[The need for urodynamic tests]

Two hundred forty women were studied, who underwent symptomatological anamnesis, clinical examination and urodynamic investigations for female urinary incontinence. Our aim was to distinguish among the three main forms of incontinence (stress, urge and mixed incontinence). When only symptomatological anamnesis is considered, there is an incidence of error in nearly a third of the cases and, when further factors like menopause, prolapse and parity are considered, the incidence of error does not reduce. A correct diagnosis can be determined only by a combined use of clinical assessment and urodynamic investigations. (As regards clinical examination, a positive stress test leads to a diagnosis of stress incontinence. As regards urodynamic investigations a cystometry positive for instability of the detrusor muscle leads to a diagnosis of urge incontinence. If both clinical examination and urodynamic investigations are positive, the diagnosis is of mixed incontinence.) Our findings suggest that routinely it is sufficient to execute only cystometry among urodynamic investigations.

Visual assessment of urethrovesical junction mobility

The aim of the study was to compare visual assessment of anterior vaginal wall descent with the Q-tip test in evaluating urethrovesical junction mobility. One hundred and eleven patients with prolapse and/or urinary incontinence were examined in the supine lithotomy position with an empty bladder. Maximum straining Q-tip tests and maximum descent of the anterior vaginal wall were measured. Using each centimeter of descent as a cutoff value, the sensitivities, specificities and positive and negative predictive values were compared to those of the Q-tip test. As the cut-off points were moved distally, specificity increased at the expense of sensitivity. There was no single cut-off point that provided adequate sensitivity and specificity to be clinically useful to replace the Q-tip test. It was concluded that visual assessment of anterior vaginal wall descent does not provide diagnostic accuracy and acceptable sensitivity and specificity to determine urethrovesical junction mobility. Other methods should be employed to assess support.

Techniques for imaging bladder support

BACKGROUND

Imaging techniques of bladder support can be of diagnostic value to differ causes of urinary incontinence like misbuilding of the lower urinary tract, hypermobility of the bladderneck and urethral wall pathology, which is valuable prior to surgery for incontinence.

METHOD

Literature about imaging techniques, especially, voiding cystourethrography, ultrasonography and MRI were studied and their diagnostic value evaluated.

CONCLUSION

Dynamic ultrasonography is the first line imaging method for studying bladder support. Bladderneck hypermobility, as a sign of defect in the adjunctive closure forces is better correlated to stress incontinence than bladder morfology, diagnosed during static cystography. Voiding cystography has its place in diagnosing misbuildings of the lower urinary tract. MRI is just at the beginning of its clinical era, and seems relevant for studies of urethral pathology.

Treatment of uterine and vaginal prolapse

As stated earlier, we as gynecologic surgeons are going to see more of these problems as we experience the increased longevity of our patients. With the patients best interest in mind, it is suggested that one inexperienced in the performance of the sacrospinous ligament suspension should serve a tutorial with one who had considerable experience with this procedure. Contrariwise, the colpectomy followed by a total colpocleisis is so straightforward that my teaching is, "See one; do one; teach one!"

Preliminary experience in pelviscopic uterine suspension using Webster-Baldy and Franke's method

OBJECTIVE

To find which method gives the best relief from dyspareunia and pelvic pain caused by a retroverted uterus using the two methods mentioned as compared to other methods reported in the medical literature.

SUBJECTS

Twenty-five patients, with ages ranging from 25-55 years old, complaining of mild to severe pelvic pain and dyspareunia seeking treatment in our OPD were evaluated and treated in a span of 3 years' time.

METHODS

Pelviscopic retrouterine ligament fixation using Webster-Baldy and Franke's method were done after each patient was evaluated as to the uterine position, degree of misalignment of the uterus and severity of adhesion. Pelvic pain and dyspareunia were reproduced by palpation of the retroverted uterus. Ultrasonographies were performed to confirm initial findings and to rule out any ovarian or uterine abnormalities. Orthopedic and psychological consultations were done to rule out any orthopedic disorders or non-organic causes of their problem.

RESULTS

Of the twenty-five patients treated, 20 patients were treated using Webster-Baldy method and five patients were treated using Franke's method, all the patients (100%) experienced great improvement 6 weeks after the operation. After 6 months, 16 patients (80%) with the Webster-Baldy method and four patients (80%) with the Franke's method had complete relief from pelvic pain and dyspareunia. The remaining four patients (20%) with the former method and one patient (20%) with the latter method complained of mild abdominal discomfort. After 6 months to 2 years of follow-up, 17 patients with Webster-Baldy method and five patients with Franke's method (88%) had improved sexual life and the remaining three patients were lost to follow-up.

CONCLUSION

When dyspareunia and pelvic pain are caused by a retroverted method, we believe uterine suspension using different procedures will certainly relieve this problem. We have presented and have chosen these two procedures mainly due to their simplicity and the almost nil possibility of bowel intussusception into the anterior cul-de-sac as compared to other methods.

[Dynamic MR colpocystorectography. A new methods for evaluating pelvic floor descent and genital prolapse]

AIM

Introduction of a new method for the dynamic evaluation of genital prolapse by using fast magnetic resonance imaging.

METHODS

Dynamic fast magnetic resonance imaging with pelvic floor contraction, relaxation and straining manoeuvres were performed with volunteers and patients presenting with pelvic descent. The urethra, bladder, vagina and rectum were opacified by using a water or Magnevist enteral solution.

RESULTS

Delineation and movement of the urethra, bladder, uterus, vagina, rectum and small bowel can be shown in a reliable manner. In comparison to dynamic fluoroscopy an equal or superior diagnosis has been achieved in all cases.

CONCLUSION

In comparison to dynamic fluoroscopy MR-Colpocystorectography is a promising new method in assessing pelvic floor descent and prolapse in women. Further studies will have to focus on standardisation and clinical implication.

Vaginal apical support: cornerstone of pelvic reconstructive surgery

Proper support of the vaginal apex is necessary to ensure successful reconstruction of pelvic prolapse. The modified McCall culdeplasty provides excellent vaginal apical support while maintaining a physiologic vaginal axis. This technique may be used transabdominally, transvaginally, or laparoscopically.

The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction

This article presents a standard system of terminology recently approved by the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons for the description of female pelvic organ prolapse and pelvic floor dysfunction. An objective site-specific system for describing, quantitating, and staging pelvic support in women is included. It has been developed to enhance both clinical and academic communication regarding individual patients and populations of patients. Clinicians and researchers caring for women with pelvic organ prolapse and pelvic floor dysfunction are encouraged to learn and use the system.

Anterior vaginal wall culdeplasty at vaginal hysterectomy to prevent posthysterectomy anterior vaginal wall prolapse

OBJECTIVE

The purpose of our study was to evaluate a surgical technique we have developed that, when used at vaginal hysterectomy, helps prevent posthysterectomy anterior vaginal segment (wall) prolapse.

STUDY DESIGN

This modified surgical procedure was used in 966 consecutive vaginal hysterectomies performed from January 1989 through December 1994. Patients returned at 1, 3, and 12 months and annually thereafter for follow-up. The longest follow-up period to date is 5.5 years.

RESULTS

Of the 925 patients in our study followed up for > or = 1 year, 908 (98.1%) retained excellent anterior vaginal support. Symptomatic anterior vaginal segment prolapse occurred in 12 patients (1.3%), and asymptomatic prolapse, with the anterior vaginal wall descending less than halfway from the ischial spines to the hymen, occurred in 5 (0.5%). None of the 42 patients followed up for <1 year has had evidence of prolapse.

CONCLUSION

This procedure is an acceptable method to help prevent posthysterectomy anterior vaginal segment prolapse.

Interobserver variation in the assessment of pelvic organ prolapse

The aim of this study was to determine the interobserver agreement of two grading systems for pelvic organ prolapse: the vaginal profile and the International Continence Society (ICS) draft proposal. Forty-nine consecutive women referred for evaluation of urinary incontinence and/or pelvic organ prolapse were studied. Patients were first examined by a physician and a nurse clinician using the vaginal profile, followed by an examination according to the technique described in the ICS draft proposal for standardization of terminology (1994). kappa statistic and Pearson's correlation coefficient were used to determine interobserver variability for the ICS system by overall stage, by stage-specific comparison, and by specific anatomic location. The vaginal profile was evaluated by obtaining a kappa for overall degree of prolapse, stage-specific comparison and by anatomic area. The kappa for the ICS stage was 0.79 (P < 0.001), and the kappa for the vaginal profile by area of greatest prolapse was 0.68 (P < 0.001), indicating substantial interobserver agreement for both systems. The ICS system was noted to have substantial interobserver agreement by a stage-specific comparison. All anatomic locations of the ICS staging system were found to correlate significantly, and a high degree of interobserver precision was found. The vaginal profile also showed significant interobserver agreement by overall degree of prolapse, by specific degree of prolapse, and by anatomic area. It was concluded that both the proposed ICS staging system and the traditional vaginal profile show significant interobserver agreement both by overall stage, stage-specific analysis and specific location. The registered nurse examination correlated well with the physician examination, indicating that the most important factor in obtaining reproducible results may be definition and close attention to examination technique.

Uterine prolapse after laparoscopic uterosacral transection in nulliparous airborne trainees. A report of three cases

BACKGROUND

Laparoscopic uterine nerve ablation (LUNA) has become a common alternative therapy for refractory dysmenorrhea. Few long-term complications have been reported.

CASES

Severe uterine prolapse was diagnosed in three young female soldiers during or after the rigors of airborne training. All three had previously undergone LUNA procedures. No other risk factors for uterine prolapse could be identified in these cases.

CONCLUSION

The etiology of uterine prolapse is complex, and although no conclusions as to cause and effect can be made, these cases suggest that LUNA should be performed with caution on women whose occupation or life-style is associated with heavy physical labor or exercises producing marked increases in intraabdominal pressure.

Dynamic assessment of pelvic floor function in women using the intravaginal device test

The aim of the study was to assess pelvic floor function and dysfunction using intravaginal devices (IVD test). One hundred and eighty-five patients were evaluated, 65 (35.1%) in the control group without genital prolapse and 120 (64.9%) in the study group, with prolapse. Anatomic changes were evaluated on a scale described by Halban, and functional classification based on palpation of the muscles of the pelvic floor during contraction. Additionally, weighted vaginal devices were used to assess pelvic floor function. Statistic analysis was performed with the Spearman-Pearson correlation coefficient, the chi2 test and the response/operator characteristic curve. There was an acceptable correlation between the IVD test and the functional classification of 0.75. Using this classification, the IVD test showed 86.58% sensitivity, 75.72% specificity, and had a positive predictive value of 73.95% and a negative predictive value of 87.64%. Significant differences between pelvic floor muscle activity in those patients with and without genital prolapse were observed (chi2 = 58.28, P=<0.005). It was concluded that pelvic floor assessment can be done through the evaluation of active muscle strength or pelvic floor integrity using the functional classification and the IVD test.

Clinical correlates in patients not completing a voiding diary

Our objective was to determine whether voiding diary non-compliance was an important clinical predictor for the absence of urinary symptoms. History questionnaires and voiding diaries are mailed to all patients before initial visits. The study included 349 patients capable of filling out the history questionnaire and voiding diary prior to their initial visit. The control group (n = 261) consisted of patients who filled out both forms. The study group (n = 88) consisted of patients who filled out their history questionnaire yet left their voiding diary blank. Study variables were extracted by chart review to determine the clinical significance of non-compliance with voiding diary completion. Non-Caucasian patients were less likely to complete their diary (P = 0.008). Patients presenting for treatment of pelvic organ prolapse (no urinary symptoms) were also less likely to complete their diary (P = 0.01, OR 0.41, 0.20-0.85). These patients should be counseled about the importance of the voiding diary in validating urinary symptoms. Urodynamic diagnosis were similar in patients considering surgical correction of pelvic organ prolapse, independent of diary non-compliance.

Uterine prolapse and urinary tract obstruction

A case is presented of total uterine prolapse accompanied by moderate bilateral hydroureteronephrosis which was diagnosed after evaluation for fever of unknown origin.

[Certain biochemical markers in women with abnormal states of the reproductive system]

The concentrations of collagen, hydroxyproline, glycosaminoglycans and estradiol were determined in 60 women aged 51 to 60 years (mean: 55.6 +/- 4.4). When compared with values from women with normal statics with women with lowered statics of the genital organ demonstrated significantly lower concentration of collagen (p < 0.05) in the teres ligaments. Women with prolapse of the genital organ had significantly lower concentration of estradiol in serum (p < 0.001) and of collagen (p < 0.01) in the teres ligaments, with significantly higher daily excretion of hydroxyproline (p < 0.01) and glycosaminoglycans (p < 0.001) in urine. In women with prolapse of the genital organ a significantly positive correlation between the concentration of estradiol and collagen (r = 0.76; p < 0.05) and negative correlation between the concentration of estradiol and hydroxyproline (r = -0.59; p < 0.05) and glycosaminoglycans (r = -0.61; p < 0.05) has been found.

Sacrospinous suspension: a local practitioner's experience

OBJECTIVE

The objective of the study was to determine the effectiveness of transvaginal sacrospinous fixation of the vaginal vault as part of the total pelvic reconstructive surgery performed for patients with uterovaginal prolapse and vaginal vault prolapse.

STUDY DESIGN

The hospital and office records of 156 patients undergoing sacrospinous suspension of the vaginal vault between Sept. 14, 1987, and March 22, 1994, were retrospectively reviewed. The preoperative pelvic support defects were compared with the postoperative pelvic support defects. The proportion test for independent samples was used to determine statistical significance.

RESULTS

Eight (5.6%) patients have had recurrence of vaginal vault prolapse, with two of these patients having undergone repeat pelvic reconstructive surgery. Eleven (7.6%) patients have had recurrent anterior segment defects, whereas two (1.4%) patients have had recurrent posterior segment defects.

CONCLUSION

Ninety-four percent of the patients who underwent sacrospinous suspension for uterovaginal prolapse and vaginal vault prolapse have had no persistence or recurrence of vaginal vault prolapse 6 to 83 months after the procedure.

'Doctor, what on earth is that terrible bulge?' The diagnosis and management of vaginal vault prolapse

Patients with vaginal vault prolapse are more frequently found in the postmenopausal age group and often delay seeking help for a myriad of reasons. A sensitive physician can provide support throughout the required comprehensive work-up. Choice of therapy depends upon the overall assessment of the patient with both conservative and more invasive definitive therapies available. The result of either approach can lay the patients fears and misunderstandings to rest and return her to a more complete and fulfilling life.

[Obstructive uropathy secondary to genitourinary prolapse]

Genital prolapse is associated to a greater concurrence of repeat urinary infections, stress urinary incontinence, arterial hypertension and obstructive uropathy with a higher or lower degree of renal impairment. Incidence of uropathy in the genital prolapse setting ranges between 4 and 13%. This paper presents a female patient with renal insufficiency secondary to bilateral obstructive uropathy caused by a concomitant genital prolapse. A brief revision is made of the pathophysiological, diagnostic and therapeutic aspects in the literature. The need to perform both prone and standing urographic studies is emphasized; also a study of the renal function should be performed in these patients in order to establish the appropriate treatment and avoid major complications and renal function impairment.

Vaginal vault prolapse

Vaginal vault prolapse is a difficult and challenging condition to treat. Standard vaginal repair operations often fail to support the prolapsed vault adequately. Transvaginal sacrospinous colpopexy is an effective procedure with many advantages over abdominal operations.

The Q-tip test and urethrovesical junction mobility

OBJECTIVE

To determine the accuracy of the Q-tip test to measure urethrovesical junction mobility.

METHODS

One hundred fourteen women with urinary incontinence or genital prolapse were evaluated with a Q-tip test and perineal ultrasound scanning to measure urethrovesical junction mobility with strain. The sensitivity, specificity, and positive and negative predictive values of the Q-tip test to diagnose urethrovesical junction hypermobility were calculated using ultrasound as the standard. Repeat Q-tip and ultrasound measurements were obtained in ten subjects and analyzed for reproducibility.

RESULTS

The Q-tip test had a sensitivity of 25%, specificity of 78%, positive predictive value of 67%, and negative predictive value of 37%. The Q-tip and ultrasound measurements were reproducible, as the within-subject variation was significantly small when compared to between-subject variation (P = .0001).

CONCLUSION

The Q-tip test is inaccurate for measurement of urethrovesical junction mobility and should not be used in the manner described to diagnose urethrovesical junction hypermobility.

Posthysterectomy rectal and vaginal prolapse, a commonly overlooked problem

The existence of combined rectal and vaginal prolapse is more common than the literature would suggest. This paper outlines a further development in the operative management which has been applied to 24 patients with this problem. All had had a hysterectomy and most had had in addition one or more vaginal repairs. The common mode of presentation was one of pelvic pain (19 patients), sometimes severe, crippling and intractable and some form of protrusion (14 patients), difficult or unsatisfied defaecation and rectal incontinence (9 patients). The vaginal prolapse which always involved the vault and usually involved the lower vagina was usually found to be incomplete and the rectal prolapse complete (but occult). The operative procedure essentially consists of a Wells type rectopexy which has a new modification in which the sling is extended to anchor the vaginal vault after correction of the enterocele by the abdominal approach. A vaginal repair is subsequently performed at the same operation where anterior or posterior vaginal prolapse persists. Important points in the procedure are the avoidance of sepsis (the vaginal vault is not opened during the procedure) and protection of the ureters by careful assessment of the lateral margins of the vaginal vault which is illuminated by transvaginal vault endoscopy. At this early stage operative morbidity has been minimal, relief of the pelvic symptoms has been most encouraging, but the length of follow-up is short (range 6-30 months, average 15.6) and long-term evaluation will be necessary as with all surgery for prolapse.

[Laparoscopy-assisted vaginal hysterectomy with the Endo GIA 30]

The improvements in laparoscopic techniques have led to the development of laparoscopic assisted hysterectomy. We report on our experience since 1991 with this method on 30 patients using a Multifire Endo GIA 30. After cutting the upper ligaments and the uterine vessels, the uterus was removed through the vagina. To avoid urological complications, the distance between the ureter and the uterus was determined preoperatively by a combined sonographical-radiological procedure. To be absolutely safe from ureter lesions, it is recommended to use an illuminated ureter catheter. Laparoscopic hysterectomy should be used in selected cases only. In a critical indication situation with this technique, it is possible to avoid abdominal hysterectomy without loss of safety because of the excellent intraabdominal view, similar to laparotomy. There were no major complications with this procedure, except one ureter lesion, which was recognised intraoperatively. All patients remained in the hospital for only four days after the operation.

Common gynecologic problems after age 75

Management of gynecologic problems in women aged 75 and over can be challenging. Appropriate examination and evaluation differs from that for younger women, and these patients are often poor surgical candidates. The most common presenting conditions include stress incontinence, atrophic changes of the vulva and vagina, and pelvic relaxation with uterine prolapse. Several techniques for nonsurgical management are available, including topical and systemic drug therapy and use of products and aids that increase comfort and encourage independence.

Genital prolapse in a preterm female infant

Genital prolapse in the female infant during the neonatal period is relatively rare and is usually associated with anomalies of the central nervous system. A case of vaginal prolapse in a small-for-gestational-age preterm female infant, without any associated nervous system anomalies, is presented. The clinical presentation, diagnostic approach, management, and outcome of the case are discussed with reference to a review of the literature.

Submucosal uterine leiomyomas: diagnosis of prolapse into the cervix and vagina based on MR imaging

OBJECTIVE

We describe the MR appearance, signs and symptoms, and pathologic findings in five patients with submucosal leiomyomas that prolapsed into the cervical or vaginal canal.

SUBJECTS AND METHODS

During the past 3 years, five women aged 33-53 years (mean, 43 years) were identified prospectively at MR imaging as having prolapsing uterine leiomyomas. The diagnosis was confirmed by surgical pathology. MR imaging was performed on a 1.5-T unit, using both T1- and T2-weighted spin-echo or fast spin-echo sequences. The images were analyzed for signal intensity, presence of a stalk, and caudal extent of the prolapsed leiomyoma.

RESULTS

These leiomyomas, the presence of prolapse, and the caudal extent of prolapse were detected prospectively on MR images in all five cases. Prospective localization of the stalk in two cases aided subsequent hysteroscopic resection. MR imaging correctly indicated the presence of hemorrhage in one, degeneration in a second, and the absence of these complications in two others. In the fifth case, a hemorrhagic focus in the distal tip of the leiomyoma was not detected on MR images obtained 3 days before surgery.

CONCLUSION

MR imaging is useful for the diagnosis and characterization of uterine leiomyomas that have prolapsed into the cervical or vaginal canal.

Intrapartum obstetric emergencies

Shoulder dystocia, uterine inversion, and prolapse of the umbilical cord are three uncommon complications of the intrapartum period. These complications share several common characteristics in that they are rare, difficult to predict, and can result in significant morbidity and mortality. This article describes the etiology, predisposing factors, and methods of management of these complications.

Postpartum hemorrhage

Early PPH remains a significant cause of maternal morbidity and mortality. Many cases occur in women with antecedent risk factors and can thus be anticipated, promptly diagnosed, and promptly treated. Postpartum hemorrhage is most commonly due to uterine atony and often responds to medical treatments such as ecbolic medications, uterine massage or bimanual compression, and blood and fluid replacement. Appropriate laboratory studies should be obtained promptly. Women with significant bleeding should receive blood product transfusions. Patients who do not promptly respond to these conservative measures should be considered and counseled for operative procedures. Surgical intervention, either to repair lacerations, transiently reduce pelvic pulse pressure, or remove the uterus, can be life-saving.

Fertility retention in the patient with genital prolapse

There are several treatments from which to choose for the patient with symptomatic uterine prolapse who wishes to retain fertility. Transabdominal construction of a sacrocervical "ligament" with transplanted fascia lata femoris is a useful solution to this problem. The technique is described.

Clinical approach to vaginal/vestibular masses in the bitch

The most common causes of vaginal/vestibular masses in the bitch are vaginal prolapse, vaginal neoplasia, and urethral neoplasia protruding into the vaginal vault. Other possible causes are clitoral enlargement, vaginal polyps, uterine prolapse, and vaginal abscessation or hematoma. Vaginal prolapse usually can be distinguished from neoplasia by the age of the patient, the time of occurrence during the estrous cycle, and the site of origin of the mass. Prolapse usually occurs in bitches under 4 years of age during proestrus, estrus, or at the end of diestrus and usually arises from the floor of the vagina, except for urethral tumors that protrude from the external urethral orifice. Appropriate diagnostic workup of bitches with vaginal vestibular masses includes complete history and physical examination, vaginal cytologic and vaginoscopic examination, retrograde vaginography or urethrocystography, serum progesterone and estradiol concentrations, and, in the case of suspect neoplasms, surgical or excision biopsy of the mass.

Pelvic floor descent in women: dynamic evaluation with fast MR imaging and cinematic display

The authors present a new method for assessing pelvic prolapse with dynamic fast magnetic resonance (MR) imaging. Twenty-six women with signs and symptoms suggesting pelvic prolapse and 16 control subjects were studied with a series of fast (6-12-second) MR images. Sagittal and coronal images were obtained with graded increase in voluntary pelvic strain, allowing for dynamic display and quantification of the pelvic prolapse process. The distance from the pubococcygeal line was used as an internal reference for measurement of descent in the maximal strain position. With use of control results for normal limit values, prolapse involving the anterior pelvic compartment (cystocele), the middle compartment (vaginal prolapse, uterine prolapse, and enterocele), and the posterior compartment (rectocele) was easily demonstrated. Significant differences between control subjects and patients with prolapse were seen at maximal strain but not in the relaxed state. Quantification of the pelvic descent process with use of fast MR imaging may be of value in surgical planning and postsurgical follow-up.

Treatment of vaginal vault prolapse

Vaginal vault prolapse is mostly a preventable complication of hysterectomy. Adequate suspension of the vaginal apex after hysterectomy with use of shortened cardinal and uterosacral ligaments will draw the proximal vagina over the levator plate. This results in support for the distal vagina. The essence of surgical repair of vaginal vault prolapse is to create a new suspension with the same vaginal support. Transvaginal sacrospinous fixation and transabdominal sacrocolpo-suspension accomplish this.

A technique to study the passive supports of the uterus

The present report concerns the position of the portio vaginalis of the uterine cervix when known amounts of downward force are applied to it under anesthesia. It is intended to provide a quantitative assessment of the passive supports of the uterus relatively independent of the active striated muscles in the pelvis. The measurements were made by connecting to the cervix a uterine insufflation cannula with a ruler attached to it and measuring the distance from the hymen to the ectocervix while varying amounts of downward traction were applied to a tenaculum with a spring scale. In 73 asymptomatic patients, the cervix lay above the hymen by the following distance with the amount of traction stated: 0 lb = 3.50 cm, 1 lb = 2.35 cm, 2 lb = 1.65 cm, 3 lb = 1.16 cm, and 4 lb = 0.81 cm. In 22 patients examined independently by two examiners, the mean difference between these measurements was 0.29 cm, and the correlation coefficient for their measurements at each level of traction ranged from 0.86-0.94, depending on the amount of force applied. This technique of measurement could be used to study the influence of such factors as age, race, parity, menopausal status, and obstetric history on the integrity of the passive support system within a population, and can provide a way to obtain objective data to study further the passive supports of the uterus.

[Artefacts in the recording of stress profiles and their clinical significance]

Using a special technique 35 women presented an artefact in the SUPP caused by urethral movement during coughing. A second artefact was found in patients presenting with extensive vaginal prolapse. The clinical evaluation of the SUPP depends on the exclusion of those artefacts.

Prolapse of an ovarian tumor during labor

A case of prolapsed tumor after home delivery is reported. At first a puerperal inversion of the uterus was suspected. At operation a dermoid ovarian tumor was found to be prolapsed through the vaginal fornix.

Psychogenic pelvic pain or occult prolapse syndrome?

Occult prolapse, a syndrome of pelvic pain, sacral ache, dyspareunia, irritable bladder, but not severe dysmenorrhoea, has been studied in 180 young parous women. Organic disease was not present, but the uterus was very mobile and descended easily down the vagina. The pain was worse in the upright posture and was relieved by lying down, supporting, elevating or removing the uterus in 87% of cases.

[Genital prolapse. Apropos of a series of 220 cases]

On the basis of a series of 220 operated cases of genital prolapse, the authors describe the complications and classify the various elementary components of the prolapse (120 complete prolapses) and the associated lesions. The operative techniques are classified by category and the results are presented with a follow-up of two and three years. This homogeneous series demonstrates that the vaginal techniques are generally more effective.

[Changes in the orientation in indications for hysterectomy--presented with the example of prolapse]

Hysterectomies, as well as conservative surgery of the uterus (where indication might have been in favour of hysterectomy), were analysed according to case records during two periods, from 1960 to 1963 and from 1978 to 1980, at the Department of Obstetrics and Gynaecology at Hannover University. In the second period the average number of hysterectomies pro year doubled, whereas the conservative uterine surgery showed a definite decline. Descensus was diagnosed in 48.5% of the hysterectomies performed during the second period compared to 13.6% during first period. Prolapse frequency was about the same in both groups. In the second period, 97.7% of the descensus operations were combined with hysterectomy, whereas this applied in the first period to only 24.3%. The results show a definite tendency towards extending the indication for hysterectomy. In the second period, sterilisation and carcinoma prophylaxis were additionally considered as indications for surgery.