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The majority of the studies suggest that postmenopausal women are at greater risk; however purchase caduet with american express, when a multiple logistic regression analysis takes age into account discount caduet 5 mg otc, menopausal status becomes nonsignificant order on line caduet, suggesting that it may be the age factor more than the decreased estrogen levels that places the woman at risk for prolapse [19,25,35,36]. Prior Pelvic Surgery 1245 This is another area where it is difficult to determine if there are any significant relationships. Therefore, subjects who have had prior prolapse surgery have many of the underlying conditions that put them at risk for prolapse, and using this as a risk factor is similar to noting the increased risk of cancer in patients undergoing treatment for cancer. Therefore, many of these patients have already been treated for prolapse and many will have been treated successfully. When the hysterectomy was done specifically for prolapse, it increases the risk even more [37]. The mechanism behind this phenomenon may be the disruption of the normal apical supports of the vagina in subjects with otherwise good support. This emphasizes the need to be ever mindful of providing strong attachment of the cardinal and uterosacral ligament complex to the vaginal cuff at the time of hysterectomy. Family History This is one area where we have almost no data; however, this may be of central importance when we counsel patients about other modifiable risk factors. There is one study where subjects who had undergone surgery for prolapse were asked about any family history of other relatives undergoing similar surgery [36]. Natural History of Pelvic Organ Prolapse This is an area of study with almost no data. Of the 64 women, 20% eventually elected an intervention, but this study demonstrated that no intervention is an acceptable therapeutic option in minimally symptomatic subjects and that patients generally do not experience rapid progression of prolapse [47]. This makes the plethora of emerging data difficult to interpret because often we are comparing apples and oranges. However, before recommendations can be made regarding preventive strategies, more studies using a consistent definition are required. Genesis of the vaginal profile: A correlated classification of vaginal relaxation. Interobserver and intraobserver reliability of the proposed International Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society pelvic organ prolapse classification system. Adoption of the pelvic organ prolapse quantification system in peer-reviewed literature. The standardization of terminology for researchers in female pelvic floor disorders. The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Distribution of pelvic organ prolapse in a general population: Prevalence, severity, etiology and relation with the function of pelvic floor muscles. Epidemiology of genital prolapse: Observations from the Oxford Family Planning Association study. Use of the pelvic organ prolapse staging system of the International Continence Society, American Urogynecologic Society, and the Society of Gynecologic Surgeons in perimenopausal women. Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors. Distribution of pelvic organ support measures in a population-based sample of middle-aged, community-dwelling African American and white women in southeastern Michigan. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Correlation of symptomatology with degree of pelvic organ support in a general population of women: What is pelvic organ prolapse? Association of the magnitude of pelvic organ prolapse and presence and severity of symptoms. Case-control study of etiologic risk factors in the development of severe pelvic organ prolapse. Pelvic relaxation and associated risk factors: The results of logistic regression analysis. Heavy lifting at work and risk of genital prolapse and herniated lumbar disc in assistant nurses. Bowel dysfunction: A pathologic factor in uterovaginal prolapse and urinary stress incontinence. Urinary incontinence and pelvic organ prolapse in women with Marfan and Ehlers–Danlos syndrome. Ehlers–Danlos syndrome: Relationship between joint hypermobility, urinary incontinence and pelvic floor prolapse. Outcomes of observation as therapy for pelvic organ prolapse: A study in the natural history of pelvic organ prolapse. Mild anterior vaginal prolapse often occurs in parous women but usually presents few problems. As the prolapse progresses, symptoms may develop and worsen, and treatment becomes indicated. The anterior vaginal wall is the most common segment of the vagina to prolapse and the segment that is most likely to fail in the long term after surgical correction. This chapter reviews the anatomy and pathology of anterior vaginal prolapse, with and without stress incontinence, and describes methods of surgical repair. The etiology of anterior vaginal prolapse is not completely understood, but it is probably multifactorial, with different factors implicated in prolapse in individual patients. Normal support for the vagina and adjacent pelvic organs is provided by the interaction of the pelvic muscles and connective tissue [2]. Pathological loss of that support may occur with damage to or impairment of the pelvic muscles, connective tissue attachments, or both. Nichols and Randall described two types of anterior vaginal prolapse: distension and displacement [4]. Distension was thought to result from overstretching and attenuation of the anterior vaginal wall, caused by overdistension of the vagina associated with vaginal delivery or atrophic changes associated with aging and menopause. The distinguishing physical feature of this type was described as diminished or absent rugal folds of the anterior vaginal epithelium caused by thinning or loss of midline vaginal fascia. It may occur unilaterally or bilaterally and often coexists with some degree of distension cystocele, with urethral hypermobility or with apical prolapse. This was first described by White in 1909 [5] and 1912 [6] but disregarded until reported by Richardson et al. Richardson described transverse defects, midline defects, and defects involving isolated loss of integrity of the pubourethral ligaments. Transverse defects were said to occur when the “pubocervical” fascia separated from its insertion around the cervix, whereas midline defects represented an anteroposterior separation of the fascia between the bladder and vagina. A contemporary conceptual representation of vaginal and paravaginal defects is shown in Figure 82. There have been few systematic or comprehensive descriptions of anterior vaginal prolapse based on physical findings and correlated with findings at surgery to provide objective evidence for any of these theories of pathological anatomy.

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Isolated tears of the rectal mucosa without involvement of the anal sphincter (Figure 93 buy caduet 5 mg without a prescription. It has been reported in 16% of instrumental deliveries [13] and 11% [14] (19% in primiparae [15]) in centers where midline episiotomy is practiced buy generic caduet 5mg on line. Midline episiotomies have been favored in North American practice while mediolateral episiotomies are favored in Europe cheap caduet. The prevalence of anal incontinence (including flatus as a sole symptom) and fecal incontinence (liquids and solids with or without flatus) following end-to-end repair ranges between 15% and 61% (n = 35; mean = 39%) and 2% and 29% (n = 25; mean = 14%), respectively (Table 93. Despite repair, persistent sonographic anal sphincter defects were identified in 34% [23] to 91% [46] of women. Anal resting and squeeze pressures are consistently lower in women who have previously sustained anal sphincter rupture [10,11,30,32,38,41,44], and the anal canal is shorter after repair [10,22]. However, these measurements were still within the normal range and no relationship was demonstrated between abnormal latency and incontinence. Although anal sphincter disruption and repair is invariably associated with some degree of denervation and atrophy, current available neurophysiological tests are neither sensitive nor specific enough to quantify pudendal neuropathy. There is, however, evidence to show that poor outcome following primary [10,25,30] and secondary [4] repair may be related more to persistent mechanical disruption as demonstrated by anal endosonography rather than pudendal neuropathy. Unsatisfactory outcome following primary sphincter repair may be attributed either to operator inexperience or repair techniques and subsequent management. Training and experience of clinicians performing perineal repair have been questioned [49,50] and hands-on training workshops have been shown to influence a change in clinical practice [51]. Fulsher and Fearl [54] also described this technique but emphasized that no sutures should pass through the sphincter muscle. More specifically, Cunningham and Pilkington [55] inserted four interrupted sutures in the capsule of the external sphincter at the inferior, posterior, and superior points. In 1948, Kaltreider and Dixon [56] described the end-to-end repair technique that was used since 1935 in which one mattress or figure-of- eight suture was inserted to approximate the sphincter ends. Obstetricians have used the end-to-end repair technique for decades either by single-interrupted sutures, “figure-of-eight” sutures, or mattress sutures [10] (Figure 93. Persistent anal sphincter defects following repair has been reported in 34% [23] to 91% [46] of women (Figure 93. By contrast, when fecal incontinence is due to sphincter disruption, colorectal surgeons favor the “overlap technique” for secondary sphincter repair as described by Parks and McPartlin [57]. Jorge and Wexner [58] reviewed the literature and reported on 21 studies using the overlap repair with good results ranging from 74% to 100%. It is now known that similar to other incontinence procedures, outcome can deteriorate with time and the follow-up study at 5-year follow-up reported 50% continence [59]. However, a number of women in this study had more than one attempt at sphincter repair [59]. They observed that compared to matched historical controls [10,61] who had an end-to-end repair, anal incontinence could be reduced from 41% to 8% using the overlap technique and separate repair of the internal sphincter. Based on this, they recommended a randomized trial between end-to-end and overlap repair. However, a true overlap [10,57] is not possible if the sphincter ends are not completely torn, and attempts at overlapping would only place tension on the repair. Of the 23 women in the end-to-end 1422 group and 18 in the overlap group, only 15 and 11 women, respectively, returned for follow-up at 3 months. No significant difference was found between the groups in terms of symptoms of fecal incontinence or transperineal ultrasound findings. However, the authors acknowledged that the major limitations of their study were that randomization was inaccurate and that their study was underpowered. This trial was specifically designed to test the hypothesis regarding suture-related morbidity. At 6 weeks, there were no differences in terms of the need for suture removal due to pain, suture migration, or dyspareunia. The authors claim that there were no differences in outcome based on repair technique. At 12 months, they had an 81% follow-up rate and found that 24% in the end-to-end and none in the overlap group reported fecal incontinence (p = 0. There were no significant differences in dyspareunia and quality of life between the groups. After 12 months, 16% of women in the end-to-end group and no subjects in the overlap group reported deterioration of defecatory symptoms (p = 0. Rygh and Korner [64] performed another randomized controlled trial (n = 101) with the primary outcome measure “of at least weekly solid stool incontinence. However, there were more women with symptoms of anal incontinence in the end-to-end repair group (34% vs. They reported significantly higher rates of flatal but not fecal incontinence in the overlap group. At a 3-year follow-up however, there was no significant difference in anal incontinence between the groups, but the rate of fecal incontinence in the end-to-end group doubled while it remained static in the overlap group [67]. This highlights the importance of longer term follow-up as one technique may prove to be more robust. At 36 months (based on only two small trials), there appeared to be no difference in flatus or fecal incontinence between the two techniques. At a median follow-up of 2 years, 23% complained of anal incontinence, 23% developed wound infection, 27% complained of dyspareunia, and one developed a rectovaginal fistula. However, a delay in repair may be justified in exceptional circumstances when an experienced obstetrician may not be 1423 available. Ideally, the repair should be conducted in the operating theater where there is access to good lighting, appropriate equipment, and aseptic conditions. In our unit, we have a specially prepared instrument tray containing a Weitlander self-retaining retractor, four Allis tissue forceps, McIndoe/Metzenbaum scissors, tooth forceps, two artery/mosquito forceps, stitch scissors, and a needle holder (www. Muscle relaxation is necessary to retrieve the ends especially if the intention is to overlap the muscles without tension. The full extent of the injury should be evaluated by a careful vaginal and rectal examination in lithotomy and graded according to the classification earlier (Figure 93. If there is any uncertainty about the grading of Grade 3a or 3b, it should always be given the higher grade. To minimize the risk of a persistent rectovaginal fistula, a second layer of tissue should be interposed between the rectum and vagina by approximating the rectovaginal fascia. In the presence of a fourth-degree tear, the torn anorectal epithelium is repaired with a continuous nonlocking fine suture such as Vicryl 3-0. The technique of interrupted sutures with the knots tied in the anal lumen is recommended when catgut is used as catgut undergoes phagocytosis in tissues and increases the risk of infection. A subcuticular repair of the anal epithelium via the transvaginal approach has also been described [5] although there is some concern that the thin anorectal mucosa could tear with the passage of stool. Compared to a braided suture, these monofilamentous sutures are believed to be less likely to precipitate infection. Nonabsorbable monofilament sutures such as nylon or Prolene (polypropylene) can cause stitch abscesses, and the sharp ends of the suture can cause discomfort, necessitating removal.

Postoperative view taken 6 months following submalar 1 year following malar midface submalar zone 5 and zone 1 augmenta- zone 5 augmentation purchase caduet 5 mg free shipping, with large Terino malar shells of 4 mm 3D Facial Volumization with Anatomic Alloplastic Implants 997 accommodate individual patients buy generic caduet canada. Success is determined by de- emphasizes the appearance of the nasolabial mound and appropriate choice of size and shape implant and knowledge corrects the sunken or flat appearance in the midface to restore of which zone or zones to augment purchase caduet 5mg without prescription. A type 4 face consists of extreme volume deficiency throughout the entire anterior maxillary region. It is identi- A useful tool to assist the surgeon in determining which ele- fied by a “flat” face, or “dish” face appearance. It has been ments are necessary to achieve facial balance in any specific described as the “polar bear” syndrome because of the defi- patient is the appreciation of malar–midface zonal deficien- ciency recession of the inferior orbital rim, which contributes cies. Although the number of variations in facial size, shape to a proptotic, bulging appearance of the ocular globe. It is and contour are infinite, there are several common midfacial also called a “negative vector” bony suborbital condition types that can easily be identified for the purpose of deter- when the rim is significantly recessed from the eyeball. Alloplastic augmentation can improve mild to moderate Several of these will be described. There are several implant designs and sizes of sili- weakness in the upper segment of the malar–midface. It cone rubber implants, which have been used successfully encompasses zones 1 and 2 over the malar bone and the over the years to alter nasojugal and premaxillary bony defi- medial third of the zygmatic arch. Augmentation in these may be associated with a downward or vertical descent of the zones creates upper cheek definition that simulates both lower eyelid causing sclera show. When a large implant Significant improvement in this type 4 aesthetic imbal- is used to augment zone 2 as well as zone 1, the upper mid- ance occurs by placement of a comprehensive shell implant, face becomes broader. This shortens the appearance of a long or more specifically, suborbital malar extended implants, and narrow face (Fig. An port to the lower eyelid and elevates it to a more attractive implant placed in this location produces volume filling that horizontal position (Fig. Utilization of a large Lateral canthopexy techniques are often necessary to cor- malar shell over the inferior aspect of the malar bone in zone rect the descent of the lower eyelid, which is common with this 1 and extending down into the submalar space creates the facial type and to prevent its worsening after malar surgery. This cific weakness of skeletal structure in the inferior orbital and type 2 midface has adequate malar bone prominence but medial tear trough region. This contributes to a tired, hollow is specifically deficient in submalar soft tissue volume. This appearance around the eyes, which occurs following the can create an older, tired, haggard look (Fig. A type 3 regional volume deficiency consists of a strong A uniquely designed suborbital tear trough implant devel- malar–zygomatic super structure accompanied by an oped by the author in 1988, extends from the medial canthus extremely deficient submalar infrastructure. It considerably improves this tion is accompanied by thin skin and subcutaneum, the appearance (Fig. Autogenous tissue transplants of appearance is one of emaciation atrophy and even sickness. Fat requires a generous submalar augmentation with a large sur- grafting along the inferior orbital rim was considered by face area midface shell that may have a projection thickness some to be advantageous, but has been abandoned by most. Since the submalar zone ends just lateral to the In general, the author’s experience is that all autolo- nasolabial smile mound, volume filling of this space gous soft tissue grafting manifests unpredictable shrink- 998 E. Postoperative views show attractive malar–midface contour from zone 1,2 malar volume enhancement 3D Facial Volumization with Anatomic Alloplastic Implants 999 Fig. Left views: Preoperative, and Right views : postoperative views, demonstrating upper midface widening. This can pro- preoperative, right: is 1 year postoperative using Terino extra large duce a sunken, tired, older look. Bottom: A 50-year-old female prominence in a type 2 or type 3 face, a large malar shell placed in with aging midfacial atrophy. Left: preoperative, right : is 1 year post- the submalar region restores a youthful fullness to the face. Top : A operative following placement of Terino extra large malar shell placed 32-year- old female with hereditary midface submalar deficiency. Left: in submalar zone 5 3D Facial Volumization with Anatomic Alloplastic Implants 1001 Fig. Utilization of a large malar Preoperative, and right views : 1 year postoperative shell into the submalar space creates the illusion of a round, full apple 1002 E. This helps to correct a flat or “dish-face” appearance age and may produce irregularities or result in negligible A type 6 midface deficiency exists in the perinasal pre- improvement. Volume deficiency or the appearance of Over the past 5 years, there has been strong interest in a retrusiveness in this aspect of the skeleton is common in cer- subperiosteal elevation of all soft tissue layers from the tain ethnic groups, especially Asians and Western Indians in maxilla followed by a suspension of them in an upward the Americas. It also exists as a congenital hereditary trait, direction to provide greater volume filling in the inferior which can be mild or severe and which may require compli- orbital rim area. This midface suspension can be accompa- cated orthognathic surgery using maxillary LeForte relation- nied by inferior orbital fat rearrangement over the inferior ships. Alloplastic augmen- rupted along the entire orbital rim to create a space for the tation is permanent. Type 6 peripyriform and premaxillary intraorbital fat to be transposed and sutured into (Figs. They are usually of lesser S ubperiosteal midfacial suspension alone without the magnitude than the greater volume/mass interrelationships addition of alloplastic implants is a technique, which is still of the malar–midface, jawline, and nose. Therefore, they do new enough to require the test of time to evaluate long-term not command as much attention during an initial aesthetic persistence of volume correction and three-dimensional facial contour consultation unless the patients are focused improvement of the suborbital hollow appearance and on their deficiency themselves and request treatment by the malar–submalar shape. This also adds support to the lower eyelid to elevate it to a more attractive horizontal position Today’s men emulate the lean, athletic, and muscular con- 12 Chin–Jawline Augmentation figuration typified by the Greco-Roman statues of the ancient world. Therefore, liposuction currently leads the list of aes- Historically, a masculine image has been characterized by thetic operative procedures performed on men (and also qualities of strength, courage, boldness, and aggressiveness. Unwanted fat deposits are eliminated from the male Masculine images that impress us since youth include those torso with relative ease. The increasing popularity of cosmetic surgery has Traditional nasal contour changes and chin augmenta- resulted in increasing demands on the part of men as well. Currently, men comprise Present images of masculine facial structure, which are being at least 20 % and perhaps 30 % of an aesthetic surgery prac- sought by today’s male patients derive in part from the 1940s tice. Their greatest desires are to attain the masculine ideal and 1950s comic strip heroes. Green Lantern, the Lone Ranger, Batman, and dozens of 3D Facial Volumization with Anatomic Alloplastic Implants 1005 Fig. Both patients demonstrate successful improve- siderably improves a type 5 deficiency. Autogenous tissue transplants of ment of the suborbital hollow, tired look using this implant (arrows) Extent of midface subperiosteal space dissection Masseter m. Preoperative photos are on the left Example of two patients in whom premaxillary retrusive contour defor- others possessed jutting jawlines, massive cheek bones, and Within this liberal climate, men are paying more attention straight, strong nasal profiles (Fig. Today’s modern health and fitness characteristics assisted greatly in the success of such promi- movement has created a new era of athletic endeavor, which nent actors as Kirk Douglas, Gregory Peck, Charlton Heston, again, emulates the ideal Greco-Roman image. Nasal contouring and chin along with a revival of Superman, Dick Tracy, and others. Now, how- Schwartzenegger, Robert Redford, Tom Selleck, Mel Gibson, ever, males are adventuring into facial and jawline changes.

However cheap 5mg caduet amex, the history is usually of several months of cyclical abdominal pain in an adolescent without menstruation caduet 5mg generic. On inspection of the vulva discount caduet online, it is usually possible to see a bulging vaginal membrane. The treatment for these patients is a simple incision with excision of a quadrate of hymenal tissue to allow drainage of the vagina and uterus. Wide excision of the hymen too close to the vaginal epithelium may result in stenosis at the introitus [17]. There have been case reports of familial cases of imperforate hymen usually between siblings, suggesting a recessive mode of inheritance [18]. There has also been a report of imperforate hymen in two generations of the same family [19], which suggests a possible dominant mode of transmission. Transverse Vaginal Septa This uncommon condition occurs in approximately 1 in 70,000 females [20]. It occurs due to a failure of the Müllerian ducts and urogenital sinus to canalize. These septa are most commonly found at the junction of the middle to upper two-thirds of the vagina. In cases of a complete transverse septum, associated uterine anomalies are common; one series reports the rate to be as high as 95% [21]. Most presentations of this condition are in young girls after the menarche with cyclical pelvic pain as a result of hematocolpos, which may be complicated by hematometra, bilateral hematosalpinges, and possibly endometriosis. It can usually be easily distinguished clinically from an imperforate hymen as there is no 1679 bulging membrane seen at the introitus. It can rarely occur before puberty when the presentation is with pelvic pain; the obstruction in this case is thought to be due to a buildup of mucous secretions from the cervical glands. In one interesting case, expectant management was employed, where the thickness of the septum and volume of the dilated vagina were monitored regularly using ultrasonography. The thickness of the vaginal septum decreased from 26 to 8 mm over a period of 5 years, thus allowing a less complicated surgical procedure in a more mature patient [22]. The thinning of the septum was felt to be due to a pressure effect of the hematocolpos. However, in the majority of cases, the treatment is surgical excision without delay. If the septa are thin and low, it may be possible to remove using a vaginal approach [24]. Care must be taken to ensure the septum is entirely removed as vaginal stenosis may result if the procedure is incomplete. Thick transverse septa or those located higher up in the vagina will require an abdominoperineal approach, which may be open or laparoscopic [25]. In those cases where the distance between the margins is too great, then some form of graft, either with skin or intestine, will be required. Longitudinal Vaginal Septa Longitudinal septa are often asymptomatic and may not present until the patient is sexually active with dyspareunia, or in some cases during labor where there may be a delay in the second stage [26]. They result as a failure of reabsorption of the vaginal septum during embryogenesis. It may be complete, and extend from the cervix to the introitus, or partial, which may be of any length along the course of the vagina. The management for the majority of these is usually surgical resection if symptomatic. Care must be taken to resect the septum right up to the cervix or dyspareunia will continue. This may cause an unusual clinical picture of apparently normal menstruation, from the unaffected side associated with pelvic pain. As menstruation appears initially normal, this results in delayed diagnosis of obstruction that would normally be made much quicker in the absence of any menstrual flow. Also, as this is an uncommon condition presenting in young females, the patient may present to a pediatrician rather than a gynecologist, especially as the patients are having what appears to be normal periods. Over 80% are thought to have an associated uterine malformation, the commonest of which is a complete uterine septum [21]. Surgical treatment of simple vaginal longitudinal septa is generally uncomplicated and is approached vaginally. As with transverse septa and imperforate hymen, postoperative vaginal stenosis should be looked for and treated if necessary. Uterine Anomalies Traditionally, it has been reported that uterine anomalies are present in 0. However, a recent cross-sectional study undertaken in Denmark has demonstrated an anomaly rate of 9. However, there was no association with miscarriage and Müllerian anomalies reported, which is contrary to previous reports in the literature [27]. The most widely accepted classification system for uterine anomalies is from the American Society for Reproductive Medicine [30]. This classification organizes the anomalies into six major uterine anatomic types (see Figure 113. The resulting anomalies can be considered to be due to one of four events [31]: 1. Failure of one or more of the Müllerian ducts to develop: Agenesis, unicornuate uterus without rudimentary horn 2. Failure of the ducts to canalize: Unicornuate uterus with rudimentary horn 1680 3. Failure of or abnormal fusion of the ducts: Uterus didelphys, bicornuate uterus 4. Failure of the reabsorption of the midline uterine septum: Septate uterus, arcuate uterus The most common of these appears to be septate uterus, which accounts for approximately 35% of all uterine anomalies [31]. It is known to result in early pregnancy loss and infertility, and this is how the majority of these patients present. However, septa can also be found by chance in women with an uncomplicated obstetric history and so the decision on treatment can be complex. If treatment is recommended, then the most appropriate treatment for septate and arcuate uterus is resection of the septum, which can be achieved via hysteroscopic metroplasty, thus avoiding the need for a laparotomy and an incision in the uterus. There is some evidence that metroplasty may improve reproductive outcomes in these women [32]. These patients also have recurrent miscarriage, premature delivery, and infertility. There have also been reported neonatal risks, and these include low Apgar scores and small-for-date infants. Pregnancies do occur in these women and they should be carefully monitored throughout. This is complicated further if there are multiple pregnancies, and twin pregnancies in bicornuate uterus have been reported [33,34].

P. Ingvar. Southern University, New Orleans.

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