Abstracts
Biochemical markers
Women with prolapse of the genital organ had significantly lower concentration of estradiol in serum and of collagen in the teres ligaments, with significantly higher daily excretion of hydroxyproline and glycosaminoglycans in urine.
In women with prolapse of the genital organ a significantly positive correlation between the concentration of estradiol and collagen and negative correlation between the concentration of estradiol and hydroxyproline and glycosaminoglycans has been found.
Stanosz, S et al:[Certain biochemical markers in women with abnormal states of the reproductive system] [Niektore markery biochemiczne u kobiet z zaburzeniami statyki ukladu plciowego.] Ginekol Pol 1995 Sep;66(9):518-22.
Joint hypermobility
Determined whether joint hypermobility, indicative of connective tissue abnormalities, is associated with genital prolapse.
Subjects were examined in the standing and nonstraining positions for cystocele, rectocele, and uterine or vault prolapse. The degree of prolapse was graded 0-3.
A separate investigator, blinded to the results of the gynecologic examination and using accepted criteria, evaluated each subject for joint hypermobility.
Clinical joint hypermobility was found in 39 of 107 (36%) study patients. Subjects with joint hypermobility had a significantly higher prevalence of cystocele (33 of 37 [89%] versus 40 of 69 [58%), rectocele (32 of 38 [84%] versus 33 of 69 [48%], and uterine or vault prolapse (25 of 38 [66%] versus 20 of 69 [29%] compared to women with normal joint mobility, respectively.
No differences in the prevalence of stress incontinence were found between the two groups.
Women with joint hypermobility have a significantly higher prevalence of genital prolapse compared to women with normal mobility, which suggests an underlying connective tissue abnormality as one etiology of pelvic relaxation.
Norton, PA et al: Genitourinary prolapse and joint hypermobility in women. Obstet Gynecol 1995 Feb;85(2):225-8.
Kyphosis & Ptosis
Is thoracic kyphosis associated with uterine prolapse?
The degree of kyphosis was compared between a group of white women and matched controls. Kyphosis was measured on lateral x-ray and measured by the Ferguson method.
The degree of thoracic kyphosis was higher (13 degrees) in patients with uterine prolapse than controls (8 degrees).
Thoracic kyphosis appears to be associated with uterine prolapse.
Lind, LR et al: Thoracic kyphosis and the prevalence of advanced uterine prolapse. Obstet. Gynecol. 1991, 87(4): 605-9.
Nutritional factors & Ptosis
In an animal study (ewes) flocks were evaluated for mineral status. Vaginal prolapse appeared to be linked to overfeeding, even though flocks in which vaginal prolapse was prevalent also showed hypocalcemia.
Hypocalcemia was probably a consequence rather than a cause.
Hosie, B.D. et al: Nutritional factors associated with vaginal prolapse in ewes. Vet. Rec. 1991 128(9): 204 - 208 [Comment Vet. Rec. 1991, 128(11): 263.
Rectal prolapse
Rectal prolapse (1)
The cause of a prolapse of the rectum is intrinsic to the organ itself. Neither paralysis of the pelvic floor sphincter complex nor a loosening of the suspending ligaments--which have never been demonstrated in situ--are causative.
Prolapse development starts with a break in between the very tight pelvic colon and the wide rectal reservoir. This can be demonstrated, radiologically. It is never larger than about the size of a fist. Rectosigmoid resection removes the cause and also improves the symptoms of constipation.
Peripheral procedures had a recurrence rate of 23.3%, whereas rectosigmoid resection had recurrences in only 3.8% of the cases. Follow-up period is 30 years.
Stelzner, F:[Etiology and therapy of rectal prolapse. Experiences with 308 cases 1956-1991] [Uber die Ursache und die Therapie des Mastdarmvorfalls. Erfahrungen bei 308 Fallen aus den Jahren 1956-1991,] Chirurg 1994 Jun; 65(6):533-45.
Rectal prolapse (2) - sugar
Incarcerated rectal prolapse is a potential surgical emergency.
The desiccating effect of granulated sugar (sucrose) was used to aid the manual reduction of prolapsed but viable rectal tissue.
Coburn WM 3rd et al., Sucrose as an aid to manual reduction of incarcerated rectal prolapse. Ann Emerg Med, 1997 Sep, 30:3, 347-9.
Renal ptosis
Renal ptosis is the caudal acquired displacement of one or both of the kidneys, with different degree and etiology, considered as a urological pathology because of its urodynamic changes and largely neglected.
Literature reports the largest incidence in females our cases are nearly the same. Second degree ptosis is the most frequent, but, in females, bilateral ptosis is prevalent (77%).
Most patients show urinary colics or lumbar pain. We also noticed UTI (62%), urinary lithiasis (26%) and pyelocalyceal ectasia (46%).
Considering the anatomic and functional changes are remarkable, renal ptosis should be taken into account as a cause of chronic renal damage, also because it is included among the causes of obstructive nephropathy, which can cause severe glomerular and tubular-intestinal changes, triggered off by a short urinary stasis and evident in the controlateral kidney too.
Boccardo, G et al: [Renal ptosis: nephrologic consequences of an organ malposition] [Nefroptosi: consequenze nefrologiche di una malposizione d'organo.] Minerva Urol Nefrol 1994 Dec;46(4):195-204.
Terminology & Ptosis
Presents a standard system of terminology recently approved by the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons for the description of female pelvic organ prolapse and pelvic floor dysfunction.
Bump, RC et al: The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996 Jul;175(1):10-7.
Visceral organs & Ptosis
Visceral organs (neurophysiology)
Visceral organs are innervated by vagal and spinal visceral afferent neurons which serve as interface between visceral domain and brain. They have multiple functions, one of which is the encoding of mechanical and chemical events and the relay of these messages to the CNS.
Visceral pain and discomfort are associated with spinal visceral afferents. Normally mechano-insensitive spinal visceral afferents which are chemosensitive may be recruited in pathophysiological conditions.
Visceral events which lead to the generation of distinct organ regulations, reflexes and sensations may be encoded by functionally specific sets of afferents or by the intensity-coding in afferents or by both.
Pain elicited from some visceral organs may not be associated with the activation of specific sets of 'visceral nociceptors' but with the intensity of discharge in spinal visceral afferents.
Janig, W: Neurobiology of visceral afferent neurons: neuroanatomy, functions, organ regulations and sensations. Biol Psychol. 1996 Jan 5;42(1-2):29-51.
Colporrhaphy
Contents:
Colporrhaphy
Vaginal eversion - surgery
Colporrhaphy
Determined the anatomical cure rate of posterior colporrhaphy and its effect on bowel and sexual function 1 to 6 years later.
Anatomical and symptomatic cure of rectocoele.
Postoperatively prolapse symptoms due to rectocoele decreased (64% vs 31%).
Constipation (22% vs 33%), incomplete bowel emptying (27% vs 38%), incontinence of faeces (4% vs 11%) and sexual dysfunction (18% vs 27%) increased.
Those with incontinence of stool were more likely to have had 2, or more, posterior colporrhaphies. 62% felt that they improved over all after surgery.
Additional postoperative symptoms included: vaginal and/or perineal splinting (33%), soiling and/or inability to wipe clean (16%), rectal digitation (23%), incontinence of flatus (19%), and rectal and/or vaginal pain (22%).
Posterior colporrhaphy corrects the vaginal defect in 76% of women. It does not necessarily correct and may contribute to bowel and sexual dysfunction, particularly in those requiring multiple procedures. The presence of the anatomical defect does not imply dysfunction.
Kahn MA & Stanton SL: Posterior colporrhaphy: its effects on bowel and sexual function. Br J Obstet Gynaecol, 1997 Jan, 104:1, 82-6.
Vaginal eversion - surgery
Total colpocleisis technique performed on women with posthysterectomy vaginal eversion and presents the outcome of this surgery.
Some women (# 24) had previously undergone a total of 40 operations for prolapse, and many had a massive prolapse with scarring and ulceration.
Total colpocleisis is an effective operation for the treatment of vaginal eversion in selected situations. When defective urethral support is corrected at the time of the operation, postoperative incontinence is not usually a problem.
DeLancey JO & Morley GW: Total colpocleisis for vaginal eversion. Am J Obstet Gynecol, 1997 Jun, 176:6, 1228-32; discussion 1232-5.
Botulinum & Ptosis
MRI
Illustrated the magnetic resonance (MR) imaging patterns of prolapse and to correlate them with symptoms in patients with constipation or fecal incontinence.
Visceral prolapse and the configuration of the pelvic floor muscles were identified at rest and during straining. Visceral descent was compared.
Visceral prolapse was seen at multiple sites, most frequently in constipated patients. There was significantly greater bladder base descent, uterocervical descent, and puborectalis muscle ballooning in the group of constipated patients when compared with the group with fecal incontinence or the asymptomatic group.
The degree of anorectal junction descent was significantly greater in the group of incontinent patients when compared with the asymptomatic group.
MR imaging clearly shows pelvic visceral prolapse and pelvic floor configuration on straining. Prolapse frequently involves multiple sites in constipated patients, which is suggestive of global pelvic floor weakness. In contrast, the weakness is frequently posterior in fecally incontinent patients.
Scott AB: Preventing ptosis after botulinum treatment. Radiology, 1997 Apr, 203:1, 77-81.
Hysterectomy & Ptosis
Contents:
Alternatives to hysterectomy (2)
Post-hysterectomy prolapse
Alternatives to hysterectomy (1)
Hysterectomy is the commonest major operation performed by gynaecologists and is the definitive cure for many of it's indications which include dysfunctional uterine bleeding, fibroids, utero-vaginal prolapse, endometriosis and adenomyosis, pelvic inflammatory disease, pelvic pain, gynaecological cancers and obstetric complications.
It is a successful operation in terms of relieving women of their presenting symptoms and high levels of satisfaction are reported by patients.
However, it has a high risk of complications, involves a prolonged convalescence, is expensive and to some women represents a loss of femininity. It should only be employed after trying conservative treatments first if appropriate. If this fails, currently only endometrial ablation and myomectomy are valid alternatives to hysterectomy.
Patient care can be improved by increasing the proportion of operations that are done vaginally and laparoscopically and decreasing the number of laparotomies.
Davies A & Magos AL: Indications and alternatives to hysterectomy. Baillieres Clin Obstet Gynaecol, 1997 Mar, 11:1, 61-75.
Alternatives to hysterectomy (2)
Hysterectomy, the most common major nonobstetric operation, is performed in more than 570,000 women in the United States each year. Although the number of hysterectomies has decreased in recent years, many authorities believe that hysterectomy is often unnecessary and unjustified.
There is no universally accepted set of criteria regarding the appropriate indications for hysterectomy. The main indications for hysterectomy include the following conditions: uterine leiomyomas, dysfunctional uterine bleeding, endometriosis/adenomyosis, chronic pelvic pain and genital prolapse.
Current literature, however, routinely recommends conservative management of most nonmalignant gynecologic conditions, with hysterectomy reserved for refractory cases.
Several nonmedical factors, such as patient race, age, geographic location, medical history and background, as well as health care provider characteristics, such as time since completion of training, gender, and affiliation with teaching hospitals, are also associated with hysterectomy rates.
Kramer MG & Reiter RC: Hysterectomy: indications, alternatives and predictors [see comments]. Am Fam Physician, 1997 Feb 15, 55:3, 827-34.
Post-hysterectomy prolapse
Explored the epidemiology of uterovaginal and post-hysterectomy prolapse.
The incidence of hospital admission with prolapse is 2 per 1,000 person-years of risk. Age, parity, calendar period and weight were significantly associated with risk of an inpatient admission with prolapse after adjustment for principal confounding factors.
The incidence of prolapse which required surgical correction following hysterectomy was 4 per 1000 person-years of risk. The cumulative risk rises from 1% three years after a hysterectomy to 5% 15 years after hysterectomy. The risk of prolapse following hysterectomy is 6 times higher in women whose initial hysterectomy was for genital prolapse as opposed to other reasons.
Among the potential risk factors that were investigated, parity shows much the strongest relation to prolapse.
Mant J et al., Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol, 1997 May, 104:5, 579-85.
Mitral valve prolapse
Mitral valve prolapse (1) - congenital?
The prevalence of mitral valve prolapse (MVP) at birth was studied in 1,734 consecutive newborns without congenital structural heart disease.
Did not not identify any case of an unequivocal pattern of MVP using auscultatory and echocardiographic diagnostic criteria.
Data argue for the concept that MVP is an acquired disease.
Nascimento R et al., Is mitral valve prolapse a congenital or acquired disease? Am J Cardiol, 1997 Jan 15, 79:2, 226-7.
Mitral valve prolapse (2) - hiatal hernia
Cardiological investigation of 23 children (13 boys) with sliding hiatal hernia revealed mitral valve prolapse in 18 patients (10 boys) suggesting a very high association rate of 78%. No other signs of connective tissue weakness were seen.
Cardiological evaluation is recommended in every child with hiatal hernia.
Horvath M: Association of hiatal hernia with mitral valve prolapse. Eur J Pediatr, 1997 Jan, 156:1, 35-6.
Mitral valve prolapse (3) - hypomagnesemia
Mitral valve prolapse syndrome (MVP) is a frequent disorder characterized by a number of complaints which lessen the quality of life. The pathogenesis of MVP symptoms has not been fully elucidated. Hyperadrenergic activity and magnesium deficiency have been suggested.
Verified the concept that heavily symptomatic MVP is accompanied by hypomagnesemia and elucidated whether magnesium supplementation alleviates the symptoms and influences adrenergic activity.
Assessed serum magnesium in 141 subjects with heavily symptomatic primary MVP and in 40 healthy controls. Decreased serum magnesium was found in 60% of patients and in 5% of controls.
Lichodziejewska B et al., Clinical symptoms of mitral valve prolapse are related to hypomagnesemia and attenuated by magnesium supplementation. Am J Cardiol, 1997 Mar 15, 79:6, 768-72.
Cervical prolapse
Uterine cervical prolapse concurrent with pregnancy is rare.
May be treated unsuccessfully with a vaginal pessary to maintain cervical placement.
The threat of preterm labor and delivery warrants close observation.
Brown HL: Cervical prolapse complicating pregnancy. J Natl Med Assoc, 1997 May, 89:5, 346-8.
Testis
Systematically examined conditions characterized by the presence of genital anomalies in humans, noting in each condition the position of the gonad, the nature of the gubernaculum and cranial suspensory ligament can provide valuable information regarding the mechanisms controlling the final position of the gonads.
In conditions where MIS is absent, the gubernaculum is "feminized', resulting in a testis in the position normally occupied by an ovary or an abnormally mobile testis that can prolapse to the inguinal region.
In conditions of androgen insensitivity the testis is located in the inguinal region, indicating that the first phase of descent is normal but that inguinoscrotal descent has failed to occur.
Ovarian descent fails to occur in congenital adrenal hyperplasia, despite exposure of the developing fetus to high levels of androgens, indicating that androgen alone does not control gonadal descent
MIS controls the swelling reaction in the male gubernaculum, which is responsible for the first phase of testicular descent to the inguinal region.
The second or inguinoscrotal phase of descent is androgen-dependent. Regression of the cranial suspensory ligament is also androgen-dependent: however, it is the gubernaculum and not the presence or absence of the cranial suspensory ligament which controls testicular descent.
This knowledge enables the clinician to accurately predict the internal anatomy of these complex sexual anomalies.
Clarnette TD et al., Genital anomalies in human and animal models reveal the mechanisms and hormones governing testicular descent. Br J Urol, 1997 Jan, 79:1, 99-112.
Uterine prolapse
Contents:
Fecal incontinence [Women]
Genital prolapse
Interdisciplinary treatment
Uterus (1)
Fecal incontinence [Women]
Determined the prevalence of, and factors associated with, fecal incontinence in women with urinary incontinence, or pelvic organ prolapse.
Fecal incontinence was defined as the involuntary loss of feces sufficient to be considered a problem by the patient.
The overall prevalence was 17%.
Any degree of pelvic organ prolapse, increasing degrees of prolapse within each vaginal segment, urinary incontinence, advanced age, postmenopausal status, increased vaginal parity, prior hysterectomy, history of irritable bowel syndrome, and abnormal sphincter tone were associated significantly with fecal incontinence.
There is a high rate of fecal incontinence in women with urinary incontinence and pelvic organ prolapse. Clinicians providing health care to a similar group of women should inquire routinely and specifically about fecal incontinence.
Jackson SL et al., Fecal incontinence in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol, 1997 Mar, 89:3, 423-7.
Genital prolapse
Operations on women for major genital prolapse.
Vesical ptosis and urinary stress incontinence treatment is carried, at one and the same time, through intervesico-vaginal prothesis and/or retropublic pexy. Long dated failures depend usually more on the sphincteral insufficiency than on the recurrence of the cervico-vesical ptosis.
Perineal and vesico-sphincteral re-education on one hand, substitutive hormonotherapy on the other hand, add a "plus" essential to the surgical repair. Sphincteral bladder insufficiency remains an ill controlled handicap. These desorders are more the consequence of constitutional fragility of connective tissue rather than obstetrical traumatism.
Seneze, J et al:[Treatment of genital prolapse. Long term results. [Traitement des prolapsus genitaux. Resultats a long terme.]. Bull Acad Natl Med 1995 Nov;179(8):1643-56.
Interdisciplinary treatment
Weakness of the pelvic floor usually affects women. The most frequent complaints are urinary incontinence and visceral descent. The usual methods of gynaecological and urological operations to cure these impairments are demonstrated. Because several patients with a lax pelvic floor suffer from anorectal incontinence a simultaneous interdisciplinary treatment is proposed.
Hansen, H:[Pelvic floor insufficiency as an interdisciplinary responsibility.] [Beckenbodeninsuffizienz als interdisziplinare Aufgabe.] Chirurg 1996 May;67(5):498-504.
Uterus (1)
Determined differences in the characteristics and type of genital prolapse in young women compared with older women.
Patients (# 191) had well-documented genital prolapse to, or beyond, the hymen. They were stratified into two age groups, those over 35 years and those 35 or younger.
Comparisons included: "complexity" of prolapse (i.e., the total number of deficient sites per patient), grade of prolapse, parity and coexistent medical conditions.
Young women were more likely than older women to have:
1) potential predisposing medical conditions (congenital anomalies or neurologic or connective tissue diseases) (22.2% versus 6.7),
2) lower mean parity (2.8 versus 3.4),
3) only one site of prolapse (56% versus 23%), and
4) lower grade of prolapse (33% versus 87% grade 3 or higher).
A higher than expected prevalence of congenital anomalies, as well as rheumatologic and neurologic diseases in the younger women is intriguing, but further study is necessary before these conditions can be implicated in the genesis of genital prolapse.
Strohbehn K et al., Pelvic organ prolapse in young women. Obstet Gynecol, 1997 Jul, 90:1, 33-6.
Uroflowmetry
Characterized uroflowmetry parameters in women with pelvic organ prolapse (POP) and urinary incontinence (UI) and assessed the effects of clinical and urodynamic variables on these parameters.
Of 655 patients, 471 (72%) had UI of whom 16% had pure detrusor instability (DI), 69% pure genuine stress incontinence (GSI) and 15% with both, and 184 (28%) had POP, 26% of whom also had DI.
Of all patients, 72% had normal uroflowmetry patterns, 13% had multiple peaks and 15% had patterns with interrupted flow; 56% had completely normal uroflowmetry.
There were significant differences in uroflowmetry values between the POP and UI groups, with the former having a lower Q(max) and Q(mean), larger PVRs and a lower percentage of totally normal uroflowmetry (33% and 64%, respectively).
Women with POP had more objective evidence of emptying-phase dysfunction than women with UI, although most emptied their bladders efficiently.
Coates KW et al., Uroflowmetry in women with urinary incontinence and pelvic organ prolapse. Br J Urol, 1997 Aug, 80:2, 217-21.
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