By M. Hamlar. Elizabeth City State University. 2019.

The rationale for its use is either relaxation of the pelvic floor striated musculature during bladder contraction or that such relaxation removes and inhibitory stimulus to reflex bladder activity buy vardenafil 10 mg. However buy cheapest vardenafil and vardenafil, improvement under such circumstances may simply be due to the antianxiety effect of the drug or to the intensive explanation cheap vardenafil uk, encouragement discount 20 mg vardenafil visa, and modified biofeedback therapy that usually accompanies such treatment in these patients. Accordingly, the primary sites of action of baclofen are the spinal cord and brain. Its effect in reducing spasticity is caused primarily by normalizing interneuron activity and decreasing motor neuron activity [159]. Drug delivery often frustrates adequate pharmacological treatment, and baclofen is a good example of this. Intrathecal infusion bypasses the blood–brain barrier and cerebrospinal fluid levels 10 times higher than those reached with oral administration are achieved with much lower doses [277]. Nanninga and colleagues [278] reported on such administration to seven patients with intractable bladder spasticity: all patients experienced a general decrease in spasticity and the amount of striated sphincter activity during bladder contraction. Potential side effects of baclofen include drowsiness, insomnia, rash, pruritus, dizziness, and weakness. Sudden withdrawal has been shown to provoke hallucinations, anxiety, and tachycardia; hallucinations due to reductions in dosage during treatment have also been reported [214]. Development of tolerance to intrathecal baclofen with a consequent requirement for increasing doses may prove to be a problem with long-term chronic usage. Dantrolene Dantrolene exerts its effect by direct peripheral action on skeletal muscle [279]. It is thought to inhibit the excitation-induced release of calcium ions from the sarcoplasmic reticulum of striated muscle fibers, thereby inhibiting excitation-contraction coupling and diminishing the mechanical force of contraction. In adults, the recommended starting dose is 25 mg daily, gradually increasing by increment of 25 mg every 4–7 days to a maximum oral dose of 400 mg given in four divided doses. Hackler and colleagues [281] reported an improvement in voiding function in approximately half of their patients treated with dantrolene but found that such improvement required oral doses of 600 mg daily. Although no inhibitory effect on bladder smooth muscle seems to occur [282], the generalized weakness that dantrolene can induced is often sufficiently significant to compromise its therapeutic effects. Potential side effects other than severe muscle weakness include euphoria, dizziness, diarrhea, and hepatotoxicity. All patients except one were able to void spontaneously, and all but two were able to discontinue catheterization. It is considered to be a centrally acting2 agent with a variety of associated systemic effects including antihypertensive, antinociceptive, and antispasmodic effects. Adverse effects included significant reductions in blood pressure and sedative effects. The drug can be administered by oral, parenteral, or intranasal spray and effectively suppresses urine production for 7–10 hours. Further studies in nonneurological patients have confirmed the efficacy and determined effective dose regimens for the treatment of nocturia [290]. Given the safety concerns over hyponatremia, it is recommended that the drug not be given in patients older than 79 years of age or to those with 24 hour urine volumes >28 mL/kg. It is also 743 recommended that serum sodium levels be checked at baseline and at 3 and 7 days after starting treatment or changing dose [292]. General precautions including limiting fluid intake from 1 hour before the dose until 8 hours after, periodic blood pressure measurements, and weight measurements to monitor for fluid overload should be instituted. The original intranasal spray has been withdrawn from the market in several countries due to side effects and unpredictable absorption. Loop Diuretics Bumetanide A similar circumventive approach is to give a rapidly acting loop diuretic 4–6 hours before bedtime. Side effects include hyperuricemia, hypochloremia, hypokalemia, hyponatremia, hyperglycemia, and serum creatinine elevation [295]. The standardisation of terminology of lower urinary tract function: Report from the Standardisation Sub-committee of the International Continence Society. Pharmacology of the lower urinary tract: Basis for current and future treatments of urinary incontinence. Antimuscarinics and the overactive detrusor—Which is the main mechanism of action? Muscarinic receptors of the urinary bladder: Detrusor, urothelial and prejunctional. Management of detrusor dysfunction in the elderly: Changes in acetylcholine and adenosine triphosphate release during aging. The effects of antimuscarinic treatments in overactive bladder: An update of a systematic review and meta-analysis. Muscarinic receptor antagonists for overactive bladder treatment: Does one fit all? Darifenacin, an M3 selective receptor antagonist, is an effective and well tolerated once daily treatment for overactive bladder. Increased warning time with darifenacin: A new concept in the management of urinary urgency. Assessment of cognitive function of the elderly population: Effects of darifenacin. Clinical efficacy, safety, and tolerability of once-daily fesoterodine in subjects with overactive bladder. Fesoterodine: A novel muscarinic receptor antagonist for the treatment of overactive bladder syndrome. Pharmacological characterization of a novel investigational antimuscarinic drug, fesoterodine, in vitro and in vivo. Impact of fesoterodine on quality of life: Pooled data from two randomized trials. Cystometric response to propantheline in detrusor hyperreflexia: Therapeutic implications. Randomized, double-blind, multi-center trial on treatment of frequency, urgency and incontinence related to detrusor hyperactivity: Oxybutynin versus propantheline versus placebo. M(3) receptor antagonism by the novel antimuscarinic agent solifenacin in the urinary bladder and salivary gland. Solifenacin appears effective and well tolerated in patients with symptomatic idiopathic detrusor overactivity in a placebo- and tolterodine-controlled phase 2 dose-finding study. Randomized, double-blind placebo controlled trial of the once daily antimuscarinic agent solifenacin succinate in patients with overactive bladder. Solifenacin: As effective in mixed urinary incontinence as in urge urinary incontinence. Efficacy and tolerability of solifenacin in elderly subjects with overactive bladder syndrome: A pooled analysis. Pharmacokinetics and pharmacodynamics of tolterodine in man: A new drug for the treatment of urinary bladder overactivity. Tolterodine is not subtype (M1–M5) selective but exhibits functional bladder selectivity in vivo. Tolterodine—A new bladder selective muscarinic receptor antagonist: Preclinical pharmacological and clinical data. Tolterodine once daily: Superior efficacy and tolerability in the treatment of overactive bladder. Effects of bladder training and/or tolterodine in female patients with overactive bladder syndrome: A prospective, randomized study. Simplified bladder training augments the effectiveness of tolterodine in patients with an overactive bladder. Clinical efficacy of tolterodine with or without a simplified pelvic floor exercise regimen. Effects of tolterodine, trospium chloride, and oxybutynin on the central nervous system. Intravesical instillation of human urine after oral administration of trospium, tolterodine, and oxybutynin in a rat model of detrusor overactivity. Effect of trospium chloride on urodynamic parameters in patients with detrusor hyperreflexia due to spinal cord injuries: A multicenter placebo-controlled double-blind trial.

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An enterocele is a form of pelvic organ prolapse with the bowel protruding into the vagina purchase genuine vardenafil on line. Why and how are etiological and pathophysiological issues which are illustrated in this chapter generic 20mg vardenafil with amex. Surgical treatment of an enterocele is often concurrent or identical to operations for vaginal vault prolapse buy vardenafil now. Therefore buy vardenafil 10 mg overnight delivery, the pouch of Douglas is an anatomical structure that plays an important and probably predisposing part. The pouch of Douglas is normally closed and does not contain intestine or omentum. In anatomy textbooks, the extent of the pouch of Douglas has traditionally been described as 2–3 cm below the uterosacral ligaments (e. Histological studies by Uhlenhuth and colleagues have demonstrated that in the fetus the pouch of Douglas may extend to the perineal body [3]. The consecutive fusion of the anterior and posterior peritoneum forms the rectovaginal septum and determines the depth of the pouch of Douglas [3–5]. According to Uhlenhuth, the rectovaginal septum is distinguishable from the “fascial” capsule of the vagina and rectum. In contrast to anatomy textbooks, intra-abdominal measurements of the depth of the pouch of Douglas in young nulliparous women revealed great variations with 25%–75% of the posterior vaginal wall covered with peritoneum [6]. The mean depth of the pouch of Douglas was 49% of vaginal length in nulliparas, 46% in parous women, and was significantly deeper (72%) in patients with posterior vaginal wall prolapse. It would appear that the deep pouch of Douglas is frequently present in young nulliparous women without pelvic organ prolapse, which implies a congenital variation and predisposition [6]. A sophisticated concept of normal pelvic organ support accentuates the imperative role of several factors including integrity of the anterior and posterior endopelvic fascia with intact attachments as well as normal tone, position, and functionality of the levator ani muscle. Normal pelvic floor muscle and fascial structures are required to hold the perineum in place and ensure normal bladder, bowel, and sexual function. It is apparent that fascial defects in the three levels of vaginal support and the posterior compartment may contribute to pelvic organ prolapse including enteroceles [7,8]: the normal pelvic floor tone is essential for the nearly horizontal axis of the vagina, which in turn is necessary to allow for a normal pelvic floor protecting intra-abdominal pressure distribution. Intra-abdominal measurements of the depth of the pouch of Douglas have shown that in women with posterior vaginal 1268 wall and anterior rectal wall prolapse the pouch of Douglas is significantly deeper and may reach the level of the perineal body [6]. In addition, the anatomy of the pouch of Douglas is considerably different, which is a recognized feature in some studies. In women with severe pelvic organ prolapse, a large or voluminous rectovaginal pouch was a consistent anatomic finding, requiring obliteration during pelvic reconstructive surgery [9–11]. Apart from a mobile vaginal axis and a dehiscence of the levator hiatus, French authors reported a “grande fosse pelvi-périnéale”—a large pelvic pouch—to be the principal lesion in women with enteroceles [12]. Other authors described this phenomenon as an abnormally deep and wide cul-de-sac with a 3D enlargement [13]. Their anatomical observations included a deep and wide rectovaginal pouch and a rectosigmoid colon, which closely follows the sacral curve (Figure 83. Although different positions and courses of the sigmoid colon and its mesentery are known [14], systematic descriptions in women with pelvic organ prolapse are scarce. Baessler and Schuessler found 64% of women with enteroceles and all women with anterior rectal wall procidentia to have these features, termed as “grande fosse pelvienne. Given these findings, it seems reasonable to regard a deep pouch of Douglas as a risk factor for enterocele formation. An enterocele can only develop when other factors open and expose the deep pouch of Douglas. Normal pelvic floor support prevents opening and exposure of the pouch of Douglas. Vaginal Axis In a woman with normal pelvic organ support, the pouch of Douglas is closed, irrespective of its depth, and lies nearly horizontally between the levator plate and the vagina [16–18]. It is known that operations that change the vaginal axis can lead to increased prolapse in the “unprotected” area. This is true for the higher incidence of cystoceles after sacrospinous fixations, where the position of the vagina is more posterior and also for the considerate rate of rectoceles and enteroceles after Burch colposuspensions or ventrofixations where the vagina is displaced anteriorly. A further process that changes the vaginal axis is excessive perineal descent (or descending perineum syndrome), which is often seen clinically in women with significant posterior vaginal wall prolapse (Figure 83. A deep pouch of Douglas is likely to accentuate the process of enterocele development once the vaginal axis is changed. Endopelvic “Fascia” The integrity of the anterior and posterior endopelvic fascia or connective tissue and its attachments is essential for normal pelvic organ support [8]. A defect in the endopelvic fascia or insufficiency is necessary for an enterocele to protrude. However, an intact endopelvic connective tissue might only prevent the enterocele from bulging into the vagina but not into the rectum causing an anterior rectal wall procidentia (Figure 83. It is not entirely apparent whether the endopelvic fascia is identical to the rectovaginal septum as the latter can be rather short [20], depending on the depth of the pouch of Douglas. Whole-thickness biopsies of the leading edge of radiologically proven enteroceles showed that in none of the 13 women examined the vaginal epithelium was in direct contact with the perineum and all had a well-defined vaginal wall muscularis [21]. These findings add to the ongoing controversy on whether the fascia exists or not. It has been suggested that it is a structure that is artificially created during surgical dissection. This debate is complicated by inconsistent histological studies, some of which do not substantiate the concept of a fascia between the rectum and vagina. However, it might simply be a question of definition: the fascia is a connective tissue usually with smooth muscle cells and it might also contain fatty or areolar tissue [22] (Figure 83. Whether the fascia is part of the vagina or rectum or whether it is a separate structure is of scientific but not clinical value. Fascia in the clinical sense means connective tissue that has tensile strength and is strong enough to hold sutures and support the underlying organs. These photos demonstrate a nearly normal position of the perineum at rest (a) but a “ballooning” of the perineum on straining (b). This patient had a large rectoenterocele that did not protrude outside the introitus. This stain is used to differentiate fibrous tissue (green) and smooth muscle (red). Note the amount of smooth muscle, organized connective tissue, and areolar tissue. Apart from bowel symptoms, which can be similar to complaints of patients with rectoceles or enteroceles, excessive perineal descent of more than 2 cm (measured in relation to the ischial tuberosities) is seen more frequently in women with posterior vaginal wall prolapse [24]. Solitary rectal ulcer, rectal prolapse, and intussusception are common concomitant findings [24,25]. The etiology is unclear, but reduced pelvic floor tone [26] with insufficient perineal and endopelvic fascial attachment and a deep pouch of Douglas and sigmoid colon elongation have been discussed. The term “ballooning” is also used to describe an enlargement of the genital hiatus during straining on perineal 3D ultrasound and is associated with pelvic organ prolapse [27]. Pulsion, Traction, Sliding, True, and Congenital: Concepts of Enterocele Development There are different concepts, and each one of them might be true in an individual patient. It is argued that a 1271 traction enterocele is accompanied by the loss of pelvic organ support [17] and a greater vault descent with normal anatomical connections between the pouch of Douglas and vagina [28,29]. In contrast, according to Nichols and Genadry [17], a pulsion enterocele is secondary to increased abdominal pressure, whereas Zacharin states that a pulsion enterocele occurs as a late complication of pelvic surgery like hysterectomies and is associated with a large rectovaginal pouch [28]. However, Zacharin is convinced that the depth of the pouch of Douglas has no bearing on enterocele development. He considers levator incompetence and relaxation of the fascial support to be the primary defects. Nichols and Genadry describe iatrogenic enteroceles as a sequela to operations that alter the vaginal axis like Burch colposuspension and congenital enteroceles, which are associated with an “unusually” deep pouch of Douglas (Figure 83. In theory, an enterocele can only develop when important anatomical factors change: the vagina becomes more vertical and the (deep) pouch of Douglas opens or the pubocervical and rectovaginal fascia are separated. Whether a discrete defect in the endopelvic connective tissue is also required remains a topic for discussion. Therefore, Zacharin’s observation of a common deep pouch of Douglas found only in Chinese females corroborates the ones mentioned earlier: their pelvic floor status including tone and support prevents an exposure of the rectovaginal pouch. Rectal Prolapse Colorectal surgeons view prolapse with a different attitude but have similar problems defining the pathophysiology of rectal prolapse, which might originate from the pouch of Douglas [30]. Altemeier described three types: type 1 is a false prolapse due to mucosal redundancy, type 2 is an intussusception without an association with the pouch of Douglas, and type 3 is a sliding hernia of the rectovaginal pouch [31].

Not all racic system that is usually found 2 or 3 cm deep to the skin patients with hyperprolactinemia present with breast hyper- at the level of the inframammary fold buy vardenafil 20mg with amex. The sensory innervation of the breast is mainly derived from Another reported association is between hypercalcemia the anterolateral and anteromedial branches of thoracic inter- and juvenile and pregnancy-induced hypertrophy purchase vardenafil 20 mg mastercard, which has costal nerves T3–T5 order 10mg vardenafil amex. The anterior branch of the lism cheap vardenafil 20 mg overnight delivery, one case of macromastia in an infant with Alagille’s third intercostal nerve also contributes to the sensitivity of syndrome has been reported in literature, in which mam- the nipple-areola complex; it takes a superficial course within mary hypertrophy was directly correlated to alterations in the subcutaneous tissue and terminates at the medial areolar the hepatic metabolism of estrogens, rather than to their border [17]. The importance of the role of indinavir for this particular 3 Treatment case of gigantomastia is confirmed by several considerations: Reduction mammaplasty is the best therapeutic approach for • Serum level of estrogens or prolactin is within the normal patients with mammary hypertrophy, for both physical and range. Its goal is to achieve a reduction of • Indinavir frequently causes nonspecific morphological breast volume while maintaining vascularization and inner- changes of some body segments (e. The first attempts at reducing breast volume were purely • Discontinuation of indinavir alone, while receiving the other functional, and it is only in the last century that aesthetic drugs, leads to a complete remission of the clinical picture. Up until 1960, techniques of breast reduction were not Another rare condition is gigantomastia in patients with safe, because of extensive skin and glandular undermining. The first In 1957, Arie realized that it was preferable to avoid any case was described by Desai in 1973. In 1963, Skoog It is likely that by reducing circulating levels of sex proposed an inferoposterior resection and the transposition hormone-binding globulin, D-penicillamine induces an of the nipple-areola complex on a laterally based dermal increase in serum levels of estrogens, thereby causing mam- pedicle flap, laying the basis for the development of modern mary hypertrophy, or possibly by chelating zinc ions, breast reduction mammaplasty. A direct action on the mammary gland is also to be with an increasing interest in reducing scars’ length [4, 11]. Discontinuation of D-penicillamine leads to an The choice of technique depends on the size of the arrest in breast enlargement [14 ]. Obesity plays an important role in the pathogenesis of breast hypertrophy; breast volume increases in all over- weight conditions, and it is not surprising that obese patients 4 Authors’ Technique (Fig. In the literature it is reported that the hypertrophic breast Accurate skin markings are made preoperatively, which basi- is composed primarily of adipose and fibrous tissue, while cally refer to Lejour’s vertical scar technique; for this pur- the glandular component remains essentially stable. She also observed that the body mass index the nipple is drawn from these points to the inframammary has more influence than age on the amount of breast fat [10]. This pathologic finding has also been highlighted by The new nipple-areola complex position is drawn at the Strömbeck, who proposed the term “macromastia” for intersection of the inframammary fold and the breast merid- patients requiring reduction mammaplasty, considering ian that usually correspond to a distance of 19–22 cm from incorrectly a diagnosis of “mammary hypertrophy” [16]. The areola Several authors confirmed the importance of the fat com- region is marked with circular patterns on photographic film, ponent in the enlarged breast and reported their experience obtaining a periareolar circumference of between 14 and with liposuction as an integral part of the surgical treatment 18 cm. The skin is then dis- marked by turning the breast in a clockwise direction and sected medially and laterally, as necessary, and the dissec- counterclockwise, respectively. Next, de-epithelialization of the of a wedge below the de-epithelialized area is performed. In patients with flaccid skin and for resections of over tion of the scar is decided upon. Lejour M (1997) Evaluation of fat in breast tissue removed by verti- therapy to control juvenile mammary hypertrophy. Cordova A, Corradino B, Maltese G, Napoli P, Graziano A, lipectomy to reduce large breasts. Plast Reconstr Surg 105: Moschella F (2000) Mastoplastica riduttiva a peduncolo superiore 2604–2607 nelle gigantomastie. Schelnz I, Kuzbari R, Gruber H, Holle J (2000) The sensitivity of classification and review of the literature. Würinger E, Mader N, Posch E, Holle J (1998) Nerve and vessel of the breast in a patient treated with indinavir. Plast 25:937–938 Reconstr Surg 101:1486–1493 Aesthetic Surgery for Breast Asymmetry L. Nicolas Mclean Breast asymmetry is a frequent and difficult problem for in order to make the appropriate surgical decision. Asymmetry of the considerations include the patient’s age, the patient’s matu- breasts can be either congenital or acquired and includes rity, the recent breast growth history, the number of children breast mound volume, inframammary fold position, pres- ence of base diameter constriction, and asymmetries of the nipple/areolar complex size and position [1, 2]. Acquired breast asymmetry can be secondary to previous aesthetic surgery or secondary to previous breast reconstructive sur- gery. This chapter will concentrate on both congenital breast asymmetry and acquired breast asymmetry second- ary to previous aesthetic surgical procedures (Figs. While aesthetics are enormously important to the suc- cess of breast reconstruction, breast reconstruction cases will not be considered here. Congenital breast asymmetry can be asymmetry of size or shape or, of course, both. Poland’s syndrome, which is the congenital absence of a part or the entire breast, is a relatively separate issue, as it requires more extensive sur- gery over a longer period of time. Congenital asymmetry with regard to size is usually due to decreased growth of one breast, but there can be infinite variables in the presentation of this problem. Conversely, the breast could also be too large on one side compared to the smaller side that is acceptable to the patient. The first consid- eration in this situation is to determine which size the patient prefers and, if neither, what size she would like to be. Mclean the patient has and expectations for future children, expecta- As mentioned above, pregnancy can certainly change breasts tions of results, family history of breast cancer, and previous by making them larger or smaller, and this may vary in the breast pathology. The age and mental maturity of the patient situation of congenital breast asymmetry. Surgery before or are important in deciding the timing for the surgical proce- after the pregnancy is not contraindicated in case of signifi- dure. For instance, the circumareolar, There is nothing set in stone about age 18, but in general, we or inverted-T operation, yields a flatter, broader breast, while prefer to not operate on patients under 18 and to consider the vertical pattern yields a more projecting, narrowly based surgery thereafter. The technique for the circumareolar reduction as deformities, operations can be performed after breast devel- described by Goes [15] (but without mesh) is our preferred opment and asymmetry have occurred. However, it is also somewhat limited by size con- emphasized to the patient and her parents that subsequent straints. The operation is done by creating a circle, the point procedures will most likely be needed. The number of children the patient has and expectations for A circle is then drawn from this area around the underlying future children should be taken into consideration, chiefly with nipple/areolar complex (Figs. A specimen is patient has had all her children, obviously the breast changes removed from the 11 to the 1 o’clock position, plicating the and concern for breast feeding are not a factor. On the other breast tissue to itself to restore the upper pole of the breast hand, if a patient is nulliparous and expects to have children, and even advancing the upper pole cephalad. It is likely that specimen can be removed from the 5–7 o’clock position infe- most patients after breast procedures will be able to breast-feed riorly, plicating the inferior pole to itself, achieving more pro- [3 – 5]. However, there is a certain percentage that cannot, and jection, and tightening the lower pole of the breast. In this situation, a patient who are usually limited to 200–300 g using this technique. We cannot seem to realize that breasts will sag over time or who reserve the choice for the circumareolar breast reduction for desire overly large breasts should be counseled with care and those patients whose sternal notch to nipple distance is no perhaps rejected until their expectations are more realistic. This is because the circumareolar design Most complications can be avoided with careful planning must be brought down to a 38–42 mm circle, which creates a and decision making. Primary augmentation demands a care- large amount of skin gathering if the distance from the sternal ful evaluation of the breast morphology and chest wall anat- notch to the nipple is greater than 24. A family history of breast cancer does not preclude The limited scarring for the circumareolar approach is breast surgery, but, again, a thorough discussion of this sub- obviously preferred, but one must be aware that the skin ject is appropriate. Multiple studies support the conclusion gathering and pleating can be significantly undesired side that silicone and saline breast implants do not delay the effects and may require conversion to the vertical or at the detection or cause breast cancer [7 – 11], but the submuscular least a secondary scar, revision procedure. Implants however appear to facilitate tumor detection on used, as described by Lassus [16]. Patients with history of previous more breast tissue can be reliably removed, although the benign or malignant breast pathology may require proce- excision of tissue is usually not carried above 500–600 g. This should be explained to the patient, the breast and gives increased anterior projection, thus mak- although radiologists have become increasingly capable of ing a more conical-shaped breast (Figs. It is also site breast is an appropriate size, reduction of the larger important to anticipate some sag of the vertical technique, as breast is performed [14]. Thus, what one have been discussed and the timing is appropriate for the sees on the operating room table is not what will be seen 3 individual patient, an operation can be decided upon. Certainly, breasts can grow after surgery, but this is relatively The inverted-T incision is rarely used in correcting con- uncommon, particularly after patients are 18 years or older. Only the very largest, most ptotic breast Aesthetic Surgery for Breast Asymmetry 249 F i g. It is important to match the larger breast, hopefully without the need for a pro- try to avoid scarring as much as possible and limit the proce- cedure on the larger breast.

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