W. Allen Addison

Abdominal sacral colpopexy with Mersilene mesh in the retroperitoneal position in the management of posthysterectomy vaginal vault prolapse and enterocele

During a 12-year study period from 1972 to 1984, 56 patients underwent abdominal sacral colpopexy with retroperitoneal interposition of a suspensory hammock between a prolapsed vaginal vault and the anterior surface of the sacrum. They were followed from 6 months to 12 1/2 years, and constitute the basis of this report. In most patients, a synthetic mesh was the material interposed. Hysterectomy had previously been performed on 53 patients, and in two patients there was congenital absence of the uterus. Indications for abdominal sacral colpopexy, surgical technique, complications, and results of operation are discussed. Seven additional patients underwent this operation after termination of the defined study period.

A Survey of Pessary Use by Members of the American Urogynecologic Society

Objective To describe trends in pessary use for pelvic organ prolapse. Methods An anonymous survey administered to the membership of the American Urogynecologic Society covered indications, management, and choice of pessary for specific support defects. Results The response rate was 48% (359 of 748). Two hundred fifty surveys were received at the scientific meeting and 109 were returned by mail. Seventy-seven percent used pessaries as first-line therapy for prolapse, while 12% reserved pessaries for women who were not surgical candidates. With respect to specific support defects, 89% used a pessary for anterior defects, 60% for posterior defects, 74% for apical defects, and 76% for complete procidentia. Twenty-two percent used the same pessary, usually a ring pessary, for all support defects. In the 78% who tailored the pessary to the defect, support pessaries were more common for anterior (ring) and apical defects (ring), while space-filling pessaries were more common for posterior defects (donut) and complete procidentia (Gellhorn). Less than half considered a prior hysterectomy or sexual activity contraindications for a pessary, while 64% considered hypoestrogenism a contraindication. Forty-four percent used a different pessary for women with a prior hysterectomy and 59% for women with a weak pelvic diaphragm. Ninety-two percent of physicians believed that pessaries relieve symptoms associated with pelvic organ prolapse, while 48% felt that pessaries also had therapeutic benefit in addition to relieving symptoms. Conclusion While there are identifiable trends in pessary use, there is no clear consensus regarding the indications for support pessaries compared with space-filling pessaries, or the use of a single pessary for all support defects compared with tailoring the pessary to the specific defect. Randomized clinical trials are needed to define optimal pessary use.

Accuracy of clinical assessment of paravaginal defects in women with anterior vaginal wall prolapse

OBJECTIVE The objective of this study was to determine the accuracy of clinical assessment of paravaginal defects in women with anterior vaginal wall prolapse. STUDY DESIGN A retrospective chart review of all women undergoing surgery for anterior vaginal wall prolapse during the years of 1994 to 1996 identified operative notes that described the surgical assessment of paravaginal support. These surgical findings were compared with the preoperative clinical assessment. Clinical parameters that predicted poor correlation were identified. Statistical analysis used the chi(2) test. RESULTS One hundred seventeen patients had surgery for anterior vaginal prolapse. Seventy had documentation of an intraoperative paravaginal support evaluation. Of these, 44 patients had vaginal procedures, and 26 had abdominal procedures. All patients had at least stage 2 prolapse before surgery, and all were noted to have excellent pelvic support 4 to 6 weeks after surgery. The prevalence of paravaginal defects at surgery was 47% on the right and 41% on the left. The sensitivity and negative predictive value for the clinical assessment for paravaginal defects were good on both the right and left sides, whereas the specificity and positive predictive values were poor. Stage of prolapse, previous hysterectomy, or previous anterior colporrhaphy did not significantly affect the accuracy of the clinical examination in predicting fascial defects. However, previous retropubic urethropexy did significantly decrease the accuracy of the clinical examination in predicting right paravaginal defects (P <.01) but not left. CONCLUSION Although preoperative clinical assessment for paravaginal defects is useful, it does not substitute for careful intraoperative evaluation for endopelvic fascial defects.

MANAGEMENT OF PELVIC ORGAN PROLAPSE

The wide variety of available pessaries permits rather precise choice of pessary to meet a given patients needs. Different approaches are reviewed. A paradigm for choosing a surgical repair based on the fascial and muscular support defects, as well as the functional demands and limitations of the patient is presented.

UNDERSTANDING LOWER URINARY TRACT FUNCTION IN WOMEN SOON AFTER BLADDER NECK SURGERY

The aim of this work was to correlate anatomic and urodynamic measures with function following bladder neck surgery. Eighty‐seven women who underwent bladder neck surgery at two tertiary academic medical centers in the southeastern U.S. were studied in this prospective outcomes analysis. Preoperative and 6‐week and 6‐month postoperative status was assessed with urodynamic testing, physical examination, and condition‐specific quality of life instruments. Correlations of dynamic urethral obstruction (quantified by pressure transmission ratio, PTR, determinations) and urethral support (quantified by urethral axis measurements) with functional status were determined. At 6 weeks, 50% of the subjects with inadequate dynamic obstruction (PTR < 90%) had genuine stress incontinence (GSI) compared to 5% of those with PTR ≥90% (P = .00002). Of those with excessive obstruction (PTR > 110%), 32% had detrusor instability (DI) and 47% had emptying phase dysfunction (EPD) compared to 6% and 24%, respectively, of those with PTR ≤ 110% (P = .006 and P = .04). At 6 months, subjects with excessive obstruction were more likely to have EPD than other subjects (75% vs. 27%, P = .001). Those with optimal dynamic obstruction (PTR ≥ 90% but ≤ 110%) were more likely to have normal function (no GSI, no DI, and no EPD) than those with higher or lower PTRs (59% vs. 34%, P = .04). Urethral axis measurements did not correlate with functional status at either follow‐up session. The magnitude of dynamic urethral obstruction is related to function after bladder neck surgery. Excessive obstruction is associated with DI and EPD, inadequate obstruction with GSI, and optimal obstruction with normal function. Neurourol. Urodynam. 18:629–637, 1999.

Fascia lata urethrovesical suspension for recurrent stress urinary incontinence

Although the physiologic mechanisms of normal micturition in the female subject are not fully understood, it is generally believed that urinary continence is maintained by a competent urethrovesical neck. Unfortunately, the patient who has had multiple operations for recurrent stress urinary incontinence often has a urethra that is shortened and fixed in scar tissue. In such patients, anterior colporrhaphy with operative release of the periurethral fibrosis and plication of the endopelvic fascia to create a functionally more normal urethrovesical junction will increase the chances for good results. A fascia lata support of the proximal 1 to 2 cm of the urethra ensures continued elevation of the urethra and with stress the sling provides a pulling-up effect. Fifty patients with a suburethral sling procedure are presented in detail. Forty-seven of these patients had a total of 121 prior operative procedures for stress urinary incontinence. Urologic studies are outlined. Forty-two patients (84%) were continent postoperatively, five were improved, and three had failures. Operative technique and complications are discussed.

The occurrence of adenocarcinoma in endometriosis of the rectovaginal septum during progestational therapy

Abstract A patient is presented who developed adenocarcinoma in endometriosis of the rectovaginal septum during a second course of hormonal therapy. Malignant transformation in an area of endometriosis during sex steroid therapy has not been previously reported. The rectovaginal septum is recognized as probably the most common site of malignant transformation in extraovarian foci of endometriosis.

Pelvic inflammatory disease: Findings during inpatienttreatment of clinically severe, laparoscopy-documented disease

OBJECTIVES We evaluated the relationship between clinically severe pelvic inflammatory disease and laparoscopic diagnosis and grading, comparative treatment with clindamycin plus cefamandole or doxycycline, and a management protocol for inpatient pelvic inflammatory disease treatment. STUDY DESIGN Thirty-three patients who met our clinical criteria for severe pelvic inflammatory disease underwent diagnostic laparoscopy. Pelvic inflammatory disease patients were randomized to double-blind treatment with clindamycin plus cefamandole or doxycycline within our management protocol; postdischarge oral antibiotics were omitted. RESULTS Laparoscopy confirmed pelvic inflammatory disease in 23 (70%) patients; 10 (44%) had mild pelvic inflammatory disease by laparoscopic grading. Laparoscopic grade alone predicted necessary duration of therapy to response: mild pelvic inflammatory disease, 2.3 +/- 0.5 days; moderate pelvic inflammatory disease, 2.7 +/- 1.5 days; and severe pelvic inflammatory disease, 3.9 +/- 1.5 days (p less than 0.05). Using the management plan presented, response rates for both antibiotic regimens were 100%. CONCLUSIONS Clinical diagnosis and grading of severe pelvic inflammatory disease has poor specificity. Laparoscopic grading of severity of pelvic inflammatory disease seems accurate. Both clindamycin plus cefamandole and clindamycin plus doxycycline are equally effective regimens for treatment of pelvic inflammatory disease and did not require supplementation after discharge. Our management plan is objective and practical; daily bimanual examination is the most sensitive indicator of persistent disease.

Effect of a topical contraceptive on endocervical culture for Neisseria gonorrhoeae

An attempt was made to determine whether the shortterm presence of a topical contraceptive in the vagina has any effect on established gonorrhea or on the standard diagnostic technique. Patients with positive endocervical cultures for N. gonorrhoeae from the Durham County Health Department were contacted by telephone informed that their culture was positive and asked to enter the study. Those who agreed were seen the next day in the Duke University Medical Center Womens Clinic. Pregnant women those felt to have active upper genital tract infection on pelvic examination and those with a known allergy to vaginal contraceptives were excluded. None of the patients were currently using topical vaginal agents for contraception. Endocervical swabbings for gonococcal culture were obtained. The patient was then given a steril disposable syringe containing 10 ml of a topical contraceptive gel the composition of which is highly representative of agents currently available in this class. Under the supervision of the nurse the patient injected the gel high into the vagina and mixed it vigorously with a finger to simulate coital events. She was instructed to remain in the area not to douche and to return to the clinic in 1 hour 2 hours and 4 hours for repeat culture from the endocervix for N. gonorrhoeae. In all 4 patients the baseline culture and all cultures at 1 hour 2 hours and 4 hours after insertion and mixing of the vaginal contraceptive agent were positive for N. gonorrhoeae from the endocervix. No patient experienced any adverse effects. Although the number of patients studied is small it is believed that the uniformity of results provides good preliminary evidence that the shortterm presence in the vagina of a contraceptive preparation has no effect on established gonorrhea or the ability to diagnose it by standard culture techniques. These data do not eliminate the possibility that the use of some other topical contraceptives may lower the sensitivity of endocervical culture for N. gonorrhoeae.