Category — Blog

Recently returned from Senegal, I came across a webposting from a USAID sponsored project to improve contraceptive access for women in this epic land of the Wolof, Fulani, Mandigo, Toucouleur and Diola.

Read for yourself here:

IntraHealh International Contraception Program in Senegal

The piece ends with

This work is an important step toward decreasing unmet need for family planning in a country where it is estimated that only 10% of married women use contraception.

…implying that lack of access is the biggest problem. And maybe it is. But in my experience, the backstory on contraception in settings of dire poverty direct from the mouths of the women it hopes to serve goes something like this:

My commentary to the blogpost:

Creating supply only works when there is demand. Dire poverty does not create demand for birth control, it decreases it, in part because poverty leads to high death rates for newborns and infants. Women living in a community where babies die young don’t want to do anything to impair the ability to conceive more children. According to Populations Reference Bureau, the 2008 infant mortality in Senegal was 58/1000 live births, equivalent to Tanzania, and far below the highest, in Afghanistan, at 155/1000 live births ( www.prb.org). I do hope that this intermediate infant mortality ranking reflects ongoing programs to reduce maternal and neonatal mortality, without which a rejection of this national contraceptive outreach program by the women it hopes to serve is virtually certain. That said, well done!  When it comes to family planning, nothing is possible without access to short and long term contraceptive methods.

This program is lead by Intrahealth and funded by US Agency for International Development as part of the parent program: Maternal, Neonatal, Child Health, Family Planning and Malaria Project. For perspective, Malaria is arguably the leading cause of death on the African continent : World Life Expectancy.

(c) Lauri Romanzi 2010

Uterine Prolapse – The Facts

Uterine prolapse affects 30% of ALL women, so there’s a good chance that it will touch you or someone you know. But before you can comprehend uterine prolapse, you need to have a basic understanding of a woman’s pelvis.

The vagina is the foundation of female anatomy, while the cervix sits above the vagina, and the uterus above the cervix. Connective tissue called uterosacral ligaments hold the uterus and cervix in place.

When it comes to uterine support, it's all about the uterosacral ligaments...

As the primary support system for the entire female pelvis, the uterosacral ligaments are extremely important! Uterine prolapse occurs when collagen fibers in these ligaments stretch or weaken, causing the cervix and uterus to drop down to the vaginal canal. If it drops far enough, it’s possible to feel and see the cervix, which looks like a small pink donut.

Although this is not usually painful, a woman may experience feelings of heaviness or pulling in the pelvis. Other symptoms of uterine prolapse may include painful sex, low backache, frequent urination, or even vaginal bleeding, although the converse is not always true, i.e; every women with frequent urination or low back pain or vaginal bleeding does not necessarily suffer uterine prolapse, as there are many reasons, prolapse among them, for each of these conditions. Your gynecologist can help sort out whether or not you are suffering uterine prolapse.

Like I said, it's all about the ligaments

A number of things can contribute to uterine prolapse. Women who give birth vaginally are more likely to experience thinning and stretching of the supportive uterosacral ligaments,especially those who experience long labors or deliver big babies. Prolapse is also more likely in women over 50, because muscle tone and onnective tissue integrity decreases with age.

Research also suggests that some women may be genetically predisposed to uterine prolapse. In other words, you can’t always PREVENT uterine prolapse, but you CAN learn about treatment options.

One effective treatment choice is a pessary, which is a vaginal support made of rubber, plastic, or silicone. A doctor fits a woman’s pessary to her body to hold the prolapse comfortably in place.

Surgery is another option, which, unlike a pessary, actually REPAIRS the prolapse. As with all surgeries, complications, including but not limited to recurrence of prolapse, are possible so make sure you understand both the risks and the benefits if you are considering prolapse surgery.

According to US Dept of Health data, one in nine cases of uterine prolapse is severe enough to warrant surgery. The good news is that uterine prolapse IS fixable without resorting to hysterectomy, so if you’re suffering uterine prolapse, understand that you don’t have to choose between hysterectomy or pessary, you have the option of uterine resuspension, hysterectomy-type prolapse repair, or pessary support.

To learn more about this and other pelvic floor conditions, visit Dr R video on HealthGuru.com.

(c) 2010 Lauri Romanzi

In the Hausa/Fulani region of Northern Nigeria and Southern Niger, “Gishiri” is the term for salt, for “tasty” and slang for the genitalia of both sexes. “Yankan” is the word for cutting, and “Yankan Gishiri” (cutting with salt) has been used for generations as a local remedy for all sorts of ailments and conditions, including:
Pain with sex (dyspareunia)

Infertility

Pelvic Organ Prolapse (dropped bladder, rectocele, uterine prolapse…)

Boils

Itching

Urinary Retention (inability to urinate)

Prolonged Labor

Episiotomy

This remarkably harsh home remedy involved rock salt in it’s traditional form, but now, in the new millenium, Gishiri cuts are made either by a barber with a knife, or a local birth attendant with a razor. Seems a bit backwards- you might expect the barber to use the razor and the lay midwife to use a knife, but this is not the case, according to today’s presentation of “Yankan Gishiri” data at the 4^th annual meeting of the International Society of Obstetric Fistula Surgeons by Dr. Amir Yola from Kano, Nigeria.

As you can imagine, these cuts can do damage, including urinary or fecal incontinence from damage to the urethral or anal sphincters, or full thickness holes, or fistula, between bladder and vagina, urethra and vagina, or rectum and vagina.

Fistula after Gishiri cuts result from deep cuts that heal open, creating a fistula defect. Of 1372 fistula patients treated by Dr. Yola and his team in Kano, Nigeria, 78 (5.7%) of the fistula were the result of “Yankan Gishiri”.

How’s that for “pouring salt on the wound”?

A Yankan Gishiri-free view with which to recuperate from this blogpost

(c) L. Romanzi 2010

After I complete this Harvard Humanitarian Initiative (www.hhi.harvard.edu) sponsored mission for fistula, prolapse, incontinence training and teaching, surgical technique exchange, and clinical protocol development at Panzi Hospital (www.panzihospitalbukavu.org) next week, I’ll attend the International Society of Obstetric Fistula Surgeons (ISOFS) 4th annual meeting in Dakar, Senegal (isofs). ISOFS a surgical society is founded and run by African surgeons taking care of African problems and setting the standard for non-African participation in evaluating, treating and preventing fistulas in Africa. I can’t tell you how fabulous this is, and I can’t wait to be at this meeting.

Dakar, Senegal

They’ve distributed a Direct Relief International (www.directrelief.org) questionnaire on fistula priorities among the meeting registrants – I thought you might like to take a look at some of the questions and my responses:

Obstetric Fistula Surgeons

Treatment Capacity Questionnaire

Information collected from this questionnaire will be used to create a mapping tool to help understand and visualize the existing treatment capacity, resources, and priority needs for improving fistula services.

We want to underscore that this questionnaire is simply a starting point in this collaborative process which will evolve over time. The data from this initial questionnaire and the resulting map will be made available to all respondents at the ISOFS Conference in Dakar, Senegal, December 7-9, 2010.

We value your input and thank you very much for your participation.

If you have questions about this questionnaire, please contact Direct Relief International at: MCHPrograms@directrelief.org.

(NB: the following is a partial excerpt from the questionnaire)

Please prioritize the following fistula issues from 1-10:

Please describe what you believe are the most pressing issues which require greater attention and support:

Prevention prevention prevention. “TURN OFF THE TAP” Train nurses in remote and outlying areas to follow partographs, provide prenatal care and perform forcep and cesarean deliveries. Improve communication with and transport to cesarean-ready facilities. Community outreach to educate and disempower the mythologies surrounding fistula, prolapse and intact bladder incontinence. Transport and psychosocial rehabilitation. Expansion of “fistula center” paradigm to ‘”Pelvic Floor Disorders Center’, since women suffering prolapse and intact bladder incontinence in nations with high obstetric fistula rates are usually equally ostracized, excommunicated, shunned and abandoned as are women with fistula, and as fistula prevention efforts take effect, women with prolapse and incontinence will continue to need help. This pelvic floor disorder concept allows all the funding and beaurocracy that depend on the perpetuation of fistula to embrace the possibility of a “post-fistula-era” future, and helps undermine any incentive to perpetuate the preventable tragedy of fistula in order to justify jobs and salaries. Do not permit any organization to fund fistula treatment unless it provides equal funding for fistula prevention.

(Not exactly ’nuff said, but it’s a start.)

NOV 23, 2010

(c) L Romanzi 2010

The Step-Sisters of Fistula – Minimally Invasive Uterine Resuspension- Hysteropexy C’est Arrive au DR Congo.

The Stuff of Prolapse *image courtesy of "Women of the Shadows"

It is difficult to express how impressed I am during each and every Harvard Humanitarian Initiative mission (www.hhi.harvard.edu) by the  skilled, motivated, and wise  pelvic floor – fistula surgeons at Panzi Hospital in Bukavu, DRC.  On these many fistula-repair missions, I’ve come to understand that one of the most important ways to add value to colleagues upon whom we descend in our zealous compulsion to fix every woman with a fistula, is to realize that, in addition to the tragic, fashionable and international charity-funded fistula women found in every developing nation on the planet, there are women in these same villages suffering equal stigma, ostracism, divorce and abandonment as their fistulous sisters because they suffer incontinence of urine or stool, or waddle about in a state of severe pelvic organ prolapse. The prolapsing cervix can look a lot like the head of a penis, and many’s the woman accused of infidelity by the husband to whom she birthed all the children and for whom she’s carried all the loads of wood, water and supplies on her head that caused the prolapse in the first place. As if she had a single ounce of energy with which to seek out and fornicate with a man other than her husband – peeleeze.  Anyhow, this sort of tragi-comic mythology surrounds many medical and surgical conditions when the people suffering said conditions do so without the benefit of education and absolutely zero comprehension of internal anatomy. You have a fistula because you are possessed by evil spirits, you have prolapse because you cheated on your husband, you died from hemorrhage after your clitoris and labia were cut off ritualistically to transform you into a marriageable chattel because you were committing the ultimate sin of pleasuring yourself to the always dangerous female orgasm. Things like that.  Feel free to throw the conditions and myths into a hat to play the game of “mix and match”. It’s all the same, as are the personal ramifications – you’re divorced, thrown out of your house, often permanently separated from your children, and excommunicated from your village, this being the only home you’ve ever known and the only people that ever mattered to you since the day you were born.

The uterosacral/cardinal ligament complex holds the uterus in place

Unlike the condition of fistula, prolapse and incontinence don’t “go away” with modern medicine, new world economics or robust personal health and wealth. Even the well-healed at the Hampton Classic include wealthy ladies who are wetting their pants and wishing their parts would stay all up in there where they belong. While fistula vanished with the advent of ether anesthesia in the mid-1800’s, rendering vaginal fistula nearly obsolete in Europe and North America well in advance of the 1900 centennial, (the world’s first fistula hospital was in New York City, torn down when rendered obsolete by access to Cesarean section, replaced by the still present Waldorf Astoria Hotel on Park Avenue), prolapse and incontinence continue to plague even the wealthiest, best educated, most fashionable of women on the planet.  But fistula virtually disappeared as anesthesia made Cesarean section the cornerstone of optimal obstetrical practice and stellar reduction in Euro-American maternal mortality and morbidity statistics, because fistulas come from obstructed labors, and no one in a developed nation is allowed to suffer through a 2 week labor resulting in a dead baby and a destroyed, fistulous vagina. We just do a Cesarean if it’s taking too long. The luxury of quick, routine, easy access to Cesarean section remains unavailable to the majority of women in Sub-Saharan Africa and other impoverished nations.

So this time, rather than play the “American fistula heroine” game, I decided to back it up into the unglamorous territory of plain old US/European style pelvic floor disorders, these being pelvic organ prolapse and urinary incontinence. While these un-funded (they’re not on UNFPA’s radar at all) women have no international advocate, yet they are equally tortured and punished for these conditions that are beyond their control as is any fistula victim’s.

We started with prolapse patients today. Magically, (there’s a lot of magic in DRC), after being informed that there was only a single prolapse patient, 10 emerged from the ether, each with the most severe form of prolaase, called procidentia. Procidentia (remove the children from the room and erase this link from your laptop history, quickly!) is a total pelvic disaster easily diagnosed by visualizing the cervix dangling between the patient’s thighs, turning the bladder upside down and kinking the urethra and rectum in the process. It’s mortifying.

From Beverly Hills to Bukavu, uterine prolapse is all about the uterosacral ligaments

We started the day with a lecture-discussion where we engaged in robust, healthy debate about current theory and principle held true among international pelvic floor disorder specialists – with the exception of avoiding hysterectomy by utilizing uterine resuspension – in the States, with rare exception, uterine prolapse = hysterectomy unless the woman can find a pelvic floor specialist who understands that the uterus is the victim of prolapse, not the cause.

This notion of preserving the uterus even though it’s falling out my Congolese colleagues understood, given the large number of young women whose lives would be equally destroyed by hysterectomy as they are by the prolapse.  Here at Panzi they use a large abdominal incision to resuspend the uterus by shortening the round ligaments of the uterus, a somewhat dated technique used very rarely inEurope and North America currently because it tends to fail and distorts pelvic and vaginal anatomy. These round ligaments contribute little (or so we believe) to the vector support of the uterus, the starring role of which falls to the ligament pair known as the uterosacral (US) ligaments. These US ligaments are like 2 cables, holding up the uterus and cervix by suspension at the top of the vagina much like a chandelier is held up by cables in the ceiling of a room.

We talked about compartment analysis, evaluating the support of the uterus (Apex), followed by evaluation of the stuff of vaginal prolapse and vaginal laxity below the level of the uterus, bladder for cystocele (Anterior) and rectum for rectocele and perineocele (Posterior), and evaluation of the levator (a.k.a. Kegel) muscles separately. We reviewed the role and evaluation of the Kegel muscles and the support and potential childbirth damage to the all-important and under-appreciated perineal body (connective tissue separating vagina from rectum). We debated and evaluated each continent prolapse patient for occult stress incontinence by filling the bladder, holding the prolapsed parts in proper anatomic position as the might be after surgical reconstruction, and asking the patient to cough and strain to see if urine leaks with abdominal exertion – the finding consistent with stress incontinence. Shocker, just like we find in the States, 40% of these women with bad prolapse and no incontinence symptoms leaked like sieves with full bladders and the prolapse temporarily corrected with vaginal support, and these women will undergo incontinence sling for stress incontinence at the time of their prolapse reconstruction. Tomorrow, in the OR (operating room), the Congolese fistula surgeons of Panzi Hospital (www.panzihospitalbukavu.org) will be the first to perform vaginal uterosacral uterine resuspension (a.k.a. hysteropexy) in Central Africa.

November 22, 2010

(c) L Romanzi 2010

Getting to Democratic Republic of Congo-DRC (formerly Zaire and not to be confused with the adjacent country of Congo)from the States is a bit like a triathlon, each part run concomitantly. –There’s the physical stamina test – how many connections and super tight/painfully long layovers can you successfully perform? Then the humanity tolerance component– how much yanking on the back of one’s seat (yes, I’m talking 28 hours of steerage here), piercingly painful body odors and airline corporate culture idiosyncrasies can you gracefully outwit without raising your voice, pulse or blood pressure? Lastly the cognitive function challenge – as your body and soul run out of gas, confusion invades and travel complications erode your preemptively organized carry on gear, will you manage to avoid losing your passport, your single-print/triple function receipt= round trip boarding pass from RwandAir, remember not to leave your eye drops, lip balm and breath mints in the seat pockets of oh-so-many seats, and pull out just enough Franglais to get the information you need about the 50 lb bag that didn’t make the connection when the 5 hour layover turned into a 20 minute sprint for the connecting flight because of a cake?

Yes, I said a cake.  A gorgeous affair marking the pre-boarding celebration of Ethiopian Airlines virgin flight of their very first, brand new Boeing 777. It’s a glorious bird, each coach seat with foot rests and movie screens. And yes, it did have that “new plane smell”. Having checked in at the gate after a quick flight from JFK (where this sort of flight belongs, by the way – ahem…) to Dulles (puhleeeze, really, all the way from Addis just base this flight in JFK WHERE IT BELONGS), and checking in at the gate, the party started.  In lieu of a boarding announcement there was a podium, speakers, movie crew, finger food, slivers of champagne, any number of dignitaries, VIP’s, square jawed pilot-types, glamour girls and cake  – a glorious edible frame around a Polaroid-style image of said brand-new, gleamingly logo’d Boeing 777 in flight at a dramatic 23 degree banking turn.

Several hours after scheduled boarding and take-off, we boarded, and about 90 minutes after queuing on the tarmac, we took off.  What was to be a 5 hour, book reading layover in Addis Ababa turned into landing with 40 minutes to make the connection, the slowest de-boarding in recorded flight history, and in my elite-triathleticism, I was given the extra challenge of being all the way at the back of this plane full of what seemed to be an endless supply of arthritic, first-time-air-travel Ethiopian grandmothers, who, having survived any number of bathroom lock-ins where they wait 15 minutes, then finally find the knob that they used to lock themselves in there, but somehow managed to urinate or defecate the skill set needed to manipulate said airplane bathroom door lock down the airplane toilet, resulting in each giving up and resort to knocking from the inside, so that the 12 people on line have to talk to them LOUDLY for another 7 minutes before each managed to extract herself from the trick toilet, (like I said, I was the back, you know, for the elite challenge championship), so as we prepared to de-plane, each one of these grandmothers suffered a group flare of said arthritis, preventing them from exiting the plane at anything faster than a snail’s pace. No problem, game on.

Then I remember the checked bag, but I was reassured that since the connecting flight was also Ethiopian Air, of course the bags would be transferred, absolutely no doubt, no problem, no worries. I was reassured by every flight attendant all the way from the back of steerage to the door, where I realized, as my descent down the 45 steps to the tarmac began, that the fate of the bag was sealed by the fact that the plane-cake-party was still going on, as we de-planed into a 30 pair gauntlet of lovely Ethiopian Air staffers handing each of us a rose, while the VIP/dignitary/glamour girl posse proceeded to their full-on tarmac party, banquets overflowing with food and drink,  a live band and candle-lit, canopy covered tables. No one was touching that cargo door. That bag, and the others connected to the connectors, were going nowhere except the Addis Ababa lost and found baggage area.

One bag gone, but eyes on the prize; where’s the connecting flight?  I jump on the packed (this is good, it ought to leave soon, especially since an empty one is sitting right behind the packed one) airport shuttle and watch the driver get on (yes!) then get off (noooooo!) then almost get back in (no words for this one), then get on (yes!), back off again (crying, would loud crying, you know sobbing interspersed with undulant gasps get that driver into the driver’s seat to do some driving?) then back on, sits down, shuts door, then starts a conversation replete with jokes and laughter out the driver side window then finally, when the last joke has been properly chortled over, the shuttle bus commences to shuttle.

It stops in front of a building with people waiting in the vestibule.  The vestibule people are waiting for a shuttle to someplace else, so I run up the stairs, grab the first official looking person I can find and am told gate 5. At gate 5 there is a flight to Cairo. There I’m told gate 1A (here’s the cognitive function obstacle course) so of course, since no other gate has an ‘A’ version, I queue up to gate 1, wait, wait, wait as each passenger goes through gate security, just about watch my bag disappear into the x-ray when I ask, to make sure, if this the Kigali flight (no gate postings, you see) and in the knick of bag-retrieval time am told no, this flight is going to Johannesburg. Grab bag, pivot, dash, scan, see gate 1A waaaay down the hall but I see heads on the security line so yay! I sprint like a lunatic anyway, just in case 1A is not the Kigali flight, requiring another dash to some other gate, but it’s all good. Kigali plane, gate 1A,  3 seats to myself.  Sweet.  I take a proper nap.

This flight arrives in Kigali at 1:30 am, and the flight to the Congolese border leaves at 8 am, so I planned to lounge around the airport for 6 hours until it boarding time. But there’s a delay, then another delay, and another, each without explanation as my brain turns to laundry lint.  When the 8 am flight finally opens for boarding at 11 am, we stampede through 2 x-ray security checks and a passport stamp. A last-minute conversation with RwandAir gate attendant Celine netted her phone number and the luggage commander at the final airport in Kemembe and a guarantee that she would personally secure my late bag from the Ethiopian Air flight and put it on the  RwandAir flight to Kemembe next day. The flight over Rwanda to the border airport in Kemembe was a carpet ride over an emerald field, so lush are the tea and banana plantations covering every Rwandan hill.

Next day, post-coma, I awake to a phone call from Celine – she secured the bag and put it on the plane to Kemembe, and 3 hours and 4 border crossings later (check out, check in, check out, check back in), bag full of supplies secured, I make my way to Panzi Hospital to begin the 2 weeks of endeavor. To date, Celine of RwandAir is the best lost bag commandant I’ve ever run across. Were said bag lost in transit to JFK or LaGuardia, I’d likely never see it again. Thank you Celine, Queen of RwandAir Customer Service, for making my travel triathlon a success.

courtesy beachtrek.fortunecity.com

Dyspareunia is the latin word for “pain with sex”. The true prevalence of women who have pain with sex is unknown, since many women believe the pain to be “normal” or something for which nothing can be done. Various conditions can contribute to the symptom, including vestibulitis (here I recommend a visit to my colleague Dr. Andrew Goldstein’s website on this difficult condition www.cvvd.org), interstitial cystitis (painful bladder syndrome), and endometriosis, for instance. Once the pain begins, the muscles of the pelvis, called the levator muscles (A.K.A. Kegel muscles and vaginal muscles) often spasm, creating a “TMJ of the vagina” type syndrome where everything hurts. The clenching of these muscles can be measured with a perineometer, a gadget that quantifies muscle tension during intentional contractions and at rest. In women with painful sex, the muscles often relax poorly, or not at all. Just like TMJ (temperomandibular joint/jaw pain), it’s important to be evaluated and managed by specialists with a track record of success. My colleague Andrew Goldstein (Washington DC and NYC) is one, and the authors of this fabulous paper, Susan Kellogg PhD and Kristene Whitmore, MD (Philadelphia) are two others. Susan and Kristene (www.sexandahealthieryou.org) are the authors of a timely paper recently published in the International Urogynecology Journal on management of this unhappy syndrome, the root of which includes Valium vaginal suppositories to relax the levator/Kegel/vaginal muscles. No joke. They work. Read a synopsis of the paper below:

Rogalski MJ, Kellogg-Spadt S, Hoffmann AR, Fariello JY, Whitmore KE. Retrospective chart  review of vaginal diazepam suppository use in high-tone pelvic floor dysfunction.  Int Urogynecol J (2010)21:895-99.

The authors review 26 charts of patients with levator hypertonus and sexual pain.  Evaluation included completion of the female sexual function Inventory (FFI) and visual Analog Scale of Pain (VAS-P). Levator muscle evaluation included perineometry and vaginal palpation exam.

21 women were premenopausal, 5 menopausal and 18 nulliparous. 85% reported dyspareunia, 81% chronic pelvic pain, 61% interstitial cystitis,  and 46% hypoactive sexual desire disorder.

Interventions included pelvic floor physical therapy, injection of trigger points with Traumeel and lidocaine, and 10 mg diazepam vaginal suppositories, inserted nightly for 30 days.

25 of 26 patients reported improved sexual function with 6 of 7 women who entered therapy abstinent due to pain resumed intercourse. Perineometry baseline muscle pressures decreased significantly, both at rest and post-voluntary contraction return to rest. Visual analog pain ratings decreased significantly for the majority of pelvic girdle muscles evaluated pre and post-therapy.

The authors propose that vaginal diazepam suppositories are a useful adjunct for the treatment of high – tone pelvic floor dysfunction, and announce plans to initiate a randomized crossover study from placebo to diazepam (valium) in newly diagnosed high-tone pelvic floor dysfunction patients.