Sharon Worcester

ORLANDO, FLA. — Early angiography is associated with improved survival in women presenting with acute coronary syndrome, Rasha N. Bazari, M.D., reported at an international conference on women, heart disease, and stroke.

Women who had coronary angiography within 2 days of presenting with ACS had significantly lower 3-year mortality rates than did those who had later procedures (7% vs. 20%), said Dr. Bazari of the Henry Ford Heart and Vascular Institute, Detroit. Angiography beyond 48 hours after presentation was the most significant predictor of mortality, after adjustment for confounding variables (odds ratio 3.7). Marginal predictors of mortality included older age and lower diastolic blood pressure, she said.

Dr. Bazari and associates reviewed the records of 836 patients (350 women and 486 men) admitted to the hospital in 1997–2000 who underwent angiography during their stay. The study also showed that fewer women than men admitted during the study period underwent early coronary angiography (63% vs. 74%), she noted.

“Gender should not be a reason to delay early angiography” she said.

ORLANDO, FLA. — Early angiography is associated with improved survival in women presenting with acute coronary syndrome, Rasha N. Bazari, M.D., reported at an international conference on women, heart disease, and stroke.

Women who had coronary angiography within 2 days of presenting with ACS had significantly lower 3-year mortality rates than did those who had later procedures (7% vs. 20%), said Dr. Bazari of the Henry Ford Heart and Vascular Institute, Detroit. Angiography beyond 48 hours after presentation was the most significant predictor of mortality, after adjustment for confounding variables (odds ratio 3.7). Marginal predictors of mortality included older age and lower diastolic blood pressure, she said.

Dr. Bazari and associates reviewed the records of 836 patients (350 women and 486 men) admitted to the hospital in 1997–2000 who underwent angiography during their stay. The study also showed that fewer women than men admitted during the study period underwent early coronary angiography (63% vs. 74%), she noted.

“Gender should not be a reason to delay early angiography” she said.

ORLANDO, FLA. — Early angiography is associated with improved survival in women presenting with acute coronary syndrome, Rasha N. Bazari, M.D., reported at an international conference on women, heart disease, and stroke.

Women who had coronary angiography within 2 days of presenting with ACS had significantly lower 3-year mortality rates than did those who had later procedures (7% vs. 20%), said Dr. Bazari of the Henry Ford Heart and Vascular Institute, Detroit. Angiography beyond 48 hours after presentation was the most significant predictor of mortality, after adjustment for confounding variables (odds ratio 3.7). Marginal predictors of mortality included older age and lower diastolic blood pressure, she said.

Dr. Bazari and associates reviewed the records of 836 patients (350 women and 486 men) admitted to the hospital in 1997–2000 who underwent angiography during their stay. The study also showed that fewer women than men admitted during the study period underwent early coronary angiography (63% vs. 74%), she noted.

“Gender should not be a reason to delay early angiography” she said.

FORT LAUDERDALE, FLA. — Constipation is a common complaint, and the causes for this condition are varied, Dana R. Sands, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

In a survey of more than 10,000 people, nearly 14% reported difficulty with evacuation, including infrequent defecation, incomplete defecation, and blockage of bowel movement.

“A surprising 12% said they need to use digital maneuvers in order to defecate—that's a high number,” said Dr. Sands of the Cleveland Clinic Florida, Weston.

Among the causes of constipation are paradoxical puborectalis contraction, rectocele, and pelvic floor failure, including rectal prolapse and rectoanal intussusception, but sometimes the cause can be as simple as a lack of fiber and water in the diet, she said.

Those who haven't tried fiber supplements and increased water intake will often find their constipation is “miraculously” cured simply by trying these two things, she noted.

But a thorough history and physical examination are important in all patients, and every complaint of bleeding and obstruction should be investigated, she said. She also recommended that some form of endoscopic evaluation be performed in patients with such complaints.

“It's our job to make sure rectal bleeding really is from hemorrhoids, and that constipation really is constipation,” and that obstructing cancer is not the cause in either case, she said, noting that she performs colonoscopy on all patients reporting changes in bowel habits.

Defecography, surface EMG, anal manometry, and colonic transit studies also may be useful. She said she also orders a cursory panel of blood work including measurement of thyroid-stimulating hormone, to look for obvious and easily correctable metabolic processes that could be causing constipation.

Most patients will be diagnosed on the basis of TSH, defecography, and/or surface EMG findings, she said.

Regardless of whether constipation is caused by dietary or metabolic conditions or by a benign condition that could be treated surgically, medical management options should be exhausted first.

For significant outlet obstruction caused by paradoxical contraction, for example, biofeedback and/or botulinum toxin (Botox) injections may be helpful. Biofeedback has had varying success, with studies showing success rates from 8% to 100%.

In a Cleveland Clinic study of 194 patients who used biofeedback, 68 (35%) had complete resolution of symptoms, 27 (14%) had partial resolution, and 99 (51%) had no improvement. However, when patients were analyzed separately according to whether they completed all 10 biofeedback sessions, those who did complete all sessions had a success rate of 63%, compared with 25% in those who did not. Motivated patients are going to have better success, Dr. Sands said. Also, remember that a “refresher course” in biofeedback may be needed.

As for use of botulinum toxin, a small series involving four patients injected with 30 U of Botox showed good results. One patient required reinjection, but none experienced incontinence. In another series involving 17 Cleveland Clinic patients injected with an average of 50 U of Botox, 11 (64%) had improvements in symptoms, and only 1 had transient fecal incontinence.

For patients with a rectocele, it is best to base therapy on the functional, rather than the anatomical, problem, Dr. Sands said. Try medical management, but consider surgery in those patients with rectoceles greater than 4 cm who fail to respond and in those who must use rectal or vaginal digitation or perineal support maneuvers to defecate.

Rectoanal intussusception is more difficult to treat. Start with dietary modification and fiber supplementation. Then try biofeedback, but don't expect too much, she said, noting that outcomes were somewhat disappointing in a recent study of 36 patients treated with dietary therapy, biofeedback, or surgery. Of 13 patients receiving dietary therapy, 5 improved, 6 had no change, and 2 worsened. Of 13 in the biofeedback group, 11 improved or had no change, and 2 worsened. Of 10 who underwent surgery, 6 improved, 1 had no change, and 3 worsened.

For rectal prolapse, it's important to evaluate for associated anterior compartment prolapse and to consider combined surgical correction when warranted. In the most severe cases of constipation, including those with severe outlet obstruction, colostomy may be necessary, although it should be a last resort. If you do perform a colostomy in these patients, consider it permanent, Dr. Sands said. Some colostomy patients will decide after several years that the precolostomy symptoms weren't so bad and will have their colostomy closed (usually by a different surgeon), but most eventually return, seeking to have the colostomy reopened because of intolerable symptoms.

FORT LAUDERDALE, FLA. — Constipation is a common complaint, and the causes for this condition are varied, Dana R. Sands, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

In a survey of more than 10,000 people, nearly 14% reported difficulty with evacuation, including infrequent defecation, incomplete defecation, and blockage of bowel movement.

“A surprising 12% said they need to use digital maneuvers in order to defecate—that's a high number,” said Dr. Sands of the Cleveland Clinic Florida, Weston.

Among the causes of constipation are paradoxical puborectalis contraction, rectocele, and pelvic floor failure, including rectal prolapse and rectoanal intussusception, but sometimes the cause can be as simple as a lack of fiber and water in the diet, she said.

Those who haven't tried fiber supplements and increased water intake will often find their constipation is “miraculously” cured simply by trying these two things, she noted.

But a thorough history and physical examination are important in all patients, and every complaint of bleeding and obstruction should be investigated, she said. She also recommended that some form of endoscopic evaluation be performed in patients with such complaints.

“It's our job to make sure rectal bleeding really is from hemorrhoids, and that constipation really is constipation,” and that obstructing cancer is not the cause in either case, she said, noting that she performs colonoscopy on all patients reporting changes in bowel habits.

Defecography, surface EMG, anal manometry, and colonic transit studies also may be useful. She said she also orders a cursory panel of blood work including measurement of thyroid-stimulating hormone, to look for obvious and easily correctable metabolic processes that could be causing constipation.

Most patients will be diagnosed on the basis of TSH, defecography, and/or surface EMG findings, she said.

Regardless of whether constipation is caused by dietary or metabolic conditions or by a benign condition that could be treated surgically, medical management options should be exhausted first.

For significant outlet obstruction caused by paradoxical contraction, for example, biofeedback and/or botulinum toxin (Botox) injections may be helpful. Biofeedback has had varying success, with studies showing success rates from 8% to 100%.

In a Cleveland Clinic study of 194 patients who used biofeedback, 68 (35%) had complete resolution of symptoms, 27 (14%) had partial resolution, and 99 (51%) had no improvement. However, when patients were analyzed separately according to whether they completed all 10 biofeedback sessions, those who did complete all sessions had a success rate of 63%, compared with 25% in those who did not. Motivated patients are going to have better success, Dr. Sands said. Also, remember that a “refresher course” in biofeedback may be needed.

As for use of botulinum toxin, a small series involving four patients injected with 30 U of Botox showed good results. One patient required reinjection, but none experienced incontinence. In another series involving 17 Cleveland Clinic patients injected with an average of 50 U of Botox, 11 (64%) had improvements in symptoms, and only 1 had transient fecal incontinence.

For patients with a rectocele, it is best to base therapy on the functional, rather than the anatomical, problem, Dr. Sands said. Try medical management, but consider surgery in those patients with rectoceles greater than 4 cm who fail to respond and in those who must use rectal or vaginal digitation or perineal support maneuvers to defecate.

Rectoanal intussusception is more difficult to treat. Start with dietary modification and fiber supplementation. Then try biofeedback, but don't expect too much, she said, noting that outcomes were somewhat disappointing in a recent study of 36 patients treated with dietary therapy, biofeedback, or surgery. Of 13 patients receiving dietary therapy, 5 improved, 6 had no change, and 2 worsened. Of 13 in the biofeedback group, 11 improved or had no change, and 2 worsened. Of 10 who underwent surgery, 6 improved, 1 had no change, and 3 worsened.

For rectal prolapse, it's important to evaluate for associated anterior compartment prolapse and to consider combined surgical correction when warranted. In the most severe cases of constipation, including those with severe outlet obstruction, colostomy may be necessary, although it should be a last resort. If you do perform a colostomy in these patients, consider it permanent, Dr. Sands said. Some colostomy patients will decide after several years that the precolostomy symptoms weren't so bad and will have their colostomy closed (usually by a different surgeon), but most eventually return, seeking to have the colostomy reopened because of intolerable symptoms.

FORT LAUDERDALE, FLA. — Constipation is a common complaint, and the causes for this condition are varied, Dana R. Sands, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

In a survey of more than 10,000 people, nearly 14% reported difficulty with evacuation, including infrequent defecation, incomplete defecation, and blockage of bowel movement.

“A surprising 12% said they need to use digital maneuvers in order to defecate—that's a high number,” said Dr. Sands of the Cleveland Clinic Florida, Weston.

Among the causes of constipation are paradoxical puborectalis contraction, rectocele, and pelvic floor failure, including rectal prolapse and rectoanal intussusception, but sometimes the cause can be as simple as a lack of fiber and water in the diet, she said.

Those who haven't tried fiber supplements and increased water intake will often find their constipation is “miraculously” cured simply by trying these two things, she noted.

But a thorough history and physical examination are important in all patients, and every complaint of bleeding and obstruction should be investigated, she said. She also recommended that some form of endoscopic evaluation be performed in patients with such complaints.

“It's our job to make sure rectal bleeding really is from hemorrhoids, and that constipation really is constipation,” and that obstructing cancer is not the cause in either case, she said, noting that she performs colonoscopy on all patients reporting changes in bowel habits.

Defecography, surface EMG, anal manometry, and colonic transit studies also may be useful. She said she also orders a cursory panel of blood work including measurement of thyroid-stimulating hormone, to look for obvious and easily correctable metabolic processes that could be causing constipation.

Most patients will be diagnosed on the basis of TSH, defecography, and/or surface EMG findings, she said.

Regardless of whether constipation is caused by dietary or metabolic conditions or by a benign condition that could be treated surgically, medical management options should be exhausted first.

For significant outlet obstruction caused by paradoxical contraction, for example, biofeedback and/or botulinum toxin (Botox) injections may be helpful. Biofeedback has had varying success, with studies showing success rates from 8% to 100%.

In a Cleveland Clinic study of 194 patients who used biofeedback, 68 (35%) had complete resolution of symptoms, 27 (14%) had partial resolution, and 99 (51%) had no improvement. However, when patients were analyzed separately according to whether they completed all 10 biofeedback sessions, those who did complete all sessions had a success rate of 63%, compared with 25% in those who did not. Motivated patients are going to have better success, Dr. Sands said. Also, remember that a “refresher course” in biofeedback may be needed.

As for use of botulinum toxin, a small series involving four patients injected with 30 U of Botox showed good results. One patient required reinjection, but none experienced incontinence. In another series involving 17 Cleveland Clinic patients injected with an average of 50 U of Botox, 11 (64%) had improvements in symptoms, and only 1 had transient fecal incontinence.

For patients with a rectocele, it is best to base therapy on the functional, rather than the anatomical, problem, Dr. Sands said. Try medical management, but consider surgery in those patients with rectoceles greater than 4 cm who fail to respond and in those who must use rectal or vaginal digitation or perineal support maneuvers to defecate.

Rectoanal intussusception is more difficult to treat. Start with dietary modification and fiber supplementation. Then try biofeedback, but don't expect too much, she said, noting that outcomes were somewhat disappointing in a recent study of 36 patients treated with dietary therapy, biofeedback, or surgery. Of 13 patients receiving dietary therapy, 5 improved, 6 had no change, and 2 worsened. Of 13 in the biofeedback group, 11 improved or had no change, and 2 worsened. Of 10 who underwent surgery, 6 improved, 1 had no change, and 3 worsened.

For rectal prolapse, it's important to evaluate for associated anterior compartment prolapse and to consider combined surgical correction when warranted. In the most severe cases of constipation, including those with severe outlet obstruction, colostomy may be necessary, although it should be a last resort. If you do perform a colostomy in these patients, consider it permanent, Dr. Sands said. Some colostomy patients will decide after several years that the precolostomy symptoms weren't so bad and will have their colostomy closed (usually by a different surgeon), but most eventually return, seeking to have the colostomy reopened because of intolerable symptoms.

Necrotizing Fasciitis

Cases of necrotizing fasciitis that are caused by community-acquired methicillin-resistant Staphylococcus aureus are on the rise, Loren G. Miller, M.D., of Harbor-UCLA Medical Center, Los Angeles, and colleagues reported.

Of 843 patients whose wound cultures grew MRSA over a 15-month period in 2003-2004, 14 had necrotizing fasciitis, necrotizing myositis, or both (N. Engl. J. Med. 2005;352:1445-53).

None of the 14 patients died, but all had one or more serious complications. Combined surgical and medical treatment was provided; all MRSA isolates showed in vitro susceptibility to clindamycin, trimethoprim-sulfamethoxazole, vancomycin, gentamicin, and rifampin.

S. aureus has been a rare cause of necrotizing fasciitis, but cases caused by community-acquired MRSA represent an emerging clinical syndrome.

Empirical treatment in suspected cases, particularly where MRSA is endemic, is necessary regardless of the presence of clinical risk factors, and should include antibiotics active against the locally circulating strains, they said.

This represents a major departure from currently recommended treatment for necrotizing fasciitis, the investigators added.

HSV-2 Shedding Risk

Hormonal contraception and two common genital tract conditions appear to be among the risk factors for genital tract shedding of herpes simplex virus type 2 in women.

In a 12-month study of 330 women who were evaluated every 4 months, independent predictors of genital tract shedding of HSV-2 were HSV-2 seroconversion during the previous 4 months (adjusted odds ratio [OR] 3.0), bacterial vaginosis (adjusted OR 2.3), heavy colonization with group B streptococcus (adjusted OR 2.2), and use of hormonal contraceptives (adjusted OR 1.8), reported Thomas L. Cherpes, M.D., and his colleagues at the University of Pittsburgh (Clin. Infect. Dis. 2005;40:1422-8).

Because use of hormonal contraception is widespread, and bacterial vaginosis and vaginal group B streptococcus colonization are two of the most common genital conditions in women of reproductive age, the associations between these variables and increased genital tract shedding of HSV-2 is of concern. The findings could have important implications for decreasing HSV-2 transmissions.

Multidrug-Resistant TB

Directly observed therapy, which has served as the primary strategy worldwide for preventing drug-susceptible tuberculosis transmissions, also is effective for reducing the transmission and incidence of drug-resistant tuberculosis, a study suggests.

In the population-based prospective study of 436 patients undergoing directly observed therapy, short course (DOTS), three indicators of ongoing TB transmissions showed that transmission declined between 1995 and 2000.

During those years, the pulmonary TB incidence rate decreased from 42 to 19 per 100,000 population, the percentage of clustered pulmonary TB cases decreased from 22% to 8%, and the rate of primary drug resistance decreased from 9 to 2 per 100,000 population, according to Kathryn DeRiemer, Ph.D., of Stanford (Calif.) University and her colleagues (Lancet 2005;365:1239-44).

Multidrug-resistant (MDR) TB also decreased significantly, as did the number of treatment failures, from 13 (11%) in 1995 to 1 (2%) in 2000. But the case-fatality rate over the study period was 12% for MDR TB, compared with 7% for strains resistant to one or more drugs (not including MDR cases), and 3% for strains susceptible to multiple drugs.

DOTS remains a valuable tool for preventing TB transmission even in this age of emerging drug resistance, but further interventions will be required to avoid treatment failure and reduce multidrug-resistant TB mortality rates, the investigators concluded.

Tomatoes and Salmonella

Roma tomatoes were implicated or suspected in three salmonella outbreaks involving more than 560 patients in 18 states and 1 Canadian province last year, according to the Centers for Disease Control and Prevention. No deaths were associated with the outbreaks, but 14%-30% of the patients were hospitalized.

In two of the outbreaks, case-control studies conducted by the CDC and state and local health departments showed associations between salmonella infection and Roma tomato consumption. For example, in the largest outbreak—involving 429 culture-confirmed cases in nine states— multivariate analysis showed that salmonella infection was strongly associated (adjusted odds ratio 7.1) with consumption of Roma tomatoes (MMWR 2005;54:325-8). In the third outbreak, no case-control study was conducted, but Roma tomatoes were the only common food exposure among patients.

Health officials investigating salmonella outbreaks should consider tomatoes as a potential vehicle, and future studies should focus on mechanisms of tomato contamination and methods of eradication of salmonella in fruit, according to the CDC.

Necrotizing Fasciitis

Cases of necrotizing fasciitis that are caused by community-acquired methicillin-resistant Staphylococcus aureus are on the rise, Loren G. Miller, M.D., of Harbor-UCLA Medical Center, Los Angeles, and colleagues reported.

Of 843 patients whose wound cultures grew MRSA over a 15-month period in 2003-2004, 14 had necrotizing fasciitis, necrotizing myositis, or both (N. Engl. J. Med. 2005;352:1445-53).

None of the 14 patients died, but all had one or more serious complications. Combined surgical and medical treatment was provided; all MRSA isolates showed in vitro susceptibility to clindamycin, trimethoprim-sulfamethoxazole, vancomycin, gentamicin, and rifampin.

S. aureus has been a rare cause of necrotizing fasciitis, but cases caused by community-acquired MRSA represent an emerging clinical syndrome.

Empirical treatment in suspected cases, particularly where MRSA is endemic, is necessary regardless of the presence of clinical risk factors, and should include antibiotics active against the locally circulating strains, they said.

This represents a major departure from currently recommended treatment for necrotizing fasciitis, the investigators added.

HSV-2 Shedding Risk

Hormonal contraception and two common genital tract conditions appear to be among the risk factors for genital tract shedding of herpes simplex virus type 2 in women.

In a 12-month study of 330 women who were evaluated every 4 months, independent predictors of genital tract shedding of HSV-2 were HSV-2 seroconversion during the previous 4 months (adjusted odds ratio [OR] 3.0), bacterial vaginosis (adjusted OR 2.3), heavy colonization with group B streptococcus (adjusted OR 2.2), and use of hormonal contraceptives (adjusted OR 1.8), reported Thomas L. Cherpes, M.D., and his colleagues at the University of Pittsburgh (Clin. Infect. Dis. 2005;40:1422-8).

Because use of hormonal contraception is widespread, and bacterial vaginosis and vaginal group B streptococcus colonization are two of the most common genital conditions in women of reproductive age, the associations between these variables and increased genital tract shedding of HSV-2 is of concern. The findings could have important implications for decreasing HSV-2 transmissions.

Multidrug-Resistant TB

Directly observed therapy, which has served as the primary strategy worldwide for preventing drug-susceptible tuberculosis transmissions, also is effective for reducing the transmission and incidence of drug-resistant tuberculosis, a study suggests.

In the population-based prospective study of 436 patients undergoing directly observed therapy, short course (DOTS), three indicators of ongoing TB transmissions showed that transmission declined between 1995 and 2000.

During those years, the pulmonary TB incidence rate decreased from 42 to 19 per 100,000 population, the percentage of clustered pulmonary TB cases decreased from 22% to 8%, and the rate of primary drug resistance decreased from 9 to 2 per 100,000 population, according to Kathryn DeRiemer, Ph.D., of Stanford (Calif.) University and her colleagues (Lancet 2005;365:1239-44).

Multidrug-resistant (MDR) TB also decreased significantly, as did the number of treatment failures, from 13 (11%) in 1995 to 1 (2%) in 2000. But the case-fatality rate over the study period was 12% for MDR TB, compared with 7% for strains resistant to one or more drugs (not including MDR cases), and 3% for strains susceptible to multiple drugs.

DOTS remains a valuable tool for preventing TB transmission even in this age of emerging drug resistance, but further interventions will be required to avoid treatment failure and reduce multidrug-resistant TB mortality rates, the investigators concluded.

Tomatoes and Salmonella

Roma tomatoes were implicated or suspected in three salmonella outbreaks involving more than 560 patients in 18 states and 1 Canadian province last year, according to the Centers for Disease Control and Prevention. No deaths were associated with the outbreaks, but 14%-30% of the patients were hospitalized.

In two of the outbreaks, case-control studies conducted by the CDC and state and local health departments showed associations between salmonella infection and Roma tomato consumption. For example, in the largest outbreak—involving 429 culture-confirmed cases in nine states— multivariate analysis showed that salmonella infection was strongly associated (adjusted odds ratio 7.1) with consumption of Roma tomatoes (MMWR 2005;54:325-8). In the third outbreak, no case-control study was conducted, but Roma tomatoes were the only common food exposure among patients.

Health officials investigating salmonella outbreaks should consider tomatoes as a potential vehicle, and future studies should focus on mechanisms of tomato contamination and methods of eradication of salmonella in fruit, according to the CDC.

Necrotizing Fasciitis

Cases of necrotizing fasciitis that are caused by community-acquired methicillin-resistant Staphylococcus aureus are on the rise, Loren G. Miller, M.D., of Harbor-UCLA Medical Center, Los Angeles, and colleagues reported.

Of 843 patients whose wound cultures grew MRSA over a 15-month period in 2003-2004, 14 had necrotizing fasciitis, necrotizing myositis, or both (N. Engl. J. Med. 2005;352:1445-53).

None of the 14 patients died, but all had one or more serious complications. Combined surgical and medical treatment was provided; all MRSA isolates showed in vitro susceptibility to clindamycin, trimethoprim-sulfamethoxazole, vancomycin, gentamicin, and rifampin.

S. aureus has been a rare cause of necrotizing fasciitis, but cases caused by community-acquired MRSA represent an emerging clinical syndrome.

Empirical treatment in suspected cases, particularly where MRSA is endemic, is necessary regardless of the presence of clinical risk factors, and should include antibiotics active against the locally circulating strains, they said.

This represents a major departure from currently recommended treatment for necrotizing fasciitis, the investigators added.

HSV-2 Shedding Risk

Hormonal contraception and two common genital tract conditions appear to be among the risk factors for genital tract shedding of herpes simplex virus type 2 in women.

In a 12-month study of 330 women who were evaluated every 4 months, independent predictors of genital tract shedding of HSV-2 were HSV-2 seroconversion during the previous 4 months (adjusted odds ratio [OR] 3.0), bacterial vaginosis (adjusted OR 2.3), heavy colonization with group B streptococcus (adjusted OR 2.2), and use of hormonal contraceptives (adjusted OR 1.8), reported Thomas L. Cherpes, M.D., and his colleagues at the University of Pittsburgh (Clin. Infect. Dis. 2005;40:1422-8).

Because use of hormonal contraception is widespread, and bacterial vaginosis and vaginal group B streptococcus colonization are two of the most common genital conditions in women of reproductive age, the associations between these variables and increased genital tract shedding of HSV-2 is of concern. The findings could have important implications for decreasing HSV-2 transmissions.

Multidrug-Resistant TB

Directly observed therapy, which has served as the primary strategy worldwide for preventing drug-susceptible tuberculosis transmissions, also is effective for reducing the transmission and incidence of drug-resistant tuberculosis, a study suggests.

In the population-based prospective study of 436 patients undergoing directly observed therapy, short course (DOTS), three indicators of ongoing TB transmissions showed that transmission declined between 1995 and 2000.

During those years, the pulmonary TB incidence rate decreased from 42 to 19 per 100,000 population, the percentage of clustered pulmonary TB cases decreased from 22% to 8%, and the rate of primary drug resistance decreased from 9 to 2 per 100,000 population, according to Kathryn DeRiemer, Ph.D., of Stanford (Calif.) University and her colleagues (Lancet 2005;365:1239-44).

Multidrug-resistant (MDR) TB also decreased significantly, as did the number of treatment failures, from 13 (11%) in 1995 to 1 (2%) in 2000. But the case-fatality rate over the study period was 12% for MDR TB, compared with 7% for strains resistant to one or more drugs (not including MDR cases), and 3% for strains susceptible to multiple drugs.

DOTS remains a valuable tool for preventing TB transmission even in this age of emerging drug resistance, but further interventions will be required to avoid treatment failure and reduce multidrug-resistant TB mortality rates, the investigators concluded.

Tomatoes and Salmonella

Roma tomatoes were implicated or suspected in three salmonella outbreaks involving more than 560 patients in 18 states and 1 Canadian province last year, according to the Centers for Disease Control and Prevention. No deaths were associated with the outbreaks, but 14%-30% of the patients were hospitalized.

In two of the outbreaks, case-control studies conducted by the CDC and state and local health departments showed associations between salmonella infection and Roma tomato consumption. For example, in the largest outbreak—involving 429 culture-confirmed cases in nine states— multivariate analysis showed that salmonella infection was strongly associated (adjusted odds ratio 7.1) with consumption of Roma tomatoes (MMWR 2005;54:325-8). In the third outbreak, no case-control study was conducted, but Roma tomatoes were the only common food exposure among patients.

Health officials investigating salmonella outbreaks should consider tomatoes as a potential vehicle, and future studies should focus on mechanisms of tomato contamination and methods of eradication of salmonella in fruit, according to the CDC.

ORLANDO, FLA. — Women presenting with myocardial infarction continue to receive less intensive treatment and have higher mortality than men with similar presentations, but the gender gap in medical interventions prescribed at hospital discharge may be narrowing, according to studies presented at an international conference on women, heart disease, and stroke.

One retrospective study included nearly 26,700 Swedish patients treated for ST-elevation MI (STEMI) at cardiac intensive care units during 1997-2001. Reperfusion therapy was administered to 71% of the 17,243 men in the study, compared with 62% of the 9,455 women in the study, Sofia Sederholm Lavesson, M.D., reported.

Men, compared with women, had lower in-hospital mortality (9% vs. 16%), 30-day mortality (11% vs. 18%), and 1-year mortality (16% vs. 25%), said Dr. Lavesson of Linköping (Sweden) University.

After adjusting for numerous confounding factors, women remained significantly less likely than men to receive reperfusion therapy (odds ratio 0.83) and to survive while in the hospital (OR 1.23), she said, noting that the differences between men and women cannot be fully explained by differences in age and comorbidities. “[Greater] age is the main explanation for the higher mortality in women, but less intensive treatment also appears to contribute,” she said.

A similar conclusion was reached in a study of more than 55,000 patients admitted to any of 153 different hospitals with a primary diagnosis of Q-wave acute MI from January 2000 through June 2004.

Mortality was 13% in the 19,034 women in the study, compared with 7% in the 35,969 men. After adjusting for 24 variables, including age, various comorbidities, and type of hospital providing the treatment (heart surgery hospital, cath lab hospital, and hospital with no heart surgery or cath lab), men were shown to be less likely than women to die (OR 0.71). Additionally, men were more likely than women to be transferred for further treatment (OR 1.24), receive thrombolytics (OR 1.16), receive percutaneous coronary intervention (OR 1.12), and/or receive coronary artery bypass grafting (OR 1.64), reported Allan L. Anderson, M.D., of the Medical City Dallas Hospital.

“Women with Q-wave acute MI continue to have significantly worse mortality rates and receive less revascularization than men,” he concluded, noting that additional research is needed to determine how women with MI can obtain clinical parity with men. But such parity is being achieved when it comes to the prescribing of medical interventions at hospital discharge in patients who present with heart attack or chest pain, a third study suggests.

That ongoing study showed such men and women are being prescribed appropriate drug interventions at the about the same frequency. The subanalysis of a National Institutes of Health-funded study of 177 men and 35 women with acute coronary syndrome showed that women were prescribed aspirin, β-blockers, and statins as frequently as men, however, it also showed that 10% of women with acute coronary syndrome didn't receive aspirin or β-blockers and that more than 30% didn't receive statins, Shu-Fen Wung, Ph.D., and Heather Hiscox of the University of Arizona, Tucson, reported in a poster.

Also, women in this study lived significantly longer than men following their hospitalization (179 days vs. 156 days), with both age and gender showing a significant association with 6-month survival. The findings suggest that more people are following the guidelines of the American Heart Association and American College of Cardiology, and that progress is being made in the treatment of both men and women, Dr. Wung said.

ORLANDO, FLA. — Women presenting with myocardial infarction continue to receive less intensive treatment and have higher mortality than men with similar presentations, but the gender gap in medical interventions prescribed at hospital discharge may be narrowing, according to studies presented at an international conference on women, heart disease, and stroke.

One retrospective study included nearly 26,700 Swedish patients treated for ST-elevation MI (STEMI) at cardiac intensive care units during 1997-2001. Reperfusion therapy was administered to 71% of the 17,243 men in the study, compared with 62% of the 9,455 women in the study, Sofia Sederholm Lavesson, M.D., reported.

Men, compared with women, had lower in-hospital mortality (9% vs. 16%), 30-day mortality (11% vs. 18%), and 1-year mortality (16% vs. 25%), said Dr. Lavesson of Linköping (Sweden) University.

After adjusting for numerous confounding factors, women remained significantly less likely than men to receive reperfusion therapy (odds ratio 0.83) and to survive while in the hospital (OR 1.23), she said, noting that the differences between men and women cannot be fully explained by differences in age and comorbidities. “[Greater] age is the main explanation for the higher mortality in women, but less intensive treatment also appears to contribute,” she said.

A similar conclusion was reached in a study of more than 55,000 patients admitted to any of 153 different hospitals with a primary diagnosis of Q-wave acute MI from January 2000 through June 2004.

Mortality was 13% in the 19,034 women in the study, compared with 7% in the 35,969 men. After adjusting for 24 variables, including age, various comorbidities, and type of hospital providing the treatment (heart surgery hospital, cath lab hospital, and hospital with no heart surgery or cath lab), men were shown to be less likely than women to die (OR 0.71). Additionally, men were more likely than women to be transferred for further treatment (OR 1.24), receive thrombolytics (OR 1.16), receive percutaneous coronary intervention (OR 1.12), and/or receive coronary artery bypass grafting (OR 1.64), reported Allan L. Anderson, M.D., of the Medical City Dallas Hospital.

“Women with Q-wave acute MI continue to have significantly worse mortality rates and receive less revascularization than men,” he concluded, noting that additional research is needed to determine how women with MI can obtain clinical parity with men. But such parity is being achieved when it comes to the prescribing of medical interventions at hospital discharge in patients who present with heart attack or chest pain, a third study suggests.

That ongoing study showed such men and women are being prescribed appropriate drug interventions at the about the same frequency. The subanalysis of a National Institutes of Health-funded study of 177 men and 35 women with acute coronary syndrome showed that women were prescribed aspirin, β-blockers, and statins as frequently as men, however, it also showed that 10% of women with acute coronary syndrome didn't receive aspirin or β-blockers and that more than 30% didn't receive statins, Shu-Fen Wung, Ph.D., and Heather Hiscox of the University of Arizona, Tucson, reported in a poster.

Also, women in this study lived significantly longer than men following their hospitalization (179 days vs. 156 days), with both age and gender showing a significant association with 6-month survival. The findings suggest that more people are following the guidelines of the American Heart Association and American College of Cardiology, and that progress is being made in the treatment of both men and women, Dr. Wung said.

ORLANDO, FLA. — Women presenting with myocardial infarction continue to receive less intensive treatment and have higher mortality than men with similar presentations, but the gender gap in medical interventions prescribed at hospital discharge may be narrowing, according to studies presented at an international conference on women, heart disease, and stroke.

One retrospective study included nearly 26,700 Swedish patients treated for ST-elevation MI (STEMI) at cardiac intensive care units during 1997-2001. Reperfusion therapy was administered to 71% of the 17,243 men in the study, compared with 62% of the 9,455 women in the study, Sofia Sederholm Lavesson, M.D., reported.

Men, compared with women, had lower in-hospital mortality (9% vs. 16%), 30-day mortality (11% vs. 18%), and 1-year mortality (16% vs. 25%), said Dr. Lavesson of Linköping (Sweden) University.

After adjusting for numerous confounding factors, women remained significantly less likely than men to receive reperfusion therapy (odds ratio 0.83) and to survive while in the hospital (OR 1.23), she said, noting that the differences between men and women cannot be fully explained by differences in age and comorbidities. “[Greater] age is the main explanation for the higher mortality in women, but less intensive treatment also appears to contribute,” she said.

A similar conclusion was reached in a study of more than 55,000 patients admitted to any of 153 different hospitals with a primary diagnosis of Q-wave acute MI from January 2000 through June 2004.

Mortality was 13% in the 19,034 women in the study, compared with 7% in the 35,969 men. After adjusting for 24 variables, including age, various comorbidities, and type of hospital providing the treatment (heart surgery hospital, cath lab hospital, and hospital with no heart surgery or cath lab), men were shown to be less likely than women to die (OR 0.71). Additionally, men were more likely than women to be transferred for further treatment (OR 1.24), receive thrombolytics (OR 1.16), receive percutaneous coronary intervention (OR 1.12), and/or receive coronary artery bypass grafting (OR 1.64), reported Allan L. Anderson, M.D., of the Medical City Dallas Hospital.

“Women with Q-wave acute MI continue to have significantly worse mortality rates and receive less revascularization than men,” he concluded, noting that additional research is needed to determine how women with MI can obtain clinical parity with men. But such parity is being achieved when it comes to the prescribing of medical interventions at hospital discharge in patients who present with heart attack or chest pain, a third study suggests.

That ongoing study showed such men and women are being prescribed appropriate drug interventions at the about the same frequency. The subanalysis of a National Institutes of Health-funded study of 177 men and 35 women with acute coronary syndrome showed that women were prescribed aspirin, β-blockers, and statins as frequently as men, however, it also showed that 10% of women with acute coronary syndrome didn't receive aspirin or β-blockers and that more than 30% didn't receive statins, Shu-Fen Wung, Ph.D., and Heather Hiscox of the University of Arizona, Tucson, reported in a poster.

Also, women in this study lived significantly longer than men following their hospitalization (179 days vs. 156 days), with both age and gender showing a significant association with 6-month survival. The findings suggest that more people are following the guidelines of the American Heart Association and American College of Cardiology, and that progress is being made in the treatment of both men and women, Dr. Wung said.

ORLANDO, FLA. — Men with heart failure and/or bundle branch block appear to be preferentially treated more aggressively with implantable devices than are women with similar health status, a review of nearly 11,000 cases suggests.

The 10,931 patients, of whom 4,138 (38%) were women, were listed in an administrative database and represented consecutive admissions to any of numerous hospitals owned by Hospital Corporation of America.

All had a diagnosis of heart failure and/or bundle branch block and underwent a primary procedure of pacemaker, cardiac resynchronization therapy pacemaker (CRT-P), implantable cardioverter defibrillator (ICD), or cardiac resynchronization therapy defibrillator (CRT-D) implantation, Robert Fishel, M.D., reported at an international conference on women, heart disease, and stroke.

Women received 52% of the pacemakers, 33% of the CRT-Ps, 22% of the ICDs, and 21% of the CRT-Ds implanted, said Dr. Fishel of the J.F.K. Medical Center, Atlantis, Fla. Logistic regression analysis showed that men were significantly less likely than women to receive a pacemaker (odds ratio 0.35) and more likely to receive an ICD (odds ratio 1.34) or CRT-D (odds ratio 1.48).

There was no significant difference in device utilization of CRP-Ps between sexes.

After controlling for device, diagnoses, age, and comorbidities, there were no significant differences between men and women in measured clinical outcomes, including mortality, postoperative stroke, postoperative infection, or ICD or pacemaker mechanical malfunction.

Further research is needed to determine if the differences in device use among men and women have any long-term effects on outcomes in women, Dr. Fishel said.

ORLANDO, FLA. — Men with heart failure and/or bundle branch block appear to be preferentially treated more aggressively with implantable devices than are women with similar health status, a review of nearly 11,000 cases suggests.

The 10,931 patients, of whom 4,138 (38%) were women, were listed in an administrative database and represented consecutive admissions to any of numerous hospitals owned by Hospital Corporation of America.

All had a diagnosis of heart failure and/or bundle branch block and underwent a primary procedure of pacemaker, cardiac resynchronization therapy pacemaker (CRT-P), implantable cardioverter defibrillator (ICD), or cardiac resynchronization therapy defibrillator (CRT-D) implantation, Robert Fishel, M.D., reported at an international conference on women, heart disease, and stroke.

Women received 52% of the pacemakers, 33% of the CRT-Ps, 22% of the ICDs, and 21% of the CRT-Ds implanted, said Dr. Fishel of the J.F.K. Medical Center, Atlantis, Fla. Logistic regression analysis showed that men were significantly less likely than women to receive a pacemaker (odds ratio 0.35) and more likely to receive an ICD (odds ratio 1.34) or CRT-D (odds ratio 1.48).

There was no significant difference in device utilization of CRP-Ps between sexes.

After controlling for device, diagnoses, age, and comorbidities, there were no significant differences between men and women in measured clinical outcomes, including mortality, postoperative stroke, postoperative infection, or ICD or pacemaker mechanical malfunction.

Further research is needed to determine if the differences in device use among men and women have any long-term effects on outcomes in women, Dr. Fishel said.

ORLANDO, FLA. — Men with heart failure and/or bundle branch block appear to be preferentially treated more aggressively with implantable devices than are women with similar health status, a review of nearly 11,000 cases suggests.

The 10,931 patients, of whom 4,138 (38%) were women, were listed in an administrative database and represented consecutive admissions to any of numerous hospitals owned by Hospital Corporation of America.

All had a diagnosis of heart failure and/or bundle branch block and underwent a primary procedure of pacemaker, cardiac resynchronization therapy pacemaker (CRT-P), implantable cardioverter defibrillator (ICD), or cardiac resynchronization therapy defibrillator (CRT-D) implantation, Robert Fishel, M.D., reported at an international conference on women, heart disease, and stroke.

Women received 52% of the pacemakers, 33% of the CRT-Ps, 22% of the ICDs, and 21% of the CRT-Ds implanted, said Dr. Fishel of the J.F.K. Medical Center, Atlantis, Fla. Logistic regression analysis showed that men were significantly less likely than women to receive a pacemaker (odds ratio 0.35) and more likely to receive an ICD (odds ratio 1.34) or CRT-D (odds ratio 1.48).

There was no significant difference in device utilization of CRP-Ps between sexes.

After controlling for device, diagnoses, age, and comorbidities, there were no significant differences between men and women in measured clinical outcomes, including mortality, postoperative stroke, postoperative infection, or ICD or pacemaker mechanical malfunction.

Further research is needed to determine if the differences in device use among men and women have any long-term effects on outcomes in women, Dr. Fishel said.

FORT LAUDERDALE, FLA. — Burch colposuspension isn't the newest or fanciest of the ever-expanding surgical options for treating urinary stress incontinence, but it does have a solid place in the surgical armamentarium for this condition, Matthew Barber, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

“In my opinion, Burch colposuspension is the standard by which all other surgeries for genuine stress incontinence should be compared,” said Dr. Barber of the Cleveland Clinic.

Numerous studies over the past decade have upheld the efficacy and safety of this procedure, he noted.

Systematic reviews of the literature in 1996 and 1997, for example, showed that colposuspension is more effective and long lasting than anterior repair or needle suspensions, and is as effective as sling procedures. And a 2001 study of 124 patients with 10- to 15-year follow-up showed a 94% long-term cure rate.

When compared with the traditional bladder neck sling and the use of tension free vaginal tape (TVT), the Burch procedure also compared favorably. In four randomized controlled trials, there was no difference in efficacy between the bladder neck sling and the Burch procedure, although in observational studies, a slightly higher rate of voiding dysfunction was seen with the Burch procedure.

In the largest randomized trial comparing open Burch with TVT, there were no differences in cure rates among 344 patients. Bladder injury was more common with TVT, but voiding and recovery times were longer with Burch, Dr. Barber said.

Disadvantages of the open Burch procedure are the abdominal incision, and—according to at least one study—lower efficacy in patients with intrinsic sphincter deficiency, he said.

The procedure also can be performed laparoscopically, but short-term data suggest this approach is less effective. The outcomes are likely skill dependent, but long-term comparisons are not yet available.

And compared with TVT, the laparoscopic Burch procedure appears to take longer and may not be as effective, at least one study suggests.

Still, the procedure is useful, Dr. Barber said.

“It works, and you shouldn't be ashamed of it,” he added.

The Burch procedure is particularly useful when combined with other laparoscopic or open repairs such as bilateral tubal ligation, hysterectomy, and sacral colpopexy, as well as in younger women who wish to maintain fertility, in women with a history of mesh complications or allergies, and in women who wish to avoid foreign materials, Dr. Barber said.

FORT LAUDERDALE, FLA. — Burch colposuspension isn't the newest or fanciest of the ever-expanding surgical options for treating urinary stress incontinence, but it does have a solid place in the surgical armamentarium for this condition, Matthew Barber, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

“In my opinion, Burch colposuspension is the standard by which all other surgeries for genuine stress incontinence should be compared,” said Dr. Barber of the Cleveland Clinic.

Numerous studies over the past decade have upheld the efficacy and safety of this procedure, he noted.

Systematic reviews of the literature in 1996 and 1997, for example, showed that colposuspension is more effective and long lasting than anterior repair or needle suspensions, and is as effective as sling procedures. And a 2001 study of 124 patients with 10- to 15-year follow-up showed a 94% long-term cure rate.

When compared with the traditional bladder neck sling and the use of tension free vaginal tape (TVT), the Burch procedure also compared favorably. In four randomized controlled trials, there was no difference in efficacy between the bladder neck sling and the Burch procedure, although in observational studies, a slightly higher rate of voiding dysfunction was seen with the Burch procedure.

In the largest randomized trial comparing open Burch with TVT, there were no differences in cure rates among 344 patients. Bladder injury was more common with TVT, but voiding and recovery times were longer with Burch, Dr. Barber said.

Disadvantages of the open Burch procedure are the abdominal incision, and—according to at least one study—lower efficacy in patients with intrinsic sphincter deficiency, he said.

The procedure also can be performed laparoscopically, but short-term data suggest this approach is less effective. The outcomes are likely skill dependent, but long-term comparisons are not yet available.

And compared with TVT, the laparoscopic Burch procedure appears to take longer and may not be as effective, at least one study suggests.

Still, the procedure is useful, Dr. Barber said.

“It works, and you shouldn't be ashamed of it,” he added.

The Burch procedure is particularly useful when combined with other laparoscopic or open repairs such as bilateral tubal ligation, hysterectomy, and sacral colpopexy, as well as in younger women who wish to maintain fertility, in women with a history of mesh complications or allergies, and in women who wish to avoid foreign materials, Dr. Barber said.

FORT LAUDERDALE, FLA. — Burch colposuspension isn't the newest or fanciest of the ever-expanding surgical options for treating urinary stress incontinence, but it does have a solid place in the surgical armamentarium for this condition, Matthew Barber, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

“In my opinion, Burch colposuspension is the standard by which all other surgeries for genuine stress incontinence should be compared,” said Dr. Barber of the Cleveland Clinic.

Numerous studies over the past decade have upheld the efficacy and safety of this procedure, he noted.

Systematic reviews of the literature in 1996 and 1997, for example, showed that colposuspension is more effective and long lasting than anterior repair or needle suspensions, and is as effective as sling procedures. And a 2001 study of 124 patients with 10- to 15-year follow-up showed a 94% long-term cure rate.

When compared with the traditional bladder neck sling and the use of tension free vaginal tape (TVT), the Burch procedure also compared favorably. In four randomized controlled trials, there was no difference in efficacy between the bladder neck sling and the Burch procedure, although in observational studies, a slightly higher rate of voiding dysfunction was seen with the Burch procedure.

In the largest randomized trial comparing open Burch with TVT, there were no differences in cure rates among 344 patients. Bladder injury was more common with TVT, but voiding and recovery times were longer with Burch, Dr. Barber said.

Disadvantages of the open Burch procedure are the abdominal incision, and—according to at least one study—lower efficacy in patients with intrinsic sphincter deficiency, he said.

The procedure also can be performed laparoscopically, but short-term data suggest this approach is less effective. The outcomes are likely skill dependent, but long-term comparisons are not yet available.

And compared with TVT, the laparoscopic Burch procedure appears to take longer and may not be as effective, at least one study suggests.

Still, the procedure is useful, Dr. Barber said.

“It works, and you shouldn't be ashamed of it,” he added.

The Burch procedure is particularly useful when combined with other laparoscopic or open repairs such as bilateral tubal ligation, hysterectomy, and sacral colpopexy, as well as in younger women who wish to maintain fertility, in women with a history of mesh complications or allergies, and in women who wish to avoid foreign materials, Dr. Barber said.

FORT LAUDERDALE, FLA. — Anterior overlapping sphincter repair is commonly performed in patients with fecal incontinence secondary to an anterior defect in the sphincter complex, but long-term outcomes are questionable.

In the short term, 50%-75% of patients achieve good control of solid and liquid bowel movements. But the limited data available on long-term outcomes are less promising, Eric G. Weiss, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

Few of the patients requiring such surgery—usually as a result of obstetric or iatrogenic trauma—have good long-term function, said Dr. Weiss of Cleveland Clinic Florida, Weston.

In one study of 42 patients who underwent the surgery, half were continent after the surgery, and only 14% were continent at a 6-year follow-up. In another study of 191 patients, 40% had some continence, but only 6% had complete continence at 10-year follow-up.

One factor that has emerged as a predictor of poor surgical outcome is the presence of neuropathy, he noted.

In patients who don't do well following surgery, consider whether the repair was successful from an anatomic standpoint, he advised.

Ultrasound can help determine whether the sphincter repair is intact or if there is a persistent defect. A second attempt at surgical repair may be warranted in cases of persistent defect, but if the initial repair is intact, an alternative procedure should be considered, Dr. Weiss said.

Among the other surgical options available or under investigation are the following:

▸ The artificial anal sphincter. A recent report on the North American experience with the artificial sphincter showed that nearly half of 112 patients required surgical revision of the device, and 37% had the device explanted (with successful reimplantation in 7 patients). Of those with a functioning sphincter at study completion, all had significant improvement in fecal incontinence and quality-of-life scores; the success rate in these patients was 85%, but the intention-to-treat success rate was only 53%.

“When it works, it works well, but it takes a lot to get it to work well,” Dr. Weiss said.

▸ Sacral nerve stimulation. This procedure, involving implantation of a device that stimulates nerves originating from the sacral nerve foramen, was originally used to treat urinary incontinence but also has proved useful for concomitant fecal incontinence. Preliminary results of ongoing trials of its use for fecal incontinence look promising, with 40%-75% of patients achieving continence.

▸ The Durasphere procedure. Microscopic carbon-coated beads are injected into the anal canal and lower rectum as part of this experimental minimally invasive office procedure, thought to improve internal sphincter function by increasing tissue bulk. Results of small phase II studies are promising, with patients experiencing significant decreases in fecal incontinence and quality-of-life scores.

Durasphere EXP Injectable Bulking Agent is approved for the treatment of stress urinary incontinence due to intrinsic sphincter deficiency in women.

▸ Secca. The Secca System is an FDA-approved device that uses radiofrequency energy to deliver scarring to the anal canal to treat fecal incontinence by changing tissue tone. In a prospective multicenter study involving 47 patients, modest but significant improvements in fecal incontinence scores (from 14 to 11 on a 0-20 scale) were seen at 6 months, with a further decrease to about a score of 9 at long-term follow-up.

▸ Stoma. A patient who fails all other options may be a candidate for a stoma. This may seem like a terrible option, but properly counseled patients may handle a stoma very well and consider this approach preferable to wearing diapers.

“We try to avoid it, but … there are patients who really do benefit from having a stoma,” Dr. Weiss said.

FORT LAUDERDALE, FLA. — Anterior overlapping sphincter repair is commonly performed in patients with fecal incontinence secondary to an anterior defect in the sphincter complex, but long-term outcomes are questionable.

In the short term, 50%-75% of patients achieve good control of solid and liquid bowel movements. But the limited data available on long-term outcomes are less promising, Eric G. Weiss, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

Few of the patients requiring such surgery—usually as a result of obstetric or iatrogenic trauma—have good long-term function, said Dr. Weiss of Cleveland Clinic Florida, Weston.

In one study of 42 patients who underwent the surgery, half were continent after the surgery, and only 14% were continent at a 6-year follow-up. In another study of 191 patients, 40% had some continence, but only 6% had complete continence at 10-year follow-up.

One factor that has emerged as a predictor of poor surgical outcome is the presence of neuropathy, he noted.

In patients who don't do well following surgery, consider whether the repair was successful from an anatomic standpoint, he advised.

Ultrasound can help determine whether the sphincter repair is intact or if there is a persistent defect. A second attempt at surgical repair may be warranted in cases of persistent defect, but if the initial repair is intact, an alternative procedure should be considered, Dr. Weiss said.

Among the other surgical options available or under investigation are the following:

▸ The artificial anal sphincter. A recent report on the North American experience with the artificial sphincter showed that nearly half of 112 patients required surgical revision of the device, and 37% had the device explanted (with successful reimplantation in 7 patients). Of those with a functioning sphincter at study completion, all had significant improvement in fecal incontinence and quality-of-life scores; the success rate in these patients was 85%, but the intention-to-treat success rate was only 53%.

“When it works, it works well, but it takes a lot to get it to work well,” Dr. Weiss said.

▸ Sacral nerve stimulation. This procedure, involving implantation of a device that stimulates nerves originating from the sacral nerve foramen, was originally used to treat urinary incontinence but also has proved useful for concomitant fecal incontinence. Preliminary results of ongoing trials of its use for fecal incontinence look promising, with 40%-75% of patients achieving continence.

▸ The Durasphere procedure. Microscopic carbon-coated beads are injected into the anal canal and lower rectum as part of this experimental minimally invasive office procedure, thought to improve internal sphincter function by increasing tissue bulk. Results of small phase II studies are promising, with patients experiencing significant decreases in fecal incontinence and quality-of-life scores.

Durasphere EXP Injectable Bulking Agent is approved for the treatment of stress urinary incontinence due to intrinsic sphincter deficiency in women.

▸ Secca. The Secca System is an FDA-approved device that uses radiofrequency energy to deliver scarring to the anal canal to treat fecal incontinence by changing tissue tone. In a prospective multicenter study involving 47 patients, modest but significant improvements in fecal incontinence scores (from 14 to 11 on a 0-20 scale) were seen at 6 months, with a further decrease to about a score of 9 at long-term follow-up.

▸ Stoma. A patient who fails all other options may be a candidate for a stoma. This may seem like a terrible option, but properly counseled patients may handle a stoma very well and consider this approach preferable to wearing diapers.

“We try to avoid it, but … there are patients who really do benefit from having a stoma,” Dr. Weiss said.

FORT LAUDERDALE, FLA. — Anterior overlapping sphincter repair is commonly performed in patients with fecal incontinence secondary to an anterior defect in the sphincter complex, but long-term outcomes are questionable.

In the short term, 50%-75% of patients achieve good control of solid and liquid bowel movements. But the limited data available on long-term outcomes are less promising, Eric G. Weiss, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

Few of the patients requiring such surgery—usually as a result of obstetric or iatrogenic trauma—have good long-term function, said Dr. Weiss of Cleveland Clinic Florida, Weston.

In one study of 42 patients who underwent the surgery, half were continent after the surgery, and only 14% were continent at a 6-year follow-up. In another study of 191 patients, 40% had some continence, but only 6% had complete continence at 10-year follow-up.

One factor that has emerged as a predictor of poor surgical outcome is the presence of neuropathy, he noted.

In patients who don't do well following surgery, consider whether the repair was successful from an anatomic standpoint, he advised.

Ultrasound can help determine whether the sphincter repair is intact or if there is a persistent defect. A second attempt at surgical repair may be warranted in cases of persistent defect, but if the initial repair is intact, an alternative procedure should be considered, Dr. Weiss said.

Among the other surgical options available or under investigation are the following:

▸ The artificial anal sphincter. A recent report on the North American experience with the artificial sphincter showed that nearly half of 112 patients required surgical revision of the device, and 37% had the device explanted (with successful reimplantation in 7 patients). Of those with a functioning sphincter at study completion, all had significant improvement in fecal incontinence and quality-of-life scores; the success rate in these patients was 85%, but the intention-to-treat success rate was only 53%.

“When it works, it works well, but it takes a lot to get it to work well,” Dr. Weiss said.

▸ Sacral nerve stimulation. This procedure, involving implantation of a device that stimulates nerves originating from the sacral nerve foramen, was originally used to treat urinary incontinence but also has proved useful for concomitant fecal incontinence. Preliminary results of ongoing trials of its use for fecal incontinence look promising, with 40%-75% of patients achieving continence.

▸ The Durasphere procedure. Microscopic carbon-coated beads are injected into the anal canal and lower rectum as part of this experimental minimally invasive office procedure, thought to improve internal sphincter function by increasing tissue bulk. Results of small phase II studies are promising, with patients experiencing significant decreases in fecal incontinence and quality-of-life scores.

Durasphere EXP Injectable Bulking Agent is approved for the treatment of stress urinary incontinence due to intrinsic sphincter deficiency in women.

▸ Secca. The Secca System is an FDA-approved device that uses radiofrequency energy to deliver scarring to the anal canal to treat fecal incontinence by changing tissue tone. In a prospective multicenter study involving 47 patients, modest but significant improvements in fecal incontinence scores (from 14 to 11 on a 0-20 scale) were seen at 6 months, with a further decrease to about a score of 9 at long-term follow-up.

▸ Stoma. A patient who fails all other options may be a candidate for a stoma. This may seem like a terrible option, but properly counseled patients may handle a stoma very well and consider this approach preferable to wearing diapers.

“We try to avoid it, but … there are patients who really do benefit from having a stoma,” Dr. Weiss said.

FORT LAUDERDALE, FLA. — Constipation is a common complaint, and the causes for this condition are varied, Dana R. Sands, M.D., said during a symposium on pelvic floor disorders that was sponsored by the Cleveland Clinic Florida.

In a survey of more than 10,000 people, nearly 14% reported difficulty with evacuation, including infrequent defecation, incomplete defecation, and blockage of bowel movement.

“A surprising 12% said they need to use digital maneuvers in order to defecate—that's a high number,” said Dr. Sands of the Cleveland Clinic Florida, Weston.

Among the causes of constipation are paradoxical puborectalis contraction, rectocele, and pelvic floor failure, including rectal prolapse and rectoanal intussusception, but sometimes the cause can be as simple as a lack of fiber and water in the diet, she said.

Those who haven't tried fiber supplements and increased water intake will often find their constipation is “miraculously” cured simply by trying these two things, she noted during the meeting.

But a thorough history and physical examination are important in all patients, and every complaint of bleeding and obstruction should be investigated, she said. She also recommended that some form of endoscopic evaluation be performed in patients with such complaints.

“It's our job to make sure rectal bleeding really is from hemorrhoids, and that constipation really is constipation,” and that obstructing cancer is not the cause in either case, Dr. Sands commented, adding that she performs colonoscopy on all patients reporting changes in bowel habits.

Defecography, surface EMG, anal manometry, and colonic transit studies also may be useful. She said she also orders a cursory panel of blood work including measurement of thyroid-stimulating hormone, to look for obvious and easily correctable metabolic processes that could be causing constipation.

Most patients will be diagnosed on the basis of TSH, defecography, and/or surface EMG findings, she said.

Regardless of whether constipation is caused by dietary or metabolic conditions or by a benign condition that could be treated surgically, medical management options should be exhausted first.

For significant outlet obstruction caused by paradoxical contraction, for example, biofeedback and/or botulinum toxin (Botox) injections may be helpful. Biofeedback has had varying success, with studies showing success rates from 8% to 100%.

In a Cleveland Clinic study of 194 patients who used biofeedback, 68 (35%) had complete resolution of symptoms, 27 (14%) had partial resolution, and 99 (51%) had no improvement. However, when patients were analyzed separately according to whether they completed all 10 biofeedback sessions, those who did complete all sessions had a success rate of 63%, compared with 25% in those who did not.

Motivated patients are going to have better success, Dr. Sands said.

Also, remember that a “refresher course” in biofeedback may be needed. In another study of 36 patients whose initial results following biofeedback were excellent, 19 of 22 (86%) who were treated nearly 3 years earlier had a return of symptoms; 11 of 14 patients (79%) treated a year before noticed a return of symptoms.

“This is a good indication to at least reevaluate if not to re-treat patients after 1 year,” she said.

As for use of botulinum toxin, a small series involving four patients injected with 30 U of Botox showed good results.

One patient required reinjection, but none experienced incontinence. In another series involving 17 Cleveland Clinic patients injected with an average of 50 U of Botox, 11 (64%) had improvements in symptoms, and only 1 had transient fecal incontinence.

For patients with a rectocele, it is best to base therapy on the functional, rather than the anatomical, problem, according to Dr. Sands.

Try medical management, but consider surgery in those patients with rectoceles greater than 4 cm who fail to respond and in those who must use rectal or vaginal digitation or perineal support maneuvers to defecate.

Rectoanal intussusception is more difficult to treat. Start with dietary modification and fiber supplementation. Then try biofeedback, but don't expect too much, she said, noting that outcomes were somewhat disappointing in a recent study of 36 patients treated with dietary therapy, biofeedback, or surgery.

Of 13 patients receiving dietary therapy, 5 improved, 6 had no change, and 2 worsened. Of 13 in the biofeedback group, 11 improved or had no change, and 2 worsened. Of 10 who underwent surgery, 6 improved, 1 had no change, and 3 worsened.

And when it comes to rectal prolapse, it is important to evaluate for associated anterior compartment prolapse and to consider combined surgical correction when warranted.

In the most severe cases of constipation, including those with severe outlet obstruction, colostomy may be necessary, although it should be a last resort. If you do perform a colostomy in these patients, consider it permanent, Dr. Sands said.

Some colostomy patients will decide after several years that the precolostomy symptoms weren't so bad and will have their colostomy closed (usually by a different surgeon), but most eventually return, seeking to have the colostomy reopened because of intolerable symptoms, she explained.

FORT LAUDERDALE, FLA. — Constipation is a common complaint, and the causes for this condition are varied, Dana R. Sands, M.D., said during a symposium on pelvic floor disorders that was sponsored by the Cleveland Clinic Florida.

In a survey of more than 10,000 people, nearly 14% reported difficulty with evacuation, including infrequent defecation, incomplete defecation, and blockage of bowel movement.

“A surprising 12% said they need to use digital maneuvers in order to defecate—that's a high number,” said Dr. Sands of the Cleveland Clinic Florida, Weston.

Among the causes of constipation are paradoxical puborectalis contraction, rectocele, and pelvic floor failure, including rectal prolapse and rectoanal intussusception, but sometimes the cause can be as simple as a lack of fiber and water in the diet, she said.

Those who haven't tried fiber supplements and increased water intake will often find their constipation is “miraculously” cured simply by trying these two things, she noted during the meeting.

But a thorough history and physical examination are important in all patients, and every complaint of bleeding and obstruction should be investigated, she said. She also recommended that some form of endoscopic evaluation be performed in patients with such complaints.

“It's our job to make sure rectal bleeding really is from hemorrhoids, and that constipation really is constipation,” and that obstructing cancer is not the cause in either case, Dr. Sands commented, adding that she performs colonoscopy on all patients reporting changes in bowel habits.

Defecography, surface EMG, anal manometry, and colonic transit studies also may be useful. She said she also orders a cursory panel of blood work including measurement of thyroid-stimulating hormone, to look for obvious and easily correctable metabolic processes that could be causing constipation.

Most patients will be diagnosed on the basis of TSH, defecography, and/or surface EMG findings, she said.

Regardless of whether constipation is caused by dietary or metabolic conditions or by a benign condition that could be treated surgically, medical management options should be exhausted first.

For significant outlet obstruction caused by paradoxical contraction, for example, biofeedback and/or botulinum toxin (Botox) injections may be helpful. Biofeedback has had varying success, with studies showing success rates from 8% to 100%.

In a Cleveland Clinic study of 194 patients who used biofeedback, 68 (35%) had complete resolution of symptoms, 27 (14%) had partial resolution, and 99 (51%) had no improvement. However, when patients were analyzed separately according to whether they completed all 10 biofeedback sessions, those who did complete all sessions had a success rate of 63%, compared with 25% in those who did not.

Motivated patients are going to have better success, Dr. Sands said.

Also, remember that a “refresher course” in biofeedback may be needed. In another study of 36 patients whose initial results following biofeedback were excellent, 19 of 22 (86%) who were treated nearly 3 years earlier had a return of symptoms; 11 of 14 patients (79%) treated a year before noticed a return of symptoms.

“This is a good indication to at least reevaluate if not to re-treat patients after 1 year,” she said.

As for use of botulinum toxin, a small series involving four patients injected with 30 U of Botox showed good results.

One patient required reinjection, but none experienced incontinence. In another series involving 17 Cleveland Clinic patients injected with an average of 50 U of Botox, 11 (64%) had improvements in symptoms, and only 1 had transient fecal incontinence.

For patients with a rectocele, it is best to base therapy on the functional, rather than the anatomical, problem, according to Dr. Sands.

Try medical management, but consider surgery in those patients with rectoceles greater than 4 cm who fail to respond and in those who must use rectal or vaginal digitation or perineal support maneuvers to defecate.

Rectoanal intussusception is more difficult to treat. Start with dietary modification and fiber supplementation. Then try biofeedback, but don't expect too much, she said, noting that outcomes were somewhat disappointing in a recent study of 36 patients treated with dietary therapy, biofeedback, or surgery.

Of 13 patients receiving dietary therapy, 5 improved, 6 had no change, and 2 worsened. Of 13 in the biofeedback group, 11 improved or had no change, and 2 worsened. Of 10 who underwent surgery, 6 improved, 1 had no change, and 3 worsened.

And when it comes to rectal prolapse, it is important to evaluate for associated anterior compartment prolapse and to consider combined surgical correction when warranted.

In the most severe cases of constipation, including those with severe outlet obstruction, colostomy may be necessary, although it should be a last resort. If you do perform a colostomy in these patients, consider it permanent, Dr. Sands said.

Some colostomy patients will decide after several years that the precolostomy symptoms weren't so bad and will have their colostomy closed (usually by a different surgeon), but most eventually return, seeking to have the colostomy reopened because of intolerable symptoms, she explained.

FORT LAUDERDALE, FLA. — Constipation is a common complaint, and the causes for this condition are varied, Dana R. Sands, M.D., said during a symposium on pelvic floor disorders that was sponsored by the Cleveland Clinic Florida.

In a survey of more than 10,000 people, nearly 14% reported difficulty with evacuation, including infrequent defecation, incomplete defecation, and blockage of bowel movement.

“A surprising 12% said they need to use digital maneuvers in order to defecate—that's a high number,” said Dr. Sands of the Cleveland Clinic Florida, Weston.

Among the causes of constipation are paradoxical puborectalis contraction, rectocele, and pelvic floor failure, including rectal prolapse and rectoanal intussusception, but sometimes the cause can be as simple as a lack of fiber and water in the diet, she said.

Those who haven't tried fiber supplements and increased water intake will often find their constipation is “miraculously” cured simply by trying these two things, she noted during the meeting.

But a thorough history and physical examination are important in all patients, and every complaint of bleeding and obstruction should be investigated, she said. She also recommended that some form of endoscopic evaluation be performed in patients with such complaints.

“It's our job to make sure rectal bleeding really is from hemorrhoids, and that constipation really is constipation,” and that obstructing cancer is not the cause in either case, Dr. Sands commented, adding that she performs colonoscopy on all patients reporting changes in bowel habits.

Defecography, surface EMG, anal manometry, and colonic transit studies also may be useful. She said she also orders a cursory panel of blood work including measurement of thyroid-stimulating hormone, to look for obvious and easily correctable metabolic processes that could be causing constipation.

Most patients will be diagnosed on the basis of TSH, defecography, and/or surface EMG findings, she said.

Regardless of whether constipation is caused by dietary or metabolic conditions or by a benign condition that could be treated surgically, medical management options should be exhausted first.

For significant outlet obstruction caused by paradoxical contraction, for example, biofeedback and/or botulinum toxin (Botox) injections may be helpful. Biofeedback has had varying success, with studies showing success rates from 8% to 100%.

In a Cleveland Clinic study of 194 patients who used biofeedback, 68 (35%) had complete resolution of symptoms, 27 (14%) had partial resolution, and 99 (51%) had no improvement. However, when patients were analyzed separately according to whether they completed all 10 biofeedback sessions, those who did complete all sessions had a success rate of 63%, compared with 25% in those who did not.

Motivated patients are going to have better success, Dr. Sands said.

Also, remember that a “refresher course” in biofeedback may be needed. In another study of 36 patients whose initial results following biofeedback were excellent, 19 of 22 (86%) who were treated nearly 3 years earlier had a return of symptoms; 11 of 14 patients (79%) treated a year before noticed a return of symptoms.

“This is a good indication to at least reevaluate if not to re-treat patients after 1 year,” she said.

As for use of botulinum toxin, a small series involving four patients injected with 30 U of Botox showed good results.

One patient required reinjection, but none experienced incontinence. In another series involving 17 Cleveland Clinic patients injected with an average of 50 U of Botox, 11 (64%) had improvements in symptoms, and only 1 had transient fecal incontinence.

For patients with a rectocele, it is best to base therapy on the functional, rather than the anatomical, problem, according to Dr. Sands.

Try medical management, but consider surgery in those patients with rectoceles greater than 4 cm who fail to respond and in those who must use rectal or vaginal digitation or perineal support maneuvers to defecate.

Rectoanal intussusception is more difficult to treat. Start with dietary modification and fiber supplementation. Then try biofeedback, but don't expect too much, she said, noting that outcomes were somewhat disappointing in a recent study of 36 patients treated with dietary therapy, biofeedback, or surgery.

Of 13 patients receiving dietary therapy, 5 improved, 6 had no change, and 2 worsened. Of 13 in the biofeedback group, 11 improved or had no change, and 2 worsened. Of 10 who underwent surgery, 6 improved, 1 had no change, and 3 worsened.

And when it comes to rectal prolapse, it is important to evaluate for associated anterior compartment prolapse and to consider combined surgical correction when warranted.

In the most severe cases of constipation, including those with severe outlet obstruction, colostomy may be necessary, although it should be a last resort. If you do perform a colostomy in these patients, consider it permanent, Dr. Sands said.

Some colostomy patients will decide after several years that the precolostomy symptoms weren't so bad and will have their colostomy closed (usually by a different surgeon), but most eventually return, seeking to have the colostomy reopened because of intolerable symptoms, she explained.

FORT LAUDERDALE, FLA. — Obstetric trauma is the most common cause of rectovaginal fistulas, Eric G. Weiss, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

Reported series suggest such trauma accounts for 50%-90% of fistulas, said Dr. Weiss, director of surgical endoscopy and a staff colorectal surgeon at Cleveland Clinic Florida, Weston.

“We don't really have a good way to prevent these—it's just one of those things that can happen after delivery,” he said, noting that such fistulas occur in fewer than 1% of vaginal deliveries.

But for such tiny holes—sometimes the size of a pinhole—these defects can lead to extensive symptoms, and can be very difficult to repair.

Rectovaginal fistulas associated with obstetric trauma usually are the result of unrecognized third- or fourth-degree perineal tears or repairs that break down as a result of infection or hematoma. Other causes include inflammatory bowel disease, infection, and other types of trauma, such as pelvic radiation therapy, Dr. Weiss noted.

A number of treatment options exist, but for simple fistulas—or those that are less than 2.5 cm in diameter, distal, surrounded by otherwise healthy tissue, and caused by trauma or infection—Dr. Weiss' treatment of choice is the transanal endorectal advancement flap.

Reported success rates for this type of advancement flap range from 41% to 100%, and the variation may be explained by differences in the way results are reported. For example, some studies include patients who also underwent sphincteroplasty, which would most likely improve results.

Patients with fistulas associated with obstetric trauma are more likely than other patients to also require sphincteroplasty. In his experience, success rates are generally in the range of 60%-65%, with higher success rates of up to 91% reported in those with an intact sphincter.

Other transanal surgical options include layered closure and the anocutaneous advancement flap, and transvaginal options include fistula inversion and vaginal flap advancement. Reported success rates for these approaches range from 72% to 100%, but findings are based mainly on very small case series.

Surgical failure is usually attributable to infection or hematoma. Prompt drainage and antibiotic therapy for infections may salvage the repair. When necessary, surgical correction can be reattempted, but success rates decline with each successive attempt, Dr. Weiss said.

Repeat surgery should be delayed until inflammation has resolved and the wounds have healed; patients with activity-limiting symptoms may require temporary diversion during this time.

One option for the repair of recurrent rectovaginal fistulas includes perineoproctotomy, which involves re-creation and repair (by closure in layers) of a third- or fourth-degree tear. Success rates are in the 88% to 100% range, and although a downside of this surgery is division of the sphincter muscle, there are no reports of postoperative incontinence in the literature, he noted.

Sphincteroplasty is the best option for those with sphincter injury. Success rates with this procedure also range from 88% to 100%.

Tissue interposition using the Martius procedure (bulbocavernosus interposition) and graciloplasty are other surgical options with reasonable success rates, he noted.

Complex fistulas—or those that are larger than 2.5 cm in diameter and caused by inflammatory bowel disease, malignancy, or radiation—are more difficult to treat, in part because patients often have complicating medical problems.

For high rectovaginal fistulas, transabdominal division of the fistula with resection and primary anastomosis is recommended. An alternative in patients with a normal rectum is division of the fistula and interposition of omentum or muscle.

Temporary diversion may be necessary in patients with a failed transabdominal surgery. If the fistula does not close spontaneously during diversion, repeat resection or interposition of the omentum is recommended, but few data are available to guide decision making regarding surgery in these patients, he said.

For radiation-induced complex fistulas, temporary diversion is usually performed first. Repair is appropriate when the patient is otherwise healthy and has no evidence of recurrent cancer. One option is coloanal anastomosis to bring in healthy tissue to replace the tissue devascularized as a result of the radiation. Other options are the Bricker on-lay patch and muscle interposition.

A number of surgeries, including transvaginal repairs, endorectal advancement flaps, and muscle interposition and resection, have been described in patients with Crohn's disease. Initial failure requires endoscopic evaluation. If proctitis is present, medical treatment or proctectomy are recommended, but if the rectum is not inflamed, a repeat repair may be successful, Dr. Weiss said.

FORT LAUDERDALE, FLA. — Obstetric trauma is the most common cause of rectovaginal fistulas, Eric G. Weiss, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

Reported series suggest such trauma accounts for 50%-90% of fistulas, said Dr. Weiss, director of surgical endoscopy and a staff colorectal surgeon at Cleveland Clinic Florida, Weston.

“We don't really have a good way to prevent these—it's just one of those things that can happen after delivery,” he said, noting that such fistulas occur in fewer than 1% of vaginal deliveries.

But for such tiny holes—sometimes the size of a pinhole—these defects can lead to extensive symptoms, and can be very difficult to repair.

Rectovaginal fistulas associated with obstetric trauma usually are the result of unrecognized third- or fourth-degree perineal tears or repairs that break down as a result of infection or hematoma. Other causes include inflammatory bowel disease, infection, and other types of trauma, such as pelvic radiation therapy, Dr. Weiss noted.

A number of treatment options exist, but for simple fistulas—or those that are less than 2.5 cm in diameter, distal, surrounded by otherwise healthy tissue, and caused by trauma or infection—Dr. Weiss' treatment of choice is the transanal endorectal advancement flap.

Reported success rates for this type of advancement flap range from 41% to 100%, and the variation may be explained by differences in the way results are reported. For example, some studies include patients who also underwent sphincteroplasty, which would most likely improve results.

Patients with fistulas associated with obstetric trauma are more likely than other patients to also require sphincteroplasty. In his experience, success rates are generally in the range of 60%-65%, with higher success rates of up to 91% reported in those with an intact sphincter.

Other transanal surgical options include layered closure and the anocutaneous advancement flap, and transvaginal options include fistula inversion and vaginal flap advancement. Reported success rates for these approaches range from 72% to 100%, but findings are based mainly on very small case series.

Surgical failure is usually attributable to infection or hematoma. Prompt drainage and antibiotic therapy for infections may salvage the repair. When necessary, surgical correction can be reattempted, but success rates decline with each successive attempt, Dr. Weiss said.

Repeat surgery should be delayed until inflammation has resolved and the wounds have healed; patients with activity-limiting symptoms may require temporary diversion during this time.

One option for the repair of recurrent rectovaginal fistulas includes perineoproctotomy, which involves re-creation and repair (by closure in layers) of a third- or fourth-degree tear. Success rates are in the 88% to 100% range, and although a downside of this surgery is division of the sphincter muscle, there are no reports of postoperative incontinence in the literature, he noted.

Sphincteroplasty is the best option for those with sphincter injury. Success rates with this procedure also range from 88% to 100%.

Tissue interposition using the Martius procedure (bulbocavernosus interposition) and graciloplasty are other surgical options with reasonable success rates, he noted.

Complex fistulas—or those that are larger than 2.5 cm in diameter and caused by inflammatory bowel disease, malignancy, or radiation—are more difficult to treat, in part because patients often have complicating medical problems.

For high rectovaginal fistulas, transabdominal division of the fistula with resection and primary anastomosis is recommended. An alternative in patients with a normal rectum is division of the fistula and interposition of omentum or muscle.

Temporary diversion may be necessary in patients with a failed transabdominal surgery. If the fistula does not close spontaneously during diversion, repeat resection or interposition of the omentum is recommended, but few data are available to guide decision making regarding surgery in these patients, he said.

For radiation-induced complex fistulas, temporary diversion is usually performed first. Repair is appropriate when the patient is otherwise healthy and has no evidence of recurrent cancer. One option is coloanal anastomosis to bring in healthy tissue to replace the tissue devascularized as a result of the radiation. Other options are the Bricker on-lay patch and muscle interposition.

A number of surgeries, including transvaginal repairs, endorectal advancement flaps, and muscle interposition and resection, have been described in patients with Crohn's disease. Initial failure requires endoscopic evaluation. If proctitis is present, medical treatment or proctectomy are recommended, but if the rectum is not inflamed, a repeat repair may be successful, Dr. Weiss said.

FORT LAUDERDALE, FLA. — Obstetric trauma is the most common cause of rectovaginal fistulas, Eric G. Weiss, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

Reported series suggest such trauma accounts for 50%-90% of fistulas, said Dr. Weiss, director of surgical endoscopy and a staff colorectal surgeon at Cleveland Clinic Florida, Weston.

“We don't really have a good way to prevent these—it's just one of those things that can happen after delivery,” he said, noting that such fistulas occur in fewer than 1% of vaginal deliveries.

But for such tiny holes—sometimes the size of a pinhole—these defects can lead to extensive symptoms, and can be very difficult to repair.

Rectovaginal fistulas associated with obstetric trauma usually are the result of unrecognized third- or fourth-degree perineal tears or repairs that break down as a result of infection or hematoma. Other causes include inflammatory bowel disease, infection, and other types of trauma, such as pelvic radiation therapy, Dr. Weiss noted.

A number of treatment options exist, but for simple fistulas—or those that are less than 2.5 cm in diameter, distal, surrounded by otherwise healthy tissue, and caused by trauma or infection—Dr. Weiss' treatment of choice is the transanal endorectal advancement flap.

Reported success rates for this type of advancement flap range from 41% to 100%, and the variation may be explained by differences in the way results are reported. For example, some studies include patients who also underwent sphincteroplasty, which would most likely improve results.

Patients with fistulas associated with obstetric trauma are more likely than other patients to also require sphincteroplasty. In his experience, success rates are generally in the range of 60%-65%, with higher success rates of up to 91% reported in those with an intact sphincter.

Other transanal surgical options include layered closure and the anocutaneous advancement flap, and transvaginal options include fistula inversion and vaginal flap advancement. Reported success rates for these approaches range from 72% to 100%, but findings are based mainly on very small case series.

Surgical failure is usually attributable to infection or hematoma. Prompt drainage and antibiotic therapy for infections may salvage the repair. When necessary, surgical correction can be reattempted, but success rates decline with each successive attempt, Dr. Weiss said.

Repeat surgery should be delayed until inflammation has resolved and the wounds have healed; patients with activity-limiting symptoms may require temporary diversion during this time.

One option for the repair of recurrent rectovaginal fistulas includes perineoproctotomy, which involves re-creation and repair (by closure in layers) of a third- or fourth-degree tear. Success rates are in the 88% to 100% range, and although a downside of this surgery is division of the sphincter muscle, there are no reports of postoperative incontinence in the literature, he noted.

Sphincteroplasty is the best option for those with sphincter injury. Success rates with this procedure also range from 88% to 100%.

Tissue interposition using the Martius procedure (bulbocavernosus interposition) and graciloplasty are other surgical options with reasonable success rates, he noted.

Complex fistulas—or those that are larger than 2.5 cm in diameter and caused by inflammatory bowel disease, malignancy, or radiation—are more difficult to treat, in part because patients often have complicating medical problems.

For high rectovaginal fistulas, transabdominal division of the fistula with resection and primary anastomosis is recommended. An alternative in patients with a normal rectum is division of the fistula and interposition of omentum or muscle.

Temporary diversion may be necessary in patients with a failed transabdominal surgery. If the fistula does not close spontaneously during diversion, repeat resection or interposition of the omentum is recommended, but few data are available to guide decision making regarding surgery in these patients, he said.

For radiation-induced complex fistulas, temporary diversion is usually performed first. Repair is appropriate when the patient is otherwise healthy and has no evidence of recurrent cancer. One option is coloanal anastomosis to bring in healthy tissue to replace the tissue devascularized as a result of the radiation. Other options are the Bricker on-lay patch and muscle interposition.

A number of surgeries, including transvaginal repairs, endorectal advancement flaps, and muscle interposition and resection, have been described in patients with Crohn's disease. Initial failure requires endoscopic evaluation. If proctitis is present, medical treatment or proctectomy are recommended, but if the rectum is not inflamed, a repeat repair may be successful, Dr. Weiss said.

FORT LAUDERDALE, FLA. — Uterosacral vaginal vault suspension is the treatment of choice for patients with apical prolapse and a low risk of recurrence, Matthew Barber, M.D., said at a symposium on pelvic floor disorders that was sponsored by the Cleveland Clinic Florida.

“This is my vaginal apex operation of choice—I believe in it,” said Dr. Barber of the clinic.

He described the operation as an anatomic procedure, as opposed to a compensatory procedure, which is more suitable for those with a higher risk of recurrence.

Age is probably the most important factor in patient selection; those aged over 60 years tend to have the lowest risk of recurrence.

Other selection criteria include a good pelvic floor and endopelvic fascia and a good caliber vagina.

Patients who are younger and those who have attenuated endopelvic fascia, neuromuscular disease, or compromised vaginal caliber are better candidates for a compensatory repair such as abdominal sacral colpopexy, Dr. Barber said.

The proximal uterosacral suspension procedure that he prefers involves provision of apical support to the anterior and posterior vaginal walls. It is associated with less recurrence than nonanatomic repairs, provides good vaginal depth of 7-10 cm, and can be performed vaginally, abdominally, or laparoscopically.

The goals of the procedure include reapproximation of the superior edge of the anterior fascia with the superior edge of the posterior fascia, and suspension of these to a strong fixed structure—in this case the proximal uterosacral ligament.

In one series involving 46 patients with an average 40-month follow-up, Dr. Barber achieved a cure rate of 90%. At a 15.5-month follow-up preoperative symptoms had improved significantly from baseline: prolapse (100% of patients at baseline to 10% at follow-up), voiding dysfunction (59% to 7%), need for splint to void (17% to 0%), and constipation (26% to 12%).

The percentage of patients with stress urinary incontinence increased during the follow-up from 5% to 15%—but most of these patients were successfully treated postoperatively, Dr. Barber noted.

A major concern with uterosacral vaginal vault suspension is the proximity of the ureters to the uterosacral ligaments. Keep in mind that the higher you go up on the ligament, the stronger it is and the farther away from the ureters you will be, Dr. Barber said.

In another series of 700 consecutive patients who underwent vaginal surgeries for apical prolapse over the past 3 years at the Cleveland Clinic, 37 had no spill—suggesting ureteral obstruction—on cystoscopy with intravenous indigo carmine. Three of the 37 were found to have renal disease, and 2 additional patients had spill initially, but had delayed injury.

The overall intraoperative obstruction rate was 5.1%.

Uterosacral vaginal vault suspension was associated with a higher rate of ureteral obstruction (5.9%) than other procedures used in the series, including proximal McCall's culdoplasty (4.4%), distal McCall's culdoplasty (0.5%), and anterior repair (0.4%), Dr. Barber said at the meeting.

In 83% of the ureteral obstruction cases, the obstruction was relieved by intraoperative suture removal. The true ureteral injury rate was 0.9%, he said.

Due to the risk for ureteral injury with uterosacral vaginal vault suspension, intraoperative cystoscopy is a must.

“Cystoscopy is not perfect, but it is beneficial,” he said, referring to the two cases of delayed diagnosis of obstruction in the 700-patient series.

When no flow is seen on cystoscopy, wait 10 minutes.

“At 8 or 9 minutes I start to worry,” he said, noting that at this time he has a nurse recheck the patient's chart for history of urologic surgery such as nephrectomy.

“My partners and I have both been burned by this before,” he added.

Next, check to be sure indigo carmine dye was actually used. Then consider furosemide (Lasix), and if this doesn't work, consider stent placement or fluoroscopy.

Still no flow? Then begin removing apical suspension sutures sequentially starting with those most distal, followed—if this doesn't work—by removal of the upper anterior repair sutures, he advised.

Reconsider stenting or fluoroscopy at this point if the obstruction remains, and when all else fails address the obstruction via laparotomy and reimplant, he said, noting that it reached this point in only 1 of the 700 patients.

FORT LAUDERDALE, FLA. — Uterosacral vaginal vault suspension is the treatment of choice for patients with apical prolapse and a low risk of recurrence, Matthew Barber, M.D., said at a symposium on pelvic floor disorders that was sponsored by the Cleveland Clinic Florida.

“This is my vaginal apex operation of choice—I believe in it,” said Dr. Barber of the clinic.

He described the operation as an anatomic procedure, as opposed to a compensatory procedure, which is more suitable for those with a higher risk of recurrence.

Age is probably the most important factor in patient selection; those aged over 60 years tend to have the lowest risk of recurrence.

Other selection criteria include a good pelvic floor and endopelvic fascia and a good caliber vagina.

Patients who are younger and those who have attenuated endopelvic fascia, neuromuscular disease, or compromised vaginal caliber are better candidates for a compensatory repair such as abdominal sacral colpopexy, Dr. Barber said.

The proximal uterosacral suspension procedure that he prefers involves provision of apical support to the anterior and posterior vaginal walls. It is associated with less recurrence than nonanatomic repairs, provides good vaginal depth of 7-10 cm, and can be performed vaginally, abdominally, or laparoscopically.

The goals of the procedure include reapproximation of the superior edge of the anterior fascia with the superior edge of the posterior fascia, and suspension of these to a strong fixed structure—in this case the proximal uterosacral ligament.

In one series involving 46 patients with an average 40-month follow-up, Dr. Barber achieved a cure rate of 90%. At a 15.5-month follow-up preoperative symptoms had improved significantly from baseline: prolapse (100% of patients at baseline to 10% at follow-up), voiding dysfunction (59% to 7%), need for splint to void (17% to 0%), and constipation (26% to 12%).

The percentage of patients with stress urinary incontinence increased during the follow-up from 5% to 15%—but most of these patients were successfully treated postoperatively, Dr. Barber noted.

A major concern with uterosacral vaginal vault suspension is the proximity of the ureters to the uterosacral ligaments. Keep in mind that the higher you go up on the ligament, the stronger it is and the farther away from the ureters you will be, Dr. Barber said.

In another series of 700 consecutive patients who underwent vaginal surgeries for apical prolapse over the past 3 years at the Cleveland Clinic, 37 had no spill—suggesting ureteral obstruction—on cystoscopy with intravenous indigo carmine. Three of the 37 were found to have renal disease, and 2 additional patients had spill initially, but had delayed injury.

The overall intraoperative obstruction rate was 5.1%.

Uterosacral vaginal vault suspension was associated with a higher rate of ureteral obstruction (5.9%) than other procedures used in the series, including proximal McCall's culdoplasty (4.4%), distal McCall's culdoplasty (0.5%), and anterior repair (0.4%), Dr. Barber said at the meeting.

In 83% of the ureteral obstruction cases, the obstruction was relieved by intraoperative suture removal. The true ureteral injury rate was 0.9%, he said.

Due to the risk for ureteral injury with uterosacral vaginal vault suspension, intraoperative cystoscopy is a must.

“Cystoscopy is not perfect, but it is beneficial,” he said, referring to the two cases of delayed diagnosis of obstruction in the 700-patient series.

When no flow is seen on cystoscopy, wait 10 minutes.

“At 8 or 9 minutes I start to worry,” he said, noting that at this time he has a nurse recheck the patient's chart for history of urologic surgery such as nephrectomy.

“My partners and I have both been burned by this before,” he added.

Next, check to be sure indigo carmine dye was actually used. Then consider furosemide (Lasix), and if this doesn't work, consider stent placement or fluoroscopy.

Still no flow? Then begin removing apical suspension sutures sequentially starting with those most distal, followed—if this doesn't work—by removal of the upper anterior repair sutures, he advised.

Reconsider stenting or fluoroscopy at this point if the obstruction remains, and when all else fails address the obstruction via laparotomy and reimplant, he said, noting that it reached this point in only 1 of the 700 patients.

FORT LAUDERDALE, FLA. — Uterosacral vaginal vault suspension is the treatment of choice for patients with apical prolapse and a low risk of recurrence, Matthew Barber, M.D., said at a symposium on pelvic floor disorders that was sponsored by the Cleveland Clinic Florida.

“This is my vaginal apex operation of choice—I believe in it,” said Dr. Barber of the clinic.

He described the operation as an anatomic procedure, as opposed to a compensatory procedure, which is more suitable for those with a higher risk of recurrence.

Age is probably the most important factor in patient selection; those aged over 60 years tend to have the lowest risk of recurrence.

Other selection criteria include a good pelvic floor and endopelvic fascia and a good caliber vagina.

Patients who are younger and those who have attenuated endopelvic fascia, neuromuscular disease, or compromised vaginal caliber are better candidates for a compensatory repair such as abdominal sacral colpopexy, Dr. Barber said.

The proximal uterosacral suspension procedure that he prefers involves provision of apical support to the anterior and posterior vaginal walls. It is associated with less recurrence than nonanatomic repairs, provides good vaginal depth of 7-10 cm, and can be performed vaginally, abdominally, or laparoscopically.

The goals of the procedure include reapproximation of the superior edge of the anterior fascia with the superior edge of the posterior fascia, and suspension of these to a strong fixed structure—in this case the proximal uterosacral ligament.

In one series involving 46 patients with an average 40-month follow-up, Dr. Barber achieved a cure rate of 90%. At a 15.5-month follow-up preoperative symptoms had improved significantly from baseline: prolapse (100% of patients at baseline to 10% at follow-up), voiding dysfunction (59% to 7%), need for splint to void (17% to 0%), and constipation (26% to 12%).

The percentage of patients with stress urinary incontinence increased during the follow-up from 5% to 15%—but most of these patients were successfully treated postoperatively, Dr. Barber noted.

A major concern with uterosacral vaginal vault suspension is the proximity of the ureters to the uterosacral ligaments. Keep in mind that the higher you go up on the ligament, the stronger it is and the farther away from the ureters you will be, Dr. Barber said.

In another series of 700 consecutive patients who underwent vaginal surgeries for apical prolapse over the past 3 years at the Cleveland Clinic, 37 had no spill—suggesting ureteral obstruction—on cystoscopy with intravenous indigo carmine. Three of the 37 were found to have renal disease, and 2 additional patients had spill initially, but had delayed injury.

The overall intraoperative obstruction rate was 5.1%.

Uterosacral vaginal vault suspension was associated with a higher rate of ureteral obstruction (5.9%) than other procedures used in the series, including proximal McCall's culdoplasty (4.4%), distal McCall's culdoplasty (0.5%), and anterior repair (0.4%), Dr. Barber said at the meeting.

In 83% of the ureteral obstruction cases, the obstruction was relieved by intraoperative suture removal. The true ureteral injury rate was 0.9%, he said.

Due to the risk for ureteral injury with uterosacral vaginal vault suspension, intraoperative cystoscopy is a must.

“Cystoscopy is not perfect, but it is beneficial,” he said, referring to the two cases of delayed diagnosis of obstruction in the 700-patient series.

When no flow is seen on cystoscopy, wait 10 minutes.

“At 8 or 9 minutes I start to worry,” he said, noting that at this time he has a nurse recheck the patient's chart for history of urologic surgery such as nephrectomy.

“My partners and I have both been burned by this before,” he added.

Next, check to be sure indigo carmine dye was actually used. Then consider furosemide (Lasix), and if this doesn't work, consider stent placement or fluoroscopy.

Still no flow? Then begin removing apical suspension sutures sequentially starting with those most distal, followed—if this doesn't work—by removal of the upper anterior repair sutures, he advised.

Reconsider stenting or fluoroscopy at this point if the obstruction remains, and when all else fails address the obstruction via laparotomy and reimplant, he said, noting that it reached this point in only 1 of the 700 patients.