Emese Zsiros, MD

• Department of Obstetrics and Gynecology
• Northwestern University? Feinberg School of Medicine
• Chicago, Illinois

Objective cosmetic and anatomical outcomes at adolescence of feminising surgery for ambiguous genitalia done in childhood treatment for long term pain from shingles buy azulfidine from india. Feminizing genitoplasty for congenital adrenal hyperplasia: what happens at puberty Impaired sexual and reproductive outcomes in women with classical forms of congenital adrenal hyperplasia visceral pain treatment guidelines order line azulfidine. Clitoroplasty for females born with ambiguous genitalia: a long-term study of 37 patients pain treatment medicine clifton springs ny cheap azulfidine 500 mg on line. Sexual behavior in adolescent and adult females with congenital adrenal hyperplasia pain disorder treatment plan purchase azulfidine 500 mg online. Type of mutation and surgical procedure affect long term quality of life for women with congenital adrenal hyperplasia pain treatment in sickle cell purchase azulfidine with mastercard. Statement of the British Association of Paediatric Surgeons Working Party on the Surgical Management of Children Born with Ambiguous Genitalia allied pain treatment center youngstown ohio discount 500mg azulfidine with amex, July 2001. Management of vaginal agenesis: review of 10 years practice at a tertiary referral centre. Others will have been diagnosed in childhood but are referred on for further management by paediatricians and endocrinologists. Some karyotypic abnormalities have little impact on gynaecological problems, but those affecting the sex chromosomes are covered briefly in this chapter. This is a rapidly changing field of medicine, and more sophisticated tests can lead to refinements in original diagnoses, so it may be appropriate to repeat genetic investigations or to test other cell lines. Although 1 in 2500 live-born girls are affected, most pregnancies with this abnormality miscarry, probably secondary to major cardiac defects. The rate of detection is partly Growth failure: low birthweight and short stature; ovarian failure: no secondary sexual development in most cases, occasionally secondary amenorrhoea in mosaicism; inverted, widely spaced nipples, and shield chest; webbed neck; puffy hands and feet in babies due to lymphoedema; low hairline; cubitus valgus; short fourth metacarpal; high, arched palate, micrognathia and defective dental development; renal dysgenesis; left-sided cardiac malformations, coarctation of the aorta; distortion of the Eustachian tube leading to otitis media; nail dysplasia; eye deformities. Intelligence is usually normal, but there is an increased risk of impairment of non-verbal skills. However, spontaneous pubertal development can occur, particularly in girls with mosaicism. In most girls, ovarian failure will have occurred early in life; although they have a uterus and vagina, they will not develop any secondary sexual characteristics without hormonal supplements. The transdermal route is preferred as it has better effects on bone density; it can be started at 6. The uterus will respond to oestrogen therapy, so after 2 years it is necessary to add progestogens cyclically to produce regular endometrial shedding, or in a continuous combined regime to suppress endometrial development. Cryopreservation of ovarian tissue may be an option for future fertility, particularly for girls with mosaicism. They may have genitourinary abnormalities but are of normal or tall height, and sexual development occurs normally. Academic performance is usually below average; there may be motor and speech delay, and attention deficit. Somewhat surprisingly, most women give birth to chromosomally normal children, but prenatal diagnosis should be considered. Almost all girls with these karyotypes have developmental delay and learning difficulties. Craniofacial anomalies such as hypertelorism, upslanting palpebral fissures and a flat nasal bridge are commonly found, as is ovarian dysfunction. A full cardiological assessment is advisable before referral to an assisted conception unit for counselling about treatment with donor oocytes. In androgen insensitivity syndrome, the problem lies with the end-organ response to testosterone. Breast development usually takes place, as circulating testosterone is peripherally converted to oestrogen, but there is absent pubic hair due to the abnormal androgen receptors. Breast development does not normally occur and typically girls present above average height with delayed puberty. Pubic and axillary hair may be present due to the effect of peripherally produced androgens. The commonest is an isochromosome for the long arm, most often found in mosaic form with 45X. Deletions of part of the long or short arm have variable effects depending on the level at which the deletion has occurred. If the short arm is missing, most girls will be of short stature; if the long arm is missing, there is usually gonadal dysgenesis. It is of interest to note that although one X chromosome is inactivated, it is necessary to have two normal X chromosomes to maintain fertility. Care of girls and women with Turner syndrome: a guideline of the Turner Syndrome Study Group. Germ cell tumours in the intersex gonad: old paths, new directions, moving frontiers. Sex steroid treatment for pubertal induction and replacement in the adolescent girl 2013. Fertility preservation in girls with Turner syndrome: prognostic signs of the presence of ovarian follicles. Mortality in women with Turner syndrome in Great Britain: a national cohort study. Increased maternal cardiovascular mortality associated with pregnancy in women with Turner syndrome. The trigger for the changes to start is an increasing frequency and amplitude of pulses of gonadotrophin release. The ovaries are then stimulated to begin to produce oestrogen, which acts on the breast tissue to promote growth. This usually begins at around the age of 9 and takes about 5 years to be completed. There is evidence to suggest that this is occurring at a younger age, particularly in African-American girls, prompting a reassessment of the age at which precocious puberty should be investigated. Pubic hair growth is stimulated by androgens released by the ovary and the adrenal gland. Breast and pubic hair development is described in five stages following the classification by Marshall and Tanner (Table 70. Even before these changes are obvious, there is acceleration of growth, which is frequently accompanied by a rapid increase in shoe size. Oestrogen promotes closure of the epiphyses, so final height is usually attained about 2 years after menarche. Initial menstrual cycles are usually anovulatory and often irregular for several years. Additional biochemical tests to assess thyroid function, prolactin and 17-hydroxyprogesterone may be appropriate. Another possibility is that it may be secondary to chronic illness, for example cystic fibrosis. Girls with anorexia nervosa have low levels of gonadotrophins and, if the problem starts at a young age, will have absent or poorly developed secondary sexual characteristics. A similar situation is found in many athletic girls, the classic example being gymnasts, who have a low bodyweight and very low body fat. In all these conditions, ultrasound will confirm the presence of an immature uterus and small, inactive ovaries. The bone age will help to differentiate cases of constitutional delay, as it will be behind chronological and height age. Treatment may be required if there are no signs of spontaneous onset of puberty, although most girls with constitutional delay will proceed to normal development if left untreated. A study conducted on untreated girls indicated that they experienced considerable distress, which affected their success at school, work or socially; 50 per cent would have preferred to receive treatment. Frequently, spontaneous sexual maturation then occurs, but if not, the dose is gradually increased over several years. In order to determine the likely cause for this it is first important to establish whether puberty itself is delayed. A detailed history should be taken, asking about general health, the age at which breast and pubic hair development started, and if the girl has had a growth spurt or still appears to be growing. The family history should include the age when mother and siblings went through puberty. Examination should include accurate measurement of height, together with assessment of the stage of breast and pubic hair development, and these should be plotted on growth charts. An internal examination should not be performed; inspection of the external genitalia is all that is necessary, as further assessment of the internal organs will be achieved by ultrasound scanning of the pelvis. Menorrhagia and dysmenorrhoea 541 Hypergonadotrophic hypogonadism this occurs when there is failure of gonadal development. The normal release of gonadotrophins occurs, but as there is no response from the gonad, there is no negative feedback to control gonadotrophin levels. Other causes include damage to the ovaries by irradiation, surgery, chemotherapy or infection. Galactosaemia is also associated with ovarian failure and its management presents a challenge, as oral preparations of oestrogen and progesterone contain lactose. One of the less common causes of congenital adrenal hyperplasia is the deficiency of 17-hydroxylase. This enzyme is required to produce both oestrogen and testosterone, so virilisation does not occur at birth, but there is also a failure of development of secondary sexual characteristics. The treatment consists of gradually increasing levels of oestrogen replacement, combined with progesterone to induce withdrawal bleed once endometrial development has been stimulated. Treatment is the same as in the older female, with dopamine agonists such as cabergoline, which will result in the onset of menstruation. Congenital adrenal hyperplasia Menarche is often delayed in this condition, and when menstruation starts it may be erratic. Poor control of the condition, often due to poor compliance with treatment, may be the cause. Fertility rates in these women are poor for a number of reasons: infrequent ovulation, difficulties in achieving penetrative sex, and failure to form relationships. Pubic hair fails to grow because of end-organ insensitivity to androgens, but breast development occurs due to peripheral conversion of androgens to oestrogen. Girls with an imperforate hymen or transverse vaginal septum usually present as an emergency with cyclical abdominal pain, possibly with a palpable abdominal mass. The blockage prevents the flow of menstrual blood and there is usually a tense blue bulge seen at the introitus. Ultrasound scanning may show a distended vagina containing blood, and normal ovaries. Where there is a thin imperforate hymen, treatment is straightforward, as incision will allow the blood to drain and the mass will resolve. Treatment of a thicker and possibly higher septum is more complex and is best dealt with in a tertiary referral centre, as injudicious excision can result in stricture formation which is difficult to treat and will lead to considerable problems with intercourse. Girls are often referred to gynaecologists because of concern about missing school, particularly when studying for state examinations, due to heavy and painful periods. Almost invariably they are accompanied by a mother who will tell you about the problems she had with her periods. It is very important to speak to the girl herself to try to establish if there is a genuine problem, and to make some effort to quantify the loss by the degree of soakage of the pads used. The number of pads used per day may be quite misleading, and as most women do not know what amount of loss is normal, it can be very difficult for a girl to know whether she is actually experiencing an abnormal amount of bleeding. Excessive menstrual loss will usually result in a fall in the haemoglobin level, and occasionally the loss can be so great that emergency admission and transfusion are required. If such a disorder is found, it may be possible to treat the girl with desmopressin on a cyclical basis. A high prolactin level should 542 Menarche and adolescent gynaecology the oral contraceptive pill is usually prescribed and, where blood loss is recurrently excessive, it can be helpful to prescribe this continuously for three or more cycles to reduce the frequency of withdrawal bleeds. However several studies have reported that the number of days of bleeding is not statistically different from conventional cyclic dosing. However, where these measures fail, it is important to bear in mind the possibility of partial obstruction of menstrual flow. There are a number of reported cases of obstructed hemivagina and uterine horn associated with ipsilateral renal agenesis. Endometriosis occurs in many of these patients, presumably secondary to the enforced retrograde menstrual flow. There are many causes of chronic pelvic pain in young women, including psychosomatic factors.

Improvements in pain occurred in some women who were subsequently found at laparoscopy not to have endometriosis severe back pain treatment vitamins purchase azulfidine 500 mg without a prescription. On the basis of this evidence pain spine treatment center order 500mg azulfidine fast delivery, there seems to be a role for a trial of empirical ovarian suppression in the management of chronic pelvic pain which is cyclically exacerbated [B] treatment for dog neck pain buy 500 mg azulfidine fast delivery. Amitriptyline should be started at a low dose urmc pain treatment center sawgrass drive rochester ny order azulfidine without prescription, typically 25 mg 2 hours before bedtime (can be reduced to 10 mg if required) treatment pain from shingles order line azulfidine. The target dose will be in the region of 75 mg pain medication for little dogs order azulfidine 500 mg with amex, although many patients will not tolerate the associated side effects including dizziness, drowsiness and anti-muscarinic effects of dry mouth and blurred vision. The substitution of nortriptyline or imipramine in similar dosages may reduce the side effects, particularly sedation. With gabapentin, patients are typically started on 300 mg daily and slowly titrated up (over a few weeks) to a target dose of 600 mg three times a day. Side effects include dizziness, drowsiness, peripheral oedema and gait disturbance, although serious effects are rare. Pregabalin has a similar sideeffect profile but may be better suited to individual patients. The starting dose is 75 mg twice a day, titrating up to a target dose of 300 mg twice a day. There is limited evidence to support the use of these adjuvant agents to manage chronic pelvic pain. To date, only one small study (56 patients)22,37 has compared gabapentin to amitriptyline for the treatment of chronic pelvic pain. It showed that gabapentin had greater efficacy (80 per cent compared to 70 per cent improvement in pain scores at 12 months). Unfortunately, this study had no placebo arm and the significance of the effect on quality of life was not evaluated. Nevertheless, increasing evidence supporting a neuropathic and central sensitisation component to chronic pelvic pain has led to the prescription of these agents to good effect in general practice and in multidisciplinary settings [C]. Further studies are required to determine their true efficacy in the treatment of chronic pelvic pain. Despite some promising results, these techniques have not been fully evaluated in women with chronic pelvic pain. Direct percutaneous electrical nerve stimulation (neuromodulation) is an alternative approach which has an established role in management of overactive bladder syndrome. Currently neuromodulation should only be undertaken in specialist centres which can provide multidisciplinary care [E]. The conditions may also coexist, in which case management should be directed towards both. Constipation may be managed with laxatives (avoiding lactulose) and diarrhoea with loperamide. The mechanism of their contribution to the pain is unclear and in many cases there may be a neuropathic component. Studies evaluating surgical division of adhesions have shown minimal or no improvement of pelvic pain22 [A] with the exception of women undergoing Acknowledgement 599 laparoscopic division of severe adhesions. Hysterectomy may be beneficial for secondary dysmenorrhoea attributed to endometriosis or adenomyosis but its role in chronic pelvic pain is unclear. A review of five studies of women undergoing hysterectomy for chronic pain presumed to be of uterine origin39 reported that symptoms were relieved in 83 to 97 per cent of women at 12-month follow-up [D]. However, the results of these studies showed that failure of pain relief was greatest among women with no demonstrable pelvic pathology, once again emphasising the importance of a multidisciplinary approach for women with unexplained pelvic pain. Chronic pelvic pain which is cyclically exacerbated may be relieved by a trial of ovulation suppression [B]. Centrally acting drugs such as amitriptyline and gabapentin appear to have a role in the management of chronic pelvic pain [C]. Other classes of antidepressants are not effective in the management of chronic pain [B]. There is insufficient evidence to support the use of pelvic nerve interruption for the relief of primary or secondary dysmenorrhoea [A]. There is no evidence that division of adhesions relieves chronic pelvic pain, with the possible exception of severe dense avascular adhesions [B]. Where possible, chronic pelvic pain should be managed in a multidisciplinary clinic [A]. Primary dysmenorrhoea is experienced by more than two thirds of women and a minority are severely incapacitated. Investigation of suspected primary dysmenorrhoea is unnecessary unless there are atypical symptoms or abnormal findings on pelvic examination [C]. The multifactorial nature of chronic pelvic pain should be discussed and explored from the start [B]. Pain resulting from disturbances in the central or peripheral nervous system (neuropathic pain) is an important component of chronic pelvic pain [C]. Alternative therapies, including physical and behavioural therapy, dietary supplements (magnesium, vitamin B1) and References 1. The prevalence of chronic pelvic pain in women in the United Kingdom: a systematic review. Prevalence and incidence of chronic pelvic pain in primary care: evidence from a national general practice database. Chronic pelvic pain: prevalence, healthrelated quality of life and economic correlates. Optimum management of chronic cyclical pelvic pain: an evidence-based and pragmatic approach. Changes in regional gray matter volume in women with chronic pelvic pain: a voxel-based morphology study. A systematic review of the accuracy of ultrasound in the diagnosis of endometriosis. A randomized clinical trial to compare two different approaches in women with chronic pelvic pain. Continuous compared with cyclic oral contraceptives for the treatment of primary dysmenorrhoea: a randomized controlled trial. The effects of an oestrogen-free, desogestrel-containing oral contraceptive in women with cyclical symptoms: results from two studies on oestrogen-related symptoms and dysmenorrhoea. A randomized controlled trial of medroxyprogesterone acetate and psychotherapy for the treatment of pelvic congestion. Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis. Antidepressant-induced analgesia in chronic non-malignant pain: a meta-analysis of 39 placebo-controlled studies. Laparoscopic adhesiolysis in patients with chronic abdominal pain: a double blind randomised controlled multicentre trial. This is considerably lower than previous estimates based on series of women undergoing laparoscopy for various indications. In a prospective study of 1542 Caucasian women in a single Scottish centre2 endometriosis was visualised in 6 per cent of women undergoing sterilisation, 21 per cent being investigated for infertility and 15 per cent being investigated for pelvic pain. Prevalence in other case series of women undergoing laparoscopy for investigation of pelvic pain has generally been higher, varying between 23 and 80 per cent. It is a common condition with many diverse manifestations and a clinical course that is highly variable and unpredictable. It may be asymptomatic, but most commonly presents with pelvic pain that is typically cyclical and in severe cases there may be associated bowel or bladder symptoms. The site of the lesions deep in the pelvis can also cause dyspareunia and there is a well-recognised but poorly understood association with subfertility. Endometriosis is usually regarded as distinct from adenomyosis (see Chapter 78), in which endometrial tissue is present within the myometrium. This chapter deals mainly with the management of pain in endometriosis, which has attracted a large literature and for which evidence-based management is relatively well developed. Haematogenous or lymphatic spread in a minority of cases may account for the rare occurrence of endometriosis at distant sites. Retrograde menstruation is observed in up to 90 per cent of women but only a minority of women develop endometriosis. It is most likely that tissue implantation is a result of failure of clearance mechanisms which may be secondary to defects in the local peritoneal immune defence system in susceptible individuals. Whatever the underlying mechanisms, it is evident that the symptoms and the progression of the disease differ considerably amongst individuals, with a poor correlation between laparoscopic appearances and clinical symptoms. Results from second-look laparoscopy in treatment trials3 have found short-term spontaneous regression of lesions in around one third of women receiving no active treatment, no change in another third and progression in the remaining third. Genetic factors appear to be relevant and these may influence local response mechanisms and the subsequent course of the disease. Endometriomas, also known as chocolate cysts, are retention cysts which form when inflammatory adhesions develop between endometriotic deposits on the ovary and the pelvic side wall or around a superficial ovarian lesion, producing progressive inversion of the surrounding cortex. Endometriomas may be multiple and very large, when they inevitably interfere with fertility by adhesion and distortion of the Fallopian tubes. In some women with endometriotic lesions predominantly affecting the uterosacral ligaments, marked fibrosis and scarring may develop, with infiltration of active endometriotic tissue into the rectovaginal septum or laterally to involve the ureters. Dense adhesions involving the rectum may lead to partial or complete obliteration of the pouch of Douglas. Deep infiltration may also occur on the uterovesical fold, leading to bladder involvement. It is not known why some women develop these more invasive forms of endometriosis. The mechanism of pain in endometriosis is presumed to involve the release of inflammatory mediators. Theories regarding the causation of chronic pelvic pain are discussed in Chapter 76. Dyschezia (pain with defaecation) and severe deep dyspareunia may be indicative of the presence of deep endometriosis. Rectal examination is useful in cases where symptoms are suggestive of rectosigmoid involvement. In many cases the examination is unhelpful and the decision to carry out further investigation is based on the history and the wishes of the patient. However there is little good-quality literature assessing the value of visual diagnosis of endometriosis at laparoscopy. Its predictive value is higher in cases of moderate/severe disease, compared with minimal/ mild disease. Laparoscopy must involve a two-port approach with careful inspection of the uterus and adnexae, uterovesical fold, pouch of Douglas, uterosacral ligaments, pelvic side wall and ovarian fossae[E]. The quality of laparoscopy is dependent on the experience of the surgeon carrying out the procedure and the operator must appreciate the varied appearances of endometriosis (Table 77. Visible evidence of endometriosis should be confirmed by biopsy [E],6,10 although this procedure is not without risk in inexperienced hands. For some patients with pain symptoms suggestive of the disease it will be preferable to undertake a therapeutic trial of hormonal suppression as initial management. Counselling must include discussion about the possible courses of action should endometriosis be diagnosed at the primary procedure. Best practice is to carry out surgical ablative therapy, if appropriate, at the initial laparoscopy,6 depending on the facilities and expertise Table 77. Medical management of pelvic pain associated with endometriosis There is a large evidence base supporting the use of medical therapy in the management of endometriosis-associated pain [A]. The majority of these therapies act by ovarian suppression and induction of amenorrhoea, resulting in inactivation of local deposits. As all the hormonal therapies have similar efficacy, their tolerability in terms of immediate and long-term side effects is important when selecting the most appropriate treatment for an individual woman [A]. In women wishing to conceive, hormonal therapy is not appropriate, as it delays rather than enhances fertility [A]. Progestogens Progestogens given continuously inhibit ovulation, depending on dosage, and have direct antiproliferative effects on endometriotic implants, causing decidualisation and eventual atrophy. They have been widely used for the treatment of pain in endometriosis and are the subject of a systematic review. A small non-randomised study has recently shown that low-dose norethisterone acetate 2. Other side effects which are likely to be dose related include weight gain, breast tenderness, bloating, headache, acne and nausea. On the basis of the evidence from the systematic review,15 continuous oral or depot progestogens can be used for suppression of endometriosis-associated pain [A] although their usefulness may be limited by side effects. Further evaluation of the role of oral desogestrel 75 mcg in endometriosis would be helpful, given its popularity as a progestogen-only contraceptive. However, few studies have addressed their role in management of endometriosis-associated pain6 and evidence for their efficacy is largely based on their use in the treatment of primary dysmenorrhoea (see Chapter 76) [A]. Indirect evidence from a systematic review of contraceptive studies14 showed that continuousor extended-dose regimens are marginally more effective than cyclical therapy in improving dysmenorrhoea [A].

Light touch sensation is ascertained by asking if the woman has any appreciation of ethyl chloride dripped on to skin pain treatment for rheumatoid arthritis buy azulfidine 500 mg low price. The extent of the block and modality of testing should be recorded in case a subsequent claim of intraoperative pain has to be defended allied pain treatment center oh purchase azulfidine online from canada. The obstetrician must clarify with the anaesthetist that it is appropriate to start surgery kidney pain treatment natural buy azulfidine 500mg mastercard. Relief of aortocaval compression by swift delivery of the baby will be required urgently blue ridge pain treatment center harrisonburg va buy discount azulfidine 500mg online. Obstetricians should not pain treatment center utah order azulfidine 500 mg, therefore pain treatment hepatitis c purchase azulfidine with visa, leave the theatre suite during induction of spinal anaesthesia. Spinal anaesthesia and pre-eclampsia Over the last few years, it has become accepted by many that pre-eclampsia is not necessarily a contraindication to singleshot spinal anaesthesia; if the abnormal systemic vasoconstriction is of humoral rather than neural aetiology, sympathetic blockade should not, logically, cause precipitous hypotension. Judicious fluid boluses and small increments of phenylephrine will correct hypotension. Epidural anaesthesia Few elective caesarean sections are now performed under epidural anaesthesia, because the quality of anaesthesia is generally poorer than that afforded by subarachnoid block. The rate of conversion to general anaesthesia for epidurals is consistently greater than that for spinals. De novo epidural anaesthesia is still favoured by some when gradual establishment of block is desired to minimise hypotension. In severe pre-eclampsia, postoperative infusion of epidural bupivacaine/fentanyl in a high-dependency area will confer optimal analgesia and contribute to blood pressure control. A South African study demonstrated that women who were fully conscious and cooperative after an eclamptic seizure could safely undergo caesarean section under epidural anaesthesia. However, the initial spinal anaesthetic block precludes ascertainment of correct positioning of the epidural catheter. In contrast to single-shot spinal anaesthesia, abrupt changes in blood pressure are unusual. Good communication among midwives, obstetricians and anaesthetists should make general anaesthesia for the woman with a working epidural a rarity. The floor of the triangle is composed, from superficial to deep, of the fascial extensions of external oblique, internal oblique, and transversus abdominis, respectively, and the peritoneum. The needle is inserted through the triangle, using the loss-of-resistance technique. The needle is shown in the transversus abdominis plane, and the fascial layers have separated as a result of the injection of local anesthetic. Although the evidence is not high level, the commonly held obstetric view that placenta praevia mandates general anaesthesia is not supported. An important distinction must be made between women with the potential for major intra-operative haemorrhage (as in placenta praevia) but who are normovolaemic. Pregnant women can compensate for significant blood loss by vasoconstriction, which will be abolished by regional anaesthesia. Any woman who has bled and is pale and tachycardic is not suitable for regional anaesthesia, regardless of the blood pressure. Regional anaesthesia might be ideal for advanced placement of uterine artery balloons immediately before caesarean section, but totally inappropriate for interventional radiological management of haemorrhage. If uterine hyperstimulation has been contributory to fetal compromise, uterine relaxation conferred by a volatile agent might be therapeutic. In contrast, a maternal stress response to excessively light general anaesthesia will be to the detriment of uteroplacental blood flow. With inhalational agent monitoring now universally available, the risk of awareness in obstetric anaesthesia should have been consigned to history. Cases of explicit awareness are attributable to failures of basic anaesthetic practice. Prior communication with a paediatrician is essential in order for preparation to be made for antagonism of opioid and provision of ventilatory support for the neonate. The onset and duration of succinylcholine are unaffected by therapeutic serum magnesium concentrations. However, the durations of action of all non-depolarising drugs are potentiated, and the use of a peripheral nerve stimulator is essential to ensure adequate reversal at the end of surgery. There should be a low threshold for blood pressure monitoring by radial arterial line, both in theatre and post-operatively in the high-dependency unit. Any patient whose larynx was noted to be swollen at laryngoscopy, or in whom intubation was traumatic, is at particular risk of laryngeal oedema. The ominous significance of stridor (impending airway obstruction) must be understood, and vigilance maintained. Special considerations for maternal cardiac disease In labour, the sympathetic blockade consequent upon highdose, intermittent bolus doses of epidural local anaesthetic must be avoided. Low-dose regimens can be embraced and topped up slowly and carefully if required for operative delivery [E]. Compared to regional anaesthesia, opioid-based general anaesthesia affords greater preservation of systemic vascular resistance. Regional anaesthesia avoids myocardial depression but can lead to unpredictable decreases in preload and/ or afterload. Good communication between the anaesthetist and obstetrician is vital in these cases, and the safety of the mother must always remain of paramount importance. If the history or evaluation of the airway suggests that tracheal intubation might be difficult, awake fibre-optic intubation should be considered. Rapid operative delivery while the anaesthetist administers pharmacological treatment will aid maternal resuscitation. Depth of anaesthesia the regimen of thiopental, succinylcholine and intubation has remained standard and largely unchanged since it superseded ether by facemask 50 years ago, and has permitted a lighter plane of inhalational general anaesthesia. The presence of morbidly obese women admitted in labour or to the antenatal ward should be brought to the attention of the duty obstetric anaesthetist. Regional blockade will almost certainly be a challenge, and general anaesthesia hazardous. Regional analgesia entails an extremely low risk of neurological complication, and does not increase the incidence of postnatal backache. Regional analgesia has been associated with an increased requirement for instrumental vaginal delivery, but not caesarean section. The addition of opioid to the local anaesthetic can reduce the incidence of intra-operative pain and provide post-operative analgesia. General anaesthesia is indicated for the majority of caesarean sections where there is immediate threat to the life of the mother or fetus and a regional technique is absolutely contraindicated or has failed. The principal risks of general anaesthesia are airway problems, aspiration of gastric contents and anaphylaxis. Ranitidine should be prescribed for women in labour with risk factors for caesarean section. General anaesthesia for caesarean section in placenta praevia is usually unnecessary. Regional anaesthesia is inappropriate for women with signs of significant haemorrhage. Sepsis is now the leading direct cause of maternal death, and prompt use of a sepsis bundle should be undertaken if sepsis suspected. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. Effect of low-dose versus traditional epidural techniques on mode of delivery: a randomised controlled trial. Ambulation in labour and delivery mode: a randomised controlled trial of high-dose vs mobile epidural analgesia. The risk of caesarean delivery with neuraxial analgesia given early versus late in labor. Assessment of a modified four-category classification of urgency of caesarean section. In: Confidential Enquiry into Stillbirths and Deaths in Infancy, 7th Annual Report. A randomised double-blinded comparison of phenylephrine and ephedrine infusion combinations to maintain blood pressure during spinal anesthesia for caesarean delivery: the effects on fetal acid-base status and hemodynamic control. The analgesic efficacy of transversus abdominis plane block after caesarean delivery: a randomised controlled trial. Epidural compared with general anaesthesia for caesarean delivery in conscious women with eclampsia. A prospective study of awareness and recall associated with general anaesthesia for caesarean section. Twin pregnancy where the leading twin is not cephalic, and higher-order multiples (see Chapter 35). Placenta praevia exists where the placenta is implanted either wholly or in part into the lower segment of the uterus. In modern obstetric practice with the routine use of ultrasound, this should always have been identified before delivery. Consultant obstetrician planned and directly supervising delivery; Consultant obstetric anaesthetist planned and directly supervising anaesthesia at delivery; Blood and blood products available on site; Multidisciplinary involvement in pre-operative planning; Discussion and consent includes possible interventions (such as hysterectomy, leaving placenta in situ, cell salvage and interventional radiology); Local availability of level 2 critical care bed. Higher success rates of around 90 per cent are seen in those who have previously had a vaginal birth also. In these cases, it is important to explore carefully and document the reasons for such a request, and fully counsel the woman to ensure she is fully informed of the risks and benefits for both the mother (Table 53. In cases of tocophobia, referral to an appropriate perinatal mental health professional who has access to the planned place of birth in the antenatal period is indicated. For the management of delay in the first stage of labour, see Chapter 50, and for the management of suspected fetal compromise see Chapters 51 and 54. The operator should be aware of any specific risk factors and include these in the counselling and consent process. Blood tests and investigations: a recent Hb should be available to identify those women with significant anaemia, and if there are concerns regarding the need for blood transfusion, blood should be sent for grouping and saving of serum. Anaesthesia: mode of anaesthesia to be employed is an anaesthetic decision, and good communication between teams is essential (see Chapter 52). If regional anaesthesia is employed, an indwelling catheter should be used to avoid post-operative urinary retention and re-catheterisation [A]. Prophylactic antibiotics should be given prior to the skin incision to reduce the risk of post-operative infection, in particular endometritis, wound infection and urinary tract infection [A]. Because of the association between coamoxiclav and necrotising enterocolitis demonstrated in preterm babies, it is advised to avoid this specific antibiotic as there are acceptable alternatives available. In cases of major haemorrhage or where the procedure lasts longer than 4 hours, a second dose of prophylactic antibiotics should be considered. This approach is associated with shorter operating times, lower blood loss, less fever and less pain when compared to the Pfannenstiel incision [A]. It is associated with increased pain and a higher incidence of wound dehiscence, and more concerns regarding the cosmetic appearance when compared to transverse incisions [B]. Once the head is lifted out of the pelvis into the incision, the assistant applies fundal pressure in a stepwise manner to effect delivery of the head. If the head is high, traditionally short curved forceps have been used to aid delivery, but disposable hand-held vacuum devices are also effective with perhaps a lower risk of trauma. It is essential to stop moving and wait for the uterus to relax before trying to advance the hand further. While the uterus is relaxed, the head can be flexed and lifted into the incision, and delivery completed. Alternatively, gentle steady traction on one or both legs will bring the breech down into the incision. A J-shaped extension on one or both sides will generally give more room than a central inverted T-incision. In the vast majority of cases, delivery will be safely achieved with these methods. In general, however, a common response is to push the fetal head up from below, often by a member of staff with little experience in this manoeuvre. This action again provokes a contraction, thus the upward pressure being applied to the fetal head is working against the downward pressure of the contraction. This approach is associated with fracture of the fetal skull and thus should only be used as a last resort. Different devices that are inserted into the vagina to elevate the fetal head are available, but are still undergoing evaluation to prove their effectiveness. Once delivery of the head is achieved, the shoulders should be released by lateral flexion, with delivery being completed by gentle traction. In cases of breech presentation, either the breech can be flexed and lifted into the incision in a similar manner to the head, or one or both feet/legs can be delivered first with delivery of the breech being achieved by Uterus Before incising the uterus, dextrorotation should be corrected, the visceral peritoneum above the bladder should be picked up to identify the upper margin of the lower segment, and the peritoneum should be incised transversely and the bladder gently pushed down to avoid injury. Following this, incision of the lower segment is the standard approach as the lower segment is thinner and less vascular than the upper segment making the procedure easier. It is also associated with fewer post-operative complications, such as ileus, peritonitis, obstruction and adhesions, as well as a significantly lower risk of scar dehiscence or rupture in a future pregnancy. Opening the uterus too low will increase the risks of extension and difficulty in delivery. The head can be delivered either by flexion or by the Burns Marshall technique of extension. With a transverse lie, it is better to try to achieve a longitudinal lie before opening the uterus.

Tumour markers again may be useful depending on the tumour type leg pain treatment youtube buy discount azulfidine 500 mg on line, and in germ cell tumours they may be diagnostic whilst in sex cord and stromal tumours treatment for nerve pain in dogs buy 500 mg azulfidine overnight delivery, they may be valuable in diagnosis and serial monitoring and follow-up sciatica pain treatment options safe azulfidine 500 mg. For post-menopausal women with ovarian and uterine suspected tumours back pain treatment kolkata buy azulfidine canada, the standard of care will usually include total hysterectomy pain treatment hemorrhoids buy discount azulfidine on-line, bilateral salpingo-oophorectomy and consideration of omentectomy and nodal dissection topical pain treatment for shingles buy azulfidine no prescription. However, many of these tumours do occur in younger women and this requires careful consideration and discussion of fertility preserving procedures. Curative treatment should always be offered to younger women, and particularly for suspected germ cell tumours fertility-sparing surgery should be at the forefront of the mind when planning the procedure as chemotherapy is highly effective and fertility can usually be preserved in spite of additional treatments. For some conditions, supra-regional services may be considered; good examples of these include management of trophoblastic cancers, and this could be extended to other rare tumour types. Post-operative management Pathology Specialist pathology review is essential by a histopathologist with a recognised subspeciality interest in gynaecological pathology. These rare tumours are often quite difficult to interpret and the differential diagnosis may be quite wide. Even with specialist immunocytochemistry there may be some degree of uncertainty about the final diagnosis. If the specimen indicates that this is a tumour associated with secretion of tumour markers then post-operatively this should be checked, but a strong case can be made for storing serum on all younger patients pre-operatively so that analysis of the markers can be taken if the germ cell or sex cord tumour is identified. For many cases which Management 925 are stage I, a watch-and-see policy with surveillance may be advised. This will include frequent measurement of tumour markers and scans as determined by appropriate protocols. Again due to the diversity of these tumours it is not possible to cover all of these. Thus these are patients who need longer-term follow-up, beyond the standard five years and arguably lifelong. Locally available protocols should identify how frequently clinical examination and imaging should be done. However because of their risk of late relapse, follow-up beyond the normal five years will be advised for selected rare subtypes. Some more slowly growing tumours with strong expression of oestrogen or progestogen receptor positivity may be treated with hormonal therapy. Although adjuvant chemotherapy often with a doxorubicin- or doxorubicin and ifosfamidebased regime is offered, the prognosis is usually very poor. For uterine and ovarian carcinosarcomas, adjuvant treatment with carboplatin and paclitaxel is frequently advised and radiotherapy is usually not given unless there is residual disease. Ovarian carcinosarcomas tend to be treated like epithelial ovarian cancers although probably carry a worse prognosis. The small cell cancers of ovary, cervix and uterus are very rare and there is no commonly accepted regime. Schedules such as platinum and etoposide or carboplatin and paclitaxel are commonly used. Much lively debate centres around the role of adjuvant radiotherapy in small cell ovarian cancer. It is probably necessary to use multiple modality therapy in these patients and even then only about one third will be long-term survivors. Follow-up It is important that all these patients are followed up but there are issues as to how to follow them up, who should follow them up, where they should be followed up and for how long. There should be local champions or enthusiasts who take on the mantle to oversee their care and write the local guidelines which should fit in with best available evidence and any national guidelines. Patients will generally be seen at intervals of around three to four months in the first and second year and then switch to six-monthly visits thereafter but certain subgroups will be seen more frequently, for example stage I germ cell tumours on surveillance will be seen much more frequently in the first two years with monitoring of tumour markers and imaging as per locally agreed protocols to detect early recurrence which can be salvaged. This differs from epithelial ovarian cancers where intervention due to rising markers does not influence survival, but in some of these rarer cancers, rising markers and imaging may lead to interventions that can improve outcome. The cautious approach is to withhold its use but consider using it in carefully selected cases where symptoms affect quality of life and the patient is fully informed of the potential risk. Setting up of registries and databases is important to record the numbers of patients being treated and this is also useful for access to histological material, serum, biomarkers and material for translational research which will be important in managing these patients in the future. National or international guidelines are being introduced to try to harmonise the treatment but this will not always be simple or straightforward. An argument could be made for having supra-regional centres to deal with some of these rarer tumours within each nation together with a more enlightened approach to dealing with ethical issues for trials in rare conditions. These cause major clinical challenges, particularly in younger patients where issues of fertility-sparing surgical approaches must always be considered. Localised databases are important to learn more about these tumours and, for the future, the identification of molecular pathways is likely to bring about improvements in diagnosis and treatment. Rare neuroendocrine tumours: Results of the surveillance of rare cancers in Europe project. Traditionally, the comparison of two related genomes is carried out by sequence alignment. There are cases where these techniques cannot be applied, for example, if two genomes do not share the same set of genes, or if they are not alignable to each other due to low sequence similarity, rearrangements, and inversions, or more specifically due to their lengths when the organisms belong to different species. For these cases, the comparison of complete genomes can be carried out only with ad hoc methods that are usually called alignment-free methods. The understanding of the whole human genome and of other species, and the mechanisms behind replication and evolution of genomes are some of the major Pattern Recognition in Computational Molecular Biology: Techniques and Approaches, First Edition. Although most of the current methods in genome sequence analysis are based only on genetic and annotated regions, this could saturate the problem because of their limited size of information. In fact, recent evidence suggests that the evolutionary information is also carried by the nongenic regions [35], and in some cases we cannot even estimate a complete phylogeny by analyzing the genes shared by a clade of species [10]. Accordingly, this chapter addresses the phylogeny reconstruction problem for different organisms, namely viruses, prokaryotes, and unicellular eukaryotes, using whole-genome pairwise sequence comparison. In contrast, only few computational methods can really handle as input entire chromosomes or entire genomes. In this section, we will discuss the use of computational tools for the comparison of whole-genome. Popular methods extract gene-specific sequences from all species under examination and build a multiple sequence alignment for each gene [42]. Other methods [24] use genes as a dictionary, counting the presence or absence of a gene. However, if the genomes in question do not share a common set of genes, or if they cannot be aligned to each other, for example, due to substantially different lengths, these traditional techniques cannot be applied. As a general example, in a pairwise comparison of genomes, popular alignment tools rely on a specific order of elements for each genome sequence, and on a set of sparse shared seeds that should then be extended to obtain a global alignment. Therefore, low sequence similarity, rearrangements, and inversions can cause major problems in identifying a possible alignment and thus the actual sequence similarity. Furthermore, when considering whole genomes, the global alignment of large sequences has become a prohibitive task even for supercomputers, hence simply infeasible. To overcome these obstacles, in the last 10 years, a variety of alignment-free methods have been proposed. In principle, they are all based on counting procedures that characterize a sequence based on its constituents, for example, k-mers [11, 34]. An important aspect in phylogeny reconstruction is the fact that gene-based methods strictly focus on comparing the coding regions of genomes, which can account for as little as 1% of the genomic sequence in humans [40]. Also most alignment-free methods in the literature use only a portion of complete genomes [39]. For instance, there are approaches that use only genic regions [11] or mitochondria; other methods filter out regions that are highly repetitive or with low complexity [34]. Recently, it has been shown that the evolutionary information is also carried by nongenic regions [35]. For certain viruses, we are not able to estimate a complete phylogeny by analyzing their genes, since these organisms may share a very limited genetic material [39]. This method needs to estimate the parameter k in order to compute a feature vector for each sequence, where the vector represents the frequency of each possible k-mer. For completeness, we note that, for large eukaryotes, they filter out high-frequency and low-complexity features among all the k-mers found. Furthermore, in case the genomes have large differences in length, they use first the block method, similarly to Reference [43], by dividing the sequences into blocks having the size of the smallest genome (with possible overlaps between the blocks). This general characterization of strings based on their subsequence composition closely resembles some of the information theory problems and is tightly related to the compression of strings. In fact, compositional methods can be viewed as the reinterpretation of data compression methods, well known in the literature [3, 6]. For a comprehensive survey on the importance and implications of data compression methods in computational biology, we refer the reader to Reference [22]. When comparing entire genomes, we want to avoid that large noncoding regions, which by nature tend to be highly repetitive, may contribute to our scoring function a multiple number of times, thus misleading the final similarity score. Furthermore, if we allow mismatches, the number of patterns can grow exponentially [4, 7, 25]. In this chapter, we will address this problem by controlling the distribution of subwords over the sequences under consideration so that their contribution will not be overcounted. Moreover, when comparing genomes, it is well known that different evolutionary mechanisms can take place. In this work, we will take into account all these symmetries in order to define a measure of similarity between whole genomes. They use a popular concept in the field of string algorithms, known as matching statistics [23]. In short, given two sequences s1 and s2, where s1 is the reference sequence, it counts the length l[i] of the longest subword starting at position i of s1 that is also a subword of s2, for every possible position i of s1 (see Table 3. In fact, with the latter the choice of the parameter k is critical, and every method needs to estimate k from the data under examination, typically using empirical measurements [34]. Since we are analyzing genome-wide sequences, this, asymptotically, can be seen as a natural distance measure between Markovian distributions. This is also known as relative entropy, information divergence, or information gain. Studied in detail by many authors, it is perhaps the most frequently used information-theoretic similarity measure [28]. The relative entropy is used to capture mutual information and differentiation between data, in the same way that the absolute entropy is employed in data compression frameworks. Given a source set of information, for example, s2, the relative entropy is the quantity of data required to reconstruct the target, in this case s1. Moreover, it is computationally less demanding than other notable phylogenomic inferences such as maximum parsimony and maximum likelihood, or other Bayesian estimations of divergence/correlation between entire genomes, where the correct estimation and use of the probability are often infeasible in practical problems-even when merely relegated to the analysis of genes and annotated regions, for example, [20]. In particular, we want to discard common motifs occurring in regions covered by other more significant motifs, for example, according to the motif priority rule introduced in Reference [41]. We define a distance-like measure based on these subwords such that each region of genomes contributes only once, thus avoiding to count shared subwords a multiple number of times. In a nutshell, this filter discards subwords occurring in regions covered by other more significant subwords. We prove that this set is by construction linear in the size of input, without overlaps, and can be efficiently constructed. In order to build a sound similarity measure between genomes, we need first to study the properties of the matching statistics. Our first contribution is the characterization of the subwords that are needed to compute the matching statistics. A second contribution is the selection of these subwords so that the resulting similarity measure does not contain overcounts. Our main idea is to avoid overlaps between selected subwords, more precisely by discarding common subwords occurring in regions covered by other more significant subwords. Our first contribution is to characterize the matching statistics in order to identify which subwords are essentials. It is well known that the total number of distinct subwords of any length found in a sequence of length n can be at most (n2). Remarkably, a notable family of fewer than 2n subwords exist that is maximal in the host sequence, in the sense that it is impossible to extend a word in this class by appending one or more characters to it without losing some of its occurrences [1]. It has been shown that the matching statistics can be derived from this set of maximal subwords [2]. Here we will further tighten this bound by showing that to compute the matching statistics it is enough to consider a subset of the maximal subwords, called irredundant common subwords. The notion of irredundancy was introduced in Reference [8] and later modified for the problem of protein comparison [14, 15]. It proved useful in different contexts from data compression [5] to the identification of transcription factors [13]. This ensures that there exists a close correspondence between the irredundant common subwords and the matching statistics. A common subword that does not satisfy this condition is called a redundant common subword. To show that the vector ls1 (i) can be derived from the irredundant common subwords, we define a new vector of scores l for each subword, where l [j] = - j + 1 represents the length of each suffix j of, with j = 1. Then, for each subword in s1,s2, we superimpose the vector l on all the occurrences of in s1.

In addition pain treatment center of baton rouge generic 500mg azulfidine visa, changes in collagen metabolism may be associated with the development of urogenital prolapse pain treatment shingles buy 500mg azulfidine with visa, increased levels of collagenases being associated with weakened pelvic support and stress incontinence pain medication for dogs with liver problems 500 mg azulfidine. Hormonal factors the effects of ageing and those of oestrogen withdrawal at the time of the menopause are often difficult to separate allied pain treatment center cheap 500 mg azulfidine visa. Rectus muscle fascia has been shown to become less elastic with increasing age pain treatment center illinois purchase azulfidine 500mg, and less energy is required to produce irreversible damage pain medication for dogs hips generic azulfidine 500 mg line. Furthermore, there is also a reduction in skin collagen content following the menopause. Both of these factors lead to a reduction in the strength of the pelvic connective tissue. More recently, oestrogen receptors, alpha and beta, have been demonstrated in the vaginal walls and the utero-sacral ligaments of pre-menopausal women, although the beta receptor was absent from the vaginal walls in post-menopausal women. However, a further study was unable to identify oestrogen receptors in biopsies from the levator ani muscles in urinary incontinent women participating in pelvic floor exercises. In conclusion, it would appear that oestrogens and oestrogen withdrawal have a role in the development of urogenital prolapse, although the precise mechanism has yet to be established. Damage to the muscular and fascial supports of the pelvic floor and changes in innervation contribute to the development of prolapse. The pelvic floor may be damaged during childbirth, causing the axis of the levator muscles to become more oblique and creating a funnel that allows the uterus, vagina and rectum to fall through the urogenital hiatus. In addition, the proportion of fascia to muscle within the pelvic floor tends to increase with increasing age, and thus once damaged by childbirth, muscle may never regain its full strength. This is supported by studies showing decreased cellularity and increased collagen content in 70 per cent of women with urogenital prolapse, compared to 20 per cent of normal controls. Over a period of time this will exacerbate any defects in the pelvic floor musculature and fascia, leading to prolapse. Prolapse of the vaginal vault may present following either vaginal or abdominal hysterectomy, although the incidence is low, with only 0. Obesity Although obesity has been linked to urogenital prolapse due to a potential increase in intra-abdominal pressure, there has been no good evidence to support this theory. Symptoms tend to become worse with prolonged standing and towards the end of the day. Women may also complain of dyspareunia, difficulty in inserting tampons and chronic lower backache. In cases of third-degree prolapse, there may be mucosal ulceration and lichenification, which results in a symptomatic vaginal discharge or bleeding. While less than 2 per cent of mild cystoceles are associated with ureteric obstruction, severe prolapse may lead to hydronephrosis and chronic renal damage. Between 33 and 92 per cent of cases of complete procidentia are associated with some degree of ureteric obstruction. A rectocele may be associated with difficulty in opening the bowels, some women complaining of tenesmus and having to digitate to defaecate. Exercise Increased stress placed on the musculature of the pelvic floor will exacerbate pelvic floor defects and weakness, thus increasing the incidence of prolapse. Consequently, heavy lifting and exercise, as well as sports such as weight lifting, high-impact aerobics and long-distance running, increase the risk of urogenital prolapse. Surgery Pelvic surgery may also have an effect on the occurrence of urogenital prolapse. Continence procedures, while elevating the bladder neck, may lead to defects in other pelvic compartments. At Burch colposuspension, the fixing of the lateral vaginal fornices to the ipsilateral ileopectineal ligaments leaves a potential defect in the posterior vaginal wall that predisposes to rectocele and enterocele formation. In a five-year followup study of women, 36 per cent had cystoceles, 66 per cent rectocele, 32 per cent enterocele and 38 per cent uterine prolapse. A further study of 109 women with vaginal vault prolapse reported that 43 per cent had previously undergone Burch colposuspension. Overall, 25 per cent of the women who had had Burch colposuspension required further surgery for prolapse. Needle suspension procedures, such as the Pereyra or Stamey endoscopically guided bladder neck suspension, are also associated with an increased incidence of recurrent cystocele, although this is not the case following sling procedures. In addition, there is an increased incidence of posterior compartment defects, such as enterocele and rectocele, after Manchester repair, caused by the anterior plication of the uterosacral and cardinal ligaments, which leaves a large posterior hiatus. There was also no significant difference in the quality-of-life measurement between the two groups. An abdominal examination should also be performed to exclude the presence of an abdominal or pelvic tumour that may be responsible for the vaginal findings. In such cases, a midstream specimen of urine should be sent for culture and sensitivity. Surgery 785 Subtracted cystometry, with or without videocystourethrography, will allow the identification of underlying detrusor overactivity, which is important to exclude prior to surgical repair. In cases of significant cystocele, stress testing should be carried out by asking the patient to cough while standing. Since occult urodynamic stress incontinence may be unmasked by straightening the urethra following anterior colporrhaphy, this should be simulated by the insertion of a ring pessary or tampon to reduce the cystocele. If stress incontinence is demonstrated, a continence procedure such as colposuspension or insertion of tension-free vaginal tape may be a more appropriate procedure. In cases of severe prolapse in which there may be a degree of ureteric obstruction, it is important to evaluate the upper urinary tract with either a renal tract ultrasound or an intravenous urogram. Although a cystocele itself may be responsible for irritative urinary symptoms, if these are unusually severe cystoscopy should be performed to exclude a chronic follicular or interstitial cystitis. Physiotherapy Pelvic floor exercises may have a role in the treatment of women with symptomatic prolapse, although there are no objective evidence-based studies to support this. Education about pelvic floor exercises may be supplemented with the use of a perineometer and biofeedback, allowing quantification of pelvic floor contractions. In addition, vaginal cones and electrical stimulation may also be used, although again, while they have been shown to be effective in the treatment of urodynamic stress incontinence, there are no data to support their use in the management of urogenital prolapse. In summary, physiotherapy probably has a role in cases of mild prolapse in younger women who find an intravaginal device unacceptable and are not yet willing to consider definitive surgical treatment, especially if they have not yet completed their family. Intravaginal devices the use of intravaginal devices offers a further conservative line of therapy for those women who are not candidates for surgery. Consequently, they may be used in younger women who have not yet completed their family, during pregnancy and the puerperium, and also for those women who may be unfit for surgery. Clearly, this last group of women may include the elderly, although age alone should not be seen as a contraindication to surgery. Pessaries should be changed every six months; long-term use may be complicated by vaginal ulceration and therefore a low-dose topical oestrogen may be helpful in post-menopausal women. Ring pessaries may be useful in the management of minor degrees of urogenital prolapse, although in severe cases, and for vaginal vault prolapse, a shelf pessary may be more appropriate. These may be difficult to insert and remove and their use is becoming less common, especially as they preclude coitus. Consequently, care should be taken to avoid constipation, which has been implicated as a major contributing factor to urogenital prolapse in Western society. In addition, the risk of prolapse in patients with chronic chest pathology, such as obstructive airways disease and asthma, should be reduced by effective management of these conditions. Hormone replacement therapy may also decrease the incidence of prolapse, although to date there are no studies that have tested this effect. A large national cohort study investigating the prevalence and risk factors for symptomatic pelvic organ prolapse women 20 years after one vaginal delivery or one caesarean delivery found that the prevalence of symptomatic prolapse was doubled after vaginal delivery compared with caesarean section, two decades after one birth. Equally, antenatal and postnatal pelvic floor exercises have not yet been shown conclusively to reduce the incidence of prolapse, although they may be protective. All patients should also have a urethral catheter inserted at the time of the procedure unless there is a particular history 786 Urogenital prolapse of voiding dysfunction, in which case a suprapubic catheter may be more appropriate. This allows the residual urine volume to be checked following a void without the need for recatheterisation. Patients having pelvic surgery are positioned in lithotomy with the hips abducted and flexed. To minimise blood loss, local infiltration of the vaginal epithelium is performed using 0. A vaginal pack may be inserted at the end of the procedure, and removed on the first postoperative day. Posterior compartment defects Posterior colporrhaphy Indication Posterior colporrhaphy is indicated for the correction of rectocele and deficient perineum. Procedure Two Allis forceps are first placed on the perineum at the level of the hymenal remnants, allowing the calibre of the introitus to be estimated. Following infiltration, the perineal scarring is excised and the posterior vaginal wall opened using a longitudinal incision. The redundant skin edges are then trimmed, taking care not to remove too much tissue and thus narrow the vagina. The pararectal and rectovaginal fasciae from each side are approximated using interrupted polyglycolic (Vicryl, Ethicon) sutures incorporating the vaginal epithelium, and the posterior wall is closed with a continuous polyglycolic (Vicryl, Ethicon) suture. Care should be taken not to create a constriction ring in the vagina, which will result in dyspareunia. Finally, a perineoplasty is performed by placing deeper absorbable sutures into the perineal muscles and fascia, thus building up the perineal body to provide additional support to the posterior vaginal wall and lengthening the vagina. Injury to the rectum is unusual, but should be identified at the time of the procedure so that the defect can be closed in layers using an absorbable suture and the patient managed with prophylactic antibiotics, low-residue diet and faecal softening agents to avoid constipation. Following pelvic floor repairs with or without vaginal hysterectomy, 50 per cent of women reported sexual dysfunction, nearly half of the cases being due to shortening of the vagina, dyspareunia or fear of injury. In addition, 22 per cent of women complained of vaginal pain, 11 per cent had incontinence of faeces and 33 per cent had constipation. Anterior compartment defects Anterior colporrhaphy Indication Anterior colporrhaphy is indicated for the correction of cystourethrocele. Procedure A midline incision is made in the vaginal epithelium from 1 cm below the urethral meatus to the cervix or vaginal vault. The redundant skin edges are then trimmed and the epithelium and fascia closed using interrupted polyglycolic (Vicryl, Ethicon) sutures. However, should a bladder or urethral injury occur, the defect can be repaired in layers using absorbable sutures and the bladder left on free drainage for ten days. Procedure First described in 1909, this offers an abdominal approach to correct an anterior compartment defect. The retropubic space (cave of Retzius) is opened through a Pfannenstiel incision and the bladder swept medially, exposing the pelvic sidewall. Long-term follow up in a series of 800 patients reported a cure rate of more than 95 per cent. Procedure An enterocele repair is normally performed using a vaginal approach similar to that of posterior colporrhaphy. It is not Surgery 787 essential to open the enterocele sac, although care should be taken not to damage any loops of small bowel that it may contain. The posterior vaginal wall is then closed as described for posterior colporrhaphy. The Moschowitz procedure10 is performed by inserting concentric purse-string sutures around the peritoneum in the pouch of Douglas, thus preventing enterocele formation. Manchester repair (Fothergill repair) Procedure this procedure is only rarely performed nowadays. Cervical amputation is followed by approximating and shortening the cardinal ligaments anterior to the cervical stump and elevating the uterus. The operation has fallen from favour, as the long-term complications include fertility problems in addition to recurrent uterovaginal prolapse and enterocele formation. Uterovaginal prolapse Vaginal hysterectomy Indication Vaginal hysterectomy is indicated for uterovaginal prolapse. Procedure A cervical incision is performed and the uterovesical fold and pouch of Douglas opened. The uterosacral and cardinal ligaments are divided and ligated first, followed by the uterine pedicles and finally the tubo-ovarian and round ligament pedicles. In cases of procidentia, care should be taken to avoid kinking of the ureters, which are often dragged into a lower position than normal. After closure of the pelvic peritoneum, the upper pedicles are tied in the midline to provide support for the vaginal vault, while the uterosacral ligaments are tied posteriorly to obliterate the potential enterocele space. In addition, a McCall suture12 may be performed, bringing the two uterosacral ligaments together in the midline as a further precaution against enterocele formation. Inclusion of the upper posterior vaginal wall also provides additional vault support. Vaginal vault prolapse Vaginal vault prolapse occurs equally commonly following vaginal or abdominal hysterectomy, with an incidence of approximately 5 per cent, although only 0. Sacrospinous ligament fixation Indication Sacrospinous ligament fixation is indicated for vaginal vault prolapse. Procedure A longitudinal posterior vaginal wall incision is performed to expose the rectovaginal space. The right ischial spine is then identified and exposed using sharp and blunt dissection. The sacrospinous ligament may then be palpated running from the ischial spine to the lower aspect of the sacrum. An absorbable braided polyglycolic suture (Dexon, Davies + Geck) is passed through the ligament using a Miya hook ligature carrier and then through the vaginal vault. Care must be taken to avoid the sacral plexus and sciatic nerve, which are superior, and the pudendal vessels and nerve, which are lateral to the ischial spine. Once the enterocele has been secured using two purse-string sutures, the upper third of the vagina is closed as previously described. The sacrospinous sutures are then tied to support the vaginal vault from the sacrospinous ligament, following which a perineorrhaphy is performed. Success rates of 98 per cent have been reported,13 although posterior fixation of the posterior vaginal wall increases the incidence of anterior compartment defects.

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