Management of obstetric anal sphincter injuries--a role for the colorectal surgeon.

AIM: To determine if surgical repair of third and fourth degree obstetric perineal tears by an experienced colorectal surgeon produces satisfactory functional results in the short and long term. METHOD: Consecutive deliveries were studied prospectively over a 32-month period. All patients with suspected third or fourth degree tears were referred to the colorectal team. Following confirmation of the injury, patients underwent surgical repair using a standard overlapped technique according to an established protocol. The patients were reviewed 2 months later. Long-term continence was determined, by postal and telephone follow up, after a minimum of 3 years. RESULTS: Fifty-nine sphincter injuries were identified and repaired by the colorectal team. Two months following repair 51 (86%) of patients had normal continence, four (7%) had urgency, and five (8%) had occasional incontinence of flatus. All patients with any degree of incontinence underwent endoanal ultrasound at which no sphincter defects were noted, and all improved symptomatically following pelvic floor physiotherapy. Long-term follow up data was obtained in 45 women. Thirty-nine (87%) had normal continence scores, 11 (24%) described urgency, but only three (7%) were often incontinent of liquid stool. Seven (15%) were occasionally incontinent of flatus. CONCLUSION: Excellent short and long-term functional results were obtained in the repair of third and fourth degree tears when performed by experienced colorectal surgeons. Since the protocol was established, obstetricians in North Cheshire have adopted the double overlapped technique, and now manage the majority of these injuries themselves.

The tension-free vaginal tape procedure in women with previous failed stress incontinence surgery.

PURPOSE: The tension-free vaginal tape procedure is an increasingly popular choice for treating female urinary stress incontinence. This ongoing, prospective, open label study presents the results of tension-free vaginal tape surgery at 1 year in women who have previously undergone unsuccessful stress incontinence surgery. MATERIALS AND METHODS: A total of 67 women with previous failed surgery for stress urinary incontinence underwent the tension-free vaginal tape procedure. Treatment outcome was categorized as cure, significant improvement or failure based on cystometry findings and urinary pad loss results at 3 months of followup, and on subjective questioning at 3 months and 1 year of followup. RESULTS: At 12 months 54 women (81%) were cured, 4 (6%) were significantly improved and 9 (13%) were no better. No serious morbidity was noted after the procedure. CONCLUSIONS: The tension-free vaginal tape procedure provides the prospect of a success rate similar to that of a conventional sling procedure in patients with previous failed surgery. It has a low rate of operative complications and postoperative morbidity.

The effect of an intrauterine application of two percent lignocaine gel on pain perception during Vabra endometrial sampling: a randomised double-blind, placebo-controlled trial.

OBJECTIVE: To determine whether two percent lignocaine gel can reduce the perception of pain during Vabra endometrial aspiration. DESIGN: Randomised, double-blind placebo-controlled trial. SETTING: Women's Health Directorate, Warrington Hospital NHS Trust. POPULATION: Women were referred to the endometrial sampling clinic for the investigation of pre and postmenopausal vaginal bleeding. METHODS: Randomisation to either pre-sampling intrauterine two percent lignocaine gel or an inert gel. Patients, recruiters and assessors were blinded to the gel used. MAIN OUTCOME MEASURES: The difference between the study groups in the proportion of women who, after Vabra sampling, recorded a pain score of > or = 6 out of 10 on a visual analogue scale. RESULTS: Three hundred and eight women were randomised, 284 (92%) completed a pain scale before and immediately after the procedure. After the procedure, 84 women (30%) recorded a pain score of > or = 6, 38 (26%) received anaesthetic and 46 (33%) an inert gel. The difference in the proportion of women recording a pain score of 6 or above between the two study groups was not significant (relative risk (RR) for the anaesthetic gel = 0.79 95% CI, 0.55, 1.14). CONCLUSIONS: Intrauterine application of 2% lignocaine gel did not significantly reduce the frequency with which women experienced unacceptable levels of pain or anxiety during endometrial aspiration compared with placebo.