Infertility and related issues

External organic dyspareunia may be due to an occlusive or rigid hymen, vaginal contracture due to any cause, or inflammatory disorders. Traumatic or infectious processes are seen in younger pa-tients and atrophic vulvovaginitis in postmenopausal women. Organic causes of internal dyspareunia include vaginal disor-ders, severe cervicitis, marked fundal retroposition, uterine prolapse or neoplasm, tuboovarian disease, pelvic endometriosis, and severe disorders of the lower urinary tract or colon. Psychiatric evaluation is indicated if complex psychosexual problems seem to be present. Specialized techniques of physical ex-amination (e.g., cystoscopy, may be required to rule out organic disease).

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y be marginal. If the cause of incontinence is atrophic change from estrogen deficiency, estrogen replacement will result in resolution of stress incontinence in 10%–30% of postmenopausal women. Vaginal es- trogen provides the most rapid response, but oral preparations main- tain the patient’s status as well as do vaginal preparations. If the patient is taking medications that stimulate ganglionic or alpha-adrenergic blocking activity (e.g., guanethidine, methyldopa, or prazosin), discontinuing their use may result in improved ure- thral tone and improved continence. Alpha-adrenergic agonists (e.g., phenylpropanolamine, pseudoephedrine) also may improve stress incontinence. Other methods, such as electrical stimulation of the pelvic floor to increase urethral closure pressure and Teflon or collagen injected periurethrally to compress the urethral mucosa and cause a mild ob- struction to urinary flow, have been performed with some success. Surgical Measures The goal of surgical procedures for incontinence is to elevate and support the urethrovesical junction to improve pressure transmis- sion to the urethra during stress maneuvers. The best results are obtained if the operative procedure for GSUI is combined with cor- rection of pelvic support defects. The procedures may be accom- plished vaginally or abdominally. The cure rate depends on patient selection, accuracy of preoperative diagnosis, skill of the surgeon, and length of follow-up. Cure rates for the abdominal procedures are 85%–90% and for vaginal procedures 75%–85%. The predominant abdominal procedures are the pubovaginal sling, Marshall-Marchetti-Krantz (MMK) procedure, the Burch pro- cedure, the paravaginal procedure, or various modifications. With the exception of the pubovaginal sling, these procedures consist of placing sutures in the periurethral, vaginal, or perivaginal tissue to elevate the urethrovesical junction and attaching these sutures to relatively strong and permanent structures. The MMK uses the periosteum of the pubic symphysis for suture fixation, whereas the Burch procedure uses Cooper’s ligaments. The obturator fascia, ar- cus tendineus of the pelvic fascia, insertion of the rectus fascia, and the periosteum of the pubic ramus have all been employed in var- ious modifications. A pubovaginal sling using autologous fascia (e.g., rectus fascia, fascia lata, or round ligaments) or synthetic material is accomplished CHAPTER 30 OTHER GYNECOLOGIC PROBLEMS 819 BENSON & PERNOLL’S 820 HANDBOOK OF OBSTETRICS AND GYNECOLOGY through a combined vaginal and abdominal approach. The sling is submucosally passed under the urethra at the urethrovesical junc- ture and then both ends (or polygycolic sutures attached to the ends) carried through the endopelvic fascia, space of Retizus, abdominal musculature (just lateral to the Rectus muscles), and rectus fascia. The sling or sutures is then loosely tied and/or sutured superficial to the rectus fascia. This provides excellent support, without undue restriction, of urethrovesical junction motion. For many authorities, the pubovaginal sling has become the technique of choice for difficult cases and most surgical failures. An interval of bladder reaccomodation is usually managed by intermittent self-catheteri- zation or use of a suprapubic catheter. Vaginal procedures for stress incontinence are based on the as- sumption that weakening of or damage to the endopelvic fascia be- tween the vagina and bladder is responsible for the poor support. The initial procedure (Kelly plication) involves an anterior colpor- rhaphy with plication at the urethrovesical angle through a midline vaginal incision. Because long-term success is limited using the endopelvic fascia, employing stronger structures (e.g., autologous fascia, pubourethral ligaments, periosteum of the pubic ramus, and pubococcygeus muscles) has met with better results. Patients with urethral scarring or atony not amenable to stan- dard surgical therapy may benefit from placement of an artificial urethral sphincter that obstructs the urethra until the patient desires to void, at which time the artificial sphincter is emptied by an in- ternal pumping system to relieve the urethral obstruction and allow the urine to flow. Surgical complications include UTI, delayed postoperative voiding, dyspareunia, frequency-urgency syndrome, and surgically induced unstable bladder, in addition to iatrogenic damage to the urinary tract, postoperative fistula, and bladder calculi from sutures perforating the bladder mucosa. The prognosis for medical management is usually an improve- ment in symptoms but not cure. Surgical management is the only definitive cure for GSUI. A poorer prognosis is likely for patients who have had a previous surgical failure, low urethral closing pres- sure at rest, concomitant local disease, combined urinary inconti- nence (GSUI plus motor urge incontinence), or systemic diseases that make healing or technical performance of surgery difficult (e.g., diabetes mellitus, obesity). DETRUSOR INSTABILITY Detrusor instability incontinence results from involuntary uninhib- ited detrusor muscle contractions. If the cause is neurologic, it is termed hyperreflexic bladder. Most cases are idiopathic, although infection and obstruction may contribute. Because the urine loss is unpredictable and large volumes may be lost, this condition may cause even more distress than does GSUI. About 1%–2% of adult females suffer from motor urge incontinence, with the highest incidence occurring in the geriatric population. Normal micturition sequence is relaxation of the urethral sphinc- teric mechanism, followed by contraction of the detrusor muscle 1–3 sec later. The sequence is unchanged in motor urge inconti- nence, but the patient cannot voluntarily inhibit the action. It may occur at any bladder volume and may be spontaneous or provoked by physical, psychologic, tactile, or auditory stimuli. Approximately 25%–50% of patients with motor urge incontinence are incontinent only with provocation. About one third have concomitant GSUI, making the distinction difficult. Most feel an urge to void immedi- ately preceding the episode, but patients with neurologic disease may have no warning. The symptoms include urgency, frequency, stress incontinence, and urge incontinence. Physical examination is usually normal un- less detrusor hyperreflexia is present with associated neurologic abnormalities. The diagnosis of motor urge incontinence is suggested by a several second delay in urine loss during a urinary stress test. The diagnosis is confirmed by cystometric evidence of involuntary de- trusor contractions at rest, during bladder filling, or after provoca- tive maneuvers. A smooth rise in pressure occurring simultaneously with visible urine leakage is typical. Urethrocystometry confirms that the involuntary contractions are preceded by a fall in urethral pressure. Urethroscopy and cystoscopy may reveal bladder trabec- ulation from hypertrophy of the detrusor muscle fascicles. The differential diagnosis includes GSUI and sensory urge in- continence. In the latter, the patient can inhibit the leakage with strong encouragement, whereas motor urge incontinence cannot be inhibited. GSUI can be distinguished using provocative cystometry or simultaneous urethrocystometry. Treatment Behavior modification techniques using hypnosis, biofeedback, bladder retraining drills, and psychotherapy may be effective if neu- rologic disease is not responsible for the unstable bladder. Bladder retraining consists of having the patient void on schedule at inter- vals that are gradually lengthened in an attempt to regain cortical control over the voiding reflex. This may be effective in up to 80% but requires compulsive patient cooperation, and recurrence rates are high. CHAPTER 30 OTHER GYNECOLOGIC PROBLEMS 821 BENSON & PERNOLL’S 822 HANDBOOK OF OBSTETRICS AND GYNECOLOGY Medication will help in 50%–80% of patients and may affect a cure in 20%–30%. The most effective drugs are anticholinergic agents, but bladder analgesics, smooth muscle antispasmodics, cal- cium channel blockers, and prostaglandin synthetase inhibitors have been effective. Surgery consisting of such procedures as denervation, cysto- plasty, and urinary diversion usually are reserved for patients with severe permanent bladder instability from neurologic disease and when all other therapy fails. Occasionally, indwelling catheters are used for patients who are severely incapacitated, but this adds the risk of chronic infection. Prognosis Recurrence rates are high, bladder retraining techniques require much time and effort, and medications have troublesome side ef- fects. Hence, motor urge incontinence is likely to be a long-term problem not easily resolved. Theoretically, bladder retraining is ideal, since there are no side effects or surgery involved. If the pa- tient responds initially, she is likely to respond to retraining should a recurrence develop. SENSORY URGE INCONTINENCE Sensory urge incontinence is diagnosed when incontinence occurs with a feeling of urgency in a stable bladder without marked de- scent of the urethra and bladder. The most common causes are infection, diverticula, neoplasia, foreign body, and psychologic and neurologic factors. It is caused by either urethral relaxation or voluntary detrusor contraction. Normally, as the bladder fills, there is a reflex urge to urinate that is subconsciously inhibited until the bladder is full. Con- ditions that irritate the bladder or urethra (e.g., infection, trauma) over stimulate this reflex, resulting in intermittent urethral relax- ation. This allows the dribbling of small amounts of urine, which further stimulates the bladder. If the patient fails to concentrate on maintaining continence, the detrusor may contract after urethral relaxation, resulting in a larger volume of urine lost. Clinical findings typically include a small bladder capacity on cystometry that normalizes under anesthesia unless scarring is pres- ent. Urethral pressure profiles or simultaneous urethrocystometry reveals urethral relaxation or marked variations in urethral pres- sure. Cystometrograms show no detrusor activity as long as the pa- tient concentrates on not voiding. Urethroscopy and cystoscopy are essential to avoid missing local treatable problems. Treatment Therapy is directed toward the direct cause if one is present. Treat in- fection (urinary or vaginal) with antibiotics. Chronic infection may have prolonged symptomatology due to the residual inflammation and edema long after bacteria have been destroyed. Urethral dilatation and instillation of anti-inflammatory agents into the bladder may provide relief. Neoplasia, diverticula, and calculi require surgery or lithotripsy. Estrogen deficiency may be responsible for sensory urge incontinence and is treated by estrogen replacement vaginally or orally. The prognosis is good with cure of the underlying disorder. Chronic causes may result in recurrence or only partial relief. OVERFLOW INCONTINENCE Overflow incontinence is the result of urinary retention with subse- quent overflow. Causes of retention are multiple. Neurogenic reten- tion may be a result of a denervated bladder with diminished or ab- sent detrusor contractions or from detrusor-sphincter dyssynergia, in which the urethra fails to relax with voiding attempts. Diabetes and lower motor neuron disorders are most commonly responsible. Also, obstruction of the urethra may occur postoperatively, with severe relaxation of pelvic supports, or from pelvic masses. Medications (e.g., ganglionic blockers, anticholinergic agents, alpha-adrenergic agonists, and spinal or epidural anesthesia) may cause overflow in- continence. Acute or chronic overdistention of the bladder results in myotonic decompensation and subsequent inability to contract. This may be idiopathic or psychogenic in origin. Cystometric findings typically reveal a large bladder capacity (as much as 1200 mL) with decreased sensation of the bladder and poor to absent detrusor contractility. Treatment Treatment in cases of acute retention is directed toward drainage to prevent myotonic decompensation, chronic retention, infection, and obstructive uropathy. To reduce urethral closing pressure and in- crease detrusor contractility, alpha-adrenolytic agents (e.g., prazosin, phenoxybenzamine), striated muscle relaxants (e.g., diazepam, dantrolene), and cholinergic agents (e.g., bethanecol) are used. If the patient has chronic urinary retention, intermittent self-catheterization is helpful. BYPASS INCONTINENCE Urinary leakage will occur whenever the urethral sphincteric mech- anism is bypassed. Abnormalities, such as fistulas, ectopic ureters, CHAPTER 30 OTHER GYNECOLOGIC PROBLEMS 823 BENSON & PERNOLL’S 824 HANDBOOK OF OBSTETRICS AND GYNECOLOGY and urethral diverticula, are the most common causes of bypass in- continence. Both fistulas and diverticula may mimic GSUI, with exacerbation during stressful activity. The urinary diverticula may retain urine until the patient stands upright to walk or increases in- traabdominal pressure, although the volume lost is usually less than with GSUI. Treatment Treatment is surgical with a good prognosis if successful. However, damage to the urethral sphincteric mechanism during surgery will result in incontinence. PSYCHOGENIC INCONTINENCE Stress incontinence, sensory urge incontinence, motor urge inconti- nence, and overflow incontinence may all have psychogenic origins. Surgery is usually unsuccessful in relieving psychogenic inconti- nence and should be avoided if possible. Psychiatric and medical therapy have the best chance of success as long as the patient’s un- derlying psychologic conflicts are resolved. INTERSTITIAL CYSTITIS Interstitial cystitis is a chronic inflammatory condition almost ex- clusively of women, most of whom are perimenopausal. It may rep- resent a defect in the protective glycosaminoglycan layer of the tran- sitional epithelium (of uncertain origin) or an autoimmune disease. Urinary frequency, urgency, suprapubic pain, discomfort with voiding, and dyspareunia strongly suggest urinary infection. When the symptomatology persists despite treatment for minimal urinary findings (including negative cultures), suspect interstitial cystitis. Interstitial cystitis is associated with stress or urge incontinence, which must be confirmed by urodynamic studies. Urethral syn- drome is commonly a misdiagnosis for interstitial cystitis, but the latter may be noted in patients with hypersensitive bladders. Chronicity of the urinary symptoms with suprapubic pain strongly suggests interstitial cystitis. Cystoscopy typically reveals a pancystitis and, occasionally, a localized fibrotic scar(s) or ul- ceration (Hunner’s ulcer). Biopsies disclose chronic inflammation (including numerous mast cells) in the submucosa and muscularis, without evidence of cancer. There is no cure for interstitial cystitis. Analgesics, bladder drill, or other feedback programs should relieve patients with slight to moderate interstitial cystitis. In severe cases, bladder distention un- der anesthesia or instillation of dimethyl sulfoxide or oxycholore- sene sodium (Chlorpactin WCS-90) may give more lasting relief. Resection or laser therapy of a Hunner ulcer may be helpful. Cys- tectomy or urinary diversion may be warranted in severe recalci- trant cases. URETHRAL CARUNCLE A small, reddened, sensitive, fleshy excrescence at the urethral mea- tus is called a caruncle. Most caruncles represent eversion (ectro- pion of the urethra) or infection at the urinary meatus or both; how- ever, vascular anomalies or benign or malignant tumors also may cause caruncle formation. The vast majority of caruncles are be- nign, persistent lesions. Caruncles may occur at any age, but post- menopausal women are most commonly affected. Caruncles appear as small, vividly red, sessile or flattened masses protruding from the urethral meatus. They may bleed, exude, or cause pain depending on the cause, size, and integrity. Dysuria, frequency, and urgency are uncommon. Laboratory tests are not diagnostic. If cancer is suspected, biopsy must be performed. Estrogen therapy for postmenopausal women and avoidance of local irritation will probably prevent and even heal caruncle for- mation. Infections, including STDs, must be treated with appropri- ate antibiotics. Estrogen (vaginal suppositories of estradiol 0.5 mg every other night for 3 weeks) may be given before specific ther- apy in postmenopausal patients who have not been receiving estrogen. If the caruncle is not markedly infected or malignant, light ful- guration under local anesthesia, cryosurgery laser vaporization, or excision may be performed. If stenosis develops, the urethral mea- tus must be dilated. The prognosis is excellent in benign cases but guarded when malignant change has occurred. URETHRAL DIVERTICULUM Urethral diverticulum is a sacculation caused by (1) congenital cys- tic dilatation of paraurethral (wolffian) remnants; (2) infection of the paraurethral glands, with rupture to the urethra; or (3) urinary, obstetric, or gynecologic injury. Most patients are 40–50 years of age and multiparous. The mid- or distal third of the urethra is the usual site. With congenital malformation, the cystic structure, usually 1–4 cm in di- ameter, may be an angled or multiloculated cavity. Calculi are pres- ent in the diverticulum in 10%–20% of patients. Clinical Findings Urinary urgency, frequency, nocturia, dribbling after urination, dis- charge of urinous or bloody, purulent fluid following stripping of CHAPTER 30 OTHER GYNECOLOGIC PROBLEMS 825 BENSON & PERNOLL’S 826 HANDBOOK OF OBSTETRICS AND GYNECOLOGY the urethra, vaginal pain, dyspareunia, urethral tenderness, pelvic discomfort, and vaginal fullness occur. There may be indefinite an- terior vaginal fullness that is periodically painful. Radiopaque contrast fluid studies generally will outline the di- verticulum. Ultrasonography is not diagnostic. Insertion of a small urethral sound will demonstrate a slight stricture of the urethra and the diverticulum just beyond. Air cystoscopy or panendoscopy will reveal the diverticular opening in most cases. Complications Urethrovaginal fistula may follow unsuccessful diverticulectomy or spontaneous rupture (often during labor), erosion by stone, inci- sional drainage, or fulguration of the cystic abnormality. Transi- tional cell carcinoma or adenocarcinoma may develop in urethral diverticula. Stricture of the urethra may be a consequence of ex- tensive or complicated surgery. Differential Diagnosis Urethritis is unassociated with postvoiding discharge or local full- ness. Urethral abscess is a phase of diverticulum development. Ure- throcele is not a swelling or herniation but a disengagement of the urethra from the points of attachment. Tumors may be primary or secondary and are firm, semifixed, and nontender. Treatment Transvaginal diverticulectomy with urethral catheter drainage for 10 days for patients with a symptomatic urethral cyst usually is curative. URINARY TRACT INJURIES FOLLOWING OBSTETRIC AND GYNECOLOGIC SURGERY Iatrogenic fistulas may occur in any part of the urinary tract and result from direct or indirect injury. Occlusions usually involve the ureter and occur as a result of angulation or obstruction by a su- ture, scarring after injury, endometriosis or infection or as a com- plication of the treatment of pelvic cancer. The kidney is rarely dam- aged directly during gynecologic surgery. The incidence of urinary tract injury in medical centers in the United States is about 0.8% following major gynecologic surgery and 0.08% following obstet- ric surgery. Postpartum fistulas of the bladder or urethra generally are caused by continued pressure of the presenting part or by instrumentation. There is usually a history of prolonged labor (especially of the sec- ond stage) or complicated operative delivery. CLINICAL FINDINGS Symptoms and Signs Unilateral ureteral injury usually causes flank pain, tenderness, and fever but does not alter the urinary volume. Ureteral injury may re- sult in constriction of the ureter, fistula, or infection. Escape of urine from the abdominal or vaginal incision indicates ureteral or blad- der fistulas or both. Ileus often follows urinary obstruction or ex- travasation. Urinary infection, especially with partial obstruction of the ureter, results in chills, fever, renal pain, and costovertebral and loin tenderness. In the absence of preexisting bacteriuria, complete obstruction of one ureter usually is asymptomatic. If urine leaks into the peritoneal cavity, there will be signs of free peritoneal fluid and peritoneal irritation. If leakage is retroperitoneal, regional pain and a fluid collection will develop. Signs of perirenal or psoas inflammation are secondary to retroperitoneal extravasation or urine. Anuria and uremia follow complete bilateral ureteral occlusion. In acute cases, rule out de- hydration, shock, lower nephron nephrosis, and congestive heart failure. Laboratory Findings ● Passage of a urethral catheter should reveal obstruction. ● Urethroscopy will often expose blockage, perforating suture, or fistula. ● Cystoscopy will disclose large vesical fistulas, but small fis- tulas may escape detection. ● Retrograde studies of the urinary tract are especially useful to rule out ureteral injury. If the ureteral catheters pass read- ily to both renal pelves and clear urine is returned, ureteral injury is excluded, except perhaps in a case of a crushing injury or small perforation. If one of these complications seems likely, the catheter should be secured in the ureter for splinting and drainage for the 10–14 days necessary for healing. URETERAL CONSTRICTION Obtain blood creatine and BUN tests to identify renal impairment. Ultrasonographic or x-ray findings may disclose ureteral obstruc- tion, fistula, or urinary extravasation. CT is the best radiographic CHAPTER 30 OTHER GYNECOLOGIC PROBLEMS 827 BENSON & PERNOLL’S 828 HANDBOOK OF OBSTETRICS AND GYNECOLOGY modality for evaluating ureteral obstruction. It can also assess the degree of renal compromise, determine the site of a fistula or an obstruction, and determine the presence of extravasated urine. Even the freshly occluded kidney will not excrete the contrast agent on excretory urography. Although the urogram can be used as a screening test, it is not as sensitive as CT for detecting ex- travasated urine. Moreover, the presence of intestinal gas will re- duce the clarity of the roentgenogram. Retrograde urography may be useful when a ureteral catheter is blocked by an occlusion. A radiopaque catheter should be used so that the level of the obstruction can be observed on the film. Injec- tion of a contrast medium into a Braach bulb catheter may reveal a fistula above the bulb fixed in the most distal portion of the ureter. Bladder Fistula and Extravasation Obtain an anteroposterior scout film of the pelvis. Fill the bladder with 50 mL of suitable radiopaque medium in 200 mL of water, and take a second film. Drain the bladder, and obtain a third film at once. Slight extravasation, not visible in the second film, may be clearly seen in the third. Complications Peritonitis is the most serious complication of urinary tract injury. Anuria or oliguria may be associated with fatal uremia after bilat- eral ureteral occlusion. Other complications are psoas or perirenal abscess or thrombophlebitis. Urinary tract infection usually follows partial ureteral obstruction. DIFFERENTIAL DIAGNOSIS Clear, yellowish, odorless drainage from the abdominal wound may represent ascites or exudative peritoneal fluid, an antecedent of wound dehiscence. Thin, brownish discharge from an abdominal or vaginal suture line may be serum from a seroma or hematoma. In ureteral obstruction, oliguria or anuria may be due to shock, dehy- dration, or lower nephron nephrosis; abdominal distention may in- dicate dynamic ileus caused by intestinal obstruction or adynamic ileus due to peritonitis; fever may be due to an infected wound, peritonitis, or thrombophlebitis; and kidney pain and costovertebral or flank tenderness may be due to nephrolithiasis, ureterolithiasis, or pyelonephritis. PREVENTION Adequate preliminary studies of the urinary tract and full knowledge of the anatomy and pathologic processes involved are essential before surgery. The ureters should be catheterized and identified ini- tially in all difficult cases, and the wire stylet should be left in the ureteral catheter for identification—to prevent the ureter from be- ing cut or clamped by mistake. All structures must be identified before clamping, incision, and ligation, and care must be taken to prevent undue traction and need- less denudation of the ureter and base of the bladder. Only fine ab- sorbable sutures should be used in or around the urinary tract. Mul- tiple ligatures should not be used for hemorrhage. Instead, pressure should be applied and a single bleeding point secured. The integrity of the bladder and the course of the ureters must be traced at the com- pletion of each abdominal operation if surgery was near the ureter. The surgeon should personally remove ureteral catheters after surgery if it is decided not to leave them in place. A hang-up may indicate ureteral constriction. TREATMENT Emergency Measures Treat shock, blood loss, and dehydration as indicated and catheter- ize the bladder. If oliguria or anuria is present, obtain creatine and BUN. Check the specific gravity of the urine. Surgical Measures Bilateral Ureteral Obstruction If both ureters are obstructed and the patient is a poor surgical risk, nephrostomy or unilateral tube ureterostomy is preferred. Use the largest urethral catheter that will enter the ureter. The other kidney should not be left obstructed for more than a few days. As soon as the patient becomes a satisfactory operative risk, relieve the second blocked kidney by nephrostomy or tube ureterostomy. Deligation alone is not satisfactory unless it can be performed easily. If deli- gation is done, insert a splinting catheter through a longitudinal in- cision several centimeters above the point of obstruction, pass it to the kidney, bring it out from the urethra, and fix it to a Foley retention catheter for 10–14 days. Then remove both catheters. The retroperitoneal area must always be drained through a separate lower quadrant or flank stab wound. A gallbladder T tube can be used in lieu of a catheter when the cross arm of the T is notched at the vertical segment; the ureter is incised longitudinally several centimeters about the defect; the tube is inserted so that its lower arm splints the point of injury; the upper arm of the tube is fixed in the proximal ureter, and the long arm is carried out retroperitoneally through a stab wound in CHAPTER 30 OTHER GYNECOLOGIC PROBLEMS 829 BENSON & PERNOLL’S 830 HANDBOOK OF OBSTETRICS AND GYNECOLOGY the flank; a drain is placed in the retroperitoneal space underlying the T tube and allowed to remain until drainage ceases (about 1 week after removal of the tube). Vesicoperitoneal Fistula Perform laparotomy as soon as the diagnosis is established. With closure of the fistula in two layers using fine catgut, avoid the mu- cosa in suturing. Drain the bladder by cystostomy or with a Foley retention catheter, and use pelvic suction drainage for about 7 days. Vesicovaginal Fistula Treat local infection by removing old sutures and concretions and by giving systemic antibiotics. Repair is indicated as outlined for vesicoperitoneal fistula. In general, attempts at closure should be delayed until 4 months or more after injury, although the use of steroids and intensive antibiotics may allow more immediate repair. All but large, inaccessible, immobile vesicovaginal fistulas (85%– 90% of the total) should be closed transvaginally. Ureterovesicovaginal Fistula Close the fistula abdominally using relatively few fine, absorbable, interrupted mattress sutures and avoiding the mucosa. Pursestring sutures should not be used. Reimplantation of the severely damaged or severed ureter into the bladder (ureteroneocystostomy) is preferable to ureteroenteros- tomy on the same side. The bladder should be drained by cystostomy or with a Foley retention catheter, and suction drainage should be used for about 7 days. Ligation of the damaged ureter and sacrifice of the kidney on the involved side are almost always contraindicated. The opposite kidney may be deficient or it may fail. PROGNOSIS Most ureteral repairs are successful if performed carefully and if urinary and extraperitoneal drainage is ensured. Very small vesico- vaginal fistulas often close spontaneously if the bladder can be kept collapsed and infection prevented. Urethral fistulas are notoriously resistant to spontaneous closure if a urethral catheter is used. Many heal well, however, when simply repaired and when a cystostomy is used instead of a urethral catheter. ANORECTAL PROBLEMS Common lesions of the anal canal are shown in Figure 30-12. PROCTALGIA FUGAX Proctalgia fugax, so-called rectal spasm or rectal neuralgia, is a sudden cramping rectal pain of short duration. It is uncommon, and its cause is not known. However, partial intussusception of redun- dant rectal mucosa is suspected. Cramping rectal pain begins with- out warning, ranges in intensity from marked to agonizing, and tends to recur. The discomfort starts low in the rectum and moves higher (perhaps combined with the urge to defecate). Pain is associated with sweating, agitation, and even collapse. It subsides gradually, leaving the patient weak and shaken. CHAPTER 30 OTHER GYNECOLOGIC PROBLEMS 831 FIGURE 30-12. Common lesions of the anal canal. (From J.L. Wilson, Handbook of Surgery, 5th ed. Lange, 1973.) BENSON & PERNOLL’S 832 HANDBOOK OF OBSTETRICS AND GYNECOLOGY Rectal examination readily differentiates proctalgia fugax from thrombosed hemorrhoids, fissure in ano, or abscess. The pain of factitial proctitis, which may follow intravaginal radium therapy or local treatment of acute rectal disease, is constant and is accompa- nied by rectal bleeding and ulceration. Sigmoidorectal obstruction causes extreme, unrelenting, progressive pain and is not likely to recur. Ample sedation and filling of the rectum with 200–300 mL of air or warm fluid may give dramatic relief. Recurrent attacks may be treated by submucosal injections of a solution containing 4% phe- nol, 50% glycerine, and water. Injections of 1 mL each at four points 1 cm apart just below the rectosigmoid junction may be curative. ANAL CONDYLOMAS (See Condylomata Acuminata, p. 578) HEMORRHOIDS Hemorrhoids (“piles”) are anorectal varicosities caused by lax pelvic veins and venous stasis. Internal hemorrhoids lie above the anorectal or mucocutaneous dentate line and are derived from the superior and middle hemorrhoidal veins. They usually are located in the right anterior and both posterior quadrants of the rectum. In- ternal hemorrhoids are covered by a thin rectal mucosa and are innervated by autonomic nerves. External hemorrhoids develop be- low the mucocutaneous line and may appear in any quadrant. They are covered by skin, are supplied by the inferior hemorrhoidal vein, and are innervated by cutaneous nerves. Combined external and in- ternal hemorrhoids are uncommon, but they may be serious if they involve at least a third of the anorectal margin. Hemorrhoids cause itching, pain (the most severe occurs with thrombosis), protrusion, and bleeding. Most women with hemor- rhoids develop them during pregnancy or delivery. Never assume that hemorrhoids are the cause of bleeding from the bowel until careful and complete physical, proctologic, and laboratory studies have failed to reveal cancer, a benign tumor, or other local or sys- temic disease. Prevention includes good bowel habits, avoidance of straining, and prompt treatment of diarrhea and anorectal disorders. No ther- apy is required for asymptomatic hemorrhoids. Stool softeners, lax- atives, and fiber-rich foods together with ample fluids should be given. Hemorrhoids causing mild or infrequent symptoms are treated with warm sitz baths, astringent ointments, or suppositories and oral analgesics. Avoid using sensitizing local anesthetics or antibiotics. Take measures to correct faulty bowel function. Hemorrhoids with moderate symptoms (large or prolapsed hem- orrhoids) should be treated as for mild symptoms. One hemorrhoid a week may be injected with 1 mL of 5% quinine and urea solu- tion or 5% sodium morrhuate solution using a 22-gauge needle. Hemorrhoids with severe symptoms (large or strangulated hemor- rhoids) are acutely painful. These and thrombosed external hemor- rhoids should be incised under local anesthesia and the clot re- moved. For the first 24 h after clot formation, treat as for mild symptoms. Later, consider hemorrhoidectomy. Symptomatic hemorrhoids during pregnancy should be treated for mild symptoms if possible. Hemorrhoidectomy should be de- ferred until after the puerperium. Open radial hemorrhoidectomy (vascular ligation and excision) is the preferred surgical method. A cleansing enema should be ad- ministered before hemorrhoidectomy. Avoid packs or drains after surgery. Cover the incision with moist gel sponge. The patient should receive daily sitz baths, mild laxatives, and parenteral anal- gesics. Antibiotics may be given if needed. Perform gentle digital rectal dilation 5–7 days postoperatively and repeat two or three times every 5–7 days to prevent bridging and fistula formation. Complications of hemorrhoidectomy include postoperative bleed- ing, perianal hematoma, infection, fecal impaction, delayed healing (with granulation tissue), rectal stenosis, and recurrence of hemor- rhoids. Hemorrhoids are never precancerous, but cancer may co- exist. Hemorrhoidectomy is curative. Hemorrhoids are unlikely to be permanently cured by injection therapy, but complications are uncommon. FISSURE IN ANO Anorectal mucosal lacerations occur frequently as a result of sud- den or marked distention (e.g., during a difficult bowel movement). Acute fissures, although temporarily painful and perhaps associated with scant bleeding, generally heal rapidly. Chronic fissures may be persistent: either they fail to heal, or they heal and break down. Recurrent fissures may be associated with the eventual development of a sentinel pile, hypertrophic papillae, and anal spasm (especially painful on rectal examination). Treatment of acute fissures is the same as that for hemorrhoids with mild symptoms. A single application of a mild styptic, such as 1% silver nitrate solution, may be beneficial. CHAPTER 30 OTHER GYNECOLOGIC PROBLEMS 833 BENSON & PERNOLL’S 834 HANDBOOK OF OBSTETRICS AND GYNECOLOGY For chronic or recurrent fissures, surgical excision of the sen- tinel pile or papilla and the fissure, preferably without suture clo- sure, may be required. Postoperative care is similar to that after hemorrhoidectomy. FISTULA IN ANO Anal fistula (Fig. 30-13) is a chronically suppurating rectoperineal tract usually caused by pyogenic bacteria, often after obstetric trauma. A complete fistula has an internal (rectal) opening and one of more external (perianal) openings. An incomplete or blind fis- tula has an internal opening only. Many others are associated with repair of a third-degree or fourth-degree perineal laceration. Anal fistulas also develop from an anal crypt, usually preceded by anal abscess. Pain is reported when the fistula closes temporarily, suppura- tion develops, and drainage brings relief. Periodic soiling by fecal discharge is a common complaint. If the internal opening of a com- plete fistula is above the sphincter, involuntary passage of flatus is reported commonly. FIGURE 30-13. Cross-section of muscles of anal wall showing usual paths of anal fistulas. (From J.L. Wilson, Handbook of Surgery, 5th ed. Lange, 1973.) Devious sinus tracts cause difficulty in identification of the in- ternal opening. Injection of 1 part hydrogen peroxide and 2 parts methylene blue into the external openings releases oxygen by con- tact with the discharges. The blue dye is carried through the tract, and on anoscopic examination, the colored solution can be seen to bubble from the opening. For x-ray studies, injection of iodized oil (Lipiodol) may outline the fistulous tract. Intestinal parasites should be identified by means of scrapings. Proper closure of an episiotomy or a complete perineal laceration usually will prevent fistula in ano. Prompt and adequate treatment of proctitis should prevent fistula in ano. Chemotherapy should be used if parasites (e.g., Eilistlytica) are present. Incision of the entire fistula with excision of all portions of the tract is the only curative treatment. If the fistula is not totally exposed and removed, recurrence is likely. ANAL INCONTINENCE Anal incontinence follows obstetric lacerations, anorectal operations (especially fistulectomy), and neurologic disorders involving spinal nerves S2–4. When incontinence is the result of trauma or a com- plication of surgery, operative correction is indicated after the in- flammation has subsided and initial healing is complete. Most se- rious lacerations due to childbirth injury should not be repaired until about 6 months after delivery. ANAL CANCER Anal cancer—almost always squamous cell type—represents only 1%–2% of all cancers of the colon, rectum, and anus. The cause is not known, but chronic granulomatous anal lesions are suspected. Anal cancer appears as a slightly raised, firm, ulcerative, and slightly tender area. Anal cancer is frequently confused with chronic fissures in ano or bleeding hemorrhoids and is treated palliatively. It may be difficult to cure if the cancer extends upward into the sphincter and around the anus and metastasizes to the inguinal glands. Biopsy of suspected or frankly tumorous anal lesions should be done under local anesthesia. Ample excision of very small anal can- cers is feasible. Most lesions are large when they are first diagnosed accurately, however, and require abdominoperineal resection and radical groin resection. Radiation treatment, even for palliation, is unsatisfactory. The 5-year survival rate is only about 50%. CHAPTER 30 OTHER GYNECOLOGIC PROBLEMS 835 BENSON & PERNOLL’S 836 HANDBOOK OF OBSTETRICS AND GYNECOLOGY CHRONIC PELVIC PAIN Acute pelvic pain and pain of ,3 months duration are more likely to have identifiable causes, whereas it is unlikely to find the initi- ating etiology of most subacute (3–6 months duration) and chronic (.6 months duration) pain. Characteristically, the originat- ing event triggered pain and the pain led to affective responses (suf- fering), which overtime, led to pain behavior. The cumulative adap- tive changes collectively known as pain behavior may be functional or dysfunctional and are made based on the pain (that may no longer even be present). Chronic pain may be categorized as: structural (from ongoing diseases, e.g., cancer, osteoarthritis) psychophysio- logic (e.g., muscle spasm leading to pain after the original insult has passed), and somatic (the internalization of stress which is ex- pressed as pain). Some have labeled the latter two groups psy- chogenic or functional. Both tend to be chronic or recurrent. Women 25–45 years of age are most susceptible. The reported incidence in gynecologic patients in the United States is 5%–25%, depending on the interests and skills of the reporting physician. Pain not attributable to physical causes may result from exag- geration of normal physiologic impulses, ignorance, fear, or ten- sion, or from a lowered perceptual threshold to disturbing stimuli. Pain is associated with past or present environmental factors. The patient’s complaint is often fixed on one anatomic area or organ system. Before the pain is labeled psychogenic, there are four other al- ternatives to consider: the pain is from a disease process that is not yet detectable, the pain may be associated with vascular disorders where no disease process can be observed, the pain may be due to nongynecologic causes (e.g., gastrointestinal, genitourinary, or skeletal), and the psychogenic overlay is the result of chronic pain. A reasonable approach is to determine what organic problems are present and what psychologic factors are present and to treat both. CLINICAL FINDINGS SYMPTOMS AND SIGNS Complaints are almost invariably multiple. In addition to pelvic pain, most patients also report dyspareunia, dysmenorrhea, abnor- mal menses, and other pelvic complaints. There may be numerous abdominal scars, indicating polysurgery. The patient insists that she is in great pain, but in at least 25% of cases, no physical abnormality can be found. In the rest, insignificant physical varia- tions or minimal lesions may be present. The historical investigation should include a description and timing of the pain (when, where, why, what relation to menses, re- lation to stress, degree, and character). It should be determined if the patient has pain in other parts of the body (e.g., headache, back- ache, or genitourinary tract pain). A careful menstrual and sexual history should be taken. Her work and leisure habits should be dis- cussed. Inquiry should be made about pelvic and abdominal infec- tions, previous operative procedures, and other gynecologic disor- ders (e.g., endometriosis, adenomyosis). A thoughtful social history should be obtained, including marital status, children, stresses in life (childhood, adolescent, and adult), and history of physical or sexual abuse. Patients with chronic pelvic pain are more likely to experience depression, substance abuse, sexual dysfunction, sleep disorders, and somatization disorders. They are more likely to have been sexually abused as a child or as an adult. Contributing factors in the patient’s life should be elicited, including physical or sexual abuse, rape or incest, domestic discord, parental divorce, alcohol or drug abuse, and so forth. A baseline general physical and neurologic examination is nec- essary in every chronic pelvic pain case. Both the abdominal and pelvic examinations should focus specific attention on pain repro- duction. Whereas laboratory evaluations are tailored to each patient they often include CBC, ESR, VDRL, UA and culture, and cervi- cal cytology. SPECIAL EXAMINATIONS Ruling Out Organic Disease After appropriate initial evaluation, it may be necessary to rule out organic disease by laparoscopy, ultrasound, CT scan, MRI, gas- trointestinal endoscopy, and genitourinary studies. Psychologic test- ing should be performed by those expert in the field. Recall that minor abnormalities of the genitourinary system are frequently in- appropriately blamed for chronic pelvic pain. COMPLICATIONS Psychoneurosis may progress to psychosis. A despondent patient may commit suicide. If unaffected uterus or ovaries are removed, the symptoms may be transferred to the gastrointestinal or urinary tract. CHAPTER 30 OTHER GYNECOLOGIC PROBLEMS 837 BENSON & PERNOLL’S 838 HANDBOOK OF OBSTETRICS AND GYNECOLOGY DIFFERENTIAL DIAGNOSIS Psychogenic disease can be differentiated from organic disease by ruling out the latter or by recognition of psychoneurosis or psy- chosis while investigating organic pathology. Most patients with psychogenic pelvic pain have many characteristic features that make a direct diagnosis possible without extensive studies. Chronic salpingitis or urinary tract infection, spastic and other types of colitis, and endometriosis must be ruled out, perhaps by laparoscopy. A comparison of organic and psychogenic pelvic pain may be helpful in diagnosis (Table 30-1). TABLE 30-1 DIFFERENTIATION OF ORGANIC AND PSYCHOGENIC PAIN Organic Psychogenic Type Sharp, cramping, Dull, continuous intermittent Time of Any time; may Usually begins onset awaken well after patient waking, when social obligations are pressing Localization Localizes with Variable, shifting, typical point generalized tenderness Progress Soon becomes Remains the same either better for weeks, or worse months, or years Provocative Often reproduced Not triggered or tests or augmented accentuated by by tests or examination manipulation, but by not mood interpersonal relationships PREVENTION Sex education, counseling, and early recognition and treatment of emotional illness are the best preventive measures. TREATMENT After examination and observation, the patient should be reassured and given simple symptomatic therapy. The physician must be em- pathetic, unhurried, a good listener, and skilled in positive rein- forcement and support. Once the diagnosis is established, the disorder must be explained to the patient in direct, convincing terms. The patient should be given an acceptable escape. A useful analogy may be that of ten- sion headache. The physicians must gain the patient’s cooperation, perhaps via reorientation and reeducation. A key is to treat the pa- tient promptly and continue on a regular basis. Simple analgesics are useful. Do not give sedatives, tranquiliz- ers, amphetamines, or narcotics because these patients are prone to addiction. Sedatives may lead to depression and suicide. Be pre- pared to spend a great deal of time talking to the patient. Do not perform operative procedures except on definite surgical indica- tions. Psychotherapy or referral to a psychiatrist may be required. Every effort must be made to assist her to adjust socially. PROGNOSIS These patients often refuse psychotherapy, withdraw early from a treatment program, and change physicians frequently. The medical future is bleak unless the patient confronts the real problem. Reas- surance and symptomatic therapy result in temporary improvement in about three fourths of patients. Psychiatric treatment results in lasting improvement in many patients. DYSPAREUNIA Dyspareunia (painful coitus) may be functional (psychogenic), or- ganic, or both. Functional dyspareunia occurs most frequently and is more difficult to treat. Either type may occur early (primary) or late (secondary) in the sexually active interval of life. The site of discomfort may be external (at the introitus) or internal (deep within CHAPTER 30 OTHER GYNECOLOGIC PROBLEMS 839 BENSON & PERNOLL’S 840 HANDBOOK OF OBSTETRICS AND GYNECOLOGY the vagina or beyond), and some women describe both types of pain. Functional dyspareunia may be caused by psychosexual prob- lems, a previous extremely negative experience (e.g., sexual mo- lestation), fear of genital damage, fear of sexually transmittable dis- ease, or fear of pregnancy. Vaginismus, an involuntary spasm of the muscles of the introi- tus and levators when the thighs are abducted, is an indication of extreme anxiety. It may be due to psychologic factors or personal emotional problems, or it may occur in anticipation of or in response to pain. External organic dyspareunia may be due to an occlusive or rigid hymen, vaginal contracture due to any cause, or inflammatory disorders. Traumatic or infectious processes are seen in younger pa- tients and atrophic vulvovaginitis in postmenopausal women. Organic causes of internal dyspareunia include vaginal disor- ders, severe cervicitis, marked fundal retroposition, uterine prolapse or neoplasm, tuboovarian disease, pelvic endometriosis, and severe disorders of the lower urinary tract or colon. Psychiatric evaluation is indicated if complex psychosexual problems seem to be present. Specialized techniques of physical ex- amination (e.g., cystoscopy, may be required to rule out organic disease). Functional dyspareunia can be treated only by counseling and psychotherapy. Both partners should be interviewed. Information on contraception is often helpful. The importance of foreplay be- fore sexual intercourse must be emphasized. An appropriate water- soluble vaginal gel may be useful. Adequate estrogen treatment of- ten is required for postmenopausal women. For functional dyspareunia, hymenal-vaginal dilations by the patient with a conical (Kelly) dilator or test tubes of graduated sizes may give confidence. Lubricants or anesthetic ointment applied to the introitus gives some relief but is of no permanent value. The treatment of organic dyspareunia varies and depends on the basic underlying cause. Organic dyspareunia due to vaginal dryness may be treated with a water-soluble lubricant. Estrogen therapy is indicated for senile vulvovaginitis. Hymenotomy, hymenectomy, perineotomy, and similar proce- dures should be performed only on clear indications. Obstructive lesions should be corrected. Treat symptomatic vaginitis or cer- vicitis appropriately. Few patients with functional dyspareunia are quickly and easily cured, even with psychotherapy. Organic dys- pareunia subsides promptly after elimination of the cause.

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