Evaluation of vaginal pessary use by South African gynaecologists

INTRODUCTION: The use of vaginal pessaries for conservative management of pelvic organ prolapse (POP) is well established. However, there are limited data on current clinical practice among gynaecologists, and the aim of this survey was therefore to evaluate vaginal pessary use among South African gynaecologists. METHODS: An anonymous self-administered one-page questionnaire was designed by the author and given out to South African gynaecologists at a local obstetrics and gynaecology meeting in 2009. RESULTS: The response rate was 31.7% (133/420). Of the respondents, 23.6% (29/123) offered vaginal pessaries as first-line treatment for POP in their clinical practice. The ring pessary was the commonest pessary used for all compartmental defects. The two most favoured reasons for pessary use were surgical or anaesthetic risk (64.0%, 85/133) and patient declining surgery (49.6%, 66/133). Recurrent involuntary expulsion (51.9%, 69/133), discomfort (41.3%, 55/133) and opting for surgery (39.1%, 52/133) were the three top reasons for discontinuation of pessary use. Of the respondents 87.6% (92/105) indicated that they would review patients within 6 weeks after initial pessary insertion, and thereafter 45.8% (44/96) would review patients at 3 - 6-monthly intervals. CONCLUSION: Compared with surveys elsewhere, fewer South African gynaecologists offer vaginal pessaries as first-line treatment to patients with symptomatic pelvic organ prolapse. Practice trends similar to those elsewhere included choice of pessary, follow-up interval and reasons for pessary discontinuation.http://www.sajog.org.z

Is pelvic floor morphology a predictor of successful pessary retention? Original research and review of the literature

BACKGROUND : Vaginal pessaries are known to be an effective treatment modality for pelvic organ prolapse (POP). Pessaries form an important part of the physician’s armamentarium in the treatment of POP, but currently many of the factors affecting their successful use are poorly understood. OBJECTIVES : To determine the association between pessary retention (PR) at 1 year, and functional pelvic floor morphology, i.e. levator hiatal distance and area, and levator avulsion. METHODS : This retrospective study reviewed the records of 73 patients with symptomatic POP at a tertiary urogynaecological centre. This multi-ethnic cohort had previously been studied for pelvic-floor morphology, had had 4D transperineal pelvic-floor ultrasound, and had opted for a vaginal pessary as a treatment option. RESULTS : Our population had a mean age of 59.4 (range 32 - 91) years, and mean body mass index of 29.4 (range 20 - 42) kg/m2, with a mean assessment of stage 3 in the Pelvic Organ Prolapse Quantifications System (POP-Q). The level of prolapse was found to be related to PR (p=0.077). We further explored this concept using symmetric measures of association (γ=–0.353), indicating that PR decreases with increasing prolapse severity. PR was also found to be inversely associated with prior pelvic reconstructive surgery (n=63; p=0.055; γ=–0.417). There was a strong correlation that failed, however, to achieve significance by a small margin (p=0.052) between hiatal distance on contraction and PR. CONCLUSION : This study found an inverse relationship between PR and hiatal distance on contraction, prior pelvic surgery and the severity of prolapse. This was a pilot study with a limited number of participants, and the authors plan a prospective study to further clarify the association between long-term PR and functional pelvic floor morphology.http://sajog.org.za/index.php/SAJOGam2019Obstetrics and Gynaecolog

Accurate anatomic repair of obstetric anal sphincter damage or rectovaginal fistula aided by prior ultrasonograghy : a cohort study

BACKGROUND : Anorectal obstetric injuries resulting in anal sphincter damage (ASD) and rectovaginal fistula (RVF) remain a major problem. The resulting flatus or faecal incontinence is devastating. Surgical repair remains a challenge. Postpartum RVF primarily results from ischaemic pressure necrosis following obstructed labour. The fistula tract is surrounded by a fibrous scar. ASD usually results from precipitous labour. The injury heals by fibrous scar leading to varying degrees of anal incontinence. Contraction and retraction of muscles around the injury renders the defect and fibrous scar larger than the primary injury. Anorectal ultrasonography has been used to define RVF and ASD, and the associated fibrous scar. PATIENTS AND METHODS : A retrospective review of patients who underwent transvaginal surgical repair of RVF and ASD was undertaken. Patients were preoperatively assessed for pathology and incontinence degree. Anorectal ultrasonography was used to define ASD or RVF and the associated scar preoperatively. Repair of RVF or ASD entails total excision of the scar with accurate anatomical layers reconstruction of healthy tissues. RESULTS : There were 23 patients, 8 RVF with a mean (SD) age 29 (6.78) years and 17 ASD with a mean (SD) age 35.25 (15.90). Twenty followed obstetric trauma (6RVF, 14 ASD), 1 prior rectocoele repair (ASD), 2 rape (1RVF + 1 ASD) and 1 was idiopathic (RVF). All patients had 1 or more prior repairs except for idiopathic RVF. Operative technique entailed transvaginal complete excision of the fibrous scar and accurate anatomical reconstruction of healthy tissue layers. A colostomy was not routinely used. There were three significant postoperative complications: ASD breakdown from an infected haematoma; perianal abscess, later a sinus after drainage; and RVF repair dehiscence during early coitus. All patients had full continence after 8 months minimum follow-up. CONCLUSION : Complete excision of the fibrous scar and accurate anatomical tissue layers reconstruction of the obstetric RVF or ASD, aided by prior ultrasonography, yielded good results.Internal Department of Surgery financial resources.https://journals.lww.com/annals-of-medicine-and-surgery/pages/default.aspxSurger

Marketing novel devices in medicine with reference to gynaecological innovations : ethical dimensions

New scientific and technological discoveries in all spheres of Medicine continuously challenge the boundaries of healthcare. To this end, the discipline is considered progressive and accomplished. The birth of this heavily professionalized discipline has leveraged the potential for the healthcare industry to innovate, regulate and disseminate proprietary products with relative ease. The rise and fall of four novel gynaecological devices represent excellent examples of ethical dilemmas in clinical medicine. This paper aims to deconstruct the power versus knowledge conflict, and suggest that reappraisal and recourse to Aristotelian virtue ethics will assist in shifting the decisional power balance primarily towards the physician.https://journals.co.za/journal/medogam2022Obstetrics and Gynaecolog

Approach to female urinary incontinence : Part 2 : Surgical management

Part one of this article deals with the assessment and medical management of the disease. The following will delve into surgical techniques in the armamentarium of treatment for both urge and stress urinary incontinence.http://www.journals.co.za/content/journal/medogObstetrics and Gynaecolog

A study to establish normal reference values of urine flow parameters in healthy South African females

BACKGROUND. Several studies have demonstrated the negative impact of lower urinary tract symptoms on health-related quality of life domains. Uroflowmetry is a simple screening test performed after taking a detailed history and examination of the patient. However, unlike men, there are no universally accepted and population-specific uroflow nomograms available for women. OBJECTIVE. To determine the normal reference values for various uroflow parameters in a healthy female South African population and to determine ethnic variations in measured parameters. METHODS. This was a cross-sectional study done at a tertiary hospital in Pretoria. Recruited females included healthy staff members, students, patients, and their relatives who attended the gynaecology outpatient department. Quantile regression was used to formulate uroflow centiles using average and maximum urine flow rate over voided volume. RESULTS. We recruited 336 females out of 353 volunteers (n=306 for study group and n=30 for control group). The mean (standard deviation (SD)) age was 35.15 (10.24) years, voided volume 179.71 (136.10) mL, voiding time (26.13 (19.48) s), time to maximum flow rate (Qmax) (5.85 (4.19) s), Qmax (20.01 (9.67) mL/s) and average flow rate (Qave) (10.16 (5.40) mL/s). Confidence limit flow-volume nomograms were developed, and these were validated against asymptomatic women (n=30). Black females (n=255) had statistically significantly higher average urine flow rate (p=0.023) than white females (n=55). CONCLUSION. The generated nomograms in healthy women add to current scientific literature on this topic. Potential ethnic variation in uroflowmetry parameters needs further exploration.http://sajog.org.za/index.php/SAJOGObstetrics and Gynaecolog

Approach to female urinary incontinence : Part 1 : Medical management

Urinary incontinence is defined as the involuntary loss of urine. It is a ubiquitous disorder, thought to occur more commonly than more familiar health issues such as hypertension, diabetes, and depression. It is a condition whose profile of affected patients includes women of all age groups and which transcends socioeconomic and cultural circumstance.2 Given the above, the social, emotional, and economic impact of the disease on individuals and communities is self-evident. The true prevalence of urinary incontinence world-wide, and in South Africa is essentially unknown. Community based studies have reported the prevalence as ranging between 14% and 67%, showing a large discrepancy from the estimates of physician-based studies, which show an estimated prevalence of between 0.5-5%. This disparity is thought to arise from a combination of underreporting, under-diagnosis, and under-treatment of the disease.http://www.journals.co.za/content/journal/medogam2019Obstetrics and Gynaecolog

Ultrasound imaging of the anal sphincter complex : a review

Endoanal ultrasound is now regarded as the gold standard for evaluating anal sphincter pathology in the investigation of anal incontinence. The advent of three-dimensional ultrasound has further improved our understanding of the twodimensional technique. Endoanal ultrasound requires specialised equipment and its relative invasiveness has prompted clinicians to explore alternative imaging techniques. Transvaginal and transperineal ultrasound have been recently evaluated as alternative imaging modalities. However, the need for technique standardisation, validation and reporting is of paramount importance. We conducted a MEDLINE search (1950 to February 2010) and critically reviewed studies using the three imaging techniques in evaluating anal sphincter integrity.http://www.bir.org.uk/bir-publications-home/bjr---about-the-journal.asp

Variations in pelvic floor thickness in relation to bony dimensions in South African women : using computed tomography scans

Pelvic floor disorders (PFDs) are a common reason for urogynaecological consultation around the world, especially in elderly women. These disorders have been associated with disruption to the structural integrity of the pelvic floor. This study explored whether there are variations in pelvic floor muscle (PFM) thickness in relation to parity, population group and age. Additionally, the study explored whether there were any correlations between PFM thickness and the bony pelvic parameters measured. This was a quantitative retrospective analysis of computerised tomography (CT) scans. A total of 125 CT scans of women belonging to black and white South African population groups were sampled from a tertiary hospital in Pretoria, South Africa. Statistical analyses were performed using Paleontological Statistics (PAST). A thicker pelvic floor was noted in black compared to white women. Pelvic floor thickness decreased with parity and age in both population groups. The intertuberous diameter, as well as the surface areas of the urogenital triangle and the perineum, were statistically significantly larger in white than in black women. Correlations between PFM thickness and bony dimensions were statistically significant for anteroposterior (AP) pelvic outlet diameter, where a greater AP outlet was associated with thinner PFMs in black women. Bony correlations with parity showed that the interspinous diameter in black women increased significantly with parity. The variations in bony pelvic dimensions and pelvic floor muscle thicknesses noted between population groups, in addition to the co-factors of parity and aging, will contribute to a better understanding of the anatomical reasons for incontinence.The National Research Fund (NRF) and Bakeng se Afrika, an Erasmus plus project of the EU.https://eurjanat.comhj2024Obstetrics and GynaecologySDG-03:Good heatlh and well-bein

Part 2 : Ultrastructural changes of fibrin networks during three phases of pregnancy : a qualitative investigation

INTRODUCTION: Normal pregnancy is characterized by significant alterations in the haemostatic system accompanied by an augmented risk of thrombosis. MATERIALS AND METHODS: The fibrin network ultrastructure of different phases of pregnancy, namely early pregnancy (week 8 – 14), late pregnancy (week 36 – 40) as well as post-partum (week 6 – 8 after birth) were compared to non-pregnant fibrin networks as well as each other to establish whether differences in fibrin network morphology exist during pregnancy. Scanning electron microscopy was employed to analyse fibrin network morphology. RESULTS: The fibrin networks from all phases of pregnancy appeared similar to each other, exhibiting prominent coagulant formation, an increase in the formation of minor, thin fibers, and the presence of granular globules. Al three phases however differ from the typical fibrin network ultrastructure exhibited by the fibrin networks from non-pregnant individuals. The increase in estrogen associated with pregnancy may cause the increase in coagulation factors and ultimately the pro-thrombotic state characteristic of pregnancy. CONCLUSIONS: Since no differences were apparent between the different phases of pregnancy it suggests that activation of the coagulation system commences with pregnancy and this pro-thrombotic state continues till at least 8 weeks after birth. These results may shed light on possible pathological mechanisms employed in the development of abnormal or ailing pregnancy.http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)1097-0029hb201