Colposuspension for urinary stress incontinence in postmenopausal patients

Eighty-seven postmenopausal patients had a colposuspension for urinary stress incontinence. A significant postoperative reduction (p<0.001) of symptoms of frequency, nocturia, urgency and urge incontinence was obtained. The cure rate for urinary incontinence was 77%. Twenty patients were found to be wet postoperatively, 8 due to stress incontinence and 12 due to detrusor instability, 9 of whom had detrusor instability preoperatively.No differences were found pre- and postoperatively in the cystometric and uroflowmetric values or in the urethral pressure profile measurements. The pressure transmission ratios were significantly improved postoperatively.During operation and postoperatively, minor complications occurred in this group of patients. In 5 patients blood transfusion was needed. Urinary tract infection was diagnosed in 21 patients, wound infections in 4 patients and enterocele in 5 patients.Colposuspension for urinary stress incontinence in postmenopausal patients is a safe procedure with a reasonable cure rate indicating that a surgical approach should be adopted in such patients.Editorial Comments: This is an extension of the authors' previously published series in SGO [2] now dealing exclusively with postmenopausal patients. Although they state that their overall cure rate was 77%, in fact the cure rate for stress incontinence was 79/87 or 91%. Adding the patients with detrusor instability gives the lower cure rate of 77%. An important contribution of this article is the documentation of a decrease of symptoms of urgency, frequency and urge incontinence subsequent to a modified Burch colposuspension. In addition they document that the pressure-transmission ratios were less than 100% in all of their failed cases. Further studies are needed in the elderly to document success or failure in this group since we will be faced with an ever increasing elderly population in years to come.     

The Ethnic Cultural and Social Aspects of Incontinence – A Pilot Study

This cross-sectional study aimed to study the religious and cultural practices of ethnic minorities that might affect the experience and ideas that sufferers of incontinence have. Subjects were multiparous women from the local community who suffered from incontinence. Structured and unstructured interviews were conducted to assess the effect of incontinence and menstruation on home life, sexual life, personal and communal prayer, rules and customs associated with menstruation, and the ability to discuss problems with their doctor and partners. Individual women differed in how they rated their daily activities, and this was not related to religious or ethnicity. Higher restrictions on activity were perceived for fecal than for urinary incontinence. Sexual relationships were restricted for Jewish and Muslim women during menses. Incontinence led to religious restriction, which was most marked for Jewish and Muslim women, and this was related to the need for cleanliness for prayer. Less then 50% of patients sought help, and this was not related to duration and severity of symptoms. Only Muslim women had a strong preference for female doctors, and this was for cultural reasons.     

The safety of the inside-out transobturator approach for transvaginal tape (TVT-O) treatment in stress urinary incontinence: French registry data on 984 women

This study examines the safety of the inside-out transobturator approach for transvaginal tape (TVT-O™, Gynaecare) treatment in stress urinary incontinence (SUI) in women based on a French registry of patients. A total of 984 women from 86 centres were enrolled in the study. Patients with predominant overactive bladder or significant pelvic organ prolapse were excluded from the study. Perioperative and post-operative complications were reported as well as urinary function at 4 and 12 weeks. Pain was assessed by the patients using a visual analog scale (VAS). The overall perioperative complication rate was 2.2%. The most commonly reported morbidities were vaginal wall perforation (1.3%) followed by haematoma (0.7%). Post-operative complication rate was 5.2%; the most common complication was residual pain (2.7%). The other complications of paravesical haematoma, urinary retention, vaginal erosion and re-intervention had an incidence of less than 1.0%. This study demonstrates that the transobturator transvaginal tape approach to the treatment of SUI is a safe procedure.     

Combined estrogen and ghrelin administration restores number of blood vessels and collagen type I/III ratio in the urethral and anal canal submucosa of old ovariectomized rats

We compare the effects of estrogen and/or ghrelin on vascular counts and collagen I/III ratio of urethral and anal canal submucosa in old vs young-adult ovariectomized rats. Ovariectomized Fisher 344 rats (18 and 3 months old, n = 24 x 2) received 42 daily intraperitoneal 17-ss estradiol (10 microg/kg), ghrelin (2 microg/kg), both, or vehicle (n = 6 x 4 per group). Blood vessel counts and collagen I/III ratio were measured, respectively, by light microscopy and Western blot analysis with immunohistochemistry of ghrelin receptors. Estrogen significantly increased urethral and anal vascular counts and collagen I/III ratio in young-adult rats. In old rats, only combined estrogen/ghrelin administration significantly increased both variables. This was not observed with estrogen or ghrelin separately. Ghrelin receptors were immunostained in urethral and anal submucosa of all samples. Combined estrogen/ghrelin administration restored postovariectomy urethral and anal canal submucosal vessel number and collagen I/III ratio in old rats suggesting independent ageing effect.     

Long-Term Outcome of Overlapping Anal Sphincter Repair

PURPOSE: This study reviews the long-term outcome of overlapping anal sphincteroplasty for acquired anal incontinence. METHODS: Seventy-one consecutive patients underwent overlapping sphincteroplasty from 1989 to 1996. Current degree of continence and associated quality of life were determined by telephone interview using the Fecal Incontinence Severity Index and Fecal Incontinence Quality of Life Scale, as validated by The American Society of Colon and Rectal Surgeons. Both the patient-rated and the surgeon-rated Fecal Incontinence Severity Index scores were recorded. Demographic and perioperative data were obtained from patient charts. RESULTS: Forty-nine (69 percent) of the 71 patients, with a median age of 38.5 (range, 22–80) years, could be contacted at a median of 69 (range, 48–141) months after sphincter repair. Four patients were diverted at the time of follow-up. Twenty-four (54 percent) patients were incontinent to liquid or solid stool, and only six patients (14 percent) were totally continent. Fifteen patients (34 percent) had the best possible Fecal Incontinence Quality of Life score of 16. The median patient-rated and surgeon-rated Fecal Incontinence Severity Index scores were 20 (range, 0–61) and 20 (range, 0–57), respectively. The patient-rated score correlated to the surgeon-rated score (r = 0.98, P < 0.001) and the Fecal Incontinence Quality of Life score (r = 0.64, P < 0.001). CONCLUSION: Years after sphincter repair surgery more than half of the patients are incontinent to liquid or solid stool. The American Society of Colon and Rectal Surgeons-validated Fecal Incontinence Severity Index and Fecal Incontinence Quality of Life scores are useful and complementary tools for evaluation of fecal incontinence.     

How does pouch construction for a final diagnosis of Crohn's disease compare with ileoproctostomy for established Crohn's proctocolitis?

PURPOSE: There is a difference of opinion concerning the role of ileal pouch-anal anastomosis in Crohn's disease, even in the absence of small-bowel or perianal disease. One view is that ileal pouch-anal anastomosis should never be entertained, the other is that ileal pouch-anal anastomosis, like ileoproctostomy, can be justified sometimes, because it allows young people a period of stoma-free life. The aim of this study was to examine the outcome of ileal pouch-anal anastomosis and to contrast it with ileoproctostomy in patients with Crohn's disease without small-bowel or perianal disease. METHODS: Ileal pouch-anal anastomosis was performed in 23 patients with Crohn's disease (12 of whom had evidence of Crohn's disease at the time of operation and 11 who were eventually found to have Crohn's disease as a result of complications) and ileoproctostomy in 35. Patients were matched for age, gender, follow-up, and medication, but all ileoproctostomy cases had relative rectal sparing. Thus, the groups were not comparable and the reasons for ileal pouch-anal anastomosis and ileoproctostomy were therefore quite different. RESULTS: The outcome in ileal pouch-anal anastomosis at a mean follow-up of 10.2 years was pouch excision, 11 (47.8 percent); proximal stoma, 1 (4.3 percent; patient preference); average small-bowel resection, 65 cm; persistent perineal sinus, 8 of 11 having pouch excision (73 percent); and mean time in hospital, 37 (range, 8–108) days. Of those in circuit having ileal pouch-anal anastomosis (n=12), 24-hour bowel frequency was 6, with no incontinence or urgency, but 6 (50 percent) were on medication. When ileal pouch-anal anastomosis was done for Crohn's disease in the resection specimen, only 4 of 12 (33 percent) were excised compared with 7 of 11 (64 percent) in whom the diagnosis was made as a result of complications. The outcome in ileoproctostomy at a mean follow-up of 10.9 years was rectal excision in 3 (8 percent), proximal stoma in 1 (3 percent), average small-bowel resection was 15 cm, persistent perineal sinus in 1 (3 percent), and time in hospital was 21 (range, 8–36) days. Of those in circuit (n=32), 24-hour bowel frequency was 5, 2 had incontinence, 3 had urgency, and 12 (36 percent) were taking medication. CONCLUSIONS: These results indicate that the overall outcome of ileal pouch-anal anastomosis is inferior to that of ileoproctostomy, especially if Crohn's disease was diagnosed as a result of complications. Nevertheless, the functional results of those with a successful outcome are comparable.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 24 to 29, 2000.     

The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population

Introduction and hypothesis  In selected populations, pelvic organ prolapse (POP) was associated with bladder/bowel symptoms, but data on the general female population are lacking. Our aim was to obtain normative data on the prevalence of POP and pelvic floor dysfunction (PFD) symptoms and signs and to identify associations. Methods  Validated questionnaires on POP and PFD (urogenital distress inventory, (UDI) and defaecation distress inventory (DDI)) were sent to a general population of 2,979 women (aged 45–85 years). Data were analysed using the Kruskal–Wallis test, chi square test and Spearman’s rank correlation coefficient. Results  Response rate was 62.7%. Associations between POP stage and parity (0.002) and vaginal bulging (<0.001) are significant. Anatomical locations of POP and PFD symptoms correlated significantly with incontinence of flatus, feeling anal prolapse, manual evacuation of stool, vaginal bulging, constipation and pain during faecal urge (p ≤ 0.005). Conclusions  Strategies should be developed to alleviate obstructive bowel disorders associated with POP. Summary  POP was strongly associated with obstructive bowel disorders. Therefore, preventive strategies should be developed.