Abstract: One of the main issues in Perineology is to obtain a complete history of the patient including the three axes (gynecological, urological and colo-proctological). Because each of these axes has two ends, one âincontinenceâ and one âobstructionâ, it is possible to draw a radar diagram including these six main symptoms (dyspareunia, prolapse, dysuria, urinary incontinence, dyschesia, anal incontinence). We called this diagram âT.A.P.E.â for âThree Axes Perineal Evaluation
Abstract: BACKGROUND: Perineodynia (vulvodynia, perineal pain, proctalgia), anal and urinary incontinence are the main symptoms of the pudendal canal syndrome (PCS) or entrapment of the pudendal nerve. The first aim of this study was to evaluate the effect of bilateral pudendal nerve decompression (PND) on the symptoms of the PCS, on three clinical signs (abnormal sensibility, painful Alcock's canal, painful "skin rolling test") and on two neurophysiological tests: electromyography (EMG) and pudendal nerve terminal motor latencies (PNTML). The second aim was to study the clinical value of the aforementioned clinical signs in the diagnosis of PCS. METHODS: In this retrospective analysis, the studied sample comprised 74 female patients who underwent a bilateral PND between 1995 and 2002. To accomplish the first aim, the patients sample was compared before and at least one year after surgery by means of descriptive statistics and hypothesis testing. The second aim was achieved by means of a statistical comparison between the patient's group before the operation and a control group of 82 women without any of the following signs: prolapse, anal incontinence, perineodynia, dyschesia and history of pelvi-perineal surgery. RESULTS: When bilateral PND was the only procedure done to treat the symptoms, the cure rates of perineodynia, anal incontinence and urinary incontinence were 8/14, 4/5 and 3/5, respectively. The frequency of the three clinical signs was significantly reduced. There was a significant reduction of anal and perineal PNTML and a significant increase of anal richness on EMG. The Odd Ratio of the three clinical signs in the diagnosis of PCS was 16,97 (95% CI = 4,68 - 61,51). CONCLUSION: This study suggests that bilateral PND can treat perineodynia, anal and urinary incontinence. The three clinical signs of PCS seem to be efficient to suspect this diagnosis. There is a need for further studies to confirm these preliminary results.
Abstract: A total of 67 patients, including 44 continent patients and 23 patients suffering from stress incontinence, underwent color Doppler examination of the urethra. The maximal urethral pressure and the amplitude of the urethral pulse were measured in 35 of the patients. Linear endovaginal sonography was performed in 25 of the patients to define the position of the urethrovesical unit at rest. The submucous vascular sheath was clearly visible. Its average thickness was 3.42 mm and its average length was 11.75 mm. The measurement reproducibility was good. The dimensions of the submucous vascular plexus and its pulsatility decreased with age and increased with maximal urethral pressure and the manometric amplitude of the urethral pulse. By coupling the sonographic data obtained with color Doppler and linear endovaginal sonography in 25 patients, we obtained a good estimate of the urethral pressure in 83% of the cases and could correctly diagnose all cases of continence in our series (n = 9) and 15 of 16 stress-incontinent patients.
Abstract: The author endeavours to detail the technical modalities which can be used to avoid uncertainty in urodynamic sonography, and to obtain easily reproducible quality imaging. The 5 major techniques (transparietal, transperineal, introital, endovaginal and endorectal) are compared. The artifacts generated are described. A choice between these different techniques is performed as a function of the methodological advantages specific to each of them and the clinical applications contemplated by the sonographer. The characteristics of the "ideal" equipment are defined to help the sonographer-to-be to choose his or her equipment with full awareness of the facts (characteristics of the probe, emission frequency, settings by the sonographer, automatic image freeze during coughing). The methodology is described in detail and widely illustrated: position of the patient, choice of the section plane, choice of the reference system, location of the urethra, and definition of the vesical neck, maintenance of the probe position during effort or free movement, degree of vesical fullness, choice of the parameters. Some difficulties can be linked to the patient's anatomical characteristics (vaginal scar, short or narrow vagina, twisted urethra,...); ways to avoid them are briefly described.
Abstract: In patients with incontinence problems, endovaginal urodynamic ultrasonography is a technique which easily complements manometric examination by permitting a precise study of peri-urethral soft tissue. Use of a linear array probe under standardised conditions gives, at present, the best results. To validate the technique, it is, however, important to understand the artefacts it provokes. Thirty-four patients underwent urethral profilometry at rest and during effort with and without the ultrasonographic probe. In the patients studied, none of the classical urodynamic parameters were modified. However, in cases of narrow vaginas (distance between the arcuate ligament and the ultrasonographic probe less than 12 mm), a small increase in the maximum urethral closure pressure (5 cm H2O) could be observed. The angle between an intra-urethral cotton swab and the horizontal plane was measured at rest and during maximum coughing effort, both with and without the ultrasonographic probe. A significant reduction of the angle was observed at rest and during effort. However, since linear regression is particularly effective in modelling these two artefacts (R2 = 0.8 and 0.7), they can be considered as constants and are not bothersome in clinical practice. Abdominal ultrasound was used in 10 patients during the introduction of the endovaginal ultrasonographic probe to study its impact on the base of the bladder. A clear increase in the posterior urethro-vesical angle was observed, which was shown to be a function of the degree of probe insertion in the vagina. As this artefact was variable and could not be controlled, this angle should no longer be measured using this technique.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: The vesicourethral junction, the urethra cannot be seen when using the abdominal approach because of the interposition of the pubic symphysis. The ultrasonic vaginal approach makes it possible. 53 patients were ultrasonically observed during an urodynamic exploration. The simultaneous utilization of both methods has permit to observe the mechanisms of normal or pathological voiding. When initiating a voluntary micturition, an area (called "prepubic muscle") located in front of the pubic symphysis between the clitoris and the urethral meatus, exert a traction on the periurethral sphincteric area. This sphincteric area, which is well shown by ultrasound, contracts longitudinally (causing shortening of the urethra and opening of the bladder neck) and causes a drop in urethral closure pressure. The increase in the distance between the inferior part of the pubic symphysis and the anterior vaginal wall comes about because of slackening of the elevator ani muscles. This slackening occurs at different times before the bladder contracts. The urethra opens; the complete course of this organ is well defined. Things return to their previous state when voiding finishes. In the case of stress incontinence, the lack of transmission of pressure urodynamically found when the woman is coughing can be seen as a sliding mechanism within the space of Retzius and at the urethro-vesical junction behind the symphysis pubis. The degree of sliding depends on the strength of the cough. In all cases of pure stress incontinence without there being low urethral closure pressure, a maximum stress caused by coughing will produce more than 5 MM sliding before the urethra opens. If the urinary incontinence is due to low urethral closure pressure, the urethra opens without sliding of the urethro-vesical junction whenever the abdominal pressure increases. Urethral instability resembles voluntary voiding but without any voluntary command. "Prepubic" contractions, longitudinal contractions in the sphincteric area and slackening of the levator ani muscles, alone or in association, explain why urethral closure pressure drops. Sometimes this drop is followed by an increase in bladder pressure.
Abstract: The authors have studied the recent literature as well as the conclusions reached at the FIGO Congress in Berlin in 1985 to define rigorous criteria for interpreting the three principal methods that are carried out for antepartum monitoring. These are the non-stress test (NST), the oxytocin test (OCT) and the biophysical score (BPS). The point out the usefulness and the reliability of the NST as a screening technique for hypoxia in utero and also how necessary it is to use more sensitive tests like OCT ou BPS to work out the degree to which the fetus is affected. The way the cases should be handled clinically according to the results of these tests is described.
