The treatment of cyclical behavioral changes in women with mental disabilities.

STUDY OBJECTIVE: This study aims to evaluate the frequency of occurrence of cyclical behavioral changes in women with mental retardation, as well as the effectiveness of several treatment modalities for this type of behavior. DESIGN: Retrospective chart analysis. SETTING: University of Michigan clinic for reproductive healthcare of women with mental disabilities. PARTICIPANTS: All clinic patients of reproductive age, presenting with cyclical behavioral changes in our clinic from November 1985 to October 1992. INTERVENTIONS: Medical treatment of cyclical behavioral changes. MAIN OUTCOME MEASURES: Presence and documentation of cyclical behavioral changes, level of retardation, type of behavior, treatment modalities and results. RESULTS: Ninety-three of 522 reproductive-age patients (18%) presented with cyclical behavioral changes. Good documentation with behavior charts was present in 46% of these records. Level of retardation among the women included: 57 (61%) severely, 12 (13%) moderately, and 1 (1%) mildly retarded. No level of retardation could be detected in 23 (25%) women. Aggressive behavior was noted in 35 (38%) women, self-mutilation in 20 (22%) a combination of both in 10 (10%) and other behavior in 28 (28%) women. Primary treatment was by physician preference. Of 46 patients who received nonsteroidal antiinflammatory drugs (NSAID), 30 (65%) showed improvement, 10 (21%) showed no improvement, and 2 patients (4%) showed worsening symptoms. Birth control pills were used in 15 patients; there were signs of improvement in 6 (40%), no improvement in 3 (20%), and worsening in 3 (20%). The use of depomedroxyprogesterone injections was successful in treating 6 of 9 patients (66%), and showed no improvement in 2 women. No statistically significant differences were found between these treatment modalities. CONCLUSIONS: Cyclical behavioral changes in women with mental retardation is a common problem (18%) and may be related to pain- possibly due to menstrual cramps, since 65% of the patients responded to NSAID. If treatment with NSAID is unsuccessful, birth control pills and depomedroxyprogesterone improved behavior in 40% to 66% of patients. Documentation is a key issue.

An anatomic approach to pelvic hemorrhage during sacrospinous ligament fixation of the vaginal vault.

OBJECTIVE: To examine the current clinical problem of life-threatening hemorrhage during sacrospinous vaginal vault suspension, define a management solution, and validate current anatomic knowledge of the area involved. METHODS: Ten cadaveric female pelves were dissected from a posterior gluteal approach and from an abdominal approach. The vascularity of the region of the sacrospinous ligament was mapped. RESULTS: There are multiple and varied collateral vascular supplies and anastomoses in the region of the sacrospinous ligament and buttock, including: 1) superior gluteal, 2) inferior gluteal, 3) internal pudendal, 4) vertebral, 5) middle sacral, 6) lateral sacral, and 7) external iliac via the circumflex femoral artery system. Anastomoses occurred in all pelves examined. The frequency of each type of anastomosis varied from 20-100%. CONCLUSION: Surgical ligation of the internal iliac artery would not likely curb massive hemorrhage during sacrospinous ligament fixation, except in certain cases of internal pudendal vascular injury. The inferior gluteal artery is probably the most commonly injured vessel in sacrospinous ligament suspension because of its location. Inferior gluteal vessel injury should be approached by the use of packing and vascular clips or packing and arterial embolization. These latter approaches should be of primary consideration in the control of hemorrhage at the time of sacrospinous ligament fixation.

Participation in an international medical practice in West Africa.

The author reflects on his personal experiences in West Africa to express the benefits of participation in international medical practice in developing countries. Health care systems, medical emphases, and surgical techniques useful in the United States may be inspired by attempts to manage the extreme problems seen in developing countries. Attitudinal changes that result from international work may be helpful to US physicians and their patients, in the current era of health care. These include the qualities of humility, gratitude, pragmatism, and simplicity. A refined consciousness of the needs of underserved women is unavoidable.

Integration of a sexuality counseling service into a reproductive health program for persons with mental retardation.

A socialization and sexuality counseling program was instituted as an integral part of a gynecologic service begun at the University of Michigan for persons with mental retardation. One hundred three patients were seen between 1986 and 1989 for counseling. Patients were referred for a variety of reasons, the most common being sexual behavior deemed inappropriate by the referring agent (i.e., direct care givers, parents, teachers, workshop supervisors, and other community professionals). Other concerns included sexual abuse, sterilization requests, sexuality and socialization education, marital questions, pregnancy assistance, abortion counseling, and family stress. Treatment techniques included gynecologic examination and follow-up, psychosexual education, psychiatric evaluation and follow-up, and group and individual psychosexual counseling. A majority of the patients improved during treatment. It is proposed that such a counseling program can play a useful role in the preparation of people with mental retardation to live in their communities as they deal with day-to-day decision making and should be an integral part of reproductive health care for this population.

Cervical cytology in women with mental retardation.

OBJECTIVE: To examine our experience with performing pelvic examination and obtaining cervical cytology in women with mental retardation. METHODS: From November 1985 to October 1992, 658 women were seen in our clinic for women with mental disabilities. A standardized clinic visit form was completed for each woman. Of these records, 574 were available for analysis. All charts were reviewed for data on the level of retardation, incidence of sedation, success in performing pelvic examination and Papanicolaou smear, technique used for cervical smear, and pathology results of the cervical cytology. RESULTS: Of the 574 women, 289 (50%) had severe, 69 (12%) moderate, and 31 (5%) mild retardation. In 185 (32%), the exact level of retardation was not established. During the study period, 1235 pelvic examinations were analyzed. Within this group, 845 examinations could be completed initially, 177 required the use of sedation (14%), and 213 (17%) examinations could not be completed. Of the 845 examinations, 706 cervical smears were available for analysis. Of these, only 243 (34%) contained endocervical cells. Two abnormal cytology results were found (0.3%). Of the 177 examinations done with sedation, 44 women (25%) still could not be examined. Cytology specimen results were obtained in 124 of the examinations, and 40 (32%) of these specimens contained endocervical cells. No cytologic abnormalities were present. In a cervical smear technique comparison, endocervical cells were present in 58% of 161 standard speculum examinations and in 18% of 93 cotton-swab tests (P < .001). CONCLUSION: Cytology specimens can be obtained without sedation in most mentally retarded women. Only one-third of Papanicolaou smears contained endocervical cells from examinations with sedation as well as those without. The cotton-swab technique has a significantly lower endocervical cell collection rate than the standard speculum technique. The incidence of abnormalities on cytologic examination appears to be low compared with other populations of women. Whether this is due to suboptimal smears, lower prevalence of human papillomavirus, or a combination of both remains to be resolved.

Surgical landmarks of the ureter in the cadaveric female pelvis.

Our purpose was to delineate the course of the ureter in the female pelvis in relationship to several important surgical landmarks. Ten female cadavers with undissected pelves were used. The ureter was identified at the pelvic brim and traced inferiorly to the bladder. Sets of measurements (+/- 0.1 cm) that help define the location of the ureter were obtained at the three landmarks; the ischial spine, the obturator canal and the insertion of the arcus tendineus on the pubic bone. The mean distances from the ureter to the pelvic floor were ischial spine, 3.2 +/- 0.1 cm; obturator canal, 3.2 +/- 0.1 cm; and the insertion of the arcus tendineus on the pubic bone, 1.6 +/- 0.1 cm. The mean distances from the arcus tendineus to the pelvic floor were ischial spine, 1.9 +/- 0.1 cm; obturator canal, 2.8 +/- 0.1 cm; and the insertion of the arcus tendineus on the pubic bone, 3.2 +/- 0.1 cm. This study defines the relationship of the ureter to the pelvic floor through measurements taken at three landmarks. The data should be useful to pelvic surgeons and are important for the development of future surgical techniques.

Intraligamentous nerves as a potential source of pain after sacrospinous ligament fixation of the vaginal apex.

The aim of the study was to investigate the histology of the sacrospinous ligament to determine whether nerve fibers exist within the substance of the sacropinous ligament itself. Six sacrospinous ligaments were removed from 4 fixed female cadavers. Representative segments were taken from the lateral (ischial), middle and medial (sacral) portions of these specimens, sectioned by microtome, mounted, and stained with hematoxylin and eosin dyes. The fixed and stained sections were then examined using light microscopy. Nerve tissue was found to be concentrated in the medial portions of the sacrospinous ligaments, but nerves were found in all segments of the ligament. It was concluded that, nervous tissue is present and widely distributed within the body of the sacrospinous ligament. A wide variety of sizes and thicknesses are also demonstrated, suggesting a variety of functions, including possible pain reception. This fact should be taken into consideration when planning operative procedures for pelvic prolapse.

Use of sodium hetastarch (Hespan) solution for reduction of postoperative adhesion formation in rabbits.

A study was conducted to determine the effect of sodium hydroxy ethyl starch (Hespan) on primary adhesion formation in a rabbit model. Hespan is a readily available volume expander. This was a randomized, double-blinded animal model in which New Zealand white rabbits were subjected to midline celiotomy. Adhesions were created by abrasion in both uterine horns, adjacent bowel, and peritoneum. Necropsies were performed at the 2-week interval and adhesions were graded. Significant decreases in type II and type III adhesions (p = .032 and p = .020, respectively) were demonstrated in Hespan-treated animals. Sodium hetastarch appears to decrease significant adhesion formation in treated animals and may have a role as an adjunct for postsurgical prevention.

The surgical anatomy of needle bladder neck suspension.

OBJECTIVE: To define the surgical anatomy of needle bladder neck suspension in order to explain this operation's effect on urethral support and gain information useful in minimizing intraoperative complications. METHODS: Needle bladder neck suspension was carried out on two unembalmed, multiparous cadavers. After fixing the suspensory sutures in place, the pelvis of one cadaver was completely dissected. The second cadaver was serially sectioned at 1-cm intervals, and the sections were subjected to both anatomic and histologic examination. These findings were correlated with the findings noted during an autopsy dissection of a woman who previously had undergone needle bladder neck suspension at our institution and with our surgical experience with this operation. RESULTS: The plane of dissection used to enter the space of Retzius lay between the vaginal mucous membrane and the visceral endopelvic fascia. The point of entry into the retropubic space lay between the levator ani muscles and its superior fascia, lateral to the arcus tendineus fasciae pelvis, the paraurethral vascular plexus, and bladder neck. It was cephalad to the perineal membrane (urogenital diaphragm). The paraurethral supporting tissues incorporated in the suspensory suture included the portion of the endopelvic fascia that lies between the vagina and urethra and, usually, the arcus tendineus fasciae pelvis. Attaching the suspensory sutures in needle bladder neck suspension seems to stabilize the bladder neck by providing a new point of lateral fixation for its supporting endopelvic fascia. CONCLUSION: Needle bladder neck suspension stabilized the supportive fascia of the urethra, and vascular injury may be minimized by detailed knowledge of paraurethral anatomy.

The epidemiology of genitourinary fistulae in Kumasi, Ghana, 1977-1992.

The aim of the study was to determine the clinical epidemiology of genitourinary fistulae as seen at Komfo Anokye Teaching Hospital in Kumasi, Ghana. A retrospective study was carried out from the hospital records and operative reports of all patients with genitourinary fistulae seen at Komfo Anokye Teaching Hospital between January 1977 and December 1992. Patient age, parity, type of fistula and cause of fistula were abstracted from the medical records. There were 164 cases of genitourinary fistula managed during the study period. There were 150 fistulae due to obstetric causes (91, 5%), the vast majority of which were due to prolonged obstructed labor (121 cases, 73.8% of all fistulae), with a minority related to complications of lower-segment cesarean section (14 cases, 8.5% of all fistulae). In 5 cases (3.1%) patients developed a rectovaginal fistula owing to perineal tears and prolonged obstructed labor. During this time period there were 157,449 deliveries, giving an obstetric fistula rate of 1 fistula per 1000 deliveries. Obstetric fistulae were most common at the extremes of reproductive age and parity Fourteen additional fistulae (8.5% of all cases) were due to gynecologic causes, most commonly from surgical injury occurring at the time of abdominal hysterectomy for leiomyomata uteri (12 cases, 7.3% of all fistulae). It was concluded that in Kumasi, Ghana, obstetric trauma from prolonged obstructed labor is the most common cause of genitourinary fistula formation. Such fistulae occur in older multiparous women as well in young primigravidae. Obstructed labour can, and does, occur in women who have previously undergone uneventful vaginal delivery. Birth attendants should be aware of that fact. Prompt referral for obstetric intervention should be made in obstructed labor, irrespective of the age and parity of the patient.

Transvaginal sacrospinous colpopexy: anatomic landmarks to be aware of to minimize complications.

Transvaginal sacrospinous colpopexy is currently used to repair varying degrees of vaginal vault prolapse. It involves placing a stitch from the vaginal cuff to the sacrospinous ligament approximately 2 cm medial to the ischial spine to correct the defect. This may be associated with pudendal artery and nerve (pudendal complex) along with sciatic nerve injury if the procedure is not carefully performed. This study was designed to emphasize the anatomic landmarks that make the sacrospinous ligament a potentially dangerous zone that surgeons must be aware of to minimize complications. Twenty-four female cadavers were obtained from the Louisiana State University Medical School anatomy laboratory. They were carefully dissected to expose the anatomic structures of interest. The following measurements were then obtained: the distance from the ischial spine to the medial border of the sacrum, the medial and lateral aspects of the pudendal complex, and the sciatic nerve. The obstetric conjugate of the pelves was also obtained. The pudendal complex and sciatic nerve were found to be 0.90 to 3.30 cm medial to the ischial spine. After the six smallest and largest pelves were compared, it was noted that the larger the obstetric conjugate the longer the sacrospinous ligament and vice versa. Also, the distance from the ischial spine to the sciatic nerve correlated with the size of the obstetric conjugate. The pudendal complex and sciatic nerve travel underneath the lateral third of the sacrospinous ligament. Therefore we recommend that the placement of the stitch be made medial to that portion of the ligament. More importantly, the stitch must be placed as superficial as possible and never across the entire thickness of the sacropinous ligament. This should decrease the rate of complications associated with this type of colpopexy.

Innovative community-based postgraduate training for obstetrics and gynecology in west Africa.

OBJECTIVE: To describe a unique international effort to develop a training program in West Africa that would be of similar quality to any other in the world (but with sensitivity to cross-cultural needs) and would retain physicians in West Africa to improve women's health in that part of the world. METHODS: Step-by-step formulation of a program included initial trainee recruitment, the inclusion of foreign guest faculty, and the establishment of institutional libraries. This was followed by a phase of curriculum development, recruitment of West African faculty, and organization of an innovative, community-based fourth year. RESULTS: Between ten and 12 postgraduates will have completed the program by January 1996, and will be placed in Ghana. More than 60% of Ghanaian postgraduates have passed the relevant regional examinations, compared with less than 25% of candidates from other countries. Nine Ghanaian specialists have returned to Ghana to become faculty members in the program. Over 20 published peer-reviewed articles have resulted from this program since 1989. The number of residents being trained has increased from three to 28. Seven new residents joined the program in 1994. An early reduction in maternal mortality from 9.9 deaths per 1000 births in 1991 to 4.2 deaths per 1000 births in 1992 was noted when senior postgraduates took over labor and delivery at the teaching hospital in Accra, Ghana, where approximately 10,000 deliveries occur per year. CONCLUSION: Specialty training in obstetrics and gynecology that is specifically aimed at meeting the needs of West Africa has been initiated successfully. Long-range success will require support from regional governments and continued long-term commitments from the international community of obstetricians and gynecologists.