Scott A. Farrell

External Iliac Artery Laceration during Tension-Free Vaginal Tape Procedure

Abstract: This is a case review of a patient who, during surgery for stress incontinence using the tension-free vaginal tape procedure, sustained a laceration to the right external iliac artery.

A Simplified Protocol for Pessary Management

Objective To evaluate a simplified protocol for pessary management. Methods Women with symptomatic pelvic organ prolapse who opted for pessaries were enrolled in a prospective simplified protocol for pessary management. After the initial pessary fitting, they were seen at 2 weeks for reexamination and thereafter at 3- to 6-month intervals. Results One hundred ten women (mean age 65 years) were enrolled, and 81 (74%) of them were fitted successfully with a pessary. Life-table analysis showed that 66% of those who used a pessary for more than 1 month were still users after 12 months and 53% were still users after 36 months. The severity of pelvic prolapse did not predict the likelihood of pessary failure except in cases of complete vaginal eversion. Patients complaining of stress incontinence were less likely to have a successful pessary fitting and more likely to opt for surgery. Current hormone use and substantial perineal support do not predict greater likelihood of pessary fitting success. No serious complications from using the pessary were observed n the study sample. Conclusion Stringent guidelines calling for frequent Pelvic examinations during pessary use can be relaxed safely. Pessaries can be offered as a safe long-term option for the mangement of pelvic prolapse.

Sexuality after hysterectomy

Objective The availability of alternative therapies for abnormal gynecologic bleeding has prompted a reexamination of the impact of total hysterectomy on a womans quality of life. This paper examines the evidence about the impact of hysterectomy on one aspect of quality of life, sexuality. Data Sources A systematic review of the English and German language literature was conducted using the search terms “sexuality,” “hysterectomy,” “libido,” “orgasm,” and “outcomes.” Additional papers found in the bibliographies of theses papers were reviewed. Methods of Study Selection Eighteen studies were found, eight prospective and ten retrospective. With a few exceptions, the methodologic quality of the studies was poor, but we opted to review all of the studies given the paucity of data on this important subject. Tabulation, Integration, and Results The studies were evaluated for methodologic quality using a scoring system described in the paper and for their findings concerning the impact of hysterectomy on sexuality. χ2 and Fischer exact test were used to analyze nominal variables. Outcome measures were usually not validated and most studies did not consider important confounding factors. Most studies in this review showed either no change or an enhancement of sexuality in women who had a hysterectomy. Conclusion The majority of research evaluating the effect of hysterectomy on sexuality was poorly designed. The available evidence shows that quality of life is improved for most women who had hysterectomy and that hysterectomy did not adversely affect sexuality. A number of confounding factors with the potential to have either a positive or negative impact on sexuality, independent of hysterectomy, should be taken into account in future studies.

Recurrent Urinary Tract Infection

OBJECTIVE to provide an update of the definition, epidemiology, clinical presentation, investigation, treatment, and prevention of recurrent urinary tract infections in women. OPTIONS continuous antibiotic prophylaxis, post-coital antibiotic prophylaxis, and acute self-treatment are all efficient alternatives to prevent recurrent urinary tract infection. Vaginal estrogen and cranberry juice can also be effective prophylaxis alternatives. EVIDENCE a search of PubMed and The Cochrane Library for articles published in English identified the most relevant literature. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date restrictions. VALUES this update is the consensus of the Sub-Committee on Urogynaecology of the Society of Obstetricians and Gynaecologists of Canada. Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1). OPTIONS recurrent urinary tract infections need careful investigation and can be efficiently treated and prevented. Different prophylaxis options can be selected according to each patients characteristics.

Hysteroscopic resection of a cervical ectopic pregnancy

OBJECTIVE To test a new surgical approach to cervical pregnancy. DESIGN Case report. SETTING University teaching hospital. PATIENT(S) A patient presenting with a cervical pregnancy. INTERVENTION(S) Hysteroscopic resection of a cervical pregnancy. MAIN OUTCOME MEASURE(S) Successful resolution of the ectopic pregnancy (EP) and preservation of the uterus. RESULT(S) Successful treatment of a cervical pregnancy by uterine resectoscope is described. CONCLUSION(S) Operative hysteroscopy permits direct visualization and complete resection of a cervical pregnancy. When it is successful, this treatment should result in prompt resolution of the EP, thus avoiding prolonged follow-up.

Histologic examination of fascia used in colporrhaphy

OBJECTIVE To perform a histologic examination of tissue identified as fascia and used during colporrhaphy. METHODS In patients undergoing primary anterior and posterior colporrhaphy, biopsies were taken from three surgically distinct vaginal tissues types: the wall, the “fascia,” and areolar tissue. The biopsies were placed in formalin, identified numerically, and sent to pathology for staining with hematoxylin‐eosin, Masson trichrome for collagen, Movat for elastin, and immunoperoxidase stain for actin in smooth muscle. Simultaneous photographs were taken of the biopsy sites. The histologic diagnosis was compared with the surgical diagnosis. RESULTS A total of 60 samples were taken from five women. The specimens from two of these patients were disqualified. The pathologist made the following histologic diagnosis for each type of surgical specimen: vaginal wall, mucosa and underlying connective tissue; fascia, moderately dense connective tissue with smooth muscle; areolar tissue, loose connective tissue. The histologic appearance of the “fascia” was indistinguishable from the deeper aspects of the vaginal wall. It was composed of the same proportions of smooth muscle, elastin, and collagen. Using the histologic appearance as the “gold standard,” the accuracy of the surgical diagnosis was: “vaginal wall,” 12 of 12 (100%); “fascia,” seven of 12 (58%); and “areolar tissue,” eight of 12 (67%). CONCLUSIONS The surgical “fascia” used during colporrhaphy consists of moderately dense connective tissue with smooth muscle similar to the deep aspects of the vaginal wall, is the same in both the anterior and posterior compartments, and is an artifact of the surgical dissection used to separate the vaginal wall from the underlying organs.

The Evaluation of Stress Incontinence Prior to Primary Surgery

OBJECTIVE To provide clinical guidelines for the evaluation of women with stress urinary incontinence prior to primary anti-incontinence surgery. OPTIONS The modalities of evaluation range from basic pelvic examination through to the use of adjuncts including ultrasound and urodynamic testing. OUTCOMES These guidelines provide a comprehensive approach to the preoperative evaluation of urinary incontinence to ensure that excessive evaluation is avoided without sacrificing diagnostic accuracy. EVIDENCE Published opinions of experts, supplemented by evidence from clinical trials, where appropriate. VALUES The quality of the evidence is rated using the criteria described by the Canadian Task Force on the Periodic Health Examination. BENEFITS, HARMS, AND COSTS Comprehensive evaluation of women considering surgery to treat urinary incontinence is essential to rule out causes of incontinence that may not be amenable to surgical treatment. Simplifying the evaluation minimizes the discomfort and embarrassment potentially experienced by women. RECOMMENDATIONS 1. Thorough evaluation of each woman is essential to determine the underlying etiology of the urinary incontinence and to guide management. (II-3B) 2. Preoperative pelvic examination should be performed to identify pelvic masses that may provoke lower urinary tract symptoms (e.g., a large fibroid uterus impinging on the bladder), concomitant pelvic organ prolapse, and to rule out latent stress incontinence. All of these findings may necessitate a modification of the surgical approach. (III-C) 3. Hypermobility of the urethra should be confirmed preoperatively, as women with fixed, well-supported bladder necks are less likely to experience a cure following standard anti-incontinence procedures. (II-2B) 4. Stress incontinence should be objectively demonstrated prior to anti-incontinence surgery. (III-B) 5. The volume of postvoid residual urine should be measured prior to anti-incontinence surgery. Elevated postvoid residual volumes are uncommon and should signal the need for further evaluation of the voiding mechanism. (III-C) 6. Urinary tract infection should be identified and treated prior to initiating further investigation or therapeutic intervention for urinary incontinence. (II-2B) 7. In women presenting with pure stress incontinence that can be objectively demonstrated during examination, preoperative urodynamic testing is not necessary (II-3B). For women with other lower urinary tract symptoms and/or mixed urinary incontinence, the clinician s judgment must guide the use of preoperative urodynamic testing (II-3B). VALIDATION These guidelines have been approved by the Urogynaecology Committee and the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.

Continence Pessaries in the Management of Urinary Incontinence in Women

OBJECTIVE To evaluate the effectiveness of continence pessaries for the management of urinary incontinence in women. METHODS A retrospective review of the records of 100 women who chose to try a pessary to treat their urinary incontinence. Demographic data, presenting symptoms, physical findings, results of objective testing (pad tests and urodynamics), and incontinence outcomes were abstracted. Factors such as age, pelvic prolapse, presenting symptoms, pessary type, and history of previous incontinence surgery were examined using the Student t-test, chi-square test, or Fisher exact test where appropriate. RESULTS The mean age of the women was 56 years (range, 28-86 years) and mean parity was 2.5 (range, 0-13). Presenting complaints included stress incontinence in 41 women, mixed incontinence in 53 women, urge incontinence in 3 women, and combined prolapse and incontinence in 3 women. All 100 women returned for follow-up visits. Forty women had their pessary size or type adjusted at the first follow-up visit. At a mean follow-up time of 11 months (range, 2-42 months), 59 women continued to experience a complete resolution or decrease in their incontinence and chose to continue use of a pessary. Age, presenting symptoms, degree of pelvic prolapse, and type of pessary did not affect the success of pessary treatment. Women who had undergone incontinence surgery prior to pessary fitting had a higher failure rate, with relative risk (RR) of 1.6. CONCLUSION Urinary incontinence pessaries are effective. More than 50% of women who try a continence pessary will continue to use it to manage their urinary incontinence.

Technical Update on Pessary Use

OBJECTIVE To review the use, care, and fitting of pessaries. OPTIONS Pessaries are an option for women presenting with prolapse and/or urinary incontinence. OUTCOMES Pessaries can be successfully fitted in the majority of women with excellent satisfaction rates and minimal complications. EVIDENCE PubMed and Medline were searched for articles published in English to September 2010, using the key words pessary, prolapse, incontinence, fitting, and complications. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis, and articles were incorporated in the guideline to May 2012. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described by the Task Force (Table 1). BENEFITS, HARMS, AND COSTS Women may choose a pessary for management of their prolapse and/or stress incontinence rather than opt for surgery. Major complications have been seen only with neglected pessaries. Minor complications such as vaginal discharge, odour, and erosions can usually be successfully treated. SUMMARY STATEMENTS AND RECOMMENDATION: Summary Statements 1. Most women can be successfully fitted with a pessary when they present with prolapse. (II-2) 2. Complications of pessary use are usually minor, and vaginal discharge is the most common complaint. (II-3) 3. Vaginal erosions can be treated with removal of the pessary and optional vaginal estrogen supplementation. (II-2) 4. Satisfaction rates with pessary use are very high. (II-2) Recommendation 1. Pessaries should be considered in all women presenting with symptomatic prolapse and/or urinary stress incontinence. (II-1A).

Trends in Major Risk Factors for Anal Sphincter Lacerations: A 10-Year Study

OBJECTIVES (1) To identify independent risk factors for anal sphincter laceration, (2) to determine the trend in rates of anal sphincter laceration over a 10-year period, and (3) to examine the impact of temporal trends in risk factors on anal sphincter laceration rates. METHODS Population-based data were obtained from the Nova Scotia Atlee Perinatal Database, on 91 206 women who had a singleton vaginal live birth > or =500 g for the years 1988 to 1997. Risk factors for anal sphincter laceration were identified using stepwise logistic regression. A multivariate model was used to study temporal changes in laceration rates after controlling for changes in parity, episiotomy rates, operative vaginal deliveries, birth weight, prolonged second stage of labour, and other determinants. RESULTS Nulliparity (relative risk [RR] = 6.97), occiput posterior position (RR = 2.44), non-vertex presentations (RR = 2.27), second stage > or =120 min (RR range = 1.47-2.02), delivery by an obstetrician (RR = 1.30), and birth weight > or =3000 g (RR range = 1.43-6.63) increased the risk of laceration. Instrument-assisted delivery involved risks that ranged from a 2-fold increase for a vacuum-assisted delivery (RR = 2.15) to a greater than 5-fold increase for a forceps delivery after an unsuccessful vacuum extraction (RR = 5.69). Episiotomy, particularly midline incisions, increased the risk of laceration (RR = 2.57). The risk of a sphincter laceration increased 2-fold from 1988 to 1997, despite controlling for risk factors. CONCLUSIONS Sufficient evidence exists about the risk factors for anal sphincter laceration to permit modification of management of labour and delivery to minimize the risk of anal sphincter laceration. Increased awareness of the clinical importance of recognition and repair of anal sphincter laceration may explain the rising incidence.