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Biomedical subjects

L L Wall

Publications and source records attributed to L L Wall.

At least 19 recordsLinked to original sources
PubMed1996

The epidemiology of genitourinary fistulae in Kumasi, Ghana, 1977-1992.

The aim of the study was to determine the clinical epidemiology of genitourinary fistulae as seen at Komfo Anokye Teaching Hospital in Kumasi, Ghana. A retrospective study was carried out from the hospital records and operative reports of all patients with genitourinary fistulae seen at Komfo Anokye Teaching Hospital between January 1977 and December 1992. Patient age, parity, type of fistula and cause of fistula were abstracted from the medical records. There were 164 cases of genitourinary fistula managed during the study period. There were 150 fistulae due to obstetric causes (91, 5%), the vast majority of which were due to prolonged obstructed labor (121 cases, 73.8% of all fistulae), with a minority related to complications of lower-segment cesarean section (14 cases, 8.5% of all fistulae). In 5 cases (3.1%) patients developed a rectovaginal fistula owing to perineal tears and prolonged obstructed labor. During this time period there were 157,449 deliveries, giving an obstetric fistula rate of 1 fistula per 1000 deliveries. Obstetric fistulae were most common at the extremes of reproductive age and parity Fourteen additional fistulae (8.5% of all cases) were due to gynecologic causes, most commonly from surgical injury occurring at the time of abdominal hysterectomy for leiomyomata uteri (12 cases, 7.3% of all fistulae). It was concluded that in Kumasi, Ghana, obstetric trauma from prolonged obstructed labor is the most common cause of genitourinary fistula formation. Such fistulae occur in older multiparous women as well in young primigravidae. Obstructed labour can, and does, occur in women who have previously undergone uneventful vaginal delivery. Birth attendants should be aware of that fact. Prompt referral for obstetric intervention should be made in obstructed labor, irrespective of the age and parity of the patient.

Adult↗
PubMed1996

Ritual meaning in surgery.

The term "ritual" is used in medicine primarily in a negative way. In a surgical context, it is usually used to refer to slavish, unthinking devotion to technique or method, or to unnecessary surgical procedures that have outlived their usefulness. But there is another aspect of ritual that has received far too little attention from medical writers: ritual in its anthropologic sense as a form of stylized behavior that serves as a vehicle for the transmission of meaning. Because a surgical operation is a structured process that takes place within a given social context, it can be analyzed as a "rite of passage" that helps move the patient from "illness" to "health." Understanding the ritual aspects of surgical operations can help deepen the doctor-patient relationship and improve the quality of care given to surgical patients.

General Surgery↗
PubMed1996

Use of a pedicled rectus abdominis muscle flap sling in the treatment of complicated stress urinary incontinence.

OBJECTIVE: A pedicled rectus muscle flap sling in the treatment of complicated stress urinary incontinence was evaluated. STUDY DESIGN: Thirty-two women underwent a combined vaginal and abdominal sling operation for stress incontinence with a pedicled muscle flap developed from the rectus abdominis muscle. All operations were performed jointly by the same two surgeons. The procedure involved transecting one rectus abdominis muscle just above its first tendinous intersection and isolating the muscle as a flap on its inferior vascular pedicle. The muscle flap was then swung beneath the urethra and bladder neck, pulled into the retropubic space on the contralateral side, and sewn to the obturator internus fascia or to Cooper's ligament. All patients undergoing the procedure had demonstrable stress incontinence on physical examination and underwent preoperative fluoroscopic video urodynamics. The diagnosis of complicated stress incontinence was based on the presence of one or more of the following factors: previous failed antiincontinence surgery (33 operations in 22 patients, average 1.5 operations), open vesical neck on fluoroscopy (14 patients), urethral closure pressure < or = 30 cm H2O by the Brown-Wickham technique (16 patients), or massive vaginal prolapse and demonstrable stress incontinence with the prolapse reduced and the urethra supported in a normal position (16 patients). Follow-up ranged from 2 to 13 months (average 6 months). Surgical outcome was assessed by physical examination and a detailed telephone interview conducted by a physician who was not involved in the operations. RESULTS: Twenty-eight patients (87.5%) were satisfied with the results of the operation. There were four surgical failures (12.5%). Stress incontinence persisted in three patients after surgery, and one patient who had mixed incontinence before surgery was cured of stress incontinence but continued to have significant urinary leakage as a result of detrusor overactivity. There appears to be less voiding dysfunction with this technique than with other sling procedures for stress incontinence. CONCLUSIONS: The sling procedure with a rectus abdominis muscle flap appears to be a viable surgical technique in the treatment of complicated stress incontinence. Further study is needed to assess the long-term results of this operation and to evaluate its proper place in reconstructive pelvic surgery.

Abdominal Muscles↗
PubMed1996

Obstructed labor injury complex: obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world.

Prolonged obstructed labor may produce injuries to multiple organ systems. The best known, and most common, of these injuries is obstetric fistula formation. When obstructed labor is unrelieved, the presenting fetal part is impacted against the soft tissues of the pelvis and a widespread ischemic vascular injury develops that results in tissue necrosis and subsequent fistula formation. Unlike the postsurgical vesicovaginal fistula, however, which is usually the result of focal trauma to otherwise healthy tissues, the obstetric fistula is the result of a "field injury" to a broad area. The field injury that is produced by prolonged obstructed labor may result in multiple birth-related injuries in addition to (or instead of) a vesicovaginal fistula. Focusing simply on the "hole" between the bladder and the vagina ignores the multifaceted nature of the injury that many of these patients have sustained. These injuries may include total urethral loss, stress incontinence, hydroureteronephrosis, renal failure, rectovaginal fistula formation, rectal atresia, anal sphincter incompetence, cervical destruction, amenorrhea, pelvic inflammatory disease, secondary infertility, vaginal stenosis, osteitis pubis, and foot-drop. In addition to their physical injuries, women who have experienced prolonged obstructed labor often develop serious social problems, including divorce, exclusion from religious activities, separation from their families, worsening poverty, malnutrition, and almost unendurable suffering. Isolated almost exclusively to the developing world, particularly Africa, this problem has not received the international attention that it deserves, from either a medical or a social standpoint.

Adolescent↗
PubMed1996

Voiding function after Burch colposuspension for stress incontinence.

OBJECTIVE: To evaluate changes in voiding function before and after Burch colposuspension for genuine stress incontinence. STUDY DESIGN: Full urodynamic evaluations were performed before and three months after surgery on 21 patients undergoing Burch colposuspension for genuine stress incontinence. Sixteen patients underwent the Burch procedure alone and five underwent an abdominal sacral colpopexy for vaginal vault prolapse in addition to the Burch procedure. The preoperative and postoperative urodynamic studies were compared with each other to see what changes in voiding function had occurred as the result of surgery. RESULTS: Statistical analysis of the differences between the preoperative, and postoperative urodynamic studies using blocked analysis of variance showed dramatic decreases in both instrumented and noninstrumented peak and mean urine flow rates and an increase in detrusor pressure at peak urinary flow during voiding. A substantial but not statistically significant increase in mean residual urine was found after surgery in patients who underwent the Burch procedure alone. There were no statistically significant differences in these parameters in patients undergoing the Burch procedure combined with abdominal sacral colpopexy. Using the criteria of a flow rate of < 12 mL/sec in association with a voiding detrusor pressure > 50 cm H2O, five patients undergoing the Burch procedure alone had evidence of postoperative outflow obstruction. Three women with complete vaginal vault prolapse had functional outlet obstruction before surgery, and another three women had postoperative outlet obstruction following the combined Burch procedure and sacral colpopexy. CONCLUSIONS: Burch colposuspension produced significant changes in postoperative voiding function three months after surgery, and outflow obstruction induced by surgery appeared to be a significant potential complication. Renewed attention should be devoted to the development of durable but nonobstructive operations for the surgical cure of genuine stress incontinence.

Female↗
PubMed1995

Are vaginal and rectal pressures equivalent approximations of one another for the purpose of performing subtracted cystometry?

OBJECTIVE: To determine if rectal and vaginal pressures are clinically equivalent to one another for the purpose of calculating subtracted detrusor pressure during routine filling cystometry and pressure-flow voiding studies. METHODS: A total of 140 consecutive filling and voiding cystometrograms were performed at separate sessions on 127 female patients undergoing routine clinical cystometry for a variety of clinical indications, usually urinary incontinence. In all cases, intravaginal as well as intrarectal pressures were measured simultaneously using microtip transducer pressure catheters, and two subtracted detrusor pressures were calculated throughout each study. Rectal and vaginal pressure measurements from the same patient were compared with the patient in the supine position with an empty bladder, in the erect position with a full bladder, and in the sitting position during voiding at the point of maximum urinary flow. RESULTS: The mean pressures were similar in all cases. Although there was no statistical difference in the mean differences between the rectal and vaginal pressures in the supine-empty position (P = .5528), significant differences were noted between them in the erect-full and sitting-voiding positions (P = .0016 and P = .0033, respectively). Linear regression analysis of the data obtained in each position was carried out, plotting vaginal pressure on the x axis and rectal pressure on the y axis. The corresponding r values for each position were 0.431 for the supine-empty position, 0.547 for the erect-full position, and 0.478 for the sitting-voiding position, indicating poor correlation between pressures in individual patients. In nine patients (6.5%) with significant vaginal relaxation and large cystoceles, a steady rise in vaginal pressure was noted during bladder filling. In six patients (4.4%), one or more spontaneous vaginal contractions were noted during the course of the study, whereas in 68 (48.9%), spontaneous rectal contractions were present. Of the 68 cases where spontaneous rectal contractions were noted, these contractions faded away in 53 cases (77.9%) as the study progressed. CONCLUSIONS: Rectal pressure and vaginal pressure are not the same during filling and voiding cystometry. Although they are reasonable approximations of each other for most qualitative clinical diagnostic purposes, potentially significant differences in subtracted detrusor pressure may occur, depending on which pressure is used as the approximation of intra-abdominal pressure. This may affect clinical management decisions in individual patients. The technique used for approximating abdominal pressure must be stated clearly in any report or publication dealing with subtracted cystometry.

Adult↗
PubMed1994

Clinical features of urinary incontinence and urogenital prolapse in a black inner-city population.

OBJECTIVE: Our purpose was to describe the clinical features and urodynamic findings of a black female inner-city population with urinary incontinence and uterovaginal prolapse. STUDY DESIGN: A retrospective review of the urogynecoloy records of 159 black female patients was performed. RESULTS: Genital prolapse was common. A cystocele was identified in 116 patients, a rectocele in 88 patients, and uterine or vaginal vault prolapse in 41 patients. Subtracted multichannel cystometry revealed detrusor overactivity in 58 patients, genuine stress incontinence in 44 patients, and mixed incontinence in 30 patients. Sixteen patients had normal urodynamic studies. The presence of a cystocele and the physical sign of stress incontinence at initial examination were found equally in patients with genuine stress incontinence, detrusor instability, and mixed incontinence at cystometry. There was no correlation between other commonly associated clinical factors (such as age, parity, and obesity) and the urodynamic diagnosis. CONCLUSIONS: Many of the factors commonly assumed to predispose women to the development of incontinence and prolapse may not apply to the black inner-city population. Urodynamic testing to establish the correct diagnosis is required, because the correlation between symptoms, physical examination, and urodynamic findings is relatively poor in this population.

Adult↗
PubMed1994

Simple bladder filling with a cough stress test compared with subtracted cystometry for the diagnosis of urinary incontinence.

OBJECTIVE: Our purpose was to compare the diagnostic efficacy of observing urine loss during simple bladder filling (without pressure measurement) and a cough stress test, with multichannel subtracted cystometry. STUDY DESIGN: The urodynamic records of 77 women complaining of urinary incontinence were reviewed. All women had undergone a full evaluation that included a standardized history and physical examination, urinalysis and urine culture, uroflowmetry with measurement of postvoid residual urine, a cough stress test performed during and after simple retrograde bladder filling, and multichannel subtracted cystometry. The results of simple bladder filling and the cough stress test were recorded as "urge incontinence," "stress incontinence,"mixed incontinence," or "incontinence not demonstrated." The subtracted cystometrogram was then performed, and the urodynamic diagnoses were recorded as "detrusor instability," "genuine stress incontinence," "mixed incontinence," or "incontinence not demonstrated." The records were reviewed, and the results of simple bladder filling with a cough stress test were compared with those obtained by subtracted multichannel provocative cystometry. RESULTS: With the subtracted multichannel cystometrogram used as the "gold standard" for diagnosis, the demonstration of "urge incontinence" during simple bladder filling had a sensitivity of 64% and a specificity of 86.8% for the demonstration of detrusor instability during cystometry, with a positive predictive value of 83.3% and a negative predictive value of 70.2%. The demonstration of "stress incontinence" during simple bladder filling had a sensitivity of 88.1% and a specificity of 77.1% for the demonstration of "genuine" stress incontinence during cystometry, with a positive predictive value of 82% and a negative predictive value of 84.4%. CONCLUSIONS: The demonstration of urge incontinence during simple bladder filling is a reliable predictor of detrusor instability, but its absence is less reliable in excluding detrusor overactivity as a cause of urinary incontinence. Similarly, the clinical demonstration of stress incontinence during simple bladder filling is predictive of the presence of "genuine" stress incontinence during subtracted multichannel provocative cystometry. The inability to demonstrate stress incontinence during simple bladder filling is highly correlated with the absence of "genuine" stress incontinence during complex urodynamic testing. Simple bladder filling is a reliable method of diagnosing urinary incontinence. In many cases it can replace complex urodynamic testing, particularly if the proposed treatment for the condition carries a low level of risk, and is helpful in selecting patients who need more extensive evaluation.

Cough↗
PubMed1994

Urodynamic characteristics of women with complete posthysterectomy vaginal vault prolapse.

OBJECTIVES: To review the symptoms and lower urinary tract function in women with posthysterectomy vaginal vault prolapse. METHODS: A retrospective review was carried out of the urodynamic records of 19 women with posthysterectomy vaginal vault prolapse who had been evaluated in the Bladder Function Laboratory of the Department of Obstetrics and Gynecology at Duke University Medical Center. RESULTS: A full urodynamic evaluation was carried out on 19 women who had had a hysterectomy and who had subsequently experienced complete prolapse of the vaginal vault. Vaginal eversion produced massive distortion of the lower urinary tract and was associated with complex symptoms. Among the cystometric findings in these patients was an early average first desire to void (94 mL) and a reduced average cystometric capacity (370 mL). Symptoms of voiding difficulty were common. During noninstrumented uroflowmetry, the average peak and mean flow rates were reduced in these women (16.5 mL/s and 8.1 mL/s, respectively), suggestive of functional obstruction of the outlet due to the prolapse. Pressure-flow voiding studies showed a reduced peak flow rate (11 mL/s) with an increased detrusor pressure at peak flow (50 cm H2O), also indicative of functional obstruction. All women underwent urethrocystoscopy, and no patient had a urethral stricture or urethral stenosis. Although symptoms of urgency (79%) and urge incontinence (63%) were common, detrusor instability was confirmed by urodynamic studies in only 3 women (16%), suggesting that urge-related symptoms in these women may often be due to anatomic distortion of the lower urinary tract rather than to detrusor overactivity. "Genuine" stress incontinence was documented in only 2 women (11%) during cystometry; however, when these patients were examined with full bladders with their prolapses reduced and returned to a normal anatomic position with a single-bladed speculum, the physical sign of stress incontinence was demonstrated in all 9 women (47%) who had a complaint of stress incontinence. This suggests that massive vaginal prolapse may mask an incompetent continence mechanism, which may then be revealed after surgical repair of the prolapse. CONCLUSIONS: Women with posthysterectomy vaginal vault prolapse present complicated reconstructive problems for the pelvic surgeon. The same pathophysiological process may produce both voiding dysfunction and stress incontinence. These patients should be evaluated carefully before surgical repair is undertaken. Stress incontinence may not be demonstrated in these patients unless they are examined with a full bladder with their prolapse carefully reduced to a normal anatomic position. Women who demonstrate stress incontinence with the vaginal prolapse reduced and the urethra supported normally should be suspected of having "type III" incontinence (demonstrable stress incontinence in the presence of normal urethral support). Women with these findings may require a suburethral sling procedure if they are to remain continent after correction of posthysterectomy vaginal vault eversion.

Adult↗
PubMed1994

Bladder neck mobility and the outcome of surgery for genuine stress urinary incontinence. A logistic regression analysis of lateral bead-chain cystourethrograms.

Bladder neck position, as determined by preoperative and postoperative resting and straining lateral bead-chain cystourethrograms, was analyzed by logistic regression analysis in 94 women undergoing 98 operations for genuine stress incontinence. A total of 384 roentgenograms were analyzed in an attempt to build a model that would predict the likelihood of surgical success in a given patient based on the preoperative films and explain a successful surgical outcome based on the characteristics of the postoperative films. The most important predictors of success were the number of previous incontinence operations, a large distance between the bladder neck and the pubic symphysis at rest, and increased mobility of the bladder neck before surgery. Successful surgery appeared to be related most closely to decreasing mobility of a previously hypermobile bladder neck.

Female↗
PubMed1994

Randomized double-blind trial of terodiline in the treatment of urge incontinence in women.

OBJECTIVE: To evaluate the effects of terodiline in women with urge incontinence. METHODS: After a 2-week run-in period, 93 women with urinary frequency and urge incontinence were randomized to either placebo or terodiline, 25 mg twice daily, in a double-blind study for 4 weeks. Symptoms were evaluated using daily frequency-volume charts to record voiding frequency, number of incontinent episodes, absorbent pad use, and quality of life. RESULTS: The terodiline group showed a 70% decrease in the mean (+/- standard deviation) number of incontinent episodes per week (15.8 +/- 24, decreasing to 4.9 +/- 11.9; P < .01), which persisted throughout the study period. The placebo group achieved a 9% reduction in the mean number of incontinent episodes (13.0 +/- 11.3, decreasing to 11.9 +/- 16; P < .05) only in the final week of treatment. Side effects, especially anticholinergic side effects, were more common in the terodiline group, but resulted in only one dropout. Both the treated and placebo groups improved in daytime frequency and quality-of-life indices. CONCLUSION: Terodiline is well tolerated and effective in reducing urge incontinent episodes in women.

Butylamines↗
PubMed1994

One hundred unstable bladders.

OBJECTIVE: To investigate the correlation between presenting symptoms and cystometric data in patients with urodynamically proven detrusor instability. METHODS: A retrospective review was conducted of standardized urodynamic data bases and cystometrograms from the gynecologic urodynamics laboratories at Duke University Medical Center, Durham, North Carolina, and Grady Memorial Hospital, Atlanta, Georgia. RESULTS: Of the 100 patients reviewed, 86% complained of urge incontinence and 78% complained of urinary urgency; however, 76% also complained of stress incontinence. Statistical evaluation of symptoms by analysis of variance showed no significant correlations between the symptoms of urinary frequency and urgency and any of the cystometric indices. Patients with motor urge incontinence had significantly smaller mean cystometric bladder capacities than patients without this complaint (299.9 +/- 132.5 versus 553.6 +/- 173.6 mL; P < .01). One-third (34) of the patients had mixed incontinence due to genuine stress incontinence as well as detrusor instability. Compared with patients suffering from detrusor instability alone, patients with mixed incontinence had significantly larger cystometric bladder capacities (396.0 +/- 172.9 versus 308.1 +/- 154.8 mL; P < .02) and a lower amplitude of the maximum detrusor contraction (38.8 +/- 21.7 versus 49.9 +/- 25.1 cm H2O; P < .04). CONCLUSIONS: Women with detrusor instability represent a diverse population with a wide variety of symptoms and urodynamic findings. Patients with mixed incontinence may represent a subpopulation distinct from those with pure detrusor instability. Further research that attempts to describe other discrete subpopulations of patients with detrusor instability may improve our understanding of this troublesome clinical problem.

Adult↗
PubMed1993

Medical management of pelvic relaxation.

Although most gynecologists consider surgery to be the treatment of choice for pelvic relaxation, there are many non-surgical forms of therapy for this problem and conditions which it may produce, such as urinary incontinence. This review highlights the importance of properly diagnosing co-existent factors which may complicate a patient's condition, and reviews therapies which may relieve her discomfort without surgery. These options include manipulation of concurrent medical factors, estrogen therapy, pelvic muscle rehabilitation through exercise and electrical stimulation, prompted voiding regimens, and the use of supportive pessaries.

Estrogen Replacement Therapy↗
PubMed1992

The treatment of urinary incontinence with electrical stimulation in nursing home patients: a pilot study.

OBJECTIVES: To test the effectiveness of electrical stimulation in the treatment of urinary incontinence in female nursing home patients. SETTING: A community long term care facility. PARTICIPANTS: Nine unselected female nursing home patients with urinary incontinence. All patients were moderately to severely cognitively impaired. By bedside cystometry, six patients had involuntary detrusor contractions while two had inconclusive results. INTERVENTION: Participants were treated with electrical stimulation for 8 weeks using the Microgyn II device. A current with a frequency of 20 hertz and a pulse width of 1 millisecond was delivered repeatedly for 2 seconds on, 4 seconds off for 15 seconds twice a week. MEASUREMENTS: The number of every-2-hour wet episodes during a 48-hour period (Wet) was recorded by a blinded observer at baseline and after 4 and 8 weeks of treatment. We evaluated the overall effect of electrical stimulation by averaging the Wet at 4 and 8 weeks for each patient and comparing it to Wet at baseline. MAIN RESULTS: The mean +/- standard deviation of intensity of electrical stimulation was 12 +/- 5 milliamps. Mean Wet at baseline was 11.8 +/- 4.2. For all patients mean Wet increased by 2.3 +/- 3.2, P = 0.07. Analysis of patients with documented involuntary detrusor contractions showed a mean increase in Wet of 2.6 +/- 3.6, P = 0.16. The volume of fluid at which an involuntary contraction occurred during cystometry showed a mean increase of 48.3 +/- 52.6 mL, P = 0.07 after 8 weeks of treatment. CONCLUSIONS: Electrical stimulation is well tolerated in elderly nursing home patients. However, it was ineffective in improving urinary incontinence. In fact, there was a tendency for the treatment to worsen the incontinence.

Aged↗