Reduction of post-surgical adhesions with ferric hyaluronate gel: a European study.

BACKGROUND: The objective of this study was to assess the safety and efficacy of a 0.5% ferric hyaluronate gel, in reducing adhesions in patients undergoing peritoneal cavity surgery by laparotomy, with a planned 'second-look' laparoscopy. METHODS: The study was a randomized (by computer-generated schedule), third party blinded, placebo-controlled, parallel-group design conducted at five centres in Europe. Females aged 18-46 years received 300 ml ferric hyaluronate (n = 38) or lactated Ringer's (n = 39) as an intraperitoneal instillate at the completion of surgery. At second-look 6-12 weeks later, the presence of adhesions was evaluated at 24 abdominal sites. RESULTS: Patients treated with ferric hyaluronate had significantly fewer adhesions compared with controls. When adhesions formed, they were significantly less extensive and less severe in the treated group. The American Fertility Society score for adnexal adhesions was reduced by 69% in the treatment group compared with controls. The safety profile of ferric hyaluronate-treated patients was comparable with those treated with lactated Ringer's solution. CONCLUSIONS: In conclusion, ferric hyaluronate was safe and highly efficacious in reducing the number, severity and extent of adhesions throughout the abdomen following peritoneal cavity surgery.

Impact of urinary and climacteric symptoms on social and sexual life after surgical treatment of stress urinary incontinence in women: a long-term outcome.

AIM: The aim of the present study was to evaluate the long-term results of surgical treatment of stress urinary incontinence (SUI) using both subjective and objective methods. BACKGROUND: Few studies have focused on the influence of biological and social changes in a woman's life on the long-term outcome of surgical treatment of stress urinary incontinence. METHODS: The study included 45 women with genuine SUI treated with either retropubic urethrocystopexy (n=30) or puboccocygeal repair (n=15). The assessment included interviews, questionnaires, urinary diary, pad test, continence test and urodynamic investigation. RESULTS: The results were evaluated at intervals of 3 months, 1 year and 5--7 years after the treatment. One year after the surgical treatment 71% of the women in the urethrocystopexy group and 80% in the pubococcygeal repair group were subjectively cured, while 5--7 years after surgery the corresponding values were 43% vs. 60%. However, according to pad test a 67% of the women in the urethrocystopexy group and 47% in the pubococcygeal repair group had ceased to leak urine 1 year after the operation whereas at the long-term follow-up the corresponding values were 64% vs. 71%. According to the questionnaire at the long-term follow-up only 35% of the women in the whole group had genuine SUI whereas 21% had urge-incontinence. Moreover, 37% experienced sweating, 23% flushing and 44% vaginal dryness. The number of women with adiposity had increased significantly (P < 0.001) at the long-term follow-up. Twenty-eight per cent of the women decreased their activities whereas the majority experienced no impediment. Seventy-nine per cent reported that they were sexually active and the majority reported satisfaction with their sexual lives. CONCLUSIONS: Accurate assessment of postoperative results of SUI demands rigorous recording of subjective and objective data taking into consideration psychological and social factors, otherwise there is a high risk of bias in the interpretation of the results of the treatment for SUI. This study indicates that, in order to give women with SUI adequate treatment the nursing care should comprehend the women's divergent experiences of urinary incontinence and its impact on social and sexual life.

Reproductive outcome after surgical treatment of ectopic pregnancy.

OBJECTIVES: Reproductive outcome after laparoscopy or laparotomy performed for treatment of ectopic pregnancy. METHODS: Data of 104 women were collected by a questionnaire and from medical records. RESULTS: No differences in pregnancy rate were found comparing the two different operative procedures. Women with a normal contralateral fallopian tube had a better pregnancy rate compared with those with a damaged contralateral tube. CONCLUSIONS: The crucial factor for future reproductive outcome after surgical treatment of ectopic pregnancy is the status of the contralateral tube.

The long-term outcome of retropubic urethrocystopexy (sutures and fibrin sealant) and pubococcygeal repair.

BACKGROUND: To evaluate the results of retropubic urethrocystopexy (with sutures and fibrin sealant) and pubococcygeal repair five to seven years postoperatively. MATERIALS AND METHODS: Thirty women with genuine stress urinary incontinence were subjected to retropubic urethrocystopexy (n=30) and 15 women to pubococcygeal repair (n= 15). The preoperative assessment included both subjective and objective methods. The results evaluated three months, one year and five to seven years after the surgical treatment. RESULTS: One year after surgery 71% of the women in the urethrocystopexy group reported that they were continent, compared with only 43% five to seven years after surgery. In the pubococcygeal repair group 80% were continent at one-year follow-up, compared with 60% at the long-term follow-up. According to pad test 79% of the women in the urethrocystopexy group had ceased leaking urine at minimal activity and 64% at maximal activity five to seven years after surgery. However, in the pubococcygeal repair group the corresponding percentage was 71% under both conditions. Intravesical pressure and Body Mass Index increased significantly in the whole group but urethra conductance and maximal urine flow decreased only in the urethrocystopexy group five to seven years after the surgical treatment. CONCLUSIONS: Accurate assessment of the results of any surgical treatment of stress urinary incontinence is difficult. During long term follow-up period significant changes may occur among the women, e.g. menopause and increase of Body Mass Index both predisposing to urinary incontinence.

Personality differences between endometrial and cervical cancer patients in relation to sexual behavior.

Possible differences in personality were investigated in a sample of endometrial (n = 30) and cervical (n = 30) cancer patients and related to sexual behavior. The assessments were based on the Karolinska Scales of Personality (KSP) and semistructured interviews. The endometrial group reported both a higher age at sexual debut and a lower number of sexual partners whereas the corresponding figures for the cervical group were within the range of representative data from the general population. Strikingly, numerous significant correlations between personality characteristics and behavioral aspects appeared in the cervical group. In a discriminant analysis between the two cancer groups, verbal aggression, number of sexual partners, irritability, use of alcohol, age at sexual debut, impulsivity and social desirability appeared to be the most powerful variables. In view of the similarity of cervical cancer women in terms of personality and sexual behavior to normative data the elaboration of adequate and large-scale preventive measures aimed at young age groups is warranted.

Predictive factors of the outcome of primary surgical treatment of stress incontinence in women.

Forty-five women with stress incontinence (mean age 50 years) scheduled for surgical treatment randomized either to retropubic urethrocystopexy or to pubococcygeal repair were prospectively studied. Fifty healthy women were used as a reference group. No difference emerged concerning the outcome for these two surgical techniques in terms of success rate. Consequently, the subjects were treated as one group. The aim of the study was to test for predictive factors of the outcome of surgical treatment. Age of the patient, duration of stress incontinence, parity, personality, psychological and social factors were investigated. The outcome of surgical treatment was estimated both subjectively and objectively (pad test). The women were classified as cured or improved/failure. There was an 80% concordance between subjective and objective methods. In the stress incontinent women who were improved/failure one year after surgery, a high degree of neuroticism, low degree of extraversion, high degree of somatic anxiety, psychic anxiety, psychasthenia and suspicion was observed compared to the cured women. Furthermore, the improved/failure women had a lower level of social integration, in terms of loneliness compared to the cured women. Our findings point to the need of psychosocial support and care in addition to the medical treatment. According to a stepwise logistic regression analysis three variables have been found of importance as predictors of the outcome of the surgical treatment: duration of stress incontinence, neuroticism and age of patient.

The partner's view about hysterectomy.

This prospective interview study was conducted to elucidate the psychological, social and sexual consequences of hysterectomy on the women's partners. In addition to the interviews, a check-list of psychological symptoms was used. Twenty-four partners to women who were scheduled for hysterectomy because of benign uterine diseases entered the study. The men were interviewed before hysterectomy and 12-15 months later. Approximately half of the men reacted with ambivalence towards their partners' decision to undergo hysterectomy. The main concerns of the men were possible complications related to the operation and a diagnosis of cancer. Generally, the men did not receive information from the medical staff, neither before nor after the hysterectomy. The women's symptoms before operation had a negative impact on sexual life and quality of life of the partners. Hysterectomy showed a positive effect not only on the sexual life but also on the overall quality of life of the majority of the men. In conclusion, the men in this study seem to have predominantly supportive attitudes and adequate reactions concerning their partner's hysterectomy. A decrease of their psychological symptoms postsurgery and an improvement of sexual life and overall quality of life could be observed.

Social adjustment and spouse relationships among women with stress incontinence before and after surgical treatment.

Forty-five women with stress urinary incontinence (SUI) and their partners have been interviewed three months before and one year after surgical treatment to investigate the social consequences of their impairment. One year after surgery 76% of the women reported that they were cured (group A, n = 34) and 24% that they were improved (group B, n = 11). The cured women were significantly younger than the improved women. The duration of urinary leakage before the operation was significantly shorter in group A than in group B. One year post surgery group A reported a significantly decrease in impediments to exert certain tasks due to urine leakage. As concerns leisure time, group A reported a higher level of overall activities before surgery than group B, whereas postsurgery both groups obtained about the same level of activities. Regarding social support, no differences between the groups occurred as concerns attachment. Furthermore, group A women showed a significantly higher degree of adequacy of social integration compared with group B. The majority of the couples could openly discuss sexual matters with their partners and were satisfied with their sexual life. More than half of the interviewed men reported an increase in sexual desire one year after their partners operation. Whereas about every third woman in both groups reported an increase in sexual desire. However, the frequency of intercourse did not change in any groups. In conclusion, this study underlines the importance of social factors in the assessment of the consequences of stress urinary incontinence and its treatment.

The pre- and postsurgical nursing of women with stress incontinence.

The aim of the present study was to evaluate subjective and objective methods used for the investigation of stress urinary incontinence (SUI) and to compare the outcome of two different surgical techniques regarding cure rate, postoperative nursing, bladder drainage and postoperative pain relief. The study included 45 women with SUI, randomized either to retropubic urethrocystopexy (n = 30) or pubococcygeal repair (n = 15). The assessment included medical history, gynaecological examination, urine analysis and culture, residual urine, pad test, frequency-continence charts, water urethrocystoscopy, continence test, and cystometry with micturition analysis. Moreover, Beck's Depression Inventory and the Eysenck Personality Inventory were used before surgery. One year after surgery no significant difference in subjective cure rate was found between the two surgical methods (73% vs. 80%, respectively). According to pad tests, 67% of the women in the urethrocystopexy group and 47% in the pubococcygeal repair group had ceased to leak urine. The bladder volume increased significantly in both groups. Sixty-three per cent of the women in the urethrocystopexy and 33% in the pubococcygeal repair group experienced severe to very severe postoperative pain. In these groups, significantly more dysphoric women were found as compared with the group of women with less postoperative pain. Furthermore, the women with more severe pain scored higher on the neuroticism scale. These findings indicate the importance of personality factors in the treatment and nursing women with SUI.

Urinary, climacteric and sexual symptoms one year after treatment of endometrial and cervical cancer.

Data regarding urinary, climacteric and sexual symptoms among women before and one year after treatment of endometrial (n = 30) and cervical cancer (n = 26) were selected by a questionnaire, survey of medical records and semistructured interviews. The results were compared with similar data from hysterectomized women (n = 30). Urinary and climacteric symptoms were frequent in all three groups of women one year after treatment. In the cancer group the occurrence of urinary incontinence was significantly more frequent among women with vaginal dryness than among those without. Sexual symptoms were common in the endometrial and cervical group but not in the hysterectomy group one year after treatment. The results from medical records were not always in accordance with the results from questionnaire. Finally, the prospective interview study proved an appropriate method for collecting relevant data concerning the women's sexual life.

Experiences of the male partner in cervical and endometrial cancer--a prospective interview study.

This article focuses on social, psychological and sexual experiences of 47 men before their partner was treated for cervical or endometrial cancer and 1 year later. As a complement to the interviews the men completed a symptom check-list. Before initiation of treatment, a great majority of the men were in psychological crisis. The number of psychological symptoms decreased from the first to the last interview. Symptoms with psychosomatic character increased, however, considerably. In the endometrial group, several had intrapsychic problems, while interpersonal problems were more common in the cervical group. Both groups found it difficult to know how to behave and how to communicate with their partner, friends and acquaintances. A majority had nobody to whom they could speak honestly, and most did not obtain basic information about their partner's disease. The experiences of intercourse were much more negative after completed treatment and a majority described impaired sexual desire. Provided that the woman herself desires it, the coping and rehabilitation of the woman, the man and the couple would improve if the male were integrated in the care program from the moment the diagnosis of cancer is made.

Urodynamics in women with stress incontinence before and after surgery.

Pad test, cystometry and analysis of micturition were performed in 36 women with stress incontinence before and a year after operation with either retropubic urethrocystopexy (n = 22) or pubococcygeal repair (n = 14). There was no difference in the subjective cure rate between the two groups of women (77% and 79%, respectively). The pad test 1 year after operation showed that 59% of the women in the urethrocystopexy group and 43% of the women in the pubococcygeal repair group had stopped leaking urine. The bladder volume had increased in both groups and the intravesical pressure of the bladder filled to the maximum had increased in the pubococcygeal repair group. The functional length of the urethra, intravesical pressure at maximal urine flow, maximal urine flow rate and urethral conductance were not affected by either operation. Pad test was a more accurate test for an objective evaluation of urine leakage before operation than were the urodynamic investigation or continence tests.

Placental alkaline phosphatase (PLAP)/PLAP-like alkaline phosphatase as tumour marker in relation to CA 125 and TPA for ovarian epithelial tumours.

The significance of the PLAP (Placental alkaline phosphatase)/PLAP-like isozyme as tumour marker in relation to CA 125 and TPA for the monitoring of patients with malignant ovarian epithelial tumours was evaluated. Of all patients (n = 85), 40% had all three markers elevated. CA 125 being the most sensitive (60%), and the PLAP/PLAP-like isozyme and TPA both 40%. A tendency to certain tumour marker patterns of these three antigens in serum can be seen with regard to histopathology. Serous and anaplastic adenocarcinomas usually have all three markers moderately elevated, mucinous and mesonephric adenocarcinomas both have low incidences and low average levels of all three markers. Endometrioid and non-mucinous adenocarcinomas are often associated with high levels of the PLAP/PLAP-like isozyme and CA 125, while TPA shows moderate elevation. The PLAP/PLAP-like isozyme is positively correlated to tumour burden and the outcome of the disease. It may provide additional information on CA 125 in the monitoring of patients with ovarian cancer.

Risk factors for tubal infertility among infertile and fertile women.

Data regarding previous pelvic inflammation, abdominal surgery, endometriosis, obstetrical anamnesis, usage of IUD, occurrence of abdominal pain, vaginal discharge and metrorrhagia were obtained from 120 women with tubal infertility and compared to similar data from 126 pregnant women. Previous abdominal surgery, especially pelvic surgery was the most frequent risk factor present in 59% of the infertile women followed by pelvic inflammation (42%) and endometriosis (10%). In 23% of the infertile women there was no history of abdominal surgery, inflammation or endometriosis. Abdominal surgery, inflammation, ectopic pregnancy, salpingectomy and ovarian resection were significantly more frequent among the women with tubal infertility than among the pregnant women. Finally, there was no significant difference in the occurrence of appendectomy, IUD usage, induced or spontaneous abortion.

The wish to have a child. A pilot-study of infertile couples.

All women (n = 30) who were to undergo microsurgical treatment for tubal infertility, and their partners (n = 29), were subject to individual interviews just before and 2 years after the tubal surgery. Initially, they answered an open question concerning their wish to have a child and then were asked to choose from a list of 36 alternatives, a maximum of five motives for having a child. The infertile couples' motives were compared with those of three reference groups: one group of 30 who had decided to continue their pregnancy, another group of 101 women who also planned to continue pregnancy and a third group of 459 women applying for legal abortion. All motives on the list were categorized as "philosophical", "social/cultural", "interpersonal" and "intrapsychic" motives. The interpersonal and intrapsychic motives dominated both the infertile women and their partners. A central motive was that a child is an ultimate expression of love between a man and a woman. The motives of the infertile couples, generally, did not differ from those of the reference groups.

Effect of intraperitoneal instillation of 32% dextran 70 on postoperative adhesion formation after tubal surgery.

The intraperitoneal instillation of 32% dextran 70 (HyskonR, Pharmacia AB, Sweden) has previously been reported to prevent the formation of postoperative adhesions. Against this background, the present study was undertaken to evaluate the efficacy of HyskonR in counteracting peritoneal adhesions following tubal microsurgery. 105 infertile women were operated upon in a prospective, randomized, controlled, double-blind, multicenter study. The intra-abdominal adhesions present from the beginning were classified by means of a standardized scoring scale and the extent of adhesions was again evaluated at follow-up laparoscopy 4-10 weeks later. A reduction in the extent of the intra-abdominal adhesions (statistically highly significant) was revealed in both the Hyskon group and the saline control group. The extent of adhesions in the Hyskon group was not lesser than in the saline group, however. The pregnancy rates in the two groups were also similar.

Psychological reactions to the medical investigation and surgical treatment of infertility.

The psychological effects of the medical investigation and surgical treatment of infertility were investigated. For 2 years 30 women with a diagnosis of tubal damage and 29 men were followed with repeated interviews. Negative effects on sexual life were recorded in all individuals and were associated with the planning of intercourse. Semen analysis was psychologically difficult to half of the men and feelings of shame and degradation were common. Fear and anxiety were increased before reconstructive tubal surgery and postoperative depression was observed in 10 women. Most couples overestimated their chances of having a child and half of them expected pregnancy to occur within a few months. After 2 years the need for professional support and counseling had increased. The medical procedure has psychological side effects in the infertile couple and may provoke anxiety. The investigation should be comprehensive and short, and psychologically traumatic investigations like basal body temperature records should be used with caution. During the period of somatic investigation and treatment repeated discussions about the marital relationship and sexual life should be initiated and psychosocial counseling should be offered to all couples.

[Female sterilization--safe and irreversible?]. / Kvinnlig sterilisering--säker och irreversibel?

PIP: With 6 case studies as illustrations, sterilization methods for women, their safety and reliability, reversibility and irreversibility are discussed. In Sweden the average pregnancy rate following sterilization is .3-.7%, in other countries 1-2%; about 3% of Swedish women subsequently regret the operation. The most frequently used methods are electrocoagulation and application of the Yoon band for tubal ligation. The use of electrocoagulation alone is not sufficient. Some of the complications after these methods include bleeding, singeing of intestines, lower abdominal pain due to torsion of distal tubal ends, and faulty placement of tubal rings. The reliability of sterilization in never 100%, as illustrated by 3 cases: a 41-year-old woman was sterilized by laparoscopy and became pregnant 7 years later, abortion and bilateral tubal resection was performed; another woman became pregnant 1.5 years after Yoon band sterilization and carried the pregnancy to term; the 3rd woman became pregnant 4 weeks after minilaparotomy (Pomeroy method) and delivered the child. Refertilization was studied in a survey of 100 Canadian women who sought reversal of sterility. They were aged 22-43, with an average of 2 children; most claimed that inadequate information had been provided about the procedure; and most desired reversal because of a new relationship. Although sterilization is regarded as a definitive method of preventing pregnancy, modern microsurgery can restore fertility up to 80% (vs. 50% by conventional tubal surgery). Often sterilization is performed after abortion in young women (368 cases out of 6415 sterilizations in Sweden in 1983) who later regret their decision. It is recommended thet the legal implications of restricting sterilization for women under 30 be explored because of the high medical and emotional risks involved.^ieng

Uterine tonicity in proliferative and secretory phases of the menstrual cycle.

Hysterometry, a method for the quantitative evaluation of drug effect on the myometrium, has now been applied in a study of the changes in uterine tonicity during the menstrual cycle. Six nulli-gravidae women with regular menstrual periods and normal gynecological examination findings, were studied. Hysterometry was performed in the midproliferative, ovulatory, and midsecretory periods of the cycle and on the first day of menstruation. Uterine tonicity was found to be higher during the proliferative compared with the secretory phase. The change in uterine tonicity was correlated with a change in the quotient of concentration of estradiol and progesterone in serum (E2/P).

Effect of an oral contraceptive on uterine tonicity in women with primary dysmenorrhea.

Hysterometry, a method for quantitative evaluation of the effect of pharmacologically active agents on the myometrium, has been applied to determine the effect of an oral contraceptive on uterine tonicity. Hysterometry was performed on the first day of each of two consecutive menstrual periods in 5 dysmenorrheic women. During the second cycle the women were given ethinylestradiol 50 microgram and lynestrenol 1 mg per day for 22 days. After the intake of this oral contraceptive, uterine tonicity decreased in all women, the decrease being accompanied by relief of dysmenorrheic pain.

PIP: The study objective was to determine uterine tonicity quantitatively by hysterometry--a method for quantitative evaluation of the effect of pharmacologically active agents on the myometrium--during menstruation in dysmenorrheic women, with special regard to the effect of an oral contraceptive (OC). 5 volunteers with severe primary dysmenorrhea were studied. The age range of these nulligravida was 17-25 years. All had normal menstrual periods and normal findings on gynecological examination. Hysterometry was performed on the 1st day of each of 2 consecutive menstrual periods, the 1st occurring after a non-medicated cycle and the 2nd after the use of an OC, ethinylestradiol 50 mc + lynestrenol 1 mg. Medication was started on the 5th day of the menstruation period and lasted 22 days. The women were instructed to register any side effects of the medication as well as the effect on the menstrual pain. All the women had severe menstrual pain before the treatment with OC. After the treatment daily for 22 days, 2 women had no pain at all and 3 only mild pain during the 1st day of the menstruation. Hysterometry on the 1st day of dysmenorrheic menstruation resulted in tonicity values (intercepts) between 110 and 217, mean 158. Hysterometry on the 1st day of bleeding after treatment with the OC resulted in tonicity values between 91 and 167, mean 117. There was almost a significant differences between the untreated and treated situations. The women who had the most marked decrease in uterine tonicity had no menstrual pain after the treatment; women who had the least decrease had mild menstrual pain during the 1st day of menstruation.