Tethered vagina syndrome: massive urine loss caused by bladder neck scarring cured by skin graft.

The bladder neck area of the vagina is known as the "zone of critical elasticity" (ZCE). Adequate vaginal elasticity at ZCE is required for the oppositely-acting muscles to independently close the distal urethra and bladder neck. Scarring at ZCE "tethers" the more powerful posterior muscles to the anterior muscles and the bladder neck is forcibly pulled open, resulting in massive urine loss. This condition is known as "tethered vagina syndrome" (TVS). In developed countries, the main cause of TVS is iatrogenic. Vaginal repairs, vaginal mesh, may cause scarring at ZCE and this directly links the oppositely-acting muscle forces. Over-elevated Burch colposuspensions may stretch the ZCE to the point where its elasticity is lost so the muscles can no longer function independently. The treatment is to dissect the vagina clear of the scarring and to insert a skin graft to the bladder neck to restore ZCE elasticity. In developing countries, extensive trauma to the vagina and bladder from obstructed childbirth can cause obstetric fistulas. In up to 40-50% of these women, there is ongoing massive urine loss after the fistula has been successfully closed. Performing a prophylactical skin graft during fistula closure if there is vaginal tissue deficit is proving to be revolutionary. In women with Goh type 4 fistula (n=45), 46% were cured (full dryness) against an expected 19%. The same operation can produce equally dramatic cures in women who continue to leak urine after successful fistula repair.

A brief physiology and pathophysiology of the anorectum based on the Integral Theory paradigm.

The remit of this review is confined to the experimental scientific works and surgeries based on the Integral Theory paradigm. The video abstract summarizes the anorectal function, how ligaments cause dysfunction and cure of fecal incontinence and obstructed defecation by ligament repair. Anorectal function is reflex and binary, with cortical and peripheral components. The same three oppositely acting reflex muscle forces which open and close the bladder, contract against the pubourethral (PUL) and uterosacral (USL) ligaments: (I) to close the anorectum for continence when the puborectalis muscle (PRM) contracts forwards; (II) to open the anorectum prior to evacuation when the PRM relaxes; (III) to stretch the rectum in opposite directions to support the anorectal stretch receptors "N" to prevent premature activation of the defecation reflex, (fecal urgency). Weak or loose PULs or USLs may cause dysfunction of closure, of evacuation, and inability to control the defecation reflex (fecal urgency). Repair of the PUL and USL can improve or cure these dysfunctions. The perineal body (PB) acts as an anatomical support for the distal vagina, anorectum and external anal sphincter (EAS). It serves as an anchoring point for the forward action of the pubococcygeus muscle (PCM), which tensions the anterior rectal wall during closure and defecation. Bladder and bowel dysfunction have a similar pathogenesis, ligament laxity, mainly pubourethral and uterosacral, with added PB damage for anorectal dysfunction. PB damage can cause obstructive defecation and descending perineal syndrome (DPS). Repair of damaged PUL and USL can restore the closure and evacuation functions of both bladder an anorectum. DPS can be cured by repair of the PB's suspensory ligaments, deep transversus perinei.

Non-Hunner's Interstitial Cystitis Is Different from Hunner's Interstitial Cystitis and May Be Curable by Uterosacral Ligament Repair.

BACKGROUND: The posterior fornix syndrome (PFS) was first described in 1993 as a predictably occurring group of symptoms: chronic pelvic pain (CPP), urge, frequency, nocturia, emptying difficulties/urinary retention, caused by uterosacral ligament (USL) laxity, and cured by repair thereof. SUMMARY: Our hypothesis was that non-Hunner's interstitial cystitis (IC) and PFS are substantially equivalent conditions. The primary objective was to determine if there was a causal relationship between IC and pelvic organ prolapse (POP). The secondary objective was to assess whether other pelvic symptoms were present in patients with POP-related IC and if so, which ones? How often did they occur? A retrospective study was performed in 198 women who presented with CPP, uterine/apical prolapse (varying degrees), and PFS symptoms, all of whom had been treated by posterior USL sling repair. We compared their PFS symptoms with known definitions of IC, CPP, and bladder symptoms. To check our hypothesis for truth or falsity, we used a validated questionnaire, "simulated operations" (mechanically supporting USLs with a vaginal speculum test to test for reduction of urge and pain), transperineal ultrasound and urodynamics. KEY MESSAGES: 198 patients had CPP and 313 had urinary symptoms which conformed to the definition for non-Hunner's IC. The cure rate after USL sling repair was CPP 74%, urge incontinence 80%, frequency 79.6%, abnormal emptying 53%, nocturia 79%, obstructive defecation 80%. Our findings seem to support our hypothesis that non-Hunner's IC and PFS may be similar conditions; also, non-Hunner IC/BPS may be a separate or lesser disease entity from "Hunner lesion disease". More rigorous scientific investigation, preferably by RCT, will be required.

Supine Colonoscopy: An Advantage over Left Lateral in Synchronous Proctological Surgery.

BACKGROUND: Repositioning sedated or anesthetized patients between colonoscopy and further surgical procedures is potentially unsafe and time consuming. We aim to show that colonoscopy performed in the modified lithotomy position offers surgical, anesthetic, and patient advantage. METHODS: Patients presenting for colonoscopy and a synchronous surgical procedure between May 2013 and August 2014 were prospectively included. Colonoscopy duration, cecal intubation rate (CIR), terminal ileum intubation rate, and patient characteristics were recorded. RESULTS: Sixty-eight patients were included in this study. Of them, 24 (35%) were women and mean age was 42.3 years. Mean colonoscopy duration was 7 minutes (2-24 minutes). CIR was 100%. Terminal ileum intubation rate was 92%. Utilization of ancillary colonoscopic maneuvers was easier for the operator/assistant. Overall theatre time was reduced and there was no increase in length of stay. CONCLUSION: The modified lithotomy position offers multiple surgical, anesthetic, theatre, and patient advantage in those undergoing a colonoscopy followed by a further proctological or surgical procedure.

Evaluating informed consent for colonoscopy.

BACKGROUND: This study aimed to collect and analyze data on patient knowledge of colonoscopy and their preferences regarding the provision of information about the procedure. Specifically, how much detail patients know about different aspects of the procedure and through which methods they best understand risk are evaluated and demographic correlations identified. MATERIALS AND METHODS: The study sample consisted of colonoscopy patients from 2 colorectal surgeons and a gastroenterologist at St Vincent's Public Hospital, Sydney for the period August 1 to November 1, 2010. A voluntary questionnaire was performed in the waiting room before colonoscopy. The questionnaire collected data on patient demographics; patient-perceived knowledge of the procedure; and understanding and preferences of various communication formats. RESULTS: Measures of patient-perceived knowledge about colonoscopy were significantly lower than those that would be preferred by patients (P=0.002). Those with higher levels of education preferred communication of colonoscopy-related information via a leaflet form, whereas those with lower levels preferred verbal information from a doctor or nurse (P=0.049). The most preferred format for explaining the risk of perforation was the pie graph, followed by both the 1000-person pictograph and absolute risk ratios. CONCLUSIONS: Patients received suboptimal levels of information about colonoscopy compared with their preferences. Key areas for improvement include providing more understandable information about the risks of colonoscopy. A combination of written information, diagrams and graphs, and then a discussion of this information to check the understanding is likely to be most effective. Further research into the communication of risk, with larger groups of patients, is likely to help clinicians in gaining fully informed consent in all patients.