Morphological changes after pelvic floor muscle training measured by 3- dimensional ultrasonography: A randomized controlled trial quality 1pack slip inn herbs chicken soup. The assessment of voluntary pelvic floor muscle contraction by three- dimensional transperineal ultrasonography discount slip inn american express shivalik herbals. Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Levator avulsion using a tomographic ultrasound and magnetic resonance-based model. Correlating signs and symptoms with pubovisceral muscle avulsions on magnetic resonance imaging. Diagnosing pubovisceral avulsions: A systematic review of the clinical relevance of a prevalent anatomical defect. Avulsion injury and levator hiatal ballooning: Two independent risk factors for prolapse? Correlation between levator ani muscle injuries on magnetic resonance imaging and fecal incontinence, pelvic organ prolapse, and urinary incontinence in primiparous women. Prevalence of major levator abnormalities in symptomatic patients with an underactive pelvic floor contraction. Levator ani defect status and lower urinary tract symptoms in women with pelvic organ prolapse. Unilateral coronal diameters of the levator hiatus: Baseline data for the automated detection of avulsion of the levator ani muscle. Three-dimensional ultrasound appearance of pelvic floor in nulliparous women and pelvic organ prolapse women. Three-dimensional ultrasound of pelvic floor: Is there a correlation with delivery mode and persisting pelvic floor disorders 18–24 months after first delivery? Vaginal birth and de novo stress incontinence: Relative contributions of urethral dysfunction and mobility. Agreement and reliability of pelvic floor measurements during contraction using three-dimensional pelvic floor ultrasound and virtual reality. Comparison of bony dimensions at the level of the pelvic floor in women with and without pelvic organ prolapse. Assessment of levator ani morphology and function in asymptomatic nulliparous women via static and dynamic magnetic resonance imaging. In vivo assessment of anterior compartment compliance and its relation to prolapse. Dynamic magnetic resonance imaging for grading pelvic organ prolapse according to the International Continence Society classification: Which line should be used? Levator co-activation is a significant confounder of pelvic organ descent on Valsalva maneuver. Levator ani subtended volume: A novel parameter to evaluate levator ani muscle laxity in pelvic organ prolapse. Study of dynamic magnetic resonance imaging in diagnosis of pelvic organ prolapse. Magnetic resonance assessment of pelvic anatomy and pelvic floor disorders after childbirth. Perineal descent and patients’ symptoms of anorectal dysfunction, pelvic organ prolapse, and urinary incontinence. Dynamic magnetic resonance imaging to quantify pelvic organ prolapse: Reliability of assessment and correlation with clinical findings and pelvic floor symptoms. Enlargement of the levator hiatus in female pelvic organ prolapse: Cause or effect? Is levator avulsion a predictor of cystocele recurrence following anterior vaginal mesh placement? Dynamic magnetic resonance imaging before and 6 months after laparoscopic sacrocolpopexy. These relationships in the asymptomatic population, and the deficiencies seen in symptomatic women, require an approach able to assess the anatomical relationships both in a static situation and also when undergoing physical stress. Cross-sectional imaging is able to achieve this and gives valuable insights from which our current knowledge-base can be developed. Such progress is invaluable for understanding female pelvic floor anatomy for populations and individuals, understanding the changes evident in symptomatic situations, identifying women potentially at risk of future problems, and understanding impact of past events, such as childbirth or surgery. Furthermore, additional post-imaging processing can focus on specific aspects of interest and potentially display the anatomy in three dimensions. This is now augmented with dynamic imaging, in which a series of scans are obtained at rest and during movement or function (e. A strong magnetic field is placed around the subject, and the scanner detects a radiofrequency signal emitted by excited hydrogen atoms. Increased magnetic strengths are commercially available, and the technological development means magnetic field strength is likely to evolve foreseeably. Stronger magnets currently require superconduction in very cold temperatures (liquid helium). Contrast between different structures is ascertained from the rate at which excited atoms return to the equilibrium state. The nature of return to the equilibrium state involves two independent processes of T1 (spin–lattice) and T2 (spin–spin) relaxation. T1 is basically representative of the different amounts of magnetization recovery, which is achieved by changing the repetition time. T2 is the difference in magnetization decay and is achieved by changing the echo time. Distinguishing T1 and T2 gives different imaging displays that may enhance detection of specific aspects, and both approaches are typically used in scanning protocols. For example, T2 is good for detecting edema and for assessing zonal anatomy, such as in the uterus. Contrast agent, comprising gadolinium and a chelating agent, can 571 also be administered intravenously. Dynamic sequences use single-slice ultrafast acquisitions during the tested activity, in coronal and axial planes (Figures 38. The T2-weighted sagittal sequences are useful to show the bladder neck and the cervix. Sagittal acquisitions help to adjust coronal images by identifying the midline of the pubic symphysis and the anatomical landmarks. Measurement of the urogenital hiatus and detection of levator ani injuries can be performed in axial plane images . Before scanning, the patient is asked to empty her bladder and she should have clear explanation of what to expect, including instructions in any dynamic maneuvers that may be required, e.
Voiding diary for the evaluation of urinary incontinence and lower urinary tract symptoms: Prospective assessment of patient compliance and burden buy genuine slip inn erbs palsy. A systematic review of the reliability of frequency-volume charts in urological research and its implications for the optimum chart duration order 1pack slip inn with mastercard herbals in american diets. Developing and validating the International Consultation on Incontinence Questionnaire Bladder Diary. Development of two electronic bladder diaries: A patient and healthcare professionals pilot study. Parameters of bladder function in pre-, peri-, and postmenopausal continent women without detrusor overactivity. The 24-h frequency-volume chart in adults reporting no voiding complaints: Defining reference values and analysing variables. Bladder diary measurements in asymptomatic females: Functional bladder capacity, frequency and 24 hour volume. The frequency/volume chart as a differential diagnostic tool in female urinary incontinence. The role of the frequency-volume chart in the differential diagnostic of female urinary incontinence. Comparison of the Danish Prostatic Symptom Score with the International Prostatic Symptom Score, the Madsen-Iversen and Boyarsky symptom indexes. Patient-reported outcomes in overactive bladder: The influence of perception of condition and expectation for treatment benefit. Health Measurement Scales: A Practical Guide to Their Development and Use, 3rd ed. This was achieved using a pair of elongated electrodes embedded within the absorbent layer of a diaper, which contained dry electrolytes. Following urine loss, the moisture between electrodes resulted in a change in electrical conductivity that could be detected and recorded. The pad test as we know it today was originally simultaneously described by Sutherst et al. It consists of the use of a perineal pad to document urinary incontinence and quantify its severity quantitatively, under natural conditions. The amount of loss is calculated by subtracting the weight of the pad before the test from its weight after the end of the test. The temperature-sensitive device uses a diode temperature sensor imbedded in the outermost layer of a pad, which records a change in voltage across the diode when urine (warmer than the perineum) is lost. These two methods are devised to detect urine leakage during ambulatory urodynamic studies without the bulk of the Urilos but are unable to quantify loss. The clinical use of these devices has never been evaluated and their accuracy was disputed. The Urilos was said to be able to detect volumes from less than 1 mL to approximately 100 mL, with a variation of up to 20% when repeated. In subsequent reliability studies, the difference in volume recorded between different nappies varied between 13%  and 25% . When comparing nappies from different boxes, the variation between them was as much as 68% . Furthermore, the Urilos was noted to be more uncomfortable and not to absorb large volumes of fluid . It may be of particular value during research studies for the objective evaluation of treatment response . Neither the patient’s perception of incontinence  nor her perception of its severity  is well correlated with urodynamic measures. To determine that the test is measuring what was intended requires some evidence of “validity” . Validity expresses the relation between observed measurements and the true state of the entity being studied . Reliability can be defined broadly by two characteristics: internal consistency and stability . Validity seeks to determine that the tool is measuring what it is intended to measure (urine loss) and does so by comparing the performance of a new tool against that of a known tool, a “gold standard. This is usually referred to as criterion, convergent, or concurrent validity and, in the case of pad test, can be achieved by comparing pad tests to symptom questionnaires, urodynamic studies, or other validated pad tests. Validity of the pad test can further be reflected by the accuracy of the measured volume lost and its sensitivity in detecting such a loss. If the sensitivity is poor, the test will at times not detect the true state of the entity, namely the presence of incontinence. However, as there is currently no means of detecting the true amount of urine leak with each incontinence episode, the validity of the pad test will be reflected in its ability to demonstrate incontinence in a patient who complains of urinary incontinence and a lack of urine loss in patients who report continence. The type of activity leading to urine loss and the impact of voiding during the test period have been evaluated [23a]. Irrespective of urodynamic diagnosis, activities leading to leakage in all women included (in increasing order of urine loss) walking around/bed-making (3–4 g); climbing stairs up and down, with or without heavy pack (5–6 g); picking objects on the floor (6 g); and spending several minutes hand washing (10 g). Voiding (with the pad removed for the voiding) during the test had no effect on the result, with a similar proportion being dry on the pad test whether they voided or not. The validity of the pad test in women with postmicturition dribble is unknown as no studies have evaluated the pad test results in affected women, This potentially relevant condition is present between 3. Perhaps, one should screen for the presence of postmicturition dribble and, if present, recommend a pelvic floor contraction before drying the vulva, as an equivalent to manual urethral compression (“milking”) shown to help men [26d]. Some studies have evaluated the feasibility of a short pad test undertaken at home, where a subject would be given preweighted pads and return the pads in a watertight sealed plastic envelope [24,25]. Mailing delays were not shown to significantly alter the measurement of pad weight. Detection Limit Increased weight of the pad test may be due to urine but also to vaginal discharge, sweating, or menstruation. Comparing 50 continent women to 100 incontinent women, a maximum pad weight gain of 1 g was measured in all continent patients versus a mean of 12. Walsh  tested six healthy continent volunteers for three consecutive days from 9 a. These results confirm the validity of the short pad test in its ability to detect incontinence between self-proclaimed continent and incontinent populations. However, a better reproducibility was noted  when bladder volume at the start of the test was taken into account. Interobserver  and test–retest  reliability studies were found to be poor, as shown by wide limits of agreement. It is important to note that a correlation coefficient merely quantifies association between two test results. If the two tests compared measure the same variable, evidently they will be associated, but high association does not necessarily translate to high agreement. The limit of agreement using the Bland and Altman method  is a better statistical analysis in describing agreement between two tests measuring the same outcome. In one study, women with urodynamic stress incontinence have greater leakage on 1- hour pad testing than those with detrusor overactivity; however, the amount of loss was not discriminatory of urodynamic diagnosis .
Repeated Voiding There was a remarkable consistency in the centile rankings of the paired first and second voids in the study of Haylen et al buy cheap slip inn herbspro. This consistency is further witnessed in the multiple voids from a single 25- year-old normal female volunteer (Figure 53 trusted slip inn 1pack herbals dario bottineau nd. Clinically, in the majority of normal women, the centile rankings of successive voids will not differ widely. It is uncertain, at present, whether this is also true for women with lower urinary tract dysfunction. As suggested previously, abnormal or unusual flow rates or curves merit repeating the study. Presence of a Catheter The aforementioned nomograms refer to free flowmetry voids; they are not applicable where pressure of another catheter is present in the urethra. All urethral catheters can be expected to have the effect of decreasing urinary flow rates for the equivalent voided volume. By necessity, potentially unfavorable environmental and psychological factors are introduced when catheterization flowmetry is performed. Ryall and Marshall  suggested that the reduction is maximum urinary flow rate caused by the fine (diameter = 2 mm) urethral catheter used in their study of 147 symptomatic men was of the order of several mL/sec. Though small, this reduction was enough to change the diagnostic categorization of one-third of their subjects. Normal Female Urine Flow Rates Female urine flow rates are higher than those of men [10,15,24]. The other study  was limited to the effect of final urodynamic diagnosis on urine flow rates. Three studies indicated that symptomatic women had slower urine flow rates than normal women with one study  showing no difference. The flow data for these women were converted to centiles from the Liverpool Nomograms for the following analyses of their median values: A Comparison of the Urine Flow Rates of Symptomatic and Asymptomatic Women Table 53. There was a close agreement between the studies with the 1990 study  performed in a different country to the 1995 study . Effect of the Presence of Genital Prolapse on Urine Flow Rates in Symptomatic Women A generally progressive decline in the maximum and average urine flow rates (median centiles) of symptomatic women  with increasing grades of genital prolapse was noted. The most significant decline occurred in the presence of uterine prolapse closely followed by cystocoele and enterocoele. More recent data , however, would suggest the significance of this may be lost in multivariate analysis of a much larger cohort of symptomatic women. The flow rates for those symptomatic women without prior hysterectomy was found to be the same as that for the asymptomatic female population. Further analysis suggests that in women with both prior hysterectomy and intercurrent genital prolapse, there is a cumulative decline in urine flow. More recent data , however, would suggest the significance of this may be lost in multivariate analysis of a much larger cohort of symptomatic women. Effect of Age and Parity on Urine Flow Rates in Symptomatic Women Unlike asymptomatic women, there is a significant effect of age on the maximum and average urine flow rates [30,31]. More recent data  suggest that age is the main association of abnormally slow urine flow rates in a large cohort of symptomatic women. Parity was not found to be a significant factor in either this or the 1999 study . Effect of Final Urodynamic Diagnosis on the Urine Flow Rates of Symptomatic Women Median urine flow rate centiles of the urogynecology patients separated according to the final urodynamic diagnosis are given in Table 53. All categories of diagnoses have their median centiles under those for the normal female population (50 by definition). The situation during voiding is the antithesis of the situation required for continence. Continence depends on intraurethral pressure being higher than intravesical pressure. Einhorning  and later Asmusen and Ulmsten  showed clearly that before any rise in intravesical pressure, a fall in intraurethral pressure occurred. This suggests that the urethra actively relaxes during voiding rather than being passively “blown open” by the detrusor contraction. Soon after the urethra has relaxed and pelvic floor descent has occurred, the detrusor contracts. The detrusor normally contrives to contract until the bladder is empty, producing a continuous flow curve. Many women void by urethral relaxation alone with minimal or no detrusor involvement. Some women appear to void entirely 841 by increasing intra-abdominal pressure, that is, by contraction of the diaphragm and anterior abdominal wall muscles. It follows from this discussion that the urine flow may differ from normal as a result of abnormalities of the urethra or the detrusor. Urethral Factors Anatomical factors The urethra may be abnormally narrow or the urethra may not be straight. The narrowest part of the urethra, as shown by video studies of voiding, is usually the midzone. However, the urethra may become narrowed and the most common site is at the external meatus associated with estrogen deficiency in the postmenopausal women. Bladder neck obstruction in the female had been thought to be extremely rare . The female urethra is usually straight, and deviation from this state is most common in anterior vaginal wall prolapse and higher degrees of uterine and vaginal vault prolapse. Data earlier point to a possible adverse effect of such prolapse on urine flow rates. The prolapse and urethral effects make bladder outflow obstruction not that uncommon in women. Pathological Factors Unusual congenital conditions such as urethral duplications, urethral diverticula, or urethral cysts may obstruct voiding. Infective lesions as in urethritis or infected paraurethral cysts may lead to voiding difficulties. Intravaginal abnormalities, such as prolapse or foreign bodies, may also obstruct micturition. Functional Factors Abnormal urethral behavior during voiding may lead to alteration in the urine flow rate recording. Urethral closure may be due to contraction of the intraurethral striated muscle or to contraction of the pelvic floor. In the neurologically abnormal patient, contraction of the intraurethral striated muscle with or without the pelvic floor is known as detrusor sphincter dyssynergia. In the nervous and anxious but neurologically normal patient, the urethra may be closed by pelvic floor contraction.
Even when present buy cheap slip inn online herbs cooking, V-A conduction in these patients is not as good as A-V conduction order cheap slip inn on line herbals stock photos. Response to Pharmacologic and Physiologic Maneuvers Patients with enhanced A-V nodal conduction behave differently than those with atrio-His bypass tracts that appear to be physiologically similar to A-V bypass tracts in their response to pharmacologic and physiologic maneuvers. As such, drugs and physiologic maneuvers that profoundly affect A-V nodal conduction without any significant effects on atrial tissue can be used to distinguish the mechanism of enhanced A-V conduction. An increase in the A-V interval in response to drugs such as digoxin, beta-blockers, calcium-blockers, or adenosine suggests that abbreviated A-V conduction is due to enhanced A-V nodal conduction, or if a bypass tract exists, it inserts into the A-V node (Figs. An increase in P-R and A-H intervals in response to atrial extrastimuli suggests the same thing. Carotid sinus pressure and other vagal maneuvers may be used in an analogous fashion to demonstrate that conduction through the A-V node is responsible for the genesis of a short 142 P-R. The change differs markedly from that of the prolongation of A-H and H-V intervals that occurs with these agents in patients with enhanced A-V nodal conduction. With atrio-His bypass tracts, both the A-H and H-V intervals prolong suddenly and markedly, because the measured A-H interval during sinus rhythm actually reflects retrograde conduction to the recorded His bundle from the site of insertion of the bypass tract and does not reflect a linear measurement of either A-V nodal or His–Purkinje conduction. Data from studies performed at a basic cycle length of 600 msec are shown in circles, and those from studies performed at 500 msec are shown in triangles. At every A1-A2 interval, the A2-H2 interval is longer at the shorter drive cycle length. Supraventricular tachycardia in Lown-Ganong-Levine syndrome: intranodal versus antinodal reentry. The A-H interval also prolonged somewhat, and the shortest cycle length with 1:1 A-V conduction increased. In patients without enhanced A-V nodal conduction, the opposite effects occurred: The functional refractory period of the A-V node shortened, the cycle length of the Wenckebach shortened, and there was a slight shortening of the A-H interval. These findings suggest that in patients with enhanced A-V nodal conduction, sympathetic tone predominates, whereas in those patients without enhanced A-V nodal conduction, parasympathetic tone predominates. It is of note, however, that regardless of the differential effects of autonomic blockade in the two patient groups, patients with enhanced A-V nodal conduction still had shorter A-H intervals, shorter cycle lengths with 1:1 A-V conduction maintained, and shorter functional refractory periods of the A-V node. The effective refractory periods of the A-V node overlapped before and after autonomic blockade. Supraventricular tachycardia in Lown-Ganong-Levine syndrome: intranodal versus antinodal reentry. As discussed, there are two predominant groups of patients, based on mechanism of the short P-R interval. Details of studies that can demonstrate “upper and lower final common pathways” are given in Chapter 8. Heterogeneous retrograde 92 93 atrial activation patterns are seen in these patients as in those with normal A-V nodal conduction. This is not surprising because the major determinant of cycle length of A-V nodal reentry is conduction down the slow pathway. In our experience, the slow-pathway conduction times and refractoriness in patients with normal and short P-R intervals are indistinguishable. On the other hand, the fast pathway in such patients is faster than in patients with normal P-R intervals; the A-Hs are shorter in sinus rhythm, 143 and capability for retrograde conduction over the fast pathway is greater. Thus, the Lown–Ganong–Levine syndrome may merely reflect a bias caused by the characteristics of the fast pathway. The bulk of evidence suggests that the fast pathway is composed of A-V nodal tissue but has more rapid 14 136 conduction and shorter refractory periods. Thus, these patients appear to represent just one part of the spectrum of patients with A-V nodal reentry and normal P-R intervals. In contrast, the cycle length of tachycardias using concealed bypass tracts tends to be much shorter in patients with short P-R intervals than in patients with normal P-R intervals. This is not surprising because in patients with concealed bypass tracts antegrade conduction proceeds over the rapidly conducting A-V node, thereby abbreviating that limb of the reentrant circuit. In fact, enhanced A-V nodal conduction and reciprocating tachycardia using concealed bypass tracts should be considered in any individual with paroxysmal reciprocating tachycardias having cycle lengths ≤250 msec. Patients with short P-R intervals that are due to either enhanced A-V nodal conduction or atrio-His bypass tracts may exhibit atrial flutter or fibrillation with a rapid ventricular response. These patients primarily present with atrial fibrillation or flutter and a rapid ventricular response, which may, in fact, induce ventricular fibrillation (Fig. They found the ventricular response to be directly related to the refractory period. Thus, the functional characteristics of the tissue responsible for A-V conduction is the main determinant of the ventricular response P. Of note, in the group of patients with enhanced A-V nodal conduction who demonstrate dual A-V nodal pathways, the ventricular response is slower. This is a result of the fact that block in the fast pathway frequently occurs with conduction over the slow pathway and repetitive concealment into the fast pathway once conduction proceeds over the slow pathway. A: Atrial flutter with 1:1 A-V conduction is present in a patient with an atrio-His bypass tract. B: 200 mg of lidocaine produced block in the bypass tract, resulting in 2:1 conduction down the normal pathway. Because most of the reciprocating tachycardias are due to A-V nodal reentry or reentry using a concealed A-V bypass tract, treatment should be the same as that for patients with normal P-R intervals with these arrhythmias. With the development of deflectable catheters and increased experience, radiofrequency ablation is the therapy of choice for most patients (see Chapter 14). Patients with atrio-His bypass tracts and atrial flutter and fibrillation with rapid ventricular responses require treatment with drugs that can suppress these bypass tracts and/or prevent the arrhythmia. In the case of atrial flutter (either as a primary arrhythmia or one created from atrial fibrillation by drugs) catheter ablation of flutter is possible and is highly successful (see Chapters 9 and 14). Catheter-delivered radiofrequency energy is the current method of choice to create A-V block (see Chapter 14). Accessory Pathways with Anterograde Decremental Conduction and Fasciculoventricular Pathways At the beginning of this chapter, we assigned all the variants of preexcitation syndromes pathophysiologic names as opposed to the eponyms formerly applied. Thus, fibers initially considered under the rubric “Mahaim” fibers are now recognized as atriofascicular, nodofascicular, nodoventricular, and fasciculoventricular bypass tracts. Nodoventricular bypass tracts were initially described by Mahaim and Benatt in 1937 as conducting tissue 148 extending from the A-V node to the ventricular myocardium. Pathologically, fibers have been described from the node to the ventricle and from the fascicle to the ventricle, usually in or adjacent to the septum. Subsequently 15 17 18 19 it was recognized that bypass tracts can arise in the A-V node and insert in the right bundle branch. Eventually it became clear that the majority of what were assumed to be antegradely conducting nodoventricular and nodofascicular bypass tracts were actually slowly conducting atrioventricular or 18 20 21 22 48 49 148 149 150 atriofascicular bypass tracts. In general if the ventricular insertion of these bypass tracts is in the ventricular myocardium, particularly, near the tricuspid annulus, they will tend to have relatively broader r waves in leads V2-V4 with slurring of the downstroke of the S wave.