Thomas E. Elkins

Stress Incontinence and Cystoceles

We studied prospectively 62 women with cystoceles by video-urodynamics before and after operative repair. Of 29 women with grades 1 and 2 cystoceles 8 had residual urine, 14 had urge incontinence and 24 had symptoms of stress urinary incontinence. Of these women 23 had urodynamic evidence of stress incontinence, as did 3 of 5 without stress incontinence symptoms. Of 33 women with large cystoceles 22 had symptoms of stress urinary incontinence but 10 more had urodynamic evidence of stress urinary incontinence. Of these 33 women 18 had significant residual urine and 24 had urge incontinence. Operative repair resolved stress incontinence in 51 of 54 women, urge incontinence in 33 of 38 and residual urine in 24 of 26. Cystoceles recurred in 3 patients, and enteroceles developed in 3 and recurred in 2. These findings indicate that cystoceles may cause voiding dysfunction and lack of symptoms of stress incontinence is unreliable in patients with cystoceles. In addition, cystoceles are associated with other symptoms, most of which actually resolve after operative repair.

Menarcheal Age in Ghanaian School Girls

In a cross‐sectional retrospective study of 2087 Ghanaian school girls in various educational institutions in the Kumasi district, Ashanti region, Ghana, the mean menarcheal age was found to be 13.98 ± 1.42 years. Differences in the menarcheal age of the girls was found to be significantly correlated to social class, parents ethnic origin, educational institution and home living area (P = 0.0001). The duration of the menarche and the interval between the menarche and the second period was found to be influenced by the age at menarche (P < 0.01). Decline in menarcheal age in concurrence with world trends was observed. Further studies are necessary to identify the inherent and specific factors in the Ghanaian population which relate to and influence the age of menarche.

Transvaginal mobilization and utilization of the anterior bladder wall to repair vesicovaginal fistulas involving the urethra.

Repair of vesicovaginal fistulas resulting from obstetric trauma remains a major challenge to surgeons worldwide. Large defects that result in partial or total urethral loss are especially difficult to repair. Even when closure of such fistulas is accomplished, return of normal urogenital function is often impaired, underscoring the need to improve existing surgical procedures. Transvaginal urethral and bladder neck reconstruction using mobilized anterior bladder wall was helpful in closing 18 of 20 vesicovaginal fistulas with urethral involvement caused by obstetric trauma. This method involves advancement of an anterior bladder wall flap into the vagina, where it is rolled into a neo-urethra or connected to whatever remnant of urethral tissue exists. Complications included stress incontinence requiring further surgery (four), small bladder capacity with detrusor instability (two), urethral stenosis requiring dilatation (two), postoperative hemorrhage (one), and vaginal stenosis (one). Continued modification of this procedure holds promise for many patients considered inoperable in the past.

Obstetric decision-making: responses to patients who request cesarean delivery

The right of patients to be actively involved in treatment decisions is now widely accepted. A survey of 112 obstetricians was conducted to determine their responses to several cases in which a laboring woman asks for a cesarean section, even though the obstetrician has recommended a continued trial of labor/vaginal delivery. In 12 of the 19 cases there was substantial variation among respondents in the decision to agree with the patient. There was also no agreement, in many of these cases, on the presence or absence of a medical indication for abdominal delivery. The ethical aspects of this problem are explored.

The Relation of the True Conjugate to Maternal Height and Obstetric Performance in Ghanaians

The true conjugate was determined intraoperatively with a caliper in 114 Ghanaian women and was correlated with their height, obstetric performance and fetal dimensions. Those patients undergoing cesarean section for cephalopelvic disproportion (Group Ia) were found to have a significantly shorter mean true conjugate (9.54 cm ± 0.63 S.D.) and mean body height (152.68 cm ± 5.46 S.D.) and a smaller true conjugate — fetal biparietal diameter difference (10.93 mm) than those who had no cephalopelvic disproportion (Group Ib) and whose mean measurements were 10.61 cm ± 0.81 S.D., 157.20 cm ± 5.69 S.D. and 21.50 mm, respectively (P = 0.0001). Recommendations for appropriate referral of rural clinic patients and for selection of patients for repeat cesarean sections are based on the above findings.

Innovative community-based postgraduate training for obstetrics and gynecology in west Africa.

Objective To describe a unique international effort to develop a training program in West Africa that would be of similar quality to any other in the world (but with sensitivity to cross-cultural needs) and would retain physicians in West Africa to improve womens health in that part of the world. Methods Step-by-step formulation of a program included initial trainee recruitment, the inclusion of foreign guest faculty, and the establishment of institutional libraries. This was followed by a phase of curriculum development, recruitment of West African faculty, and organization of an innovative, community-based fourth year. Results Between ten and 12 postgraduates will have completed the program by January 1996, and will be placed in Ghana. More than 60% of Ghanaian postgraduates have passed the relevant regional examinations, compared with less than 25% of candidates from other countries. Nine Ghanaian specialists have returned to Ghana to become faculty members in the program. Over 20 published peer-reviewed articles have resulted from this program since 1989. The number of residents being trained has increased from three to 28. Seven new residents joined the program in 1994. An early reduction in maternal mortality from 9.9 deaths per 1000 births in 1991 to 4.2 deaths per 1000 births in 1992 was noted when senior postgraduates took over labor and delivery at the teaching hospital in Accra, Ghana, where approximately 10,000 deliveries occur per year. Conclusion Specialty training in obstetrics and gynecology that is specifically aimed at meeting the needs of West Africa has been initiated successfully. Long-range success will require support from regional governments and continued long-term commitments from the international community of obstetricians and gynecologists.

Urologic Evaluation After Closure of Vesicovaginal Fistulas

Eighteen patients at University College Hospital in Ibadan, Nigeria, underwent urologic evaluation after repair of obstetrics-related vesicovaginal fistulas. This included a questionnaire, assessment of vaginal scarring, urodynamics and urethroscopy. Eight patients demonstrated stress urinary incontinence, with 4 revealing type III incontinence with either low maximum urethral closure pressure or open vesical neck on urethroscopy. This study documents some of the persistent problems that occur even after successful closure of vesicovaginal fistulas. Continued evaluation should lead to better surgical and medical techniques to diminish the incidence of continued bladder dysfunction after closure of fistulas.

A Clinical Observation of a Program to Accomplish Pelvic Exams in Difficult-to-Manage Patients with Mental Retardation

Abstract Providing routine gynecologic care to patients with mental retardation can be a very difficult task. A program was developed at the University of Michigan to facilitate routine gynecologic examinations of patients with mental retardation so that evaluations could be made without excess physical force or unnecessary inducement of fear. Special techniques allowing for gynecologic examination of mentally retarded women are described. Early experience using intravenous or intramuscular Valium and chloral hydrate was unsuccessful for completion of gynecologic exams without force. As a result, it was necessary to perform eight pelvic examinations under general anesthesia. After instituting a protocol using oral ketamine and midazolam, excellent outpatient sedation was achieved and only 4 of 25 patients subsequently referred for an examination required general anesthesia. The medications were well tolerated and without significant side effects, allowing for discharge home within 60 minutes of achieving effective sedation. A satisfactory gynecologic exam can be accomplished in the vast majority of mentally retarded women while avoiding unnecessary physical and emotional trauma and the need for general anesthesia.

The surgical anatomy of needle bladder neck suspension

Objective To define the surgical anatomy of needle bladder neck suspension in order to explain this operations effect on urethral support and gain information useful in minimizing intraoperative complications. Methods Needle bladder neck suspension was carried out on two unembalmed, multiparous cadavers. After fixing the suspensory sutures in place, the pelvis of one cadaver was completely dissected. The second cadaver was serially sectioned at 1-cm intervals, and the sections were subjected to both anatomic and histologic examination. These findings were correlated with the findings noted during an autopsy dissection of a women who previously had undergone needle bladder neck suspension at our institution and with our surgical experience with this operation. Results The plane of dissection used to enter the space of Retzius lay between the vaginal mucous membrance and the visceral endopelvic fascia. The point of entry into the retropublic space lay between the levator ani muscles and its superior fascia, lateral to the arcus tendineus fasciae pelvis, the paraurethral vascular plexus, and bladder neck. It was cephalad to the perineal membrance (urogenital diaphragm). The paraurethral supporting tissues incorporated in the suspensory suture included the portion of the endopelvic fascia that lies between the vagina and urethra and, usually, the arcus tendineus fasciae pelvis. Attaching the suspensory sutures in needle bladder neck suspension seems to stabilize the bladder neck by providing a new point of lateral fixation for its supporting endopelvic fascia. Conclusion Needle bladder neck suspension stabilized the supportive fascia of the urethra, and vascular injury may be minimized by detailed knowledge of paraurethral anatomy.

Plastic Surgical Techniques in the Repair of Vesicovaginal Fistulas: A Review

A variety of plastic surgical techniques may be used in the repair of vesicovaginal fistulas. The indication for their use include: (a) diameter greater than 4 cm; (b) involvement of the bladder neck/proximal urethra; (c) radiation-induced fistulas; and (d) previous failed repair(s). In the developing world the vast majority of complex fistulas are caused by obstetric trauma; elsewhere they occur mainly following radiotherapy or radical surgery for gynecologic malignancy. The majority of complex fistulas requiring tissue donation may be effectively treated using a vaginal approach and a modified Martius graft. There is probably little or no advantage in encorporating bulbocavernosus muscle fibers in this graft. Although some concern exists regarding the long-term viability of these grafts in radiation-induced fistulas, in view of the relatively simple operative technique, together with the low associated morbidity, modified Martius grafts may be deemed suitable for first-time repairs. The gracilis muscle graft should be considered next in cases of exclusive transvaginal repair. The omental graft is undoubtedly the most versatile: it can be used in both abdominal and combined abdominovaginal procedures. The recently described posterosuperior sliding bladder flaps warrant further evaluation. For most fistulas involving the bladder neck/proximal urethra, there is no clear advantage in bladder flap reconstruction over vaginal flap reconstruction, the latter being augmented by an anti-stress incontinence procedure were appropriate. When continent urinary diversion is required, the Indiana pouch appears preferable to the Kock pouch; ureterosigmoidostomy is, however, technically and culturally more acceptable in these circumstances in the developing world.