Abdominal sacral colpoperineopexy: a new approach for correction of posterior compartment defects and perineal descent associated with vaginal vault prolapse

OBJECTIVE: Our purpose was to assess a modification of abdominal sacral colpopexy in 19 patients. STUDY DESIGN: The rectovaginal space was dissected to the superior aspect of the posterior vaginal fascia still contiguous with the perineal body. Mersilene (Ethicon, Somerville, N.J.) mesh was sutured to this fascia and along the entire posterior vaginal wall. Patients with vault prolapse, perineal descent, and associated rectoceles or enteroceles are reported. Outcome measures included bowel symptoms and pelvic organ prolapse staging. Defecography was performed in three patients. Wilcoxon signed rank analysis was used for comparison of prolapse measures. RESULTS: Mean follow-up was 11 weeks. Bowel symptoms improved in 8 of 11 women. No subjects had greater than stage II prolapse postoperatively and median improvement in stage was 3 (range 2 to 4). The mean decrease in the genital hiatus measurement was 3.13 +/- 1.25 (range 2 to 6) cm. Postoperative defecography documented correction of rectoceles and enteroceles and improvement in perineal descent with straining. CONCLUSIONS: Abdominal sacral colpoperineopexy is effective surgery for vaginal vault prolapse associated with perineal descent and posterior vaginal defects.     

Uterosacral ligament fixation for vaginal vault suspension in uterine and vaginal vault prolapse

OBJECTIVE: The purpose of this study was to determine the simplicity, safety, anatomic, and functional success of using the uterosacral ligaments for correction of significant complex uterine and vaginal vault prolapse by the vaginal route. STUDY DESIGN: Fifty women with uterine or vaginal vault prolapse with descent of the cervix or the vaginal vault to the introitus or greater were treated between 1993 and 1996 by the same surgeon with bilateral uterosacral ligament fixation to the vaginal cuff by the vaginal route. Included were patients with significant enterocele, cystourethrocele, rectocele, and stress urinary incontinence who had concomitant repair of coexisting pelvic support defects. An etiology of vaginal vault prolapse is discussed. RESULTS: Uterosacral ligaments were identified and used for successful vaginal vault suspension by the vaginal route in all 50 consecutive patients without subsequent failure or significant complications with a maximum follow-up of 4 years. One patient had recurrent stress urinary incontinence and two had asymptomatic cystoceles. Three patients had erosion of monofilament sutures at the vaginal apex. CONCLUSIONS: In these 50 patients with significant complex uterine or vaginal vault prolapse, uterosacral ligaments could always be identified and safely used for vaginal vault suspension by the vaginal route with no persistence or recurrence of vaginal vault prolapse 6 to 48 months after surgery. Excessive tension by the surgeon on tagged uterosacral ligaments at the time of hysterectomy may be an etiologic factor in vaginal vault prolapse.     

Prediction of genital prolapse after Burch colposuspension

OBJECTIVE: The aim of this prospective observational study was to investigate the gynecological and defecographic features in women with stress urinary incontinence operated with Burch colposuspension in order to analyze if the findings could predict subsequent development of genital prolapse. SUBJECT: Twenty-one women with urodynamically proven genuine stress urinary incontinence were consecutively operated with the Burch colposuspension during 1991-1992. No concomitant prolapse repair surgery was performed. METHODS: All were carefully examined in the lithotomy position at rest and with the Valsalva maneuver. The pelvic floor laxity was graded semiquantitatively. The defecography and the clinical examination were done preoperatively and repeated one year postoperatively. RESULTS: The clinical examination revealed a significant progression of rectoceles (p = 0.003) after the colposuspension. The colposuspension cured a significant number of cystoceles (p = 0.035). Six women (29%) had subsequent corrective prolapse surgery median 2 years after the colposuspension. The defecographic measurements showed a significant increase of the recto-vaginal distance (RVD) following the operation (p = 0.020). At the postoperative measurement the group with subsequent prolapse surgery had a significantly larger RVD as compared to the group without further surgery (p = 0.004). The kappa reliability test showed poor agreement between the defecographic and clinical assessment of the rectoceles. CONCLUSION: We failed to find any clinical or defecographic characteristic which could predict the development of surgery-demanding genital prolapse following colposuspension. The colposuspension seemed to accelerate the deterioration of the pelvic floor. However, only a minority of the patients developed symptomatic genital prolapse demanding corrective surgery. We suggest that only women with symptomatic prolapse should be considered for concomitant corrective surgery at the time of the colposuspension.     

Bilateral transvaginal sacrospinous colpopexy: preliminary experience

OBJECTIVE: Our goal was to determine how often a transvaginal sacrospinous colpopexy procedure can be done bilaterally. STUDY DESIGN: Between August 1993 and July 1996, 66 patients were prospectively evaluated for uterine prolapse (19 patients) and posthysterectomy vaginal vault prolapse (47 patients). Twenty-six patients (25 with posthysterectomy vaginal vault prolapse) underwent an abdominal sacral colpopexy. The remaining 40 patients (18 with uterine prolapse, 22 with posthysterectomy vaginal vault prolapse) were preoperatively and intraoperatively assessed for a bilateral sacrospinous colpopexy. All patients with uterine prolapse underwent hysterectomy. RESULTS: In 10 of the 18 (56%) patients with uterine prolapse and in 16 of the 22 (73%) patients with posthysterectomy vaginal vault prolapse, bilateral suspension to the sacrospinous ligament was carried out. Follow-up has ranged from 6 to 40 months, and no recurrent vaginal cuff prolapses have been detected in any patients. In 3 patients, however, all in the bilateral fixation categories, distention cystoceles have developed; one patient has undergone a successful anterior colporrhaphy. CONCLUSIONS: The bilateral suspension is different from the unilateral suspension in that the former requires significant intraoperative judgment in its feasibility and in maintaining the width of the vaginal cuff to allow a bilateral suspension without tension. A bilateral fixation appears more attainable in a patient with posthysterectomy vaginal vault prolapse than in one with uterine prolapse.     

Role of radiologic diagnosis in rectal mucosal prolapse

Defecography (DG) is a useful method to detect many morpho-functional deformities of anus and rectum and pelvic floor. We report on a clinical and radiologic study of 165 patients (36 men and 129 women) suffering from defecation disorders and rectal muscosal prolapse (RMP). All the patients had been submitted to clinical examination, endoscopy and double contrast enema to rule out organic colorectal conditions. DG was performed with a dedicated conmode and high-density barium and videorecorded on VHS cassettes to assess the dynamics of evacuation phases and to reduce exposure doses. DG showed single RMP in 28% of cases and multiple RMP in 72% of cases; the condition was isolated in 22% of cases, while in 88% of cases it was associated with other anorectal dysfunctions, such as rectocele (65%), perineal descent syndrome (PDS) (15%), puborectal muscle syndrome (14%) and intussusception (8%). RMP appeared at DG as a wall defect bulging into rectal lumen, which was more evident under straining and during barium evacuation. In 12 patients with multiple RMP, dynamic CT of the pelvis was carried out to study the whole pelvic floor and in 5 cases it showed levator ani diastasis. Fifty-eight patients were submitted to surgery by elastic binding of RMP; DG follow-up showed RMP remission in 47 patients, single RMP relapse in 3 patients and multiple RMP relapse in 3 patients. One patient with PDS and intussusception was submitted to rectopexy and mucosectom.     

Bladder neck competency at rest in women with incontinence

PURPOSE: We determine the presence of an open bladder neck during video urodynamic studies and relate that finding to the presence of stress urinary incontinence. MATERIALS AND METHODS: Patients presenting with urinary incontinence, voiding dysfunction or pelvic floor prolapse underwent video urodynamics. With the patient upright and after 200 ml. contrast material had been instilled into the bladder the bladder neck was viewed to determine if it was open or closed. At that point the abdominal leak point pressure was measured. RESULTS: Of 102 women, average age 56.5 years (range 31 to 82), 13% had an open bladder neck and demonstrable stress incontinence on video urodynamics with an average abdominal leak point pressure of 45 cm. water (range 26 to 90). Of those with stress incontinence on urodynamics 23% had an open bladder neck. No continent patient had an open bladder neck. CONCLUSIONS: The presence of an open bladder neck with the bladder filled to 200 ml. correlates strongly with the presence of stress incontinence.     

Vaginal topography does not correlate well with visceral position in women with pelvic organ prolapse

The objective was to determine whether vaginal topography accurately predicts the location of the pelvic viscera on fluoroscopy in women with pelvic organ prolapse. Eighty-nine women undergoing preoperative evaluation for reconstructive pelvic surgery at a tertiary care referral practice formed the study population. Each woman completed a comprehensive urogynecologic history and physical examination, which included a quantified (POP-Q) assessment of her vaginal topography, as described by Bump et al. In addition each woman underwent pelvic floor fluoroscopy (PFF). Visceral sites were selected which corresponded clinically to the vaginal sites measured by the POP-Q. The most dependent portion of the bladder, small intestine, rectum and urethrovesical junction was measured. Twenty-five (28%) women had stage II prolapse, 34 (38%) had stage III prolapse, and 28 (32%) had stage IV prolapse. The remaining 2 women were symptomatic, with stage I prolapse. For the entire study population there was no correlation between the fluoroscopic position of the small bowel and/or rectum and any apical or posterior wall POP-Q site (C, Ap or Bp). There was no correlation with the fluoroscopic position of the UVJ at rest or with straining and the corresponding POP-Q site (Aa). The fluoroscopic position of the most dependent portion of the bladder correlated only modestly with the upper (Ba, rho = 0.51) and lower Aa, rho = 0.68) anterior vaginal wall POP-Q sites. In women without prior surgery (n = 33) there was only modest correlation between the fluoroscopic position of the bladder and the corresponding POP-Q site (Aa, rho = 0.71). In this unoperated subpopulation there was no correlation with PFF and any other POP-Q site. In women who had undergone prior hysterectomy (n = 25) or hysterectomy with anterior and/or posterior colporrhaphy (n = 17), there was only a modest correlation of the most dependent portion of the bladder and the upper anterior vaginal wall site (Bb, rho = 0.67 and rho = 0.55, respectively). It was concluded that vaginal topography does not reliably predict the position of the associated viscera on PFF in women with primary or recurrent pelvic organ prolapse.     

Digital imaging: a valuable technique for the postoperative assessment of cochlear implantation

OBJECTIVE: To determine differences between vaginally parous and nulliparous women presenting with urinary incontinence and pelvic organ prolapse. METHODS: Seven hundred forty eight consecutive referrals with urinary incontinence or pelvic organ prolapse, 62 of whom were nulliparous, were included in the analysis. Five hundred thirty-seven (72%) had urinary incontinence and 235 (31%) had at least stage III pelvic organ prolapse. Each subject had standard history, physical examination, and multichannel urodynamic testing. Differences between parous and nulliparous women were compared using parametric and nonparametric analysis of variance and the chi2 test with Yates correction where appropriate. RESULTS: The only significant demographic difference between the groups was that parous women had more previous continence and prolapse surgery. There were significant differences in distribution of diagnoses according to parity, with the nulliparas much less likely to have pelvic organ prolapse. Among incontinent women without prolapse, nulliparas were significantly more likely to have pure detrusor instability. Of those with pure genuine stress incontinence, nulliparas were older, had less anterior vaginal wall descent, less bladder neck mobility, narrower genital hiatus and perineal body measurements, and lower maximum urethral closure pressures. Of those with pure detrusor instability, the only difference was that nulliparas were significantly younger. For women with stage III pelvic organ prolapse or worse, no significant difference in any measured characteristic was noted. CONCLUSION: Nulliparous women were less likely to present with pelvic organ prolapse and those with urinary incontinence differed little from incontinent parous women.     

Hearing loss and vestibular dysfunction in childhood from the use of streptomycin in Albania

OBJECTIVE: To analyze which factors, including gynecological surgery in particular, contribute to the occurrence of pelvic relaxation. METHOD: A retrospective analysis of 711 consecutive patients treated surgically for pelvic relaxation from 1983 to 1989 at the Department of Obstetrics and Gynecology of Turku University Central Hospital was undertaken. RESULT: The patients who underwent surgery for recurrent pelvic relaxation were significantly older (66.8 vs. 62.1 years) and suffered significantly less (20% vs. 41%) from urinary stress incontinence than patients undergoing primary surgery for pelvic relaxation. Anterior vaginal segment relaxation (i.e. cysto- and urethrocele) was common in patients undergoing the initial operation (n = 684), and posterior vaginal segment relaxation (i.e. rectocele and perineal laceration) in recurrent operations (n = 58). Of the patients studied, 87 had pelvic relaxation, which had developed after partial (n = 46), total abdominal (n = 16) or vaginal (n = 25) hysterectomy. CONCLUSION: Care must be taken in the treatment of the posterior vaginal segment during the initial operation for pelvic relaxation in order to avoid late sequelae. Moreover, when the removal of the uterus is planned, the matter of a stable vaginal vault must be taken into account especially when partial hysterectomy should be performed.     

Carbon dioxide laser for laparoscopic enterocele repair

The use of the carbon dioxide (CO2) laser for laparoscopic enterocele repair was evaluated in four women with an enterocele as the only pathology. Three women had a large enterocele after earlier hysterectomy, and one young woman had a congenital enterocele. The technique consists of vaporizing the peritoneum of the enterocele; however, it is important first to delineate carefully the lesion's circumference because of the strong retraction during vaporization. Subsequently, a posterior culdotomy is performed taking care to restore the horizontal position of the upper vaginal axis by shortening the uterosacral ligaments, which are sutured together on the midline and the posterior vaginal wall. The (CO2) laser has the advantage that the superficial vaporization it produces is rapid (<5 min), safe, and completely bloodless. The shrinking during vaporization facilitates subsequent repair. Postoperative morbidity and recovery were uneventful for all patients. The (CO2) laser seems to have some advantages over sharp endoscopic resection of enteroceles. The relative simplicity of technique and the low postoperative morbidity suggest that endoscopy could become routine in pelvic floor surgery, improving diagnosis and complementing vaginal surgery while avoiding laparotomy.     

Transvaginal urethrolysis for urethral obstruction after anti-incontinence surgery

PURPOSE: Urethral obstruction following a stress incontinence procedure occurs in 5 to 20% of patients. We examine the success of transvaginal urethrolysis in resolving voiding dysfunction. MATERIALS AND METHODS: A retrospective chart review was performed on 39 patients who had undergone transvaginal urethrolysis for urethral obstruction following an anti-incontinence procedure. Preoperatively, a history was taken, and pelvic examination and either video urodynamics or cystoscopy were done. RESULTS: All 39 patients complained of urge incontinence, 13% had urinary retention, 51% had incomplete bladder emptying and 36% voided to completion but had irritative voiding symptoms. Previous surgery included retropubic urethropexy in 41% of the cases, pubovaginal sling in 38% and bladder neck suspension in 21%. Mean length of followup after urethrolysis was 16 months. Of the 39 patients 33 (85%) had resolution of urge incontinence but 5 still required occasional intermittent catheterization. The remaining 6 patients had continued urge incontinence. An augmentation procedure was performed in 4 patients with improvement of symptoms. CONCLUSIONS: Our data support transvaginal urethrolysis for the treatment of iatrogenic urethral obstruction. It is a rapid, effective and minimally invasive technique that should be considered if voiding dysfunction does not resolve spontaneously.     

Gonadotropin triggers the generation of proteinaceous factor in vitellogenic perch (Anabas testudineus) oocyte which stimulates ovarian aromatase activity

OBJECTIVE: Evaluation of the feasibility of bilateral sacropinous ligament suspension with a stapler. Morbidity study and short term results. STUDY DESIGN: Prospective study from July 1994 to August 1996. RESULTS: Bilateral sacrospinous ligament suspension with a stapler was possible in 100% of cases and surgical technique is described. Our indications are stage III Bp and stage IV genital prolapses (according to the American Urogynecologic Society classification, 1996), with or without uterus, and when a Bologna's procedure is performed, in order to prevent enterocele. In 24 patients, the uterus was present. 20 vaginal hysterectomies and 4 conservative bilateral uterine suspensions were performed. The sacrospinous ligament suspension was associated to anterior colporrhaphy (in 74% of patients), repair of rectocele (82%), repair of enterocele (26%), posterior colpoperineorrhaphy (79%), bladder neck suspension (71%). No vascular injury nor post operative constipation was noted. In 2 patients, a small rectal laceration occurred, and in one patient one branch of the staple transfixed the rectal mucosa. Removal of the staple was easily performed without any post-operative complication. First results after an average 19 months follow-up (range 9 to 32) shows a perfect anatomic result in 77% of cases. We noted one recurrence of a vaginal vault prolapse; the patient underwent a second sacrospinous ligament fixation with good result. One patient had a stage II Aa cystocele post-operatively and three patients had a short vagina (< 6 cm). Patients who were continent before the sacrocolpopexy did not develop further urinary stress-incontinence. CONCLUSION: Bilateral transvaginal sacrospinous ligament suspension with a stapler facilitates the procedure. No post-operative constipation was noted with this method. Our first results are good. The cost of the stappler may limit its extensive use.     

4-Defect repair of grade 4 cystocele

PURPOSE: The 4-defect repair of grade 4 cystocele corrects discrete and severe deficiencies of vesicourethral support. We describe this technique used during pelvic reconstruction in 130 women. MATERIALS AND METHODS: During a 3-year period 130 patients (age range 35 to 96 years) underwent repair of grade 4 cystocele using the 4-defect repair technique. Cystocele repair had been performed in 60 patients (46%) and hysterectomy had been performed in 85 (65%). A "goalpost incision" is used in the vaginal wall to facilitate separation of the wall from underlying perivesical fascia, entry into the retropubic space, and exposure of the urethropelvic ligament, cardinal ligament and perivesical fascia. The 4 polypropylene sutures are used to provide an anterior vaginal wall sling which is modified to incorporate perivesical fascia and cardinal ligaments. Central defect repair is achieved by approximation of the cardinal ligaments and midline plication of the perivesical fascia over absorbable mesh. RESULTS: A total of 112 patients were available for followup which ranged from 6 to 42 months (mean 21). Repair of grade 4 cystocele was accompanied by other transvaginal repairs in 94 patients (83%), including rectocele repair in 81, hysterectomy in 22 and enterocele repair in 31. Of the patients 92% had excellent objective and subjective results for anatomical cystocele repair. Of the patients with preoperative stress urinary incontinence 90% had excellent or good subjective results. De novo urge incontinence was seen in 7% of patients. CONCLUSIONS: The 4-defect repair technique relies on anatomical restoration of 4 distinct deficiencies of pelvic support and is highly effective for relief of symptoms of grade 4 cystocele.     

Bladder neck support prosthesis: a nonoperative treatment for stress or mixed urinary incontinence

PURPOSE: We evaluated the usefulness and safety of a bladder neck support prosthesis in patients with stress or mixed incontinence. MATERIALS AND METHODS: A total of 57 women with stress and 20 with mixed incontinence completed a 12-week prospective clinical trial of a bladder neck support prosthesis. While indexes of incontinence episodes, leakage amounts and urgency along with a bothersome index were subjectively evaluated, a 60-minute pad test and urinary flow parameters were objectively evaluated. Three patients scheduled to undergo surgery for stress incontinence voluntarily used the device, and provided urodynamic data and cystourethrograms. Two prongs at 1 end of the ring, a type of elastic vaginal pessary, elevate the bladder neck against the pubic bone and facilitate pressure transmission around the bladder neck, resulting in urinary continence. RESULTS: Four subjective indexes significantly improved. There was no urinary flow obstruction. Urine loss decreased from 20.6 to 4.8 gm. per hour (p < 0.001) on the 60-minute pad test. Of the patients 22 (29%) reported complete continence and 39 (51%) had decreased severity of incontinence by more than 50%. Minor adverse effects occurred in 26% of the patients. Taking subjective evaluation, changes in objective parameters and adverse effects into consideration, 62 patients (81%) had some or maximum benefit according to the global usefulness rating. CONCLUSIONS: The bladder neck support prosthesis is safe, well tolerated and clinically effective for the treatment of stress or mixed incontinence.     

The incidence of low-pressure urethra as a function of prolapse-reducing technique in patients with massive pelvic organ prolapse (maximum descent at all vaginal sites)

OBJECTIVE: Our aims were to compare several prolapse-reducing techniques during urodynamic evaluation and prospectively evaluate their usefulness in identifying the incidence of low urethral closure pressure in continent patients with massive prolapse. STUDY DESIGN: This preoperative, prospective, repeated-measures urodynamic study evaluated the maximum urethral closure pressure with the use of four different techniques in 30 consecutive continent patients with grade 4 prolapse at all vaginal sites. Twenty patients with grade 0 prolapse served as the control group. All patients from the prolapse group underwent surgical treatment and were followed up clinically for a minimum of 1 year. RESULTS: Use of the Scopette (Birchwood Laboratories, Eden Prairie, Minn.) reduction technique to reduce the prolapse in a linear orientation during multichannel urodynamics revealed a 56% incidence of low-pressure urethra and an overall genuine stress urinary incontinence of 83% in patients with massive pelvic organ prolapse but without clinical urinary incontinence. CONCLUSIONS: There may be an increased indication for sling urethropexy in patients with massive prolapse.     

Outcome of treatment of upper third vaginal recurrences of cervical and endometrial carcinomas with interstitial brachytherapy

PURPOSE: To describe an original brachytherapy technique using a dedicated intravaginal template for the treatment of vaginal vault recurrences and to evaluate the results of such a treatment. METHODS AND MATERIALS: Between 1978 and 1993, 78 patients with isolated recurrence of cervical or endometrial carcinoma located in the vaginal vault have been treated in Lyon. Initial treatment was surgery alone in 49 cases and irradiation with surgery in 37 cases. Treatment of the vaginal recurrence was performed with interstitial Iridium 192 brachytherapy combined with pelvic external beam radiation therapy in 34 patients. The tumor was implanted with a dedicated intravaginal plastic template. Six parallel metallic needles were implanted in the vaginal vault and afterloaded with Iridium 192 wires of 4 to 6 cm long. The mucosa of the upper half of the vagina received the same dose as the one encompassing the tumor on the 85% isodose of the Paris system. RESULTS: At 5 years the local control rate was 70% and the overall survival rate 56%. Grade 3 complications occurred in 10% of the cases and only in patients who had received irradiation during the initial treatment of the primary tumor. CONCLUSIONS: This brachytherapy technique makes it possible to perform Iridium 192 implants in a difficult situation with a favorable long-term control rate and an acceptable rate of complications.     

Abdominopelvic CT scan findings after surgery for ovarian cancer

AIMS: To evaluate abdomino-pelvic changes in patients who had total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO) for stage I ovarian cancer. METHOD: The postoperative computed tomographic (CT) scans of 23 patients who had undergone TAH and BSO for stage I ovarian tumours between 3 and 14 weeks previously were assessed, providing there had been no treatment with chemotherapy or radiotherapy and that each patient had normal tumour marker (CA125) levels after surgery. After the CT scan patients were followed up and had no clinical or biochemical (CA125) evidence of relapse for a median of 27 months (range 11 to 78 months). The following sites were assessed by two observers: the vaginal vault, round ligaments, bladder, rectum, perirectal fat, pelvic sidewalls, omentum, surgical scar and abdominal wall. Any abnormality was recorded, with re-evaluation on follow-up CT scans in ten patients (between three and 17 months). RESULTS: The following abnormalities were seen: (1) Thickened round ligaments (n=12) with bulbous masses at the surgically transected ends (n=7). This was bilateral in eight patients. (2) Vaginal vault thickening (n=11) either uniform (n=6) or bulbous bilaterally (n=2) or unilaterally (n=3). (3) Subtle omental bed stranding or nodularity (n=11). (4) Peritoneal thickening underlying the scar (n=4). (5) Asymmetrical rectus abdominis muscles (n=3) adjacent to the surgical scar or thickened scar tissue in the anterior abdominal wall (n=4). No significant bladder, rectal, perirectal or nodal abnormalities were found. CONCLUSION: Pseudotumours at the transected ends of the round ligaments, or uniformly swollen round ligaments, may be identified in patients who have had TAH and BSO, as may vaginal vault thickening. Other changes which may be observed in the abdomen and pelvis are peritoneal thickening adjacent to the scar and omental bed stranding.     

A constipation scoring system to simplify evaluation and management of constipated patients

PURPOSE: Constipation is a common complaint; however, clinical presentation varies with each individual. The aim of this study was to assess a standard scoring system for evaluation of constipated patients. MATERIALS AND METHODS: All consecutive patients with idiopathic constipation who were referred for anorectal physiologic testing were assessed. A subjective constipation score was calculated based on a detailed questionnaire that included over 100 constipation-related symptoms. Based on the questionnaire, scores ranged from 0 to 30, with 0 indicating normal and 30 indicating severe constipation. The constipation score was then compared with the objective findings of the physiology tests, which include colonic transit time (CTT), anal manometry (AM), cinedefecography (CD), and electromyography (EMG). Colonic inertia was defined as diffuse marker delay on CTT without evidence of paradoxical contraction on AM, CD, or EMG. Pelvic outlet obstruction was defined as paradoxical puborectalis contraction, rectal prolapse or rectoanal intussusception, rectocele, or sigmoidocele. RESULTS: A total of 232 patients (185 females and 47 males) of a mean age of 64.9 (range, 14-92) years were evaluated. All patients had a score of more than 15; on evaluation of the significance of different symptoms in the constipation score with the Pearson's linear correlation test, 8 of 18 factors were identified as significant (P < 0.05). These factors included frequency of bowel movements, painful evacuation, incomplete evacuation, abdominal pain, length of time per attempt, assistance for evacuation, unsuccessful attempts for evacuation per 24 hours, and duration of constipation. All 232 patients had objective obstruction attributable to one or more of the following causes: paradoxical puborectalis contraction (81), significant rectocele or sigmoidocele (48), rectoanal intussusception (64), and rectal prolapse (9). CONCLUSION: The proposed constipation scoring system correlated well with objective physiologic findings in constipated patients to allow uniformity in assessment of the severity of constipation.     

Clinical and instrumental evaluation after Burch's colposuspension in patients with stress urinary incontinence

The authors performed a retrospective study of 29 patients undergoing Burch's anterior colposuspension to treat stress incontinence. Patients were aged between 32 and 71 years old and before surgery presented a urodynamic picture with low mictional pressure, normal filling and Max P of lower closing at 40 mm. Follow-up monitoring ranged from a minimum of 6 months to a maximum of 5 years (mean length 33 months) and was carried out using a urodynamic examination and transvaginal scan to evaluate the distance of the bladder neck from the posterior face of the pubic symphysis. Seventeen women (65.5%) were fully cured after surgery, whereas 27% improved. In "dry" patients the urodynamic examination showed increased significantly of the functional length of the urethra and the transvaginal scan showed that mean values of the distance between bladder neck and pubic symphysis were lover than those in those patients who still presented symptoms. The authors also used ultrasonography to evaluate the efficacy of the latter in the study of urinary incontinence. As reported in other studies, they affirm that intracavitary ultrasonography using a linea probe is equivalent to radiography using cystography with metallic repere, making the examination less invasive and easily repeatable; in addition, it is also important for studying the dynamics of the pelvic floor to establish effective rehabilitative treatment.     

Immediate management of posterior urethral disruptions due to pelvic fracture: therapeutic alternatives

PURPOSE: We retrospectively reviewed the results of 3 types of initial management of pelvic fracture urethral disruption in children. MATERIALS AND METHODS: From 1980 to 1994, 35 boys 2 to 15 years old (mean age 8.1) with prostatomembranous urethral disruption were treated, including 17 who also had associated injuries. Immediate treatment included suprapubic cystostomy and delayed urethroplasty in 19 patients (group 1), urethral catheter alignment without traction and concomitant suprapubic cystostomy in 10 (group 2), and primary retropubic anastomotic urethroplasty in 6 (group 3). RESULTS: In all patients in groups 1 and 2 severe urethral obliteration developed. Four group 3 patients (66%) had a stricture at the site of anastomotic repair. After delayed urethroplasty 16 group 1 (84%) and all 10 group 2 patients were continent. However, only 3 group 3 patients (50%) achieved continence. Retrospectively associated bladder neck injury occurred in 5 of the 6 incontinent boys. Erections were observed before and after treatment in all but 3 children. Unstable pelvic ring fractures (type IV) comprised 28% of all pelvic fractures with a high rate of associated injuries. CONCLUSIONS: As described, urethral alignment was not beneficial for avoiding urethral obliteration. Therefore we recommend suprapublic cystostomy as the only form of initial treatment in these cases. Urinary incontinence seems more likely related to associated bladder neck rupture and the severity of pelvic fracture rather than to initial treatment or delayed urethral repair. Consequently, when associated bladder neck injury is present, we advocate immediate surgical repair.