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Structural testing measures include ultimate load purchase kamagra polo with visa, ultimate elongation kamagra polo 100mg amex, and stiffness buy cheapest kamagra polo. These parameters are obtained directly from load–elongation curves and do not account for variations in sample dimensions. Mechanical testing properties include ultimate strength, ultimate strain, and tangent modulus. These measures are normalized by specimen dimensions and are used to characterize the mechanical behavior of continuous materials. While materials such as single filament of polypropylene can be characterized using mechanical properties, porous textiles such as synthetic mesh must be characterized by structural properties. In addition, the lack of knowledge concerning the cause of mesh-related complications (erosion, exposure, infection, dyspareunia, and pain) highlights the necessity for examining the host response to grafts in the vagina. Such an understanding is imperative to improve patient outcomes following mesh implantation. Recent studies have begun to enhance our understanding of the impact of mesh implantation on the morphology, composition, and biomechanical behavior of the vagina. Further, Gynemesh significantly increased the number of apoptotic cells in the subepithelium and adventitia layers, rising from 0. Overall the impact of mesh was apparent, as a majority of apoptotic cells were located around the individual mesh fibers. Interestingly, changes in vaginal morphology and apoptosis were less pronounced following the lower-stiffness UltraPro and Restorelle implantation. Gynemesh also negatively impacted the composition of the extracellular matrix, decreasing collagen and elastin content by 20% and 43%, respectively. While UltraPro and Restorelle were not detrimental to collagen content, UltraPro induced a decrease in elastin content by as much as 49%. Overall, these results clearly demonstrate that the vagina undergoes a maladaptive remodeling response following mesh implantation with heavier-weight, lower-porosity, and higher-stiffness meshes elicite the most detrimental changes. The degenerative response was the most consistent with a phenomenon referred to as stress shielding, a mechanosensitive phenomenon in biological tissues, which results in thinning of the tissues associated with a prosthesis. Alternatively, degradation could be the end result of chronic inflammation associated with a foreign body response. Regardless of the mechanism, these findings are consistent with processes that result in degradation of the vagina, predisposing vaginal tissue to mesh exposure. Here, the red signal represents positive staining of alpha-smooth muscle actin, the green signal represents apoptotic cells, and the blue signal represents nuclei. Further, increased apoptosis was observed surrounding the mesh (mesh designated by M). Nearly all meshes groups tested reduced smooth muscle contractility relative to sham samples. UltraPro and Restorelle also interfered with smooth muscle contractility; however, such negative effects were much less than that observed with Gynemesh. Passive properties, typically representing the mechanical integrity of fibrillar extracellular matrix proteins (collagen and elastin), were evaluated via ball burst testing, as typical planar mechanical tests are invalid for composite mesh– tissue structures of these dimensions. Accounting for the combined stiffness of both mesh and tissue, Gynemesh significantly reduced the passive mechanical integrity of the tissue, decreasing the estimated stiffness of the vagina to almost 0 N/mm, nearly a 10-fold reduction . This result suggests that Gynemesh implantation nearly abolishes the mechanical integrity of underlying and associated vagina in agreement with reports of decreased total collagen and elastin content following mesh implantation . Overall, mesh implantation appears to be detrimental to the mechanical properties of the vagina, particularly with the heavier-weight, lower-porosity, and higher-stiffness devices. This is concerning as 1382 degradation of the vaginal smooth muscle, collagen, and elastin (key constituents of vaginal tissue) are already thought to be compromised in women with prolapse . Ideally, mesh implantation would enhance or, at minimum, maintain the supportive capabilities of the vagina, though synthetic mesh, as currently utilized, has the potential to damage native vaginal tissue. Thus, the majority of current data in the literature, as well as vendor marketing pamphlets, use legacy methods to demonstrate biocompatibility of prolapse mesh products, by implanting synthetic mesh in the abdominal wall. While there is great utility in such studies, namely, verifying a lack of outright host rejection, the abdominal wall and pelvic floor are quite dissimilar in regard to the biologic environment and the mechanical demands placed on a mesh implant. Because the current generation of synthetic mesh is based on the technology developed for abdominal hernia repair, it is deemed compatible for prolapse repair based on premarket characterization, yet the transfer of this technology from abdominal use to reconstruction of the pelvic organ support leaves much room for optimization. As such, current urogynecologic mesh is largely a prototype solution rather than an optimal one, as evident by the complications associated with mesh implantation. Despite the distinct differences between the abdominal wall and the vagina, many of the design changes responsible for recent reductions in prolapse mesh complications have directly resulted from findings in the abdominal wall. Perhaps the most important concepts shown to impact the host response to synthetic meshes in urogynecologic applications are material type, filament type, and pore size. Material Type Since the introduction of the first synthetic nylon sling in the 1950s, urogynecological grafts have been constructed from a variety of materials, resulting in a wide range of outcomes . These materials include polyethylene terephthalate (Mersilene), polypropylene (Marlex), polytetrafluoroethylene (Teflon), and expanded polytetrafluoroethylene (Gore-Tex) . Ex vivo and in vitro studies have shown that these materials are nontoxic and have a high tensile strength, demonstrating their ability to be used in reconstructive pelvic surgeries. Though the material chosen for mesh construction likely plays a role in dictating the host response, additional structural features of a mesh design have confounded the impact of many graft materials. For instance, Teflon and Gore-Tex experienced disastrous results as prolapse meshes. The distinctive trait for these materials was poor integration with host tissues, and while the ease of removal was initially touted as a benefit, Gore-Tex was plagued with numerous complications of alarming severity . Gore-Tex slings were reported to have a removal rate of at least 35%, with a significant number of sinus tract formations (10%), in addition to infections and reports of vaginal exposures . Similarly, in a large prospective multicenter trial, Gore-Tex was found to be a significant risk factor for mesh exposure into the vagina following sacrocolpopexy [19,27]. Still, the failure of Gore-Tex is likely due to the small pore size (<10 μm) used in this product rather than the polymer itself. Another material that has been linked to poor clinical outcomes is polyethylene terephthalate, a polyester polymer. This polymer was used to construct a graft using a woven, multifilament construction technique and manufactured as Mersilene. Although Mersilene was associated with increased rates of exposure and infection relative to other meshes, surgeons continued to use this material until recently. Interestingly, Mersilene slings also had numerous complications including infection, exposure, erosion, and fistula formation, though manufacturers and surgeons failed to appreciate the problems associated with the use of polyester attempting to overcome the problem by coating it with silicone (marketed as the Protegen sling) . As more data was published on the problems associated with this material, it was gradually been pushed out of the market. Our current understanding of host response to mesh suggests that the adverse host response to Mersilene is likely due to interstices as small as 1 μm that arise from the woven textile construction, rather than the use of polyethylene terephthalate per se. It is thought that such small spaces harbor bacteria because immune cells cannot easily pass into these areas, leading to chronic infection, inflammation, mesh exposure, 1383 erosion, and fistula formation. In the recent decades, polypropylene has become the primary material for synthetic mesh used in incontinence and prolapse surgeries. Unlike the woven construction used for polyethylene terephthalate, polypropylene mesh is most often knitted. Initial studies found polypropylene to elicit a strong inflammatory response including fibrotic tissue formation and multinucleated giant cells (i.
Apart from four autobiographical works 100mg kamagra polo mastercard, the ﬁrst of which dated 1936 discount 100mg kamagra polo free shipping, Maltz published at least ten books between 1960 and 1975 purchase 100 mg kamagra polo with visa, on cosmetic surgery. On the other side of the Ocean, aesthetic surgery devel- oped mainly in Paris, Berlin, and Vienna. In Paris worked Suzanne Nöel, Raymond Passot, Julien Bourguet, and Maurice Virenque. Mazzola In 1926, Suzanne Nöel published La Chirurgie Esthétique: Son Rôle Sociale , one of the ﬁrst textbooks on this topic and the ﬁrst written by a woman. Julien Bourguet (1876–1952), renowned for having ﬁrst described the transconjunctival approach for baggy eyelid in 1929 , wrote La véritable Chirurgie Esthétique du Visage in 1936  where he showed spectacular results of surgery for facial rejuvenation (Fig. Raymond Passot (1886–1933) added innovative tech- niques for breast ptosis, abdomen, facial rejuvenation, and eyelid correction using Bourguet’s method. His book La Chirurgie Esthétique pure, dating from 1931 , shows a wide range of operations in the ﬁeld of aesthetic surgery (Figs. Maurice Virenque (1888–1946) was a maxillofacial sur- geon from Paris and a member of the French association “Les gueles cassées” (the facial cripples). He worked in Le Mans military hospital and for a certain period of time he was Tessier’s chief, when Paul Tessier attended the Le Mans, Maxillo-Facial Unit. Due to his large experience in maxillo-facial surgery and his great knowledge of facial anatomy, Virenque developed new original approaches to Fig. In an era where face-lifting excision for face-lifting, illustrated in Joseph’s book, became was purely by skin undermining, he advocated the plication soon the standard method  (Fig. In the 1970s, the Face and Neck)  is of great importance in the his- Tord Skoog  realized that skin and subcutaneous tis- tory of face-lifting. Regrettably, it is seldom acknowledged sue are closely related to each other to form a compound and quoted. By pulling on In Berlin, Jacques Joseph (1864–1934), the father of aes- the orbicularis and platysma muscles, wrinkles are greatly thetic rhinoplasty, was well known for his operations for reduced and the ﬁnal result lasts longer. The importance facial rejuvenation and eyelid correction The design of skin of the fascia superﬁcialis was ﬁrst emphasized by the b c d Fig. Conclusions Face-lifting started in the 1920s with simple, mini-inva- sive procedures performed under local anesthesia and on outpatient basis. In recent years, it has considerably evolved, from pure skin dissection, with a limited durabil- ity over the years, to more and more aggressive tech- niques, which involve the deep structures. Knowledge of anatomy and physiology of the aging process was at the basis of this development. Wreszinski W (ed) (1912) Der Londoner Medizinische Papyrus und der Papyrus Hearst, vol 153. Bulwer J (1653) Anthropometamorphosis: man’s transform’d: or the artiﬁcial changeling. Kromayer E (1905) Rotationsinstrumente: ein neues technisches Verfahren in der dermtologischen Kleinchirurgie. Chir Dermatol Ztschr 12:26–36 Italian Giuseppe Sterzi (1879–1919) who described it in 7. Bourguet J (1928) Notre traitement chirurgical de « poches » sous 65:517–524 les yeux sans cicatrice. The correction of featural Transactions of the 2nd congress of the international society of plas- imperfections, 2nd edn. Half a millennium has passed since Leonardo da Vinci com- 1 Tissue Layers of the Face posed this frank, yet detailed self-portrait in which he described the effects of time on his face. Our preoccupation with facial The scalp is the basic archetype for understanding facial aging has a long and well-deserved history. It is difﬁcult to anatomy, as it contains the same tissue layers and planes, envisage da Vinci’s portrait devoid of the extensive grooves without the complexity of the modiﬁed areas of function and furrows, such is their contribution to our perception of found overlying the bony cavities of the face proper . A brief glimpse of a person’s face The skin provides the visible surface that undergoes affords a wealth of information, including an estimate of the intrinsic changes as well as reﬂecting changes to the deeper person’s age, gender, emotional state, racial background, and soft tissue layers of the face. We use these cues, almost subliminally, to guide specialisations occur, with thick dermis containing addi- our interactions with people, as the cues are predictive of the tional collagen over the less mobile areas, such as the nasal behaviour we should expect from each person in return. While the visual effect is obvious, the The arrangement of the retinacular cutis ﬁbres of the face process is not easily described, as it is the culmination of the is not homogenous. It varies in accordance with the anatomy simultaneous changes of several different, but adjacent tis- of the fourth layer (discussed later). Accordingly, this perpendicular fashion to reach the dermis and retain the der- chapter is structured around a description of the concentric mis here in close proximity to the underlying ligaments. Then Where soft tissue spaces are located in the fourth layer, the effect of aging on the structure of each layer is analysed, the overlying retinacular ﬁbres are oriented more parallel to so that each of the characteristic stigmata of aging can be the dermis, providing less restriction to movement . The third layer of the archetype corresponds to the con- ﬂuence of the galea aponeurotica which invests the occipito- frontalis in the scalp, the temporoparietal fascia of the B. The superﬁcial cervical fascia invests platysma in the same manner as the galea aponeurotica invests the occipito- J. O’Brien In the scalp, the fourth layer is a glide plane composed of loose areolar tissue that allows the overlying layers to move relative to the skeleton. In the face, consistent with the com- plexity of its function, the fourth layer is more complex, as it contains more discrete areas of glide plane, known as the soft tissue spaces. These spaces are separated by the immobile retaining ligaments and immobile areas of fascial condensa- tion that contain important anatomical structures, in addition to the deep layer of mimetic muscles extending from their periosteal origin . With regard to facial aging, there are several clinically important spaces within the fourth layer; the preseptal space of the lower lid, the prezygomatic space, and the premasseter space. Each of these spaces has a ﬂoor formed by tissue of the ﬁfth layer, and a roof formed by tissue of the third layer. Each space has boundary structures that have a varying propensity for the development of laxity with aging. These spaces will be discussed with respect to age-related changes visible on the regions of the face that they underlie. The periosteum of the skull and facial bones is conﬂuent with the ‘masticator’ fascia and with the investing layer of the deep cervical fascia of the neck. In the neck, this layer of fascia invests sternomastoid and trapezius, while in the face, the muscles of mastication are invested; temporalis, masse- ter, and the lateral and medial pterygoids. The masticator fascia over temporalis is known as the ‘temporalis fascia’, and over masseter as the ‘masseter fascia’. The investing layer of deep cervical fascia affords pro- tection to the cervical plexus (deep) and the spinal acces- sory nerve (within the fascial investiture) as they course towards their destinations. Similarly, the masseteric fascia affords protection to the zygomatic, buccal, and marginal Fig. The commonly utilised mandibular branches of the facial nerve as they course surgical planes are shown in relation to the tissue layers anteriorly, changing plane only when they approach the retaining ligaments of the fourth layer. It is this protection of the facial nerve rami in the lateral face where they lie face of these superﬁcial muscles, and thin on the superﬁcial deep to layer ﬁve that provides for safe dissection in the surface, extending into the retinacular cutis. Where the superﬁcial ﬂat muscles of the face are not present, these two fascial lay- ers are fused and become aponeurotic. Among the ﬁrst cle, and 3c – the thicker fascia on the underside of the mus- noticeable changes are the expression lines and wrinkles cle. The Aging Face 857 Repetitive action of the vertical orbicularis oculi ﬁbres in the region of the lateral orbicularis raphe contribute to the for- mation of crow’s feet lines at their most lateral extent .
Tis tells the the head to chest buy kamagra polo with amex, with the end of the frame starting medical examiner that the laceration occurred during just before the top of the head and ending somewhere transit order kamagra polo visa. Te body may have been photographed in frame discount kamagra polo 100mg line, taking care to include little to no extraneous wearing a ring at the scene but may not have the ring on material. Tere are many diferent frst section so nothing is missing in sequential pho- situations where documenting the body on arrival may tos. Clean Overalls Backgrounds It is very important to have clean, dry overalls of the When shooting from the side, it is good to have a slid- body in all cases. Clean pho- the photographer to shoot without having distractions tographs are only taken afer all the evidence needed is behind the body (technicians, doctors, other bodies, collected by the doctor on staf (see Figure 12. Also, the background should be a neu- Tere are two ways to photograph the back of a body, on tral color; 18% gray is the best choice for accurate light the side or prone. On the Side You can roll the body onto its side, which reveals the fat surface of the back. Photograph the back Shooting Overalls from Overhead In photography in three or four overlapping sections. If the pho- require labels with the case number facing the foot of tograph is taken from the side, the top area will be the photographer in each photograph. It is best if a back- omitted; however, if you photograph it only from the ground is included for these pictures to cut out distrac- top looking down, you may be missing injuries on the tions (see Figure 12. Lateral Prone You may want to orient the decedent so he/she and top-down shots must be done to get a complete is prone. Tis may not be necessary in from the back to the side or to document injuries that most cases, though. Regarding to get a general idea of the weight, height, and condi- homicides, it is good practice to roll the decedents over tion of the body and only one view may be needed. Tis is To take overalls from overhead, one will need either a also helpful in severe trauma cases for proper documen- ladder or an overhead camera stand. Once the body is prone, it can be shot overhead should also be taken in three or four sections, keep- with necessary side photos or both from the side and ing the lens as true to 50 mm as possible and the per- overhead (see Figure 12. Overlap each photo to make sure nothing is missing in sequential photo- Face Photograph graphs. Tis photograph should be framed from the top of pedestrian versus vehicle accidents. Tey are also the camera in any way, and use a 50-mm lens to minimize necessary for homicides that may have injuries such distortion. When using a camera fash, keep the camera as gunshot wounds or stab wounds on the surface (see away from the body to let the fash dissipate. Line the long end of the frame up time the photographs will show where something is on with the long end of the face to get the best results. Tis will place the fash in example, if there is a gunshot wound, before taking a the center of the face instead of of to one side. When the close-up, a midrange photograph would be taken to show camera is vertical and the fash is set to the right or lef where the gunshot wound is. Tis is why show the gunshot wound and an identifable part of the refectors and ring fashes are useful. Following sufcient midrange photos, the close-ups can stay the same as the overall; however, if too much would be next. If you are showing a relationship between falls of with f11, the f-stop can be raised to f16 if there is wounds, you are telling a story about what may have hap- enough fash output (see Figure 12. For example, you might show an entrance gunshot wound on an arm, an exit wound on the same arm, and an entrance wound on the body together. Tese photos should be taken with a 50-mm lens with the label oriented toward the foot of the decedent. Te label should face this direction to help orient the doc- tor when the area is unidentifable. If the label is always facing the foot of the decedent, then the doctor knows where the head is and where the feet are without seeing them. Forensic photographers should always be consis- tent with this unless otherwise requested by the doctor. Midrange photographs also include isolated body parts, such as a single foot or hand. Forensic photogra- phers should always photograph all aspects of the hands on a homicide before evidence is collected. If the decedent has injuries on the hands, then you would photograph them again once they are clean (see Figure 12. Te label again should always face the foot of the decedent, especially now that there is noth- ing to orient the viewer. When shooting close-up, a higher f-stop is necessary since the focal length drops of quicker. Specimen photographs (a) usually consist of an overall and a close-up of a specifc area. Te label should always face the bottom of the specimen for orientation (see Figure 12. Copy Stands If you have a budget and room for a copy stand, they are highly advantageous. Tey are great for shooting small to medium-sized fat evidence, such as money, identif- cation, credit cards, and so on. Tey are also good for shooting slices of cut organs, which can be very shiny and troublesome when shot with a fash. Although bul- lets are not fat, they are small enough to shoot on the copy stand as well. When using a copy stand, make sure the lights are (b) daylight-balanced for good color correction. Since the camera is mounted, slower shutter speeds can be used; however, staying above 1/50 of a second shutter speed is recommended. Slower shutter speeds can let too much ambient light in and disturb the color balance. Appropriately, then, this book is about information—how it is obtained, how it is analyzed, and how it is interpreted. The information about which we are concerned we call data, and the data are available to us in the form of numbers. The objectives of this book are twofold: (1) to teach the student to organize and summarize data, and (2) to teach the student how to reach decisions about a large body of data by examining only a small part of it. The concepts and methods necessary for achieving the first objective are presented under the heading of descriptive statistics, and the second objective is reached through the study of what is called inferential statistics. Chapters 2 through 5 discuss topics that form the foundation of statistical inference, and most of the remainder of the book deals with inferential statistics. Because this volume is designed for persons preparing for or already pursuing a career in the health field, the illustrative material and exercises reflect the problems and activities that these persons are likely to encounter in the performance of their duties. Some of the words and phrases encountered in the study of statistics will be new to those not previously exposed to the subject.
For example order kamagra polo with a visa, the effect of catheter rotation will be relevant when urethral pressure is measured by a catheter-mounted transducer buy 100 mg kamagra polo visa. Urethral pressure might order kamagra polo 100 mg on-line, nonetheless, be measured as follows: ∘ At rest, with the bladder at a given volume ∘ During coughing or straining ∘ During the process of voiding a. Urethral pressure (intraluminal): This is the fluid pressure needed to just open a closed urethra. For external transducers, the reference point is the superior edge of the symphysis pubis. Methodology should be noted  including patient position, catheter type, transducer orientation, fluid and rate of infusion (if fluid-filling system), bladder volume, and rate of catheter withdrawal. Functional profile length: The length of the urethra along which the urethral pressure exceeds Pves in a woman. Functional profile length (on stress): The length over which the urethral pressure exceeds the Pves on stress. Pressure “transmission” ratio: This is the increment in urethral pressure on stress as a percentage of the simultaneously recorded increment in Pves. For stress profiles obtained 1797 during coughing, pressure transmission ratios can be obtained at any point along the urethra. If several transmission ratios are defined at different points along the urethra, a pressure transmission “profile” is obtained. Normal urethral closure mechanism: A positive urethral closure pressure is maintained during bladder filling even in the presence of increased Pabd, although it may be overcome by detrusor overactivity. Incompetent urethral closure mechanism: Leakage of urine occurs during activities that might raise intra-abdominal pressure in the absence of a detrusor contraction. Urethral relaxation incompetence (“urethral instability”): Leakage due to urethral relaxation in the absence of raised Pabd or a detrusor contraction. Urodynamic stress incontinence: This is the involuntary leakage of urine during filling cystometry, associated with increased intraabdominal pressure, in the absence of a detrusor contraction. Leak point pressures [2,32,33]: There are two types of leak point pressure measurement. The pressure is the lowest value of the Pdet at which leakage is observed in the absence of increased Pabd or a detrusor contraction. It is the lowest value of the intentionally increased Pves that provokes urinary leakage in the absence of a detrusor contraction . Voiding cystometry: This is the pressure/volume relationship of the bladder during micturition . It begins when the “permission to void” is given by the urodynamicist and ends when the woman considers her voiding has finished . Measurements to be recorded should be the intravesical, intraabdominal, and detrusor pressures and the urine flow rate. Premicturition pressure: The pressure recorded immediately before the initial isovolumetric contraction. Opening time: The time elapsed from initial rise in pressure to the onset of flow. It reflects the time taken for the fluid to pass from the point of pressure measurement to the uroflow transducer. Flow measurement delay should be taken into account when measuring the opening time. Opening pressure: The pressure recorded at the onset of measured flow (consider time delay). Contraction pressure at maximum flow: This is the difference between pressure at maximum flow and the premicturition pressure. Flow delay: This is the delay in time between a change in pressure and the corresponding change in measured flow rate. Normal detrusor function: Normal voiding in women is achieved by an initial (voluntary) reduction in intraurethral pressure (urethral relaxation) . This is generally followed by a continuous detrusor contraction that leads to complete bladder emptying within a normal time span. The amplitude of the detrusor contraction will tend to increase to cope with any degree of bladder outflow obstruction . Detrusor underactivity: Detrusor contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span. Acontractile detrusor: The detrusor cannot be observed to contract during urodynamic studies, resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span. The term “areflexia” has been used where there is a neurological cause but should be replaced by neurogenic acontractile detrusor. This may be at one specific point, for example, high-pressure zone, or it may be measured as a profile. Bladder outflow obstruction: This is the generic term for obstruction during voiding. A urethral stricture or obstruction due to higher degrees of uterovaginal prolapse or obstructed voiding after stress incontinence procedures is among the possible causes. Dysfunctional voiding: This is characterized by an intermittent and/or fluctuating flow rate due to involuntary intermittent contractions of the periurethral striated or levator muscles during voiding in neurologically normal women. Detrusor sphincter dyssynergia: This is incoordination between detrusor and sphincter during voiding due to a neurological abnormality (i. Ultrasound in urogynecology: Ultrasound has become an increasingly frequent adjunct investigation in urogynecology and female urology both in the office and in the urodynamic laboratory. Current routine possible uses of ultrasound in urogynecology and female urology a. Bladder neck descent/mobility/opening ‡ ∘ Position of bladder neck at rest and on Valsalva. Consensus has not been reached on criteria for excessive bladder neck mobility nor the relationship of this finding to a diagnosis of urodynamic stress incontinence . Transverse diameter (width) of the levator hiatus was measured between the stars at the point of maximum extension of the levator muscles at the level of the urinary bladder and proximal urethra. Postoperative findings: For example, bladder neck position and mobility, position of meshes, tapes, or implants. Pelvic floor/levator defects: Bladder neck elevation during pelvic floor contraction. Descent of pelvic organs: Visualization of descent of the bladder, uterine cervix, and rectum during Valsalva and coughing. Applications with the most current research include (1) major morphological abnormalities such as levator defects  and (2) excessive distensibility of the puborectalis muscle and levator hiatus (“ballooning”—). Other assessments: Synchronous ultrasound screening of the bladder and/or urethra and measurement of the bladder and Pabd during filling and voiding cystometry. Anal ultrasound (endosonography) : This is the gold standard investigation in the assessment of anal sphincter integrity. There is a high incidence of defecatory symptoms in women with anal sphincter defects. Intravenous urography : This provides an anatomical outline of the urinary tract including a nephrogram prior to passage of the contrast to the calyces, renal pelvis, ureter, and bladder.