Cervical cytology in women with mental retardation.

OBJECTIVE: To examine our experience with performing pelvic examination and obtaining cervical cytology in women with mental retardation. METHODS: From November 1985 to October 1992, 658 women were seen in our clinic for women with mental disabilities. A standardized clinic visit form was completed for each woman. Of these records, 574 were available for analysis. All charts were reviewed for data on the level of retardation, incidence of sedation, success in performing pelvic examination and Papanicolaou smear, technique used for cervical smear, and pathology results of the cervical cytology. RESULTS: Of the 574 women, 289 (50%) had severe, 69 (12%) moderate, and 31 (5%) mild retardation. In 185 (32%), the exact level of retardation was not established. During the study period, 1235 pelvic examinations were analyzed. Within this group, 845 examinations could be completed initially, 177 required the use of sedation (14%), and 213 (17%) examinations could not be completed. Of the 845 examinations, 706 cervical smears were available for analysis. Of these, only 243 (34%) contained endocervical cells. Two abnormal cytology results were found (0.3%). Of the 177 examinations done with sedation, 44 women (25%) still could not be examined. Cytology specimen results were obtained in 124 of the examinations, and 40 (32%) of these specimens contained endocervical cells. No cytologic abnormalities were present. In a cervical smear technique comparison, endocervical cells were present in 58% of 161 standard speculum examinations and in 18% of 93 cotton-swab tests (P < .001). CONCLUSION: Cytology specimens can be obtained without sedation in most mentally retarded women. Only one-third of Papanicolaou smears contained endocervical cells from examinations with sedation as well as those without. The cotton-swab technique has a significantly lower endocervical cell collection rate than the standard speculum technique. The incidence of abnormalities on cytologic examination appears to be low compared with other populations of women. Whether this is due to suboptimal smears, lower prevalence of human papillomavirus, or a combination of both remains to be resolved.

Surgical landmarks of the ureter in the cadaveric female pelvis.

Our purpose was to delineate the course of the ureter in the female pelvis in relationship to several important surgical landmarks. Ten female cadavers with undissected pelves were used. The ureter was identified at the pelvic brim and traced inferiorly to the bladder. Sets of measurements (+/- 0.1 cm) that help define the location of the ureter were obtained at the three landmarks; the ischial spine, the obturator canal and the insertion of the arcus tendineus on the pubic bone. The mean distances from the ureter to the pelvic floor were ischial spine, 3.2 +/- 0.1 cm; obturator canal, 3.2 +/- 0.1 cm; and the insertion of the arcus tendineus on the pubic bone, 1.6 +/- 0.1 cm. The mean distances from the arcus tendineus to the pelvic floor were ischial spine, 1.9 +/- 0.1 cm; obturator canal, 2.8 +/- 0.1 cm; and the insertion of the arcus tendineus on the pubic bone, 3.2 +/- 0.1 cm. This study defines the relationship of the ureter to the pelvic floor through measurements taken at three landmarks. The data should be useful to pelvic surgeons and are important for the development of future surgical techniques.

Intraligamentous nerves as a potential source of pain after sacrospinous ligament fixation of the vaginal apex.

The aim of the study was to investigate the histology of the sacrospinous ligament to determine whether nerve fibers exist within the substance of the sacropinous ligament itself. Six sacrospinous ligaments were removed from 4 fixed female cadavers. Representative segments were taken from the lateral (ischial), middle and medial (sacral) portions of these specimens, sectioned by microtome, mounted, and stained with hematoxylin and eosin dyes. The fixed and stained sections were then examined using light microscopy. Nerve tissue was found to be concentrated in the medial portions of the sacrospinous ligaments, but nerves were found in all segments of the ligament. It was concluded that, nervous tissue is present and widely distributed within the body of the sacrospinous ligament. A wide variety of sizes and thicknesses are also demonstrated, suggesting a variety of functions, including possible pain reception. This fact should be taken into consideration when planning operative procedures for pelvic prolapse.

Use of sodium hetastarch (Hespan) solution for reduction of postoperative adhesion formation in rabbits.

A study was conducted to determine the effect of sodium hydroxy ethyl starch (Hespan) on primary adhesion formation in a rabbit model. Hespan is a readily available volume expander. This was a randomized, double-blinded animal model in which New Zealand white rabbits were subjected to midline celiotomy. Adhesions were created by abrasion in both uterine horns, adjacent bowel, and peritoneum. Necropsies were performed at the 2-week interval and adhesions were graded. Significant decreases in type II and type III adhesions (p = .032 and p = .020, respectively) were demonstrated in Hespan-treated animals. Sodium hetastarch appears to decrease significant adhesion formation in treated animals and may have a role as an adjunct for postsurgical prevention.

The epidemiology of genitourinary fistulae in Kumasi, Ghana, 1977-1992.

The aim of the study was to determine the clinical epidemiology of genitourinary fistulae as seen at Komfo Anokye Teaching Hospital in Kumasi, Ghana. A retrospective study was carried out from the hospital records and operative reports of all patients with genitourinary fistulae seen at Komfo Anokye Teaching Hospital between January 1977 and December 1992. Patient age, parity, type of fistula and cause of fistula were abstracted from the medical records. There were 164 cases of genitourinary fistula managed during the study period. There were 150 fistulae due to obstetric causes (91, 5%), the vast majority of which were due to prolonged obstructed labor (121 cases, 73.8% of all fistulae), with a minority related to complications of lower-segment cesarean section (14 cases, 8.5% of all fistulae). In 5 cases (3.1%) patients developed a rectovaginal fistula owing to perineal tears and prolonged obstructed labor. During this time period there were 157,449 deliveries, giving an obstetric fistula rate of 1 fistula per 1000 deliveries. Obstetric fistulae were most common at the extremes of reproductive age and parity Fourteen additional fistulae (8.5% of all cases) were due to gynecologic causes, most commonly from surgical injury occurring at the time of abdominal hysterectomy for leiomyomata uteri (12 cases, 7.3% of all fistulae). It was concluded that in Kumasi, Ghana, obstetric trauma from prolonged obstructed labor is the most common cause of genitourinary fistula formation. Such fistulae occur in older multiparous women as well in young primigravidae. Obstructed labour can, and does, occur in women who have previously undergone uneventful vaginal delivery. Birth attendants should be aware of that fact. Prompt referral for obstetric intervention should be made in obstructed labor, irrespective of the age and parity of the patient.

Hard choices: the gynecologic cancer patient's end-of-life preferences.

Few reports in gynecologic literature have addressed patient preferences about terminal care. In light of the current discussions about end-of-life decision-making, a study was designed to assess the desires of patients with gynecologic cancer. A questionnaire was completed by 108 patients under treatment for gynecologic cancer at the University of Michigan Medical Center and by 39 patients from the routine gynecology clinic at the same institution. Participants were asked about their reactions to a poor prognosis, their desires for the location of terminal care, and their preferences for withdrawing or withholding life-sustaining technologies. Five percent of these cancer patients anticipated giving up the fight against their disease. Seventy-eight percent specifically expressed resolve to continue the fight against their disease. Feedback from these patients about their end-of-life preferences served to define the concept "fight." A majority preferred to receive care at home. Ninety percent of these cancer patients could envision their conditions deteriorating to the point that they would not want ventilator support. Thirty-four percent could envision refusing surgery for another life-threatening condition; 37%, a time when artificial nutrition would be refused; 22%, a time when antibiotics would be rejected. This study suggests that limiting the use of artificial respiratory support while continuing the use of artificial nutrition and hydration support would be consistent with the preferences of gynecologic cancer with end-stage disease.

Full-thickness Martius grafts to preserve vaginal depth as an adjunct in the repair of large obstetric fistulas.

We performed a modified bulbocavernosus full-thickness pedicle graft procedure on four patients with large obstetric fistulas in Ghana, West Africa. The bulbocavernosus fat pad was harvested in the usual manner, and the full-thickness skin patch was taken from the medial thigh. All grafts showed 100% take by the tenth postoperative day. Adequate vaginal depth and caliber were obtained in all patients. Sexual function resumed in all patients except one, who suffered a recurrent vesicovaginal fistula. This method of vaginoplasty may be useful in patients who have massive vaginal-wall destruction of either gynecologic or obstetric origin.

Surgery for ovarian remnant syndrome. Lessons learned from difficult cases.

Ten cases of ovarian remnant syndrome jointly managed by gynecology and urology departments are presented. Complications of the surgery included a high incidence of ureteral and bowel injury. Preoperative, intraoperative and postoperative considerations may reduce the complications or minimize their significance. One case of ovarian cancer developed among the instances of ovarian remnant syndrome in this series. Preoperative, intraoperative and postoperative considerations can reduce the complications of surgery for ovarian remnant syndrome.

Surgery for the obstetric vesicovaginal fistula: a review of 100 operations in 82 patients.

OBJECTIVE: Vesicovaginal fistula resulting from prolonged obstructed labor remains a major problem in developing countries where medical care is limited. For many years surgical closure of the fistula was almost impossible. However, closure rates today range between 65% and 95%. Attention now is being focused on training more surgeons to repair simple fistulas, identifying and preventing complications that occur even with successful vesicovaginal fistula closure, developing new techniques to close the most difficult fistulas to repair, and working to improve obstetric care to prevent future vesicovaginal fistulas. This study reviews contemporary efforts to manage vesicovaginal fistulas with these goals in mind. STUDY DESIGN: One hundred consecutive vesicovaginal fistula repair operations that I performed in 82 patients are reviewed. Specific repair techniques are described for each vesicovaginal fistula type by anatomic vesicovaginal fistula classification. Primary closure rates and complications are examined by vesicovaginal fistula type, location, size, and number of prior repair attempts. RESULTS: After 100 operations, 78 of the 82 patients (95%) had successful vesicovaginal fistula closure. Primary closure rates were noted to be 31 of 33 (94%) for suburethral fistulas, 10 of 14 (71%) for midvaginal fistulas, 9 of 10 (90%) for juxta-cervical fistulas, 10 of 12 (83%) for urethral fistulas, 6 of 6 (100%) for uterovesical fistulas, but only 4 of 7 (57%) for combined vesicovaginal and rectovaginal fistulas. Repairs were only 50% successful on second attempts and only 33% successful on third attempts. Even in those patients who had successful closure of the fistula, serious complications occurred in 59% of patients, including other types of urinary incontinence, gynatresia, amenorrhea, and leg weakness. CONCLUSION: Basic principles of fistula surgery remain important in all types of vesicovaginal fistula repairs. Further research is needed into prevention and management of associated complications, into innovative repair of those few patients who do not have successful closure, and into training more surgeons to address the vesicovaginal fistula problem.

Chronic pelvic pain. Differentiating anatomic from functional causes.

Patients with chronic pelvic pain are challenging, from both diagnostic and therapeutic viewpoints. At the pain clinic at the Medical College of Georgia School of Medicine, Augusta, we have discovered over the past 3 years that psychiatric disease is probably underrecognized in these patients and that physicians are often reluctant to discuss intimate details of a patient's sex life even though they may provide important information. In addition, sleep disorders are very prevalent. Use of vaginal-probe ultrasound may decrease the need for diagnostic laparoscopy, especially in patients without pelvic disease. In most cases, ovarian cysts in ovulating patients do not represent an abnormality. Laparoscopy and major pelvic surgery should be limited to patients with a high probability of anatomic abnormalities or persistent symptoms.

Compelled cesarean section. An ethical perspective.

Recent position statements by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists and the emergence of legal and ethical analyses on the nature of compelled cesarean section have instigated much discussion on how the primary care physician should respond when a pregnant woman refuses to consent to surgery. This article clarifies the ethical obligations of the physician and mother and the nature of their relationships to the fetus. The formulation of an agreement, the physician-mother-fetal contract, is discussed as a teaching tool for helping to clarify the roles of all parties. Also, the function of the primary care physician as proactive educator is highlighted.

The cost of choice: a price too high in the triple screen for Down syndrome.

PIP: At US national medical society meetings in 1992, researchers from a major university presented their data on a triple screen of maternal serum tests for the detection of trisomy 21 or fetal Down syndrome. Low maternal serum levels of estriol and alpha-fetoprotein, along with a high level of human chorionic gonadotropin can predict pregnancies at risk. The authors claimed that a person with Down syndrome costs approximately $196,000 including health, education, and residential costs. Simple economic costs about persons with Down syndrome in the cost analysis seem unbalanced. Some recent studies show no increase in divorce rates for families including persons with Down syndrome. In a 1971 review of 104 brothers and sisters of persons with Down syndrome, no specific behavioral disturbances were noted. Among complex costs triple screening threatens the integrity of the medical profession. Genetics counselors promoting nondirective informed consent, but the cost analysis description of Down syndrome are in the mild-to-moderate mental retardation range consistent with a 3rd-9th grade reading level. Less than 1% have leukemia, and less than 3% have in operable cardiac disease. Another cost that is difficult to measure includes the value placed on the maternal, paternal, and familial anxiety caused by genetic screening tests. Triple screening for Down syndrome is about societal concerns and social character. Many methods of health care rationing await the American medical system. A large number of factors must be considered before any system of limiting costs and choices is selected in a pluralistic society. Accepting the fact that limitations to choice must occur is the first step toward future rationality in genetic counseling.^ieng

Etiology of closure-related adhesion formation after wedge resection of the rabbit ovary.

Adhesion formation after closure after ovarian wedge resection of the rabbit ovary may be related to the use of polyglactin suture rather than to the closure itself.

Vulvar vestibulitis and interstitial cystitis: a disorder of urogenital sinus-derived epithelium?

BACKGROUND: Vulvar vestibulitis and interstitial cystitis are enigmatic and controversial conditions. They are increasingly recognized as important causes of genitourinary pain in young women. This report proposes an etiologic association between the two conditions. CASES: We report three patients with both vulvar vestibulitis and interstitial cystitis. Although an association between these conditions has previously been proposed, these are the first case reports of the coexistence of these conditions in the same patient. CONCLUSION: Because both the vestibule of the vulva and the bladder are derived from the urogenital sinus, we propose that the coexistence of vulvar vestibulitis and interstitial cystitis in some patients represents a generalized disorder of urogenital sinus-derived epithelium.

Conservative management of bilateral massive edema of the ovary. A case report.

A case of bilateral massive ovarian edema with unilateral ovarian torsion is reported. Following surgical removal of the adnexa with the torsion, the edema of the opposite ovary resolved with oral contraceptive therapy. This has not been previously reported. This case is instructive because the nodular appearance and yellow color of the ovaries and the presence of yellow ascitic fluid could lead to an erroneous diagnosis of malignancy, resulting in performance of a more radical surgical procedure than is necessary. A review of the literature and the unusual nature of this lesion indicates the need for caution in diagnosis and management.

Transvaginal mobilization and utilization of the anterior bladder wall to repair vesicovaginal fistulas involving the urethra.

Repair of vesicovaginal fistulas resulting from obstetric trauma remains a major challenge to surgeons worldwide. Large defects that result in partial or total urethral loss are especially difficult to repair. Even when closure of such fistulas is accomplished, return of normal urogenital function is often impaired, underscoring the need to improve existing surgical procedures. Transvaginal urethral and bladder neck reconstruction using mobilized anterior bladder wall was helpful in closing 18 of 20 vesicovaginal fistulas with urethral involvement caused by obstetric trauma. This method involves advancement of an anterior bladder wall flap into the vagina, where it is rolled into a neo-urethra or connected to whatever remnant of urethral tissue exists. Complications included stress incontinence requiring further surgery (four), small bladder capacity with detrusor instability (two), urethral stenosis requiring dilatation (two), postoperative hemorrhage (one), and vaginal stenosis (one). Continued modification of this procedure holds promise for many patients considered inoperable in the past.

Oxygen free radicals and pelvic adhesion formation: II. The interaction of oxygen free radicals and adhesion-preventing solutions.

A three-part animal and in vitro study gives evidence that oxygen free radicals are produced by intraperitoneal macrophages in response to pelvic surgery. These macrophages appear to ingest high-molecular-weight substances used to prevent adhesions (such as 32% dextran 70 and carboxymethylcellulose). However, the production of oxygen free radicals is not enhanced by the presence of 32% dextran 70 or carboxymethyl cellulose.