 40 transvesical injections of phenol into the pelvic nerve plexuses. Following primary phenol injection only 8 patients (29%) had a significant response to therapy and all relapsed during follow-up. Only 3 of 11 patients undergoing a second injection had a clinical response to this therapy and 1 developed a vesicovaginal fistula. This suggests that phenol injections have little place in the management of urge incontinence and it is unwise to proceed to 2 or more injections because of the risk of fistula.

Approach for and assessment of interactive communication via cytokines of cellular components of skin

Structure and function of skin are dependent upon interaction of the cells and matrix components that are unique to skin which, in turn, are dependent upon an interactive message system of cytokines acting over distance. Our laboratory has utilized a system which is sufficiently complex to permit a component of the skin to mature into a functional unit that can be indirectly influenced by cell types inherent to the skin, message over distance. The system, human epidermal cells, maturing into an epidermis on an overlying Millicell-HA membrane in the presence of normal fibroblasts or peripheral blood mononuclear cells in a lower chamber has been used to assess the role of interactive cytokines in skin. Data demonstrate: (a) normal fibroblasts enhance the outgrowth and induce a more organized phenotype in squamous cell carcinoma cells; (b) keratinocytes enhance fibroblast proliferation while squamous cell carcinoma cells suppress fibroblast proliferation, and (c) both activated and nonactivated mononuclear cells affect the outgrowth and organization of the squamous cell carcinoma cell line. It is concluded that cells of the skin, by their mediators, do affect the growth of one another in a highly interactive way.

Expectant management of abdominal pregnancy. A report of two cases

In two recent consecutive cases of abdominal pregnancy the diagnosis was made at 18 weeks' gestation, and the patients refused immediate surgery and elected to maintain the pregnancy until fetal viability developed. Both patients were managed expectantly with continuous antepartum hospitalization. Fetal assessment was by serial ultrasound assessment of growth and amniotic fluid volume and by nonstress testing. Planned operative delivery was accomplished at 28 1/2 weeks and 33 weeks' gestation. In the second case the diagnosis was confirmed by magnetic resonance imaging. That fetus was also assessed with umbilical artery Doppler flow studies. Despite significant morbidity, both the mothers and infants are alive and well.