Dynamic cystoproctography and physiological testing in women with urinary stress incontinence and urogenital prolapse.

In order to determine the frequency of posterior compartment pathology in females with anterior and middle compartment pelvic floor weakness, 10 women with urinary stress incontinence and 10 women with uterovaginal prolapse underwent detailed review of their history and clinical findings, and were studied by simultaneous evacuation proctography and cystography. Radiological findings were correlated with anorectal physiological testing. Considerable symptom overlap and occult defaecatory symptoms were revealed. The combined radiological examination visualized cystocoele, enterocoele, rectocoele and rectal intussusception, and diagnosed higher degree prolapse than did clinical examination. There was no significant difference in the frequency of any of these findings with respect to either group, nor was there any significant difference in proctographic measurements. Additionally, there was little significant difference in physiological measurements between the groups, and when cystoproctographic features were compared to the results of anorectal physiological testing, there was little correlation between results obtained from either set of tests. In conclusion, modification of standard proctographic techniques enhances the diagnostic potential of the study, allowing accurate demonstration of the site and degree of pelvic floor weakness in women. Weakness often involves all pelvic compartments, despite differing clinical presentations, suggesting a global pathology. Embarrassing symptoms may not be volunteered, and should be sought so that imaging is appropriate.

The partial shift system: the way forward?

We have successfully introduced a partial shift for seven SHOs working in a busy department. The key to success has been combining the reduction in hours with improved clinical care and strengthened training opportunities. We are now into the second 6-month period of the new system and none of the SHOs want to revert to the old rota system.

Bowel dysfunction: a pathogenic factor in uterovaginal prolapse and urinary stress incontinence.

OBJECTIVE: To investigate the aetiological importance of bowel dysfunction in patients with uterovaginal prolapse and urinary stress incontinence. DESIGN: Observational study using a questionnaire about obstetric history and bowel function, and anorectal physiological studies. SETTING: Physiology unit and gynaecological outpatients departments of two teaching hospitals. SUBJECTS: Twenty-three women with uterovaginal prolapse (mean age 57 years), 23 women with urinary stress incontinence (mean age 52 years) and 27 control women (mean age 52 years). RESULTS: There was no statistically significant difference between the three groups in their parity, age or birthweight of their children. However, straining at stool as a young adult prior to the development of urogynaecological symptoms was significantly more common in women with uterovaginal prolapse (61% vs 4%, P < 0.001) and women with urinary stress incontinence (30% vs 4%, P < 0.05), compared with controls. A bowel frequency of less than twice per week as a young adult was also more common in women with uterovaginal prolapse than in control women (48% vs 8%, P < 0.001). At the time of consultation, 95% of the women with uterovaginal prolapse were constipated, compared with only 11% of control women. Many of these women also needed to digitate to achieve rectal evacuation. Compared with controls, women with uterovaginal prolapse had a prolonged pudendal nerve terminal motor latency (1.9 ms vs 2.2 ms, respectively, P = 0.003). Women with stress incontinence of urine had a normal pudendal nerve latency (2.0 ms). Other tests of anorectal function were normal. CONCLUSIONS: Constipation, in addition to obstetric history, appears to be an important factor in the pathogenesis of uterovaginal prolapse.

Unsuspected sphincter damage following childbirth revealed by anal endosonography.

Anal endosonography was performed in 62 consecutive patients with incontinence of flatus or faeces following obstetric trauma, and in 18 parous controls. Of the incontinent group, 90% had defects in the external sphincter, 65% in the internal sphincter and 44% disruption of the perineal body, compared with none of the controls. This triad of lesions is pathognomonic of obstetric trauma. Anal endosonography revealed a higher prevalence of sphincter damage than expected from anorectal physiology tests, and therefore has a role in screening patients following complicated or difficult deliveries.

Circulating levels of GH-releasing hormone and GH during human pregnancy.

To study the potential role of GH-releasing hormone (GHRH) in maintaining circulating levels of GH during pregnancy, 302 maternal plasma samples were collected from non-fasted subjects at various stages of pregnancy and assayed for GHRH using a 'two-site' immunoradiometric assay. The GH and placental lactogen levels were also determined. In addition, maternal plasma samples taken during labour, amniotic fluid and cord blood were also assayed for these hormones. Maternal plasma GHRH levels were similar to non-pregnant levels throughout gestation despite fluctuations in GH values which were always higher than non-pregnant levels. There was no significant difference between GHRH levels in maternal plasma and cord blood although high GH levels were observed in the latter. These findings suggest that peripheral GHRH levels do not play an important role in maintaining circulating GH levels during pregnancy.