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The committee’s efforts over the past two decades have resulted in the worldwide acceptance of terminology standards that allow clinicians and researchers interested in the lower urinary tract to communicate efficiently and precisely buy indinavir without a prescription treatment quadricep strain. While female pelvic organ prolapse and pelvic floor dysfunction are intimately related to lower urinary tract function discount indinavir online medicine organizer box, such accurate communication using standard terminology has not been possible for these conditions indinavir 400mg cheap medications and pregnancy. There is no universally accepted system for describing the anatomic position of the pelvic organs. Many reports use terms for the description of pelvic organ prolapse, which are undefined; none of the many aspiring grading systems has been adequately validated with respect either to reproducibility or to the clinical significance of different grades. The absence of standard, validated definitions prevents comparisons of published series from different institutions and longitudinal evaluation of an individual patient. A primary goal of this report is to introduce a system that will allow the accurate, quantitative description of pelvic support findings in individual patients. This document is a first effort toward the establishment of standard, reliable, and validated descriptions of female pelvic anatomy and function. The subcommittee acknowledges a need for well- designed reliability studies to evaluate and validate various descriptions and definitions. We have tried to develop guidelines that will promote new insights rather than existing biases. Although the specifics of the examination technique are not dictated by this document, authors should describe their specific technique precisely. Segments of the lower reproductive tract will replace such terms as “cystocele, rectocele, enterocele, or urethrovesical junction” because these terms may imply an unrealistic certainty as to the structures on the other side of the reproductive tract bulge, particularly in women who have had previous prolapse surgery. Conditions of the Examination Many variables of examination technique may influence findings in patients with pelvic organ prolapse. It is critical that the examiner sees and describes the maximum protrusion noted by the individual subject during her daily activities. Therefore, the criteria for the end point of the examination and the full development of the prolapse must be specified in any report. Suggested criteria for demonstration of maximum prolapse should include one or all of the following: Any protrusion of the vaginal wall has become tight during straining by the patient. For example, the subject may use a small handheld mirror to visualize the protrusion. Other variables of technique that should be specified during the quantitative description and the ordinal staging of pelvic organ prolapse include the following: The position of the subject (e. Researchers should determine the intra- and interobserver reliability of measurements made with their assessment techniques before utilizing them as baseline and outcome variables. Manuscript descriptions of assessment techniques should include sufficient detail to ensure that other researchers can replicate them precisely. Quantitative Description of Pelvic Organ Position This description system is a tandem profile in that it contains a series of component measurements grouped together in combination, but listed separately in tandem, without being fused into a distinctive new expression or “grade. Finally, it allows similar judgments as to the outcome of surgical repair of prolapse. Definition of Anatomic Landmarks Prolapse should be evaluated by a standard system relative to clearly defined anatomic points of reference. There are two types of points of reference: fixed reference points and defined points for measurement. Fixed Point of Reference Prolapse should be evaluated relative to a fixed anatomic landmark that can be consistently and precisely identified. The hymen will be the fixed point of reference used throughout this system of quantitative prolapse description. Although it is recognized that the plane of the hymen is somewhat variable depending upon the degree of levator ani dysfunction, it remains the best landmark available. In the sitting or standing position, or in situations with limited viability due to obesity or limited ability for hip abduction, the position of the cervix or the leading point of the prolapse relative to the ischial spines may be measured by palpation. Measurements so obtained should be normalized to the level of the hymen by noting the distance between the ischial spines and the plane of the hymen. For example, a cervix that is 3 cm distal to the ischial spines would be at −2 cm if the spines were 5 cm above the plane of the hymen. Because the only structure directly visible to the examiner is the surface of the vagina, anterior prolapse should be discussed in terms of a segment of the vaginal wall rather than the organs that lie behind it. Thus, the term “anterior vaginal wall prolapse” is preferable to “cystocele” or “anterior enterocele” unless the organs involved are identified by ancillary tests. This corresponds to the approximate location of the “urethrovesical crease,” a visible landmark of variable prominence that is obliterated in many patients. By definition, the range of position of point Aa relative to the hymen is −3 to +3 cm. By definition, point Ba is at −3 cm in the absence of prolapse and would have a positive value equal to the position of the cuff in women with total posthysterectomy vaginal eversion. These points represent the most proximal locations of the normally positioned lower reproductive tract. It represents the level of uterosacral ligament attachment to the proximal posterior cervix. It is included as a point of measurement to differentiate suspensory failure of the uterosacral–cardinal ligament complex from cervical elongation. When the location of point C is significantly more positive than the location of point D, this is indicative of cervical elongation, which may be symmetrical or eccentric (e. Analogous to anterior prolapse, posterior prolapse should be discussed in terms of segments of the vaginal wall rather than the organs that lie behind it. Thus, the term “posterior vaginal wall prolapse” is preferable to “rectocele” or “enterocele” unless the organs involved are identified by ancillary tests. If small bowel appears to be present in the rectovaginal space, the examiner should comment on this fact and should clearly describe the basis for this clinical impression (e. By definition, point Bp is at –3 cm in the absence of prolapse and would have a positive value equal to the position of the cuff in a woman with total posthysterectomy vaginal eversion. By definition, the range of position of point Ap relative Other Landmarks and Measurements 1819 The genital hiatus is measured from the middle of the external urethral meatus to the posterior midline hymen. If the location of the hymen is distorted by a loose band of skin without underlying muscle or connective tissue, the firm palpable tissue of the perineal body should be substituted as the posterior margin for this measurement. The perineal body is measured from the posterior margin of the genital hiatus (as just described) to the midanal opening. The total vaginal length is the greatest depth of the vagina in centimeters when point C or D is reduced to its full normal position. Making and Recording Measurements The position of points Aa, Ba, Ap, Bp, C, and (if applicable) D with reference to the hymen should be measured and recorded. Positions are expressed as centimeters above or proximal to the hymen (negative number) or centimeters below or distal to the hymen (positive number) with the plane of the hymen being defined as zero (0). For example, were direct measurements made using a probe, ruler, glove, speculum, or other device marked in centimeters, were indirect measurements made with the examiner’s fingers and then measured off a centimeter tape, were measurements estimated by the examiner without using a graduated device, or were combinations of techniques used?

The course of the viral infection is usually self-limiting cheap indinavir 400mg free shipping treatment qt prolongation, with spontaneous recovery typically occurring within several months [1 order indinavir 400 mg overnight delivery medicine that makes you throw up,185] proven 400 mg indinavir medications valium. Poliomyelitis Following a World Health Organization resolution in 1988, great strides have been made in the eradication of poliomyelitis worldwide, with only 11 countries currently affected with endemic polio [186]. Poliomyelitis results in destruction of the gray matter of the anterior horn cells and selective destruction of large-diameter fast-conducting motor neurons [187]. Polio is essentially a pure motor neuropathy with sensory function usually preserved [188]. Urinary retention may occur in up to 40% of patients, depending on disease severity. Patients with post-polio syndrome may manifest an increased incidence of irritative lower urinary tract symptoms, although studies on this issue are incomplete [1]. Tethered Cord Syndrome and Short Filum Terminale The tethered cord syndrome results from impediment of the cephalad migration of the conus medullaris and may result from a short filum terminale, intraspinal lipoma, or fibrous adhesions resulting from the surgical repair of spinal dysraphism [190,191]. The syndrome is classically diagnosed in children, especially during adolescence, but rarely, the process may occur in adulthood [192,193]. Lower urinary tract dysfunction is common in this syndrome, and, in otherwise asymptomatic children, urodynamic abnormalities may be the basis for surgical intervention [194]. Urodynamic Evaluation Detrusor areflexia has been reported in 60% of patients, although recovery of lower tract function approached 60% with surgical release of the cord [192]. These nerve fibers can be disrupted during complicated pelvic surgical procedures, or following pelvic fracture, with resultant lower urinary tract dysfunction. Sympathetic (thoracolumbar) nerves promote urine storage by relaxing the detrusor muscle and relaxing the bladder outlet. Similarly, in cases involving predominately sympathetic innervation, the resultant symptoms usually include intrinsic sphincter deficiency with stress urinary incontinence. Study of patients with voiding dysfunction following major pelvic surgery has shown resolution of symptoms in 6 months for up to 80% of affected patients [198]. The courses of the pelvic nerves are as follows: From the inferior hypogastric plexus, it has multiple branches forming a weblike complex within the endopelvic fascial sleeve, some of which innervate the bladder detrusor. A main branch traveling inferolateral to the rectum remains deep to the fascia of the levator ani muscle and courses to the external urinary sphincter. At the level of the bladder neck in females, this pelvic nerve branch sends direct branches to the urinary sphincter [201]. As a result of this course, this has been associated with significant lower urinary tract dysfunction as an operative complication [202]. Prior studies reveal evidence of sympathetic denervation in 100%, parasympathetic denervation in 38%, and pudendal denervation in 54% of patients postoperatively [1]. The postoperative voiding dysfunction is usually transitory, although sphincteric insufficiency may be permanent [204]. However, the location of the plexus inferolateral to the rectum reduces the disruption of the parasympathetic nerve fibers during hysterectomy, and the extent of pericervical dissection (e. Persistent postoperative lower urinary tract dysfunction is best managed with a combination of anticholinergic therapy to decrease intravesical storage pressure and catheterization for retention, with most oncologists leaving the patients catheterized for a minimum of 1 week postoperatively. The incidence of fistula is also increased by the radical dissection compared to those hysterectomies for benign indications. Diabetic Cystopathy Diabetes mellitus is the most prevalent medical condition resulting in sensory neurogenic lower urinary tract dysfunction affecting 2% of the U. Voiding symptoms generally develop at least 10 years after the onset of the disease, as a result of one of three types of neuropathy: peripheral neuropathy, mononeuritis multiplex, and autonomic neuropathy [91,208]. Metabolic abnormalities of Schwann cell function result in segmental demyelinization and subsequent axonal degeneration, impairing nerve conduction [209,210]. Clinical and Urodynamic Features Diabetes contributes significantly to voiding dysfunction in women [211]. Gradual development of impaired bladder sensation is the first sign, usually associated with other sensory impairments consistent with peripheral neuropathy. Decreased sensation leads to increased intervoiding intervals, which cause an increase in bladder capacity. Eventually, the bladder may become progressively overdistended, impairing contractility and leading to incomplete emptying [212]. Subsequently, symptoms associated with traditional “diabetic cystopathy” may include urinary hesitancy, slowing of the urine stream, and decreasing urinary frequency [211,213]. These symptoms may progress to include a sensation of incomplete emptying or even urinary dribbling from overflow incontinence [211,214]. When questioned, up to 50% of unselected diabetes mellitus patients have subjective evidence of traditional diabetic cystopathy. The urodynamic evaluation, however, suggests alterations in lower urinary tract function in only 27%–85% of these patients [214,215]. Urodynamic studies frequently reveal impaired bladder sensation, increased cystometric bladder capacity, decreased detrusor contractility, an impaired urine flow, and an elevated postvoid residual urine volume [91]. Kaplan and Te reported on another group of patients with diabetes referred because of voiding symptoms. In addition, poor diabetic control will contribute to urgency and frequency as a result of decreased warning time from impaired sensation and polyuria from the elevated glucose. Upper tract changes depend upon the duration and severity of the disease process as well as the effect on intravesical pressure. The effect of diabetes-induced lower urinary tract dysfunction on the upper urinary tract is difficult to determine because of the other effects of diabetes on renal function [1]. When managing patients with diabetic cystopathy, preservation of renal function is paramount. A direct effect of diabetes on renal microvasculature, combined with upper tract obstructive changes resulting from diabetic cystopathy, put the diabetic kidneys at great risk. A timed voiding schedule is effective in those with impaired contractility, while intermittent catheterization is reserved for those who experience greater difficulty with emptying. A high index of suspicion should be maintained where the severity of symptoms is disproportionately high or in rapid onset of symptoms. A brief neurological examination at the time of presentation of new patients —or during urodynamic—should be considered as a standard for good practice. Management of voiding dysfunction in patients with neurological comorbidities requires consideration of functional disabilities and other medications. The standardization of terminology in lower urinary tract function: report from the standardization sub-committee of the international continence society. High incidence of occult neurogenic bladder dysfunction in neurologically intact patients with thoracolumbar spinal injuries. Mice lacking M2 and M3 muscarinic acetylcholine receptors are devoid of cholinergic smooth muscle contractions but still viable.

In lipoplasty discount 400mg indinavir overnight delivery treatment lichen sclerosis, calves purchase indinavir 400mg with visa medicine woman, ankles buy indinavir overnight delivery treatment 7th march, hips, waist, upper abdomen, flanks, chest depending on the aesthetic goals, both the superficial fatty wall, and the back. In general, it takes more effort to extract layer and the deep layer are targeted for fat extraction. The patient is asked about specific areas of concern and the improvement she/he is seeking. Physical examination includes assessment of the thickness of the subcutaneous fatty layer by means of the skin pinch test. Laxity and sagging are assessed by lifting the skin up against the gravitational pull and by observ- ing body contours in the upright, reclining, sitting, and flexed tive. Areas of fat excess and fat deficiency are deter- molipectomy, which results in much longer scars compared mined. The location of cannula entry sites from the previous with the original liposuction incisions. The surgeon visualizes the ideal contour, determines the sites for harvesting the fat, and discusses the surgical plan 4 Procedure for Treating with the patient (Fig. Postliposuction Contour Irregularities Variable retention of the fat graft, realistic expectations, limitations, and potential need for additional procedures, Minor contour irregularities can be treated by limited addi- which may be major or minor financial cost, are all thor- tional liposuction, performed under local anesthesia or intra- oughly discussed. Autologous fat transfer is used to correct early (3–6 months) and late intervention appear to be effec- contour problems due to fat deficiency [4–9]. The fat from the protuberant areas is redistributed be lost after the liposuction phase (various surgical markings into the deficient areas using manual massage with or with- are illustrated in the following case presentation). In planning the cannula entry sites for corrective liposuc- The more severe and complex cases of postliposuction tion, the surgeon should select the most direct approach to contour irregularities require systematic approach which the areas to be aspirated. Attempts to hide the incisions may includes: compromise cannula movement and the final results. Liposuction of areas of protuberance the excess fat, helps to establish the correct cannula pathway, 2. Liposuction around the areas of depression avoids unwanted fat removal, and maximizes the accuracy of 3. During the harvesting of fat, the infiltration of wetting The technique described below has the advantage of being solution is minimized in order to obtain fat of maximal solid- simple and safe. Autologous fat into all the operative sites is minimized in order to facilitate grafting has been used successfully for replacement for vol- intraoperative evaluation of the contour, as fat is aspirated or ume deficiency in various body sites including the abdomen, added. General anesthesia is used in patients with more thighs, hips, waists, buttocks, arms, breasts, and knees. The use of minimal wet- Certain anatomical conditions tend to promote better fat ting solution also reduces the chance of overresection. These conditions include absence of dense subcu- The fat is collected by pouring it directly from the patient taneous scarring, preservation of good quality of the skin, end of the liposuction tubing, or by an interposed sterile gentle slope in the area of indentation, and abundance of sub- specimen trap (Fig. To optimize the quality of the fat used cutaneous fatty tissue in and around the area of depression. If the fat is dilute or if the amount is small, a centrifuge or absorbent gauze can be used to concentrate the fat. Direct inspection of the body and inspection of photographs com- Prior to fat grafting in areas where there is dense subcutane- plement each other to render the most accurate preoperative ous scarring and adhesion, a blunt-tipped cannula without drawing. Some defects are better seen on photographs than suction may be passed beneath the area of depression to with direct inspection of the patient. Different lighting techniques may reveal different Fat is injected with a small blunt-tipped cannula with an information about the contour irregularities. A blunt-tipped cannula is can be very informative and easy to reproduce for postopera- preferred because it is less likely to cause bleeding during fat tive comparison (see Case 2 after). A sharp needle offers the advantage of more pre- Areas of maximal depression, areas of maximal protuber- cise and effective fat deposition, especially in densely fibrotic ance, and adjacent transition zones are indicated with skin areas or in the superficial layer of the skin. The markings Sometimes, the surgeon can identify the original incision should also reflect the differences in the amount of fat that through which the overresection was performed. Digital photographs The fat is injected in small increments, in multiple passes, with the surgical markings are produced for intraoperative and at multiple depths. The path of the fat injection may be Lipofilling and Correction of Postliposuction Deformities 391 parallel or crisscross as needed. Fat injection may be carried out as the reversal process of fat extraction in liposuction. During the injection, frequent visual inspection of progressive changes in the contour and skin pinch test provide additional means of assessing the adequacy of fat replacement. The aim of the corrective surgery is to create a smooth contour while the patient is on the operating table. Postoperatively, compression garment is not used in order to prevent any pressure and distortion in the fat-grafted areas. Postoperative manual massage is applied when there is firm- ness, which may result from large amount of fat deposition. The results of surgical correction of postliposuction con- tour irregularities using corrective liposuction and autolo- gous fat grafting are presented in the following sections. Cases are presented in the following areas: abdomen, waist, hips, inner, outer thighs, and knees. Transitional zone from the areas of maximal indentation to the areas of maximal protuberance was left without markings (Fig. Sixteen months after the corrective surgery, the abdomi- nal contour was improved (Figs. Subsequently, the patient requested and received minor additional liposuc- tion to reduce the periumbilical fullness. She presented with postliposuc- tion contour irregularities of the abdomen and the waist. Her condition consisted of a large area of indentation in the right lower abdomen and multiple areas of indentation and pro- tuberance in the mid- and upper abdomen. Another preoperative photograph was taken without any flash, the only source of light being ceiling fluores- cent light. This picture revealed the indentation in the right upper quadrant and upper mid-abdomen more distinctly than the photo taken with flash (Fig. In the preoperative markings, the solid black areas indi- cate areas to receive autologous fat grafting. One hundred thirty cc was injected into the supraumbilical and upper abdominal areas. The donor sites of the fat consisted of the abdomen, suprapubic area, and the posterior iliac crest areas (Fig. The postoperative course was noted for swelling and sub- cutaneous firmness in the right lower quadrant area, which responded to massage and time.

It is also a technically difficult study that requires a special catheter known as the Davis or Trattner catheter [3 purchase 400 mg indinavir fast delivery medications gout,80] (Figure 110 cheap 400 mg indinavir amex spa hair treatment. This catheter has two balloons—one of which is placed just inside the bladder neck and the other at the external meatus discount indinavir line medicine lodge kansas. Rule out hamartoma malignancy Malignant Urethral or vaginal Solid mass; may None or extrinsic compression; ± Wide local urethral or wall or hematuria have pain, may be adjuvant therapy erythema, obvious excision, vaginal seen on lesion or tumor growing from the radiation, neoplasms cystoscopy diverticulum into the urethral lumen. Wang and colleagues advocate for 2D and 3D transvaginal ultrasound as an accurate and cost-effective imaging modality for the assessment of lower urinary tract perineal masses [83]. One limitation is that the modality is dependent on the technical skills of the operator. Advantages include real-time evaluation and the ability to clarify the spatial relationships between the diverticulum and the urethra [67]. This results in improved signal-to-noise ratio and higher-resolution 1627 imaging of the urethra [93]. The signal intensity of fluid is high on T2-weighted images and isointense on T1-weighted images (Figure 110. The superior imaging also may facilitate surgical planning by accurately delineating the extent of the diverticulum. One blade of the scissors is placed in the vagina and the other in the urethra; the incision results in marsupialization of the cavity. It has been recommended that patients have a documented negative urine culture, though many advocate for a short course of oral antibiotics for several days just prior to the day of surgery [4]. The full thickness of the diverticular septum is incised and (d) a running locking absorbable suture ensures hemostasis. A 14 Fr or 16 Fr urethral Foley catheter is passed into the urethra and a weighted vaginal speculum and a Scott ring retractor facilitate exposure. The endopelvic fascia is perforated with the bladder completely emptied, and the retropubic space is developed. A strip of rectus fascia is harvested through a Pfannenstiel incision, and the fascia is closed. Helical #0 Vicryl sutures are placed in the ends of the fascial strip, the sling is placed into antibiotic irrigation, and the low abdominal incision is packed with a moist sponge until the sling is placed later in the procedure (see section titled “Concomitant Anti-Incontinence Procedures”). The diverticulectomy is continued with creation of a vaginal flap via sharp dissection in the white shiny layer of the vaginal wall. Mobilization of the vaginal flap toward the bladder neck, followed by a transverse incision in the periurethral fascia (Figure 110. In these cases, careful cauterization of the inner epithelial surface can be utilized to facilitate obliteration of the cavity. The urethral defect is closed longitudinally without tension over a urethral catheter using a full-thickness #4-0 Vicryl stitch, with care to incorporate the urethral mucosa in each stitch (Figure 110. The periurethral fascia is closed transversely with running #3-0 Vicryl (Figure 110. A Martius flap, if utilized, is placed between the periurethral fascia and the vagina. The third and final layer of closure is the inverted U-incision in the vaginal wall, which is closed with #2-0 absorbable suture. The three layers of closure include the urethral wall longitudinally, the periurethral fascia transversely, and the vaginal U-incision. Because of their complexity, they frequently present as recurrent diverticula that have been operated on previously. The authors utilized a double- wrapped porcine xenograft to aid in filling of dead space. However, for circumferential diverticula, a separate vaginal incision would also be necessary to excise the ventral portion of the diverticulum (Figure 110. A parasagittal vaginal incision has been described with detachment of the urethra from the inferior pubic ramus laterally to facilitate anterior dissection [120]. Once excised, an end-to-end urethroplasty or diverticular sac urethroplasty is performed [121]. Martius flap interposition was performed in nearly all patients in their series to help with closure of dead space (Figures 110. If a Martius flap is also being utilized, the sling is generally placed over the Martius fat pad. The dilemma is the need for cystoscopy following retropubic passage of the needles used to deliver the sling sutures from the vaginal to the suprapubic incision to ensure that the sling passers have not entered the bladder or urethra (Figure 110. Many advocate for passing the sling prior to the diverticulectomy or following excision of the diverticulum, but prior to the urethral closure. If placed prior to the diverticulectomy, the sling can be carefully packed into the vaginal incision out of harm’s way or permitted to hang loosely while the urethra is addressed. In this fashion, gentle cystoscopy can be performed prior to opening the urethra to avoid enlarging the urethral defect or injuring the urethral tissues. The advantage of passing the sling sutures prior to the diverticulectomy is that the cystoscope does not have to be passed over an open 1636 urethrotomy or urethral reconstruction; however, the presence of the diverticulum can make the retropubic needle passage difficult. Conversely, while the passage of the needles may be easier if the diverticulectomy has already been completed, cystoscopy with a urethral disruption requires a skilled touch to avoid enlarging the urethral defect. Finally, some will proceed with completion of the diverticulectomy and closure of the first two layers prior to passing the sling, understanding the risk of passing a scope over a fresh urethral closure. While there is no single correct approach, surgeons must be aware of the pros and cons of each alternative. A synthetic sling should never be utilized in the face of a diverticulectomy due to the risk of urethral erosion, though one group did report placement of a synthetic sling over a biological graft interposed between the urethra and the sling [122]. Consideration of a synthetic sling in patients who have undergone a diverticulectomy in the past and at what interval postdiverticulectomy remains controversial. Consideration of a Burch urethropexy is reasonable in this situation, though it is limited by the necessity to enter the abdomen (Figure 110. Postoperative Management The vaginal packing is removed no later than the morning of postoperative day 1. Two had abnormal pathology within the diverticulum, including one with leiomyoma and the other with squamous cell carcinoma. One hundred and twenty-two patients underwent urethral diverticulectomy over the course of 12 years. Sixty-one (50%) of the patients responded to a questionnaire at a mean follow-up of 50. This situation can be avoided by a comprehensive preoperative evaluation such that, if indicated, urinary leakage can be addressed at the time of diverticulectomy [4,11,16]. Though preoperative urinary urgency and frequency symptoms tend to abate in most patients following urethral diverticulectomy, some patients will have persistent symptoms (Stav, 2008). First-line therapy includes behavioral therapy and dietary modification and second-line therapies include antimuscarinic or beta-3 agonist pharmacotherapy (Figure 110. Incomplete excision of the diverticular neck and faulty closure of the urethral defect are also possible causes. This problem, if anticipated intraoperatively based on tissue quality, can be managed with interposition of a Martius fat pad graft between the vagina and urethra [11]. For small, distal recurrences, endoscopic saucerization or Spence marsupialization may suffice [4]; however, caution must be exercised not to injure the proximally located continence mechanism.

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