Wendy M.N. Reid

Evaluation of the fascial technique for surgical repair of isolated posterior vaginal wall prolapse.

OBJECTIVE To study the anatomic and functional efficacy and assess long-term success of the fascial technique in the repair of rectocele. METHODS Forty-two women with symptomatic posterior vaginal wall prolapse of at least stage II underwent a surgical repair using the technique of reconstruction of the rectovaginal septum. These women were evaluated at 6 weeks and 18 months postoperatively for anatomic improvement in the grade of their rectocele and a functional improvement in their vaginal, bowel, and sexual symptoms. RESULTS Ninety-five percent (40 of 42) were assessed at 6 weeks and 78.5% (33 of 42) attended follow-up at 18 months. Preoperative symptoms included 1) vaginal protrusion (78%); 2) defecation symptoms (76%), which included fecal incontinence alone in 9.5%, evacuation difficulties in 57%, and both fecal incontinence and evacuation difficulties in 9.5%; and 3) sexual dysfunction (33%). At 6-week follow-up there was resolution of vaginal protrusion in 87.5%, and bowel symptoms in 87%. At 18 months there was anatomic cure in 92%, improvement in defecation in 81%, and improvement of sexual dysfunction in 35%. No major complications were seen. CONCLUSION This technique is effective in providing relatively long anatomic cure of the rectocele and resolution of its symptoms.

Magnetic resonance imaging of normal levator ani anatomy and function.

OBJECTIVE To evaluate the anatomy and function of the levator ani in normal women by dynamic magnetic resonance imaging. METHODS Twelve asymptomatic, nulliparous, premenopausal women with no previous pelvic surgery underwent a dynamic magnetic resonance imaging scan of their pelvis. The origin, orientation, thickness, and function of the two components of the levator ani were studied. RESULTS The ileococcygeus is a thin muscle with an upward convexity. It slopes forward and medially. It is of variable thickness (mean thickness 2.9 mm, standard deviation 0.8 mm). There are apparent gaps in the muscle diaphragm and at its site of origin from the obturator fascia. The puborectalis is a thicker muscle. It is shaped like a belt encasing the pelvic organs. It is taller posteriorly than anteriorly. It is not attached to the bladder neck, but the midurethra and lower urethra lie in close proximity to it. The puborectalis moves dorsoventrally, whereas the ileococcygeus moves craniocaudally. CONCLUSION The levator ani is not a single muscle but has two functional components that vary in thickness, origin, and function. The ileococcygeus has a mainly supportive function, whereas the puborectalis has a sphincteric function. Gaps in the diaphragmatic portion of the ileococcygeus are a normal finding. Individual components of the levator ani may be prone to different types of childbirth trauma and should therefore be assessed separately when planning rehabilitation.

Assessment of response to treatment in vulvar vestibulitis syndrome by means of the vulvar algesiometer

OBJECTIVE A pilot study was undertaken to investigate the utility of the vulvar algesiometer in correlating symptom improvement with treatment response. STUDY DESIGN Women with a diagnosis of vulvar vestibulitis syndrome attending a specialist vulvar clinic were assessed with the vulvar algesiometer before and after treatment. RESULTS The conditions of 25 patients had improved to the point of discharge, and readings from before and after treatment were compared. There was a statistically significant difference in the vulvar algesiometer readings before and after treatment and this improvement was reflected in patient response. Nine patients had no response to treatment and also no significant improvement in vulvar algesiometer score. CONCLUSION The vulvar algesiometer provides an easy noninvasive means of assessing vestibular tenderness in vulvar vestibulitis syndrome that is well tolerated by the patients and provides a degree of biofeedback for them.

Benign and premalignant disease of the vulva

It is likely that many women with vulval problems present to their general practitioner and are referred to genitourinary medicine clinics or dermatologists and not necessarily to gynaecologists. To a certain extent, this referral pattern reflects our inability to provide comprehensive services in the management of women with vulval symptoms. This review concentrates on the areas of benign and premalignant disease and the areas in which gynaecologists should become increasingly involved.

The clinical application of a dual head gamma camera with coincidence detection in 20 women with suspected ovarian cancer

Objective To assess the effectiveness of a dual head coincidence gamma camera in identifying ovarian cancer as a less expensive alternative to the traditional 2‐[18F] fluoro‐2‐deoxy‐D‐glucose (18FDG) system using positron emission tomography.

Sacrohysteropexy with synthetic mesh for the management of uterovaginal prolapse

duration of detrusor activity in this study are not clear. Mild, moderate and severe contractions were defined ‘according to Coolsaet’, although the parameters described by the authors are different from those in the quoted reference. We share the authors’ concerns regarding the lack of standardisation in the conduct and interpretation of ambulatory urodynamic monitoring, and also welcome the recent report on standardisation by the International Continence Society. The validation of a protocol for ambulatory urodynamic monitoring, for the assessment of detrusor function, compared with conventional urodynamics, is contentious, since conventional urodynamics as the standard in this context has been recently challenged. The relationship between ambulatory urodynamic monitoring and symptoms is clearly important. However, retrospective analysis of the urodynamic trace in the presence of the woman re-introduces a subjective element to cystometry that ambulatory urodynamic monitoring was designed to avoid. Our experience, and that of others, suggests that measurements of detrusor contractions (amplitude, duration, frequency and bladder volume), combined with the woman’s symptoms, may be used to differentiate clinical detrusor instability from detrusor activity which may be regarded as a variation of normal.