Teaching clinical anatomy of the female pelvic floor to undergraduate students: A critical review of nevralgic points

Pelvic floor anatomy is complex and its three-dimensional organization is often difficult to understand for both undergrad- uate and postgraduate students. Here, we focused on several critical points that need to be considered when teaching the perineum. We have to deal with a mixed population of students and with a variety of interest. Yet, a perfect knowledge of the pelvic floor is the basis for any gynecologist and for any surgical intervention. Our objectives are several-fold; i) to estab- lish the objectives and the best way of teaching, ii) to identify and localize areas in the female pelvic floor that are suscepti- ble to generate problems in understanding the three-dimensional organization, iii) to create novel approaches by respecting the anatomical surroundings, and iv) prospectively, to identify elements that may create problems during surgery i.e. to have a closer look at nerve trajectories and on compression sites that may cause neuralgia or postoperative pain. A feedback from students concludes that they have difficulties to assimilate this much information, especially the different imaging tech- niques. Eventually, this will lead to a severe selection of what has to be taught and included in lectures or practicals. Another consequence is that more time to study prosected pelves needs to be given.

Pelvic floor dysfunction 6 years post-anal sphincter tear at the time of vaginal delivery.

INTRODUCTION AND HYPOTHESIS: This study aims to estimate fecal, urinary incontinence, and sexual function 6 years after an obstetrical anal sphincter tear. METHODS: Among 13,213 women who had a vaginal delivery of a cephalic singleton at term, 196 women sustained an anal sphincter tear. They were matched to 588 controls. Validated questionnaires grading fecal and urinary incontinence, and sexual dysfunction were completed by the participants. RESULTS: Severe fecal incontinence was more frequently reported by women who had sustained an anal sphincter tear compared to the controls. Women with an anal sphincter tear had no increased risk of urinary incontinence, but reported significantly more pain, difficulty with vaginal lubrication, and difficulty achieving orgasm compared to the controls. A fetal occiput posterior position during childbirth was an independent risk factor for both severe urinary incontinence and severe sexual dysfunction. CONCLUSIONS: Fecal incontinence is strongly associated with an anal sphincter tear. A fetal occiput posterior position represents a risk factor for urinary incontinence and sexual dysfunction.

Patient satisfaction after biofeedback for constipation and pelvic floor dyssynergia.

Patients referred for chronic constipation frequently report symptoms of straining, feeling of incomplete evacuation, or the need to facilitate defecation digitally (dyschezia). When such patients show manometric evidence of inappropriate contraction or failure to relax the pelvic floor muscles during attempts to defecate, they are diagnosed as having pelvic floor dyssynergia (Rome I). To evaluate long-term satisfaction of patients with pelvic floor dyssynergia after biofeedback. Forty-one consecutive patients referred for chronic constipation at an outpatient gastrointestinal unit and diagnosed as having pelvic floor dyssynergia who completed a full course of biofeedback. Data have been collected using a standardised questionnaire. A questionnaire survey of patients' satisfaction rate and requirement of aperients was undertaken. Mean age and symptom duration were respectively 41 and 20 years. Half of patients reported fewer than 3 bowel motions per week. Patients were treated with a mean of 5 biofeedback sessions. At the end of the therapy pelvic floor dyssynergia was alleviated in 85% of patients and 49% were able to stop all aperients. Satisfaction was maintained at follow-up telephone interviews undertaken after a mean period of 2 years, as biofeedback was helpful for 79% of patients and 47% still abstained from intake of aperients. Satisfaction after biofeedback is high for patients referred for chronic constipation and diagnosed with pelvic floor dyssynergia. Biofeedback improves symptoms related to dyschezia and reduces use of aperients.

Fonctions du plancher pelvien: de la phase expulsive à la consultation du post-partum [Pelvic floor functions: from the beginning of the second phase of labor to the postpartum consultation].

Vaginal delivery can cause lesions of the various pelvic structures responsible for the mechanisms of continence. These lesions may perhaps be prevented in the future by measuring pressure generated during childbirth. Tear of the anal sphincter during childbirth is a marker of a global impairment of the urinary, ano-rectal and sexual pelvic functions in the short and medium term. Persistence of a defect of the anal sphincter is frequent in spite of immediate suture. The correlation between these defects and ano-rectal incontinence are not established in our experience. The quality of the contraction of the sphincter complex and pubo-rectal sling seems to play a more important role in ano-rectal continence after a traumatic childbirth.

Most residues on the floor of the antigen binding site of the class I MHC molecule H-2Kd influence peptide presentation.

A panel of 15 single alanine substitutions on the floor of the peptide binding groove of the murine class I histocompatibility molecule H-2Kd has been analyzed. All but two mutant molecules were expressed on the cell surface, and were tested for peptide binding and presentation to specific cytotoxic T lymphocytes. Eleven out of 13 mutant molecules appeared to be functionally altered. Five of the substituted residues were involved in the presentation of all peptides tested. Three participated in the presentation of certain peptides but not others. Three other residues participated in epitope formation through indirect interactions. Only two mutations had no detectable effect.

Effects of epidural analgesia on pelvic floor function after spontaneous delivery : a longitudinal retrospective study

Abstract: The aim of the study was to assess the effects of epidural analgesia on pelvic floor function. Eighty- two primiparous women (group 1, consisting of 41 given an epidural, and group 2 of 41 not given an epidural) were investigated during pregnancy and at 2 and 10 months after delivery by a questionnaire, clinical examination, and assessment of bladder neck behavior, urethral sphincter function and intravaginal/intra-anal pressures. The prevalence of stress urinary incontinence was similar in both groups at 2 months (24% vs. 17%, P = 0.6) and 10 months (22% vs. 7%, P = 0.1), as was the prevalence of decreased sexual vaginal response at 10 months (27% vs. 10%, P= 0.08). Bladder neck behavior, urethral sphincter function and intravaginal and intra-anal pressures showed no significant differences between the two groups. Ten months after spontaneous delivery, there were no significant differences in the prevalence of stress urinary incontinence and decreased sexual vaginal response, or in bladder neck behavior, urethral sphincter function and pelvic floor muscle strength between women who had or had not had epidural analgesia.

Mesozoic sequence of Fuerteventura (Canary Islands): Witness of Early Jurassic sea-floor spreading in the central Atlantic

The Fuerteventura Jurassic sedimentary succession consists of oceanic and elastic deposits, the latter derived from the southwestern Moroccan continental margin. Normal mid-oceanic-ridge basalt (N-MORB) flows and breccias are found at the base of the sequence and witness sea-floor spreading events in the central Atlantic. These basalts were extruded in a postrift environment (post-late Pliensbachian), We propose a Toarcian age for the Atlantic oceanic floor in this region, on the basis of the presence higher up in the sequence of the Bositra buchi filament microfacies (Aalenian-Bajocian) and of elastic deposits reflecting tectono-eustatic events (e.g,, late Toarcian to mid-Callovian erosion of the rift shoulder). The S-l sea-floor oceanic magnetic anomaly west of Fuerteventura is therefore at least Toarcian in age. The remaining sequence records Atlantic-Tethyan basinal facies (e.g., Callovian-Oxfordian red clays, Aptian-Albian black shales) alternating with elastic deposits (e.g., Kimmeridgian-Berriasian periplatform calciturbidites and a Lower Cretaceous deep-sea fan system). The Fuerteventura N-MORB outcrops represent the only Early Jurassic oceanic basement described so far in the central Atlantic. They are covered by a 1600 m, nearly continuous sedimentary sequence which extends to Upper Cretaceous facies.

Acute pulmonary toxicity following occupational exposure to a floor stain protector in the building industry in Switzerland.

BACKGROUND: Waterproofing agents are widely applied to leather and textile garments; they are also used as floor stain protectors by professionals. Acute respiratory injury is described in three cases of young healthy adults following occupational inhalation of a new waterproofing formulation containing an acrylate fluoropolymer. Within 1 or 2 h after exposure they developed a rapidly progressive dyspnoea; two of them had hypoxaemia and flu-like reactions. All patients improved with supportive treatment in a few days. The mechanism of toxicity is still under investigation, but experimental data suggest the role of this new acrylate fluoropolymer. CONCLUSION: Tilers should be warned against spraying floor stain repellents; there is also a need to make consumers aware that the spraying of waterproofing agents in a closed environment and concomitant smoking should be avoided.

Depleted arc volcanism in the Alboran Sea and shoshonitic volcanism in Morocco: geochemical and isotopic constraints on Neogene tectonic processes

Samples of volcanic rocks from Alboran Island, the Alboran Sea floor and from the Gourougou volcanic centre in northern Morocco have been analyzed for major and trace elements and Sr-Nd isotopes to test current theories on the tectonic geodynamic evolution of the Alboran Sea. The Alboran Island samples are low-K tholeiitic basaltic andesites whose depleted contents of HFS elements (similar to0.5xN-MORB), especially Nb (similar to0.2xN-MORB), show marked geochemical parallels with volcanics from immature intra-oceanic arcs and back-arc basins. Several of the submarine samples have similar compositions, one showing low-Ca boninite affinity. Nd-143/Nd-144 ratios fall in the same range as many island-arc and back-arc basin samples, whereas Sr-87/Sr-86 ratios (on leached samples) are somewhat more radiogenic. Our data point to active subduction taking place beneath the Alboran region in Miocene times, and imply the presence of an associated back-arc spreading centre. Our sea floor suite includes a few more evolved dacite and rhyolite samples with (Sr-87/Sr-86)(0) up to 0.717 that probably represent varying degrees of crustal melting. The shoshonite and high-K basaltic andesite lavas from Gourougou have comparable normalized incompatible-element enrichment diagrams and Ce/Y ratios to shoshonitic volcanics from oceanic island arcs, though they have less pronounced Nb deficits. They are much less LIL- and LREE-enriched than continental arc analogues and post-collisional shoshonites from Tibet. The magmas probably originated by melting in subcontinental lithospheric mantle that had experienced negligible subduction input. Sr-Nd isotope compositions point to significant crustal contamination which appears to account for the small Nb anomalies. The unmistakable supra-subduction zone (SSZ) signature shown by our Alboran basalts and basaltic andesite samples refutes geodynamic models that attribute all Neogene volcanism in the Alboran domain to decompression melting of upwelling asthenosphere arising from convective thinning of over-thickened lithosphere. Our data support recent models in which subsidence is caused by westward rollback of an eastward-dipping subduction zone beneath the westemmost Mediterranean. Moreover, severance of the lithosphere at the edges of the rolling-back slab provides opportunities for locally melting lithospheric mantle, providing a possible explanation for the shoshonitic volcanism seen in northern Morocco and more sporadically in SE Spain. (C) 2004 Elsevier B.V. All rights reserved.

High-field (3T) magnetic resonance defecography with functional assessment of the evacuation phase : a pictorial essay : P10

Purpose: Dynamic high-field magnetic resonance (MR) defecography including the evacuation phase is a promising tool for the assessment of functional pelvic disorders, nowadays seen with increasing frequency in elderly women in particular. Learning objectives: 1. To describe the adequate technique of dynamic high-field MRI (3T) in assessing pelvic floor disorders. 2. To provide an overview of the most common pathologies occurring during the evacuation phase, especially in comparison with results of conventional defecography. Methods and materials: After description of the ideal technical parameters of MR defecography performed in supine position after gel rectal filling with a 3 Tesla unit and including the evacuation phase we stress the importance of using a standardized evaluation system for the exact assessment of pelvic floor pathophysiology. Results: The typical pelvic floor disorders occurring before and/or during the evacuation phase, such as sphincter insufficiency, vaginal vault and/or uterine prolapse, cystourethrocele, peritoneo-/ entero-/ sigmoïdocele or rectal prolapse, are demonstrated. The difference between the terms "pelvic floor descent" and "pelvic floor relaxation" are pictorially outlined. MR results are compared with these of conventional defecography. Conclusion: Exact knowledge about the correct technique including the evacuation phase and the use of a standardized evaluation system in assessing pelvic floor disorders by dynamic high-field MRI is mandatory for accurate and reproducible diagnosis.