Paravaginal Defect Repair

Paravaginal Defect

The goal of the paravaginal defect repair is to correct anterior vaginal wall prolapse that results from loss of lateral support by reattaching the lateral vaginal sulcus to its normal lateral attachment site. The lateral vagina attaches to the levator ani muscle on each side along a line from the anterior pubic rami to the ischial spine known as the white line or arcus tendineus fasciae pelvis (ATFP). The ATFP is formed from a condensation of the obturator internus and levator ani fascia and...

Genital Prolapse

Genital prolapse is a common condition that can affect women of all ages. Multiple risk factors have been identified and studied that are thought to contribute to the development of genital prolapse, including age, parity, menopausal status, body mass index (> 30kg m2), race, genetics, connective tissue disease, tobacco use, chronic lung disease, chronic constipation, occupational straining, and previous surgery. Genital prolapse is a general term for weakening or loss of support to the...

Partial Colpocleisis Latzko Procedure

This technique was described by Latzko as an alternative repair of simple, deep vaginal vault fistulas. This procedure is convenient for fistulas less than 1.5 cm. It does not involve excision of the fistula nor does it place any intrav-esical sutures, thus eliminating the need for performing ureteral reimplantation. The procedure requires a short period of hospitalization. However, the disadvantage of this partial colpocleisis is shortening of the vagina. Figure 13-1.1. Circumferential...

Laparoscopic Augmentation Cystoplasty

Augmentation cystoplasty remains the most widely accepted reconstructive technique for creating a compliant, large-capacity bladder that protects the upper urinary tract and provides urinary continence for people with bladder dysfunction secondary to noncompliance or reduced functional capacity. This form of bladder reconstruction may even be combined with developing a continent catheteriz-able stoma for use as an accessible port for bladder emptying. Since 1888, the standard enterocystoplasty...

Sacrospinous Ligament Fixation

The sacrospinous fixation is likely the most popular vaginal approach to vaginal vault suspension in the United States (US). Initially described in Germany and popularized in the US during the 1980s, this procedure has a high degree of effectiveness and longevity in restoring vaginal vault support. The vaginal apex is attached to the sacrospinous ligaments with permanent or delayed absorbable sutures. The procedure can be performed via a posterior vaginal dissection or anterior paravaginal...

Efficacy of Biofeedback Literature Review

When interpreting the reported clinical outcomes, one should keep in mind that there are no established guidelines regarding the number of sessions, teaching methods, clinician qualifications, type of equipment used, or patient inclusion criteria, nor are there subjective or objective data used to establish success. Hyman et al.4 reported in their critical review that perhaps most importantly, there is no identified standard for training biofeedback clinicians to treat pelvic floor disorders....

Anterior Colporrhaphy

The excess vaginal epithelium is then trimmed and the incision is closed with use of a 2-0 polyglycolic acid suture. A vaginal pack is then placed for postoperative hemostasis. Cystoscopy should then be performed to ensure bladder and ureteral integrity. Anterior vaginal prolapse resulting from a central defect is best corrected through a transvaginal approach. The anterior colporrhaphy was popularized by Howard Kelly in 1912,2 and although no longer an acceptable treatment for stress urinary...

Potential Risk Factors

Epidemiologic studies conducted in various populations reveal a number of variables related to the development of UI including several possible risk factors.2 Most studies have found that the prevalence of UI tends to increase with advancing age.3-5 Prevalence has always been higher in institutionalized adults because residents in institutions tend to be older and more impaired than commu nity dwellers. Some studies have found that the proportions of types of UI differ by age. A survey of young...

Treatment of Complex Rectovaginal Fistulas

Complex fistulas are high, large, or recurrent and are often secondary to cancer, IBD, or radiation. Consequently, the condition of surrounding tissues (involved with cancer, IBD, scar, or irradiation) may preclude repair with local procedure such as the advancement flap.3 These types of fistulas occur more often in older patients with numerous comorbid conditions, and therefore require more careful preoperative evaluation. In addition,the fistulas themselves require more intense evaluation by...

Anal Sphincter Repair

Fecal continence relies on normal sensory, motor, and reflex activity of the colon, rectum, and anus. Stool consistency, colonic transit, rectal sensation, neural integrity, and sphincter function all have a role in individual control of stool and gas. The principal component in facilitating continence is the anal sphincter, whereas the hemorrhoidal cushions, sensory epithelium of the anal mucosa, intrinsic anorectal reflexes, and pelvic floor muscles contribute to its function. The anal...

Modified McCall Culdoplasty

McCall7 described the technique of surgical correction of enterocele and deep cul-de-sac during vaginal hysterectomy. The McCall culdoplasty closes the redundant cul-de-sac and associated enterocele, provides apical support, and lengthens the vagina. In a randomized study, Cruikshank and Kovac8 demonstrated the superiority of McCall culdoplasty to uterosacral plication and simple peritoneal closure in the prevention of posthysterectomy enterocele. For this reason, we advocate using this...

Treatment of Simple Rectovaginal Fistulas

Rectovaginal Fistula

Simple fistulas may be approached through the vagina, perineum, or rectum. Vaginal approaches are most often used by gynecologists and include the inversion technique and the layered closure. With the patient in the lithotomy position, the inversion technique involves exposure of the fistula by pressure on the rectal side. The vaginal mucosa is incised circumferentially around the fistula. A purses-tring suture is placed in the fistula tract and the needle is passed to the rectal side. Tying of...

Rectoanal Intussusception

Rectoanal intussusception and SRUS have many common features. Dysfunction of the rectum with the development of abnormal defecatory patterns is usually the underlying pathogenesis. Chronic straining may induce intussusception of the rectal mucosa, which in turn may develop into full-thickness rectal prolapse. The occult intussusception may also predispose to a persistent feeling of incomplete evacuation with the chronic urge to strain. Straining may cause excessive tensile forces on the...

The Constipation Scoring System

The clinical presentation of constipation includes a broad spectrum of symptoms, partially attributed to the myriad etiologies. Specifically, constipation may result from slow transit,pelvic outlet obstruction,or other mechanical,phar-macologic, metabolic, endocrine, and neurogenic reasons. Generally, physicians use the term constipation to define infrequent,incomplete,difficult,or prolonged evacuation or to describe stools that are too difficult to pass. However, many patients are more...

Overlapping Sphincter Repair

For most women with fecal incontinence secondary to obstetric trauma, sphincter damage is often occult, persistent, or associated with pudendal nerve damage leading to fecal incontinence many years after delivery. For women with fecal incontinence secondary to a functional yet anatomically disrupted anterior EAS, overlapping sphinc-teroplasty is the operation of choice. This technique is the result of an evolution of a variety of modifications of the initial descriptions of sphincter repair....

Practical Aspects of Biofeedback Therapy for Pelvic Floor Dysfunction

Practical aspects of biofeedback therapy for PFM dysfunction to treat symptoms of urinary incontinence, voiding dysfunction, constipation, and fecal incontinence include the technical, therapeutic, behavioral, and pelvic muscle rehabilitation (PMR) components. The technical component involves the instrumentation used to provide meaningful information or feedback to the user. Devices include surface electromyography (sEMG), water-perfused manometry systems, and the solid-state manometry systems...

Sigmoidoceles

A sigmoidocele, similar to an enterocele, is a true hernia with a break in the fascial supports of the upper vagina-uterosacral-cardinal ligament complex and the rectovagi-nal septum. With increased abdominal pressure, the sigmoid herniates into the cul-de-sac, through the defect, and abuts the vaginal mucosa. This requires a significant redundancy in the sigmoid and a deep cul-de-sac to allow herniation to occur. Sigmoidoceles are believed to cause constipation by obstructing defecation....

Causes of Female Sexual Dysfunction

Similar to its counterpart in the male, there are numerous causes of FSD (Table 5-1.3). In fact, any factors influencing normal physiology, or any step of the sexual response in women, may contribute to FSD. The etiologies can be grouped as being either psychogenic or organic in nature, although overlap often exists. Psychogenic FSD may be noted as either a result of, or a causative factor for, depression. In fact, it behooves the physician to rule out a primary diagnosis of depression in any...

Interstitial Cystitis Painful Bladder Syndrome

Khater Interstitial cystitis (IC) is a chronic, debilitating disease of the urinary bladder characterized by urinary frequency, nocturia, urgency, and frequently pain. It affects more females than males by a ratio of approximately 10 1.' Recently, the International Continence Society has developed a somewhat broader term for IC described as IC-painful bladder syndrome. This new term is defined as the complaint of suprapubic pain related to bladder filling, and is...

Antidepressants and Female Sexual Dysfunction

Although numerous medications can have an adverse impact on sexual function, few classes of medications have been demonstrated to have more impact on sexual function than antidepressants. Although many of the various classes of antidepressant agents can affect sexual function, the selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, sertraline, or fluoxetine, have been shown to adversely affect libido, arousal, as well as the ability to reach orgasm.27 Under a physician's care,...

Colectomy with Ileorectal Anastomosis

Surgical treatment is guided by the results of the specific investigations.3-5 Patients with slow transit constipation, as demonstrated by the failure to eliminate all markers by 7 days during the colonic transit study should be considered for a colectomy and ileorectal anastomosis (IRA). However, this may not be the best option for patients who are unable to evacuate a balloon in the anal physiology laboratory as this may signal rectal dysfunction. Nonetheless, these patients may still be...

Oxybutynin

Oxybutynin is an antimuscarinic agent with pronounced antispasmodic effects and local anesthetic activity, and it has served as the gold standard for treatment of OAB for 3 decades. Several double-blind, controlled studies have demonstrated its efficacy with reports of 50 symptomatic improvement in 61 to 86 of subjects at 15mg daily.4 The original formulation (OXY-IR) is an immediate-release oral administration dosed at 5 mg three to four Table 7-1.1. Available anticholinergic agents for...

Treatment

Women diagnosed with vulvar vestibulitis, particularly at specialty centers, have usually seen multiple clinicians, received numerous courses of medications for infections, and have often been told the problem is psychological. Giving patients a firm diagnosis, reassuring them the problem is real and not in their head, and using the examination to educate them on their genital anatomy can assuage many of their anxieties and increase compliance with recommended therapy. Removing all possible...

Timed Voiding and Fluid Management

Paraiso and George Abate Timed voiding (also referred to as bladder retraining training, bladder drill, bladder discipline, and bladder reeducation) is a behavioral exercise used to establish bladder control in adults. Evidence indicating that bladder training is effective in women with urodynamic urge incontinence with or without associated detrusor overactivity, sensory-urgency without incontinence,1 and urodynamic stress incontinence,2 has led to the 1996 Clinical Practice...

Anorectal Coordination Maneuver for Constipation and Dysfunctional Voiding

The goal is to produce a coordinated movement that consists of increasing intraabdominal (intrarectal) pressure while simultaneously relaxing the pelvic muscles. During the initial sEMG evaluation of the Valsalva maneuver, patients are asked to bear down or strain as if attempting to void or evacuate, which may elicit an immediate pelvic muscle contraction and closure of the anorectal outlet. This correlates with symptoms of constipation including excessive straining and incomplete evacuation....

Risk of Failure and Complications

Clinical conditions that increase the risk of surgical failure for retropubic urethropexy include obesity, menopause, prior hysterectomy, and prior anti-incontinence proce- dures. Advanced age does not seem to be associated with lower rates of cure after colposuspension. Urodynamic findings that increase the risk of surgical failure include signs of intrinsic urethral sphincter deficiency, abnormal perineal electromyography, and concurrent detrusor over-activity. Patients with intrinsic...

Enterourinary Fistula

T.Cristina Sardinha,Samir M.Yebara,and Steven D.Wexner Enterourinary fistulas are usually the result of underlying pathology involving the gastrointestinal or genitourinary tract. Pathologies such as diverticulitis, Crohn's disease, radiation enteritis, trauma, iatrogenic injury, bladder cancer, appendicitis, colon carcinoma, and gynecologic tumors are causes of enterourinary fistulas. The true incidence of enterourinary fistula is unknown, although the most frequent site of fistulization is...

Magnetic Resonance Imaging

Utites Prolaps

The development of fast-scanning magnetic resonance imaging (MRI) techniques has improved our ability to describe and quantify anatomical changes that may cause pelvic floor relaxation. Yang et al.3 were the first to popularize dynamic fast MRI for the evaluation of pelvic organ prolapse. Since then, other investigators have shown that MRI is more sensitive than physical examination for defining pelvic prolapse.4,5 Whereas some advocate the use of contrast opacification of the bladder, vagina,...

Treatment of Urogenital Atrophy

Estrogen replacement therapy is the hallmark of treatment for urogenital atrophy. Because the underlying factor for atrophic changes is a devascularization process, systemic estrogen replacement may not impact the urogenital tissues. This was best described in the recent HERS trial, where stress incontinence symptoms actually worsened on low-dose systemic estrogen replacement therapy.4 Table 11-1.2. Urogynecologic aspects of local estrogen replacement Primary indications Atrophy with urgency,...

Female Sexual Dysfunction and Colorectal Surgery

The occurrence of sexual dysfunction after CRS is a well-recognized phenomenon. Prior studies in men have demonstrated that the incidence of sexual dysfunction is between 20 and 34 in patients undergoing rectal excision, and is related to the extent of the procedure.9 Sexual dysfunction has been attributed to damage of the autonomic nerves, especially during pelvic dissection. Injury to the sympathetic nerves often results in retrograde ejaculation whereas parasympathetic nerve injury can...

Contents

vii ix SECTION I Concept of the Pelvic Floor as a Unit 1-1 Concept of the Pelvic Floor as a Unit SECTION II Epidemiology and Prevalence 2-1 Epidemiology of Non-Neurogenic Urinary Dysfunction Usama M. Khater, Gassan Haddad, and Gamal M. Ghoniem 9 James Doty and Jonathan E. Efron 15 2-3 Genital Prolapse, Urogenital Atrophy, and Sexual Dysfunction Minda Neimark 19 Gamal M. Ghoniem 26 3-1 Primary Evaluation of the Pelvic Floor Nathan Guerette, Dana R. Sands, and G. Willy Davila 27 Gamal M. Ghoniem...

Neurologic Evaluation of the Pelvic Floor

Pudendal Electromyography

Several elegant methods of neurophysiologic assessment of the anal and urethral sphincters exist. Their purpose is to help localize the site of neurologic pathology leading to the disturbance of bowel and bladder continence and evacuation. Although the clinical neurologic examination may sufficiently determine if the lesion involves the muscle or the nerve control to the muscle, a quantitative assessment of the disturbance by neurophysiologic means is often needed for clinical monitoring and...

Acupuncture for Pelvic Floor Dysfunction

Acupuncture is an important mainstay of traditional Chinese medicine (TCM). Empirically derived by thousands of years of observation, Chinese medical doctors recorded their treatments almost 2000 years ago in the then modern text, Yellow Emperor's Book of Internal Medicine. Although the physiologic reasoning may seem bizarre to modern allopathic physicians, accepting and understanding the basic tenets does then provide a logical choice of therapy that has withstood the test of time,longer than...

Suggested Reading

Evolving concepts in the pathophysiology of functional gastrointestinal disorder. J Clin Gastroenterol 2002 35(suppl 1) S2-S6. 2. Thumshirn M. Pathophysiology of functional dyspepsia. Gut 2002 51(suppl 1) i63-i66. 3. Talley NJ. Dyspepsia management guidelines for the millennium. Gut 2002 50(suppl IV) iv72-iv78. 4. Talley NJ, Janssens J, Lauritsen K, Racz I, Bolling-Sternevald E. Eradication of Helicobacter pylori in functional dyspepsia randomized double blind placebo controlled trial...

Sphincter of Oddi Dysfunction

Sphincter of Oddi dysfunction (SOD), also referred to as biliary dyskinesia, presents with typical symptoms of biliary colic of right upper quadrant pain with nausea and vomiting. However, this pain is not actually caused by gallstones but instead a motility disorder with spasms of the sphincter of Oddi. By definition, an ultrasound would not show gallstones. In fact, the majority of these patients have already undergone a cholecystectomy, either for gallstones or suspected microlithiasis,...

Dyspepsia

Dyspepsia is derived from the Greek dys and peptein, which literally interpret as bad digestion. The term dyspepsia encompasses a variety of symptoms of persistent upper abdominal pain and discomfort. The predominant symptoms may include pain, heartburn, nausea, early satiety, or postprandial fullness or bloating. This is the most common type of functional upper GI disorder, with a prevalence rate in Western countries estimated at 25 , although less than half will seek medical attention. There...

Bowel Retraining for Anal Incontinence

Anal incontinence is the involuntary loss of control of rectal contents (solid, liquid, or gas) and can be secondary to a variety of causes. Conservative measures such as dietary manipulation, pharmacologic intervention, scheduled rectal emptying, perineal exercises, and biofeedback therapy are effective in many patients who are not surgical candidates or who do not desire surgical intervention for fecal incontinence. The bowel can then be trained to effectively reestablish continence using...

Biofeedback Sessions

At Cleveland Clinic Florida, all patients are requested to keep a 3- to 7-day diary of bladder and bowel habits, laxative, enema, or suppository use, fluid intake, number of home exercises completed, fiber intake, and any associated symptoms of constipation or incontinence. The initial session begins with a history and description of the anatomy and physiology of the bowel, bladder, and pelvic muscle function using anatomic diagrams and visual aids. This is followed by a description of the...

Bowel Retraining for Constipation

The surgeon's first priority when faced with a patient complaining of constipation is to eliminate mechanical obstruction as the cause of the constipation. A complete history and physical examination should be performed. The history needs to focus on multiple factors, but specific attention should be given to the patient's medications as well as their diet and exercise regimen. If mechanical obstruction has not been ruled out before evaluation of the patient, this should be done either by...

Vaginal Devices

Urethral Insertion Tampon

Pessaries have long been used to treat stress urinary incontinence. Standard-shaped pessaries, or those that have been modified with a ball or a protuberance, may successfully treat incontinence. These pessaries stabilize the bladder neck and increase urethral resistance. Vierhout and Lose2 found a 63 subjective cure or improvement rate with pessary use in their review of the literature. A 36 to 66 rate of complete continence has been reported when pessaries were used to treat exercise-induced...

Uroflowmetry

Uroflowmetry Patterns

Uroflowmetry is the measurement of urine flow rate over time, and is the most commonly used urodynamic study. It is performed as an initial screening test when voiding dysfunction is suspected, and the results may prompt further investigations. Uroflowmetry is performed by having the patient void into a specially designed commode that allows the volume voided to be measured over time. Uroflowme-ters use various measurement techniques,such as the rotating disk method, electronic dip, weight...

Evacuation Disorders

One of the most common complaints of patients seeing colorectal surgeons is constipation. The prevalence of chronic constipation in the United States varies from 2 to 34 .' Constipation is caused by several etiologies. Pelvic outlet obstruction POO is a common cause of constipation and is attributed to muscular dysfunction of the pelvic floor. The reported incidence of POO as a cause of constipation was reported as high as 50 at a tertiary referral center.2 Population studies have demonstrated...

Contributors

George Abate, DO Department of Obstetrics and Gynecology, The Cleveland Clinic Foundation, Cleveland, OH, USA Joseph Abdelmalak, MD Glickman Urological Institute, The Cleveland Clinic Foundation, Cleveland, OH, USA Matthew D. Barber, MD, MHS Section of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, The Cleveland Clinic Foundation, Cleveland, OH, USA Daniel H. Biller MD Section of Urogynecology and Reconstructive Pelvic Surgery, Department of...