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OBJECTIVE:To assess the menstrual hygiene needs of low-income women in St. Louis, Missouri.METHODS:Using an exploratory, cross-sectional design, women 18 years of age and older were recruited from a purposive sample of 10 not-for-profit community organizations that serve low-income women in St. Loui

Objectives To review the historical background surrounding the early work of Dr. J. Marion Sims, who developed the first consistently successful surgical technique for the repair of obstetric vesicovaginal fistulas by operating on a group of young, enslaved, African American women who had this condition between 1846 and 1849. Methods Review of primary source documents on Sims and his operations, early 19th century clinical literature on the treatment of vesicovaginal fistula, the introduction of ether and chloroform anesthesia into surgical practice, and the literature on the early 19th century medical ethics pertaining to surgical innovation. The goals are to understand Sims's operations within the clinical context of the 1840s and to avoid the problems of "presentism," in which beliefs, attitudes, and practices of the 21st century are anachronistically projected backward into the early 19th century. The object is to judge Sims within the context of his time, not to hold him accountable to standards of practice which were not developed until a century after his death. Results A narrative of what Sims did is presented within the context of the therapeutic options available to those with fistula in the early 19th century. Conclusions Review of the available material demonstrates that Sims' first fistula operations were legal, that they were carried out with express therapeutic intent for the purpose of repairing these women's injuries, that they conformed to the ethical requirements of his time, and that they were performed with the patients' knowledge, cooperation, assent, and assistance.

Importance Adequate management of menstrual hygiene is taken for granted in affluent countries; however, inadequate menstrual hygiene is a major problem for girls and women in resource-poor countries, which adversely affects the health and development of adolescent girls. Objective The aim of this article is to review the current evidence concerning menstrual hygiene management in these settings. Evidence Acquisition A PubMed search using MeSH terms was conducted in English, supplemented by hand searching for additional references. Retrieved articles were reviewed, synthesized, and summarized. Results Most research to date has described menstrual hygiene knowledge, attitudes, and practices, mainly in sub-Saharan Africa and South Asia. Many school-based studies indicate poorer menstrual hygiene among girls in rural areas and those attending public schools. The few studies that have tried to improve or change menstrual hygiene practices provide moderate to strong evidence that targeted interventions do improve menstrual hygiene knowledge and awareness. Conclusion and Relevance Challenges to improving menstrual hygiene management include lack of support from teachers (who are frequently male); teasing by peers when accidental menstrual soiling of clothes occurs; poor familial support; lack of cultural acceptance of alternative menstrual products; limited economic resources to purchase supplies; inadequate water and sanitation facilities at school; menstrual cramps, pain, and discomfort; and lengthy travel to and from school, which increases the likelihood of leaks/stains. Areas for future research include the relationship between menarche and school dropout, the relationship between menstrual hygiene management and other health outcomes, and how to increase awareness of menstrual hygiene management among household decision makers including husbands/fathers and in-laws. Target Audience Obstetricians and gynecologists, family physicians. Learning Objectives After completion of this educational activity, the obstetrician/gynecologist should be able to define what is meant by “adequate menstrual hygiene management,” identify the challenges to adequate menstrual hygiene management that exist in resource-poor countries, and describe some of the intervention strategies that have been proposed to improve menstrual hygiene management for girls and women in those countries.

Rupture of the gravid uterus is an obstetric catastrophe associated with high levels of maternal-fetal mortality and morbidity.The aim of this study was to review the clinical experience with uterine rupture in resource-poor countries.A MEDLINE search of the clinical literature since 1960 was carried out using the headings "uterine rupture" and "ruptured uterus," including the Medical Subject Heading "developing countries." Further bibliographic compilation was assisted by hand searches of references from retrieved articles. The available articles were then reviewed, synthesized, and summarized.Uterine rupture remains a major obstetric problem in resource-poor countries. In industrialized, high-resource countries, uterine rupture occurs most often in women who have had a previous cesarean delivery, whereas in resource-poor nations, uterine rupture is more commonly associated with obstructed labor, injudicious obstetric interventions/manipulations (often performed by untrained birth attendants), lack of antenatal care, grand multiparity, and poor access to emergency obstetric care. Uterine rupture after a prior cesarean delivery is becoming more common in these countries as more women gain access to emergency obstetric care.Uterine rupture afflicts the world's poor women disproportionately. In resource-poor settings, uterine rupture is a reflection of ill-equipped, badly managed, and underresourced health care systems that seem largely indifferent to the reproductive health needs of women. The ultimate success (or failure) of these countries depends in large part upon their commitment to maintaining a healthy and productive female population.

An obstetric fistula is classically regarded as an "accident of childbirth" in which prolonged obstructed labor leads to destruction of the vesicovaginal/rectovaginal septum with consequent loss of urinary and/or fecal control. Obstetric fistula is highly stigmatizing and afflicted women often become social outcasts. Although obstetric fistula has been eliminated from advanced industrialized nations it remains a major public health problem in the worlds poorest countries. Several million cases of obstetric fistula are currently thought to exist in sub-Saharan Africa and south Asia. Although techniques for the surgical repair of such injuries are well known it is less clear which strategies effectively prevent fistulas largely because of the complex interactions among medical social economic and environmental factors present in those countries where fistulas are prevalent. This article uses the Haddon matrix a standard tool for injury analysis to examine the factors influencing obstetric fistula formation in low-resource countries. Construction of a Haddon matrix provides a "wide angle" overview of this tragic clinical problem. The resulting analysis suggests that the most effective short-term strategies for obstetric fistula prevention will involve enhanced surveillance of labor improved access to emergency obstetric services (particularly cesarean delivery) competent medical care for women both during and after obstructed labor and the development of specialist fistula centers to treat injured women where fistula prevalence is high. The long-term strategies to eradicate obstetric fistula must include universal access to emergency obstetric care improved access to family planning services increased education for girls and women community economic development and enhanced gender equity. Successful eradication of the obstetric fistula will require the mobilization of sufficient political will at both the international and individual country levels to ensure that adequate resources are devoted to this problem and that maternal health becomes a high priority on national political agendas. TARGET AUDIENCE: Obstetricians & Gynecologists and Family Physicians. LEARNING OBJECTIVES: After participating in this CME activity physicians should be better able to apply the Haddon matrix a tool commonly used for injury analysis to the field of obstetrics and gynecology; analyze the problem of obstructed labor and obstetric fistula formation in low-resource countries using the Haddon matrix and implement possible strategies for the prevention of obstetric fistulas and the mitigation of harm in cases of obstructed labor that arise from the use of the Haddon matrix.

Most physicians deny their professional integrity can be "bought" by something as trivial as a cup of coffee or a free lunch. In this paper, we review the social science literature arguing that "gifting" physicians in this way is, in fact, a highly successful method of boosting drug sales. Unlike ordinary consumer goods, the sale of prescription drugs does not take place directly between the producer and the consumer; rather, prescription drug sales are mediated by the physician who writes the script for the medication. Pharmaceutical sales practices are geared toward influencing physician drug recognition so that, when prescriptions are written, their drug is the first one that comes to mind. Even small gifts produce in their recipients a disproportionately powerful willingness to reciprocate in some manner. The simple act of providing food has been shown to make any message more palatable and more likely to be favorably received. We argue that physician prescribing habits should be based upon careful consideration of what medication is really in the patient's best clinical interests, not on who most recently provided the doctor with a free lunch.

As marketing efforts by drug companies become more aggressive, physicians are being asked to provide clinical "preceptorships" to pharmaceutical sales representatives. During a "preceptorship" of this type, the company representative spends a day with the physician seeing patients "as an educational experience," and the physician receives an "honorarium" from the drug company in return. We explore the implications of this practice. First, we examine the nature of the doctor/patient relationship and the fiduciary obligations incumbent upon physicians in their role as healers. Second, we examine four interlocking ethical principles-nonmaleficence, beneficence, respect for patient autonomy, and justice-that should govern doctor/patient encounters. Third, we critique several hypothetical scenarios involving individuals who might put forth a claim to enter the doctor/patient relationship (ie, a pharmacist, a social scientist, the husband of the patient, and a pharmaceutical sales representative). We conclude that the practice of providing clinical "preceptorships" to pharmaceutical sales representatives is unjustifiable, is unethical, and should not be permitted.

Objective: To determine if the clinical diagnosis of stress urinary incontinence made on the basis of simple criteria correlates with the diagnosis of genuine stress incontinence as determined by provocative multichannel urodynamic testing. Methods: The charts of 652 women who presented for clinical evaluation of a variety of lower urinary tract complaints were reviewed if they met all of the following criteria: 1) a predominant complaint of stress incontinence, 2) positive cough stress-test results, 3) postvoid residual urine volume no more than 50 mL, 4) a functional bladder capacity of at least 400 mL as determined by a completed 24-hour frequency-volume chart, and 5) a full multichannel urodynamic evaluation. Seventy-four patients met all these criteria. The clinical diagnosis of stress incontinence was based on the presence of factors 1–4; this diagnosis then was compared with the results of provocative multichannel urodynamic testing. Results: Genuine stress incontinence was confirmed in 72 (97%) of 74 patients meeting the aforementioned clinical criteria. In one patient, detrusor instability alone was demonstrated during urodynamic testing. In 11 patients with genuine stress incontinence (15%), an element of detrusor instability was also present at the time of urodynamic testing. One patient had normal urodynamic study findings, with no incontinence demonstrated. Conclusion: Rigorously defined clinical criteria are highly reliable in predicting the presence of genuine stress incontinence at the time of urodynamic testing. Because of the potential implications of this finding for clinical practice, further investigation is warranted.

Objective To determine if rectal and vaginal pressures are clinically equivalent to one another for the purpose of calculating subtracted detrusor pressure during routine filling cystometry and pressure-flow voiding studies. Methods A total of 140 consecutive filling and voiding cystometrograms were performed at separate sessions on 127 female patients undergoing routine clinical cystometry for a variety of clinical indications, usually urinary incontinence. In all cases, intravaginal as well as intrarectal pressures were measured simultaneously using microtip transducer pressure catheters, and two subtracted detrusor pressures were calculated throughout each study. Rectal and vaginal pressure measurements from the same patient were compared with the patient in the supine position with an empty bladder, in the erect position with a full bladder, and in the sitting position during voiding at the point of maximum urinary flow. Results The mean pressures were similar in all cases. Although there was no statistical difference in the mean differences between the rectal and vaginal pressures in the supine-empty position ( P =.5528), significant differences were noted between them in the erect-full and sitting-voiding positions ( P =.0016 and P =.0033, respectively). Linear regression analysis of the data obtained in each position was carried out, plotting vaginal pressure on the x axis and rectal pressure on the y axis. The corresponding r values for each position were 0.431 for the supine-empty position, 0.547 for the erect-full position, and 0.478 for the sitting-voiding position, indicating poor correlation between pressures in individual patients. In nine patients (6.5%) with significant vaginal relaxation and large cystoceles, a steady rise in vaginal pressure was noted during bladder filling. In six patients (4.4%), one or more spontaneous vaginal contractions were noted during the course of the study, whereas in 68 (48.9%), spontaneous rectal contractions were present. Of the 68 cases where spontaneous rectal contractions were noted, these contractions faded away in 53 cases (77.9%) as the study progressed. Conclusions Rectal pressure and vaginal pressure are not the same during filling and voiding cystometry. Although they are reasonable approximations of each other for most qualitative clinical diagnostic purposes, potentially significant differences in subtracted detrusor pressure may occur, depending on which pressure is used as the approximation of intra-abdominal pressure. This may affect clinical management decisions in individual patients. The technique used for approximating abdominal pressure must be stated clearly in any report or publication dealing with subtracted cystometry.

Detrusor instability is a urodynamic diagnosis made when the detrusor is shown objectively to contract, spontaneously or on provocation, during the filling phase of a cystometrogram while the patient is attempting to inhibit micturition. It often is responsible for symptoms of urgency, frequency, nocturia, urge incontinence, and nocturnal enuresis, but is not synonymous with any of them. Furthermore, it may be responsible for urinary incontinence which appears to be simple stress incontinence, and should be excluded before an operation for genuine stress incontinence is undertaken. Patients with mixed incontinence should have their detrusor instability treated before an attempt at surgical correction of stress incontinence is made. A number of therapeutic options exist for the unstable bladder. The simplest is bladder drill. My own preference is to start patients on bladder drill in conjunction with oxybutynin chloride 5 mg orally three times daily, with the plan of weaning them off the medication if possible in 3-6 months. Propantheline bromide in dosages of 15-30 mg orally four times daily also appears to be effective. Imipramine, in dosages of 25-50 mg orally twice daily, or up to 75 or 100 mg orally at night also may be helpful, especially if the patient suffers from nocturia or nocturnal enuresis. The effects of imipramine appear to be additive to those of other drugs, and this makes it a useful adjunct in therapy. Emepronium bromide and flavoxate hydrochloride appear to be less useful pharmacologic agents. The expected addition within the next few years of terodiline hydrochloride to the drugs available in the United States is likely to improve significantly our ability to treat detrusor instability. The use of prostaglandin synthetase inhibitors in women with perimenstrual exacerbations of their symptoms may be useful on a case-by-case basis. Patients who do not experience improvement with behavioral intervention and pharmacologic treatment may be candidates for electric stimulation therapy or surgery. The efficacy of electric stimulation therapy is diminished in many cases by poor patient acceptance. The most effective surgical treatment for refractory detrusor instability appears to be augmentation cystoplasty, which should be attempted only by a trained reconstructive urologist, and which should be reserved for the most refractory and difficult cases.

OBJECTIVE : To evaluate changes in voiding function before and after Burch colposuspension for genuine stress incontinence. STUDY DESIGN : Full urodynamic evaluations were performed before and three months after surgery on 21 patients undergoing Burch colposuspension for genuine stress incontinence. Sixteen patients underwent the Burch procedure alone, and five underwent an abdominal sacral colpopexy for vaginal vault prolapse in addition to the Burch procedure. The preoperative and postoperative urodynamic studies were compared with each other to see what changes in voiding function had occurred as the result of surgery. RESULTS : Statistical analysis of the differences between the preoperative and postoperative urodynamic studies using blocked analysis of variance showed dramatic decreases in both instrumented and noninstrumented peak and mean urine flow rates and an increase in detrusor pressure at peak urinary flow during voiding. A substantial but not statistically significant increase in mean residual urine was found after surgery in patients who underwent the Burch procedure alone. There were no statistically significant differences in these parameters in patients undergoing the Burch procedure combined with abdominal sacral colpopexy. Using the criteria of a flow rate of 50 cm H 2 O, five patients undergoing the Burch procedure alone had evidence of postoperative outflow obstruction. Three women with complete vaginal vault prolapse had functional outlet obstruction before surgery, and another three women had postoperative outlet obstruction following the combined Burch procedure and sacral colpopexy. CONCLUSIONS : Burch colposuspension produced significant changes in postoperative voiding function three months after surgery, and outflow obstruction induced by surgery appeared to be a significant potential complication. Renewed attention should be devoted to the development of durable but nonobstructive operations for the surgical cure of genuine stress incontinence.

BACKGROUND:Women with a history of pregnancy loss in the second trimester are often diagnosed with cervical insufficiency and are treated with cervical cerclage. We present an unusual complication of this procedure that mimicked preterm rupture of membranes.CASE:A 38-year-old woman with a history of

Background: Several antihypertensive medications affect lower urinary tract function and may cause urinary incontinence. Case: A 59-year-old woman on doxazosin mesylate for control of her hypertension presented with stress urinary incontinence. Because this drug is known to cause loss of urethral tone leading to stress incontinence in some patients, she was switched to enalapril maleate, an angiotensin converting enzyme inhibitor. Her incontinence improved on the new medication, but she developed a persistent dry cough that continued to cause episodic stress incontinence. Because a persistent cough is a known side effect of angiotensin converting enzyme inhibitors, her medication was changed to a calcium channel blocker, amlodipine besylate. Her cough resolved, and her stress incontinence was no longer a clinical problem. Conclusion: Gynecologists should be aware of the unexpected side effects of medications on the lower urinary tract.

Bladder neck position, as determined by preoperative and postoperative resting and straining lateral bead-chain cystourethrograms, was analyzed by logistic regression analysis in 94 women undergoing 98 operations for genuine stress incontinence. A total of 384 roentgenograms were analyzed in an attempt to build a model that would predict the likelihood of surgical success in a given patient based on the preoperative films and explain a successful surgical outcome based on the characteristics of the postoperative films. The most important predictors of success were the number of previous incontinence operations, a large distance between the bladder neck and the pubic symphysis at rest, and increased mobility of the bladder neck before surgery. Successful surgery appeared to be related most closely to decreasing mobility of a previously hypermobile bladder neck.

Although most gynecologists consider surgery to be the treatment of choice for pelvic relaxation, there are many non-surgical forms of therapy for this problem and conditions which it may produce, such as urinary incontinence. This review highlights the importance of properly diagnosing co-existent factors which may complicate a patient's condition, and reviews therapies which may relieve her discomfort without surgery. These options include manipulation of concurrent medical factors, estrogen therapy, pelvic muscle rehabilitation through exercise and electrical stimulation, prompted voiding regimens, and the use of supportive pessaries.