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It is about fourth tendon compartment is easy to see during small 25mm long purchase capoten 25mg otc, takes an arc-shaped trajectory around Lis- alternating finger extension movements (e purchase 25mg capoten with visa. Lister’s tubercle acts as a deflection pulley for the located on the dorsum of the hand order capoten 25mg amex, ulnar to the tendon of extensor pollicis longus muscle and enables reposition. It is about 25mm long and 10mm For this reason, it is not possible to move any of the four wide, and begins its course 5mm proximal to the exten- fingers in isolation. In the distal part, the tendon sheath the index and little fingers is possible as the extensor adopts a fan-shaped path over the dorsum, ending in a indicis muscle allows the index finger to move and the recess. Medi- extensor digiti minimi muscle also allows the little finger ally it is about 49 mm wide and on the ulnar side about to move. Dorsal digital expansion Extensor retinaculum before each branch establishes contact with the ring and communis muscle should be inhibited by means of recip- little fingers, respectively. This is accomplished by asking the pa- tient to press the fingertips of all the fingers except the thumb on a surface, and then extend only the little finger. Fifth Dorsal Tendon Compartment This will make it easier to palpate the tendon of the The fifth dorsal tendon compartment is located directly extensor digiti minimi. It is the longest dorsal tendon compart- Sixth Dorsal Tendon Compartment ment and guides the tendon of the extensor digiti minimi muscle in the direction of its insertion onto the dorsal The sixth dorsal tendon compartment contains the exten- digital expansion of the little finger. The tendon can sor carpi ulnaris tendon and is located directly ulnar to easily be palpated across its entire course if the patient the ulnar head (▶Fig. To make sure the fifth dor- long and 6mm wide, and extends through a bony groove sal tendon compartment is not mistaken for the extensor between the ulnar head and the ulnar styloid process. It digitorum communis muscle, the extensor digitorum extends up to the base of the fifth metacarpal and has 90 2. Sixth dorsal Extensor tendon carpi ulnaris compartment additional insertions at the pisiform, hook of hamate, and Brachioradialis pisometacarpal ligament. Owing to the large range of Extensor carpi radialis longus motion of this tendon compartment, it rotates in a some- Extensor carpi what radial direction toward the ulnar head during supi- radialis brevis nation. It is easiest to palpate the sixth dorsal tendon compartment directly next to, and distal to, the ulnar head. Practical Tip Various types of tendinitis can be diagnosed by specifi- cally stretching the compartment in question. In the case of de Quervain’s tenosynovitis, the examiner places the thumb in maximum adduction and sharply deviates the wrist ulnarward (Finkelstein’s sign220). Proper extensor digiti minimi and Extensor carpi ulnaris extensor digitorum communis 2. The superficial dorsal muscles of the forearm, which include the brachioradialis, extensor carpi ulnaris longus area of the lateral epicondyle (▶Fig. Their muscle and brevis, extensor digitorum, extensor digiti minimi, bellies are visible up to the lower part of the forearm, and and extensor carpi ulnaris muscles, arise entirely in the become flatter from proximal to distal. The supinator 91 2 Surface Anatomy of the Forearm, Wrist, and Hand Structures Fig. Extensor carpi ulnaris muscle cannot be palpated at its origin because it is too Note deep; this makes it difficult to assess hypertonicity of this muscle. The dorsal muscles, which are located deep and Using the ring finger palpation technique is a good way distal, include the abductor pollicis longus, extensor polli- to locate and assess the muscle tone of the superficial cis brevis and longus, and extensor indicis. If the patient makes small finger Palmar Wrist, Three Palmar Tendon extension movements, slight contractions in the area of Compartments, and Palmar Nerves the lateral epicondyle make this muscle easy to see. Once and Vessels the muscle has been located, the examiner’s ring finger is placed on the muscle with the ring finger pointed proxi- On the palmar aspect and ulnar side, the pisiform, the mally (▶Fig. The examiner then places the other flexor carpi ulnaris muscle and ulnar artery, and the hook fingers of the hand on the forearm so that they are of hamate can be palpated (▶Fig. The tendon of the flexor and are more or less fused together, they cannot be pal- carpi radialis lies laterally to the radial artery and rests on pated separately. The trapezium, trapezoid, scaphoid, and medially the index finger, and the brachioradialis muscle below the capitate and lunate, can then be located on the radial the thumb. With these structures as landmarks, the flexor The ring finger palpation technique, in which palpa- retinaculum with the carpal tunnel can be located. The tion is performed by the ring finger, can also be used to third palmar tendon compartment with the superficial palpate the deep dorsal muscles (▶Fig. To do this, and deep flexor digitorum muscles can be located on the the thumb is brought into reposition, which makes the ulnar aspect. The pal- of the flexor pollicis longus muscle can be located on the pating ring finger follows this tendon toward the ulna radial aspect. The extensor pollicis longus muscle is located below the Note ring finger, the proper extensor indicis muscle is located below the little finger, the extensor pollicis Fewer structures can be palpated directly on the palmar brevis muscle is located below the middle finger, and surface of the hand than on the dorsal surface. However, the abductor pollicis longus muscle is located below it is still very important to be familiar with the approxi- the index finger. Proper extensor indicis Extensor pollicis longus Extensor Abductor pollicis pollicis brevis longus Pisiform with triquetrum Fig. Flexor carpi Hamate with hook ulnaris of hamate Ulnar nerve Ulnar artery Superficial branch of ulnar nerve margin of the hand. The hand is placed in pronation posi- tion with the wrist slightly flexed and the pinch grip is used to immobilize the pisiform. From this position, the The first step is to look for the pisiform, which is easy to mobility of the pisiform can be tested easily. This bone is located at the level of the distal wrist carpi ulnaris tendon is located directly proximal to the crease on the lateral side of the proximal end of the pisiform. It extends across the pisiform and the hook of 93 2 Surface Anatomy of the Forearm, Wrist, and Hand Structures hamate to its insertion at the palmar base of the fifth Note metacarpal. The flexor carpi ulnaris tendon is easy to pal- pate if the wrist is placed in isometric ulnar deviation. Ongoing pressure (such as during cycling) in the area of The ulnar nerve—which cannot be palpated—lies on the the ulnar tunnel can lead to paresthesia in the region of radial aspect of the flexor carpi ulnaris muscle, with the the hypothenar, the little finger, and half of the ring fin- ulnar artery at the end (the pulse, which is rather weak, ger, and the entire area innervated by the ulnar nerve (in is easy to palpate here). Within this tunnel, the ulnar nerve divides into a superficial sensory branch and a deep motor branch. On the ulnar aspect, the superficial On the radial aspect, the flexor carpi radialis tendon is branch gives off a branch for sensory innervation of the easy to see and extends into the first palmar tendon hypothenar eminence between the pisiform and the compartment of the wrist. The main branch runs past the hook of directly lateral to this tendon and can be clearly felt as hamate on the radial aspect and then divides into smaller a strong pulse on the flat palmar plateau of the radius. If one follows the flexor ment between the pisiform and the hook of hamate carpi radialis tendon from proximal to distal, the sca- causes paresthesia in the area of the hypothenar emi- phoid tubercle is easy to palpate at the level of the nence, directly radial to the hook of hamate in the little pisiform. In so doing, it crosses under the extensor polli- cis longus tendon, extends across the first and second intermetacarpal space back toward the palmar aspect, and finally merges with the deep palmar arch. The palmaris longus tendon is located in the medial palmar wrist and is easily visible; however, it is not present in about 15% of the population. First palmar tendon compartment Flexor retinaculum with flexor carpi radialis tendon 94 2. The trapezium cannot be palpated from the pal- compartment, it extends directly into the carpal tunnel, mar side.

Electrophysiologic and pharmacologic characteristics of automatic ectopic atrial tachycardia cheap 25 mg capoten amex. Ectopic automatic atrial tachycardia in children: clinical characteristics order capoten 25 mg amex, management and follow-up purchase capoten 25mg. Reversibility of left ventricular dysfunction after successful catheter ablation of supraventricular reentrant tachycardia. Time course of improvement in ventricular function after ablation of incessant automatic atrial tachycardia. Regression of a dilated cardiomyopathy after radiofrequency ablation of incessant supraventricular tachycardia. Multiple reentrant tachycardias due to retrograde conduction of dual atrioventricular bundles with atrioventricular nodal-like properties. Participation of fast and slow A-V nodal pathways in tachycardias complicating the Wolff-Parkinson-White syndrome. Role of the surface electrocardiogram in the diagnosis of patients with supraventricular tachycardia. Chapter 9 Atrial Flutter and Fibrillation Atrial fibrillation and its cousin, atrial flutter (typical and atypical), are the most common arrhythmias with which we must deal clinically, yet they are the group of arrhythmias about which we know the least. For the past decade, experimental data as well as clinical electrophysiology studies have allowed a better, but still incomplete, understanding of these arrhythmias. It appears that they represent a heterogeneous group of disorders that are markedly influenced by the functional and anatomic structures of the right and left atrium as well as the autonomic nervous system. Atrial fibrillation and flutter frequently coexist and can appear spontaneously or can be induced in the same patient. The clinical and electrophysiologic definitions of atrial fibrillation and flutter are hard to decipher. More recently, atrial fibrillation has been divided into paroxysmal (self-terminating within 7 days), persistent (lasting greater than 1 week or requiring electrical or pharmacologic cardioversion), and permanent (failed cardioversion or not 1 attempted). Others have tried to categorize atrial fibrillation by assumed mechanisms, such as a focal atrial fibrillation, vagally mediated atrial fibrillation, sympathetically mediated atrial fibrillation, etc. Atrial fibrillation has also been classified based on whether or not it appears as an isolated electrical phenomenon (lone atrial fibrillation) or whether it is associated with some form of organic disease. The fact that there are so many definitions attests to our lack of total understanding of this arrhythmia. Typical flutter is a term now used to describe both “classic” counterclockwise flutter in which the inferior leads demonstrate a sawtooth-like undulating baseline with positive flutter waves in lead V and negative flutter waves in V , and clockwise flutter, which has1 6 positive, notched flutter waves in the inferior leads and in V and negative flutter waves in V. Both of these6 1 patterns are currently believed to be due to reentry with opposite directions of activation (counterclockwise and clockwise) in the same anatomic circuit. The term “atypical” flutter is currently applied to any macrorentrant atrial tachycardia that is different from these two. It is therefore necessary to distinguish a reentrant mechanism from an automatic mechanism to diagnose “atrial flutter” versus atrial tachycardia when tachycardia rates are 250 to 320 beats per minute (bpm) in the absence of drugs. I prefer to use the terms macrorentrant and focal atrial tachycardia; the term “flutter” is too often misused and incorrect. The term typical flutter should be used to describe macroreentrant, tricuspid-caval isthmus-dependent atrial tachycardia. Given all these variables, this chapter will discuss the role of electrophysiology studies in evaluating these arrhythmias. Programmed atrial stimulation and endocardial activation mapping techniques have been used to (a) analyze the electrophysiologic substrates of atrial conduction, refractoriness, and ectopic atrial impulse formation that may be responsible for the initiation of either macroreentrant atrial tachycardia (i. Additional benefits of an electrophysiologic study are the ability to determine the nature of P. Electrophysiologic and Anatomic Substrates of Macroreentrant Atrial Tachycardia (Typical and Atypical Atrial Flutter) and Fibrillation Atrial fibrillation occurs in many disease states, but can occur in the absence of disease, that is, lone atrial fibrillation. Microscopic abnormalities can be found in patients with and without atrial fibrillation which may be part of normal aging. Even in those cases of lone atrial fibrillation, pathologic studies have demonstrated a variety of abnormalities including myocardial hypertrophy, vacuolar degeneration, ultrastructural evidence of fibrillolysis, lymphocytic infiltrates, and patchy fibrosis, all of which suggest a myopathic process with various degrees of 2 inflammation. While none of these abnormalities are specific for patients developing spontaneous atrial fibrillation, similar findings were not observed in patients undergoing open heart surgery for Wolff–Parkinson– White syndrome with no history of atrial fibrillation. The atria are a complex three-dimensional structure with many anatomic obstacles as well as variable oriented muscle fiber adjacent to and overlying one another on both the endocardial and epicardial surfaces, particularly in the left atrium (Fig. These multiple adjoining regions, in and of themselves, produce abnormalities of propagation in the absence of differing electrophysiologic properties. However, to complicate matters, the cellular electrophysiology of the various parts of the atrial tissue vary. For example, along the crista terminalis, cells possess phase 4 depolarization and a prolonged phase 2 following a 3 transient outward current. Septal myocardial cells do not show diastolic depolarization and have triangulated action potentials. Other areas in the atrium show postrepolarization refractoriness due to different recovery kinetics of potassium currents and/or impaired excitability. Thus, there is heterogeneity of recovery of excitability or functional refractoriness throughout the atria. Anisotropic propagation is nonuniform and gets progressively 4 5 more nonuniform with age. The atria are also markedly influenced by cholinergic as well as sympathetic innervation. Thus, the atria have anatomic, electrophysiologic, and neurologic heterogeneity to such an extent that it is surprising why everybody does not have atrial arrhythmias. Their proximity can lead to far-field signals from these structures recorded in the pulmonary veins. Conduction Defects in Patients with Atrial Fibrillation and Flutter Many patients with atrial fibrillation and macroreentrant, tricuspid-caval isthmus-dependent atrial tachycardia (i. These are characteristic findings of so-1 called left atrial abnormality and are present in the vast majority of patients with atrial flutter or fibrillation, regardless of the underlying etiology. The broad notched P wave in the inferior leads is the most common abnormality, while the exaggerated negative terminal force in V is the next most common. One or more of these1 abnormalities are seen in 80% to 85% of patients with these arrhythmias. In nearly two-thirds of patients, the P-wave duration exceeds 120 msec when all 12 leads are assessed simultaneously. For patients with so-called left atrial abnormalities, right atrial conduction time is normal in 80% of patients with a mean right atrial conduction time of less than 50 msec. For the remaining patients, right atrial conduction time was only modestly prolonged except for six patients with dilated cardiomyopathy who had prolonged right atrial conduction times exceeding 62 msec. Where the site of delay is located is unclear, but there appears to be delay between the right and left atrium at the region of Bachmann bundle as well as at the lower septum. A more detailed analysis of intra-atrial conduction during sinus rhythm in patients with atrial fibrillation is important to assess the potential role, if any, of intra-atrial conduction disturbances in the pathogenesis of atrial fibrillation. Detailed mapping with the Carto system (Biosense, Cordis/Johnson and Johnson, see Chapter 3) has been of value in this regard. Correct interpretation of intra-atrial and interatrial conduction requires mapping along the posterior left atrium and left atrial septum in order to more specifically localize the sites of delay.

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The syndrome described by Clare Fowler is associated with polycystic ovaries (Fowler’s syndrome) [51] generic capoten 25 mg otc. Sustained contraction of the urethral sphincter has an inhibitory effect on bladder afferents and efferents buy capoten without prescription, resulting in loss of bladder sensation and urinary retention capoten 25mg generic. The mean age of a series of women with this problem was 27 years; spontaneous onset appears to be more common in women under 30 [52]. Characteristically, the women present with a bladder capacity in excess of 1 L, and, although this may cause painful distension, they lack any expected sensations of urinary urgency. There may or may not be a history of infrequent voiding prior to the onset of urinary retention. These women are taught to do clean intermittent self-catheterization and commonly experience difficulties with this technique, in particular pain and difficulty in removing the catheter. It should certainly be carried out before stigmatizing a woman as having “psychogenic urinary retention. With degeneration of muscle fibers, the motor units loose them; the number of motor units, however, may not change. Such changes have not been reported in the pelvic floor, even in patients known to have generalized myopathy [57]. Furthermore, the concentric electrode can be employed at the same diagnostic session for recording motor evoked responses and/or reflex responses [21]. However, the technique requires access to stimulation of the nerve at two separated points and measurement of the distance between them (Figure 36. An electrophysiological parameter that requires a shorter length of motor nerve to be accessible is measurement of the terminal motor latency of a muscle response [2]. The more widely employed technique of obtaining the pudendal terminal motor latency relies on stimulation with a special “surface electrode assembly” fixed on a gloved index finger [63], often referred to as the “St Mark’s” device. It consists of a bipolar stimulating electrode fixed to the tip of the gloved finger with the recording electrode pair placed 5 cm proximally on the base of the finger. The finger is inserted into the rectum or vagina and stimulation is performed close to the ischial spine. A “rounded” response is recorded from the surface electrodes at the base of the finger (which is claimed to be the M wave from the external anal sphincter) with a typical latency around 2 ms. In studies, as a rule only latencies have been studied as amplitudes of the “M wave” response have not proved contributory. From studies using this test, it was concluded that occult damage to the pudendal innervation of the external anal sphincter occurs after vaginal delivery, and the conditions worsen over many years by abnormal straining patterns of defecation [47]. It was said to be of pathogenetic importance for idiopathic stress urinary incontinence, fecal incontinence, and pelvic floor prolapse [44]. The prolonged latency and the muscle defect were thought to reflect a common traumatic cause. This however, is mistaken, as prolongation of latency is a poor measure of denervation. In contrast to earlier studies, more recent work suggests the test does not predict improvement, or the lack of improvement, after surgical repair of anal sphincter defects [66]. A prospective evaluation of anorectal physiological tests in 90 patients with fecal incontinence did not find that pudendal terminal latency test results changed treatment decisions [67]. Indeed, the American Gastroenterological Association statement indicated that “pudendal terminal latency cannot be recommended for evaluation of patients with fecal incontinence” [68]. Nerve entrapment initially results in axonal excitability and excessive ectopic spike discharges that is followed by central sensitization, which plays an important role in maintaining chronic pain. These functional changes cannot be identified by clinical neurophysiology and only when entrapment is severe enough do abnormalities appear. Segmental demyelination results in conduction block with focal nerve conduction slowing, which may not be identified in the short length of the pudendal nerve measured. Also, these techniques investigate motor functions, whereas symptoms and signs are mainly due to sensory dysfunction [69]. Currently, measuring pudendal nerve latencies in incontinence is not recommended [70]. A selective needle recording of a (sphincter or pelvic floor) muscle response (M wave) on appropriate electrical stimulation may be informative in selected patients with suspected “lower motor neuron– type” lesions. Anterior Sacral Root (Cauda Equina) Stimulation Transcutaneous stimulation of deeply situated nervous tissue became possible with the development of special electrical [71] and magnetic [72] stimulators. When applied over the spine, these stimulators stimulate mainly the roots at the exit from the vertebral canal [73]. It has been shown that responses from gluteal muscles may contaminate attempts to record from the sphincters and lead to error [77]. Positioning of the ground electrode between the recording electrodes and the stimulating coil should decrease the artifact (Figure 36. Stimulation of the roots may be used to obtain a peripheral conduction time so that a central conduction time (see next section) can be calculated [79]. Assessment of Central Motor Pathways Using the same magnetic or electrical stimulation as mentioned earlier, it is possible to stimulate the motor cortex and record a response from the pelvic floor. Magnetic stimulation is less unpleasant; electrical cortical stimulation is nowadays only used intraoperatively in anesthetized patients. The mean latencies were between 30 and 35 ms if no “facilitatory maneuver” was used. Central conduction times of approximately 22 ms without and about 15 ms with the facilitation (i. Substantially, longer central conduction time in patients with multiple sclerosis and spinal cord lesions as compared to healthy controls have been found [1], but all those patients had clinically recognizable cord disease. Normative values for the urethral sphincter and the puborectal muscle in adult women have been reported for transcranial magnetic stimulation [80,81]. It has been demonstrated that in comparison to the motor area for hand muscles, the anal sphincter motor cortex has less intracortical inhibition [83]. Because of the significant influence of voluntary contraction, there is a possibility of variability of both total conduction times and central conduction times. Later negative (at around 55 ms) and then further positive waves are interindividually quite variable in amplitude and expression and furthermore have little known clinical relevance. Special techniques of stimulation isolate each dorsal clitoral nerve and may be more sensitive at locating the precise site of pathology [90]. A study that looked at the value of the pudendal evoked potential when investigating urogenital symptoms for detecting relevant neurological disease found it to be of lesser value than a clinical examination looking for signs of spinal cord disease in the lower limbs, i. There may, however, be circumstances in routine diagnostics— such as when a patient is complaining of loss of bladder or vaginal sensation—that it is reassuring to be able to record a normal pudendal evoked response. The first reflex component is spurious at the applied stimulation strength, which was two-times sensory threshold; the second (late) reflex component is obvious. When making such measurements, it is of utmost importance to use bipolar stimulation in the bladder or proximal urethra; otherwise, somatic afferents will be depolarized [95,96]. The typical latency of the most prominent negative potential (N1) is approximately 100 ms [95,97].

Traditionally generic capoten 25mg without prescription, gynecologists and urologists have asked questions to their patients pertaining to sex order capoten with visa, which are comfortable for both to ask and answer cheap 25 mg capoten mastercard. The enquiry may be directed to areas perceived by clinicians as influenced by the disease or condition and that may reasonably be expected to improve with intervention. These include sexual activity, often phrased as frequency of penetrative vaginal intercourse, and pain or dyspareunia. More qualitative components of sexual function may be more difficult to assess unless posed in a questionnaire format. Asking about orgasm frequency or quality, satisfaction, arousal, and sexual desire may be difficult for both clinicians and patients, particularly if they perceive they have had inadequate training [3,4]. As these factors frequently vary between couples depending on the length and quality of relationship, the age of both partners, and the menopausal or peripartum status, a questionnaire that is sensitive enough to determine these factors may be important if trying to assess the impact of an intervention such as surgery. It is likely that issues of lesser concern to individuals were previously focused on, and this underestimates the true incidence of sexual difficulties. At present, it appears anatomical vaginal measurements in urogynecological patients do not predict function [5]. Investigations such as urodynamic measures, pelvic blood flow, 4D ultrasound, vaginal plethysmography, and nerve conduction studies may give quantitative values to compare population or study groups, but the evaluation of their relationship to sexual function is in its infancy. Whether they will ever graduate to useful clinical measurements with respect to sexuality is arguable. However, sexual problems are also highly prevalent, with a North American study reporting that up to 43% of women and 31% of men aged between 18 and 59 admitted a problem in the previous year [6]. British studies have indicated that the prevalence of sexual problems in primary care is high with 22% of men and 40% of women being diagnosed with a sexual dysfunction, although this was poorly recognized and documented [7]. However, when the degree of distress or “bother” is considered by clinicians, the proportion with a sexual problem approximately halves in many studies [8]. Questionnaires that are sensitive enough to detect these differences and the modification that can be expected from 215 urogynecological interventions may help individual patients and studies. Over the twentieth century, models of human sexual behavior have been proposed, and its classification of normal and abnormal became clinical measurable entities. However, the norms for function and activity are varied, and at present, there is a debate over how medicalization of human sexual behavior has been propagated by the prospect of pharmaceutical intervention. Yet, there is also a drive from women as expectation of a full and satisfying sexual life has been raised, with over half of one study of 1805 European menopausal women stating it was important [9]. Many other international studies of older populations reinforce these findings [10,11]. The Masters and Johnson human sexual response cycle model from the 1960s details the changes occurring during sexual activity based on observations from laboratory-based sexual encounters [12]. This contrasts to the linear human sexual response model of Masters and Johnson more in keeping with male sexuality, having an inbuilt sexual drive, i. Women, in contrast to men, may only achieve orgasm in 50% of penetrative intercourse and a further 20% with external stimulation. The International Consensus Group model of female sexuality indicates that a spontaneous sexual drive to be involved in sexual activity does not need to be present for satisfactory relationships to be maintained. Therefore, it is important to understand the other features influencing an individual woman’s ability to be sexual in order to explain why she may be experiencing difficulties. How much urogynecological complaints contribute to this may not be clear to the clinician or patient themselves. Sexuality is modulated by many factors and normal features of life, including life events, reproductive events, health, relationships, and cultural factors. Female sexuality is a complex interplay of physiological, psychological, and cultural factors. The quantification of these disorders including the identification and qualification of pain can be adapted for clinical and research settings. Specific dysfunctions can be diagnosed if the domains within an instrument are sufficiently sensitive. Not all instruments are diagnostic of dysfunctions, while others are specific to one disorder, e. Before choosing an instrument for use, the outcomes sought should be clarified so fitness for purpose can be ensured. Questionnaires may be designed to give a composite score that can be broken down into domains to diagnose or screen for a specific dysfunction (e. Many instruments may have a more “user-friendly”short form for use in clinical practice but are likely to be less sensitive. Surveys have reported that this is due to lack of time and treatment options, the older age of many of the patient groups, and the perceived lesser importance of this aspect of functioning [3,4]. However, there is objective evidence that pelvic floor problems adversely affect sexual relationships and sexuality, making it important clinicians are aware of change in functioning. Most studies report that 50%–60% of urogynecology research participants are sexually active. There is a reluctance on the part of patients to seek help that may be mitigated by the doctors’ comfort and ability to communicate about such personal matters. It can be easier for both the doctor and patient to use a questionnaire to detect these difficulties. However, this can also be perceived as an avoidance tactic by surgeons with a different agenda. Questionnaires do help to reduce the time constraint of the doctor–patient interaction by having patients complete the questionnaires while waiting for the consultation or before their clinic visit. Furthermore, in the area of sex, reduction of embarrassment may result in more valuable answers. Yet, as all clinicians would agree, these instruments have no replacement for the consultation and should be interpreted and integrated with the patients’ complaints. Up to 50% of women with urinary incontinence complain of coital incontinence with approximately one-third admitting it compromises their sexual health [16]. This has been reported widely as impacting on quality of life [17], yet surgical cure for this complaint is not always reported to improve sexual function [18]. Similar findings have been reported with pelvic organ prolapse procedures although the huge variation in surgical techniques and individual patient anatomy may be potential confounding factors [19]. Validity and reproducibility may depend on the tools used to measure these outcomes and explain the conflicting results from many urogynecological studies with respect to sex [20]. Objective Measures There have been numerous objective measures developed to diagnose and assess erectile function (e. Diagnosis and assessment of men with premature ejaculation has relied on the use of time (stopwatch assessment) to ejaculation (intravaginal latency time). For women, objective measures have been developed such as vaginal photoplethysmography and Doppler ultrasonography [23]. Subjective Measures Subjective measures of sexual health have flourished over the past 10 years.

By B. Ballock. Humboldt State University.

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