Study Objective: This study aims to evaluate the frequency of occurrence of cyclical behavioral changes in women with mental retardation, as well as the effectiveness of several treatment modalities for this type of behavior. Design: Retrospective chart analysis. Setting: University of Michigan clinic for reproductive healthcare of women with mental disabilities. Participants: All clinic patients of reproductive age, presenting with cyclical behavioral changes in our clinic from November 1985 to October 1992. Interventions: Medical treatment of cyclical behavioral changes. Main Outcome Measures: Presence and documentation of cyclical behavioral changes, level of retardation, type of behavior, treatment modalities and results. Results: Ninety-three of 522 reproductive-age patients (18%) presented with cyclical behavioral changes. Good documentation with behavior charts was present in 46% of these records. Level of retardation among the women included: 57 (61%) severely, 12 (13%) moderately, and 1 (1%) mildly retarded. No level of retardation could be detected in 23 (25%) women. Aggressive behavior was noted in 35 (38%) women, self-mutilation in 20 (22%) a combination of both in 10 (10%) and other behavior in 28 (28%) women. Primary treatment was by physician preference. Of 46 patients who received nonsteroidal antiinflammatory drugs (NSAID), 30 (65%) showed improvement, 10 (21%) showed no improvement, and 2 patients (4%) showed worsening symptoms. Birth control pills were used in 15 patients; there were signs of improvement in 6 (40%), no improvement in 3 (20%), and worsening in 3 (20%). The use of depomedroxyprogesterone injections was successful in treating 6 of 9 patients (66%), and showed no improvement in 2 women. No statistically significant differences were found between these treatment modalities. Conclusions: Cyclical behavioral changes in women with mental retardation is a common problem (18%) and may be related to pain— possibly due to menstrual cramps, since 65% of the patients responded to NSAID. If treatment with NSAID is unsuccessful, birth control pills and depomedroxyprogesterone improved behavior in 40% to 66% of patients. Documentation is a key issue.

This text is about fistulas, but it cannot help but become much more.It is also a discussion of the foundational development of gynecologic pelvic floor surgery and the innovations and motivations in our field, throughout history.Reflections on genital tract fistulas in women take us back to the beginnings of written history itself.Such reflections also unite the problem of (urinary) incontinence with that of pelvic organ prolapse, since these were the two common gynecologic problems of women noted in the Kahun papyri of ancient Egypt (--2000 BC), perhaps the earliest written 'medical' text [1].To understand the history of genitourinary fistulas and subsequent pelvic surgery, it has been helpful to return to rural West Africa, where such findings are still common.Over 35 trips, spanning nearly 4 of the past 21 years, have resulted in many of the insights presented in this discussion.In rural Africa true obstructed labor is common because of early childbearing, an inherited anthropoid/android pelvis with marked lumbar lordosis, and a lack of medical care.The absence of modern healthcare systems results in a reliance upon traditional healthcare customs and treatments that often delay or prevent access to contemporary obstetric care when it is available.The general lack of effective family planning also contributes to the problem.When appropriate care for a laboring patient is finally sought, the lack of transportation, roads and communication systems often make such efforts futile.The result has been a mortality ratio of 6-10 maternal deaths per 1000 deliveries in major medical centers in West Africa, and an average of

A socialization and sexuality counseling program was instituted as an integral part of a gynecologic service begun at the University of Michigan for persons with mental retardation. One hundred three patients were seen between 1986 and 1989 for counseling. Patients were referred for a variety of reasons, the most common being sexual behavior deemed inappropriate by the referring agent (i.e., direct care givers, parents, teachers, workshop supervisors, and other community professionals). Other concerns included sexual abuse, sterilization requests, sexuality and socialization education, marital questions, pregnancy assistance, abortion counseling, and family stress. Treatment techniques included gynecologic examination and follow-up, psychosexual education, psychiatric evaluation and follow-up, and group and individual psychosexual counseling. A majority of the patients improved during treatment. It is proposed that such a counseling program can play a useful role in the preparation of people with mental retardation to live in their communities as they deal with day-to-day decision making and should be an integral part of reproductive health care for this population.

OBJECTIVE:This study was undertaken to assess the life views, practices, values, and aspirations of women with various stages of gynecologic cancer. STUDY DESIGN:A self-administered questionnaire was completed by 108 women with various stages of cancer and 39 women with benign gynecologic disease. The questionnaire included items on demographics in addition to 16 multiple choice and 4 true-false items. The four questions related to criteria of good care, degree of involvement in decision making, psychosocial well-being, religious experience, and aspirations form the basis of this study. The data were analyzed with the Pearson chi 2 test (Systat, version 5.1) with significance set at p < 0.05. RESULTS:The women in this study placed greatest emphasis on receiving "straight talk" (96%) and compassion (64%) from their physicians. The newly diagnosed group put significantly less emphasis on compassion (33%, p = 0.037). Less than half expected their physicians to cure (43%, 56% for newly diagnosed) or contain (49%) the disease. For these women fear was the most dominant psychosocial consequence of having cancer, with difficulty communicating or feeling abandoned, isolated, or embarrassed less common. Those who specified their ears were afraid of pain (63% vs 39% for patients with benign disease, p = 0.019), dying (56%), losing control (48%), or becoming totally dependent (46%). Seventy-six percent indicated that religion had a serious place in their lives, with 49% becoming more religious since their cancer diagnosis, whereas no one became less religious. Ninety-three percent believed that the religious commitment helped sustain their hopes. CONCLUSIONS:These data suggest that (1) physicians should aim to educate their patients sufficiently for them to exercise control over their experience, to allay their fears, and to make personal decisions that further their aspirations, (2) patients in different stages of disease varied in their perceptions of themselves and their aspirations, (3) patients are dealing with fear as a primary problem, and (4) women with gynecologic cancer depend on their religious convictions and experiences as they cope with the disease.

The aim of the study was to investigate the histology of the sacrospinous ligament to determine whether nerve fibers exist within the substance of the sacropinous ligament itself. Six sacrospinous ligaments were removed from 4 fixed female cadavers. Representative segments were taken from the lateral (ischial), middle and medial (sacral) portions of these specimens, sectioned by microtome, mounted, and stained with hematoxylin and eosin dyes. The fixed and stained sections were then examined using light microscopy. Nerve tissue was found to be concentrated in the medial portions of the sacrospinous ligaments, but nerves were found in all segments of the ligament. It was concluded that, nervous tissue is present and widely distributed within the body of the sacrospinous ligament. A wide variety of sizes and thicknesses are also demonstrated, suggesting a variety of functions, including possible pain reception. This fact should be taken into consideration when planning operative procedures for pelvic prolapse.

Throughout the developing world managing prolonged obstructed labor remains problematic and involves the use of destructive procedures. There were 2870 deliveries between 1990 and 1993 at the Baptist Medical Center in Nalerigu Ghana. 17.9% of these deliveries were to women aged 15-19 years while 35% were to women aged 20-24. 92.8% had gestations at term and nulliparous patients constituted 59% of patients. 28 of the deliveries were destructive operations. There was a mean average of 99 cesarean sections performed annually most commonly due to obstructed labor and a mean of 4.4 maternal deaths per 1000 births. Cesarean sections are associated with more than 70% of maternal deaths. The destructive operations were performed on fetuses of quite low birth weight. The most common presentation during the destructive operation was cephalic (75%) followed by transverse lie (17.9%). The distance which patients travel to the hospital is a significant factor in the incidence of destructive procedures performed for long-obstructed labor with fetal death.

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

T he ACOG Ethics Committee is to be commended for continuing to offer guidance for the admittedly and necessarily “evolving ethic” regarding obstetrician/gynecologist responsibilities in cases complicated by human immunodeficiency virus (HIV). This most recent revision replaced the 1990 Committee Opinion on the subject.’ When clinical realities warrant terms such as “plague” and “epidemic,” the stakes are obviously high and the emotions run deep.* We have written this commentary with the practicing obstetrician/gynecologist in mind. The need for a revised statement apparently stemmed from the need for ethical reflection to keep pace with the epidemiological and clinical information being gathered about HIV infection. The revised statement reflects both format and content changes. The organization of the statement into sections makes for a much more coherent statement. Data about patient-to-professional risk of transmission are referenced as confirmation of the committee’s earlier argument that, with universal precautions, the risk is very slight (with hepatitis as a point of contrast now included).3 The revised statement recognizes that HIV infection has spread into all socioeconomic levels.

The authors report a case of voiding dysfunction with reduced sensation and areflexia 13 months after a repeat LUNA due to pelvic nerve injury. Anatomic distortion and increased vascularity were likely contributing factors. Repeat procedures may expose patients to a risk of such injury due to anatomic distortion.

Vesicovaginal fistulas (VVFs) occurring as a result of obstetric trauma are a vast problem in Nigeria and Ghana, where at least 20 000 women await repair, and fewer than 50 physicians have the necessary expertise. Through a series of conferences those VVFs that are at high risk and those at low-risk for repair failure, were identified. A clinic was established where repair of low-risk VVFs was done on an ongoing basis in a remote region of Ghana. A visiting surgical team was utilized to repair the difficult, or high-risk, VVFs, which included 4–6 cm VVFs (3), recurrent VVF (1), combined VVF and RVF (rectovaginal fistula), a large 5 cm juxtacervical VVF (1), and a vesicouterine fistula (1). Management of these patients and others with VVF repair complications is discussed.

Over a period of 30 months, 200 patients were seen in the combined gynecology/urology clinic of the University of Michigan Medical Center. Nintey-nine patients (49.5%) were referred by urologists and 86 (43%) by gynecologists. The mean number of visits by patients to the clinic was 1.7, with a range of 1–3; 78 patients (39%) visited the clinic on just one occasion; 116 patients (58%) had undergone previous gynecologic and/or urologic surgery. At least one diagnosis was confirmed in 183 patients (91.5%). A total of 151 operations were performed, 43 (28.5%) by gynecologists and urologists working together.

To establish the present status of ethics education in obstetrics and gynecology, 256 questionnaires were sent to residency (graduate) and student (undergraduate) education programs. One hundred ninety-eight questionnaires were returned. Fifteen programs offered no ethics education; 167 offered resident level courses; 123 offered undergraduate (student) level courses; and 84 offered postgraduate education. The median number of hours offered was 2 undergraduate, 4 graduate, and 2 postgraduate. The courses offered relied primarily on formal lecture presentation, even though this was not considered most effective by the respondents. Most institutions (85%) used more than one format to present ethics material. General ethics principles were covered in 78% of the reporting institutions. Where ethics case histories were used, they were rated higher in efficacy by the respondents. Only 15% of the reporting institutions had any means of measuring outcomes. The issues cited most frequently as critical in a curriculum were abortion, maternal-fetal conflicts, issues surrounding care decisions at the end of life, and informed consent. The few hours dedicated to ethics were small relative to a long list of issues. Obstetric-gynecologic faculty with any training in medical ethics were uncommon (29%). The form of teaching, except in rare circumstances, seemed to lack structure or design and used few of the available reading materials. Recommendations from this survey include the development of a uniform national curriculum for undergraduate and graduate medical ethics, development of evaluation alternatives for ethics education, and encouragement and support for faculty development in medical ethics.

Peroneal nerve injury, resulting in leg weakness and foot drop, is seen frequently after long, obstructed labor that has caused an obstetric vesicovaginal fistula. Nine hundred and forty-seven consecutive patients treated in northern Nigeria for obstetric fistulas were reviewed for the presence of peroneal nerve trauma. The first 470 patients were reviewed retrospectively, and 25 (5.3%) were noted to have presented with significant motor weakness. The next 470 patients were prospectively evaluated by both history and physical examination. In this group, 311 (64.9%) women had either a history or current signs of peroneal nerve injury at the time of admission for fistula repair. Injuries were more common on the right side and were more commonly apparent in the first 2 years after the obstetric trauma causing the fistula.

Combined stress urinary incontinence (SUI) and genital prolapse after fracture of the female pelvis has not been well described to date; four such cases are reported. Three of the patients had undergone reconstructive urogynecologic surgery prior to referral. None of the patients had a history of urinary incontinence or genital prolapse prior to injury. In order to correct persistent urinary incontinence and prolapse the following operations were performed: pubovaginal sling and transvaginal cystocele repair, Raz needle suspension and rectus muscle graft to the pelvic floor followed by a unilateral Burch colposuspension. On follow-up at a mean interval of 14.2 months (range 12–17), 2 have mild SUI and all 4 are without significant genital prolapse.

A variety of plastic surgical techniques may be used in the repair of vesicovaginal fistulas. The indication for their use include: (a) diameter greater than 4 cm; (b) involvement of the bladder neck/proximal urethra; (c) radiation-induced fistulas; and (d) previous failed repair(s). In the developing world the vast majority of complex fistulas are caused by obstetric trauma; elsewhere they occur mainly following radiotherapy or radical surgery for gynecologic malignancy. The majority of complex fistulas requiring tissue donation may be effectively treated using a vaginal approach and a modified Martius graft. There is probably little or no advantage in encorporating bulbocavernosus muscle fibers in this graft. Although some concern exists regarding the long-term viability of these grafts in radiation-induced fistulas, in view of the relatively simple operative technique, together with the low associated morbidity, modified Martius grafts may be deemed suitable for first-time repairs. The gracilis muscle graft should be considered next in cases of exclusive transvaginal repair. The omental graft is undoubtedly the most versatile: it can be used in both abdominal and combined abdominovaginal procedures. The recently described posterosuperior sliding bladder flaps warrant further evaluation. For most fistulas involving the bladder neck/proximal urethra, there is no clear advantage in bladder flap reconstruction over vaginal flap reconstruction, the latter being augmented by an anti-stress incontinence procedure were appropriate. When continent urinary diversion is required, the Indiana pouch appears preferable to the Kock pouch; ureterosigmoidostomy is, however, technically and culturally more acceptable in these circumstances in the developing world.

Eighteen patients at University College Hospital in Ibadan, Nigeria, underwent urologic evaluation after repair of obstetrics-related vesicovaginal fistulas. This included a questionnaire, assessment of vaginal scarring, urodynamics and urethroscopy. Eight patients demonstrated stress urinary incontinence, with 4 revealing type III incontinence with either low maximum urethral closure pressure or open vesical neck on urethroscopy. This study documents some of the persistent problems that occur even after successful closure of vesicovaginal fistulas. Continued evaluation should lead to better surgical and medical techniques to diminish the incidence of continued bladder dysfunction after closure of fistulas.

Previous articleNext article No AccessSedating Women with Mental Retardation for Routine Gynecologic Examination: An Ethical AnalysisDouglas Brown, David Rosen, and Thomas E. ElkinsDouglas BrownUniversity of Michigan Medical Center, Ann Arbor Search for more articles by this author , David RosenUniversity of Michigan Medical Center Search for more articles by this author , and Thomas E. ElkinsUniversity of Michigan Medical Center Search for more articles by this author PDFPDF PLUS Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinkedInRedditEmail SectionsMoreDetailsFiguresReferencesCited by Volume 3, Number 1Spring 1992 Published on behalf of the MacLean Center for Clinical Medical Ethics Article DOIhttps://doi.org/10.1086/JCE199203115 Views: 1Total views on this site © 1992 The University of Chicago. All rights reserved.PDF download Crossref reports no articles citing this article.