[Factors associated with fecal incontinence after childbirth. Prospective study in 525 women]. / Facteurs liés à l'incontinence anale du post-partum. Etude prospective chez 525 femmes.

OBJECTIVE: To determine the prevalence of fecal incontinence after childbirth and to identify the risk factors. METHODS: This was a prospective observational study with a consecutive inclusion of 525 women who delivered over a three months period. Women were questioned about their fecal continence four days and six weeks after delivery. RESULTS: The incidence of fecal incontinence four days and six weeks after childbirth was respectively 8.8% and 3.3%. The risk factors for fecal incontinence at 4 days after childbirth were instrumental delivery by forceps (adjusted odds ratio 8.64, 95% confidence interval 3.55-21.0, p < 0.001) and unassisted delivery at home (adjusted OR 8.06, 95% CI 1.30-50.0, p = 0.025). Independent risk factors for the presence of fecal incontinence 6 weeks later were: instrumental forceps delivery (adjusted OR 10.8, 95% CI 2.82-41.3, p = 0.001), unassisted delivery at home (adjusted OR 50.0, 95% CI 3.09-802, p = 0.006), bi-parietal diameter of the newborn > 93 mm (adjusted OR 4.56, 95% CI 1.46-14.1, p = 0.009) and maternal age >30 years (adjusted OR 4.60, 95% CI 1.11-19.1, p = 0.036). CONCLUSION: Fecal incontinence is common after childbirth and its prevalence is predominantly associated with instrumental delivery, unassisted delivery at home, bi-parietal diameter of the newborn and maternal age.

[Comparison of 2 therapeutic strategies in severe endometriosis, in young women consulting for sterility or pain. II. In the case of infertility, value of ovarian stimulation with intrauterine insemination after surgery]. / Comparaison de deux stratégies thérapeutiques dans les endométrioses sévères, chez des femmes jeunes consultant pour stérilité ou douleurs. II. En cas d'infertilité, intérêt des stimulations ovariennes avec inséminations intra-utérines après la chirurgie.

AIM OF THE STUDY: Define the best medico surgical strategy in infertile women with stage III-IV endometriosis. MATERIAL AND METHODS: Two groups, A (N26) and B (N 37), treated for infertility associated or not with pelvic pain, due to stage AFS III or IV endometriosis, were compared. They had similar surgical procedure: operative laparoscopy including resection of endometriotic lesions, more particularly endometriomas and rectovaginal septum nodules. Associated medical strategy was different: group A, operative laparoscopy without preoperative treatment and in 40% a second laparoscopy taking place after 2-3 months of LHRH analogues; no post operative treatment; group B, operative laparoscopy taking place after ovarian blockage with 3-6 weeks of Diane (Androcur + ethinyl estradiol), then 2-3 months of analogue postoperative treatment immediately followed by ovarian stimulation (OS) + intrauterine insemination (IUI) in women more than 30 years old with operative tubes (N 22), no treatment for six months in similar cases less than 30 (N 5), and IVF in women with damaged tubes (N 5) or after OS + IUI failure (N 4). One patient refused two patients with high FSH level had oocyte donation. RESULTS: Two years evolutive pregnancy rate was significantly higher (p < 0.01) in group B (59%) versus group A (23%) and was higher after OS + IUI (68%) than after IVF (55%) or without any treatment in women < 30 (43%). The difference is equally significant by age (p < 0.05), for endometriomas (p < 0.01) and for recurrences (p < 0.01). CONCLUSION: Similar results obtained for pelvic pain (see chapter I) suggest that both strategies are similarly successful in treating endometriosis. These results confirm the interest of an ART after surgery for stage III-IV endometriosis and show that OS + IUI, a less costly than IVF technique, can be used successfully in selected cases with operative tubes.

[Comparison of 2 therapeutic strategies for severe endometriosis, in young women counsulting for sterility or pain. Results in cases of chronic pelvic pain]. / Comparaison de deux stratégies thérapeutiques dans les endométrioses sévères, chez des femmes jeunes consultant pour stérilité ou douleurs. Résultats en cas de douleurs pelviennes chroniques.

AIM OF THE STUDY: Compare two medical strategies associated to surgery in women requiring for chronic pelvic pain due to stage III-IV endometriosis. MATERIAL AND METHODS: Two different patient groups, A (N 27) and B (N 41), requiring for chronic pelvic pain, associated with AFS stage III-IV endometriosis, operated on from 1992 to 1997, were compared. The medium age was 35 and 34 years, respectively. Pelvic pain, classified in three stages, was similar in both groups but they were more AFS stage IV in group A, 67% than in group B, 46% (p < 0.01). Both groups had similar operative procedure: laparoscopic resection of deep endometriotic nodules or endometriomas, plus destruction of small superficial lesions using CO2 laser (A) or bipolar coagulation (B). Associated medical strategy was different: group A: operative laparoscopy without preoperative treatment and in 25% a second laparoscopy taking place after two-three months of LHRH analogues; no postoperative treatment; group B, operative laparoscopy taking place after ovarian blockage with three-six weeks of Diane (Androcur + ethinyl estradiol), then two-three months of analogue postoperative treatment immediately followed by long term progestoid treatment in order to prevent recurrences in women without pregnancy desire. RESULTS: After one year, 6/27 (22%) of A and 3/41 (7%) of B had no follow-up. Of the followed patients, a complete improvement was observed in 18/21 (86%) A, 33/38 (87%) B, moderate pelvic pain continued in 2/21 (10%) A, 4/38 (11%) B, and the treatment was in failure in 1/21 (5%) A, 1/38 (3%) B, without significant difference. After two years, 67% of A and 76% of B had a follow-up and the corresponding rates of complete improvement are 72% (A), 87% (B), incomplete improvement: 22% (A), 10% (B) and failure: 6% (A), 3% (B). The difference is lightly significant (p < 0.05) and remains so if patients without follow-up are considered as failures. There was no persistence nor recurrence of endometriosis nor endometrioma two years after the surgery was completed. CONCLUSION: Since there were more stage IV endometriosis in group A than in B, the different medical strategies and particularly the long term postoperative treatment used in B seem have little influence on results. However, these data was obtained in women of medium age > 30, with a relatively short follow-up. It should be of interest to compare in a prospective multicentric study the long term follow-up of two cohorts of young women operated on for stage III-IV endometriosis, receiving or not a long term medical treatment after surgery in order to prevent recurrences.