V. Mazin. Southwestern Assemblies of God University.
Five-year outcome of uterus sparing surgery for pelvic organ prolapse repair: A single-center experience purchase generic gasex line gastritis main symptoms. Abdominal sacrohysteropexy in young women with uterovaginal prolapse: Results of 20 cases gasex 100caps free shipping gastritis diet ÝūŚÍ. Abdominal sacral hysteropexy: A pilot study comparing sacral hysteropexy to sacral colpopexy with hysterectomy cheap gasex 100 caps visa chronic gastritis malabsorption. Laparoscopic sacral colpopexy approach for genito-urinary prolapse: Experience with 363 cases. Lumbosacral spondylodiscitis: An unusual complication of abdominal sacrocolpopexy. Sacral colpopexy followed by refractory Candida albicans osteomyelitis and discitis requiring extensive spinal surgery. It is further divided into different categories based on the anatomical location of the herniation to include anterior, apical, and posterior prolapse. Apical prolapse is further described as the descent of the uterus and cervix or vaginal vault in posthysterectomy cases toward the hymen. This chapter will focus on the treatment of apical prolapse using laparoscopic techniques with or without robotic assistance. Claims and encounters database estimated the lifetime risk for females 18 years and older to develop pelvic floor dysfunction and need for surgical management to be as high as 20% in the United States . Several studies have shown that of these patients, up to 30% will require an additional surgery for recurrence of prolapse [3,4]. Caucasian and Latina females have a fourfold to fivefold increase when compared to African- American females . McCall in 1957 using the culdoplasty technique that revealed the importance of this suspension at the time of a vaginal hysterectomy to prevent an enterocele and posthysterectomy vaginal vault prolapse . Now nearly 60 years after McCall described his technique, the same attachment points and surgical principles are used via laparoscopic approaches. Laparoscopic Approach for High Uterosacral Ligament Suspension Laparoscopic Port Placement Traditionally, three laparoscopic ports are placed in the abdomen. The first is the camera port placed in the umbilicus or up to 2 cm caudal to the umbilicus depending on the patient‚Äôs habitus. The second and third ports are 5 mm ports placed suprapubically and at the right paramedian  (Figures 87. The patient is transitioned into steep Trendelenburg to assist with bowel retraction and to better visualize the pelvic sidewalls. To further assist with visualization of the uterosacral ligaments, a probe is placed in the vagina to hold the ligaments on tension. This will assist the surgeon in tracing the ligaments back to their proximal origin . This is performed so that the pubocervical fascia and the rectovaginal fascia can be visualized. Next, a figure-eight suture is then placed approximately two- thirds cephalad to the proximal origin of the ligament and 1 cm caudal to the most anterior palpable margin of the sacrum . We recommend using a delayed absorbable or permanent suture cut to a length of 36‚Äď48 in. Additionally, when first performing this technique, it is recommended to use the extracorporeal approach with a closed knot pusher to secure knot placement, as this is the easiest method to both learn and teach. After knots are secured in place, the ureters should be inspected on each side, and an intraoperative cystoscopy should be performed. It is important that cystoscopy is performed prior to the removal of the laparoscopic ports, so that any ureteral compromise can be addressed prior to the completion of the case. For the main operative ports, a line is marked 16 cm cephalad to the inferior margin of the symphysis pubis. A left and right port are then placed 9 cm lateral to this mark once the abdomen has been insufflated. This is to prevent the robot arms from colliding with each other during the procedure. The third arm port is then placed on the left side, 4 cm superior and 3 cm lateral to the camera port. An assistant 5 mm diameter port is placed 5 cm lateral to the camera port  (Figure 87. Technique Once the patient is placed in steep Trendelenburg, the robot patient side cart is positioned either between the patient‚Äôs legs to align the center of the cart with the patient‚Äôs midline (central docking) or aligned alongside the patient for parallel docking. Identification of the uterosacral ligaments can be achieved by placing traction on the vaginal apex 1341 with a probe in the vagina when the uterus is not present or by using a uterine manipulator when the uterus is present. If the later method is indicated, after the uterus has been completely devitalized and prior to colpotomy, upward pressure is placed on the uterine manipulator to help with the identification of the uterosacral ligaments. The complete pelvic course of the ureter is then identified prior to placing sutures. At this level, the uterosacral ligaments are the furthest from the ureters as they are heading toward S3 and the ureters are clearing the pelvic brim. The distal end of the sutures are then passed through the pubocervical and rectovaginal fascia and then incorporated into the vaginal cuff. The vaginal cuff is then tied down after the completion of the cuff closure with polyglactin sutures. A third row of sutures can be used in the instance of elongated uterosacral ligaments. Again as stated in the laparoscopic section, an intraoperative cystoscopy should be performed prior to removal of the ports. The goal of both procedures is to restore normal anatomical support by suspending the apex of the vagina above the level of the ischial spines toward the level of the sacrum without causing any significant distortion to the vaginal axis . In most cases, removing the offending suture(s) will alleviate any obstruction without consequence as long as the surgeon finds the problem intraoperatively [14,15]. Other potential complications include bowel injury, pelvic abscess, dyspareunia, hemorrhage and in rare cases bladder injury, and exposure of permanent sutures into the vaginal lumen . Outcomes Although multiple studies and meta-analyses have been performed evaluating the long-term success of uterosacral ligament suspension when approached vaginally, there are few studies describing the long- term outcomes associated with the laparoscopic and robotic-assisted approach. However, in this study, the uterus was conserved in the laparoscopic approach . In this series, at 6 months follow-up, there was a 100% objective success rate [18,19]. Contrary to many previous studies, this further suggests that the laparoscopic approach is as effective as the traditional vaginal approach. The laparoscopic and robotic approach to performing uterosacral ligament suspension allows the surgeon to have a more global view to inspect the pelvic cavity. Other advantages include the ability to use pneumoperitoneum to access better surgical planes and the also the accuracy of suture placement to achieve an optimal result .
Standardisation of urethral pressure measurement: Report from the Standardisation Sub-Committee of the International Continence Society purchase gasex 100 caps on line gastritis toddler. Standardisation of outcome studies in patients with lower urinary dysfunction: A report on general principles from the Standardisation Committee of the International Continence Society gasex 100caps free shipping gastritis diet using frozen. Outcome measures for research in treatment of adult males with symptoms of lower urinary tract dysfunction buy generic gasex moderate gastritis diet. Good urodynamic practice: Report from the Standardisation Sub-Committee of the International Continence Society. Standardisation of ambulatory urodynamic monitoring: Report of the Standardisation Sub-Committee of the International Continence Society for ambulatory urodynamic studies. These voids before and after sleep may need to be considered in research studies, for example, in nocturnal polyuria. If this definition were used, then an adapted definition of daytime frequency would need to be used with it. In scientific communications, the definition of incontinence in children would need further explanation. If the term bladder capacity is used, in any situation, it implies that this has been measured in some way, if only by abdominal ultrasound. In children, the ‚Äúexpected volume‚ÄĚ may be calculated from the formula (30 + [age in years x 30] in mL). The Swedish, French, and Italian expression ‚Äúeffort incontinence‚ÄĚ is preferable; however, words 1781 such as ‚Äúeffort‚ÄĚ or ‚Äúexertion‚ÄĚ still do not capture some of the common precipitating factors for stress incontinence such as coughing or sneezing. The Cred√© maneuver is used by some spinal cord injury patients, and girls with detrusor underactivity sometimes press suprapubically to help empty the bladder. Dysuria literally means ‚Äúabnormal urination‚ÄĚ and is used correctly in some European countries. However, it is often used to describe the stinging/burning sensation characteristic of urinary infection. In the investigation of bladder pain, it may be necessary to exclude conditions such as carcinoma in situ and endometriosis. This may be done precisely by measuring the volume of each drink or crudely by asking how many drinks are taken in a 24-hour period. If the individual eats significant quantities of water-containing foods (vegetables, fruit, salads), then an appreciable effect on urine production will result. In practice, almost all investigations are performed using medium filling rates, which have a wide range. Furthermore, it may be simplistic to relate urgency just to the presence or absence of detrusor overactivity when there is usually a concomitant fall in urethral pressure. The phrase ‚Äúwhich the patient cannot completely suppress‚ÄĚ has been deleted from the old definition. However, in complete spinal cord injury patients, there may be no sensation whatsoever. As a compromise, they were allocated to idiopathic and neurogenic overactivity, respectively. In the absence of sensation, the cystometric capacity is the volume at which the clinician decides to terminate filling. The reason(s) for terminating filling should be defined, for example, high detrusor filling pressure, large infused volume, or pain. In the presence of sphincter incompetence, the cystometric capacity may be significantly increased by occlusion of the urethra, for example, by Foley catheter. If symptoms are seen in association with a decrease in urethral pressure, a full description should be given. Any delineation into categories such as ‚Äúurethral hypermobility‚ÄĚ and ‚Äúintrinsic sphincter deficiency‚ÄĚ may be simplistic and arbitrary and requires further research. Leak point pressures may be calculated in three ways from the three different baseline values that are in common use: zero (the true zero of intravesical pressure), the value of pves measured at zero bladder volume, or the value of pves immediately before the cough or Valsalva (usually at 200 or 300 mL bladder capacity). While it is felt that pelvic floor contractions are responsible, it is possible that the intraurethral striated muscle may be important. Although the urethral and periurethral striated muscles are usually held responsible, the smooth muscle of the bladder neck or urethra may also be responsible. In addition, there is often urodynamic stress incontinence during bladder filling. The retention volume should be significantly greater than the expected normal bladder capacity. In patients after surgery, due to bandaging of the lower abdomen or abdominal wall pain, it may be difficult to detect a painful, palpable, or percussable bladder. If used, a precise definition and any associated pathophysiology, such as reduced urethral function, or detrusor overactivity/low bladder compliance, should be stated. The term chronic retention excludes transient voiding difficulty, for example, after surgery for stress incontinence, and implies significant residual urine; a minimum figure of300 mL has been previously mentioned. The term ‚Äúdiagnosis‚ÄĚ is defined as ‚Äúthe determination of the nature of a disease: clinical, made from a study of the symptoms and signs of a disease; and laboratory,‚ÄĚ multiple options mentioned . Such a specific report would require a full outline of the terminology for all symptoms, signs, urodynamic investigations for female pelvic floor dysfunction, the imaging associated with those investigations, and the most common diagnoses. It may have been possible in the past to combine all the terminology for lower urinary tract function in men, women, and children into one report. The 1988 report by the Committee on the Standardization of Terminology  is one such example. With the increasing specificity and complexity of female diagnoses, a combined report may now be an anachronism. The 2002 report  still provided the traditional core terminology and some useful modifications, many of which are repeated in this document. However, it also revealed evidence that (1) a coherent and user-friendly combined report may be starting to become too difficult and (2) the terminology for women, due to the absence of specific diagnoses as well as other female- specific terminology, may not have been advantaged by this approach . The need for standardized terminology in female pelvic floor dysfunction to enable accurate communication for clinical and research purposes has been highlighted for some time . There is indeed the need for a general terminology, forming a ‚Äúbackbone‚ÄĚ or ‚Äúcore‚ÄĚ terminology to which more specific terminologies can be attached. As user-friendly as possible: It should be able to be understood by all clinical and research users. Clinically based: Symptoms, signs, and validated investigations should be presented for use in forming workable diagnoses. Sections 1 through 3 will address symptoms, signs, urodynamic investigations, and current associated pelvic imaging modalities routinely used in the office or urodynamic laboratory to make those diagnoses. This report does not specifically address terminology for neurogenic pelvic floor dysfunction. The terms  ‚Äúurodynamic observation‚ÄĚ and ‚Äúcondition‚ÄĚ (nonmedical) have not been used in this report. The scope of the report will exclude (1) more invasive investigations requiring anesthetic and (2) evidence-based 1784 treatments for each diagnosis. Able to indicate origin and to provide explanations: Where a term‚Äôs existing definition (from one of multiple sources used) is deemed appropriate, that definition will be included and duly referenced. A large number of terms in female pelvic floor function and dysfunction, because of their longterm use, have now become generic, as apparent by their listing in medical dictionaries.
For each exercise purchase cheap gasex line chronic gastritis x ray, as appropriate buy 100 caps gasex visa gastritis diet pregnancy, explain why you chose a one-sided test or a two-sided test cheap 100caps gasex amex gastritis diet eggs. Discuss how you think researchers or clinicians might use the results of your hypothesis test. What clinical or research decisions or actions do you think would be appropriate in light of the results of your test? The investigators recruited 31 postmenopausal women with ankle fractures and 31 healthy postmenopausal women to serve as controls. One of the variables of interest was the length from the most superoanterior point of the body of the hyoid bone to the Frankfort horizontal (measured in millimeters). Do these data provide sufficient evidence to allow us to conclude that the two sampled populations differ with respect to length from the hyoid bone to the Frankfort horizontal? Eighty-two subjects with essential hypertension were randomly assigned to an intervention or a control group. The intervention group received monthly monitoring by a research pharmacist to monitor blood pressure, assess adherence to treatment, prevent, detect, and resolve drug-related problems, and encourage nonpharmaco- logic measures for blood pressure control. The changes after 6 months in diastolic blood pressure (pre √Ä post, mm Hg) are given in the following table for patients in each of the two groups. Intervention Group Control Group 2 2 24 6 10 12 2 2 8 3 26 √Ä 2 √Ä 20 8 14 6 10 0 12 0 2 √Ä 14 14 10 8 14 10 28 √Ä8 30 8 2 16 4 √Ä2 √Ä18 16 18 20 18 √Ä12 √Ä2 2 12 12 6 √Ä6 Source: Data provided courtesy of Jose Garcao,S~ M. The sample sizes and means and standard deviations of the test scores were as follows: Sample n x s 1 15 4. Group 2 subjects delivered by either cesarean section or the vaginal route following spontaneous labor. The sample sizes, mean cortisol levels, and standard deviations were as follows: Sample n x s 1 10 435 65 2 12 645 80 Do these data provide sufficient evidence to indicate a difference in the mean cortisol levels in the populations represented? Sample 1 consisted of 50 adult male alcoholics with ring sideroblasts in the bone marrow. The mean protoporphyrin levels and standard deviations for the two samples were as follows: Sample x s 1 340 250 2 Can one conclude on the basis of these data that protoporphyrin levels are higher in the represented alcoholic population than in the nonalcoholic population? The mean levels, standard deviations, and sample sizes for the two samples studied were as follows: Sample n x s With condition 35 8. Subjects in group A were subjected to a 10-day period of sensory deprivation, while subjects in group B served as controls. At the end of the experimental period, the alpha-wave frequency component of subjects‚Äô electroencephalograms was measured. The following are the cell diameters mm of 40 lymphocytes and 50 tumor cells obtained from biopsies of tissue from patients with melanoma: Lymphocytes 9. A hypothesis test based on this type of data is known as a paired comparisons test. Reasons for Pairing It frequently happens that true differences do not exist between two populations with respect to the variable of interest, but the presence of extraneous sources of variation may cause rejection of the null hypothesis of no difference. On the other hand, true differences also may be masked by the presence of extraneous factors. One method would be to select a simple random sample of subjects to receive sunscreen A and an independent simple random sample of subjects to receive sunscreen B. We send the subjects out into the sunshine for a specified length of time, after which we will measure the amount of damage from the rays of the sun. Suppose we employ this method, but inadvertently, most of the subjects receiving sunscreen A have darker complexions that are naturally less sensitive to sunlight. Let us say that after the experiment has been completed we find that subjects receiving sunscreen A had less sun damage. We would not know if they had less sun damage because sunscreen A was more protective than sunscreen B or because the subjects were naturally less sensitive to the sun. A better way to design the experiment would be to select just one simple random sample of subjects and let each member of the sample receive both sunscreens. We could, for example, randomly assign the sunscreens to the left or the right side of each subject‚Äôs back with each subject receiving both sunscreens. After a specified length of exposure to the sun, we would measure the amount of sun damage to each half of the back. If the half of the back receiving sunscreen A tended to be less damaged, we could more confidently attribute the result to the sunscreen, since in each instance both sunscreens were applied to equally pigmented skin. The objective in paired comparisons tests is to eliminate a maximum number of sources of extraneous variation by making the pairs similar with respect to as many variables as possible. Litter mates of the same sex may be assigned randomly to receive either a treatment or a placebo. Pairs of twins or siblings may be assigned randomly to two treatments in such a way that members of a single pair receive different treatments. In comparing two methods of analysis, the material to be analyzed may be divided equally so that one-half is analyzed by one method and one-half is analyzed by the other. Or pairs may be formed by matching individuals on some characteris- tic, for example, digital dexterity, which is closely related to the measurement of interest, say, posttreatment scores on some test requiring digital manipulation. Instead of performing the analysis with individual observations, we use di, the difference between pairs of observations, as the variable of interest. When the n sample differences computed from the n pairs of measurements constitute a simple random sample from a normally distributed population of differences, the test statistic for testing hypotheses about the population mean difference md is d √Ä m d0 t ¬ľ (7. When H0 is true, the test statistic is distributed as Student‚Äôs t with n √Ä 1 degrees of freedom. Although to begin with we have two samples‚ÄĒsay, before levels and after levels‚ÄĒ we do not have to worry about equality of variances, as with independent samples, since our variable is the difference between readings in the same individual, or matched individuals, and, hence, only one variable is involved. The arithmetic involved in performing a paired comparisons test, therefore, is the same as for performing a test involving a single sample as described in Section 7. The following example illustrates the procedures involved in a paired comparisons test. Solution: We will say that sufficient evidence is provided for us to conclude that the fundoplication is effective if we can reject the null hypothesis that the population mean change md is different from zero in the appropriate direc- tion. We may obtain the differences in one of two ways: by subtracting the preop percents from the postop percents or by subtracting the postop percents from the preop percents. Farrell, ‚ÄúGallbladder Function Before and After Fundoplication,‚ÄĚ Journal of Gastrointestinal Surgery, 6 (2002), 806‚Äď811. The observed differences constitute a simple random sample from a normally distributed population of differences that could be generated under the same circumstances. The way we state our null and alternative hypotheses must be consistent with the way in which we subtract measurements to obtain the differences. If, therefore, we subtract the preop percents from the postop percents √įpostop √Ä preop√ě, we would expect the differences to tend to be positive. Furthermore, we would expect the mean of a population of such differences to be positive. So, under these conditions, asking if we can conclude that the fundoplication is effective is the same as asking if we can conclude that the population mean difference is positive (greater than zero). If the null hypothesis is true, the test statistic is distributed as Student‚Äôs t with n √Ä 1 degrees of freedom. From the n ¬ľ 12 differences di,we compute the following descriptive measures: P di 41:5 28:2 √į 37:0√ě√ĺ√Ā√Ā√Ā√ĺ 6:0 216:9 d ¬ľ ¬ľ ¬ľ ¬ľ 18:075 n 12 12 P 2 P 2 P 2 2 √į di √Ä d n d √Ä di 12 15669:49 216:9 s2 ¬ľ ¬ľ i ¬ľ ¬ľ 1068:0930 d n √Ä 1 nn√Ä 1 √į√ě12 √į√ě11 18:075 √Ä 0 18:075 t ¬ľ pÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨ÉÔ¨É ¬ľ ¬ľ 1:9159 1068:0930=12 9:4344 8.
These symptoms are indistinguishable from those of infectious syndromes but are most commonly confused with those of acute Candida vaginitis (e discount 100 caps gasex with mastercard symptoms of gastritis ulcer. There is an enormous list of topical factors that are responsible for local inflammatory reactions and symptoms gasex 100 caps for sale chronic gastritis frequently leads to, and many more have yet to be defined generic gasex 100caps without prescription gastritis diet recommendations. Unfortunately, given the anticipated 20% colonization rates in normal asymptomatic women, a positive yeast culture sometimes reflects the presence of an ‚Äúinnocent 911 bystander‚ÄĚ organism rather than the cause of a patient‚Äôs vulvovaginal symptoms. The only logical way of establishing the role of Candida in this context is to treat the patient with an oral antifungal agent and assess the clinical response. Once a local chemical, irritant, or allergic reaction is suspected as the cause of vaginitis and/or vulvitis, a detailed inquiry into possible causal factors is essential. Offending agents or behaviors should be eliminated whenever possible, including the avoidance of chemical irritants and allergens (e. The immediate management of severe vulvovaginal symptoms of noninfectious etiology should not rely on topical corticosteroids, which are rarely the solution to such symptoms; moreover, high-potency steroid creams often cause intense burning. Local relief measures include sodium bicarbonate sitz baths and oral antihistamines. Effect of lactobacillus in preventing post-antibiotic vulvovaginal candidiasis: A randomised controlled trial. Mannose-binding lectin gene polymorphism, vulvovaginal candidiasis and bacterial vaginosis. Effects of recent sexual activity and use of a diaphragm on the vaginal microflora. Recurrent vulvovaginal candidiasis: Results of a cohort study of sexual transmission and intestinal reservoir. Oral versus intravaginal imidazole and triazole anti-fungal treatment of uncomplicated vulvovaginal candidiasis (thrush). Clinical practice guidelines for the management of candidiasis: 2009 update by the infectious Diseases Society of America. Single oral dose fluconazole compared with conventional clotrimazole topical therapy of Candida vaginitis. Treatment of complicated Candida vaginitis: Comparison of single and sequential doses of fluconazole. Treatment of Candida glabrata vaginitis: A retrospective review of boric acid therapy. Prevalence of Candida glabrata and its response to boric acid vaginal suppositories in comparison with oral fluconazole in patients with diabetes and vulvovaginal candidiasis. Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis, N Engl J Med 2004;351:876‚Äď883. Individualized decreasing-dose maintenance fluconazole regimen for recurrent vulvovaginal candidiasis (ReCiDiF trial). Molecular analysis of the diversity of vaginal microbiota associated with bacterial vaginosis. The role of bacterial vaginosis and vaginal bacteria in amniotic fluid infection in women in preterm labor with intact fetal membranes. Vaginal lactobacilli, microbial flora, and risk of human 912 immunodeficiency virus type 1 and sexually transmitted disease acquisition. Association between acquisition of herpes simplex virus type 2 in women and bacterial vaginosis. Centers for Disease Control and Prevention Sexually Transmitted Disease Treatment Guidelines. Reduced incidence of preterm delivery with metronidazole and erythromycin in women with bacterial vaginosis. Boric acid addition to suppressive antimicrobial therapy for recurrent bacterial vaginosis. The prevalence of Trichomonas vaginalis infection among reproductive-age women in the United States, 2001‚Äď2004. Trichomonas vaginalis is associated with pelvic inflammatory disease in women infected with human immunodeficiency virus. Molecular testing for Trichomonas vaginalis in women: Results from a prospective U. Genitourinary syndrome of the menopause: New terminology for vulvovaginal atrophy from the International Society for the Study of Women‚Äôs Sexual Health and the North American Menopause Society. The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Symptoms persisting for a minimum of 6 weeks included backache, headache, hemorrhoids, depression, and bowel and bladder symptoms. Sleep and Grant  reported that 15% of women experience dyspareunia up to 3 years after a normal vaginal delivery and up to 8% experience perineal pain 12 weeks after a normal vaginal delivery. Interesting perineal pain can occur even without perineal trauma and women who sustain anal sphincter damage have significantly greater pain ratings at 7 weeks after delivery compared to those with lesser degrees of perineal trauma . However, although health problems seem to be common after childbirth, it appears women often do not seek medical attention . This chapter will concentrate on urinary and fecal incontinence, which have a significant negative impact on quality of life and sexual function particularly if both are present . Urinary and/or fecal incontinence and genital prolapse are often considered to be inevitable sequelae of a vaginal birth. One in every three women will experience some symptoms of incontinence during her lifetime and, of these, up to 65% will recall that it began either during pregnancy or after childbirth . Certainly in prospective series, antenatal leakage was a strong risk factor for postnatal leakage . This is most likely related to the detrimental impact of vaginal delivery on the pelvic floor [7‚Äď10]. Furthermore, it appears that the first vaginal delivery is the time when women sustain the most significant damage [8,11]. However, the effects of mode of delivery in higher-order pregnancies are less certain. Supporting these findings are several studies showing a relationship between vaginal delivery and mechanical and neurological damage to the pelvic floor, which are related to the development of urinary or anal incontinence or both [11‚Äď13]. More recently, interest has turned to looking the more subtle changes with sensory nerve function  and further work in this area will undoubtedly add to our knowledge in the future. Other factors of relevance include an increased predisposition to pelvic floor trauma and, thus, incontinence and prolapse, due to an inherent weakness of collagen within the pelvic floor fascia [15,16]. This chapter focuses on the effect of pregnancy and childbirth on the pelvic floor and discusses the possible mechanisms by which pelvic floor damage may occur and its long-term sequelae. Direct Perineal Trauma Direct perineal trauma from perineal laceration and episiotomy is a well-known complication of vaginal delivery. Episiotomy  is one of the commonest surgical interventions and was traditionally advocated to decrease perineal damage; it reduces anterior perineal laceration but has not been shown to reduce pelvic floor damage, urinary, or fecal incontinence or protect the newborn from intracranial 914 trauma. The long-term sequelae of perineal injuries include pain, dyspareunia, fistulae, and anal incontinence [11,17,18]. The incidence of lacerations involving the anal sphincter has been reported as 0%‚Äď6. There does not, however, seem to be a significant association between episiotomy and the development of urinary incontinence .