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.

Pelvic organ prolapse surgery with and without tension-free vaginal tape in women with occult or asymptomatic urodynamic stress incontinence: a randomised controlled trial.

INTRODUCTION: We set out to determine if insertion of a retropubic tension-free vaginal tape (TVT) sling at the time of pelvic organ prolapse surgery improves continence outcomes in women with pre-operative occult stress incontinence (OSI) or asymptomatic urodynamic stress incontinence (USI). METHODS: We conducted a randomised controlled study of prolapse surgery with or without a TVT midurethral sling. The pre- and post-operative assessment at 6 months included history, physical examination and urodynamic testing. Quality of life (QOL) and treatment success was assessed with the UDI-6 SF, IIQ-7 SF and a numerical success score. The primary outcome was symptomatic stress urinary incontinence (SUI) requiring continence surgery (TVT) at 6 months. Long-term follow-up continued to a minimum of 24 months. Secondary outcomes were quality of life parameters. RESULTS: Eighty women received prolapse surgery alone (n = 43) or prolapse surgery with concurrent TVT (n = 37). Six months following prolapse surgery 3 out of 43 (7 %) patients in the no TVT group requested sling surgery compared with 0 out of 37 (0 %) in the TVT group (ARR 7 % [95 %CI: 3 to 19 %], p = 0.11). After 24 months there was one further participant in the no TVT group who received a TVT for treatment of SUI compared with none in the TVT group (4 out of 43, 9.3 % versus 0 out of 37; ARR 9.3 % [95 %CI: -1 to 22 %], p = 0.06). Both groups showed improvement in QOL difference scores for within-group analysis, without difference between groups. CONCLUSION: These results support a policy that routine insertion of a sling in women with OSI at the time of prolapse repair is questionable and should be subject to shared decision-making between clinician and patient.

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.

Host Specificity of Amblyomma cajennense (Fabricius, 1787) (Acari: Ixodidae) with Comments on the Drop-off Rhythm

The parasitic specificity of larval, nymph and adult Amblyomma cajennense on six different host species: Oryctolagus cuniculus, Rattus norvegicus, Gallus gallus domesticus, Anas platyrhynchus, Coturnix coturnix and Streptopelia decorata is described. In terms of the numbers of larvae and nymphs recovered, O. cuniculus was the best host species. The modal day for drop-off of larvae and nymphs was day three for the mammal hosts, but variable in the birds. We conclude that adult A. cajennense have a strong degree of specificity due to the fact that the tick failed to complete its life cycle on any of the evaluated hosts. The immature stages, on the other hand, showed a low level of specificity, most especially in the larval stage, indicating the existence of secondary hosts which probably serve as dispersers in the wild. The results also indicated a variable drop-off rhythm for larvae and nymphs in two periods, diurnal (6-18 hr) and nocturnal (18-6 hr), which differed depending upon the host.

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.

Attrition in the Swiss Household Panel: Is change associated with later drop-out?

This study examines the importance of change in characteristics and circumstances of households and household members for contact and cooperation patterns. The literature suggests that there might be an underrepresentation of change in panel studies, because respondents facing more changes would be more likely to drop out. We approach this problem by analysing whether previous changes are predictive of later attrition or temporary drop-out, using eleven waves of the Swiss Household Panel (1999-2009). Our analyses support previous findings to some extent. Changes in household composition, employment status and social involvement as well as moving are associated mainly with attrition and less with temporary drop-out. These changes affect obtaining cooperation rather than obtaining contact, and tend to increase attrition.

Clinical characteristics, prognosis, and treatment of pelvic cryptorchid seminoma.

PURPOSE: To analyze the clinical characteristics, prognosis, and treatment outcome of pelvic cryptorchid seminoma (PCS), and to determine whether whole abdominal-pelvic irradiation for Stage I disease is necessary. METHODS AND MATERIALS: From 1958 to 1991, 60 patients with PCS were treated at the Cancer Hospital of Chinese Academy of Medical Sciences, Beijing. They presented with a lower abdominal mass and showed a predominance for the right side. A high proportion of patients with PCS [26 of 60 (43%)] had metastatic disease, compared to 20% of those with scrotal seminoma, and there was a tendency toward a higher frequency of pelvic nodal metastases. There were 34 Stage I, 6 Stage IIA, 11 Stage IIB, 5 Stage III, and 4 Stage IV patients. Of these 60 patients, 56 underwent laparotomy with or without cryptorchiectomy (37 radical orchiectomy, 7 partial orchiectomy, and 12 biopsy of the primary or cervical node), and 4 cervical node biopsy only. All patients were further treated with radiotherapy, chemotherapy, or a combination of both. Patients with Stage I and II disease received radiotherapy, whereas patients with Stage III and IV were treated with chemotherapy. RESULTS: The overall and disease-free survivals at 5 and 10 years were 92% and 87%, and 88% and 84%, respectively. The 5- and 10-year survivals were 100% for Stage I, 94% and 87% for Stage II, and 56% and 42% for Stage III/IV, respectively (p < 0.05). Volume of irradiation, i.e., whole abdominal-pelvic radiotherapy (10 patients), versus hockey-stick encompassing paraaortic, ipsilateral iliac nodes and the primary tumor or tumor bed (17) did not influence outcome in Stage I patients. Five patients relapsed within 2-12 years after treatment, and four of these patients were successfully salvaged. Four patients developed a second malignant tumor and died. CONCLUSION: Stage I and II PCS can be adequately controlled by radiotherapy regardless of the surgical procedure. Whole abdominal-pelvic irradiation for Stage I and IIA disease is not required, and fields can be limited to the paraaortic, ipsilateral iliac nodes and primary tumor or tumor bed. We recommend platinum-based chemotherapy for Stage IIB-IV PCS.

Attrition in the Swiss Household Panel: Is change associated with drop-out?

This study examines the importance of change in characteristics and circumstances ofhouseholds and household members for contact and cooperation patterns. The literaturesuggests that there might be an underrepresentation of change in panel studies, becauserespondents facing more changes would be more likely to drop out. We approach this problemby analysing whether previous changes are predictive of later attrition or temporary drop-out,using eleven waves of the Swiss Household Panel (1999-2009). Our analyses supportprevious findings to some extent. Changes in household composition, employment status andsocial involvement as well as moving are associated mainly with attrition and less withtemporary drop-out. These changes affect obtaining cooperation rather than obtaining contact,and tend to increase attrition.

Is There a Crime Drop in Western Europe?

Combining data from police statistics and crime victim surveys, this article analyses the evolution of crime in Western Europe from 1988 to 2007. The results show that there is no general drop in crime. Property offences and homicide have been decreasing since the mid 1990s, while violent and drug offences have increased during the period under study. These trends highlight the limits of the explanations to the crime drop in the United States, which are based on the premise of a correlation in the evolution of all offences. The drop in property offences seems related to changes in the socioeconomic situation in Europe as well as to increases in security measures in households, and the reinforcement of private security. The increase in violent offences can be explained by the combination of several factors, including changes in youth's free time provoked by the development of the Internet, changing demographics, and the rise of episodic heavy alcohol consumption and street gangs.

Impact of genetic SLC28 transporter and ITPA variants on ribavirin serum level, hemoglobin drop and therapeutic response in patients with HCV infection.

BACKGROUND & AIMS: In the last decade, pegylated interferon-α (PegIFN-α) plus ribavirin (RBV) was the standard treatment of chronic hepatitis C for genotype 1, and it remains the standard for genotypes 2 and 3. Recent studies reported associations between RBV-induced anemia and genetic polymorphisms of concentrative nucleoside transporters such as CNT3 (encoded by SLC28A3) and inosine triphosphatase (encoded by ITPA). We aimed at studying genetic determinants of RBV kinetics, efficacy and treatment-associated anemia. METHODS: We included 216 patients from two Swiss study cohorts (61% HCV genotype 1, 39% genotypes 2 or 3). Patients were analyzed for SLC28A2 single nucleotide polymorphism (SNP) rs11854484, SLC28A3 rs56350726, and SLC28A3 rs10868138 as well as ITPA SNPs rs1127354 and rs7270101, and followed for treatment-associated hemoglobin changes and sustained virological response (SVR). In 67 patients, RBV serum levels were additionally measured during treatment. RESULTS: Patients with SLC28A2 rs11854484 genotype TT had higher dosage- and body weight-adjusted RBV levels than those with genotypes TC or CC (p=0.02 and p=0.06 at weeks 4 and 8, respectively). ITPA SNP rs1127354 was associated with hemoglobin drop ≥3 g/dl during treatment, in genotype (relative risk (RR)=2.1, 95% CI 1.3-3.5) as well as allelic analyses (RR=2.0, 95%CI 1.2-3.4). SLC28A3 rs56350726 was associated with SVR in genotype (RR=2.2; 95% CI 1.1-4.3) as well as allelic analyses (RR=2.0, 95% CI 1.1-3.4). CONCLUSIONS: The newly identified association between RBV serum levels and SLC28A2 rs11854484 genotype, as well as the replicated association of ITPA and SLC28A3 genetic polymorphisms with RBV-induced anemia and treatment response, may support individualized treatment of chronic hepatitis C and warrant further investigation in larger studies.