Markers of collagen synthesis and degradation in urogenital tissue and serum from women with and without uterovaginal prolapse.

Diverging results have been published concerning collagen metabolism in uterovaginal prolapse (UP). We have investigated collagen turnover in urogenital tissue in urologically healthy women with (UP patients) and without UP or any history of UP (controls). Markers of collagen turnover, carboxy-terminal propeptide of type I procollagen (PICP), amino-terminal propeptide of procollagen III (PIIINP) and carboxy-terminal telopeptide of type I collagen (ICTP) were assayed in urogenital tissue homogenates and serum. Tissue and serum concentrations of collagen turnover markers were related to UP and to menopausal/estrogen status. UP patients were significantly older than the controls. UP patients had significantly higher tissue PICP and PIIINP and significantly lower tissue ICTP levels than the controls, but the difference in ICTP disappeared after matching for menopausal/estrogen status and age. There were no associations between tissue collagen turnover markers on the one hand and menopausal/estrogen status or age on the other. The higher tissue concentrations of PICP and especially PIIINP in tissue from women with UP compared to controls, suggest an increased collagen breakdown in UP. This pattern differs from that in stress urinary incontinent women without UP, where tissue levels of collagen turnover markers are low, indicating reduced collagen breakdown.

Magnetic resonance imaging to evaluate NASHA/Dx gel (Zuidex) for stress urinary incontinence.

The Zuidex system for the treatment of stress urinary incontinence consists of non-animal stabilised hyaluronic acid/dextranomer (NASHA/Dx) gel and a precision guide, the Implacer. Whether the Implacer accurately deposits NASHA/Dx gel in the desired location within the urethral wall was investigated by magnetic resonance imaging (MRI), performed at a mean of 35 days post-treatment. Three or more deposits were observed in 11 of 16 patients (68.8%), with 39 of the 50 deposits clearly located within the urethral wall, as intended. Fourteen of 16 patients (87.5%) demonstrated improvement in their incontinence at 3 months, sustained at 12 months in 13 patients. No significant correlations between total implant volume and improvements in incontinence were observed at 3 months (p > or = 0.16) and 12 months (p > or = 0.30). In conclusion, accurate placement of NASHA/Dx gel into the desired location within the urethral wall was achieved in the majority of cases using the Implacer device, without endoscopic guidance.

Effectiveness of two conservative modes of physical therapy in women with urinary stress incontinence.

Stress incontinence is the most prevalent form of female urinary incontinence and it affects approximately 5% of younger women to nearly 50% of elderly women. Women have traditionally been treated with pelvic floor muscle exercises alone or with the use of vaginal cones. A new treatment mode, vaginal balls, has been developed. The aim of this study was to compare pelvic floor muscle training with and without vaginal balls and to collect information on women's subjective feelings about the two training modes. The study was carried out as a prospective randomized clinical trial. Thirty-seven women aged 25-65 were assigned either to a pelvic floor muscle training program or to a training program using weighted vaginal balls for 4 months. Treatment outcomes were assessed by a pad-test with a standardized bladder volume, vaginal palpation, and by women's self-reported perceptions. The sense of coherence score was compared with the score for a normal population. Ninety-three percent of the women completed the study. Both training modes were effective in reducing urinary leakage: with vaginal balls (P < 0.0001) and without (P < 0.019); and increasing pelvic floor muscle strength: with vaginal balls (P < 0.0039) and without (P < 0.0002). However, the reduction of urinary leakage after four months of exercise in the training group with vaginal balls was significantly better (P < 0.03) than the results in the group training with pelvic floor muscle exercises alone. The study found the weighted vaginal balls to be a good alternative for training pelvic floor muscles in women with stress urinary incontinence.

Changed pattern in the use of episiotomy in Sweden.

OBJECTIVE: To study changes in the use of episiotomy since 1989, controlling for variables such as severe tears, epidural anaesthesia, duration of the second stage of labour, instrumental deliveries, birthweight and maternal position at delivery. DESIGN: Retrospective study. Data were obtained from original birth records and questionnaires. SETTING: Huddinge University Hospital and all labour wards (n = 62) in Sweden. POPULATION: 10,661 women who were delivered vaginally (4575 nulliparae, 6086 multiparae) between 1992 and 1994, and 3366 nulliparae delivered in all Swedish hospitals during the month of March 1995. MAIN OUTCOME MEASURES: Episiotomy rates, severe tears and instrumental deliveries. RESULTS: The rate of episiotomy was 1% and of severe tears 0.6% among multiparae delivered vaginally (including instrumental deliveries) at Huddinge University Hospital between 1992 and 1994. The rate of episiotomy was 6.6% and of severe tears 2.3% among nulliparae. Vacuum extraction and epidural anaesthesia were more commonly associated with episiotomy. Factors significantly associated with severe tears were infant birthweight > or = 4000 g, vacuum extraction and episiotomy. In all Swedish labour wards in 1995 the mean incidence of episiotomy in nulliparae was 24.5%, a significant decrease from 33.7% in 1989. Wide variations occurred between hospitals (4%-50%). CONCLUSION: The use of episiotomy was much reduced at Huddinge University Hospital, with a consistently low rate of severe tears. This supports the growing evidence for individualised and restrictive use of episiotomy at childbirth.

Fibrinolytic factors in endometriotic tissue, endometrium, peritoneal fluid, and plasma from women with endometriosis and in endometrium and peritoneal fluid from healthy women.

OBJECTIVE: To determine whether there is a difference in fibrinolytic compounds in endometriotic tissue, endometrium, peritoneal fluid (PF), and plasma from women with endometriosis and in endometrium and PF from healthy women. DESIGN: Prospective study. SETTING: Two university clinics. PATIENT(S): Regularly menstruating women with and without endometriosis. INTERVENTION(S): Tissue samples, PF, and blood were collected at surgery performed for clinical reasons. MAIN OUTCOME MEASURE(S): The antigen concentrations of plasminogen activators and plasminogen activator inhibitors (PAls) in tissue homogenates, PF, and plasma were assayed by ELISA. RESULT(S): The concentrations of urokinase plasminogen activator (u-PA) and PAI-1 were higher in endometrium from women with endometriosis than in endometrium from controls and even higher in endometriotic tissue than in endometrium from both groups. In PF, the concentration of PAI-2 was higher in women with endometriosis than in controls. CONCLUSION(S): The high concentrations of u-PA and PAI-1 in endometrium from women with endometriosis might facilitate implantation of endometrial cells and the high concentration in endometriotic tissue might contribute to their invasive growth. The inflammatory reaction may contribute to the high concentration of PAI-2.

Effect of predilatation of the uterine cervix by laminaria tent on activity of the placenta.

Serum concentrations of hCG were determined in blood samples taken 18-20 h and immediately before vacuum aspiration in 45 women in gestational weeks 7-9, admitted for legal abortion. In 35 of the women, a laminaria tent was inserted for cervical dilatation immediately after the first blood sampling. Serum hCG values decreased significantly in the women pretreated with laminaria tent, but were unchanged in the untreated women. This finding may indicate that pretreatment with a laminaria tent induces a partial placental detachment.

PIP: At the Karolinska Institute at Huddinge University Hospital in Huddinge, Sweden, serum levels of human chorionic gonadotropin (hCG) in 35 patients who had been inserted with a laminaria tent 18-20 hours prior to and immediately after vacuum aspiration were compared with those of 10 women who chose not to have laminaria tents inserted prior to vacuum aspiration. Gestational age ranged from 7 to 9 weeks. All the pregnant women were primiparous. The mean serum hCG values did not differ greatly between the cases and controls (84,260 U/1 and 75,878 U/1, respectively). Yet the mean serum hCG levels of women treated with laminaria tents to induce dilation fell considerably more than those in the control group (76,468 U/1 vs. 84,939 U/1; p.01). The concentrations fell in all treated women. Since serum hCG values normally increase during this period, the decrease indicated that laminaria tents induced partial detachment of the placenta. The results also explained the significant bleeding and/or presence of placental tissue in the cervical canal. These results suggest that laminaria tents cause partial placental detachment as well as labor contractions.

The effect of mediolateral episiotomy at delivery on pelvic floor muscle strength evaluated with vaginal cones.

In a prospective study, pelvic floor muscle strength was investigated pre- and post partum in 87 women with uncomplicated pregnancies. Those vaginally delivered were 71 primiparas, while 16 underwent an elective cesarean section. The objective was to evaluate the effect of the delivery procedure on the pelvic floor muscle strength with the aid of vaginal cones. In the group of women with vaginal delivery three subgroups were identified: episiotomy, spontaneous laceration and intact perineum. Pelvic floor muscle strength was weakest in the episiotomy subgroup, the difference in values between this subgroup and each of the other subgroups and the elective cesarean section group being significant. No significant difference was evident between the spontaneous lacerations and intact perineum subgroups.

Proctosigmoidoscopy in primary health care.

Of 282 patients who underwent rigid proctosigmoidoscopy (PSS) in primary care in the city of Västerås during 1985, 5.7% had polyps or tumours in the rectum. Barium examination of the large bowel was performed on 194 of these 282 patients and showed polyps or tumours in 6.2%. Use of these two methods led to diagnosis of polyps or tumour in the large bowel in 9.6% (27/282). Polyps were found by both methods in only one patient. Of four patients with tumours, two were discovered by barium examination and two by PSS. Barium examination and PSS complement each other in the search for polyps and tumours in the large bowel.

Sulprostone, a synthetic PGE2 analogue in first trimester abortion. Clinical efficacy and influence on serum progesterone of different single doses.

First trimester legal abortions were induced in 20 patients by i.m. injection of a single dose of 1,000, 1,200 or 1,500 micrograms of sulprostone. Complete expulsion of the conceptus within 24 h occurred in 16 of the women. There was a tendency to a higher rate of complete expulsion, as well as gastrointestinal side effects, at higher dosages. No association was found between the completeness of expulsion and the patients' serum progesterone levels before or after sulprostone injection.

Short-term maximal electrical stimulation--a conservative treatment of urinary incontinence.

Seventeen women with stress and 20 with motor-urge urinary incontinence were treated ambulatorily with short-term maximal electrical stimulation. The duration of the treatment was 20 min daily for 12 weeks. According to the patients' subjective evaluation, two thirds were improved. A markedly diminished leakage of urine (greater than 50% by use of pad test) was found in 6 out of 17 women with stress, and in 13 out of 20 women with motor-urge urinary incontinence. There were no significant differences observed in urodynamic parameters between the registrations performed before and after the present electrical stimulation therapy.

The effect of cervical dilatation by laminaria tent in first trimester legal abortions on blood loss related to fibrinolytic activity in the decidua and placenta.

Increased blood loss (BL) has been reported after cervical dilatation by laminaria tent in legal abortions. The BL was measured in 72 women in whom first trimester legal vacuum aspiration was performed. The cervical canal was dilatated by laminaria tent in 37 patients, and mechanically with Hegar dilators in 35 patients. BL was studied in relation to the plasminogen activators (u-PA, t-PA) and the plasminogen activator inhibitors (PAI-1, PAI-2) in the decidua and placenta. There was no significant difference in BL between the two groups. Decidual PAI-1 concentrations were significantly higher in the laminaria tent group than in the Hegar dilator group. An inactivation of u-PA by PAI-1 might explain the lack of increase in BL among the laminaria tent group.

Biochemical changes in human cervical connective tissue during pretreatment with laminaria tents in legal first trimester abortions.

In 14 legal first trimester abortions, vacuum aspiration was preceded by dilatation of the cervical canal by laminaria tent for 16-20 h. Biopsy specimens obtained from the cervix before insertion and before removal of the laminaria tent were analyzed for biochemical changes in cervical connective tissue. Pretreatment with laminaria tents resulted in a decrease of the total collagen concentration and of the collagenolytic activity, though the differences were without statistical significance. Both these findings and those concerning the subfractions of the hydroxyproline concentration suggest that pretreatment with laminaria induces a certain degree of softening of the cervix, similar to that reported after intracervical application of PGE2 gel.

Contractile activity in the human uterine cervix and corpus during cervical dilatation by laminaria tent in first trimester legal abortions.

Millar microtransducers were used in 7 patients to record contractile variations in the cervix and corpus during dilatation of the cervical canal by Laminaria tent preceding first-trimester vacuum aspiration. The spontaneous contractile activity was registered in a control group of 5 patients without laminaria pretreatment. Two Millar catheters were used. The sensor tip of one Millar catheter was placed extra-amniotically in the uterine cavity, and the other one in the mid-cervical canal. Both sensor tips faced the wall of the cervix and corpus. The study showed that laminaria tents not only have a gentle dilatating effect on the cervix, but also induce painless uterine contractions, of amplitudes reaching 20 mmHg, and increased contractile activity in the cervix for the duration of dilatation.

The influence of cervical dilatation by laminaria tent and with Hegar dilators on the intrauterine microflora and the rate of postabortal pelvic inflammatory disease.

In a prospective study, 519 women were randomly selected for cervical dilatation by laminaria tents or Hegar dilators before scheduled vacuum aspiration. In other 68 women randomly divided into a laminaria group and a control (Hegar) group, placenta, decidua and blood were separately aspirated from the uterine cavity before the vacuum aspiration and cultured for micro-organisms. The rate of postabortal inflammatory disease (PID) was significantly lower after pretreatment with laminaria tent irrespective of patient's age and parity. However, a higher risk of postabortal PID was found in gestational age of 10-12 weeks than of 5-9 weeks. Previous PID and abortion did not increase the risk of postabortal PID. Vaginal/cervical micro-organisms were, irrespective of method for cervical dilatation, identified in two thirds of the patients.

Placental and decidual u-PA, t-PA, PAI-1 and PAI-2 concentrations, as affected by cervical dilatation with laminaria tents or Hegar dilators.

The effect of cervical dilatation on PA and PAI concentrations was compared in a laminaria tent group and a mechanical dilatation (control) group. In both groups, u-PA and t-PA were found to be present both in decidual and placental tissue. Values for PAI-1 in the decidua were higher in the laminaria tent group than in controls, and those for PAI-2 in the placenta were lower. These findings provide support for the contention that cervical dilatation with laminaria tents may result in partial detachment of the placenta.

PIP: It has been suggested that placental detachment is associated with increased fibrinolytic activity in the villous tissue. There are also indications that cervical dilatation with laminaria tents contributes to detachment of the placenta. In this study, the decidual and placental concentrations of plasminogen activators (PAs) and plasminogen activator inhibitors (PAIs)--key components of the fibrinolytic system--were measured in 69 1st-trimester abortion patients, 35 of whom were dilated by laminaria tent and 34 of whom were in Hegar dilator group. PAI-1 concentrations were significantly higher in the laminaria tent group than in controls, while PAI-2 values were significantly lower. The inverse relationship between urokinase-related PAs (u-PAs) and PAI-1 in the decidua was largely the same in both groups, while there was a significant difference between groups in the relationship between u-PA and PAI-2. Decidua in the laminaria tent group further differed from controls with regard to the relationship between blood vessel-related PA (t-PA) and PAI-2., but not between t-PA and PAI-1. In placental specimens, the 2 groups differed in terms of the relationship between u- PA and PAI-1 concentrations; inhibitor activation decreased with increasing u-PA values in the laminaria tent group. Laminaria tent subjects showed an inverse relationship between placental concentrations of u-PA and PAI-2, while Hegar dilator controls demonstrated a horizontal regression line. Finally, relationships between t-PA and both PAI-1 and PAI-2 placental concentrations were opposite in the 2 study groups. These findings support the observation that laminaria tent cervical dilatation contributes to placental detachment.

Testing and training of the pelvic floor muscles after childbirth.

In a prospective study of 83 women, two different physiotherapy methods for strengthening the pelvic floor muscles after childbirth were evaluated. The training program was carried out by the patients at home for 12 weeks, starting 8 weeks after spontaneous uneventful delivery. Forty-two women did pelvic floor exercises in accordance with the method presented by Kegel. Forty-one women used standard vaginal cones with weights increasing in 10 g stages from 20 to 100 g, to be retained in the vagina both when standing erect and moving. Pelvic floor muscle strength, defined as the weight in grams of the heaviest cone that could be retained in the vagina, was recorded before and after the 12-week training period. Training with vaginal cones produced significantly better pelvic floor muscle strength than did exercise without cones.

Extrauterine pregnancy four weeks after successful tubal sterilization.

A case of ectopic pregnancy four weeks after successfully performed tubal sterilization is described. The possibility of conception prior to sterilization is pointed out and discussed.

PIP: A 35-year old multigravida was admitted to hospital, 3 weeks a fter bilateral tubal cornual resection, with vaginal bleeding and abdominal pain. An erroneous diagnosis of incomplete spontaneous abortion was made. A week later, she was readmitted for continued pain and vaginal bleeding, and was correctly diagnosed as having a tubal pregnancy, conceived prior to sterilization. Left salpingectomy was performed. Women should be advised to use barrier methods of contraception after their last menstrual period before sterilization.

Retropubic urethrocystopexy with fibrin sealant: a long-term follow-up.

Transabdominal urethrocystopexy by using a two-component fibrin sealant as a substitute for sutures was performed in 99 women suffering from proved urinary stress incontinence. All were assessed preoperatively, both clinically and by urodynamic tests. This report deals with the results after a follow-up period not shorter than 1 year and up to 4 years. We found it essential not to report postoperative results concerning observation periods shorter than 1 year, as most relapses are observed more than 1 year after operation. Success was defined as absence of objective urine loss at coughing or straining with full bladder in upright position. The results imply that this simple technique is worthy of trial in correcting urinary stress incontinence in women.