Antoine Weil

Diagnosis of anal sphincter tears by postpartum endosonography to predict fecal incontinence

Objective To determine whether anal endosonography immediately after vaginal delivery can predict subsequent fecal incontinence. Methods We studied nulliparas who delivered vaginally and had no anal sphincter tears (third- or fourth-degree perineal tears) diagnosed clinically by endosonography before any suture of the perineum. The sonographer was unaware of delivery details and the obstetrician and the women were not informed of endosonography results. Therefore, the suture of the perineum and the outcomes were not influenced by sonographers diagnoses. Three months after delivery, we assessed fecal incontinence by self-administered questionnaires. Results Clinically undetected tears of the anal sphincter were diagnosed by anal endosonography in 42 of 150 women (28%). The external anal sphincter alone was involved in 30 women (20%), the internal anal sphincter alone in two (1.3%), and both in ten (7%). The postal questionnaire was returned by 144 women. Incontinence was reported by 22 (15%, 95% confidence interval [CI] 10%, 22%), consisting mainly of incontinence to flatus only (16 of 22, 73%, 95% CI 50%, 89%). Clinically undetected anal sphincter tears diagnosed by endosonography were associated with incontinence 3 months after delivery (odds ratio [OR] 8.8; 95% CI 2.9, 26.5). The sensitivity of anal endosonography was 68% (95% CI 49%, 88%) and the positive predictive value 37% (95% CI 22%, 51%). Conclusion Anal endosonography immediately after vaginal delivery allows diagnosis of clinically undetected anal sphincter tears that might be associated with subsequent fecal incontinence.

Modifications of the urethral rest and stress profiles after different types of surgery for urinary stress incontinence.

Summary. Full urodynamic assessment, including urethral profiles at rest and under stress, using microtransducers, was made before and at least 6 months after surgery for urinary stress incontinence in 86 patients. Cure was assessed objectively. Procedures compared were Burch colposus‐pension, Pereyra urethrovesical suspension and anterior colporrhaphy. The Burch colposuspension increased the pressure transmission ratio more efficiently than the vaginal operations and the cure rate was 91%. Only 50% of Pereyra operations were successful and success was related to an increase in the functional urethral length and in the pressure transmission ratio. The success rate for anterior colporrhaphy was 57% and was associated with a significant decrease in the maximal urethral closure pressure and the continence area. The prognostic value of the urethral profiles at rest and under stress and the therapeutic implications are discussed.

Does a second delivery increase the risk of anal incontinence

Objective To evaluate the prevalence of anal incontinence and anal sphincter defects after a first vaginal delivery and assess the effect of a second delivery.

Effect of lumbar epidural analgesia on lower urinary tract function in the immediate postpartum period

Summary. Urodynamic investigations including cystometry and electronic simultaneous urethro‐cystometry were made in 27 primiparae between 2 and 5 days after delivery to assess possible effects of lumbar epidural analgesia on the function of the lower urinary tract. Three groups of patients were studied: 11 patients had vaginal delivery without epidural analgesia, 11 patients with similar obstetrical characteristics were delivered vaginally with epidural analgesia, and five others were delivered by caesarean section under epidural analgesia. The group of patients who were delivered vaginally under epidural analgesia had a significantly higher incidence (n= 4) of hypotonic bladders as determined by cystometry than the group without epidural analgesia (n= 0), (P < 0 05). The maximum cystometric capacity was significantly greater (P < 0.05) in the group who delivered vaginally with epidural analgesia than in the group without epidural analgesia, as well as the caesarean section group (with epidural analgesia), (P < 0.01). Possible side effects of epidural analgesia implied by these results are discussed and a method for surveillance of urethro‐vesical function both during labour and after parturition is proposed.

Endometrial and plasma concentrations of pregnancy‐associated plasma protein‐A (PAPP‐A)

Summary. Pregnancy‐associated plasma protein‐A (PAPP‐A), oestradiol and progesterone levels have been measured by radioimmunoassay in plasma and in endometrial homogenates of 30 women undergoing hysterectomy. Results were grouped according to the histological stages of the endometrium. In plasma, oestradiol and progesterone concentrations changed from proliferative to secretory stages in the well‐established pattern of the menstrual cycle, but PAPP‐A levels did not change. In endometrium, oestradiol levels were high during the proliferative stage and low in inactive and secretory endometrium. Endometrial PAPP‐A and progesterone concentrations increased from inactive to secretory stages, but only the increase in PAPP‐A was statistically significant. A positive correlation observed between endometrial PAPP‐A concentrations and plasma oestradiol/progesterone ratio suggests a possible hormonal control for the presence of PAPP‐A in the uterus.

Urodynamic and clinical assessment of the Lyodura sling operation for urinary stress incontinence

Summary. A Lyodura sling operation for urinary stress incontinence was performed on 36 patients. The success rate was 89%, when success was defined as absence of objective urine loss at coughing or straining. with full bladder in the upright position and during a Urilos test. at least 6 months after surgery. Full urodynamic assessment, including urethral rest and stress profiles, were performed before, and 6 months after, surgery. Success of the operation depended mainly on enhancement of urethral pressure transmission. Functional length of the urethra and maximal urethral pressure did not influence the success rate. The procedure is especially suitable in patients with some degree of uterine or vaginal prolapse.

Estradiol Receptors in the Urethra and the Bladder of the Female Rabbit

The presence of estradiol receptors was investigated in urethral and bladder tissue of mature pregnant and nonpregnant rabbits. Cytosolic fraction and nuclei were incubated with tritiated estradiol (3H-E2) at concentrations from 1 nM to 20 nM at 30 degrees C for 3 h with or without a 100-fold excess of diethylstilbestrol (DES). Incubation at 30 degrees C was selected so as to measure both occupied and unoccupied binding sites. The number of binding sites and their association constants were calculated by Scatchard analysis. Cytosolic binding sites for estradiol with high affinity (Ka = 0.31-0.58 X 10(9) M-1) were found in urethral tissue (785 fmol/mg DNA) and in bladder tissue (771 fmol/mg DNA). These results suggest that lower urinary tract of female rabbit could be a target organ for estradiol.

Urodynamic and Clinical Assessment of the Lyodura Sling Operation for Urinary Stress Incontinence

A Lyodura sling operation for urinary stress incontinence was performed on 36 patients. The success rate was 89%, when success was defined as absence of objective urine loss at coughing or straining, with full bladder in the upright position and during a Urilos test, at least 6 months after surgery. Full urodynamic assessment, including urethral rest and stress profiles, were performed before, and 6 months after, surgery. Success of the operation depended mainly on enhancement of urethral pressure transmission. Functional length of the urethra and maximal urethral pressure did not influence the success rate. The procedure is especially suitable in patients with some degree of uterine or vaginal prolapse.

Modifications of the Urethral Rest and Stress Profiles after Different Types of Surgery for Urinary Stress Incontinence

Full urodynamic assessment, including urethral profiles at rest and under stress, using microtransducers, was made before and at least 6 months after surgery for urinary stress incontinence in 86 patients. Cure was assessed objectively. Procedures compared were Burch colposuspension, Pereyra urethrovesical suspension and anterior colporrhaphy. The Burch colposuspension increased the pressure transmission ratio more efficiently than the vaginal operations and the cure rate was 91%. Only 50% of Pereyra operations were successful and success was related to an increase in the functional urethral length and in the pressure transmission ratio. The success rate for anterior colporrhaphy was 57% and was associated with a significant decrease in the maximal urethral closure pressure and the continence area. The prognostic value of the urethral profiles at rest and under stress and the therapeutic implications are discussed.