Diagnosis: Pelvic Floor General

A valsalvometer can be effective in standardising the Valsalva manoeuvre.
Greenland HP, Hosker GL, Smith AR
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Aug 29;.

A prospective randomised controlled study was performed in order to study the effectiveness of a device designed to reduce the variability in intra-abdominal pressures generated by individuals performing the Valsalva manoeuvre. One hundred women were recruited to take part in the project which compared a traditional Valsalva manoeuvre following standardised verbal instruction with forced expiration through a flow restriction device called a 'valsalvometer'. The abdominal pressure was measured using an air-filled rectal balloon catheter linked to a pressure transducer. The use of the valsalvometer was associated with a reduction in variation of intra-abdominal pressure between women to 50% of the standard deviation. The new device has the capacity to reduce the variation in intra-abdominal pressure produced when performing the Valsalva manoeuvre. The rise in intra-abdominal pressure may act as a standard against which other measurements are made.

June

The role of magnetic resonance imaging in minimal access surgery.
Byrne H, Ball E, Davis C
Curr Opin Obstet Gynecol. 2006 Aug;18(4):369-73.

PURPOSE OF REVIEW: Magnetic resonance imaging is commonly used for gynaecological malignancies, but also is increasingly used for the investigation of benign gynaecological complaints. This review summarizes the current evidence regarding its use as an adjunct to minimal access surgery for endometriosis, adenomyosis, adhesions and fibroids. RECENT FINDINGS: Magnetic resonance imaging appears to be equal in efficacy to ultrasound for the diagnosis of both fibroids and endometriosis, and perhaps superior for the diagnosis of adenomyosis. It is extremely useful for the preoperative investigation of severe endometriosis, especially recto-vaginal disease. Milder endometriosis is, however, still difficult to diagnose by either ultrasound or magnetic resonance imaging. Magnetic resonance imaging can also be helpful for the detection of adhesions, pelvic collections, congenital defects and fibroids. It is also useful following fibroid embolization. SUMMARY: Currently, it is not cost-effective to use magnetic resonance imaging as the modality of first choice when investigating pelvic pain and or menstrual disorders. If preoperative patients are carefully selected, however, it can substantially reduce surgical morbidity by using it to diagnose severe endometriosis and adhesions which may lead to cost savings overall.

May

Effect of vaginal delivery on endosonographic anal sphincter morphology.
Starck M, Bohe M, Valentin L
Eur J Obstet Gynecol Reprod Biol. 2006 May 17;.

OBJECTIVE: To describe the effect of vaginal delivery with no clinically recognized sphincter tear on endosonographic anal sphincter morphology and sphincter pressure and to relate endosonographic results to anal sphincter pressure and anal incontinence score. STUDY DESIGN: Thirty-two nullipara underwent anal endosonography and anal manometry in the third trimester of pregnancy, 2 weeks and 6 months post-partum. The sphincter defect scores (1-16) and the thickness and length of the sphincters were measured by endosonography, and sphincter pressures and manometric sphincter lengths were determined. The Wexner incontinence score (1-20) was used to classify anal incontinence 6 months post-partum. RESULTS: Five (16%) women had small endosonographic anal sphincter defects (score 3-4) before delivery. Eight women (25%; confidence interval 11-43%) had new defects detected post-partum, five small, one moderate (score 7), and two large (score 10-11). Six (75%) of eight women with new defects post-partum had undergone episiotomy versus five (21%) of 24 women with no new defects (p=0.02). Six months after delivery 16 (50%) women reported anal incontinence, and there was a positive correlation between the endosonographic defect score 6 months post-partum and the Wexner incontinence score. The sphincter was significantly longer during pregnancy than 6 months post-partum. CONCLUSION: New sphincter defects may arise after vaginal delivery without any clinically recognizable sphincter tear. There is a positive correlation between the endosonographic defect score 6 months post-partum and the Wexner incontinence score.

April

The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for pelvic organ prolapse.
Gustilo-Ashby AM, Jelovsek JE, Barber MD, Yoo EH, Paraiso MF, Walters MD
Am J Obstet Gynecol. 2006 May;194(5):1478-85.

OBJECTIVE: The objective of the study was to determine the incidence of ureteral obstruction during vaginal surgery for pelvic organ prolapse and the accuracy and efficacy of intraoperative cystoscopy. STUDY DESIGN: The study was a retrospective review of 700 consecutive patients who underwent vaginal surgery for anterior and/or apical pelvic organ prolapse with universal intraoperative cystoscopy. RESULTS: Thirty-seven patients (5.3%) had no spillage of dye from 1 or both ureters intraoperatively. The false-positive and negative cystoscopy rates were 0.4% and 0.3%, respectively. Thus, the true incidence of intraoperative ureteral obstruction was 5.1%. Intraoperative cystoscopy was accurate in 99.3% of cases, with a sensitivity and specificity of 94.4% and 99.5%, respectively. Suture removal relieved ureteral obstruction in 88% of cases. Six subjects (0.9%) had true ureteral injuries. CONCLUSION: Vaginal surgery for anterior and/or apical pelvic organ prolapse is associated with an intraoperative ureteral obstruction rate of 5.1%. Intraoperative cystoscopy accurately detects ureteral obstruction and allows for relief of obstruction in the majority of cases.

March

The rectovaginal examination: physician attitudes and practice patterns.
Davisson L, Clark K, Powers R, Hobbs G
South Med J. 2006 Mar;99(3):212-5.

BACKGROUND: The value of screening with the rectovaginal examination (RVE) has not been validated. This study describes physician attitudes and practice patterns regarding the RVE. METHODS: Cross-sectional survey of residents and faculty in general internal medicine and obstetrics/gynecology (OB/GYN) at a university hospital. RESULTS: Thirty-four percent of physicians surveyed reported routinely performing the RVE. More OB/GYN than internal medicine physicians reported doing the RVE routinely (60% versus 27%, P = 0.02), and felt it provided additional information (80% versus 44%, P = 0.01). More respondents believed that it provides additional information to the routine pelvic examination (53%) than agreed with its routine inclusion (42%) or that reported routinely performing it (34%). (P = 0.0001) CONCLUSIONS: More OB/GYN than internal medicine physicians routinely perform the RVE and believe it adds additional information to the routine pelvic examination. Additional research is indicated to determine if frequent omission of the RVE impacts women's health.

February

Videomanometry of the pelvic organs: A comparison of the normal lower urinary and gastrointestinal tracts.
Ito T, Sakakibara R, Uchiyama T, Zhi L, Yamamoto T, Hattori T
Int J Urol. 2006 Jan;13(1):29-35.

Background: Both the lower urinary tract (LUT) and the caudal part of the lower gastrointestinal tract (LGIT) are innervated by the sacral spinal cord. We aimed to compare the normal physiology of the LUT and LGIT using the same videomanometry method. Methods: We recruited fifteen healthy volunteers (eight men and seven women; mean age, 60 years). The videomanometric measures included fluoroscopic images, subtracted bladder/rectal pressures, urethral/anal sphincter pressures, sphincter electromyography, and urinary/fecal flow. Results: During the resting phase, the urethral/anal sphincter pressures showed almost the same values (mean, 70 cmH(2)O and 68 cmH(2)O, respectively). During the storage phase, the volumes at first sensation and maximum capacity for the LGIT (129 mL and 320 mL) were slightly smaller than those for the LUT (170 mL and 405 mL). Compliance of the LGIT (65 mL/cmH(2)O) was almost as high as that of the LUT (99 mL/cmH(2)O). However, the LGIT showed spontaneous phasic rectal contractions (SPRC) that were never seen in the bladder. None of the subjects experienced leakage during bladder/rectal filling. During the evacuation phase, rectal contraction on defecation (14 cmH(2)O) was present, but was weaker than bladder contraction on micturition (42 cmH(2)O; P < 0.01). Abdominal strain on defecation (70 cmH(2)O) was greater than that on micturition (25 cmH(2)O; P < 0.01). Sphincter pressure increase on defecation (13 cmH(2)O) was greater than that on micturition (-52 cmH(2)O). An illustrative case of SPRC that were seen during urodynamic recording was shown. Conclusion: SPRC and abdominal strain are features of the LGIT, whereas micturition bladder contraction is a feature of the LUT. These features can aid in understanding the possible rectal 'artifacts' of videourodynamics and neurogenic pelvic organ dysfunction.

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