Periurethral collagen injection: a long-term follow-up study.

OBJECTIVE: To determine the long-term success of the periurethral injection of collagen (Contigen(R), Bard UK) in women with genuine stress incontinence. PATIENTS AND METHODS: Sixty-one women with genuine stress incontinence were enrolled in a trial of periurethral collagen injections between 1 September 1990 and 31 August 1992. They were assessed at 1, 3, 6, 12 and 24 months after the last collagen injection. In 1998, their notes were reviewed, and a standardized questionnaire was sent to 46 women who were still alive and had undergone no further anti-incontinence surgery. RESULTS: Of the 53 women who were either known failures or who had follow-up information beyond 5 years, 26% were subjectively improved. Women who had a maximum urethral closure pressure of >20 cmH2O and those who had urinary incontinence for <10 years before their first injection were more likely to have had long-term success. There was no correlation between long-term success and the number of previous operations, body mass index, age or preoperative pad loss. Neither the number of injection sessions, total volume of collagen injected nor perceived bulking at the time of surgery affected long-term success rates. Of the 14 women who considered themselves subjectively improved, seven had daily incontinence and only one was completely dry. Urinary retention and urinary tract infection were the most common complications. In addition, one woman reported a flare-up of her skin test and transient 'flu-like symptoms 2 weeks after the injection, and one woman developed a right upper lobe pneumonia 2 weeks after the collagen injection. CONCLUSION: The long-term results of periurethral collagen injections are disappointing. We found no evidence to support the use of periurethral collagen injections in women with intrinsic sphincter deficiency, who had a higher failure rate than those with hypermobility. Further research is essential to develop agents that are not immunogenic, produce minimal inflammatory response and yet are durable.

Clinical features of urinary incontinence and urogenital prolapse in a black inner-city population.

OBJECTIVE: Our purpose was to describe the clinical features and urodynamic findings of a black female inner-city population with urinary incontinence and uterovaginal prolapse. STUDY DESIGN: A retrospective review of the urogynecoloy records of 159 black female patients was performed. RESULTS: Genital prolapse was common. A cystocele was identified in 116 patients, a rectocele in 88 patients, and uterine or vaginal vault prolapse in 41 patients. Subtracted multichannel cystometry revealed detrusor overactivity in 58 patients, genuine stress incontinence in 44 patients, and mixed incontinence in 30 patients. Sixteen patients had normal urodynamic studies. The presence of a cystocele and the physical sign of stress incontinence at initial examination were found equally in patients with genuine stress incontinence, detrusor instability, and mixed incontinence at cystometry. There was no correlation between other commonly associated clinical factors (such as age, parity, and obesity) and the urodynamic diagnosis. CONCLUSIONS: Many of the factors commonly assumed to predispose women to the development of incontinence and prolapse may not apply to the black inner-city population. Urodynamic testing to establish the correct diagnosis is required, because the correlation between symptoms, physical examination, and urodynamic findings is relatively poor in this population.

Simple bladder filling with a cough stress test compared with subtracted cystometry for the diagnosis of urinary incontinence.

OBJECTIVE: Our purpose was to compare the diagnostic efficacy of observing urine loss during simple bladder filling (without pressure measurement) and a cough stress test, with multichannel subtracted cystometry. STUDY DESIGN: The urodynamic records of 77 women complaining of urinary incontinence were reviewed. All women had undergone a full evaluation that included a standardized history and physical examination, urinalysis and urine culture, uroflowmetry with measurement of postvoid residual urine, a cough stress test performed during and after simple retrograde bladder filling, and multichannel subtracted cystometry. The results of simple bladder filling and the cough stress test were recorded as "urge incontinence," "stress incontinence,"mixed incontinence," or "incontinence not demonstrated." The subtracted cystometrogram was then performed, and the urodynamic diagnoses were recorded as "detrusor instability," "genuine stress incontinence," "mixed incontinence," or "incontinence not demonstrated." The records were reviewed, and the results of simple bladder filling with a cough stress test were compared with those obtained by subtracted multichannel provocative cystometry. RESULTS: With the subtracted multichannel cystometrogram used as the "gold standard" for diagnosis, the demonstration of "urge incontinence" during simple bladder filling had a sensitivity of 64% and a specificity of 86.8% for the demonstration of detrusor instability during cystometry, with a positive predictive value of 83.3% and a negative predictive value of 70.2%. The demonstration of "stress incontinence" during simple bladder filling had a sensitivity of 88.1% and a specificity of 77.1% for the demonstration of "genuine" stress incontinence during cystometry, with a positive predictive value of 82% and a negative predictive value of 84.4%. CONCLUSIONS: The demonstration of urge incontinence during simple bladder filling is a reliable predictor of detrusor instability, but its absence is less reliable in excluding detrusor overactivity as a cause of urinary incontinence. Similarly, the clinical demonstration of stress incontinence during simple bladder filling is predictive of the presence of "genuine" stress incontinence during subtracted multichannel provocative cystometry. The inability to demonstrate stress incontinence during simple bladder filling is highly correlated with the absence of "genuine" stress incontinence during complex urodynamic testing. Simple bladder filling is a reliable method of diagnosing urinary incontinence. In many cases it can replace complex urodynamic testing, particularly if the proposed treatment for the condition carries a low level of risk, and is helpful in selecting patients who need more extensive evaluation.

Adnexal torsion: can the adnexa be saved?

OBJECTIVE: Our purpose was to identify which cases of adnexal torsion may be managed with adnexal conservation. STUDY DESIGN: A retrospective chart review was conducted on all patients diagnosed with adnexal torsion between February 1983 and February 1993 at four hospitals in the Emory University system. RESULTS: Fifty-nine patients ranging in age from 23 months to 73 years (mean 31.9 years) were reviewed. Almost half of the patients were nulliparous. Lower abdominal pain (83%) and an adnexal mass (72%) were the most common presenting findings, but in general clinical findings were nonspecific. Most patients were treated with extirpative therapy of the affected adnexa. Untwisting of the adnexa was performed in 10 patients; however, adnexal conservation was accomplished in only one patient. There were no thromboembolic complications in any of the patients. CONCLUSIONS: Adnexal torsion is a diagnostic challenge, often with nonspecific symptoms. There is growing evidence that untwisting the involved adnexa to observe for tissue reperfusion and viability is safe. However, significant delay in surgical intervention may result in irreversible tissue necrosis, rendering the adnexa unsalvageable.

One hundred unstable bladders.

OBJECTIVE: To investigate the correlation between presenting symptoms and cystometric data in patients with urodynamically proven detrusor instability. METHODS: A retrospective review was conducted of standardized urodynamic data bases and cystometrograms from the gynecologic urodynamics laboratories at Duke University Medical Center, Durham, North Carolina, and Grady Memorial Hospital, Atlanta, Georgia. RESULTS: Of the 100 patients reviewed, 86% complained of urge incontinence and 78% complained of urinary urgency; however, 76% also complained of stress incontinence. Statistical evaluation of symptoms by analysis of variance showed no significant correlations between the symptoms of urinary frequency and urgency and any of the cystometric indices. Patients with motor urge incontinence had significantly smaller mean cystometric bladder capacities than patients without this complaint (299.9 +/- 132.5 versus 553.6 +/- 173.6 mL; P < .01). One-third (34) of the patients had mixed incontinence due to genuine stress incontinence as well as detrusor instability. Compared with patients suffering from detrusor instability alone, patients with mixed incontinence had significantly larger cystometric bladder capacities (396.0 +/- 172.9 versus 308.1 +/- 154.8 mL; P < .02) and a lower amplitude of the maximum detrusor contraction (38.8 +/- 21.7 versus 49.9 +/- 25.1 cm H2O; P < .04). CONCLUSIONS: Women with detrusor instability represent a diverse population with a wide variety of symptoms and urodynamic findings. Patients with mixed incontinence may represent a subpopulation distinct from those with pure detrusor instability. Further research that attempts to describe other discrete subpopulations of patients with detrusor instability may improve our understanding of this troublesome clinical problem.

Evaluation of adhesion formation using Interceed (TC7) absorbable adhesion barrier on ovarian surgical wounds in the rabbit model.

OBJECTIVE: To determine whether an Interceed patch would decrease adhesion formation in ovarian surgical wounds healing by second intention in the rabbit model. METHODS: Twenty-five New Zealand White female rabbits underwent midline laparotomy. Using microsurgical technique, each ovary was bivalved longitudinally with a no. 15 blade scalpel, and hemostasis was achieved with bipolar electrocautery. One ovary was then covered with an Interceed patch in a randomized fashion, while the other ovary served as a control. The animals were then allowed to recover routinely. Four weeks later, the rabbits were euthanized and the adhesions were graded by a blinded observer. Adhesion scores between the Interceed-treated ovaries and the control ovaries were compared by Wilcoxon signed-rank test. RESULTS: The mean adhesion score of the Interceed-treated ovaries (1.65 +/- 0.87) was not significantly different from the mean adhesion score of the control ovaries (1.5 +/- 1.0) (P = .51). Some degree of atrophy was noted in 14 of the 50 ovaries. The mean adhesion score in the atrophied ovaries was significantly higher than in the nonatrophied ovaries, regardless of whether the ovaries had been treated with Interceed (2.21 versus 1.40; P = .01). There was no difference in the incidence of atrophy between the Interceed-treated and untreated sides. Exclusion of the ovaries with atrophy again demonstrated no difference in the mean adhesion scores between the treated and untreated sides. CONCLUSION: We were not able to demonstrate any benefit from using Interceed to decrease postoperative adhesion formation of ovarian surgical wounds in the rabbit model.

Transverse transperineal repair of rectovaginal fistulas in the lower vagina.

OBJECTIVE: The management of a rectovaginal fistula is a significant challenge for the patient and the surgeon, with many acceptable surgical techniques for repair. The transverse transperineal repair is a method that preserves an intact external anal sphincter, allows wide mobilization of rectal and vaginal tissues, and closes the fistula with at least five layers of tissue. We have used this technique in patients with rectovaginal fistulas in the lower vagina for the past several years and recently reviewed our results. STUDY DESIGN: A chart review of 21 patients who had a transverse transperineal repair of a rectovaginal fistula in the lower vagina in our institutions from 1983 to 1990 was performed. RESULTS: All patients had a satisfactory recovery with no recurrence of a fistula during a follow-up period ranging from 3 months to 8 years (mean 18 months). The series includes seven patients with Crohn's disease and/or previous failed repairs. CONCLUSIONS: Our experience suggests this method provides excellent anatomic and physiologic results with minimal morbidity.

The incidence of genital prolapse after the Burch colposuspension.

OBJECTIVE: Our objective was to determine the incidence of postoperative genital prolapse after the Burch colposuspension and to identify risk factors for the development of subsequent prolapse. STUDY DESIGN: The charts of 131 patients who had a Burch colposuspension performed by the senior author (S.L.S.) between 1977 and 1986 were reviewed at the Urodynamic Unit of St. George's Hospital, London. Emphasis was placed on the degree of genital prolapse on clinical examination and whether further surgery was required to correct the prolapse. RESULTS: Thirty-five patients (26.7%) required a total of 40 operations to correct genital prolapse after colposuspension. At 20 operations, more than one procedure was required to correct combined prolapse. The patient's age, weight, parity, menopausal status, and prior pelvic surgery did not affect the incidence of postoperative prolapse. The only preoperative risk factor identified was the presence of a large cystocele. CONCLUSION: Postoperative genital prolapse is a significant complication of the Burch colposuspension. It is unclear whether this is due to a disruption of the vaginal axis or to an intrinsic weakness of the pelvic floor in these women.

Primary fallopian tube carcinoma with coexistent tuberculous salpingitis: a case report.

A case of primary carcinoma of the fallopian tube with coexistent tuberculosis has been presented, and previously reported cases in the literature reviewed. These cases represent a rare occurrence where the diagnosis might be missed without a thorough pathologic evaluation. Clinicians should maintain an index of suspicion for fallopian tube carcinoma in perimenopausal or postmenopausal women with menometrorrhagia who fail to respond to hormonal therapy and a D and C. The finding of a tuboovarian abscess in a postmenopausal woman should also cause concern for tubal carcinoma, as it is usually a disease of menarcheal women. Similarly, a possibility of granulomatous salpingitis should always be borne in mind in the differential diagnosis of inflammatory diseases of the fallopian tube.

The Sister (Mary) Joseph nodule: its significance in gynecology.

Twenty-five cases of metastatic carcinoma of the umbilicus in women diagnosed and treated at Emory University Hospitals from 1973 to 1989 were reviewed, as were all previously reported cases in the English language literature. In our series, overall survival was greatest in patients treated with aggressive surgery and chemotherapy, compared with patients receiving no therapy or those treated with either surgery or adjunctive therapy alone. Individual survival was enhanced when the primary tumor site was of ovarian origin.

Adhesion formation after ovarian wound repair in New Zealand white rabbits: a comparison of ovarian microsurgical closure with ovarian nonclosure.

Thirty female New Zealand white rabbits underwent standard laparotomy. Each ovary was bivalved and hemostasis was achieved with bipolar electrocautery. One ovary was then randomized to the closure group, whereas the other ovary was placed in the nonclosure group. In the closure group, the ovarian capsule was closed with a continuous suture of 8-0 Vicryl absorbable surgical suture material with microsurgical technique. In the nonclosure group, the ovaries were left open. Three weeks later the animals were killed and the ovarian adhesions were graded with a standardized scale by an observer (A. A. T.) blinded to the closure status of the animals. Five control animals underwent sham operations with minimal adhesion formation. Statistical analysis of the study animals by the paired Student t test showed a significantly higher adhesion score on the ovaries that were microsurgically closed compared with the ovaries not closed (p = 0.02).

Amniotic membranes in the treatment of necrotizing fasciitis complicating vulvar herpes virus infection.

Necrotizing fasciitis of the vulva developed in an immunocompromised patient with chronic myelogenous leukemia, apparently from secondarily infected herpes simplex lesions. In addition to surgical debridements and broad-spectrum intravenous antibiotic therapy, the wound was treated using specially prepared amniotic membranes as a wound dressing. The patient died on hospital day 65 because of complications of her immunocompromised state, with autopsy findings of disseminated cytomegalovirus. However, use of amniotic membranes as a wound dressing appeared to be beneficial.