3rd International Congress On Pelvic Floor Disorders (1)

Cairo (Egypt) March 14-17, 2001

International Pelvic Floor Dysfunction Society

(2) Inhibition of the Hyperactive C.Afferent Fibers in A Hyperreflexic Animal Model By Sacral Root Neuromodulation Induces: A Possible Mechanism of Action

Hassan Shaker # Dinh Loung* , Lina Balbaa*, Michel Fehling and Magdy Hassouna * 
#Ain Shams University, Cairo , Egypt. * University of Toronto, Canada.

Introduction: Sacral root neuromodulation is an impressive new concept that has been used recently for treatment of refractory voiding and storage problems. Unfortunately, the mechanism of action remains to be clarified. We hypothesize that sacral root neuromodulation works through inhibition of the C-afferent fibers. According to the gate theory of Melzack and Wall (1) stimulation of the afferent fibers that is converging on the same dermatome of a smaller size afferents can inhibit the later fibers. 
Methods: Sixty female sprague Dawley rats have been included in this study. These have been divided into three groups of normal controls, spinalized rats at T10 and spinalized rats that have been subjected to bilateral S1 electrostimulation for 6 hours daily. Three weeks post spinalization, urodynamics was performed and Substance P (SP), Neurokinin A (NKA) and Calcitonin gene related peptides (CGRP) were extracted from the dorsal root ganglia (DRG) of L5 and L6 roots
and quantified using radio immuno-assay (RIA). In addition electrophysiological studies for the reflex arcs supplying the urinary bladder was performed. 
Results: Spinalized rats developed urinary bladder hyperreflexia after 3 weeks of spinalization. This was associated with a significant increase in the neuropeptide content of the DRG of L6. S1
electrostimulation lead to the decrease of the neuropeptide content of L6 significantly. In addition,
electrostimulation lead to the reduction in the amplitude of the longer latency evoked responses
(probably mediated by the C-afferent fibers) without marked affection of the latency. In contrast,
spinalization and S1 neurostimulation did not affect the neuropeptide content of L5 DRG except for the CGRP, which increased with spinalization and decreased with neurostimulation. 
Conclusion: Sacral root neurostimulation abolished the hyperreflexia with a simultaneous drop of the elevated neuropeptide content of L6 root DRG in spinalized animals. This may indicate that blocking of the hyperactive C-afferent fibers is one of the mechanisms of action of sacral root neuromodulation.

 

(3) Pelvic Floor Endometriosis : A Challange for all Specialities

Ahmed EL Tagy, Al -Azhar University, Faculity of Medicine

Endometriosis first described by Von Rokitanisky 1680, though benign disease, can cause crippling
pelvic pain, genital bleeding and reproductive failure. The correct incidence is difficult to assess, as many cases are asymptomatic. Since the classic paper from Sampson 1920 as a case report the incidence is ever increasing. General incidence is 0.6-10%. Fivty-Two percent of cases with chronic pelvic pain. The myth half- thruths and misconception in endometriosis come from * the etiology is still uncertain. * diagnosis is difficult, no pathognomonic test is available. * the challenges of treatment. Peritoneal fluid macrophages IL1/TNFa , PGE2, MCP-1, and C3 increase. Th/Ts ratio increases Th1/TH2 ratio diminishes. Peritoneal fluid is rich in prostaglandin as evidenced by high level of TXB and 6 - kero PGF. The disease seems dependent on estrogen and also EGF, IGFI, PDGF, and protooncogen. Twenty percent of cases are asymptomatic . Symptoms are pelvic pain, dysmenorrhoea, dyspareunia, dyscasia, dysurea, menuria, hematuria, rectal bleeding. uterosacral nodularity, and induration and adnexul mass. Some cases are still asymptomatic. There are wide range of medical treatment options, with success rate in improving symptoms or achieving
pregnancy rate 60-80% with 20% recurrence by two years, surgical options are conservative, radical, conventional surgery and laparoscopic surgery utilizing electrodiathermy or laser.

(4) Influence of Aging on the 3D Organization of the Female Pelvic Floor 

Christose Constantinou Urology Stanford University Stanford, California-U.S.A.

The extend to which the function pelvic floor (PF) is associated with increasing age and the question as to which of these changes are associated with urinary incontinence remains to be established. The existence of a causative relationship is considered in view of observation that the incidence of stress urinary incontinence is also age related, having an onset during the peri-menapausal years. Evidently, an understanding of the mechanism of action of the PF in preventing urinary continence requires a clear understanding of the interplay between its anatomical/functional components in terms of age. This presentation attempts to demonstrate the differences in the anatomical/functional characteristic of the PF of asymtomatic of young normal subjects 30 years old in comparison to peri-menapausal women 55 years old using MRI. Based on the imaging obtained from these 2 age groups, the 3D configuration of the PF was reconstructed using 7 consecutive planes in each of the axial, sagittal and coronal dimensions. The combined reconstruction demonstrate the variations in the path of the pubococcygeus muscle originating from the pubis passing along the urethra, vagina, and rectum, to the rectum, attachment to the distal half of the vagina, and inserting between the internal and external anal sphincters. The 3D reconstruction clearly shows the origin of the iliococcygeus and demonstrate the relatively large range of motion of the PF muscles in younger women and the significantly restricted displacement in the older women. The age related differences in the anatomical/functional imaging of the PF demonstrate the detailed anatomy of the levator ani muscle and introduce the concept of the age related PF-VOLUME to voluntary contraction. Finally the results demonstrate the extend of redundancy in FP function before demonstrable urinary incontinence emerges as a clinical problem

(5) Value of Imaging and Urodynamics in the Diagnosis of Pelvic Floor Dysfunction

Christose Constantinou Urology Stanford University Stanford, California,U.S.A. 

The objective of diagnostic tests designed to evaluate pelvic floor function relevant to urinary continence are based on the concept of examining: (1) the anatomical integrity of the skeletal musculature of relevant muscles in terms of contractility (2) the adequacy of the neuronal supply to these muscles in terms eliciting adequate recruitment rate secondary to the initiation of the guarding reflexes. (3) the biomechanical properties of the interconnecting tissues and their attachment to the sacral and pelvic structures. Appreciation of the contribution of these three components is essential not only for the proper diagnosis of pelvic floor function but also in deriving the most appropriate treatment modality to be employed. In this presentation, careful consideration is made of these concepts to specify the appropriate urodynamic and/or imaging protocol for the appropriate diagnosis to be employed. The combined results obtained from static and dynamic urodynamic measurements together with MRI and ultrasound imaging are used to explore the limits and value of the separate and the combined diagnostic testing. Particular emphasis is placed on the distribution of forces along the pelvic floor as a result of its voluntary activation. A specific evaluation is presented regarding the compressive effects on the urethra, consequent to active pelvic contraction in comparison to passive valsalva. The ultimately goal of these considerations is to identify with the minimum of testing the damage occurring in each element of the continence mechanism, and to select appropriate treatment plans on the basis of the abnormality found in individual patients. As an example, in the conservative treatment of the patient who has lost neuromuscular control of pelvic floor muscles, the appropriate diagnostic test can save the subject from prolonged and frustrating efforts of attempting pelvic muscle strengthening that is futile. By contrast a patient with neuromuscularly intact albeit weak muscles has the potential to be treated with exercise. Finally we present emerging imaging approaches and new instrumentation technologies that can potentially contribute to a valuable diagnosis.

(6) Urodynamics in non Neurogenic Bladder-Sphincter Diseases in Repeated Urinary Tract Infections in Younger Patients Superficial Perineal Electromyography(SPE) and Seauential Pudendal Relaxation evaluation (SPR)

Esteban M., Perez-Balseiro V., Dehaini A., Guil M., Salinas J., Zapico A., Cortes J., Sanchez- Chapado M. , Departments of Urology and Gynaecology. Principe de Asturias Hospital Alcale de Henares University Madrid SPAIN. 

Lower urinary tract symptoms (LUTS) and repeated urinary tract infections (RUTI) in younger patients (2nd to 4rd decades) are frequent in urologic consultation. Image techniques usually donÕt show organic data. A series of 28 patients (22 women and 6 men), average 25. 1 years old were evaluated through clinical history neurourologic S2-S4 examination, urodynamics (MMS UD 2000), including flowmetry/SPE, cystography and lumbosacral MRI. Treatment was SPR-SPE assisted (10m V initial). Protocol included 15 minutes session during 6 weeks. Curation was considered in 100% and improvement in 50% symptoms elimination. Symptoms were: enuresis and diurnal symptoms (16 cases), urgency-incontinence (8) and voiding difficulty (4). In flowmetry /SPE, EMG silence was observed in 26 cases and activity in 2. other urodynamics findings were: Bladder instability (21), Acontractile bladder (6) and Obstruction (1). EMG activity in detrusor flow test/SPE were observed in 18 cases during uninhibited contractions. Perineal contraction strength during instability was significant higher (mean 199.07mV) than voluntary perineal contraction (39..69m V). In cystography, VUR was observed in 5 patients, diverticular bladder in 6 and Òurethral nickÓ in 4. Treatment was finished in 22 cases (6 in protocol yet). Results were: 45% (10 cases) curation, 45% (10 cases) improvement, and 10% (2) failure. Relapse rate (6 months follow-up) was 40% (8). A statistical relationship was demonstrated between improvement in 3rd -4th treatment session and 100mV last session rehabilitation level. There were a bladder-sphincter disease in younger patients group (RUTI and LUTS) without neurological findings. In these patients urodynamics/SPE were specially useful in diagnosis. Treatment first election must be SPR-SPE assisted.

(7) Experimental Study of Submucosal Injection of N-ButyL-2-Cyanoacrylate (Histoacryl) in the Urinary Bladder as a Bulk Enhancing Agent (Canine Model) 

Moossa F. E, El Sahel Teaching Hospital, Cairo , Egypt Farag K. A. Faculty of Veterinary Medicine, Cairo University, Egypt 

Introduction and Aim of the Work: N-buty L-2 cyanoacrylate is a watery tissue adhesive which hardens within 20 seconds in moist conditions. The purpose of this study is to evaluate the usefulness of N-buty L-2-cyanoacrylate as a bulk-enhancing agent when injected submucosally in the urinary bladder of dogs. 
Materials & Methods: In 6 Mongrel dogs, the bladder was opened through a midline incision Half cc of N-buty L-2 cyanoacrylate was injected submucosally in the upper right lateral wall and half cc saline was injected in the upper left lateral wall as a control. Clinical monitoring was performed for all animals . The animals were followed up by abdominal u/s every 15 days to evaluate the size of injected materials for 3 months, then all animals were sacrificed for postmortem examination. 
Results: No significant postoperative morbidity was noted. Sonographically, no remarkable changes in the size of solidified cyanoacrylate swelling were observed through the follow up period compared with complete absence of the control. The external surface of the bladder at the injection site was intact and the brain and lung were found normal. Histologically, cyanoacrylate was found to induce minimal inflammatory tissue reaction around it while the overlying mucosa was intact. Conclusion: N-buty 1-2- cyanoacrylate could be a useful inexpensive injectable enhancing agent and warrant trial of application in human in treating urethral intrinsic sphincteric deficiency.

(8) Defecation with Paradoxal Contraction of the External Anal Sphincter in Children with Chronic Functional Constipation

Pieczarkowski S., Prazybyszewska k., Fyderek K., Stadekm., Gruszka M., Czunryna A. Department of Pediatrics, Gastroenterology and Nutrition Polish American Childrens Hospital, Jagiellonian University Poland. 

Background & Aims: In our study we estimated children with at least one-year history of constipation in whom organic causes of constipation were excluded. The aim of our study was to answer the question whether paradoxal contraction of the external anal sphincter during defection (abnormal defection dynamics) is a common cause of functional constipation in children. 
Materials: For further evaluation a group of 30 constipated children was included, age: 4 to 16 years, mean 8.3 + SD 3.3, 20 boys (66.6%) age: 4 to 16 years, mean 7.3 + SD 2.9 and 10 girls (33.3%), age 5 to 16 years, mean 10.4 + SD 3.2 Eighteen children (60%) were constipated for more than two years, 12 children (40%) more than one year. Twenty-three children (76.6%) were encopretic, 11 children had incomplete evacuation of stool.
Methods: Segmental and total colonic transit time based on HintonÕs method with radiopaque markers was estimated (children ingested 10 radiopaque markers each day on six successive days, and on the seventh day a plain abdominal radiograph was performed). Complex anorectal manometry with a four channel perfused catheter and a balloon was performed . For further estimation we focused on recordings assessed during at least five simulated defecation trials. Defecation dynamics was defined as normal if during bearing down the middle rectal pressure was higher than the middle relaxing pressure recorded 1 cm above the anal varge (in the high-pressure zone).

(9) Vaginismus - The Pelvic Floor in Panic

Ditza Katz , Ross Lynn Tabisel WomenÕs Therapy Center (U.S.A.)

The intense presentation that explores the nature of Vaginismus , the involuntary muscle spasm of the pelvic floor. The presenters will introduce their pioneering work, which approaches this devastating affiction as being another feature of the bodyÕs response mechanism to (physical and/or emotional) stress, thereby defined as a Òpanic attack of the pelvic floorÓ. Vaginismus affects a woman’s life on many levels, bringing with it physical pains, emotional anguish and the sense of failure and inadequacy. Sexual dysfunctions are an inevitable outcome as are simple activities like the inability to insert a tampon of undergoing a pelvic exam. Additionally, bodyÕs neglect and/or self-mutilation may often be the vehicle of choice for coping with Vaginismus. By morging the expertise of a urogynecologic physical therapist/sex therapist and a psychotherapist/sex therapist, the presenters have established a unique, comprehensive treatment approach whereby the patient’s body and mind are treated simultaneously for optimal intervention. The specific physiological reactions associated with anxiety/panic will be discussed, as will the accompanying emotional manifestations. In-death case studies, lab practice and treatment approaches will be introduced as time allows. 

(10) Evaluation of Paravaginal Repair for Treatment of Women with Stress Incontinence and Pelvic Floor Defects 

Mamdouh Abol-Nasr, Mohamed Dyaa Saleem, and Nial T.M. 
Galloway Emory school of medicine (USA), El-Minia, and Sohag University Hospitals (Egypt) 

Aim of the Study: Evaluation of the efficacy of paravaginal repair for treatment of stress incontinence accompanying pelvic floor defects. Patients and Method : Forty four female patients with genuine stress incontinence (34 hystrectomy and 19 prior urethropexy) associated with cystocele (27), emerocele (17), rectocele (30), vault prolapse (30) with prior 19 vaginal repairs. All patients underwent vaginal shelf repair associated with pelvic floor repair; vaginal repair (23), perineorraphy (11), culdoplasty (26), and colposuspension (15). All patients are followed up (mean; 14.5).
Results: Mean hospital stay 5.9 days. Early post-operative complications: leakage (32), urinary retention (6), wound infection (5), severe pelvic pain (10, urgency (18) and urge incontinence (21), Late follow up revealed difficulty in voiding (35), urinary retention (2), urge still preset (12), and urinary tract infection (15) being recurrent in one. Recurrence of stress incontinence occurred in 12 patient (27%) after a mean period of 19.1 month and re-operation was done in only seven (16%) and the remaining were improved by conservative methods .Recurrence was more in the patients who had multiple pelvic floor reconstructive procedures.
Conclusion: Paravaginal shelf repair is effective in restoration of the normal pelvic floor anatomy and control of continence. Other urethropexy procedures may be needed in cases with multiple pelvic floor defects.

(11) Evaluation and Outcome of the Altemeier Procedures in the Treatment of Rectal Prolapse

O. Alabaz, E.U. Erkocak, H.Ezici. University of Cukurova, School of Medicine, Department of General Surgery, Adana, Turkey. 

Management of rectal prolapse is surgical. Operations for prolapse can be classified into two groups based upon anatomic approach: transabdominal repairs and perineal repairs. Each operation has its own indications and advantages in a particular subset of patients. Transabdominal approach have low recurrence rates, but are associated with significant morbidity. Altemeier procedure is safe and affective approach, but has high recurrence rate. This study was designed to assess the results of the Altemeier procedure in the treatment of patients with rectal prolapse. 
Methods: From June 1997 to September 2000, 15 patients had a Altemeir procedure performed for the treatment of rectal prolapse. They were interviewed, undertaken a physical examination and evaluated by anal manometry, defecography and electromyelography. Patients were followed up for complications and functional results. Results: Fifteen patients (11 females) ages 19 to 73 (mean, 54.3) years were followed up for duration of the study (mean follow-up, 13 months). Mean resection length of rectosigmoid was 19cm. and these patients, one coloanal anastomotic leaks and one anastomotic strictures were observed. There were one postoperative death. Pre and postoperative anal manometry reveal statistically significant changes in each procedures. Ninety-three percent of patients had complete objective resolution of prolapse, and 81% had subjective improvement after repair. 
Conclusion: In selected rectal prolapse, the Altemeier procedures gives good results regarding fecal incontinence without complications in surgical treatment. 

(12) Three Dimensional Endo Anal Sonography in the Evaluation of Anal Canal Injury

Ashraf Talaat Yousef, Abdel-Aziz Khames, Hesham Amer, Ahmed Fathy Ismail

Introduction and the Aim of Work: *Damage to the anal canal sphincters following obstetric trauma or anorectal surgery is common causes of fecal incontinence. Patients with localized sphincter defects should be identified because surgical repair can restore continence in most of these patients (Nielson 93), until recently digital examination, electromyographic mapping and manometry has been the only methods of identifying anal sphincter defects. However very little information on the sphincter morphology is obtained, further more accurate localization of weak areas in the sphincter complex is difficult, electromyography is invasive, painful, time consuming and is a potential source of subcutaneous infection (Swash 1985), (Law 1990). * Endosonography mapping of the external and internal sphincters has been shown to correlate closely with the electromyographic and operative findings during surgical repair (Sultan 1994), (Law 1990), however conventional 2D ultrasonography does not gives an idea about the length of the sphincteric defects or its configuration. * The aim of the present study is to assess the value of 3D endo-anal ultrasonography in evaluating the length, volume and the configuration of he sphincteric defect and to correlate the results with the operative findings. Patients and Methods : * 30 patients with fecal incontinence following obstetric and surgical traumas were evaluated. * The patients were examined in left lateral decubitus position with 3D transrectal probe (volusion 530 D-Kretz technique). * Multiple sections were taken throughout the length of anal canal and examined with mutiplanar 3D reconstruction in transverse, longitudinal and coronal planes for the integrity of internal and external sphincters. * For estimating the length width of the sphincteric defect then 3D rending surface mode was obtained for analysis of the shape in various directions. Results : * 2 cases showed internal sphincteric defects. * 20 cases showed external sphincteric defects. * 3 cases showed combined external and internal sphincteric defects. * All were proven at surgery and by electromyography. * Another 3 cases showed diminished thickness of internal sphincter. Conclusion: * 3D transrectal U/S has the advantages over 2D ultrasonography that it gives an accurate idea about the shape, extension and dimensions of the anal canal sphincteric defects. * It is more valuable than electromyography in evaluating the location, size and shape of sphincteric defects.

(13) Predicting the Outcome of Anterior Sphincter Repair Using Artificial Neural Networks 

GB Makin, A Gardiner, G S Duthie Academic Surgical Unit, Castle Hill Hospital, Hull, UK 

Background: Prediction of success after anterior sphincter repair (ASR) for incontinence is difficult. Standard multivariate analysis techniques have only 75-80% accuracy. Artificial intelligence, including Artificial Neural Networks (ANN), have been used in the analysis of complex clinical data and have also been proved to be successful in predicting the outcome of surgery. Using a neural network algorithm we have assessed the probability of success following ASR. 
Methods: Prospective ano-rectal physiology data of patients undergoing anterior sphincter repair was collected. Complete data sets of 75% of the series were used to train an ANN, the remaining 25% were used for the data validation. The output was continence grading, ranging from 0 - 4 (worse to continent). Results : The outcome at 3, 6, and 12 months post-operatively was obtained and assessed. The best correlation between actual data value and ANN value was found at 12 months, (r = 0.931 ; P=0.0001). Clear correlations were also found at 3 months (r = 0.898 ; P = 0.0001), and 6 months (r = 0.742;P = 0.002). 
Conclusion: Artificial Neural Networks are more accurate (93%) than statistics (75%) when applied to the prediction of outcome following anterior sphincter repair. This assessment confirms the usefulness of pudendal latency in the prediction of ASR outcome. The results obtained highlight the obvious usefulness of ANNÕs which can now be used in a prospective evaluation for application of the technique. 

(14) Endoscopically Assisted Gracilloplasty for Faecal Incontinence. 

GB Makin, A Gardiner , GS Duthie Academic Surgical Unit. Castle Hill Hospital, Hull , UK 

Introduction: End stage faecal incontinence with an unreconstructable anal sphincter is currently being managed with either a Gracilis neosphincter or an artificial sphincter. Gracilloplasty has been shown to be effective, but the full length thigh wound needed to harvest the muscle results in considerable pain initially and subsequently parasthesia. harvesting the Gracilis muscle endoscopically should reduce this morbidity. We analyse our results including a patient satisfaction survey. 
Methods: Patients with end stage faecal incontinence suitable for a Gracilis neosphincter were entered into the trial. The Gracilis muscle was harvested endoscopically using the Ethicon vein harvester via a 4cm groin and a 2cm knee incision. A standard Gracilloplasty was then performed using an Anchorlok screw to attach the tendon to the Ischeal tuberosity. Complications were recorded and the patients filled out a satisfaction survey. 
Results: Of the 12 patients (11 females) there were 3 minor immediate postoperative complications. Two had a perineal wound infection that settled with antibiotics and one had a perineal wound haematoma. There has been no complication of harvesting the Gracilis endoscopically. Average inpatient stay was 3 days (range 2-5). Follow up ranged between 10 and 24 months with one patient complaining of minor leg pain but requiring no analgesia and another developing a peri-anal fistula which required a covering loop ileostomy which has since been closed. There has been no leg parasthesia. One implanted battery had to be removed as it eroded through the skin of a thin male patient. 75% and 66% of the patients reported symptomatic improvement in solid and liquid incontinence respectively. Pad usage decreased in 50% and lifestyle improvement was reported in 66%. 
Conclusion: The endoscopically assisted Gracilloplasty is a worthwhile procedure, with reduced morbidity, improved continence and high patient satisfaction. 

(15) Quality of Life Improvement in Chronic Constipation After the Antegrade Colonic Enema Procedure

GB Makin, R.P. Baker , GS Duthie Academic Surgical Unit. Castle Hill Hospital, Hull , UK 

Introduction: Antegrade Colonic enema (ACE) via an appendicocaecostomy has been successfully used in paediatric practice for chronic constipation and faecal leakage. Usually adults with these symptoms are a difficult group of patients to manage. We report our experience of ACE and patient quality of life outcome. 
Methods: We undertook a retrospective review from case notes and stoma care nurse records of the patients who have had an ACE procedure. We first performed this technique in August 1997. Patients are extensively counselled prior to the procedure. Quality of life was assessed in postoperative patients with the verified SF-36 form and compared to a similar cohort of patients awaiting the procedure. 
Results: Ten patients (8 female) mean age 29, have undergone the ACE procedure. Seven were performed laparoscopically. Six suffered with chronic constipation. 3 with faecal leakage and 1 a mixed picture. All recovered well postoperatively with no immediate surgical complications. Six patients required readmission due to minor difficulties with the irrigation procedure, 2 having surgical revision of the stoma and 4 stricturoplasty. One of these became constipated again due to irrigation difficulties and required inpatient aperients. QOL comparisons showed significant improvement in the mean mental component score of the SF-36 form from 32.3 to 49.0 (p=0.038) and an improvement albeit not statistically significant in the mean physical component score from 36.28 to 43.3 (p=0.133).
Conclusion: Patients who have had the procedure demonstrate a significant improvement in the mean mental component score of the SF-36 QOL assessment despite early irrigation problems. The ACE procedure is technically simple and effective in the treatment of adults with chronic.

(16) Pudendal Latency An Important Prognostic Indicator in Anterior Sphincter Repair 

Makin GB, Cundall JD, Gardiner A. Duthie GS Academic Surgical Unit. Castle Hill Hospital, Hull UK 

Introduction: It has been suggested that pudendal nerve terminal motor latency (PNTML) has little part to play in predicting the outcome of anterior sphincter repair. This study utilised artificial neural networks to analyse the preoperative investigations to determine if they could predict outcome. 
Methods: We reviewed retrospectively the preoperative investigations on 30 patients who had an anterior sphincter repair, including anorectal physiology, endoanal ultrasound and PNTML measurements. 15 of them underwent biofeedback therapy before surgery. The results of the repair were graded as 1 no change, 2 mildly improved. 3 socially continent .4 excellent result. The variables were then processed through a neural network and a Spearman correlation between the predicted and actual results was performed. The neural networks were then altered by removing parts of the data (table 1) 
Results: The results show that the full use of preoperativedata is necessary to get the best correlation and that if only PNTML and biofeedback are used then the correlation is poor. It also shows that by removing either has a dramatic effect on the correlation. However if PNTML only is used then the correlation at 12 months is 78%. 
Conclusion: PNTML is an important factor in the pre operative investigation in patients who may receive an anterior sphincter repair. By using an artificial neural network we have been able to show that both PNTML and the results of biofeedback are important prognostic factors. 

(17) Double Synchronous Abdomino-perineal Approach (ZacharinÕs Procedure) to correct Complex Pelvic Floor Disorders

B. Roche, J. Deleaval. A. Fransioli, F. Di Dio, M.C, Marti Hopital Cantonal Universityaire de Geneve 

From 1994 till 1999, 36 women aged from 24 to 73years (M=56,6y) were operated for a symptomatic rectocele associated with complete or incomplete rectal prolaps. A double synchronous abdominal (left hemi-pfannenstiel) and vaginal approach is performed. The enlarged pelvic hiatus is closed by approximation of both limbs of the levator and of the pubo-rectalis muscle. A rectopexy is performed mostly without bowel resection. Deep Douglas pouch is excised. The posterior bolpomyoraphy allows correction of the rectocele. If necessary a sphincteroplasty may be added. In two cases the bladder has been suspended. Postoperative results show no death, no infection, no recurrence of symptoms. Continence is complete. Exoneration was improved in every case even if 8 patients still require some minor laxatives (bulky forming agent). Urinary continence is improved in every case. No vaginal narrowing was observed and no dyspareunia. One patient developed 6 months postoperatively a vaginal vault prolaps. This double approach is a safe one and should be considered if a rectocele is associated with a rectal prolaps.

(18) Comparison of Transanal and External Perineal Ultrasonography 

B.Roche, J. Deleaval, A. Fransioli, F.Di Dio, M.C.Marti Hopital Cantonal Universitaire de Geneve 

Purpose: Anal endosonography with rotating endoprobes provides state of the art imaging of sphincter integrity. However, the technique is not widely available, requires expensive equipment. Since the pelvic anatomy permits the use of standard external ultrasound probes, we tested the feasibility, tolerance and reproductibility of uniplanar perineal sonography, with respect to visualisation of the anal sphincter, using both convex and linear 3.5 - 7.5 MHz and 360o rotating 7MHz probes.
Materials & Methods: Twenty healthy nulliparus female volunteers were investigated. Endosonography and perineal sonography were performed in duplicate by two operators, each blinded to the findings of the other. We then used this technique to examine 20 post partum primiparus patients. 
Results: The internal anal sphincter appeared in perineal sonography as a hypoechogenic ring surrounded by an echogenic ring representing the external anal sphincter. Endosonography revealed 6 sphincter tears. Perineal sonography recognised in all cases external sphincter tears. In one case the internal sphincter defect was missed. 
Conclusion: Perineal sonography appears to be a feasible alternative to anal endosonography in female patients and provides good information on external sphincter defects suggesting that this procedure might be particularly useful in incontinence screening.

(19) Long Term Results of Anal Sphincteroplasty 

M.C Marti and Br. Roche Outpatient Clinic for Surgery HUG University of Geneva 

Sphincteroplasty is the procedure of choice to correct traumatic rupture of anal sphincters. Success rate are over 70% in most series. Published data show that results are becoming worst with time. We review 238 consecutive operated cases (Mean age : 48,7y). Functional results were classified according MillerÕs score. Mean preoperative MillerÕs score was 15.9 + 1.6. Postoperative score at 3 months was 1.8 + 1.45. Altogether, successful reconstruction (score < 3) without problems for liquid or solid stools could be achieved in 87% of our cases. We could demonstrate that sphincteroplasty can be successfully performed even on long lasting lesions, on old patients. The outcome was the same for patients below or over 60 years. At 5 years, 75% of our patients still have satisfactory results. We could demonstrate a different evolution at 5 years between patients who had postoperative physiotherapy and biofeedback and those who did not . It seems that patients with physiotherapy have better learnt to train regularly by their own muscles and have even improved their scores at five years. The difference is statistically significant. We recommend therefore that patients routinely undergone postoperative physiotherapy even if the postoperative results are excellent. 

(20) Pelvic Floor Disorders Single or Multiple Organ Failure 

M. C. Marti Outpatient Clinic for Surgery HUG University of Geneva

In case of pelvic floor disorders, surgical correction of a single organic lesion or anatomical abnormality doesn’t give satisfactory functional results and is followed on long term by a high rate of recurrence: 20% of patients suffering from rectal prolaps and 30% of patients with a rectocele were previously operated for hysterectomy; 10 to 30% of hysterectomies will be complicated with a vaginal vault prolaps and 1-16% with a enterocele. It is mandatory to evaluate clinically, radiologically and by laboratory investigations all components of the pelvic floor. Surgical correction should include all components of the pelvic floor and pelvic organs. It is therfore mandatory that such a condition should be treated by a multidisciplinary team of surgeons, radiologists, coloproctologists, urologists , gynecologists and physiotherapists. A single organ should not be treated alone if pelvic floor disorders result from a multiple organ failure.

(21) Investigation of Urinary Incontinenle in Moroccan Women

R. Aboutaieb, I. Sarf, M. Dauir, M. Fethi Universary Hospital, Center IbnRochd Casablanca Morocco 

Objective: To approach the role of urinary incontinence (U.I) prevalence in female Moroccan population, the degree of bothersomeness, and the impact in different usual activities. 
Material and Methods: 368 women (>18 years old) had a direct questionnaire.
Results: Age: 18 Y-79 Y, Joblessness : 42,9%,nulliparity : 46%, multiparity : 25%, menopausis: 19%. 114 cases reported at least two onset of U.I in the last month (30,9%). Out of these incontinent women, 13.5% had stress U.I and 17.5% had urge U.I. The urine leakage was judjed mild in 36% and important in 26.9% with a major impact in usual activities. In this incontinent population 25,3% didn’t ask for treatment, 25.3% was seen by a doctor (generalist in 43.5%, gynecologist in 34.8% and urologist in 21,7%). The reason of the managementÕs refusal was shame in 25.3%, financial in 21.3% and fatality in 18.7%. 
Conclusion: The U.I represente a frequent pathology in women. 31% of the moroccan women present this affection. Only the quarter of them ask for treatment. They donÕt complain plainly from this affection even with bothersome symptoms. It is mandatory to inform the population and also generalist doctor in order to seek systematically this affection in women for the improvement of quality of life by an adequate treatment.

(22) Urogenital Aging - Creation of Improved Wareness Towards A Hidden Problem 

Mohammed Salama Gad, MD. Obstetrics and Gynaecology Department, Faculty of Medicine, El-Menoufia University

As female life expectancy increases, many women will now spend almost 40% of their lives in the postmenopausal state . The menopause is associated with symptoms of estrogen deficiency which may be extremely debilitating and seriously reduce the quality of life . All women regardless of race ,culture, or socioeconomic background experience urogenital atrophy during menopause. Replacement of estrogen to reverse urogenital aging is the standard of care, with recent attention focused on the local delivery of estrogen by the vaginal route. Urogenital aging is given a low priority in the medical community and is an entity not well known to the general public . Many women are not aware of the possible disorders of the lower urinary tract and the vagina because ofestrogen deficiency . These changes are perceived often as a normal part of the general aging process not associated with the possibility of medical attention, diagnosis, and treatment . Access to the information that certain urogenital dysfunction, in particular incontinence, and vaginal discomfort respond to estrogen replacement therapy is not available for every woman . In addition, physicians and patients may hesitate to address these issues because of feelings of shame and embarrassment, feelings commonly encountered and specific for the complex of urogenital aging . Educational efforts and promotion of information with use of various media might help to improve knowledge and remove the taboo attached to urogenital aging in both health care providers and the general public . Thus a better understanding of urogenital aging would be achieved and the potential of estrogen replacement extended .
Key words: Urogenital aging estrogen deficiency, estrogen replacement therapy, womens health 

(23) Non Orgasmic Coitus Among Circumcised Females (Lecture)

Aziz Ahmed Khattab Ain Shams Faculty of Medicine

Non resolved sexual tension syndrome discovered by Masters & Johnson (1979), among researched females practicing coitus interruptus and other types of sexual activity short of orgasm revealed the critical erogenous role of the three primary erogenous zones. 95% of Egyptian females sustain partial vulvectomy during female genital mutilation (FGM), hence they loose 2/3 of their erogenous zones, namely: the clitoris and labia minora. Chronic coital anorgasmia leads to pelvic vasocongestion, varicosity and varicocele sometimes. Signs and symptoms of residual neuromuscular tension manifested overtime by bilateral adnexal pain, low backache and uterine pain are long undiagnosed by gynaecologists. Problems of inhibited libido, dyspareunia and anorgasmia leads ultimately to protective frigidity. Documented psychogenic and organic causes of anorgasmia are fitting perfectly with our sexually handicapped circumcised females and
consequently reflected adversely upon their male partners unfortunately. Reported coital anorgasmia among circumcised females was around 48% contrary to 10% among non-circumcised females. Recent research abroad (1999) documented a rise in female dysfunctions ainly: diminished libido, problems of arousal and lubrication, dyspareunia and anorgasmia, all are depending upon the emotional quality of partnership. FGM inflicted upon millions of African young females
is not only a surgical hazard but it often causes tragic gynaecological, obstetrical, psychological and
sexological misfortunes.

(24) Nabil Amin , M.D Urologist Consultant Andrology El - Mansoura - D.K. Egypt Video film demonstrating Ò a new technique for preservation of the central artery and most of the cavernous tissue during implantation A.M.S. Ambicor inflatable penile prosthesis through penoscrotal approach.

(25) Value of Evacuation Proctography (Defecography) in Genital Prolapse
Emam, M.A, and Shadi, M. Mansoura University Hospital , Mansoura Faculty of medicine

Objective: To evaluate the value of defecography (evacuation proctography ÒEPÓ) in women with genital prolapse generally and in particular its role in assessment of defects in posterior pelvic compartment (enterocele and rectocele). Subjects and Methods : Sixty two women with genital
prolapse were subjected to Defecography. All these women were multipura, none was with recurrent prolapse. Full evaluation of the anterior, middle and posterior pelvic compartments was carried out. The rectum was filled with 30cc fluid barium; then 200-300 cc barium paste till the patient desired to defecate. Also vaginal opacification was performed with 25ml of liquid barium mixed with 15ml of paste. Lateral radiograms for the pelvis in resting, squeezing and straining were taken. Also postevacuation film for residual barium was taken. When enterocele was suspected, Barium meal was done to opacify the small bowel. The data obtained were tabulated and interpreted. 
Results: Defecography revealed resting anal incontinence in 31% of the cases with stress urinary incontinence (SUI). Also, it revealed that 26% of the genital prolapse did have enteroceles and 6% sigmoidoceles, while clinically only 13% were suspected to be enteroceles, and no cases of sigmoidoceles can be diagnosed. Also many concomitant findings were estimated like rectal intussusception, spastic and excessive descent of the pelvic floor. Also the significance of barium trapping in the cases of rectoceles was clicited. 
Conclusion and recommendation: Defecography is of great importance in cases of genital prolapse generally, and in particular in posterior compartment defects, as it can clarify the exact anatomical details of the anorectal area. Also when it is performed with vaginal opacification, it can provide an objective method for detecting enteroceles and sigmoidoceles preoperatively. Also we recommended its uses in all the cases of SUI due to the frequent association of this problem with anal incontinence as proved by defecography.