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Another potential cause of patient dissatisfaction is over fold and distracts from the overall aesthetic result then an epi- Westernization of the upper eyelid appearance muscle relaxant klonopin cheap cilostazol. Epicanthoplasty has a his- cannot emphasize enough that the majority of Asian patients tory fraught with undue complexity including incisions in do not necessarily want to look Caucasian spasms symptoms 100 mg cilostazol mastercard, but merely seek diverse directions spasms in legs 100 mg cilostazol purchase otc, inability to incorporate the medial canthal to enhance the natural beauty of their Asian eyelids muscle relaxant stronger than flexeril discount cilostazol 100 mg with mastercard. This is incisions with the rest of the double-lid incision muscle relaxant football commercial cilostazol 100 mg order with visa, lack of clear achieved by creation of a supratarsal fold that reduces the landmarks and reference points, and prominent scarring. In our experience, Most of our supratarsal folds are placed at 6–8 mm from the 758 H. Le blepharoplasty may also be applied to Caucasian blepharo- plasty to afford a clean, crisp, well-defined upper lid fold, but not necessarily vice versa. Although a very commonly performed procedure that appears quite simple technically, the Asian upper blepharoplasty can be fraught with dissatisfaction. In order to successfully perform Asian upper blepharoplasty it is important to have a clear understanding of the patient’s desire and expectation, cultural norms and identity, underlying anatomical differences, and a reliable and durable surgical technique. This is a procedure where differences in millimeters can have a huge impact on the desired outcome. It is a procedure that requires meticulous attention to detail and clearly exem- plifies the artistic finesse in combination with clear under- standing of the anatomy and technical expertise of the plastic surgeon. Arch Otolaryngol 111:149–153 to allow for sufficient preseptal skin remaining to drape over 4. Clin Plast Surg the crease, thus hiding the incision and determining the 1(1):157–170 desired amount of lid show. Korean J Plast Surg 17:196 Although a strong bite of levator aponeurosis is desired 7. Ann weeks at which time the upper lid crease may appear higher Plast Surg 13(4):263–723 10. As the swelling subsides on the insertion of the levator palpebra suprioris muscle. Am J the supratarsal skin will relax and drape over the incision Ophthalmol 85:742–801 enhancing the appearance of the crease and setting the 11. Morikawa K, Yamamoto H, Uchinuma E et al (2001) Scanning amount of pretarsal show. Aesthetic Plast Surg 25(1):20–24 trol of hypertension are routine for the postoperative course. Uchida J (1962) A surgical procedure for blepharoptosis vera and pseudoblepharoptosis orientalis. Plast Reconstr Surg 83:236 The goal of the “double eyelid” procedure is to create a small 15. Facial Plast Surg Clin North make the eye look slightly larger and give the appearance of Am 4:315–326 16. Many of the techniques learned from Asian 102(2):502–508 Asian Upper Blepharoplasty 759 17. Boehm and Foad Nahai 1 Introduction tarsoligamentous laxity and skin excess appear, and the eye assumes a more rounded appearance with a negative canthal Surgery is a discipline grounded in precision and exactitude. Volume deflation and skin atten- Surgeons must possess technical skill, anatomic knowledge, uation confer a hollow or concave contour. Herniation of the and an ability to improvise when intraoperative situations infraorbital fat pads becomes prominent and the demarcation change or prove different than anticipated. There are how- between the lower lid and cheek becomes a well-defined ever some operative procedures that have more narrow mar- structure at the level of the infraorbital rim (Fig. A com- gins for error than others, where the difference of a millimeter prehensive lower lid blepharoplasty technique must there- in positioning or scar formation can dramatically affect out- fore strive to correct all of these aging changes in an effort to come. The periorbita is unquestionably a focal feature of the Success in lower lid blepharoplasty surgery relies on the face. Its nuances and subtleties convey individuality as well ability to recognize the specific changes in an individual as emotional expression. The eyes are a most important and patient, appreciate the anatomic basis for these changes and often initial means of nonverbal communication. Such is the motivation behind the lower lid blepharoplasty 2 Anatomy being one of the most common surgical procedures in both men and women. While the lid region may be relatively Viewed externally, the lower lid is perhaps better described small in terms of area, it is one of anatomic complexities. The lower eyelid safe performance of blepharoplasty and achieving youthful, is ideally positioned just slightly above the inferior limbus natural results that can be maintained for years postopera- without any visible scleral show. Accurate assessment of the changes that occur with the lid margin is the lower lid crease formed by the lower lid aging and familiarity with the techniques to correct these can retractors inserting into the dermis. The lower lid tends to restore youthfulness to the lower lid and minimize those slope upward as it moves from medial canthus to lateral can- complications which can have both aesthetic and functional thus conferring what is known as a positive canthal tilt. Skin and orbicularis muscle compromise the 2 mm higher than the medial canthal angle, thereby anterior lamella, whereas the posterior lamella includes the creating an upward or positive canthal tilt. The lid skin is extremely thin with minimal subcutaneous fat, in con- tradistinction to the cheek skin which is thicker with a more substantial subdermal fat layer. Nahai divided into orbital and palpebral portions, with the palpe- central fat pad and is commonly visualized during lower blepha- bral portion further subdivided into pretarsal and preseptal roplasty. The pretarsal fibers coalesce with other support arcuate expansion of Lockwood’s ligament. Along with lies in the preperiosteal plane just deep to the orbital por- preseptal orbicularis muscle fibers, it inserts laterally along tion of the orbicularis muscle. A second midface fatty layer, laris and overlying skin perpetuated over years results in fine the malar fat pad, lies in the subcutaneous plane anterior rhytids in the infraorbital and lateral canthal region. The orbitomalar ligament skin elasticity and ultraviolet damage also factor into wrinkle is the primary retaining ligament of the midface. The specifically the tarsoligamentous sling comprised of the tar- integrity of the orbitomalar ligament maintains a youthful sal plate and canthal ligaments which insert into bony perios- lid-cheek junction. The lower lid tarsal mity is attributable to the arcus marginalis, orbitomalar plate has an average height of 4 mm and is 1 mm thick. It inserts into Whitnall’s lateral tubercle and a defined lid-cheek junction that is a hallmark of peri- located within the lateral orbital rim. Consequently, surgical techniques to superior to Whitnall’s tubercle and can be a useful guide for correct midface aging often rely on division of the orbito- canthoplasty suture placement along the lateral orbital rim. The anterior reflection is not as dynamic a structure as the upper lid, the lid nonethe- blends with pretarsal orbicularis fibers and extends anteri- less depresses with downgaze and shifts horizontally with orly to the lacrimal sac fossa. The capsulopalpebral fascia in the lower lid single reflection structure which arises from the lateral tarsal is analogous to the levator aponeurosis in the upper lid. It plate and inserts into the lateral orbital tubercle posterior to originates from the inferior fascia and lies atop the inferior the orbital rim, usually measuring 5–7 mm in length (Fig. A portion of the capsulopalpebral fascia trav- Its posterior attachment maintains the curve of the globe. Other strands insert at the base of the rectus check ligaments, and Whitnall’s and Lockwood’s liga- tarsus along with the inferior tarsal muscle and orbital sep- ments also coalesce to help form the lateral canthal tendon. Additional strands penetrate the orbicularis and insert While the lateral canthal ligament is a fixation point, fibrous onto the lower lid dermis creating the lower lid crease. The connections with •the check ligament of the lateral rectus capsulopalpebral fascia also fuses with Lockwood’s liga- muscle impart some mobility to the lateral canthus allowing ment, an important support structure for the globe. Primary vascular supply to the lower lid arises from the The orbital septum lies deep to the orbicularis muscle. This attaches to the orbital rim along what is known as the arcus becomes the infraorbital artery which penetrates through marginalis. It anastomoses with branches of encircles the entire orbit passing deep to Whitnall’s tubercle the dorsal nasal artery to supply the lower lid. Along the lower based primarily medially from the inferior palpebral artery lid, the septum fuses with the capsulopalpebral fascia and inserts travel along the lower lid margin as well. It ultimately extends medi- laterally with the lacrimal and zygomatic facial branches of ally up to the anterior lacrimal crest. Surgical maneuvers including compartments along the lower lid: nasal, central, and temporal. Lymphatic drainage blood supply is based predominantly medially, interruption is based either medially or laterally. The nasal portion of of lateral blood supply such as with a lateral canthotomy the lower eyelid drains along lymphatics that parallel the can be done safely without jeopardizing lower lid circula- course of the facial vein and ultimately into the subman- tion. It branches into the infraorbital nerve inferior ophthalmic vein traverses the inferior orbital fis- which exits through the infraorbital canal and ultimately sure to empty into the pterygoid plexus which communi- gives rise to terminal branches along the lower lid margin. The zygomatic facial nerve emerges along the inferior lateral orbit and supplies additional sensation to the lateral lower lid. Motor innervation to the orbicularis oculi muscle origi- nates from branches of the facial nerve, primarily the frontal, superior tarsal zygomatic, and buccal branches (Fig. These changes are an external reflection tubercle of altered anatomy that occurs in response to several fac- tors including environment, sun exposure, and genetic predisposition. Particularly in the periorbital region, structural changes such as decreased elasticity, volume deflation, and tissue descent manifest themselves in con- sistent ways that confer an aged appearance. Specifically in the periorbita, the lower eyelid and midface region intersect as one aesthetic unit. Senescent changes seen along the lower lid are accompanied by similar type changes in the cheek region. Over time, the skin of the lid region will undergo both microscopic as well as more macroscopic changes. Sun inferior tarsal plate exposure, smoking, and dynamic activity like smiling will lateral canthal tendon exert their influences on the already thin lower lid skin and cause decreased elasticity. Conditions that cause repeated swelling or inflammation will also alter tissue elasticity and resilience. At the more severe end of the spectrum, patients can present with malar festoons, redundant folds of lax skin and orbicularis muscle of the lower eyelids that extend from can- thus to canthus. In these cases, attenuation of the orbicularis oculi muscle in combination with laxity between the orbicu- laris and the deep fascia allows the muscle and overlying skin to progressively sag until multiple folds become sus- pended across the infraorbital rim (Fig. The aging, the hollowing will progress from medially to laterally weakened septum allows anterior protrusion of the orbital and in most advanced cases appear as a circumferential hol- fat, manifest as infraorbital fat pad prominence or “palpebral lowness along the entire infraorbital rim. This fat protrusion will contribute to further thinning and lengthening of the overlying orbicularis muscle, thereby worsening infraorbital hollowing and increasing the vertical 3 Surgical Techniques distance from lower lid to cheek margin. Several orbicularis retaining ligaments affix the orbicu- Aging changes of the infraorbital and midface region are laris muscle to the inferior orbital rim. Various refinements greatest length along the central portion of the rim, and of the technique can be incorporated to address the specific decrease in length when moving medially or laterally. The anatomic changes present in an individual, including fat her- orbitomalar ligament is the primary supportive ligament. It niation, infraorbital hollowness, skin wrinkling, midface extends from the inferior orbital rim, through the orbicularis descent, and malar festoons. Incisions alone can be transconjuncti- descends, formation of a well defined lid cheek junction val, externally cutaneous, or endoscopic [2]. Laterally, the orbicularis is attached to the frontal can be treated with removal, redraping, or transfer. The routinely combine lower lid blepharoplasty and subperios- zygomatic facial ligaments retain the malar fat pad and cheek teal midface whereas others do not. These normally dense sus- technique to apply lie in accurate preoperative assessment of pensory attachments attenuate over time and the orbicularis anatomic deformities as well as surgeon’s level of comfort muscle loses tone, leading to descent of the midface and with performing the required surgical maneuvers [3, 4]. Ptosis of the malar fat pad Most blepharoplasty patients present with some degree of and deepening of the nasolabial sulcus result. With soft tis- skin excess or redundancy and thus necessitate an external sue descent, the bony infraorbital rim becomes exposed and incision for skin removal or redraping. A lateral incision is more visible, leading to a well defined lid-cheek junction as made with a #15 blade in one of the natural rhytids in this opposed to a more smooth transition between the two struc- region. Successful rejuvenative procedures often rely on teum along the lateral orbital rim. Scissors are introduced release, elevation, and resuspension of such tissues for cor- through this incision to undermine the skin and muscle rection of these changes. The With age, the canthal tendons stretch allowing the once scissors are then turned and cut the skin and muscle to com- taut lid to sag and become more easily distracted away from plete the subciliary incision (Fig. The other skeletal support along the lid margin, placed to stabilize the inferior cut edge while the needle tip the tarsal plate, also weakens over time. The diminished tone cautery dissection elevates a skin-orbicularis flap off of the along the lower lid ultimately alters lower lid position and underlying septum (Fig. At the level of the rim, orbicularis atrophy and lengthening of the orbicularis retain- the cautery is turned deeper to dissect in the preperiosteal ing ligaments, can lead to inferior migration of the lid margin plane. Dissection is continued over the inferior orbital rim, itself, manifest as inferior scleral show, an increased lateral releasing the orbitomalar ligaments, and over the malar emi- scleral triangle, and ectropion in more severe cases. These maneu- with prominent eyes are particularly predisposed to this vers will allow greater mobilization of the skin-muscle flap downward migration and scleral show development. Inferior cases, the eye assumes a more round shape as opposed to the dissection is performed for approximately 1 cm in the course almond shape seen in youth. Care should be The tear trough deformity refers to the triangular perior- taken to preserve the infraorbital and zygomatic facial nerves bital hollowing along the inner canthus. It is often one of the so as to maintain sensation over the mid-cheek and malar earliest signs of periorbital aging. The septum overlying the fat pads is incised either with orbital portion of the orbicularis muscle, the levator labii cautery or sharp scissors. Digital pressure on the globe can superioris, and the levator alaeque nasi muscle. The scant subcutaneous tissue between the skin and orbicularis in fat contents are gently freed from their postseptal pockets. With continued elevation and abduction of the globe is located between the Lower Eyelid Blepharoplasty 767 Fig. Specifically in this region, the fat can be transferred to lie over the inferior orbital rim to camouflage the lid-cheek junction and create a more convex contour [5 – 7 ].

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As anatomic concepts developed muscle relaxant names purchase cheap cilostazol, surgeons ascertained that the main support of the uterus was the vagina quercetin muscle relaxant cilostazol 100 mg buy visa, which in turn is supported by the insertion of the levator ani muscles into the perineum muscle spasms 6 letters buy cheap cilostazol 100 mg on-line. This concept was the basis for the incorporation of plication of the levator ani muscles into posterior colpoperineorrhaphy infantile spasms 2013 100 mg cilostazol overnight delivery, with the surgical goals of restoring the anatomic support of the vagina and rectum without compromising functionality muscle relaxant lorzone cilostazol 50 mg buy lowest price. Until recently, very little attention has been given to the functional derangements that are commonly associated with rectoceles. In 2010, an estimated 166,000 women underwent surgery for pelvic organ prolapse with a rectocele procedure occurring in approximately half of the cases [1]. A rectocele is an outpocketing of the anterior rectal and the posterior vaginal wall into the lumen of the vagina and is fundamentally a defect of the rectovaginal septum, not of the rectum. Some rectoceles may be asymptomatic, whereas others may cause such symptoms as incomplete bowel emptying, sensation of a vaginal mass, pain, and pressure. The size of the defect does not necessarily correlate with the amount of functional derangement or severity of bowel symptomatology [4,5]. This chapter reviews the anatomy, pathophysiology, diagnosis, and management of rectoceles. This layer of connective tissue is fused to the undersurface of the posterior vaginal wall. Histologically, the rectovaginal septum shows that the distal portion contains dense connective tissue; the midportion contains fibrous tissue, fat, and neurovascular tissue; and the proximal portion is mostly fat cells [7]. Posterior to the rectovaginal septum lies the rectovaginal space, which provides a plane for dissection. In between the rectovaginal septum and the rectum is the pararectal “fascia”; inside this fibromuscular layer lies blood vessels, nerves, and lymph nodes, which supply the rectum. The pararectal fascia, originating from the pelvic sidewalls, divides into fibrous anterior and posterior sheaths, which encompass the rectum. Histological study of the smooth muscle content of the posterior vaginal wall of women with prolapse revealed significantly reduced smooth muscle content compared to women without prolapse [8]. Further support is provided by the levator ani, which are composed of paired iliococcygeus, puborectalis, and pubococcygeus muscles. These muscles function to maintain a constant level of baseline tone and a closed urogenital hiatus. The puborectalis muscle act as a sling that angles the posterior wall about 45° from the vertical and closes the potential space of the vagina. These levator ani muscles also provide a contraction reflex to increased intra-abdominal pressures, preventing incontinence and prolapse. The anterior sacral nerve roots S2–S4, which innervate these muscles, cross the pelvic floor, and are stretched and compressed during labor, increasing the risk of injury [7,9]. However, rectoceles and enteroceles have been noted to occur in approximately 40% of asymptomatic parous women [10]. Rectoceles may be more prevalent than previously thought and may not be a result of parity [11]. Traumatic obstetric events, which usually occur when the presenting fetal part descends quickly in the second stage of labor, can predispose to rectocele formation. The forces of labor may separate, tear, or distend the pelvic floor, altering the functional and anatomic position of the muscles, nerves, and connective tissues. Low rectoceles are isolated defects in the suprasphincteric portion of the rectovaginal “fascia. A palpable defect at the level of the introitus will be noted on the physical examination. High rectoceles often occur from pathological overstretching of the posterior vaginal wall as the rectovaginal “fascia” does not exist at this level. Rectoceles may occur as a result of pathologic stretching of the pudendal nerves during descent of the fetal head, causing atrophy, and denervation of the pelvic floor muscles. Sultan reported that most damage to the pelvic support occurs in the first vaginal delivery [13,14]. Denervation will probably recover after the postpartum period; however, it has been demonstrated that injury may be cumulative with increasing parity [9]. Increased labor duration and weight of the baby directly influence the perineal damage and denervation of the pelvic floor. This neuropathy can lead to the weakening of pelvic floor muscles and development of a rectocele. They may lead to the weakening of the rectovaginal septum by continuous straining against an obstruction. Some patients may suffer from paradoxical sphincter reaction (anismus), which is the unconscious contraction of the voluntary striated muscles when attempting to defecate. This constant straining with bowel movements has been shown to cause or worsen a preexisting rectocele and to increasingly weaken the rectovaginal septum by denervation injury [15]. Anismus eventually leads to the accumulation of stool in the rectum, which may complicate pelvic outlet obstruction and cause a progressive cycle, worsening the rectocele. This pseudorectocele has its posterior vaginal wall exposed because of the lack of inferior support; this may be corrected by surgical reconstruction of the perineum. Congenital absence allows for deepening of the cul-de-sac and weakening of the rectovaginal septum, leading to the development of a high rectocele and enterocele [10,12]. Clinical Presentation The symptoms associated with a rectocele are summarized in Table 84. A common complaint is constipation, which can occur in 20%–58% of patients with rectoceles [16]. Patients may also complain of incomplete rectal emptying, a sense of rectal pressure, or a vaginal bulge. Vaginal digitation/splinting or perineal support is sometimes necessary to facilitate defecation [5,17–19]. It is also important to note that many women with rectoceles do not have to splint with defecation, and women without rectoceles may require splinting [4]. Constipation and straining may worsen the symptoms and lead to left lower quadrant abdominal pain if impaction occurs. The patient may be in the dorsal lithotomy position (for the gynecologist) or in the left lateral decubitus position (for the colorectal surgeon). The use of the split blade of a Sims or Graves speculum will support the apex and the anterior compartment and can aid in visualization. An exam should also be performed with the patient standing, as a vaginal exam in this position may identify a more prominent rectocele and rectovaginal examination will reveal small bowel herniating into this space when an enterocele is present. Of women with rectoceles, up to 80% are asymptomatic and can only be diagnosed on physical examination [9,20]. This nomenclature has replaced the respective terms cystocele, enterocele, and rectocele as it is often uncertain which specific structures are contributing to prolapse at each segment. Prolapse is measured in centimeters relative to the hymenal ring in relation to the six defined points. Points proximal to the hymen are denoted as negative and points distal as positive. Point Ba corresponds to a point 3 cm proximal to the hymen in the midline of the posterior segment. In the presence of complete vaginal eversion, the maximum value equals the value of C. Richardson described site-specific defects in the rectovaginal septum that occur in various locations including the superior, inferior, right, left, and midline areas [6]. One study has suggested that locating defects during clinical evaluation of the posterior vaginal wall is often inaccurate when compared to surgical assessment at the time of defect-specific repair [18]. However, the use of imaging 1286 studies does become useful when combined with other ancillary data, especially history and symptomatology for the following patients: (1) symptomatology and physical findings do not correlate, (2) the pelvic anatomy is unusual or altered due to previous pelvic surgery or a congenital defect, and (3) the patient is unable to exert maximal straining during pelvic examination. Imaging results should not be used alone to make treatment decisions as studies have noted that radiographic findings of posterior compartment defects do not necessarily correlate with patient symptomatology [23,24]. Currently, universally accepted radiologic criteria for defining pelvic organ prolapse are lacking [25]. In order to identify a rectocele on imaging, a measurement is made from a reference line to a predefined point. Dynamic Proctography or Defecography The use of contrast media in pelvic fluoroscopy allows the various prolapsed organs to be opacified and seen in real time providing a two-dimensional view of rectal emptying. Traditionally, it has mainly been used in the study of anorectal dysfunction as evacuation proctography, which is also known as defecography. The addition of a cystogram (dynamic cystoproctography) to this modality allows further information to be gained during the assessment especially when the possibility of an enterocele or sigmoidocele exists [28]. The equipment required includes a thick barium paste, a radiolucent toilet, and video equipment. Images are taken at rest, during straining effort, and during and after evacuation. A rectocele is seen radiographically as an anterior rectal bulge that is usually measured as the distance from the anterior border of the anal canal to the maximal point of the bulge of the anterior rectum into the posterior vagina wall. The cutoff value has not been universally agreed, but some authors consider a depth of >3 cm to be abnormal (many asymptomatic women will be found to have a small rectocele 2 cm or less in depth) [11,29]. Identification of posterior anatomic defects on defecography does not always indicate the need for evaluation. In a study of 52 symptomatic women over the age of 75, posterior compartment defects that were found on imaging did not correlate with reported bowel symptoms [23]. Proctography will also note the finding of postevacuation barium trapping, which may help to explain any evacuation dysfunction [30]. During testing, patients can be taught how to apply manual pressure in the vagina to obtain relief from the symptoms associated with incomplete emptying. Defecography may suggest the diagnosis of anismus, which may be the main contributor to a patient’s bowel dysfunction rather than a rectocele [31]. This has important implications because anismus is treated with biofeedback therapy rather than with surgery. An enterocele is noted as a herniation of the small bowel into the vagina, rectovaginal space, or both. The vagina and small bowel in the pelvis need to be opacified to obtain this diagnosis. They are most evident after evacuation as a full rectum may obscure its visualization. However, there still may be false negatives with proctography due to insufficient filling of contrast media into the sigmoid. Identification of a sigmoidocele is important in that a patient may require a sigmoid resection or sigmoidopexy as treatment. Proctography will detect many enteroceles and sigmoidoceles not seen on pelvic examination [32]. Studies have shown that enteroceles are only identified approximately 50% of the time on physical examination, which is less than the rates of identifying rectoceles and cystoceles [20,33]. This has been attributed to the failure of the patient to strain maximally during pelvic examination, an impediment that is removed during the evacuation phase of cystoproctography. Another benefit is that fluoroscopy will identify the specific organs involved in the prolapse. It has many advantages over dynamic proctography: 1287 It is able to contrast soft tissue structures well. It also shares some of the same advantages, including identifying prolapse not noted on physical examination. Fluoroscopy may not detect enteroceles in 20% of cases in which small portions of peritoneal fat enter the rectovaginal space [35]. Dynamic anorectal endosonography has also been described and may detect the presence of enteroceles [39]. Dietz and Lekskulchai performed translabial ultrasound to define cutoff points for prolapse on the basis of patient’s symptoms. They concluded that descent of the rectum >15 mm below the symphysis pubis was associated with symptoms [40]. The use of endoanal ultrasound may be indicated on patients with decreased anal sphincter tone to evaluate the integrity of anal sphincter complex, which, if damaged, may lead to consideration of a sphincteroplasty. The role of these alternate modalities in regard to posterior compartment defects has not been fully elucidated and needs further study. Anal Manometry Anal manometry measures rectal pressures by a transducer or balloon. Its measurement of rectal sensation evaluates the first feeling, urge, and discomfort; this information is used to distinguish causes of constipation. When an individual is able to tolerate increased volumes without signs of increased discomfort or the urge to defecate, overflow incontinence may occur. Careful consideration must be given to this evaluation process because individuals able to tolerate only small volumes in the rectum may have an irritable rectum, causing incontinence or urgency. Overflow incontinence and irritable bowel syndrome may mimic rectocele symptoms such as incontinence or incomplete emptying. If misdiagnosis of a rectocele is made, rectocele repair may exacerbate these disorders by causing a worsening of symptoms [15,42]. Obstetrical trauma denervates and causes atrophy of the pelvic floor muscles and tissue, which may lead to subsequent pelvic floor weakness. Colonic Transit Studies In colonic transit studies, the patient ingests radiopaque markers, which are measured, and the patient undergoes serial abdominal imaging, typically over a period of 5 days, to follow the markers through the right colon, left colon, sigmoid colon, and rectum. A normal transit time is defined as 80% of the ingested markers being expelled by day 5 [43]. Clinically slow transit time is defined as less than two bowel movements per week over several years. The utility of this test in individuals with rectoceles is controversial; some have normal transit times whereas others have prolonged times [44]. Patients whose symptoms did not improve after repair were found to have longer transit times preoperatively [17]. Once the clinical diagnosis has been made and (if necessary) confirmed by ancillary studies, the decision to operate or to treat conservatively must be made.

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In late specifc investigations are: maturers muscle spasms yahoo answers cilostazol 50 mg buy line, both short stature and delayed puberty coexist xanax spasms order cilostazol 50 mg online. Karyotyping muscle relaxant hair loss 50 mg cilostazol order, especially in girls in order to exclude Tese late maturers eventually attain better heights com- Turner syndrome muscle relaxant hair loss cheap cilostazol 50 mg visa, pared to early maturers muscle relaxant 8667 discount 50 mg cilostazol with visa. Bone age assessed through radiological examination of z Growth (height) velocity less than 4 cm per year. In infancy, knee, wrist and hand, and in later years z Existence of characteristic features of an endocrinal cause or a elbow, wrist and hand are appropriate sites for bone age syndromal state. Idiopathic Zinc supplementation, growth Important comparative features of familial, constitu- hormone tional, growth hormone defciency and hypothyroid short Skeletal dysplasia Limb-lengthening surgery is possible stature are presented in Table 4. Occasionally, surgical excision may z Idiopathic short stature with low growth velocity. Fetal overgrowth Cost of therapy z Maternal diabetes Today’s genetically engineered growth hormone i. Administration and dosage Postnatal overgrowth z Age: It is mandatory to start such a therapy before 11 years of age z Familial for attaining the optimal height. Other anthropometric indices include: Skin-fold thickness Waist-hip ratio Weight for height. Around 50 million (20% in resource-limited world) children under 5 years of age are top of regular diet by children, lack of physical activity is the estimated to be overweight. Tis occurs as a result of excessive dietetic consumption, Physiological Obesity today’s most important nutritional problem in the Euro- pean countries (Box 4. But it is now beginning to hit the Tis occurs in early adolescence and is frequent among girls in particular. It is temporary and regresses after ado- upper strata of society in the developing world as well; that lescence. Manifestation in a child with exogenous obesity include: Obesity, excessive deposition of adipose tissue, results Fat deposition is generalized (Fig. But, as a matter of fact, they sufer from z Constitutional loneliness and profound psychological trauma. Manifestations in endogenous obesity depend on the Endogenous underlying condition (Figs 4. In Cushing z Genetic/chromosomal syndromes: Laurence-Moon-Biedl syn- syndrome, for example, obesity is typically central with drome, Turner syndrome, Prader-Willi syndrome involvement of upper trunk and face. Intelligence Normal Usually low Central:Upper trunk and face predominantly involved Height Either normal or Usually stunted as in Cushing syndrome. In order to label a child Bone age Either normal or Usually retarded fatty, the weight should be above 20% of average weight for advances age and body mass index above 95th percentile (30 kg/m2). Endocrinal Nothing apparent Acne, hirsutism, menstrual Height may be normal or little more than the average. Appetite-inhibiting/suppressant agents, though often recommended in adults, are best avoided in pediatric obe- sity. Whereas amphetamines should be avoided, orlistat, metformin, leptin, and octreotide may be considered in select pediatric cases. Orlistat, a gastric lipase inhibitor, is the frst anti- obesity agent approved for children. Leptin, which reduces the hypothalamic drive is indi- cated in leptin-defciency obesity. Curtailment of intake of snacks in between main meals and Restriction of television viewing to <2 hours daily. Te trafc-light plan for various foods are to cut down weight via acceptable means, including given in Table 4. Since the Type of Fruits, vegetables Lean meats, dairy, Fatty meats, stif skull vault does not allow the brain to grow, a kind of food starches, grains sugar, fried foods situation resembling raised intracranial tension may result. Quantity Unlimited Limited Infrequent or Underdeveloped sinuses are a common accompaniment. However, as a compensatory mechanism, excessive skull growth occurs parallel to the involved suture, resulting in a skull deformity varying with the afected suture. In addition to the primary craniosynostosis (resulting from abnormal development of skull per se), failure of brain growth, maturation and expansion may cause secondary craniosynostosis. As a result, skull grows ant- It is the anteroposteriorly fattened and side-to-side eroposteriorly and thus assumes an elongated appearance widened skull (Fig. Two scaphocephaly which is the most common type of cranios- types are—(1) frontal and (2) cephalic. Oxycephaly (Acrocephaly, Turricephaly, Tower Head/Skull) Tis means fusion of multiple sutures. Te characteristic appearance is an abnormally high (tower- shaped) skull with a steep ascent of frontal and parietal areas. Plagiocephaly Asymmetrical fusion of suture(s), usually right-sided, leading to an asymmetrical skull with fattened occiput and bulging of the ipsilateral forehead (Fig. In doubtful cases, cephalic index may be of help, especially in diferentiating scaphocephaly from brachycephaly. Some cases may have congenital heart disease, corneal opacities, genu valgus and anteriorly. It is the triangular skull secondary to premature fusion of It is inherited as an autosomal dominant trait. It is characterized by a keel-shaped prominent eyes, short and broad thumb and great toes and partial head that is narrow anteriorly and wide posteriorly, pointed soft-tissue syndactyly. As a rule, it coexists with 19bp chromosome This is an autosomal dominant condition. Tese include headache, vomiting, proptosis, squint, convulsions, hyperrefexia, hypertonia and mental retardation. An index <70 points to scaphocephaly and >80 to brachy- Secondary Microcephaly cephaly. In plagiocephaly in which shape of head is asym- Reduced brain size as a result of insult to a previously metrical, it is not helpful. Abnormal shape of the head with premature closure of sutures evidenced by the ridge at the suture line points to craniosynostosis. Gross motor It is a global phenomenon involved in acquisition of new Head/neck holding 3 months motor, social, cognitive and language skills mandatory for Rolling over 5 months optimal functioning of the child. Sitting (without support) 7–8 months Development depends on the maturation and myeli- Standing (with support) 9 months nation of brain, leading to developmental milestones such Walking with support 10 months as social smile, head-holding, sitting, standing and walk- Crawling/creeping 11–12 months ing. Gross motor development: It pertains to control of the child over his body and is observed in ventral suspen- Climbing stairs (down) 1 steps at a time 2 years sion, supine, prone, sitting and standing positions. Fine motor and adaptive development: It pertains to Climbing stairs (down) 2 steps at a time 4 years fne coordination of eyes, hand-eye, and hand-mouth, Riding tricycle 3 years and skills for manipulation with hands. Personal/social development: It pertains to interper- Skipping 5 years sonal and social skills like social smile, mimicry, waving Fine motor bye-bye, etc. Language development: It pertains to hearing, sounds, Reaching out for a bright object (intentional 4–5 months understanding and true speech. Additional (palmar grasp) features of gross motor development in the neonatal and Holding a small object between index fnger and 9–12 months infancy periods are listed in Box 5. Language z In a 3-month old, head lag is minimal and spine rounding too is Turning head to sound (rattle, ball) 1 month less. Laughing 4 months Ventral suspension Monosyllables (ma, pa, ba, da) 6 months z When a newborn is held in prone position and then lifted above Bisyllables (mama, papa, baba, dada) 9 months the bed, he is unable to hold the head in line with trunk, i. Two words with meaning 1 year z By 6 weeks, he can hold the head for a moment in line with trunk Simple sentence 2 years (horizontal position). Knows full name and gender 3 years z By 8 weeks, he can maintain the horizontal position well enough. Telling a story, singing a rhyme 3–4 years z By 12 weeks, he tends to lift his head above the horizontal plane. Account of recent events 4 years Prone position Enquires about meaning of words 5 years z The newborn upto 2 weeks lies with high pelvis and drawn up knees. Follows light up to 45° Birth month z By 8 months, he can crawl with abdomen on ground. Follows light up to 180° 3 months Fixating at mother 1 month Fixating at an object 3–4 months Reaching out for an object 6 months Transferring an object from one hand to the other 7 months Hearing Response to sounds (startle, crying, blinking) Neonatal period Turns head towards source 3–4 months Turns head to one side, then downward in 5–6 months response to a sound below level of ears Directly looks at the source of sound 10 months Fig. Makes a train z Plain 2 years z With rattle 2½ years Makes a tower of 9 blocks 3 years Makes a bridge 3 years Makes a gate 4 years Makes steps 6 years Dressing skills Pulls of socks, cap, etc. Starting from spontaneous scribbling with a pencil, the child slowly progresses to copying a triangle at 5 years, Fig. Postneonatal Factors D G Erratic infant and young child nutrition resulting in Figs 5. For instance, head- malaria, hepatic encephalopathy, head injury, drown- holding, sitting, standing and walking occur in same sequence in all children. Else, skills may remain dormant to a consider- able extent in spite of good maturation of the nervous system. Psychosocial Factors z Loss of primitive refexes and milestones: There are some primi- tive refexes (e. Likewise, asymmetric tonic refex need to be lost before the Institution placement leave a considerable adverse efect infant learns to turnover. The Protective Factors site of a colorful, bright object prompts an infant (say 4-month- Breastfeeding old) to respond in a disorganized manner-moving extremities with excitement and loud noise. The response in a toddler to such an Te breastfeeding has a protective and promotive infuence object is in an organized manner. He is likely to be asking for it and on neurodevelopment of the child stands well established. Today, thanks to high level of tertiary neonatal care, a good z Risk factors: Any adverse factors that could delay or regress develop- ment. Tey stand signifcant Physical examination risk of sufering from developmental delay and disability. Defnitive tests to defne impairment in sphere and z Vocal responses z Fine motor skills degree. In case of preterm babies, it is important to take into account the designed to identify children who should receive more corrected age* rather than postnatal age till two years of age. It is essential for Upper limit of age for achieving diferent milestones must be detecting abnormal developmental delay which is expected borne in mind before labeling a milestone as delayed. Occasionally, there may be variation (dissociation) in achieving milestones in individual felds, e. A single feature should not be considered sufcient for labeling Informal screening: It aims to correctly identify chil- developmental delay. A neonate born at 36 weeks ents about their concerns concerning child’s develop- of gestation is preterm by 4 weeks. Routine formal screening: It consists in systematic developmental screening of all children with the help High-risk neonates (for developmental delay) Box 5. Tis approach in need of focused developmental screening is neither feasible nor cost efective. Fur- Guidelines thermore, it should be ascertained if the developmental delay is global or dissociative (limited to just one of more domains). It is advisable to Te guidelines for developmental screening are summa- calculate the developmental quotient (wide infra). Various Tests Employed such tests as Stanford-Binet intelligence scale, Wechsler Te most widely used screening for detecting develop- intelligence scale and Goodenough draw a man test. For older Denver Developmental Screening Test children, 3 to 15 years, one may use the development Developed in 1967, Denver developmental screening test charts. Te major diferences from the original test are: Points to parts of a doll (3 parts) 15. Designation of caution items Identifcation of items for which there is a clinically sig- Goodenough Draw-a-Man Test nifcant diference between the norms of one or more (Goodenough-Harris Drawing Test, Goodenough- subgroups and the composite norms of the total samples. Te child scores as many Availability of a video instructional program and pro- points as the number of items he includes in his drawing. For every 4 points he is awarded one year that is added to Note that it is only a screening test for identifying chil- the basal age (3 years). In order to have a suitable developmental Once screening test(s) have demonstrated an impairment, screening test for Indian children, it was adopted from defnitive determination of degree and sphere may be Bayley development scale by Phatak from Baroda. Te test done by more sophisticated tests such as: is relevant for age 0–30 months. Tese are carried out by a trained developmental psy- chologist rather than a pediatrician. Once identifcation of developmental delay has been made, early treatment and intervention (say application of stimulation modalities) must begin before it afects the functioning of the child and the family. Borderline 70–85 Vulnerable to educational problems z Putting an extra efort to make the child sit, stand or walk. Mild 50–70 Educable usually via special classes z Talking to the child and stimulating him to respond by speaking. Severe 20–35 Trainable (self-care skills) Profound <20 Custodial care elopment of the child. For instance, nothing matches the proper toilet training to the child starting at the appropriate age of the parents. It is a score derived from one of several standardized tests designed Balanced Television-Exposure for its assessment. Te term was coined by the German psychologist, William Television viewing has become a part and parcel of life. Recently, a new term, emotional intelligence, has Persistence of two or more such signs in later years been proposed. Tis refers to the emotional health of an should be considered abnormal neurodevelopment in the individual–his/her ability to balance his emotions and following ways: understand others emotions.


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Typically spasms knee generic cilostazol 50 mg buy, one will see distal urethral narrowing with proximal urethral ballooning [1] spasms upper right abdomen discount cilostazol 50 mg with visa. For example muscle relaxant names buy line cilostazol, if the bladder neck is closed with Valsalva zyprexa spasms quality 50 mg cilostazol, that is usually the level of continence muscle relaxant medication prescription generic 50 mg cilostazol amex. However, if with straining the bladder neck opens and the level of continence is at or near the stricture, there may be concern for posturethroplasty incontinence. Finally, endoscopic evaluation can be helpful to evaluate the extent of the stricture. Gentle dilatation of the stricture can be performed to facilitate endoscopy, especially if a biopsy is desired. Perhaps, this discrepancy is attributable to the relative rarity of stricture disease in women, combined with the more varied causes of strictures in women. In men, urethral strictures are commonly caused by blunt trauma; however, due to the female urethra’s short length, its anatomic position behind the pubic arch, and its relative mobility, the incidence of stricture following trauma in females is low (range of 0%–6%). More commonly, stricture disease in women is seen following endoscopic or open urethral surgery, urethral dilatation, and pelvic radiation therapy for gynecological malignancies. Salvage procedures (bladder neck closure and/or urinary diversion) The driving factors for treatment of female urethral stricture will often be based on the patient’s degree of obstruction, bothersome symptoms, and emptying patterns. In cases in which a patient is adequately emptying and not encumbered with bothersome symptoms, they may be offered the option to be conservatively monitored with routine follow-up. In cases in which treatment is warranted, the course of treatment should be based on the degree of urethral stenosis and/or retention, the functionality of the bladder, and the risk for any upper tract dysfunction. Additionally, if the underlying mechanism of stricture formation can be ascertained, such as radiation, this should be kept in consideration. Ultimately, if there is suspicion for urethral stricture in a woman, it is imperative to fully assess them in order to make an accurate diagnosis for which a proper treatment course may be offered. For example, in cases of pelvic floor dysfunction or dysfunctional voiding, it may present and appear as a urethral stricture, but the treatments are profoundly different. Counseling the patient is very important throughout the process, as symptoms of frequency and urgency may persist even after treatment of a stricture [13]. Selfcatheterization involves teaching the patient how to perform intermittent catheterization at various intervals based on the degree and timing of scarring. If a stricture is diagnosed early, self-catheterization can likely be initiated without requiring urethral dilations or surgical therapies. The patient should be followed at regular intervals to ensure no problems with or worsening symptoms between catheterizations. If a patient fails intermittent self-catheterizations or elects to have more definitive therapy, a discussion regarding other conservative and surgical options should be initiated with the patient. Urethral dilation gained rapid popularity in the 1960s when it was proposed to dilate a “contraction ring” noted in the urethras of young girls up to 32–45 French [14]. This notion as a treatment for “urethral syndrome” in those with recurrent urinary tract infections and chronic urethritis subsequently expanded. Since then, studies have demonstrated that in the absence of a true stricture, urethral dilation does little in the way of helping with urinary symptoms of frequency and urgency [15,16]. In general, emerging literature advocates against the use of urethral dilation in the absence of a true urethral stricture. This change in management trends is reflected in surveys given to practicing urologists, with those trained within the 10 years prior to 1999 considering dilation to be as largely unsuccessful, contrasted by 21% of those trained more than 10 years before 1999 considering it to be very successful [17]. Another recent British survey found that 69% of urologists still regularly perform urethral dilation despite data to suggest its lack of efficacy [18]. It is unclear why this practice continues, and it has been suggested that generous reimbursements by Medicare may play a role. Analysis of public datasets estimate an annual cost of $61 million for treatment of stricture disease in women, of which the majority (67%) were for ambulatory surgery visits [19]. Diagnosis of urethral stricture in a woman averages a cost of $8444 in health-care costs compared to $4658 in those with similar complaints without that diagnosis. Long-term data on outcomes of dilation are scarce, and many studies are performed in the absence of the diagnosis of a true urethral stricture. They were dilated to 30 French, left with a catheter for 1 week, and then asked to intermittent catheterized once a day for 6 months. All women had at least one prior dilation prior to presentation, and of those that underwent another dilation, nearly all had a recurrence (16 of 17 patients) subsequently requiring another dilation or urethroplasty. Success rate at a mean follow-up of 2 years was a meager 6%, thereby prompting the authors to conclude that urethral dilation is very rarely effective. At a mean follow-up of 43 months, the urethral dilation success rate was 47% with higher rates of success in those that had not had a prior dilation (58%) than if they had a prior dilation (27%). The authors concluded that in cases of repeat dilation, it often serves primarily a palliative purpose rather than as a cure likely due to extension of the scarring. The group concluded that on-demand dilations are superior because they provide similar outcomes with less urethral manipulation. Finally, adjunctive therapy with vaginal estrogen in order to improve atrophy and improve tissue either pre- or posttreatment can be considered [13,24]. Very scant literature exists on endoscopic management of urethral strictures in women. Most of the existing literature for lasers is for the treatment of male urethral strictures and as with literature in female strictures is sparse [27,28]. These range from meatoplasty to vaginal inlay flaps for distal strictures, more extensive vaginal flap urethroplasty for midurethral strictures, and onlay grafts for mid and proximal urethral strictures. We will describe examples of each of these techniques based on the anatomic location of the stricture. Successful urethral reconstruction, no matter where the location of the stricture, is based on several principles including identification of the entire stricture, tension-free reconstruction, and adequate drainage/stenting when necessary. Meatal stenosis and stricture of the distal urethra are two of the most common indications for urethral reconstruction. The distal urethra is particularly susceptible for stricture from instrumentation, trauma, radiation, and aging. The two most common types of urethral reconstruction that we utilize for distal 1650 urethral stricture are (1) distal urethrectomy with advancement meatoplasty for very distal strictures (usually involving the distal 1 cm of the urethra) and meatal stenosis and (2) a proximally based distal vaginal flap urethroplasty (Blandy urethroplasty) for lesions 1–2 cm proximal to the urethral meatus. Stricture and other lesions of the midurethra often result from iatrogenic injury associated with urethral diverticulectomy, incontinence surgery or urethral instrumentation, and endoscopic trauma. They can be associated with urethrovaginal fistulae or loss of the mid to distal urethra that can occur as a result of long-term indwelling catheters. For midurethral lesions, beyond the limits of a Blandy urethroplasty, we will typically employ a vaginal flap urethroplasty or, in cases when suitable vaginal tissue cannot be found or is not appropriate, a free graft using buccal mucosa. For proximal strictures and strictures involving the entire urethra, the buccal mucosal graft is our procedure of choice. Distal Urethrectomy with Advancement Meatoplasty Meatotomy can be performed to treat distal stenosis by simple ventral incision of the meatus and suturing the cut end of the meatus to the vaginal wall. However, in our experience, circumferential, distal urethrectomy and advancement meatoplasty work best for distal strictures and urethral prolapse. It can be applied to meatal stenosis and strictures within approximately 1 cm from the meatus, but works best for true meatal stenosis [29]. To start, the extent of the stricture is identified to make certain that distal urethrectomy is appropriate. If desired, interrupted absorbable sutures can be placed in the more proximal, healthy urethral mucosa (at least 2 mm proximal to the strictured segment), at the 6 and 12 o’clock position, so that the mucosa does not retract inward. Sometimes, a small ventral urethrotomy is necessary to determine the proximal extent of the stricture. Depending on the degree of reconstruction, a urethral catheter may be left in place for 1–3 days postoperatively. This is particularly useful as postoperative swelling can cause urinary retention. Distal Urethroplasty with Vaginal and Vestibular Inlay Flaps For distal strictures that have a proximal limit of up to 2 cm from the urethral meatus, a Blandy urethroplasty or proximally based vaginal pedicle inlay flap can be done. The procedure was originally described but never reported by Blandy, but was subsequently reported on by Schwender et al. This procedure recreates the ventral portion of the urethral meatus and replaces the distal ventral urethra with a flap of vaginal wall. As with any stricture, the first step is identifying the proximal extent of the stricture. After completion on the urethroplasty, a 14– 16 French Foley catheter is left indwelling for several days. Outcomes for Distal Urethral Reconstruction Early postoperative complications of distal urethral reconstruction are generally self-limiting and include bleeding, transient urinary retention secondary to swelling, and urinary tract infection. There is little in the literature regarding the outcomes for distal urethral reconstruction. Regarding distal urethrectomy and advancement meatoplasty, we would expect similar success rates. When this procedure occasionally fails, it is usually due to the reformation of scar tissue caused by inadequate resection at the initial procedure. The most critical components of both active and passive continence are located in this important segment of urethra. The Blandy proximally based vaginal flap urethroplasty (described earlier) can be used to treat some midurethral strictures, particularly those that are at the more distal portion of the midurethra. In cases of strictures that are isolated to the midurethra and do not include the distal urethra, one may also consider a free graft, such as buccal mucosa (see section “Onlay Urethroplasty Using a Free Graft” and Figure 111. Vaginal flap urethroplasty, popularized by Blaivas [33], can be utilized to recreate a functional urethra by way of local, healthy tissues. It can be used for strictures as well as ablation/erosion of the mid to distal urethra. This technique can also be applied in cases of a shortened urethra associated with vaginal voiding in order to improve urethral length. In cases of urethral stricture, a longitudinal incision is made in the anterior vaginal wall directly beneath the urethra. The urethra is exposed and a longitudinal incision is made in the ventral urethra exposing the entire segment of strictured or diseased urethra, until more proximal, viable tissue is identified. In cases of urethral ablation, the vaginal wall distal to the urethra meatus becomes the ventral plate of the urethra. There are two variations of the vaginal flap urethroplasty that we commonly employ. In the first, a flap of full thickness vaginal wall, including the epithelium, in a U configuration can be employed as a patch or ventral plate of neourethra (Figure 111. The second, for cases of urethral ablation, where there is compromised anterior vaginal wall tissue proximal to the urethra, medially based flaps can be created from the vaginal wall distal to urethra. In both cases, an autologous rectal fascia pubovaginal sling can be done simultaneously if there is coexisting stress urinary incontinence (Figure 111. In both cases, a Foley catheter is left indwelling for 10–14 days after the surgery. Outcomes for Vaginal Flap Urethroplasty Success rates for vaginal flap urethroplasty are quite good. In the largest series in the literature, Flisser and Blaivas reported successful anatomic repair in 93% of 72 women [33]. Sixty-two of the patients were incontinent and underwent simultaneous pubovaginal sling with a success rate of 87%. Incontinence occurred postoperative in 25% of women who were continent preoperatively. Potential complications of vaginal flap urethral reconstruction include recurrent urethral stricture/meatal stenosis, vaginal flap necrosis, de novo stress or urgency incontinence, vaginal shortening, and dyspareunia. Simonato and colleagues used a distal C-shaped flap for midurethral strictures [11]. The distal to midurethral is incised from the meatus through the stricture, and the vaginal wall is mobilized from one side on a laterally based pedicle to create a new ventral mid to distal urethra. In cases of stricture, where the opened urethra will be used as the dorsal plate of the neourethra, the top of the U is at the level of the proximal part of the opened urethra. In cases of urethral ablation (shown here), the top of the U extends to where the neomeatus will be. Lateral vaginal wall flaps are made so that the anterior vaginal wall can be closed primarily, creating a second layer of tissue beneath the newly created urethra. If desired, an autologous fascia or biological pubovaginal sling can be placed at the bladder neck. In addition, an inverted-U incision is made with the apex of the U at the level of the lower border of the rectangle flap. If desired, a pubovaginal sling can be placed prior to advancement of the inverted-U flap. Buccal mucosa, which has been used extensively in male urethral reconstruction, is currently the most widely used free graft in female urethral reconstruction as well. Some authors have used lingual mucosa harvested from the ventral–lateral aspect of the tongue claiming that it has many of the same properties as buccal mucosa, and avoid potential injury to the parotid duct and mental nerve. We prefer dorsal placement primarily because graft is well supported mechanically and rests on a well-vascularized bed. Traction sutures may be placed in the urethral mucosal at the meatus at the 3 and 9 o’clock positions. The urethra is sharply dissected from the vulvar epithelium, and a plane is developed between the urethra and clitoral cavernosal tissue with care so as not to damage the bulb, clitoral body crura, or the anterior portion of the striated sphincter that should be reflected upward. The urethra is incised dorsally at the 12 o’clock position from the urethral meatus through the stricture, to normal unscarred urethral mucosa (Figure 111. A stay suture of 4-0 or 5-0 polyglycolic acid or Monocryl can be placed at this point. The stricture is measured so that an appropriately sized length of buccal (or lingual) mucosa approximately 1. The graft is fixed to the apex of the stricture with the previously placed stay suture. The sides of the graft are sutured to the urethra with 4-0 or 5-0 polyglycolic acid or Monocryl sutures over a 14–18 French Foley catheter (Figure 111.

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To conduct the physical examination spasms near belly button order on line cilostazol, a number of diagnostic tests are available to the physiotherapist muscle relaxant for stiff neck cilostazol 50 mg free shipping. The severity of the stress muscle relaxant alcoholism purchase cilostazol 100 mg with mastercard, urgency muscle relaxant menstrual cramps 100 mg cilostazol order free shipping, or mixed incontinence depends not only on the condition of the pelvic floor and the bladder but also on the posture spasms in upper abdomen generic cilostazol 100 mg amex, respiration, movement, and the general physical and psychological condition [52,53]. Information on the severity of stress, urgency, or mixed incontinence can also be obtained by studying the voiding diaries mentioned earlier with relevant data about incontinence. With such questionnaires, it is possible to illustrate the degree of incontinence in a reproducible manner [54]. Especially in patients with stress incontinence, a pad test can be useful to test the extent and severity of the involuntary loss of urine [55]. The objective of physical examination is to understand The functionality of the pelvic floor in rest and during activities in terms of coordination, tonus, endurance, and strength The possibility and degree of contraction (with or without awareness) and relaxation of the pelvic floor muscles The influence of other parts of the body on the function of the pelvic floor, by inspection at rest and while moving For qualification and quantification of strength of contraction, level of relaxation, coordination, endurance, repeatability, and displacement, manual assessment of the function of the pelvic floor muscles is the most commonly performed technique by physiotherapists. To test maximal strength, the patient is instructed to contract the pelvic floor muscles as hard as possible. Muscular endurance is tested by asking the patient to sustain a near to maximum contraction for at least 10 seconds repeatability to repeat as many as possible maximal contractions followed by 659 complete relaxation during 15 seconds. Digital palpation is also used to determine pelvic floor muscle (over, under) activity, pelvic floor muscle activity differences and differences between the left and the right side of the pelvic floor (Figure 43. For assessment of contraction of the levator ani muscles, the pelvic physiotherapist inserts first his or her index, if possible followed by his or her middle finger from below inside the vagina until he or she feels the levator ani muscles. To assess a conscious contraction, the patient is instructed to contract the pelvic floor muscles (“withhold a flatus; contract the anus inward; stop the urine”). In all cases, a correct contraction is a simultaneous circumferential squeeze around the physiotherapist’s index or index and middle finger and inward/upward movement or elevation of the levator ani muscles. To quantify the (static and dynamic) strength of a voluntary or reflex contraction, the International Continence Society and the International Association of Urogynecology recommend the use of the tool in Figure 43. Therefore, the investigator should always start with a contraction and then ask for relaxation. The strength of the pelvic floor muscles can also be measured by a vaginal squeeze pressure device connected to a manometer (pressure manometry, perineometer) [56] or pelvic floor dynamometer (a kind of strain gauge device for the pelvic floor to measure precisely forces produced during a pelvic floor muscle contraction independently of the evaluator’s judgment) [57]. These methods are complicated to perform, demand clinical experience and skills in order to produce a methodologically high-quality result or are not yet clinically available [58]. More recently, an increasing number of pelvic physiotherapists assess pelvic floor function with perineal ultrasound. Dynamic evaluation of pelvic floor function includes position and elevation or descent of the bladder neck. Also, the puborectalis muscle at rest as well as pelvic floor precontraction, voluntary pelvic floor maximal and submaximal contractions, hold during respiration and sneezing or coughing, stabilization of the urethra, and hold of bladder neck position during coughing or abdominal maneuvers can all be evaluated. However, although pelvic floor imaging using ultrasound becomes more and more popular, diagnostic ultrasound is reported to be well known for its operator-dependent nature and should only be used after appropriate and effective education [59]. A limitation of the different measurement methods common to all clinic-based measurements of pelvic floor muscle function is that they are performed in the supine position or other standard positions. One should keep in mind that this might not reflect functional or usual activity of the pelvic floor during daily life activities as a response to increased abdominal pressure [58]. After the history taking, physical examination, and functional tests, analysis and evaluation of the results of physiotherapeutic diagnostic phase and relevant medical data will complete this process. The diagnosis of the referring provider can be confirmed or changed, and the indication for physiotherapy ascertained. Therefore, answering the following questions is necessary: Is referral diagnosis likely? A given severity of the health problem at referral has an impact on the prognosis and the evaluation of the likely effect of the physiotherapeutic intervention. He or she estimates whether full recovery can be achieved or only compensation of the complaints is possible. Also, he or she determines his or her strategy, procedure, methods of treatment to reach the goal, and whether or not he or she has the skills and capability to do the job. Comprehension on the part of the patient will promote the motivation to start on other stages of treatment. The interplay between patient and physiotherapist is very important in this process. Before starting the specific therapy modalities on the pelvic floor, it is important to know 663 and appreciate the position and the function of the pelvic floor and how to contract and relax the pelvic floor muscles. To achieve satisfactory results from intervention (in the long term), information and supervision by the physiotherapist throughout the intervention phase are essential, especially concerning the adequate use of the pelvic floor muscles during daily life activities and efforts and behavior of micturition. If the pelvic floor muscles are normally innervated and sufficiently attached to the endopelvic fascia, and, if by contracting her pelvic muscles before and during a cough, a woman is able to decrease that leakage [61], then simply learning when and how to use her pelvic muscles may be an effective therapy. In such cases, the subject needs to train to use this skill during those activities that transiently increase abdominal pressure [62]. DeLancey has also suggested that an effective pelvic floor muscle contraction may press the urethra against the pubic symphysis, creating a mechanical pressure rise [30]. Also Bø has suggested that a well-timed, fast, and strong pelvic floor muscle contraction may prevent urethral descent during intra-abdominal pressure rise [67,68]. So pelvic floor muscle training is especially focused on adequate timing, strength improvement, and coordination of the periurethral and the pelvic floor muscles. The frequency and the number of repetitions of exercises should be selected following assessment of the pelvic floor muscles. Daily regimes of increasing repetitions to the point of fatigue seem to be recommended (8–12 maximal pelvic floor muscles contractions, 1–3 seconds to 6–8 seconds hold/relax, three extra quick peak contractions superimposed on the maximal contraction, three times a day for at least 6 months [70]). A process of patient awareness of isolated contractions to fully automatic controlled function of the pelvic floor during multiple complex tasks is required [16]. It is very important to select relevant starting positions tailored to the individual patient while training. In addition, functional activities must be incorporated into the training program as soon as possible [43]. An individually tailored home exercise program manageable during daily life activity is essential [68]. In general, intensive training showed better results than a low intensity program [43,75,76]. Twenty-five percent of females are still dry after 5 years, while two-thirds of them indicate by follow-up that they are very satisfied with their present state and that they wish no further intervention. Biofeedback refers to a range of audiovisual techniques whereby information regarding “hidden” 664 physiological processes, in this case pelvic floor muscles contractions and relaxations, is displayed in a form understandable to the patient, to permit self-regulation of these events [43]. Recently, wireless biofeedback devices have been developed, introducing new technology and training program strategies (Figure 43. With the help of wireless biofeedback, numerous actions related to involuntary urine loss during daily activities can be mimicked, also enhancing the patient’s motivation and adherence. Further studies to validate these promising innovative techniques and applications are needed. They concluded that this form of biofeedback takes little time (an average of 5 minutes) and is effective as well as efficient and as such is a useful strategy to teach patients to produce the right contractions. Ultrasonography can also be used to estimate the volume (thickness) of the pelvic floor. Further research will be needed to assess methodological aspects of this type of biofeedback, such as its validity and reliability [58]. An incontinence patient can be taught, with the aid of biofeedback, to be selective in the use of the pelvic floor muscles (Figure 43. Nevertheless, in patients with urinary incontinence who have insufficient or no awareness of the pelvic floor muscles and therefore are not able to voluntary contract or relax their pelvic floor muscles or have very poor quality (intensity) of contraction at initial assessment, biofeedback is suggested to be an important strategy to quicken up and restore this awareness [43,55,67,82]. Electrical stimulation is generally provided by clinic-based electrical equipment (i. For stress incontinence electrical stimulation is focused on the restoration of the reflex activity through stimulation of the fibers of the pudendal nerve with the purpose to create a contraction of the pelvic floor muscles [83]. Electrical stimulation is suggested to lead to a motor response by patients for whom a voluntary contraction is not possible as a result of an insufficient pelvic floor, on the condition that the nerve is (partly) intact [84]. Although electrical stimulation appears to be better than placebo, its effect in stress incontinence has not been sufficiently demonstrated due to inconsistency in study protocols [43,72]. There are many differences in potential clinical application that have not yet been investigated. Equally, it may be that some populations or subgroups of patients benefit from electrical stimulation more than others. The following parameters may be used as a starting point: Pulse shape: bipolar rectangular square wave Frequency: 50 Hz Pulse duration: 200 microseconds Duty circle: ratio 1:2 Intensity of current: maximal tolerance Two times/week office bound, two times/day at home, until voluntary contraction by the patient himself or herself is possible and adequate 666 Magnetic stimulation has been developed for stimulating both central and peripheral nervous systems noninvasively [85]. Magnetic stimulation has been applied to pelvic floor therapy and the treatment of urinary incontinence and was reported in treatment of this condition for the first time in 1999 by Galloway et al. Within the chair’s seat is a magnetic field generator (therapy head) that is powered and controlled by an external power unit. Conventional stimulators deliver, at frequencies of 10–50 Hz, repetitive pulses of current between less than 100 microseconds [66] and 275 microseconds [65] in duration. Size and strength of the magnetic field are determined by adjusting this amplitude by the physiotherapist [86]. A concentrated steep gradient magnetic field is directed vertically through the seat of the chair. When seated, the patient’s perineum is centered in the middle of the seat, which places the pelvic floor muscles and sphincters directly on the primary axis of the pulsing magnetic field. Because of this, all tissues of the perineum can be penetrated by the magnetic field. Galloway indicated that no electricity, but only magnetic flux, enters the patient’s body from the device [86]. Goldberg indicated that, in contrast to electrical current, the conduction of magnetic energy is unaffected by tissue impedance, creating a major advantage in its clinical application compared to electrical stimulation. In that way, structures, such as sacral roots or pudendal nerves, might therefore be magnetically stimulated without patient’s discomfort or inconvenience of probe insertion for electrical stimulation [87]. On the other hand, the need for repeated office-based treatment sessions represents an inherent disadvantage. In contrast to electrical stimulation units, this kind of technology lacks portability, and, because both the depth and width of magnetic field penetration is proportional to coil diameter, the present technology according to Goldberg is best suited for stimulation of a field, rather than a narrowly focused target such as the sacral roots or the pudendal nerve [87]. Stimulation of sympathetic fibers maintaining smooth muscle tone within the intrinsic urethral sphincter seems to be involved in this mechanism of action [92,93]. Previous studies suggested a stimulation frequency of 50 Hz to be the most effective for urethral closure [86]. There was considerable variation in diagnostic groups, the regimen, protocols, intensity, and duration of treatment. The idea is that the stronger the pelvic floor muscles grow, the higher weight of a cone can be held in place and therefore continue to stimulate the pelvic floor muscles to hold the cone inside the vagina. Vaginal cones may add benefit to a training protocol if subjects are asked to contract around the cone and simultaneously try to pull it out in lying or standing position while performing their pelvic floor muscle exercises in the way described earlier [96]. Because of the lack of evidence about their efficacy and doubts regarding the theoretical basis of this treatment modality, Bo et al. On the other hand, in the latest update of their Cochrane Collaboration Review, Herbison and Dean suggest that, based on the sparse evidence that weighted vaginal cones are better than no active treatment, these could be offered as one treatment option, if women find them acceptable [97]. During the treatment, the following techniques are used: digital palpation either by the patient herself or by the physiotherapist and electrical stimulation and/or biofeedback in combination with pelvic floor muscles training. If a pelvic floor dysfunction coexists with dysfunctions of the respiration or the locomotive tract or with inadequate toilet behavior, these issues need to be addressed additionally. The ultimate aim of the treatment is a complete restoration of the functionality of the pelvic floor. Here, pelvic floor training can only provide some degree of compensation at the most. Stress Incontinence in Combination with General Factors That Inhibit or Delay Improvement or Recovery In this case, physiotherapy will aim at the reduction of these negative general factors. Avoiding specific situations by the patient, impaired social participation, and feelings of shame related to involuntary urine loss can be reduced by the physiotherapist using relevant information, education, counselling, and care. All physiotherapeutic modalities can be used alone or in combination with each other or in combination with medication. Patient information and education is provided about the lower urinary tract function, the function of the pelvic floor, and the way to contract and relax the pelvic floor. The goal of toilet training is to change inadequate toilet behavior and regimens, i. BlT aims to restore normal bladder function using patient education together with a scheduled voiding regimen in order to increase the time interval between two consecutive voidings [98,99]. The next component involves training to inhibit the sensation of urgency and to postpone voiding. The third is to urinate according to a timetable in patients with an interval less than 2 hours between two consecutive micturitions in order to reach an interval of at least 3 hours between two consecutive voidings and to reach larger voided volumes. Especially in those patients whose functional capacity of the bladder is too small, a BlT program can provide normalization of bladder capacity. Improvement of cortical inhibition over involuntary detrusor contractions [101], central modulation of afferent sensory impulses or cortical facilitation over urethral closure during bladder filling [102], and behavioral changes leading to an increase of “reserve capacity” of the lower urinary tract system [103] have been proposed. The level of activation is so high that selective contraction of the pelvic floor muscles in order to achieve reciprocal inhibition of the bladder is very difficult or not possible [106]. Teaching selective contraction and relaxation of the pelvic floor muscles is then an important first step. After testing a patient’s ability to hold contractions for at least 20 seconds by digital palpation by the physiotherapist, patients are instructed to do so, followed by a relaxation period of 10 seconds. A more functional training program (pelvic floor exercises during daily living activities) completes the exercise program. Electrical stimulation aims to inhibit involuntary detrusor contractions through selective stimulation of afferent and efferent nerve fibers in the pelvic floor. This activity results in contraction of the para- and periurethral musculature either directly or via spinal reflexes [84].

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Ines, 55 years: The mechanisms of the different forms of acceleration probably differ, but documentation would require detailed study with multisite mapping of the reentrant circuit.

Mitch, 61 years: Once the supplies are gathered, positioning the patient in a semireclining position with good lighting will aid her in seeing the urethral orifice with a mirror.

Julio, 21 years: Care must be taken to avoid a “knitting needle” effect between instruments and the laparoscope; all ports should be placed in such a way that they have free movement and do not interfere with one another.

Mezir, 63 years: They help in the blood and lymph stream, accumulated proliferation and circulation of T and B cells.

Potros, 58 years: Although there has been some evidence supporting a congenital etiology, this theory seems less likely to be the principle etiology given that two large series included no patients younger than 10 years of age [14,20].

Marlo, 45 years: This suggests complete sinoatrial block as well as intrasinus Wenckebach-type block.

Kalan, 30 years: The most common arrhythmias requiring conversion are atrial flutter, atrial fibrillation, ventricular tachycardia, and ventricular fibrillation.

Ben, 34 years: Two tricks can be used: Placing the patient on steep reverse Trendelenburg Inserting an extra 5 mm trocar above and to the left of the umbilical trocar (Fig.

Rhobar, 25 years: National Health and Wellness Survey, which were an Internet-based questionnaire of a national sample of adults (total n = 75,000).

Jared, 64 years: The system also provides activation and voltage analysis, making it ideal for ablation of stable rhythms.

Sugut, 37 years: Proteins of vegetable origin are usually biologically incomplete since they lack one or more of the essential amino acids.

Porgan, 51 years: No matter what view a picture is taken from, you always want a view looking back to where you entered.

Raid, 27 years: In vitro studies show a strong dose-related relaxant effect of β -agonists on the bladder body of2 rabbits but little effect on the bladder base or proximal urethra.

Masil, 62 years: Although increasing the current shortened the measured refractoriness from 10 to 70 msec, there was no relationship between the degree of shortening of measured refractoriness and the ability to terminate the tachycardia (Fig.

Dargoth, 42 years: Short forms to assess life quality and symptom distress for urinary incontinence in women: The Incontinence Impact Questionnaire and the Urogenital Distress Inventory.

Rakus, 48 years: One study has shown that 16% of its Turner’s population have undergone spontaneous puberty [78].

Kerth, 38 years: When the cannula is torqued or forced to go around a curved surface, the result may be sub- optimal.

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