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Pelvic Floor: General

Morphologic study on levator ani muscle in patients with pelvic organ prolapse and stress urinary incontinence.
Zhu L, Lang JH, Chen J, Chen J
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):401-4. Epub 2005 Jul 9.

The objective of this study was to determine the morphologic changes of the levator ani muscle of patients with pelvic organ prolapse and stress urinary incontinence. Histological and histochemical analyses of the biopsy specimens of the levator ani muscle obtained from patients with stress urinary incontinence (SUI), pelvic organ prolapse (POP), and a control group were performed. The striated muscle-positive biopsy rate was 26.7% in the SUI group, 15.8% in the POP group, whereas it was 100% in the control group. The diameters of types I and II fibers decreased significantly with age and menopausal time in the control group. Splitting or fragmentation of fibers with red granules, which are called ragged-red fibers, were found in the SUI group. The diameters of levator ani muscle fibers in the control group were significantly larger than those in the SUI group (p=0.034<0.05). The degenerative change in histology and decrease in relative number of levator ani muscle might be associated with women suffering from SUI.

Dr. George Hayward (1791-1863): a forgotten pioneer of reconstructive pelvic surgery.
Wall LL
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):330-3. Epub 2005 Jun 23.

American surgeon George Hayward (1798-1863) has become lost to the historical memory of practicing urologists and urogynecologists, yet he deserves to be remembered for his important contributions to the advancement of pelvic surgery. In addition to being an observant commentator on the surgical practice of his day, he performed the first major operation carried out under ether anesthesia and he was the originator of the "flap-splitting" operation for the repair of vesico-vaginal fistula commonly, but erroneously, attributed to Lawson Tait. This article reviews George Hayward's career and professional accomplishments with the hope of restoring his well-deserved prominence as a pioneer of reconstructive pelvic surgery.

Functional bowel and anorectal disorders in patients with pelvic organ prolapse and incontinence.
Jelovsek JE, Barber MD, Paraiso MF, Walters MD
Am J Obstet Gynecol 2005 Dec;193(6):2105-11.

OBJECTIVE: The purpose of this study was 1) to determine the prevalence of functional bowel and anorectal disorders as defined by the Rome II criteria in patients with advanced pelvic organ prolapse (POP) and urinary incontinence (UI), and (2) to determine if the extent of prolapse on gynecologic examination is related to the subtypes of constipation or any functional anorectal pain disorder. STUDY DESIGN: Three hundred and two consecutive female subjects presenting to a tertiary urogynecology clinic were enrolled. Demographic, general medical, and physical examination information, including POPQ measurements and a standardized sacral neurologic evaluation, were collected. The prevalence of functional disorders of the bowel, rectum, and anus as defined by the Rome II criteria were collected using the Rome II Modular questionnaire. Relationships of functional disorders to various components of the vaginal examination were reviewed. RESULTS: Thirty-six percent (108/302) met the criteria for constipation, including the following subtypes: 19% outlet constipation, 5% functional constipation, 5% constipation predominant irritable bowel syndrome (IBS), and 7% IBS-outlet. Nineteen percent (56/302) of subjects had IBS or 1 of its subtypes. Functional diarrhea was seen in 6% (17/302), fecal incontinence in 19% (58/302), and anorectal pain disorders in 25% (77/302). After controlling for age, parity, diabetes, constipating medications, and previous pelvic surgery, there were no differences in the prevalence of constipation or any of its subtypes between patients with UI and those with stage 3 or 4 POP. Fecal incontinence was independently associated with UI (adjusted odds ratio [OR] 6.3; 95% CI 2.6-19.1), but not advanced POP. Neither overall stage of POP nor stage of posterior vaginal prolapse was significantly associated with any of the functional bowel disorders, including constipation and its subtypes. Perineal body measurement was significantly longer in patients with outlet type constipation (mean 3.5 +/- 0.6 cm vs 3.1 +/- 0.9 cm, P < .01) and in those with proctalgia fugax (mean 3.4 +/- 1.0 vs 3.1 +/- 0.8, P < .05). CONCLUSION: There is a high prevalence of constipation and anorectal pain disorders in women with urinary incontinence and pelvic organ prolapse. However, patients with stage 3 or 4 pelvic organ prolapse have similar rates of constipation compared with those with urinary incontinence. Constipation and its subtypes are not related to the stage of pelvic organ prolapse. It appears that either constipation is not a significant contributor to prolapse, or constipation contributes equally to the development of both urinary incontinence and pelvic organ prolapse.

Concerns regarding pelvic reconstructive surgery.
Shull B, Karram MM
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul-Aug;16(4):251-2.

Should women be offered elective cesarean section in the hope of preserving pelvic floor function?
Sand PK
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul-Aug;16(4):255-6. Epub 2005 Jun 2.

Should women be offered elective cesarean section in the hope of preserving pelvic floor function?
Nygaard I
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul-Aug;16(4):253-4. Epub 2005 Jun 2.

Descending Perineum Syndrome: Are Abdominal Hysterectomy and Bowel Habits Linked?
Pucciani F, Boni D, Perna F, Bassotti G, Bellini M
Dis Colon Rectum 2005 Sep 22;.

PURPOSE: This retrospective study evaluates the effect of abdominal hysterectomy on patients affected by descending perineum syndrome. METHODS: Eighty-nine female patients affected by descending perineum syndrome and one group of 10 healthy women with normal bowel habits were studied retrospectively. Thirty-two descending perineum syndrome patients (Group 1) had received an abdominal hysterectomy for benign diseases, while 57 descending perineum syndrome patients (Group 2) had not undergone this surgery. All 99 subjects underwent clinical evaluation, computerized anorectal manometry, and defecography. RESULTS: Dyschezia was found predominantly in Group 2 subjects (P < 0.05). Fecal incontinence was significantly higher in Group 1 than in Group 2 (P < 0.05). The worst anal resting pressure was found in the incontinent Group 1 patients (P < 0.01). Rectoanal intussusception was a significant defecographic sign in Group 1 subjects (P < 0.05). CONCLUSIONS: Clinical evaluation and instrumental data suggested a possible link between fecal incontinence and abdominal hysterectomy in patients affected by descending perineum syndrome.

Evidence for the innervation of pelvic floor muscles by the pudendal nerve.
Guaderrama NM, Liu J, Nager CW, Pretorius DH, Sheean G, Kassab G, Mittal RK
Obstet Gynecol 2005 Oct;106(4):774-81.

OBJECTIVE: To evaluate whether the pudendal nerve innervates the levator ani muscles by assessing the effect of pudendal nerve blockade on pelvic floor muscle function. METHODS: Eleven nulliparous women without symptoms of anal or urinary incontinence were studied before and after pudendal nerve blockade with vaginal manometry, electromyography of the external anal sphincter and puborectalis muscle, and 3-dimensional transperineal ultrasound imaging of the urogenital hiatus during rest and squeeze. RESULTS: After pudendal nerve blockade, mean vaginal resting pressures decreased from 19 +/- 10 mm Hg to 15 +/- 10 mm Hg (P < .05), and mean vaginal squeeze pressures decreased from 61 +/- 29 mm Hg to 37 +/- 24 mm Hg (P < .05). After pudendal nerve blockade, the anterior-posterior length of the urogenital hiatus increased from 51 +/- 4 mm to 55 +/- 5 mm at rest (P < .05) and increased from 47 +/- 3 mm to 52 +/- 5 mm during squeeze (P < .05). Resting and squeeze electromyography amplitude of the external anal sphincter and puborectalis muscle was markedly reduced by pudendal nerve blockade. CONCLUSION: Pudendal nerve blockade decreases vaginal pressures, increases length of urogenital hiatus, and decreases electromyography activity of the puborectalis muscle, all of which suggest that the pudendal nerve does innervate the levator ani muscle. LEVEL OF EVIDENCE: II-2.

Arcus tendineus fascia pelvis: a further understanding.
Albright TS, Gehrich AP, Davis GD, Sabi FL, Buller JL
Am J Obstet Gynecol 2005 Sep;193(3 Pt 1):677-81.

OBJECTIVE: The study was undertaken to further define the anatomy of the arcus tendineus fascia pelvis (ATFP). STUDY DESIGN: Thirty cadavers were dissected to find the average length, SD, and range of the ATFP. Comparisons were made to height and pelvis type. The average distance between the ischial spine and the attachment of the fascia of the rectovaginal septum (RVF) to the ATFP was measured. RESULTS: The average length, SD, and range in centimeters for the ATFP are 9.0, 0.70, and 7 to 10.5, respectively. The length of the ATFP increased with height. No associations could be made regarding pelvis type. The average distance between the ischial spine and the attachment of the RVF to the ATFP is 2.15 cm with a SD and range of 0.21 and 1.75 to 2.5, respectively. CONCLUSION: In this study, an average length for the ATFP is established and the distance between the ischial spine and the attachment of the RVF to the ATFP is redefined.

Terminologia Anatomica versus unofficial descriptions and nomenclature of the fasciae and ligaments of the female pelvis: A dissection-based comparative study.
Ercoli A, Delmas V, Fanfani F, Gadonneix P, Ceccaroni M, Fagotti A, Mancuso S, Scambia G
Am J Obstet Gynecol 2005 Oct;193(4):1565-1573.

OBJECTIVE: The aims of this study were: (1) to define and classify those connective structures of the female pelvis that are of potential clinical interest, (2) to evaluate the adequacy of the Terminologia Anatomica (official nomenclature) and (3) to establish a correspondence between the official nomenclature and the most commonly used terms. STUDY DESIGN: The results of 30 macroscopic and laparoscopic dissections of fresh cadavers with and without vessel injection of colored latex solutions were compared with the descriptions and definitions in the Terminologia Anatomica and the most frequently cited English and non-English literature from 1890 to 2003. RESULTS: We identified 3 groups of fasciae, parietal pelvic fascia, visceral pelvic fascia, and extraserosal pelvic fascia, which could be divided into diverse clinically relevant anatomical structures characterized by different locations, spatial orientation, and consistency. These structures differed considerably with regard to number and nomenclature from those described in the Terminologia Anatomica and part of the literature. CONCLUSION: Our results suggest that the official terminology applied to the connective structures of the female pelvis could be profitably revised and expanded. We offer a complete description of these structures and suggest a classification that may be useful for teaching and clinical purposes.

Magnetic resonance imaging of the cervix during pregnancy: Effect of gestational age and prior vaginal birth.
House M, O'callaghan M, Bahrami S, Chelmow D, Kini J, Wu D, Patz S, Bhadelia RA
Am J Obstet Gynecol 2005 Oct;193(4):1554-1560.

OBJECTIVE: To investigate how gestational age and prior vaginal birth affect cervical anatomy on magnetic resonance imaging during pregnancy. STUDY DESIGN: Magnetic resonance images of the cervix were obtained in consecutive patients referred for a suspected fetal abnormality. We used an image processing protocol to measure cervical dimensions, orientation, and signal intensity. We determined how outcome variables were affected by gestational age and prior vaginal birth. RESULTS: Adequate images were obtained in 53 of 57 patients at 17 to 36 weeks. As gestational age increased by 12 weeks, the mean cross-sectional area of the cervical canal and cervical stroma increased 31% (95% confidence interval 0% to 73%) and 31% (95% confidence interval 11% to 55%), respectively. The normalized signal intensity of the stroma increased from 0.83 (95% confidence interval 0.81 to 0.85) at 20 weeks to 0.91 (95% confidence interval 0.88 to 0.94) at 32 weeks. None of the outcome variables were affected by prior vaginal birth. CONCLUSION: Magnetic resonance imaging revealed that cross-sectional area and signal intensity of the cervical stroma increase with increasing gestational age.

Levator trauma after vaginal delivery.
Dietz HP, Lanzarone V
Obstet Gynecol 2005 Oct;106(4):707-12.

OBJECTIVE: To date, the evidence on pelvic floor injury in labor remains sketchy due to a lack of prospective studies comparing pelvic floor imaging before and after childbirth. We intended to define the incidence of major trauma to the pubovisceral muscle. METHODS: A total of 61 nulliparous women were seen at 36-40 weeks of gestation in a prospective observational study. The assessment included an interview and 3-dimensional translabial ultrasound and was repeated 2-6 months postpartum. RESULTS: Fifty women (82%) were seen postpartum. Of the 39 women delivered vaginally, levator avulsion was diagnosed in 14 (36%, 95% confidence interval 21-51%). Among those delivered vaginally, there were associations with higher maternal age (P = .10), vaginal operative delivery (P = .07), and worsened stress incontinence postpartum (P = .02). CONCLUSIONS: Avulsion of the inferomedial aspects of the levator ani from the pelvic sidewall occurred in approximately one third of all women delivered vaginally and was associated with stress incontinence 3 months after childbirth. LEVEL OF EVIDENCE: II-3.

30th Annual Meeting of the International Urogynecological Association, 9-12 August 2005, Copenhagen, Denmark. Abstracts.
Int Urogynecol J Pelvic Floor Dysfunct 2005;16 Suppl 2:S35-S130.

Endotoxin: The uninvited guest.
Gorbet MB, Sefton MV
Biomaterials 2005 Dec;26(34):6811-7.

In the laboratory environment where biomaterials are synthesized and their biocompatibility assessed, we find that endotoxin contamination is hard to avoid and must not be ignored. In those relatively few cases where endotoxin was known to be present, it has been clearly shown that endotoxin can significantly affect the biological response observed and hence confound any effect of the material. This short review explains what endotoxin is, how to test for it and remove it and what its effect on the biological response to biomaterials is. We advocate routine testing of endotoxin on biomaterials and of reagents used in experimental evaluation of biomaterials and this should be the responsibility of every scientist to ensure the validity of any biomaterial study.

The choice of elective cesarean delivery in obstetrics: a voluntary survey of Canadian health care professionals.

Farrell SA, Baskett TF, Farrell KD
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun 24;

To survey Canadian health care professionals about their willingness to offer elective cesarean delivery and to evaluate how their knowledge of obstetric-related pelvic-floor injury influences their practice. A voluntary questionnaire was distributed to health care professionals attending the 58th Annual Meeting of the Society of Obstetricians and Gynaecologists of Canada in 2002. Appropriate statistical analysis was used. One hundred and sixty-two questionnaires were completed. One hundred respondents were female (62%). Twenty-three percent (37/162) of respondents approved elective cesarean delivery after informed request in nulliparous women without an obstetrical indication. Males were more likely than females to perform cesarean delivery in these circumstances (34% versus 16%; OR 2.7, CI 1.2, 6.0). When questioned about the impact of mode of delivery on bladder and bowel continence, the number of respondents who answered "usually" or "always has a detrimental effect" were: vaginal birth, 16%; forceps, 20%; and cesarean delivery "reduces bladder and bowel problems", 44%. Males were more likely to emphasize a protective effect of cesarean delivery (55% versus 38%; OR 1.9, CI 1.0, 4.0). Health care professionals would opt for cesarean delivery for themselves when forceps delivery was the alternative more often than they would offer cesarean delivery to their patients (OR 1.98, CI 1.1, 3.5). While a significant number of women's health care professionals are prepared to offer cesarean delivery to nulliparous women, informed choice seems to motivate the offer rather than a conviction that cesarean delivery will protect the pelvic floor.

Concerns regarding pelvic reconstructive surgery.
Shull B, Karram MM
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun 22;.

Advances in urogynecology.
Klingele CJ
Int J Fertil Womens Med 2005 Jan-Feb;50(1):18-23.

Pelvic floor disorders include urinary incontinence, pelvic organ prolapse, and bowel dysfunction, all of which can cause considerable disability and anxiety. One third of all women will suffer from these disorders at some point in their life. All are often embarrassing and may act as barriers to healthy living as many women suffer in silence. The field of urogynecology has evolved over time to meet the needs of women who struggle with disorders of the pelvic floor. An increase in the awareness and treatment of these disorders has led to improved scientific research in the form of prospective randomized clinical trials to develop a unified understanding of their epidemiology, biology, and treatment. This review explores the literature that has promoted advances in the understanding of pelvic floor disorders and discusses some of the new technology and research that is being done in the field.

The hidden epidemic of pelvic floor dysfunction: achievable goals for improved prevention and treatment.
DeLancey JO. Am J Obstet Gynecol 2005 May;192(5):1488-95.

Each year, pelvic floor dysfunction affects between 300,000 and 400,000 American women so severely that they require surgery. Approximately 30% of the operations performed are re-operations. The high prevalence of this problem indicates the need for preventive strategies, and the common occurrence of re-operation indicates the need for treatment improvement. Efforts at prevention and treatment improvement will only be possible if research clarifies causative mechanisms and scientifically valid studies discover why operations fail. By reaching a goal of 25% prevention we could save 90,000 women from experiencing pelvic floor dysfunction and with 25% treatment improvement we could avoid 30,000 women from needing a second operation. To achieve these goals we must discover specific events or behaviors in a woman's life that lead to these problems and that are amenable to preventive strategies. In addition, we must define specific biologic and behavioral factors that explain why certain women have recurrence after surgery. Because the pelvic organ support system is comprised of muscles, ligaments, and nerves arranged in a complex tension-based apparatus, the basic nature of this work must include biomechanical analyses of the overall mechanism and targeted research into the biology of muscle, ligament, nerve, and their complex interactions in normal pelvic floor function and in symptomatic patient. Each of these scientific disciplines is well developed so that engaging scientists in the effort to move forward will bring predictably important results. With an integrated approach to this problem over the next 20 years, it should be possible to achieve these goals and reduce the suffering for more than 100,000 afflicted women.

Use of a continence nurse specialist in an extended care facility.
Klay M, Marfyak K. Urol Nurs 2005 Apr;25(2):101-2, 107-8.

PURPOSE: The aim of this study was to determine if the number of incontinence episodes for an elderly female population could be decreased through an individualized continence program in a Connecticut long-term care center. METHODS: Forty-two female residents who in a long-term care facility who were incontinent or had urgency related to overactive bladder were included in the incontinence program. Total numbers of incontinent episodes for each participant were recorded 1 week prior to the study. An individualized plan of care for each patient was developed by the continence specialist and the plan of care implemented for at least 1 year. FINDINGS: After the continence specialist recommended a program of treatment and the program of treatment was implemented for 1 year, the number of UTIs (31 preintervention year; 6 postintervention year) and pressure ulcers (15 preintervention year; 2 postintervention year) were substantially decreased and the number of falls cut by more than 50% (18 preintervention; 7 postintervention). CONCLUSION: A nurse continence specialist can be used to help long-term care facilities plan a program that will direct individualized nursing interventions that will improve patient outcomes related to UTI, pressure sore and fall rates, and reduce the costs of care.

Sacral Neuromodulation: Long-Term Experience of One Center.
Elhilali MM, Khaled SM, Kashiwabara T, Elzayat E, Corcos J. Urology 2005 May 20;

OBJECTIVES: To perform a retrospective analysis of the long-term results of our experience with neuromodulation. Our center has been involved in the early studies leading to approval of the NeuroStim system of neuromodulation for the treatment of patients presenting with refractory lower urinary symptoms of urgency/frequency with or without incontinence and chronic urinary retention. METHODS: A total of 52 patients have undergone implantation at our center since 1990 using very rigid criteria, including temporary percutaneous nerve evaluation for up to 7 days and a requirement of 50% improvement before consideration for implantation. Patients were followed up closely and a telephone questionnaire was conducted for those patients not seen in the previous 6 months. Of the 52 patients, 11 were not available for evaluation. Of the 41 remaining patients, 22 had urgency/frequency syndrome, 6 had urgency incontinence, 9 had urinary retention, and 4 had interstitial cystitis with intractable pelvic pain. RESULTS: Of the 41 patients, 5 required explantation. These 5 patients were offered reimplantation but declined. Of the 22 patients in the urgency/frequency group, 10 (45%) had persistent improvement. In the urgency incontinence group, 3 of the 6 patients required explantation, and 1 (17%) reported improvement in the frequency of incontinence episodes. Of the 9 patients in the chronic urinary retention group, 7 (78%) had improvement. CONCLUSIONS: The long-term (up to 13 years) results of neuromodulation in patients presenting with urgency/frequency with and without urge incontinence and urinary retention were reviewed. The long-term results in the first two groups were not maintained over time. The patients with chronic urinary retention, although a small sample, fared better.

Posterior sagittal anorectoplasty for the management of blunt anorectovaginal injury: case report.
Ohno Y, Furui J, Kanematsu T
J Trauma 2005 Apr;58(4):863-6.

Pelvic floor digest.
Tech Coloproctol 2005 Apr;9(1):75-78.

New screening technique for sacral nerve stimulation under local anaesthesia.
Hetzer FH, Hahnloser D, Knoblauch Y, Lohlein F, Demartines N
Tech Coloproctol 2005 Apr;9(1):25-8.

BACKGROUND : The purpose of this study was to assess the influence of the type of anaesthesia (local vs. general) and of the electrode used (test electrode vs. tined lead) on a successful screening period. METHODS : Between May 2001 and January 2004, we performed 25 percutaneous nerve evaluation (PNE) tests in 20 patients (11 women). The first 15 PNE tests were followed by introducing a conventional electrode, and since 2003 by a tined lead electrode. Success was defined as reduction of symptoms by more than 50%. RESULTS : A stimulator was implanted in 13 (68%) patients, including 4 of 14 screened with the conventional electrode and 9 of 10 screened with tined lead electrode (p=0.005). Eleven (44%) of the PNE tests were done under local anaesthesia, but the success rate was not influenced by the type of anaesthesia (local 46% vs. general 61%, p=0.682). CONCLUSIONS : PNE testing and implantation of the tined lead electrode can be easily performed at the same time under local anaesthesia. The use of the new tined lead electrode significantly increased the success rate for the screening phase.

The now and the not yet of pelvic floor dysfunction.
Whiteside JL
Int Urogynecol J Pelvic Floor Dysfunct 2004 Nov-Dec;15(6):367-8. Epub 2004 Sep 22.

Pelvic floor surgery in the older woman: enhanced compared with usual preoperative assessment.
Richter HE, Redden DT, Duxbury AS, Granieri EC, Halli AD, Goode PS
Obstet Gynecol 2005 Apr;105(4):800-7.

OBJECTIVE: To examine whether knowledge of deficits obtained in a preoperative geriatric assessment may benefit postoperative health outcomes in older women undergoing pelvic surgery. METHODS: This study employed a pre-post intervention cohort design. Primary outcome was difference in scores of the Physical Component Summary and Mental Component Summary of the Medical Outcomes Study Short Form 36 Health Survey in 62 older women who had undergone "usual" compared with an "enhanced" preoperative assessment consisting of Activities of Daily Living, Instrumental Activities of Daily Living, Get Up and Go Test, Draw a Clock Test, Mini Nutritional Assessment, Geriatric Depression Scale, and Social Support Scale. The assessment results were placed on the participant's hospital chart. Repeated measures analysis was used. RESULTS: There were no significant differences in Mental Component Summary scores between the usual and enhanced assessment cohorts preoperatively (mean +/- standard deviation; 49.14 +/- 10.61 compared with 53.2 +/- 9.33), at 6 weeks (53.69 +/- 8.61 compared with 55.47 +/- 9.46), or at 6 months postoperatively (53.85 +/- 10.77 compared with 56.25 +/- 7.25); P = .120 for group effect and P = .798 for group by time interaction. Significant time effect was noted (P = .036). There was no significant difference in Physical Component Summary scores between the usual and enhanced assessment cohorts with respect to group effect (P = .986); there was a significant time effect (P = < .001) and a significant group by time interaction (P = .026). Satisfaction with treatment was high in both cohorts at 6 weeks and 6 months. CONCLUSION: A preoperative geriatric assessment did not seem to have differential benefit in healthy older women undergoing elective pelvic floor surgery. LEVEL OF EVIDENCE: II-2.

Relations between pregnancy-related low back pain, pelvic floor activity and pelvic floor dysfunction.
Pool-Goudzwaard AL, Slieker Ten Hove MC, Vierhout ME, Mulder PH, Pool JJ, Snijders CJ, Stoeckart R
Int Urogynecol J Pelvic Floor Dysfunct 2005 Apr 1;

To assess the occurrence of pelvic floor dysfunction (PFD) in pregnancy- related low back and pelvic pain (PLBP) patients, a cross-sectional study was performed, comprising 77 subjects. Each subject underwent physical assessment, and filled in the Urogenital Distress Inventory completed with gynaecological questions. Differences in the presence of PFD between PLBP patients and healthy controls as well as differences in pelvic floor muscle activity were tested for significance. Interaction by age and vaginal delivery were tested. PFD occurred in 52% of all PLBP patients, significantly more than in the healthy control group. In PLBP patients a significantly increased activity of the pelvic floor muscles could be demonstrated with respect to healthy controls. The occurrence of PFD and PLBP was influenced by a confounding effect of age. Clinicians should be aware of the relation between PLBP and PFD and hence address both problems at the same time.

[Design of a prototype operating seat with SESAM (Ergonomic System of Mobile Forearm Rests) mobile armrests designed to optimize the surgeon's ergonomy during pelvic laparoscopy]
Lorin S, Poumarat G, Memeteau Y, Wattiez A, Tostain J
Prog Urol 2004 Dec;14(6):1181-7.

INTRODUCTION: Pelvic laparoscopic surgery offers multiple advantages for patients, but requires uncomfortable, non-ergonomic positions for the surgeon. Only a remote operator (Robot "slave" reproducing the surgeon's movements performed on a "master" console situated away from the patient), like Da-Vinci or Zeus (Intuitive Surgical) can improve the laparoscopic surgeon's working conditions. The objective of this study, based on an ergonomic analysis and recording of a laparoscopic surgeon's movements, was to define the specifications for the manufacture of an operating seat with armrests, based on the surgeon's position using a remote operator. MATERIAL AND METHODS: Movements of the centre of pressure and upper limbs of 12 urologists and gynaecologists with various levels of experience, were recorded using a force platform and a SAGA 3 RT movement analysis system (Biogesta), during 4 exercises performed on a pelvi-trainer, with the surgeon positioned to the left (introduction of a needle, unravelling of a cord, dissection, suture). Ergonomic analysis of the laparoscopic surgeon's movements was based on video recordings of a surgeon under real operating conditions. The specifications were defined from all of these data. RESULTS AND DISCUSSION: The small amplitude of movements of the surgeon 's centre of pressure (< 45 cm2) confirmed that surgeons can be seated during laparoscopy. Recordings of the upper defined the elbow working zones and the need for 3D mobile armrests. Ergonomic analysis of posture defined the characteristics of the prototype. On the basis of these specifications, a prototype operating seat was developed. This prototype now needs to be validated or invalidated clinically.

Association of spontaneous perineal stretching during delivery with perineal lacerations.
Walfisch A, Hallak M, Harlev S, Mazor M, Shoham-Vardi I
J Reprod Med 2005 Jan;50(1):23-8.

OBJECTIVE: To evaluate the effect of perineal stretching on perineal damage during vaginal delivery. STUDY DESIGN: Patients at term in active labor were included. Perineal length was measured during the active phase, second stage and 24 hours postpartum. Perineal damage was assessed before repair and 24 hours postpartum. RESULTS: Three hundred women were included. Mean perineal length during the active phase was 4.02 +/- 1.07 cm, and mean stretching was 2.25 +/- 1.2 cm. Of the parturients who had stretched the perineum > 150%, 40.7% required perineal repair as compared with 19.5% of parturients with less perineal stretching (p < 0.005). Significant risk factors included: age and parity, ethnicity, use of epidural, second-stage length, and perineal stretching. Stretching of > 150% remained significant in a multivariate mode (OR 2.11, p < 0.01). CONCLUSION: Second-stage perineal stretching > 150% was predictive of perineal damage. In trying to avoid unnecessary episiotomies, this method may prove helpful.

The role of repeat angiography in the management of pelvic fractures.
Shapiro M, McDonald AA, Knight D, Johannigman JA, Cuschieri J
J Trauma 2005 Feb;58(2):227-31.

BACKGROUND: Angiographic embolization has emerged as the treatment modality of choice for bleeding pelvic fractures. The purpose of this study is to identify potential indicators for ongoing pelvic hemorrhage despite initial therapeutic or non-diagnostic angiography. METHODS: The trauma registry of a Level I trauma center was used to identify patients with pelvic fractures between January 2000 and June 2002. Records were reviewed for demographics, severity of injury, hemodynamic status, initial and subsequent base deficit, blood and fluid requirements, length of stay, and mortality. Statistical analysis was performed using Student's t test, and univariate and multivariate analysis, significance was assigned to p < or = 0.05. RESULTS: During the study period, 678 patients had pelvic fractures. Angiography was performed in 31 (4.6%) of these patients. Arterial hemorrhage was diagnosed initially on 16 (51.6%) patients requiring embolization. Three (18.8%) of these embolized patients required repeat angiography and embolization due to ongoing pelvic hemorrhage. Of the initial 15 patients with negative angiograms, five (33.3%) had repeat angiograms due to continued hypotension and acidosis. Four (80.0%) of these five patients were found to have arterial hemorrhage requiring embolization. Of the seven (22.6%) patients requiring repeat angiography for control of ongoing pelvic hemorrhage, three independent factors were predictive: continued or recurrent hypotension (SBP < 90), absence of intra-abdominal injury, and persistent base deficit of 10 for greater than 6 hours. The presence of all three independent predictors was associated with a 97% probability of pelvic bleeding (p = 0.001). CONCLUSION: Angiographic embolization is highly effective in controlling arterial bleeding associated with pelvic fractures. However, repeat angiography should be performed in patients with pelvic fractures with ongoing evidence of hemorrhage demonstrated by persistent base deficit and hypotension once other potential sources of bleeding have been excluded.

Pelvic floor trauma in childbirth - Myth or reality?
Dietz HP, Schierlitz L
Aust N Z J Obstet Gynaecol 2005 Feb;45(1):3-11.

Abstract The issue of traumatic damage to the pelvic floor in childbirth is attracting more and more attention amongst obstetric caregivers and laypersons alike. This is partly due to the fact that elective Caesarean section, as a potentially preventative intervention, is increasingly available and perceived as safe. As there are a multitude of emotive issues involved, including health economics and the relative roles of healthcare providers, the discussion surrounding pelvic floor trauma in childbirth has not always been completely rational. However, after 25 years of urogynaecological research in this field it should be possible to determine whether pelvic floor trauma in childbirth is myth or reality. On reviewing the available evidence, it appears that there are sufficient grounds to assume that vaginal delivery (or even the attempt at vaginal delivery) can cause damage to the pudendal nerve, the caudal aspects of the levator ani muscle, fascial pelvic organ supports and the external and internal anal sphincter. Risk factors for such damage have been defined and variously include operative vaginal delivery, a long second stage, and macrosomia. It is much less clear, however, whether such trauma is clinically relevant, and how important it is in the aetiology of pelvic floor morbidity later in life.

Pelvic organ support in pregnancy and postpartum.
O'boyle AL, O'boyle JD, Calhoun B, Davis GD
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jan-Feb;16(1):69-72. Epub 2004 Jul 31.

The purpose of this study was to evaluate pelvic organ support during pregnancy and following delivery. This was a prospective observational study. Pelvic organ prolapse quantification (POPQ) examinations were performed during each trimester of pregnancy and in the postpartum. Statistical comparisons of POPQ stage and of the nine measurements comprising the POPQ between the different time intervals were made using Wilcoxon's signed rank and the paired t-test. Comparison of POPQ stage by mode of delivery was made using Fisher's exact test. One hundred thirty-five nulliparous women underwent 281 pelvic organ support evaluations. During both the third trimester and postpartum, POPQ stage was significantly higher compared to the first trimester (p<0.001). In the postpartum, POPQ stage was significantly higher in women delivered vaginally compared to women delivered by cesarean (p=0.02). In nulliparous pregnant women, POPQ stage appears to increase during pregnancy and does not change significantly following delivery. In the postpartum, POPQ stage may be higher in women delivered vaginally compared to women delivered by cesarean.

The bion device: a minimally invasive implantable ministimulator for pudendal nerve neuromodulation in patients with detrusor overactivity incontinence.
Bosch JL
Urol Clin North Am 2005 Feb;32(1):109-12.

Injectable neuromodulatory agents: botulinum toxin therapy.
Frenkl TL, Rackley RR
Urol Clin North Am 2005 Feb;32(1):89-99.

Neuromodulation for constipation and fecal incontinence.
Jarrett ME
Urol Clin North Am 2005 Feb;32(1):79-87.

Percutaneous neuromodulation.
Cooperberg MR, Stoller ML
Urol Clin North Am 2005 Feb;32(1):71-8.

Complications and troubleshooting of sacral neuromodulation therapy.
Hijaz A, Vasavada S
Urol Clin North Am 2005 Feb;32(1):65-9.

Expanding indications for neuromodulation.
Bernstein AJ, Peters KM
Urol Clin North Am 2005 Feb;32(1):59-63.

European experience with bilateral sacral neuromodulation in patients with chronic lower urinary tract dysfunction.
van Kerrebroeck EV, Scheepens WA, de Bie RA, Weil EH
Urol Clin North Am 2005 Feb;32(1):51-7.

Current indications for neuromodulation.
Daneshgari F, Moy ML
Urol Clin North Am 2005 Feb;32(1):37-40.

Surgical techniques of sacral implantation.
Chai TC
Urol Clin North Am 2005 Feb;32(1):27-35.

Selecting patients for sacral nerve stimulation.
Siegel SW
Urol Clin North Am 2005 Feb;32(1):19-26.

How sacral nerve stimulation neuromodulation works.
Leng WW, Chancellor MB
Urol Clin North Am 2005 Feb;32(1):11-8.

Neuromodulation in voiding dysfunction: a historical overview of neurostimulation and its application.
Fandel T, Tanagho EA
Urol Clin North Am 2005 Feb;32(1):1-10.

Neuromodulation: past, present, and future.
Steers WD
Urol Clin North Am 2005 Feb;32(1):xv-xvi.

Pelvic neuromodulation.
Daneshgari F
Urol Clin North Am 2005 Feb;32(1):xiii-xiv.

Pelvic neuromodulation.
Resnick MI
Urol Clin North Am 2005 Feb;32(1):xi.

Solitary fibrous tumor in the pelvic cavity with hypoglycemia: report of a case.
Nagase T, Adachi I, Yamada T, Murakami N, Morita K, Yoshino Y, Katayanagi K, Kurumaya H
Surg Today 2005;35(2):181-4.

A case of solitary fibrous tumor (SFT) in the pelvic cavity with hypoglycemia is reported. The patient was a 60-year-old man who was referred to our hospital for a closer examination of hypoglycemia. Computed tomography demonstrated a mass, measuring 14 x 9 cm in size, in the pelvic cavity. Magnetic resonance imaging showed the mass to have a low signal intensity on T1-weighted images and a high intensity on T2-weighted images. Laparotomy revealed no peritoneal dissemination nor lymph node metastasis. An en bloc excision of the tumor was performed with a good recovery, and the hypoglycemia disappeared. Histologically, the tumor was composed of spindle-shaped and oval cells in sarcoma, based on a moderate mitotic rate and cellularity. Immunohistochemically, the tumor was positive for CD34 and negative for keratin, alpha-smooth muscle actin, desmin, S100 protein, c-kit protein, and epithelial membrane antigen. Based on these findings, the tumor was diagnosed to be malignant SFT in the pelvic cavity.