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Late Complications of Female Sterilisation
573
discussing these questions with the the and journalists who write for the public. public the medical profession, who need to This involves keep an informed opinion on environmental risks, and to tell their patients and the public when nothing should be done or when action is needed, and especially when we need public cooperation in the gathering of information on the risks of modern life. more
time
Late Complications of Female Sterilisation A HIGH’ percentage of women who have had tubal sterilisation complain later of menorrhagia or dysmenorrhcea.1-8 MULDOON,6for instance, found that, out of 374 patients followed for at least ten years after operation, nearly 19% came to hysterectomy. The figures are not in dispute; but could there be an antecedent common cause? Are women who are sterilised more likely than average to complain later of increased or painful menstrual bleeding ? These symptoms, particularly increased bleeding, become more common with the passage of time. Their incidence in unsterilised women matched for race, age, social class, parity, and menstrual blood-loss is not known. Psychological factors also operate, possibly by altering hormonal control of the menstrual cycle via higher centres, and certainly by affecting the threshold for complaints (perhaps more readily in women who have been sterilised). Moreover, there is no way of directly measuring menstrual pain, and workers who have measured menstrual blood-loss (usually by the method of HALLBERG and NILSSON9) can testify to the unreliability of reports of menorrhagia. For example, in a studylO of women presenting in a family-planning clinic with no complaint of heavy bleeding and requesting intrauterine contraception, 14% had a measured mean menstrual loss, over two normal periods, of more than 80 ml (80 ml is regarded as the normal,11 12 and above it irori-deficiency anaemia becomes more common). The effect of contraception is another imponderable: contraceptive-pill users may dislike their normal periods when these return after sterilisation; and the type of contraception used by a control group may affect the natural history of menstrual bleeding. The published investigations with one exception have been uncontrolled, all have been retrospec1. Sacks, S., La Croix, G. Obstet. Gynec. 1962, 19, 22. 2 Lu, T., Chun, D. J. Obstet. Gynœc Br. Commonw 1967, 74, 875. 3. Lang, L. P., Richardson, K. D. ibid. 1968, 75, 972. 4. Whitehouse, D. B. Br. med. J. 1971, ii, 707. 5. Houseman, R. J. ibid. 1971, iii, 184. 6 Muldoon, M. J. ibid. 1972, i, 84. 7. Chamberlain, G., Foulkes, J. Lancet, 1975, ii, 878. 8. Neil, J. R., Noble, A D., Hammond, G. T., Rushton, L., Letchworth, A. T. ibid. 1975, ii, 699. 9. Hallberg, L, Nilsson, L. Scand. J clin. Lab. Invest, 1964, 16, 244. 10. Guillebaud, J., Bonnar, J., Morehead, J., Matthews, A. Lancet, 1976, i, 387. 11. Hallberg, L., Hogdahl, A. -M., Nilsson, L., Rybø, G. Acta obstet. gynœc. scand 1966, 45, 320. 12. Rybø, G. ibid. 1966, 45, suppl. 7.
was measured in none. on self-rating quesbased al.," study tionnaires, compared the responses of patients up to 28 months after abdominal tubal ligation or laparoscopic tubal diathermy with those of women whose husbands had been sterilised. Increased menstrual loss and menstrual pain were reported by significantly more sterilised women than controls, and the women sterilised by laparoscopic tubal diathermy seemed to suffer most. However, 10% more of the control group had been on the pill before their husband’s sterilisation, 22-28% of the questionnaires were not returned, and subjective variables may have affected responses. Vasectomy has been socially acceptable for a far shorter time than female sterilisation, so couples are likely to be defensive and could well be less ready to admit to any problems after it—especially since "common sense" dictates that there would be no effect on menstruation. There has been one small objective study: menstrual blood was collected and measured in 25 women for three periods before operation and for up to one year afterwards.13 No significant difference was detected between blood-losses before and after the procedure (abdominal tubal ligation in all but one case). This investigation should obviously be repeated with larger numbers and longer follow-up. Ideally, such a prospective study should include a control group matched initially for age, parity, and menstrual blood loss and similarly followed up with blood-loss measurements; but the logistics, and the difficulty of allowing for the effects of continued contraception in the control group, are daunting. For the present, there exists a possibility that operation on the fallopian tubes may tend to cause increased or more painful menstruation, and a number of mechanisms have been proposed.8 14 Some observations suggest that prostaglandin-synthetase inhibitors may improve dysmenorrhoea and reduce measured menstrual blood-loss, and the prostaglandin status of the -uterus may possibly be altered by damage to utero-ovarian blood-supply. But -elucidating the mechanism of any possible effect of tubal surgery on menstruation would be a major undertaking; and the main hypothesis has yet to be established. There can, however, be little doubt that when a woman asks for sterilisation there -is a fairly high chance that she has early or established menstrual
tive, and menstrual loss NEIL
et
in
a
problems. So couples requesting permanent contraception should invariably be interviewed together. A thorough menstrual history should be taken from the wife: she should be questioned about the number of pads and tampons used per period and about "flooding", or clots, or very frequent changing (more than once an hour) on her heavy days. 13. Kasonde, J. M., Bonnar, J. Unpublished. 14. Darwish, D. H., Saafan, S. T. A. Lancet, 1975, ii, 975.
574
She should also be examined vaginally for incidental pathology and a recent cervical smear report should be to hand. Logically the wife should be so assessed even if the initial request was by her husband for a vasectomy-at least if she is aged 35 or more. If, as in most cases, examination is normal and the menstrual history indicates a normal or light loss without excessive pain, then vasectomy, abdominal sterilisation, or laparoscopic sterilisation would all be reasonable. Otherwise, in selected cases, hysterectomy may be preferable. The mortality and morbidity (including possible psychological effects) of hysterectomy should be weighed in each couple against the likelihood of a further operation in the future on the same individual if the wife is to be sterilised or, if the man seeks vasectomy, on his partner. Published reports suggest that the operative risks of laparoscopic sterilisation may be of the same order as those of hysterectomy. Finally, if either male or femal sterilisation is planned, should the woman discontinue oral contraception for at least six months beforehand to discover whether she can now tolerate her normal periods? Would the increased risk of unwanted pregnancies outweigh the potential benefits?
FISTULA-IN-ANO A
is
abnormal communication between epithelial surfaces; unless epithelialised it tends naturally to close. Healing, however, may be frustrated by any one of a number of different agencies. Anal fistulas in particular are well-known for their chronicity, and their successful management entails an understanding of the reasons why. There is still disagreement about their nature. One theory had it that the suppuration preceding them resulted from infection entering the anal wall through mucosal cracks, the track being completed by release of pus through the perianal skin. Continued patency was ensured, supposedly, by proximal contamination during defalcation. This explanation influenced treatment: by laying it open-and shelving and packing the wound-the surgeon could persuade the track to epithelialise and become part of the anal lining. Although the treatment is satisfactory the explanation is not. Firstly, fistulation almost never follows even the most severe anal submucosal infection-the internal sphincter seems an effective barrier. Secondly, in about 50% of anal fistulas the internal opening cannot be found. The anal glands were first incriminated in the aaiology almost a hundred years ago;’ their ducts sometimes pass entirely through the internal sphincter to end in FISTULA
an
two
rudimentary
mucous
glands
in the
inter-sphincteric
space. Eisenhammerzsuggested that infection in the glands produced the primary lesion of anal fistula-an inter-sphincteric abscess. The final track was regarded 1. Chiari, H. Wien med. Press, 1878, 19, 1482. 2. Eisenhammer, S. Surgery Gynec. Obstet. 1958,
106,
595.
secondary effect dependant on the course then taken by the pus. Parks3 confirmed Eisenhammer’s theory histologically, and in addition found evidence in his specimens that the glands had been dilated before infection. He suggested that anal fissure-antedating the fistulahad obstructed the ducts by fibrosis and so predisposed them to suppuration. His theory also explained (as he pointed out) the observed proclivity of fistulas for the anterior and posterior commissures. As a result of his work and that of Lillius,4 the anal glands are now widely believed to be implicated in the aetiology of most if not as a
’
all anal fistulas. The classification of fistula-in-ano has long caused confusion (ironically, since its purpose is to assist), and it was with the aim of providing a practical guide for the surgeon that Parks et al.5 have lately recorded a study of 400 cases. A concept central io their thesis is that anal fistulas have as their starting-point an inter-sphincteric abscess. Their message is that successful surgery depends on a sound knowledge of anorectal anatomy coupled with a clear understanding of the different paths the secondary track may take. They describe four main types of fistula and create subdivisions for the different varieties encountered in each. For instance their "intersphincteric" group contains six subgroups designated according to the characteristics of the inter-sphincteric extension. Their other main groups are "trans-sphincteric", "supra-sphincteric", and "extra-sphincteric". Of course, the main concern of the surgeon in dealing with a difficult fistula is the preservation of continence; with this particularly in mind, Parks et al. describe the way in which the various types of "high" fistula can imitate one another and yet have totally different treatments. Although not primarily concerned with technique, their clear three-dimensional portrayal of fistula anatomy, their emphasis on continence mechanisms, and their description of the various pitfalls furnish the reader with the information required for the design of a sound operation. It should be said, however, that their cases-all had been referred to a specialist unit-give a distorted picture of the relative incidence of difficult fistulas, and it is important to keep the subject in perspective. In this respect Thompson’s6 concept of only two groups has much to recommend it. He recognised simple ’fistulas (straight low tracks, easy to treat, and accounting for 95% of cases) and complex ones (curved high tracks, difficult to deal with, 5%). Certainly in the great majority the inter-sphincteric abscess, taking the path of least resistance, extends along the plane of the fanning-out fibres of the conjoined longitudinal muscle straight to the skin. Only seldom does it traverse the external sphincter high up where, posteriorly, it would arrive in the post-sphincteric space with unhindered. progress thence into either or both ischiorectal fossae ("horseshoeing") ; extending cephalad, it might pass the levator plate. The bizarre fistulas described by Parks and his colleagues clearly present a tremendous challenge and these workers’ lucid account will prove of great value to those faced with similar cases. Complicated fistulas being rare, few general surgeons will ever encounter the more
frightening-looking supra-sphincteric variety
3. Parks, A.G.Br. med. J. 1961, i, 463. 4. Lillius, H. G.Acta chir.scand. 1968, suppl. 383. 5. Parks, A. G., Gordon, P.H., Hardcastle, J. D. Br. J.Surg. 6. Thompson, H. R.Proc.R. Soc.Med. 1962, 55, 754.
1976, 63, 1.
discussing these questions with the the and journalists who write for the public. public the medical profession, who need to This involves keep an informed opinion on environmental risks, and to tell their patients and the public when nothing should be done or when action is needed, and especially when we need public cooperation in the gathering of information on the risks of modern life. more
time
Late Complications of Female Sterilisation A HIGH’ percentage of women who have had tubal sterilisation complain later of menorrhagia or dysmenorrhcea.1-8 MULDOON,6for instance, found that, out of 374 patients followed for at least ten years after operation, nearly 19% came to hysterectomy. The figures are not in dispute; but could there be an antecedent common cause? Are women who are sterilised more likely than average to complain later of increased or painful menstrual bleeding ? These symptoms, particularly increased bleeding, become more common with the passage of time. Their incidence in unsterilised women matched for race, age, social class, parity, and menstrual blood-loss is not known. Psychological factors also operate, possibly by altering hormonal control of the menstrual cycle via higher centres, and certainly by affecting the threshold for complaints (perhaps more readily in women who have been sterilised). Moreover, there is no way of directly measuring menstrual pain, and workers who have measured menstrual blood-loss (usually by the method of HALLBERG and NILSSON9) can testify to the unreliability of reports of menorrhagia. For example, in a studylO of women presenting in a family-planning clinic with no complaint of heavy bleeding and requesting intrauterine contraception, 14% had a measured mean menstrual loss, over two normal periods, of more than 80 ml (80 ml is regarded as the normal,11 12 and above it irori-deficiency anaemia becomes more common). The effect of contraception is another imponderable: contraceptive-pill users may dislike their normal periods when these return after sterilisation; and the type of contraception used by a control group may affect the natural history of menstrual bleeding. The published investigations with one exception have been uncontrolled, all have been retrospec1. Sacks, S., La Croix, G. Obstet. Gynec. 1962, 19, 22. 2 Lu, T., Chun, D. J. Obstet. Gynœc Br. Commonw 1967, 74, 875. 3. Lang, L. P., Richardson, K. D. ibid. 1968, 75, 972. 4. Whitehouse, D. B. Br. med. J. 1971, ii, 707. 5. Houseman, R. J. ibid. 1971, iii, 184. 6 Muldoon, M. J. ibid. 1972, i, 84. 7. Chamberlain, G., Foulkes, J. Lancet, 1975, ii, 878. 8. Neil, J. R., Noble, A D., Hammond, G. T., Rushton, L., Letchworth, A. T. ibid. 1975, ii, 699. 9. Hallberg, L, Nilsson, L. Scand. J clin. Lab. Invest, 1964, 16, 244. 10. Guillebaud, J., Bonnar, J., Morehead, J., Matthews, A. Lancet, 1976, i, 387. 11. Hallberg, L., Hogdahl, A. -M., Nilsson, L., Rybø, G. Acta obstet. gynœc. scand 1966, 45, 320. 12. Rybø, G. ibid. 1966, 45, suppl. 7.
was measured in none. on self-rating quesbased al.," study tionnaires, compared the responses of patients up to 28 months after abdominal tubal ligation or laparoscopic tubal diathermy with those of women whose husbands had been sterilised. Increased menstrual loss and menstrual pain were reported by significantly more sterilised women than controls, and the women sterilised by laparoscopic tubal diathermy seemed to suffer most. However, 10% more of the control group had been on the pill before their husband’s sterilisation, 22-28% of the questionnaires were not returned, and subjective variables may have affected responses. Vasectomy has been socially acceptable for a far shorter time than female sterilisation, so couples are likely to be defensive and could well be less ready to admit to any problems after it—especially since "common sense" dictates that there would be no effect on menstruation. There has been one small objective study: menstrual blood was collected and measured in 25 women for three periods before operation and for up to one year afterwards.13 No significant difference was detected between blood-losses before and after the procedure (abdominal tubal ligation in all but one case). This investigation should obviously be repeated with larger numbers and longer follow-up. Ideally, such a prospective study should include a control group matched initially for age, parity, and menstrual blood loss and similarly followed up with blood-loss measurements; but the logistics, and the difficulty of allowing for the effects of continued contraception in the control group, are daunting. For the present, there exists a possibility that operation on the fallopian tubes may tend to cause increased or more painful menstruation, and a number of mechanisms have been proposed.8 14 Some observations suggest that prostaglandin-synthetase inhibitors may improve dysmenorrhoea and reduce measured menstrual blood-loss, and the prostaglandin status of the -uterus may possibly be altered by damage to utero-ovarian blood-supply. But -elucidating the mechanism of any possible effect of tubal surgery on menstruation would be a major undertaking; and the main hypothesis has yet to be established. There can, however, be little doubt that when a woman asks for sterilisation there -is a fairly high chance that she has early or established menstrual
tive, and menstrual loss NEIL
et
in
a
problems. So couples requesting permanent contraception should invariably be interviewed together. A thorough menstrual history should be taken from the wife: she should be questioned about the number of pads and tampons used per period and about "flooding", or clots, or very frequent changing (more than once an hour) on her heavy days. 13. Kasonde, J. M., Bonnar, J. Unpublished. 14. Darwish, D. H., Saafan, S. T. A. Lancet, 1975, ii, 975.
574
She should also be examined vaginally for incidental pathology and a recent cervical smear report should be to hand. Logically the wife should be so assessed even if the initial request was by her husband for a vasectomy-at least if she is aged 35 or more. If, as in most cases, examination is normal and the menstrual history indicates a normal or light loss without excessive pain, then vasectomy, abdominal sterilisation, or laparoscopic sterilisation would all be reasonable. Otherwise, in selected cases, hysterectomy may be preferable. The mortality and morbidity (including possible psychological effects) of hysterectomy should be weighed in each couple against the likelihood of a further operation in the future on the same individual if the wife is to be sterilised or, if the man seeks vasectomy, on his partner. Published reports suggest that the operative risks of laparoscopic sterilisation may be of the same order as those of hysterectomy. Finally, if either male or femal sterilisation is planned, should the woman discontinue oral contraception for at least six months beforehand to discover whether she can now tolerate her normal periods? Would the increased risk of unwanted pregnancies outweigh the potential benefits?
FISTULA-IN-ANO A
is
abnormal communication between epithelial surfaces; unless epithelialised it tends naturally to close. Healing, however, may be frustrated by any one of a number of different agencies. Anal fistulas in particular are well-known for their chronicity, and their successful management entails an understanding of the reasons why. There is still disagreement about their nature. One theory had it that the suppuration preceding them resulted from infection entering the anal wall through mucosal cracks, the track being completed by release of pus through the perianal skin. Continued patency was ensured, supposedly, by proximal contamination during defalcation. This explanation influenced treatment: by laying it open-and shelving and packing the wound-the surgeon could persuade the track to epithelialise and become part of the anal lining. Although the treatment is satisfactory the explanation is not. Firstly, fistulation almost never follows even the most severe anal submucosal infection-the internal sphincter seems an effective barrier. Secondly, in about 50% of anal fistulas the internal opening cannot be found. The anal glands were first incriminated in the aaiology almost a hundred years ago;’ their ducts sometimes pass entirely through the internal sphincter to end in FISTULA
an
two
rudimentary
mucous
glands
in the
inter-sphincteric
space. Eisenhammerzsuggested that infection in the glands produced the primary lesion of anal fistula-an inter-sphincteric abscess. The final track was regarded 1. Chiari, H. Wien med. Press, 1878, 19, 1482. 2. Eisenhammer, S. Surgery Gynec. Obstet. 1958,
106,
595.
secondary effect dependant on the course then taken by the pus. Parks3 confirmed Eisenhammer’s theory histologically, and in addition found evidence in his specimens that the glands had been dilated before infection. He suggested that anal fissure-antedating the fistulahad obstructed the ducts by fibrosis and so predisposed them to suppuration. His theory also explained (as he pointed out) the observed proclivity of fistulas for the anterior and posterior commissures. As a result of his work and that of Lillius,4 the anal glands are now widely believed to be implicated in the aetiology of most if not as a
’
all anal fistulas. The classification of fistula-in-ano has long caused confusion (ironically, since its purpose is to assist), and it was with the aim of providing a practical guide for the surgeon that Parks et al.5 have lately recorded a study of 400 cases. A concept central io their thesis is that anal fistulas have as their starting-point an inter-sphincteric abscess. Their message is that successful surgery depends on a sound knowledge of anorectal anatomy coupled with a clear understanding of the different paths the secondary track may take. They describe four main types of fistula and create subdivisions for the different varieties encountered in each. For instance their "intersphincteric" group contains six subgroups designated according to the characteristics of the inter-sphincteric extension. Their other main groups are "trans-sphincteric", "supra-sphincteric", and "extra-sphincteric". Of course, the main concern of the surgeon in dealing with a difficult fistula is the preservation of continence; with this particularly in mind, Parks et al. describe the way in which the various types of "high" fistula can imitate one another and yet have totally different treatments. Although not primarily concerned with technique, their clear three-dimensional portrayal of fistula anatomy, their emphasis on continence mechanisms, and their description of the various pitfalls furnish the reader with the information required for the design of a sound operation. It should be said, however, that their cases-all had been referred to a specialist unit-give a distorted picture of the relative incidence of difficult fistulas, and it is important to keep the subject in perspective. In this respect Thompson’s6 concept of only two groups has much to recommend it. He recognised simple ’fistulas (straight low tracks, easy to treat, and accounting for 95% of cases) and complex ones (curved high tracks, difficult to deal with, 5%). Certainly in the great majority the inter-sphincteric abscess, taking the path of least resistance, extends along the plane of the fanning-out fibres of the conjoined longitudinal muscle straight to the skin. Only seldom does it traverse the external sphincter high up where, posteriorly, it would arrive in the post-sphincteric space with unhindered. progress thence into either or both ischiorectal fossae ("horseshoeing") ; extending cephalad, it might pass the levator plate. The bizarre fistulas described by Parks and his colleagues clearly present a tremendous challenge and these workers’ lucid account will prove of great value to those faced with similar cases. Complicated fistulas being rare, few general surgeons will ever encounter the more
frightening-looking supra-sphincteric variety
3. Parks, A.G.Br. med. J. 1961, i, 463. 4. Lillius, H. G.Acta chir.scand. 1968, suppl. 383. 5. Parks, A. G., Gordon, P.H., Hardcastle, J. D. Br. J.Surg. 6. Thompson, H. R.Proc.R. Soc.Med. 1962, 55, 754.
1976, 63, 1.