Descending perineal syndrome cure by deep transversus perinei ligament repair: surgical options.

Descending perineal syndrome (DPS) was described by Parks et al. as descent of the anus on straining, typically 3-4 cm below a line drawn from the coccyx to the lower end of the. DPS is associated with obstructed defecation, with increased bulging of the perineum with straining, although perineal descent can also be seen at rest. In their review, Chaudhry and Tarnay stated: "It is controversial whether surgical management is even an option for patients with DPS". The deep transversus perinei (DTP) ligaments are the suspensory ligaments of the perineal body (PB). DTP are approximately 4 cm long. They attach behind the upper 2/3 and lower 1/3 of the descending ramus. If, at childbirth, the PB is overstretched and displaced laterally and inferiorly, the DTP lengthens. DPS is described as descent of the anus on straining, typically 3-4 cm below a line drawn from the coccyx to the lower end of the symphysis. DPS is associated with obstructed and often, assisted defecation, with increased bulging of the perineum with straining descent of the anus on straining. The surgical methodology begins as a standard PB repair which dissects the rectum from the vagina and PB and approximates the displaced components of the PB. We added an additional step: identifying the DTPs, shortening and reinforcing them with the Tissue Fixation System (TFS) minisling or No. 2 polyester sutures. High cure rates for obstructed defecation were achieved with the TFS minisling, and initial results using No. 2 polyester sutures are favourable. The key messages from both operations is DPS is caused by stretching and elongation of DPS ligaments, and these are surgically repairable.

Structural, functional, and dysfunctional pelvic anatomy.

The structural basis of the Integral Theory is holistic. Four main pelvic muscles interact holistically with five main pelvic ligaments to maintain pelvic organ structure and function. The vagina is structurally weak. The support it provides to the bladder base is contingent on being stretched by opposite pelvic muscle forces, much like a trampoline. Its main role is to transmit muscle forces to facilitate continence, evacuation and control of urgency. Therefore, as an organ that cannot regenerate, the vagina should be conserved, and not excised. The ligaments provide the main structural support for the organs and are the most vulnerable part of the anatomical system to injury because their structural collagen is depolymerized prior to labour, and stretched during labour. Further ligament weakening occurs after menopause due to collagen breakdown. Hence, collagen loss is the main cause of organ prolapse and lower urinary tract symptoms (LUTS). The strengthening of damaged ligaments, whether surgically or non-surgically, can improve or cure symptoms and prolapse. Because collagen loss in ligaments is a principal cause of dysfunction in older women, collagen-creating techniques are advised: precisely inserted tapes to create neoligaments, or wide-bore No. 2 or No. 3 polyester ligament sutures instead of dissolvable sutures.

Descriptive analysis of childbirth healthcare costs in an area with high levels of immigration in Spain.

BACKGROUND: The aim of this study was to estimate the cost of childbirth in a teaching hospital in Barcelona, Spain, including the costs of prenatal care, delivery and postnatal care (3 months). Costs were assessed by taking into account maternal origin and delivery type. METHODS: We performed a cross-sectional study of all deliveries in a teaching hospital to mothers living in its catchment area between October 2006 and September 2007. A process cost analysis based on a full cost accounting system was performed. The main information sources were the primary care program for sexual and reproductive health, and hospital care and costs records. Partial and total costs were compared according to maternal origin and delivery type. A regression model was fit to explain the total cost of the childbirth process as a function of maternal age and origin, prenatal care, delivery type, maternal and neonatal severity, and multiple delivery. RESULTS: The average cost of childbirth was 4,328€, with an average of 18.28 contacts between the mother or the newborn and the healthcare facilities. The delivery itself accounted for more than 75% of the overall cost: maternal admission accounted for 57% and neonatal admission for 20%. Prenatal care represented 18% of the overall cost and 75% of overall acts. The average overall cost was 5,815€ for cesarean sections, 4,064€ for vaginal instrumented deliveries and 3,682€ for vaginal non-instrumented deliveries (p < 0.001). The regression model explained 45.5% of the cost variability. The incremental cost of a delivery through cesarean section was 955€ (an increase of 31.9%) compared with an increase of 193€ (6.4%) for an instrumented vaginal delivery. The incremental cost of admitting the newborn to hospital ranged from 420€ (14.0%) to 1,951€ (65.2%) depending on the newborn's severity. Age, origin and prenatal care were not statistically significant or economically relevant. CONCLUSIONS: Neither immigration nor prenatal care were associated with a substantial difference in costs. The most important predictors of cost were delivery type and neonatal severity. Given the impact of cesarean sections on the overall cost of childbirth, attempts should be made to take into account its higher cost in the decision of performing a cesarean section.