Faculty Bibliography

Fecal incontinence can be devastating to the patient who suffers from this condition, greatly affecting quality of life issues. It is important to actively elicit these symptoms from the patient, as embarrassment may prohibit the patient from bringing up the topic. An accurate history and physical examination can often identify the etiology of the problem. A detailed obstetric history should also be obtained. Symptom diaries are excellent tools not only for diagnosis but also to monitor progress. Further anorectal physiology studies can help identify proper surgical candidates and direct therapies, especially in those in whom more conservative measures have failed. By understanding the physiology of anal continence and the utility of the tools available to assess anorectal function, we can best assist our patients in improving their quality of life

OBJECTIVE: The object of this study was to determine the prevalence of anal incontinence among women with previous multiple pregnancy and childbirth and assess risk factors. STUDY DESIGN: A 77-item questionnaire was administered to 769 mothers of multiples. Statistical analyses included chi(2), Student t test, and logistic regression. RESULTS: Seven hundred thirty-three (95.3%) women completed the survey, 94% of them white, with a median age of 37 years. Fecal incontinence affected 10% (6.3% arose during pregnancy, 40.6% after delivery, 53.1% unrelated to childbirth). Although delivery by cesarean section only was associated with lower prevalence in univariate analysis (5.8% vs 11%, P=.02), age was the only significant covariate in multivariate regression (P=.0001). Flatal incontinence affected 25.2% (21.2% during pregnancy, 30.3% after delivery, 48.5% unrelated), increasing with age (P=.0001). Soiling affected 10%, increasing with age (P=.0001). CONCLUSION: Mothers of multiples reported substantial rates of fecal (10%) and flatal (25.2%) incontinence. Advancing age was the major risk factor. Delivery by cesarean section only was not significantly protective, although elective (before labor) cesarean deliveries were not separately assessed

The purpose of our study was to examine the incidence of prolapse in a group of women who had had an isolated Tanagho modification of the Burch colposuspension performed without significant pelvic organ prolapse preoperatively. Sixty women were identified who underwent an isolated Burch procedure for genuine stress incontinence between 1991 and 1999. Thirty-four women returned for postoperative Pelvic Organ Prolapse Quantification (POP-Q) staging evaluation. Overall, 6 (17.6%) had stage II anterior prolapse. Eleven (32.4%) had stage II posterior prolapse. Three (8.8%) had stage II uterine prolapse. None of these patients with identified support defects was symptomatic. Two patients had subsequently undergone vaginal hysterectomy. One had this performed for dysfunctional uterine bleeding 3 years after her Burch procedure. One patient developed symptomatic uterine prolapse and underwent a vaginal hysterectomy 5 months after her Burch procedure. The majority of patients undergoing an isolated Tanagho modification Burch procedure without preoperative prolapse do not appear to be placed at increased risk for subsequent operative intervention

OBJECTIVE: The purpose of this study was to assess the impact of delivery mode on the risk of urinary incontinence among women with previous multiple childbirth. STUDY DESIGN: A 77-item questionnaire was administered to 733 mothers of multiples. Multivariate regression was used to control for potentially confounding variables. RESULTS: The mean rate of stress urinary incontinence among women who were delivered by cesarean-only delivery was 39.6%, which was significantly lower than the 60.4% among women who reported previous vaginal births (P =.005). Cesarean-only delivery was associated with a markedly reduced risk (odds ratio, 0.52; P =.002) after controlling for age, parity, and body mass index by multivariate regression. Weaker associations were found for age (odds ratio, 1.08), body mass index (odds ratio, 1.06), and parity (odds ratio, 1.46). Urge incontinence was associated with parity, body mass index, and age, but not delivery mode (P =.76). CONCLUSION: Vaginal delivery represents a major risk factor for stress incontinence among mothers of multiples. Delivery by cesarean delivery only confers an independent protective effect

OBJECTIVE: Our purpose was to examine the frequency of significant intraoperative cystoscopic findings during major vaginal reconstructive and urogynecologic surgeries. STUDY DESIGN: The records of 526 consecutive women who underwent routine cystoscopy with intravenous injection of indigo carmine at the time of their urogynecologic and major vaginal reconstructive procedures between January 1, 1997, and April 20, 2001, were reviewed. We determined the incidence of significant cystoscopic findings and their effect on intraoperative management. Two-tailed t tests and logistic regression analyses were used to compare characteristics between the groups with and without significant cystoscopic findings. RESULTS: During the 526 operations, 26 significant findings (4.9%) were unsuspected before cystoscopy and 15 (2.9%) of these findings were operative injuries that required intervention. Seventy-nine subjects (15.0%) had no anti-incontinence operation performed. Of these patients, there was one partial ureteral obstruction from an anterior colporrhaphy (1.3%). Seven of 184 Burch procedures (3.8%) resulted in injuries to the lower urinary tract, of which 3 (1.6%) required intervention that were unrecognized before cystoscopy. Seven of the 15 cases resulting in changes in intraoperative management were caused by anterior colporrhaphy sutures (2.0% of all anterior colporrhaphies). There were no unrecognized injuries that caused morbidity after surgery. There were no significant differences between patients with abnormal and normal cystoscopic findings in regard to mean age, weight, parity, estimated blood loss, previous surgery, or previous incontinence surgeries. No complications or morbidity occurred as a direct result of intraoperative cystoscopy. CONCLUSION: Intraoperative cystoscopy with intravenous indigo carmine is a safe and effective way to detect injury of the lower urinary tract. Cystoscopy detected unsuspected operative injuries in 2.9%. In cases that did not involve anti-incontinence procedures, the rate of injury was 1.3%. With a significant rate of detection, cystoscopy allows for immediate recognition and easier repair of lower urinary tract injury, lowering the patient's risk for morbidity. Anterior colporrhaphy was the most common cause of unrecognized ureteral compromise

Overactive bladder affects the lives of millions of people. Anticholinergic medications are traditionally used to treat this condition, but some patients find these agents difficult to tolerate and ineffective. Conservative treatment with pelvic floor exercises, with or without biofeedback, electric stimulation, and behavioral modification, are excellent modalities that can be effective in the motivated patient. This review describes the available literature supporting the efficacy of pelvic floor exercises in the treatment of overactive bladder and guidelines for patient selection

Critical-current (J(c)) measurements for YBa2Cu3O7-delta (YBCO), Gd0.6Ca0.4Ba1.6La0.4Cu3O7-delta (TX-GBCO) and TX-CBCO/YBCO bilayers were performed different applied magnetic fields. rue film samples were prepared by pulsed laser deposition and patterned as microbridges. The highest J(c) (1.5 x 10(6) A/cm(2)) at 75 K in 5 Tesla (Hllab) was observed for TX-GBCO/YBCO bilayers, which showed a 40 % increase in J(c) over YBCO under the same conditions. The bilayer samples possess a T-c at 90 Ii and display superconducting properties similar to YBCO. A possible mechanisms for the high J(c) of bilayer YBCO films is discussed. Development of these bilayer and multilayer structures represents a promising new direction to improve the superconducting properties of YBCO since the TX-GBCO layer provide both protection against corrosion and a significant improvement in J(c).