Understanding Rectocele, Levatorplasty and Site-specific Rectocele surgery techniques

You may be unacquainted with the term “rectocele,” but for almost 19% of women, the condition is all too familiar!

In a normal female pelvis, the rectum rests behind the vagina.

The two are separated by a thin wall of fibrous tissue called fascia.

When the fascia becomes weakened or damaged, the front of the rectum can bulge into the vagina. This is known as rectocele.

Rectocele - how it looks to the patient

Pregnancies and childbirth, chronic constipation and the natural aging process are the most common causes, but other factors can contribute to weakening of the fascia, too, including: chronic cough or bronchitis, repeated heavy lifting, and being overweight or obese.

Whatever the cause, rectoceles may induce a sensation of rectal pressure or fullness.

Difficulty having bowel movements and a feeling that the rectum has not fully emptied afterward are also common.

Severe rectoceles may even become visible, appearing as a ballooning bulge protruding through the vaginal opening.

For more mild cases of rectocele, a vaginal pessary may effectively treat the problem. Pessaries are removable supportive devices that hold the rectum in place.

More often than not, though, treatment for a severe rectocele requires surgery, performed through a small incision in the back wall of the vagina. .

The most common type of rectocele surgery is a levatorplasty, using sutures to bring the inside edges of the levator ani, or Kegel, muscles closer together, reducing the rectocele bulge back to a normal contour.

This method works because the levator muscles support the entire pelvic floor like a sling, and they’re often pulled apart with rectocele.

Some specialists believe, and some clinical research shows, that levatorplasty rectocele surgery may be more likely to result in pain than other rectocele repair techniques.

Knowing this, some doctors choose to do a newer procedure called site-specific rectocele, which uses sutures to close ONLY the holes in the connective fascia tissue, bypassing the levator muscles completely.

Although LESS likely to cause pain, site-specific rectocele techniques are MORE likely to result in recurrence of the rectocele.

Because each procedure has its good and bad points, it’s important to discuss the best rectocele repair for YOU with your surgeon.

For more information, see this video on Understanding Rectocele, courtesy HealthGuru.com

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

PELVIC ORGAN PROLAPSE:

NO DIFFERENCE IN SEXUAL QUALITY OF LIFE BETWEEN PROLAPSE PATIENTS CHOOSING PESSARY VS SURGERY.

Ladies, it's all about choice

Pelvic organ prolapse is a condition where the organs around the vagina are out of place – bladders drop (called cystocele), rectums bulge forward and sometimes out of the vaginal opening (rectocele), and/or the uterus drops down, literally falling out of the vagina turning everything inside out when its severe (uterine prolapse).  When prolapse is so bad that things are bulging out between the vaginal labia (yup, it happens) most women are uncomfortable to want to do something about it.
With severe prolapse, whatever the prolapsing part(s), and it’s usually more than one thing out of place, there are 2 choices – reconstructive surgery, or a vaginal prosthesis called a pessary.  A pessary is a vaginal widget that holds things up where they need to be when it’s inside. They come in all shapes and sizes – the easiest pessaries are ring-shaped. They’re easy because women can remove and insert them easily and reliably without assistance. Ring pessaries are sort of like contraceptive diaphragms in terms of insertion and removal. But sometimes, due to weak, thin Kegel muscles or uterine prolapse so severe that it pushes the rings out, sturdier pessaries, such as Gellhorns, donuts and Gehrungs, are the only ones that stay in.

Some women don’t like pessaries – or can’t find any that fit comfortably. They usually opt for prolapse surgery that puts all the organs back into position. The surgery can be complicated and, as with all surgeries, results can be less than perfect, making pessaries a viable option for women who are poor surgical candidates or simply don’t want to undergo extensive soft-tissue reconstructive surgery.

These British researchers undertook the task of looking at whether or not either treatment choice, surgery or pessary, affected sexual quality of life.  In data published in the March 2011 issue of the International Urogynecology Journal, they  found some interesting trends – women choosing surgery were younger, and at first glance seemed to have better sexual quality of life than their pessary using sisters, but when the statistician removed age differences, the sexual quality of life was the same between the two groups. Interestingly, 31 women who started with pessary didn’t like it and switched to surgery. Not much is said about them as the study design excluded data of patients who switched groups after the initial choice of treatment.

Here’s the study summary written for the June 2011 literature review for Journal of Sexual Medicine:

Abdool Z, Thakar R, Sultan AH, Oliver RS

Prospective evaluation of outcomes of vaginal pessaries versus surgery in women with symptomatic pelvic organ prolapse.

Int Urogynecol J (2011)22:273-78.

A prospective, non-randomized design compared women with prolapse opting for pessary management vs reconstructive surgery of pelvic organ prolapse, using baseline  and 1 year quality of life data, including but not limited to sexual function (Sheffield Pelvic Organ Prolapse Quality of Life questionnaire-SPS-Q).

Women referred to the Urogynaecology unit of Mayday University Hospital in Surrey, England were evaluated and counseled regarding prolapse management.  Each completed the SPS-Q, a 13 item quality of life assessment tool addressing impact of prolapse on bladder, bowel and sexual function using four-point ordinal response scales (never, occasionally, most of the time, all of the time), validated and sensitive to changes in clinical status. Women choosing pessary were first fitted for ring pessaries; the most user-friendly. If rings did not work, gellhorn or donut pessaries were fitted for sexually inactive women, and cubes fitted for sexually active women, as cubes are easily removed for sexual activity.

Patients were excluded if they underwent incontinence surgery or switched from pessary to surgery (N=89) either due to use of pessary as interval measure in preparation for surgery (N=58), or because pessary was too problematic, prompting a change of heart in favor of prolapse surgery (N=31).

554 women entered the trial, 359 with pessary and 195 choosing surgery. Women excluded from final analysis numbered 195 in the pessary group and 88 in the surgery group.  The final analysis was carried out on women completing questionnaire at 1 year who either underwent surgery as first option or were still using pessary at 1 year, 46% of the pessary group and 55% of the surgical patients.

Mean age was higher in the pessary group (68 vs 60 yrs). Other demographic measures were equivalent. At 1 year there was statistically significant improvement in sexual function in both pessary and surgery patients, in addition to similar improvement in bladder, bowel and prolapse symptoms. Frequency of intercourse was better in the surgical group (54% vs 46% p=0.028), however this sexual frequency difference faded when controlling for age.

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

Prolene Mesh and Pelvic Organ Prolapse

Cystocele, rectocele, erosions, sex, mesh shrinkage, folding and thickening

You can’t make this stuff up.

Prolene mesh is the product name for a permanent plastic mesh with many implantation applications in reconstructive surgery. Prolene mesh is used to fix large and small abdominal hernias, inguinal hernias, hernias of the diaphragm; it’s used to resuspend kidneys (nephropexy) rectums (rectopexy), uteri (aka uterus’ plural) (sacrohysteropexy), prolapsed vaginas after hysterectomy (sacrocolpopexy), chin augmentations (mentoplasty), chest wall repair in certain thoracic surgeries, (abdominal hernias (inguinal, umbilcal, ventral) and both male and female urethral sling operations for stress urinary incontinence, to name a few.

Over the last 8-10 years, the use of prolene mesh for vaginal prolapse surgery has expanded to include cystocele and rectoceele repair, In an effort to standardize application and, arguably, make it easier for gynecology, urogynecology and urology surgeons to use the mesh, and, definitely, to market the new pelvic organ prolapse mesh kits effectively, Prolene mesh companies have tweaked mesh pore size (degree of laciness), thickness, and density; they’ve mixed it with other graft materials, impregnated it with various materials, each in an effort to reduce horrific complications and claim clinical superiority. The industry cannot advertise or market superiority without data, so they sponsor scientific clinical trials hoping for favorable data that will legally permit them to claim product  superiority in marketing activities, via studies paid for in part or in full by the companies manfacturing the mesh, often but not always recruiting surgeons who work as paid advisors and consultants, much the same way pharmaceutical companies use paid advisors to participate in clinical drug trials. I know, I’ve been, at various points in my career, one of those advisor/consultants. It is a very fine ethical tightrope clinicians walk when participating at that level. The perks are large. The rewards many. It’s an elite group of clinical industry insiders that trumpet the merits of these meshes. Those surgeons publishing outside of the advisory board arena compete for journal space along side industry funded trials.

A few times a year, I and a few colleagues comb the literature for the Journal of Sexual Medicine, fashioning reviews of research with a sexual function implication. This month, I found three that “turn me on” – 2 of which focus on Prolene mesh for vaginal implantation in pelvic organ prolapse surgery for cystoceles (dropped bladders) and rectoceles (back wall vaginal hernias).

Here are the two trials on 2 different Prolene mesh kits: AMS Perigee and Gynecare Prolift.

The first study, using Prolift, found that young sexually active women were more likely to suffer vaginal erosion of mesh, literally mesh showing where the vaginal skin over it has eroded away. A bit of a problem, if your young, like sex, have prolapse, and use Prolene mesh, at least with this particular kit, to have it fixed. Prolene mesh in the vagina creates a mechanical risk of sexual dysfunction; your sex life could, quite literally, hit the skids. Forget carpet burns, we’re talking penis-meets-sand paper. Woops.

The second study, using a different brand of Prolene mesh vaginal prolapse kit for dropped bladder (cystocele) repair called Perigee, claims a close-to-zero mesh erosion rate, each erosion “minimal and easily remedied” with a bit of tinkering in the office. The investigators report some interesting ongoing changes in the sonographic appearance of the mesh once implanted in the vagina. In this study, Prolene mesh demonstrated folding in a few, and continued to shrink or shorten and thicken more and more at each of three sonograms done in the first year after implantation. Makes you wonder how it’s behaving after, say, 5  or 10 years.

I’ve said before and I’ll say again here, Prolene mesh ribbons for uterine suspension, vaginal cuff suspension after hysterectomy and female urethral sling operations for urinary incontinence have been around a long time and really do seem, in my experience and in my opinion, to work very well with low rates of minimally bothersome, easy to fix complications. BUT I’ve seen nightmares with Prolene mesh kits used for cystocele and rectocele repair – full recurrence of the prolapse, sometimes worse that before surgery, along with horrific, painful, bleeding mesh  vaginal or bladder erosions, kinking of ureters (the tubes that drain urine from your kidney to your bladder) glued to the mesh requiring ureteral re-implantation into a diffierent part of the bladder (this is big surgery, not a quickie), in addition to mesh bundles eroding into the vagina creating bleeding vaginal wounds that make sex impossible. Explanting (removing it in full) Prolene mesh from the anterior and posterior walls of the vagina is no easy task.  Not to mention, who wants a vagina literally lined on all’round with plastic mesh? Pore size, shmore size – it’s a Franken-vagina. How can that be good?

To date, I use this paper by Dr. Donald Ostergard as the yardstick by which all Prolene mesh graft products are to be measured, including the uses I consider acceptable and continue to employ. I don’t see any similar works coming from other surgical specialties about Prolene mesh as a surgical graft material. Urogynecology seems to be the lightning rod specialty for Prolene mesh graft considerations.

In 2008 the  FDA issued an official warning about Prolene mesh implantation in the vagina, and continue to express concern, as we see here in this Feb 2009  FDA newsletter posting:

Serious Complications with Surgical Mesh for Gynecologic Surgery

The FDA is alerting healthcare professionals about rare but serious complications associated with the surgical mesh used to treat pelvic organ prolapse and stress urinary incontinence. The mesh is usually placed transvaginally using minimally invasive techniques.

Over the past three years, FDA has received over a thousand reports of complications. The most frequent included erosion of the mesh through the vaginal epithelium, infection, pain, urinary problems, and recurrence of the prolapse or the incontinence. There were also reports of bowel, bladder, and blood vessel perforation during insertion. In some cases, vaginal scarring and mesh erosion led to a significant decrease in quality of life due to discomfort and pain, including dyspareunia.

Treatment of the complications included IV therapy, blood transfusions, drainage of hematomas or abscesses, and additional surgical procedures, in some cases to remove the mesh.

Clinicians using mesh for treatment of pelvic organ prolapse and stress urinary incontinence should:

• Obtain specialized training for each mesh placement technique, and be aware of its risks.

• Be vigilant for potential adverse events from the mesh, especially erosion and infection, and also from the tools used in transvaginal placement, especially bowel, bladder and blood vessel perforations.

• Inform patients about the potential for serious complications and their effect on quality of life, including scarring and pain during sexual intercourse. Patients should also be informed that implantation of surgical mesh is permanent, and that some complications associated with the mesh may require additional surgery that may or may not correct the problem.

• Provide patients with a written copy of the patient labeling from the surgical mesh manufacturer, if it is available.

So here’s some of the latest research data on both sides of the Prolene mesh fence – 1st up – if you’re young and like sex and need cystocele/rectocele prolapse repair, beware Prolene mesh. Second up – a study showing that kit- Prolene for bladder lift/cystocele repair is great stuff, no major problems, the authors reporting great results and almost no complications! However, sonographic evaluation of Prolene mesh over the first year showed that folding might occur early on, and mesh shrinkage and thickening increased steadily at each sonogram evaluation. These papers were back-to-back in a recent issue of a major urogynecology journal. Kudos to the editorial board of the International Urogynecology Journal.

Sorry for the confusion – this is the world we live in:

Prolene mesh kits for cystocele and rectocele repair: erosion correlates to young age and sexual activity

Kaufman Y, Singh SS, Alturki H, Lam A.

Age and sexual activity are risk factors for mesh exposure following transvaginal mesh repair.

Int Urogynecol J (2011)22:307-13.

A prospective, observational study evaluates safety and complication risk factors of the Prolene mesh prolapse surgery product, GYNECARE PROLIFT.  Polypropylene mesh kits are available for cystocele, rectocele and global (total vaginal lift) prolapse repair, each marketed as a more reliable method of prolapse repair with lower recurrence rates. This study evaluated 114 consecutive Gynecare Prolift patients for graft exposure (erosion of prolene mesh through the vaginal wall). Women were excluded if they were unwilling to undergo risks of polypropylene mesh vaginal grafting, or had severe vaginal scarring from prior operations. Exposure was further divided into early (< 6 weeks post-op) and late > 6 weeks post-op) categories, comparing each to demographic factors to determine what patient characteristics are associated with Prolift prolene mesh vaginal erosion.  Standardized pelvic floor/sexual function quality of life questionnaires were used in addition to pre-and post operation examination. Age, parity and demographic factors were collected.

114 women met criteria for inclusion, average age 61, BMI 26, parity 3. Follow-up ranged from 6.3-7.4 months, average 7.4.  19 underwent cystocele Prolift, 14 rectocele Prolift, and 81 Total (cystocele and rectocele) Prolift.  Only 58 (51%) of participants were sexually active before surgery, 18 (31%) of whom reported dyspareunia before surgery. 52 women were sexually active after surgery, 14 (27%) reporting de novo dyspareunia and 9 (17%) with persistent dyspareunia.  Four (3.5%) demonstrated early mesh exposure and 10 (8.8%) late mesh exposure with 6 (5.3%) repair procedure failures, all of which carries implications for sexual function.  Mesh exposure was higher in overweight women and women of higher parity. Early mesh exposure correlated to greater degree of pre-surgery prolapse and higher parity. Younger age and sexual activity were risk factors for late mesh exposure, most commonly on the anterior vaginal wall.  The authors found no correlation between mesh exposure and dyspareunia, postulating that painful sex may reduce mesh exposure by paradoxically deterring sexual activity, the erosion-risk behavior. The authors further caution that sexually active, especially younger, patients must be cautioned as to the potential for Prolift polypropylene mesh exposure, a complication with severe negative implications for sexual quality of life.

Prolene mesh kits for cystocele repair: mesh erosions and prolapse recurrence minimal, mesh shrinkage and thickening seen on sonogram.

Lo TS, Ashok K.

Combined anterior transo-obturator mesh and sacrospinous ligament fixation in women with severe prolapse-a case series of 30 months follow-up.

Int Urogynecol J (2011)22:299-306.

A prospective, observational study evaluates efficacy and safety risk factors of the anterior Prolene mesh prolapse surgery product, PERIGEE. In women with severe pelvic organ prolapse.  Polypropylene mesh kits are available for cystocele, rectocele and global (total vaginal lift) prolapse repair, each marketed as a more reliable method of prolapse repair with lower recurrence rates. This study evaluated 128 Perigee patients for recurrence of prolapse, mesh erosion, mesh folding and mesh shortening, shrinkage and thickening. No exclusion criteria are reported.   Standardized pelvic floor/sexual function quality of life questionnaires were used in addition to pre-and post operation examination, urodynamics evaluation of bladder function,  and post-operation introital sonography to evaluate in situ mesh characteristics. Age, parity and demographic factors were collected.

120 women met criteria for inclusion, average age 63, BMI 25, parity 4. Follow-up ranged from 12-47 months, average 30 months. Post-operation evaluation included  prolapse examinations for recurrence, and introital sonograph measurement of distance from edge of mesh to bladder neck, length and thickness of mesh, plus thickness of vaginal wall at 1, 3 and 12 months and urodynamics evaluation before and 12 months after Perigee implantation.

Recurrence of prolapse was minimal with only 2 recurrences to severe prolapse and an overall 93.3% success rate at 30 months median follow-up. Urodynamics data showed significant changes consistent with relief of prolapse-related bladder outlet obstruction. Graft evaluation showed only 5 (4.1%) cases of mesh erosion, all occurring between 3 weeks and 3 months, each small, and all responded to trimming and outpatient wound management with no further cases of Prolene mesh exposure noted over the course of the study. With regard to sonographic evaluation of  in-situ mesh, 5 (4.1%) demonstrated frank mesh folding beneath the vaginal skin, one with mesh erosion into the vaginal space. Mesh both thickened and shortened significantly and increasingly over the one year of post-surgery sonographic monitoring, average 20%, shortening consistent with other reports of ongoing changes in Prolene mesh morphology after vaginal implantation.

This careful and detailed report did not include specific evaluation of sexual function.  Prolene mesh erosion rates were low, consistent with prior reports for this Perigee Prolene mesh product. Prolene mesh vaginal grafting for pelvic organ prolapse continues to be a force in the clinical marketplace. The vast difference in reported safety and complication outcomes between permanent Prolene mesh products warrants careful scrutiny by clinicians and surgeons when counseling patients, particularly with regard to vaginal sexual function. This study, showing steady ongoing changes in implanted mesh morphology (folding, thickening, shortening), highlights the bio-active dynamics of in situ vaginal Prolene graft.

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

(c) L. Romanzi, 2011

Urethral Sling & Pregnancy

Can you have a Urethral Sling operation and still have a child afterwards?  What are the option and risks? I had one about a year ago, and am having second thoughts about another child.C
Hello C, Some recent data shows that women have safely carried a baby to term and delivered vaginally after urethral sling operations. The risks are best discussed with the surgeon who placed the sling and your obstetrician who delivered your child(ren). Once a surgeon has operated on a patient, that patient always has the right to return to ask any question related to the surgery at any time.
All the best to you!
Dr. R

KEGEL EXERCISE: THE FACTS

If you have a vagina and you’re old enough to vote, then Kegel Exercise belongs in your feminine fitness daily routine. Before you dive into pelvic fitness, it’s important to know what Kegel muscles actually DO. Kegels—or the levator ani muscles—wrap around a woman’s most important parts: her bladder, vagina, and rectum.

Research shows that toned levator ani muscles can reduce urinary incontinence, prevent problems with vaginal laxity and help a woman achieve a stronger orgasm. Clinicians and researchers in urogynecology also suspect, but have yet to prove, that these muscles help prevent pelvic organ prolapse, a condition in which  a woman’s bladder, rectum, or uterus falls into her vagina.

For women looking to live their best lives, strengthening your Kegel muscles—or pelvic floor fitness—just makes sense!

HOW TO CHECK YOUR KEGEL EXERCISE ACCURACY:

To get started, sit in bed relaxed against pillows, knees up and separated, using a hand mirror to look at your perineum,which is the skin between your anus and vagina.

Pull in using the muscles you use to urinate, as if you’re trying to stop urine midstream.

If you’re Kegeling correctly, you’ll see your perineum retract into your body.

You should feel the pull in your urethra and anus, NOT your butt or abs.

If you have trouble with proper Kegeling, talk to your gynecologist about pelvic floor physical therapy.

Pelvic floor physical therapy involves working with a Kegel coach, using biofeedback, and/or pelvic muscle electrical stimulation, each designed to “train” your pelvic muscles to perform correctly.

Once you’ve got the art of Kegeling down, get in the habit of doing tKegels daily.

Here’s Dr. Romanzi’s “Starter Set for Kegel Beginners”:

For the first set, perform 10 controlled, sustained contractions, holding each for five seconds, relaxing out of each slowly, and contracting into the next one without taking a break in between. Don’t forget to BREATH. If you find yourself holding your  breath, count softly or sing while contracting the levator muscles.

For the second set, perform 30 quick contractions, holding for just one second each.

There’s no need for a break between the two sets. Simply move from one right on to the next.

Do 2-3 of each set per day. Be creative! There are many ways and settings in which one can Kegel – no one will know if you’re Kegeling on the bus or in a meeting or while driving your car (at a stop sign, preferably).

In terms of where you should do your Kegel exercises, there’s only one rule: NEVER do them on the toilet!

Not only is 8 seconds of urination too short to really benefit your muscles, but it’s also distracting to your bladder, which has an important job of its own to do!

Other than that, you can fit in a Kegel routine whenever—and wherever—you prefer!

For more information, check out this  video \”Kegel Exercise: The Facts\”, courtesy HealthGuru.com

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

DROPPED BLADDER: CYSTOCELE FACTS

Image of the Bladder on X-Ray

At birth, a female’s bladder rests in front of her vagina and just behind the pubic bone. The bladder and vagina are separated by connective tissue called the vesicovaginal fascia. This fascia is anchored to each hip bone by tendons known as the arcus tendineus fascia pelvis.

Vesicovaginal connective tissue is NOT particularly strong. Even in a young woman who has never given birth, the tissue layer is only about as thick as five sheets of paper! When a woman gives birth, the vesicovaginal fascia can weaken and stretch. Other factors that can contribute to the weakening of this and other pelvic supportive tissue include: being overweight or obese, engaging in recurrent heavy lifting, the normal aging process, and repeated coughing or constipation.

Weakened vesicovaginal connective tissue may result in a vaginal hernia that allows the bladder to drop, a condition called cystocele. If the vesicovaginal space wears out in the center, the bladder may bulge into the vagina in what’s called a CENTRAL cystocele. Meanwhile, if the tissue disconnects from the arcus tendineus inside the hip bones on either side, the result is a PARAVAGINAL cystocele.

Cystocele Symptoms

But no matter the type, cystocele can cause unpleasant symptoms, like a vaginal bulge coming out between the labia, or make urinary incontinence worse, or prevent the bladder from emptying fully. Women may also experience chronic pressure in the pelvis or vagina that may be worse when coughing, bearing down, or lifting. Severe cystoceles may even emerge through the vaginal opening, causing a soft bulge that may feel like sitting on an egg.

Cystocele Treatment

While it can be uncomfortable and embarrassing, treatment options DO exist to repair cystocele, or dropped bladder . In mild cases, a removable support device called a pessary can push the bladder back into place. More severe cystoceles may require surgery. Traditionally, bladder lift surgery involved tucking stitches into the remnants of the supportive tissue between the bladder and the vagina during a procedure called anterior colporrhaphy.

This surgery has a recurrence risk as high as 30%, so many surgeons may prefer to insert a graft, which is a thin sheet of body-friendly material, as extra support between the bladder and the vagina. The trade-off for the graft’s sturdier hold is a slightly higher risk of complications including prolonged healing inside of the vagina and slightly longer time on the operating table. The recurrence rate of cystocele repaired with graft material is much lower than traditional colporrhaphy repairs.

Because each procedure has its pros and cons, talk to your doctor about the best repair option for YOU!

For more information on cystocele, visit Cystocele and Pelvic Organ Prolapse information and see this video on Understanding Cystocele, courtesy HealthGuru.com

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

Welcome to Grand Rounds May 3, 2011, the official blog of Better Health: smart health commentary.

This week’s medical blog sampler brings you fresh perspectives on

INTERNATIONAL HEALTH

A preview of the final act - Dr. Mariana Perroni in Haiti

Semen and Scandal, American Style:

We open with a classic “America, Land of the Hypocrite, Home of the Knave” perspective on the downfall of University of Michigan Professor Emeritus, Lazar Greenfield MD, brought to us by Laikas Mediblog, a medical librarian exploration from the Netherlands entitled How a Valentine’s Editorial about Chocolate & Semen Lead to the Resignation of Top Surgeon Greenfield.

Renowned for the Greenfield caval filter, Dr. Greenfield terminally undermined his career after alluding to published data on the mood enhancing effects of sperm exposure in one of his many editorials published in Elsevier’s throw-away, Surgery News. Seriously, what is UP with us in this country? From ABC news to the NY Times to the Huffington Post to the Association of Women Surgeons, this pre-eminent surgeon suffered an horrific public skewering for these (if you ask me, the most it warrants is a short chuckle and a Brooklyn-style rolling of the eyes) words:

“So there’s a deeper bond between men and women than St. Valentine would have suspected, and now we know there’s a better gift for that day than chocolates.”

The feeding frenzy of self-righteous, “Oh no he didn’t”  mayhem was squelched only by the resignation of one of the living legends of our medical times. Once again, American culture perpetuates utter bewilderment from the other side of the pond. Thank you, Laika.

Travel Clinic: Safeway saves the day

Dr. Pullen makes it easier to grab your passport and flee to saner shores, spreading the good word on the merits of Travel Clinics located in Safeway Pharmacies. Run, don’t walk, to your nearest Safeway for convenient, cost effective travel screening and medical preparation on the spot for a fee I, I’m tellin’ ya, you’ve got to see it to believe it, this decimal point warrants a double take.

Psychosis: don’t let it make you crazy

Once you”ve made your post-Safeway escape, should you find yourself in Holland and suffering your first psychotic break, which, if your name is Lazar Greenfield, MD, may well be the case, W.W. van den Broek, MD, PhD suggests you never wean from your anti-psychotic regimen, lest you suffer a relapse, which, apparently you will, per the recently published PhD thesis of Geartsje Boonstra on the continuation of medication (good idea) compared to weaning from medication after a period of stability (not so good, apparently).

Afghan women and U. S. Marines – not so different, actually

While perusing van den Broek’s Dr Shock: a neurostimulating blog I came across another irresistible posted video on the U. S. military’s ingenious use of female troops to “win the hearts and minds” of Afghan women suffering the terrors of home-grown gender apartheid.  Just watching it made me healthier. Thanks, W. W.

Haiti

Medical Practice Manager extraordinaire, Mary Pat Whaley, shares a post submitted by her consultant, Donna Izor. Donna worked in Haiti, taking her nursing skills out of 20 years in mothballs in order to “Do what you can, with what you’ve got, in the moment you’re given”. My favorite part… they started in the neighboring Dominican Republic at La Romana, one of the premiere resorts of the West Indies. I’ve ridden the polo ponies of ambassadors at La Romana. What a culture-warp! In the end, she found it painful to leave Haiti, a testament to the powerful humanity of Haitian people. More on that later…

Canadian Healthcare

From David Williams, co-founder of MedPharma Partners LLC, we get an outsider’s inside perspective on  the merits and demerits of Canadian Healthcare gleaned from time spent working and living among our friends North of the Border. Guess what? Pandering in Media happens everywhere. Shocking.

Cosmetic breast surgery & breast cancer screening

Ramona L. Bates MD,  plastic surgeon with a blog-habit, brings us squarely back to some State-Side reality with her entry on the poignant under-utilization of breast cancer screening prior to cosmetic breast surgery all too painfully common among a survey of American cosmetic surgeons. A wee bit alarming, frankly.

Haiti (re-verb…)

And with great pleasure, I bring you the most endearing of entries,  sent by email for direct posting of content and images, by Mariana Perroni, MD, Physician (Intensive Care and Internal Medicine) and Social Media Specialist at Albert Einstein Hospital, São Paulo, Brazil. She writes: “I wrote the following post for my hospital blog in February 27, 2010, while working as a volunteer in a field hospital in Haiti. It was called Love a Child Recovery Center and it was run by us (Albert Einstein Hospital – São Paulo – Brazil), Harvard Medical School and University of Chicago Medical School. ”

Haiti. Courtesy Dr. Mariana Perroni

We have, according to the census, 39 patients under our care today. This amount represents 15% of the total number of patients in the field hospital. Still, the number of family tragedies is uncountable.

While entering one of the tents during the morning rounds, I laid my eyes on a skinny and smiling 15 year young man. Some locals had already told me that this boy was trapped under the earthquake wreckage for days, with his family. And that both him and his father were forced to watch the slow and painful death of his mother, while stuck in the ruins. When they finally managed to escape, they carried the corpse for three days aimlessly through the destroyed streets, searching for a decent place to bury her. Being unable to find one, they were forced to make one of the toughest decisions of their lives: leave her in the street and move forward in the struggle for survival.

When I asked the young man how he felt, he answered “God wanted this to happen in my life for a reason. I am very grateful for having had the chance to continue to living it. I’m fine. “ And, on my way out of that hot and dusty tent, I heard father and son heard chanting a prayer with excitement.

It was then, amidst all that dust, pain, mutilation and misery, when I realized the powerful presence and importance that music has on the lives of the people in Haiti. The sound of melodies is constant. Whether in tents, where families spend time and distract themselves from the pain while singing songs about hope; in the streets, where women motivate themselves to do their laundry chanting prayers in unison; in the tiny radios inside the tents and in the night meetings, where the locals sing, pray and dance, with or without crutches, with great enthusiasm. Much more than vitamins and painkillers, I conclude that musical notes are the most power and effective adjuncts to the treatments performed here.

I couldn’t help but remembering the words of Aldous Huxley, who said that “after silence, music is what comes closest to expressing the inexpressible.” In my second day in Haiti, I am beginning to doubt it was him, and not a Haitian, who said that.

In the OR, UNFPA Fistula Center, Karachi, Pakistan 2011

Welcome!

The theme for May 3, 2011 Grand Rounds is International Health -

Have a story to share about your experience working abroad? Research or program development in international health? A personal tale of being an actual patient outside the States? A cross-cultural perspective gleaned from patients in your care or your own emigration? A “House” style fascinoma with global overtones? Let’s have it!

Send your posts to drromanzi@urogynics.org

NB: Grand Rounds – the blog of  Better Health: smart health commentary

Sexy = no pull-up Huggies in the ocean

Apr 2011 Journal of Sexual Medicine Literature Review

Handa VL, Whitcomb E, Weidner AC, et al. Sexual Function Before and After Nonsurgical Treatment of Stress Urinary Incontinence. Female Pelvic Med Reconstr Surg 2011;17:30-35.

A secondary analysis of the larger “Non-surgical management of stress urinary incontinence: ambulatory treatments for leakage associated with stress (ATLAS) incontinence” published in 2010, this study of 445 sexually active and inactive women described sexual function in women seeking stress incontinence therapy, compared the impact on sexual function of incontinence pessary alone, Kegel exercise and behavior modification alone, and combined pessary/Kegel/behavior modification, in addition to determining whether or not these non-surgical management therapies for stress urinary incontinence (SUI) improve sexual function.

Women who were sexually active answered 2 validated questionnaires before and 3 months after therapy, both the Pelvic Organ Prolapse – Urinary Incontinence Sexual Function Questionnaire (PISQ-12) that has been validated only in sexually active women in heterosexual relationships, and the generic short form Personal Experiences Questionnaire (SPEQ) that is validated among peri-menopausal women both sexually active and inactive.  The SPEQ total score and individual domain scores of libido, arousal and dyspareunia were included for all women while the sexually active women also underwent PISQ data analysis included total score and questions directly evaluating impact of incontinence on sex; “Are you incontinent of urine with sexual activity?” and “Does fear of incontinence (urine or stool) restrict your sexual activity?”

Women in all three treatment arms were about 49 years of age, mostly white, and evenly divided between pre- and post-menopausal women of normal BMI.  Analysis included women with only SUI and women with mixed stress and urge urinary incontinence.  PISQ scores were lower, indicating lesser sexual satisfaction, the mixed compared to pure stress urinary incontinence group.  Women successfully treated for pure SUI had greater improvement in overall PISQ score, greater reduction of leakage with sexual activity and greater reduction in restriction of sexual activity due to incontinence-related anxiety than did the women not successfully treated, such that improved sexual scores correlated most strongly to whether or not treatment of incontinence was successful.  The improvement in incontinence during sexual activity was greatest for the combined therapy group than for the pessary only group and similarly for the behavior/exercise only group compared to the pessary only group. While pelvic muscle score (Brinks model) was associated with successful SUI therapy, it did not, in turn, correlate to improvement in either the PISQ or SPEQ score. SPEQ scoring did not differ between stress only or mixed incontinence groups except for dyspareunia that was higher in the mixed incontinence group, nor were changes in SPEQ score different in successful and unsuccessful treatment.  The results suggest that consideration ought to be given to Kegel exercises and behavioral incontinence strategies for non-surgical treatment of women suffering incontinence during sex and who restrict sexual activity due to coital incontinence anxiety.