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OBJECTIVE: To assess the effectiveness and perioperative morbidity of the modified Pereyra procedure in the treatment of recurrent stress urinary incontinence. METHODS: Data of 54 patients who underwent a modified Pereyra procedure for the treatment of recurrent stress urinary incontinence between January 1, 1978, and August 1, 1992, were analyzed retrospectively regarding presenting symptoms, preoperative evaluation, surgical procedure, complications, and cure and failure rates. The patients were divided into two groups depending on the preoperative absence (group I) or presence (group II) of risk factors for repeated failure (detrusor instability, low-pressure urethra, fibrotic urethra, negative Q-tip test, and neurogenic incontinence). RESULTS: After a mean follow-up of 36.3 months, the cure rate of 81.6% in group I (N = 38) was significantly (P = .005) higher than that in group II (N = 16; 43.8% cured). The mean time of occurrence of failure was 11.9 months for group I and 6.8 months for group II. The incidence of intraoperative complications (Pereyra suture in bladder, hemorrhage) for both groups was 7.4%. Immediate postoperative complications were found in 25.9% of all patients; these were mainly infectious processes. Late postoperative complications occurred in 33.3%, with the most prevalent being new-onset urge incontinence and de novo detrusor instability (11.1%) and obstructive voiding dysfunction (9.3%). The rates of perioperative morbidity were not significantly different between the groups. CONCLUSION: The modified Pereyra procedure is well suited for the treatment of uncomplicated recurrent stress urinary incontinence, with a long-term cure rate of over 80%. However, success rates are significantly lower for recurrent stress incontinence in association with persistent risk factors for failure. In either instance, the procedure is associated with appreciable perioperative morbidity.

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Pessaries have been used for centuries in the management of uterine prolapse. Although surgical repair has been popularized by surgeons and gynecologists for younger women with pelvic relaxation, pessaries remain a useful palliative strategy for patients who refuse surgery or represent higher operative risks. Despite the fact that pessaries are commonly used today, there is scant geriatric literature to describe their use among elderly patients. This article will review the indications and management of pessaries among elderly women with the goal of preventing complications and promoting investigation for their clinical application.

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Childhood lichen sclerosus is a rare disorder. A 4-year-old girl with chronic vulvar pruritus who was initially suspected to be the victim of child abuse was treated. Vulvar biopsy was performed, confirming the diagnosis of lichen sclerosus. The child was treated with 2% progesterone cream, with complete resolution of her pruritic symptoms and signs of traumatic injury to the vulvar skin. The basic condition, lichen sclerosus, has persisted.

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Clinical experience has indicated that the prophylactic use of antibiotics reduces infectious morbidity in patients undergoing cesarean section. Several factors must be considered (for instance, in vivo and in vitro efficacy, patient allergies, side effect profiles, status of host defenses, the total cost of therapy, and the risk of selecting resistant organisms that cause superinfections) before prescribing prophylactic antibiotic drugs for this indication. Moreover, medical-legal consequences associated with potential postpartum infections must be considered in assessing the costs and impact of a prophylactic regimen. Results of comparative antibiotic trials in indigent patients undergoing cesarean section demonstrated differing rates of successful antibiotic prophylaxis: piperacillin, 98%; cefoxitin, 91%; cephalothin and ceftazidime, 82%; cefotaxime, 80%; and ampicillin, 77%. Although the acquisition costs of antibiotics vary greatly, these costs are dwarfed by the substantial cost savings that can be realized by use of broad-spectrum antibiotics, which, in our hands, have resulted in reduced laboratory and pharmacy expenses and decreased hospital stays for both mother and neonate. Controlled studies designed to investigate microbiologic as well as clinical efficacy of antibiotics are indicated. Further refinements in individualizing antibiotic regimens according to patient population should be sought.

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Trichomonas vaginalis, a common genital pathogen, was found to possess both specific estrogen and specific androgen receptors. These 4.3 S macromolecules were proteinaceous in nature. Both metronidazole-resistant and metronidazole-sensitive strains possessed both types of sex hormone-binding proteins. The estrogen receptor binding was competitively inhibited by the antiestrogen tamoxifen citrate, and the androgen binding was competitively inhibited by the antiandrogen cyoctol. The presence of these specific receptors may allow the use of hormonal and antihormonal manipulation in the treatment of infections caused by these organisms.

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The modified Pereyra procedure, a retropubic urethropexy for the correction of anatomic stress urinary incontinence represents a safe, rapid, and well-tolerated technique for restoration of the normal retropubic position of the urethrovesical junction in selected patients. When general or regional anesthesia seem contraindicated due to age, medical risk, or anatomic factors, the procedure may be performed satisfactorily under local anesthesia. Of ten patients who underwent this procedure, nine reported excellent tolerance of the local technique. The postoperative hospital stay averaged three days. The average time from the injection of anesthesia to the termination of the surgical procedure was 45 minutes. Results were successful in 90%. This dependable surgical procedure for the correction of anatomic stress urinary incontinence may be performed in selected patients under local anesthesia with a high degree of patient tolerance.

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We have reviewed the results of 10,000 2nd trimester amniocenteses performed at our centre. Over 80 per cent of these were done only because of maternal age (MA); there were three times as many less than 35 year-old women in 1984 compared to 1975. Of women aged 30-34 years at delivery 0.69 per cent were found to have a MA-related chromosome abnormality compared to 0.94 per cent in those aged 35-40 years. Because only about 7 per cent of births occurred to women greater than or equal to 35 years and 18.6 per cent between 30-34 years, and a practical utilization rate of 50 per cent, we recommend that amniocentesis be made available to women aged greater than or equal to 30 years. We believe that 27 per cent of Down syndrome (DS) pregnancies could be identified if 50 per cent of pregnant women in this age category availed themselves of the test. With the same utilization rate, about three times as many amniocenteses would be required in California as performed here in 1983.

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The origin of squamous papillae of the vulvar vestibule is controversial. Although some are considered as asymptomatic normal variants of pelvic anatomy, a review of 12 cases of vulvar squamous papillae in patients visiting the Infectious Diseases Clinic at UCLA reveals a distinctly symptomatic variety. A syndrome complex of premonitory vulvar vestibular pruritus, pain or burning, dyspareunia, and progressive development of squamous papillae was noted. Microscopic examination of tissue specimens of the areas of squamous papillae reveals the presence of koilocytic change suggestive of viral infection with human papillomavirus. Furthermore, immunoperoxidase stain revealed human papillomavirus capsid antigen in two cases, which has heretofore not been reported in the literature to the authors' knowledge. Evidence of partner infection on physical examination of sexual partners of these women revealed changes consistent with human papillomavirus in four of six partners who were available for examination. Treatment with podophyllin, cryotherapy, laser, or a combination seems to give predictable resolution of the condition and associated symptoms.

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Fifty-three patients with twin gestation were seen at the University of California, Los Angeles, between January 1, 1977 and June 30, 1983 for antenatal genetic studies. The diagnosis of twins was successfully made in 52 patients using ultrasound. Forty-eight patients with viable fetuses requested sampling of both sacs. Amniotic fluid was successfully obtained from both sacs in 47 patients. There was only one spontaneous abortion six weeks after the amniocentesis. In five patients, one of the fetuses was delivered alive, whereas another was delivered as a stillborn without any apparent reason. Eleven sets were delivered prematurely at less than 36 weeks. There were two neonatal deaths, one from prematurity and one with multiple congenital anomalies. This study showed that differential amniocentesis can be used safely to obtain reliable information about each fetus in twin gestation.

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We tested 10,715 low-risk pregnancies in a voluntary maternal serum alpha-fetoprotein screening program for the detection of neural tube defects in California. In all, 5.3 percent of women had one elevated serum level, 3.3 percent were referred for sonography and 1.5 percent for amniocentesis. There were 12 cases of open neural tube defects (1.1 per 1,000); all of the mothers had one elevated serum alphafetoprotein level: nine (75 percent) completed the protocol and the neural tube defects were correctly identified. No normal pregnancies were terminated. The risk of an open neural tube defect occurring was about 1 in 50 after the first abnormal serum level and 1 in 15 at amniocentesis. We found significantly increased risk for fetal death and low birth weight after one elevated serum alpha-fetoprotein level, though the likelihood of a normal pregnancy outcome was about 80 percent. Maternal serum screening was also useful in identifying twin pregnancies and correcting underestimated gestational dates.

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We confirmed the relation between maternal weight and serum alpha-fetoprotein concentration and have shown a further relation--to ethnic origin. Of these two, maternal weight is the more closely related. Oriental, white, and Hispanic women showed no significant differences in serum AFP concentrations when corrections for maternal weight were applied. Black women showed consistently higher values, by an average of 10% at each week of gestation. These corrections only affected values falling just above or below the 95th centile cutoff. We conclude that corrections for maternal weight and race should be applied when values for alpha-fetoprotein in maternal serum are being interpreted.

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In a double-blind clinical study, 93 patients with vulvovaginal candidiasis were randomly assigned to treatment with either clotrimazole (1%) or miconazole (2%) vaginal cream for seven days. The treatments were comparable in reducing the severity of presenting signs and symptoms. At one and four weeks posttherapy, negative vaginal cultures were found in 84.4% and 75.0%, respectively, of the clotrimazole-treated patients and in 85.4% and 74.5%, respectively, of the miconazole-treated patients. The incidences of recurrence/reinfection and treatment failures were comparable in the two groups. Treatment failures and recurrences/reinfections were not correlated with positive perianal cultures for Candida species. Patients using oral contraceptives had a higher incidence of positive vaginal cultures at four weeks posttherapy than did patients not using oral contraceptives or using other methods.

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The present study supports the thesis that failures in urethral suspensory-type operations in women with anatomic stress urinary incontinence often are caused by pull-out of suspensory sutures attached to attenuated endopelvic fascia around the urethrovesical junction. Thickening of this fascia helps impede suture pull-out. Such thickening is facilitated by detaching the fascia from the pubis to enfold it. Freeing the fascia from the inferior pubis exposes the posterior pubourethral ligaments to direct view. Binding the much stronger posterior pubourethral ligaments and enfolded fascia together with the suspensory sutures provides maximum resistance to suture pull-out. Of 54 women treated with this modified Pereyra procedure as a primary operation for anatomic stress urinary incontinence, 94.5% showed complete cure or marked improvement 4 to 6 years postoperatively.

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At the UCLA Vulvovaginitis Clinic, 63 patients were diagnosed as having symptomatic Candida albicans vaginal infections. In a random select manner 3-day treatment with 200-mg clotrimazole suppositories was compared with 7-day treatment using 100-mg clotrimazole suppositories. 7- and 35-day follow-up of all patients entered revealed no statistical difference between the two groups, suggesting that short-term treatment is most efficacious and can be expected to work better since patient compliance is primarily a function of duration of treatment. In 50 cases of C. albicans patients treated with miconazole or clotrimazole in a random manner, the recurrence rate was 8 or 16. All patients in the study received perianal cultures for C. albicans before treatment and 7 and 35 days after treatment. 5 of the 8 patients with recurrence had perianal positive cultures at the 7- and 35-day check suggesting this as a source of recurrence. It is suggested that patients with persistently high perianal cultures after treatment be given an oral fungicide or fungistat to lower chronic recurrent C. albicans.

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Two cases of constriction of the umbilical cord resulting in fetal demise following midtrimester amniocentesis are presented. In both cases, real-time ultrasonography prior to amniocentesis revealed a viable fetus. Fetal demise was identified immediately following the procedure in the first case and one month later in the other. A localized constriction at the fetal end of the umbilical cord in both, with torsion of the constricted segment in the second case, was observed. Wharton's jelly was noted to be deficient in this segment of the cord in the first case. The mechanism of fetal demise is discussed. It is suggested that this abnormality should be considered when fetal demise follows midtrimester amniocentesis.

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Patients with mycologically proven symptomatic fungal infections of the vagina were treated ina double-blind trial with either one 100-mg clotrimazole vaginal tablet daily for seven days (group I) or two tablets daily for three days (group II). Patients were evaluated at one and four weeks after therapy. The investigator's evaluation of treatment efficacy showed 85% (22/26) success in group II compared with 75% (21/28) in group I (P = 0.46). Both groups had improvement itching, discharge, and vaginal and vulval irritation. No significant (P less than 0.10) differences were seen between groups after therapy. Only three side effects were seen. It is concluded that a three-day course of two clotrimazole vaginal tablet daily is as effective and safe as the previously recommended one tablet daily for seven days, and the shorter therapy is likely to improve patient compliance.

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The authors analyzed the outcome of 2000 consecutive second-trimester amniocenteses. Seventy-three percent were performed for maternal age of 34 years or more. The risk of spontaneous abortion before 28 weeks' gestation was 1.3% and for stillbirth or neonatal death, 1.4%. Total fetal loss was 2.7%, compared with 2.2% in a control population. Congenital malformations were found in 1.6% of the study group and in 1.9% of controls; no increase in skeletal problems was observed. Prematurity, defined as a birth weight of less than 2500 g, was noted in 3.6%, compared with 3.7% and 3.9% in 2 control populations. Respiratory difficulties persisting for more than 24 hours were observed in 0.8% of patients, compared with 0.7% of controls. Analyses of the outcome of amniocenteses performed at a single large center do not show an increase in perinatal complications or malformations.

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