CHRONIC OBSTRUCTIVE IN FEMALE~

by SATISH N. SHAH,* M.S.

In pure practice, the propor­ Anatomical and Physiological Conside­ tion of female patients is small as com­ rations: pared to males, in the proportion of 1 to Anatomically, female urethral design 6. Even in these patiebts, there is a is such that it is naturally more suscep­ majority that fall in certain nonspeci­ tible to infection. The reasons for this fic infection group. Of course, all well are, a short course, absence of external known groups of conditions viz. tuber­ urethral sphincter, proximity to vaginal culosis, tumour, calculi, etc., should be opening and general exposure of vulvar kept in mind and, if identified, must be region to unhygeinic atmosphere of water treated accordingly. This is a small and clothes. Again, there is wide varia­ group of patients in whom an attempt at tion in the anatomical configuration of establishing the aetiology and, more im­ external and its rela­ portant, a rational tn,atment for a cure tions with vaginal outlet. The usual dis­ rather than remission was made. Most tance between the two is about H to 2~ of these patients have close anatomical, ems., but there are extremes in this. It physiological, pathological and therapeu­ is often found inside the vaginal canal, tic relations with female genital track. in the anterior vaginal wall, about 3 (U T I) in ems from the outlet. In others, it is females is a very common condition, about 4-5 ems. anterior to the outlet; more prevalent than is generally thought which, of course, is not important from of. Most patients take it for granted that our point. However, it is observed with it is normal to have some urinary com­ good logic that the closer the meatus plaints for females, as they do with situated to the vaginal outlet, the more leucorrhoea. Such patients do not com­ susceptible is the patient to infection. A plain except when asked a leading ques­ minimum of H ems distance is considered tion. Doctors, mainly general practition­ necessary by some authors and _in the ers, do not feel at ease in asking ques absence of this, some ·have advocated tions related to genito . repairs to extend the length of . ~ Again in usual general practice, there is Again, in women susceptible to infec­ no privacy while interrogating or exa­ tions the urethral meatus was found to mining patients. Therefore, it is very be covered' up by folds of mucosa or common for most general practitioners mucosal fronds, which sorrounded it like and even for consultants of other labia. These fronds made it difficult to branches to treat such patients without distinguish the meatus and! merged im-- any local examination. perceptibly. with .the vaginal outlet,. _ In small. girls, - this anatomy makes. * Urologist, Baroda Surgical Clinic, Nawab­ wada, Raopura, Baroda. them . susceptibJe · to infections from Received for pubLication on 28-8-1970. fomites , and household dust~ In married 358 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA women, the friction of intercourse has substantiated by the dramati.c response an irritant effect on the meatus, more to oestrogen therapy. so in susceptible patients. This also ex­ Then there is a group of patients plains the so called 'Honeymoon under 10 years of age. It is difficult to i Cystitis'. incriminate the only factor of unhygeinic Physiologically, the single most im­ surroundings. In most such patients, the portant factor is the status of urinary urethral meatus is small and urethra is bladder sphincter mechanism. It is not long. However, it is difficult to say this difficult to explain the ascending infec­ with certainty as there is no proper tion in patients with marked damage to standardisation about the size of urethra this mechanism, as in uterine prolapse in children. However, dramatic results with cystourethrocele. But minor degree to dilatation therapy are unmistakable. of damage often gives deceptive pictures. Varying degree of cystourethrocele with­ Material and Method out actual prolapse of the uterus is a A series of 1500 urological cases were definite condition, frequently encounter­ studied. The total number of female ed in such cases. History of stress incon­ patients were 255 out of which 114 were tinance is obtained only on asking lead­ found suitable to fit into the present ing questions, and in some cases, there series. The total period was 2! years. is a tendency to hide the symptoms in The only common factor in these patients presence of other relatives. Some degree was recm:nnt or chronic infections, in of pelvic floor weakness may also he whom other common aetiology like allowing ascending infection, though stones, tuberculosis, tumour, _etc. were may not give rise to obvious stress in­ ruled out reasonably clinically and by continance. On the contrary, some cases common investigations. In case of tuber­ of stress incontinance do not reveal any culosis, it is often difficult to rule out degree of pelvic floor weakness. How­ with surity, and in some cases both th2 ever, such patients, on cystoscopy, show aetiologies are kept in mind and! the thickming of bladder neck and loss of diagnosis is revised as necessary. elasticity, which probably interferes with These patients were studied from the proper closure of the sphincter. In some, view point of complaints, history, physi­ the whole length of urethra shows simi­ cal examination, speculum and vaginal ( lar changes. This is more commonly examinations and some routine investi· found in patients with , and gations like analysis and plain X­ having senile vaginitis. These patients ray of abdomen. In ~elected cases have a small vaginal outlet, dry pale intervenous pyelography and urine mucosa and small external urinary cultures and sensitivitifiS studies meatus flush with the surface. This open­ were done. In the early part of the study, ing is rigid and is comparable to the golf cystoscopy was done as a routine but, hole opening of with tuberculosis. after pilot evaluation, it was reserved The mucosa is dry, itchy and painful to only for selected cases. This included touch. In short, urethral mucosa in the cases with very severe infection, atypi­ female is as sensitive to oestrogens as is cal symptoms, suggestions of tubercu­ vaginal mucosa. This is true, not only in losis and not responding usually to dila­ women with menopause, but also in some tation therapy. With this, an attempt is very young patients too. This view is made to isolate cases who fall in the

. . CHRONIC OBSTRUCTIVE URETHRITIS IN FEMALES 359

present group and then to subdivide Most of the patients (80.% ) have been them into various subgroups from aetio­ suffering from this condition for a logical point of view and also for treat­ period of 1 month to 5 .years, but in ment. Results are studied with a follow extreme cases it has been noticed in up of 6 months to 2! years. At the end neonatal period and on the other hand of the study, an attempt is made to de­ for more than 10 years in 6 cases. fine various conditions from clinical point of view so that these patients can TABLE III Symptomatology be managed well without many exten­ sive and expensive investigations, which 1. 97 may be reserved for oot responding 2. Frequency 91 cases only. 3. Leucorrhoea 64 4. Low backache 58 Analysis of the series: 5. Stress incontinance 30 6. Suprapubic pain 28 Total cases over a period of 3 years, 7. Renal angle pain 18 of urology . , 15CO 8. Fever with ,rigor 18 Total females 255 9. Fever without rigor 12 Total cases of obstructive ureth- 10. HI o diabetes 14 ritis 114 11 . Perineal pain 14 Number of followed up cases 99 12. Bowel disturbance 30 13 . H / o catheterisation TABLE I 8 Age Distribution Almost ubiquitous symptoms are 1. Upto 10 years 17 a. 1 month-6 months 3 dysuria and frequency. LeuC'orrhoea and b. 7 months-1 year 1 low backache are next and! other less c. 1 year-S years 8 common symptoms are stress incontin­ d. 6 years-10 years 5 ance, suprapubic pain, renal angle pain 11 years to 20 years 8 2. and fever with or without rigor. Other 3. 21 years to 30 years 20 4. 31 years to 40 years 38 related points in history are history of 5. 41 years to 50 years 19 past catheterisation in 8 cases, of dia­ 6. 51 years to 60 years 8 betes in 14 cases and bowel disturbances 7. Above 61 years 4 in 30, which includes constipation in 18 and diarrhoea in 12' cases. Though maximum number of patients are in 3rd, 4th and 5th decades, no age TABLE IV is exempt. Twelve patients under 5 Gynaecological History years and 17 under 10 years age do draw Undergoing menopause 10 special attention. Past menopause 23 Leucorrhoea 64 TABLE II Oligomenorrhoea 4 Duration of Symptoms Dysmenorrhoea 14 Menorrhagia 16 1. Upto one month 31 H / 0 hysterectomy 12 2. Upto 6 months 21 H/0 recent D & C 4 3. Upto 1 year 19 4. Upto 5 years 26 5. Upto 10 years 11 Role of leucorrhoea is discussed else­ 6. Upto more than 10 years 6 where. The posthysterectomy patients 360 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA are specifically prone to this condition TABLE VI ;,md the aetiology is probably a combi­ Urine Analysis nation of weakened pelvic supports and Pus cells/ H.P.F. .R.B.C./HPF senile vaginitis. Again, in some of them, 0 to 5 57 cases 0 to 10 51 there is a history of immediate post­ 5 to 25 . . 34 More than 10 8 operative voiding troubles or catheter 25 to 100 7 problems. Most of the patients under­ More than 100 4 ,. going or past menopause have changes pH of urine of senile vaginitis and have showed good Acidic 48 Alkaline 34 response to oestrogens. • Neutral 10 Not done 22 TABLE V Findings at Physical Examination In urinalysis the single most important Suprapubic tenderness 20 Renal angle tenderness 14 finding was number of pus cells. In the 21 majority of cases, there were less than Urethral meatal fronds 13 5 pus cells per high power field. Only 8 in 11 cases there were more than 25, Cystourethrocele without indicating that this condition is rarely marked uterine prolapse 24 Uterine prolapse 10 associated with very heavy infection. In Cervical erosion 25 few cases the urine reports from outside Marked leucorrhoea were not specifi<;, and so not included without erosion 23 for study. Microscopic haematuria was present in about half the cases but only Suprapubic tenderness found in 20 rarely marked. Only patients with de­ patients and renal angle tenderness in finite caruncle complained of terminal 14 were not of severe degree. Only on bleeding of one or two drops. Urine re­ inspection, meatal stenosis was suspect­ action of fresh spEICimen showed that it ed in 21 cases, but often this was de­ had a tendency towards alkaline reaction ceptive. Out of a total of 34 cases of in about half the cases, mostly indicating prolapse, only 30 showed stress incon­ some residual urine, and infection. In tinance, indicating that some cases of short, even almost absence of pus cells in prolapse do not have stress incontinance urine does not rule out this condition and and some cases of stress incontinance do mild to moderatE\ amount . of microscopic not have prolapse. Caruncle was obvious haematuria only goes along with the con­ in 8 cases, but its deceptive nature is dition. realised after some dilatation. Also, in TABLE VII some cases, there were folds of mucous Radiologica.l Findings membrane on the posterior lip, but still could not be definitely labled as caruncle. Normal plain X-ray 31 cases I.V.P. normal 6 Out of 64 patients with history of leu­ Chronic pyelonephritis 3 corrhoea, erosion was found in 25 cases, Cystogram diverticuli 1 marked visible discharge in 23, endo­ cervicitis without erosion in 4 cases and Radiological investigations were done in remaining 12 cases no pathology was in a limited! number of cases because of detected. financial reasons. Plain X-J:ay of abdo- CHRONIC OBSTRUCTIVE URETHRITIS IN FEMALES 361

men done in 31 cases were normal. Of bration should be done with Otis Bougie course, those with obvious calculi were -a- boule, which we are trying to ac­ excluded from this study as defined in quire. The site of obstruction is recorded the early discussion. Intravenous pyelo­ as external meatus, internal meatus or graphy was done in only 10 cases, was total length. The distribution of site of normal in 6, showed definite changes of obstruction is seen in table No. 8. pyelonephritis in 3 and showed bladder TABLE VIII diverticuli in one, in which a cystogram Distribution of site of Obstruction was done to confirm. External meatus 25 Cystoscopy and dilatation Internal meatus 32 The first id!ea of using dilatation came Throughout the length 16 from one of my first patients who had Not possible to decide 42 undergone diagnostic cystoscopy for The commonest site of obstruction is in­ chronic pyelonephritis of unknown cause ;, ternal meatus. All children are not pos­ for about 10 years. She was grateful for I sible to assess as to the site of obstruc­ the drammatic cure after cystoscopy tion. Total length obstruction was com­ t which automatically did dilatation. Since mon in post menopausal patients. The then, dilatation is made routine before calibration gave following results. We cystoscoping all the females. This routine consider No. 16 french as usual minimum also revealed some buried caruncles. diameter in adults for this purpose. Also, only because of this policy, we are Considerable resistance was felt with in a position to study probable signs of No. 12 catheter in 8 cases, No. 13 cathete.c future caruncle or sort of precarunclar in 22 cases, No. 14 catheter in 34 cases condition. Our experience is limited to and No. 15 catheter in 19 cases. One comment on this at present. Out of 38 dilatation with No. 18/ 21 sound wa3 cystoscopies in the early part of the enough to relieve the obstruction in 70 study, only 5 showed signs of exten­ cases. Twenty required two dilatations sive cystitis, but most showed , and nine required more than two dilata­ and varying degree of bladder neck tions. Fifteen patients are lost to follow rigidity and oedema. In menopausal up after the diagnosis or the first dila­ cases total length of urethra showed pale tations. and inelastic mucosa. After some ex­ perience, cystoscopy was not thought TABLE IX necessary for all the cases, and then it Follow up and results was reserved only for cases where other pathology was suspected. Lost to follow up 15 Fair Dilatation is now done as a routinP., 25 Good 44 but some details are important. First, Very good 15 the largest number of rubber catheter Excellent 15 that can be passed without difficulty is noted. This gives a rough idea about the We will take the 15 unfollowed cases calibration of the urethra. Anaesthesia as failures. In others the follow up is used is almost always local with from 6 months to 2! years. The results Xylocaine jelly, except in children where are disregarding the number of dilata­ general anaesthesia is used. Ideally, cali- tions, but are based on the relief of CHRONIC OBSTRUCTIVE URETHRITIS IN FEMALES 363

good symptomatic relief in patients with Obstructive Urethritis". On the basis of marked perineal pain. anatomical and physiological backgrounds it is easy to explain all the symptoms as In patients with menopausal syndrome, also various subgroups, their characteris­ male and female hormones were given tics and the logic behind the treatment. while in those with senile vaginitis, But, it is very difficult to provide any oestrogens were used. Oestrogen cream E:!Xperimental proof. However, dramatic locally also gives good results in whom results are enough to stimulate the study. it is well tolerated. However, the inci­ Enough discussion has been given to dence of severe irritation was quite draw some conclusions about definition high. In patients with very long dura­ of the condition. First of all, all the tion and in whom psychosomatic symp­ specific conditions like tuberculosis, cal­ toms were suspected, mood elevators culi, growths, etc. are excluded. The were of better help than tranquilirors. positive features of the condition may Discussion with illustrative cases now be described. This condition is pri­ marily urinary tract infection combined This condition is much more common with some degree of anatomical or func­ than is usually believed to be and most tional obstruction at any level in ure­ of the nonspecific urinary infections in thra. It is restricted to females but no females can be classified as belonging to age is exempt. The infection is usually this group. Awareness on the part o£ mild to moderate, intermitant and re­ treating physician is important in recog­ current, with definite sense of obstruc­ nising it. Direct questions and local exa­ tion to the flow of urine. This is decep­ minations can pinpoint the condition. tive in some patients who in the begin­ Though not severe, because of low grade ning refuse to admit of obstruction, but morbidity and frequency, the condition in almost all the cases, after the dilata·­ is very important for physicians of all tion therapy, they confess the improve­ branches, especially for urologists and ment in the flow of urine to a marked gynaecologists. The treatment advocated degree, as compared to predilatation flow is so simple, inexpensive and . harmless rate. The other common features are that a therapeutic trial may be given straining at micturition in children, leu­ even in cases where other causes for corrhoea in child-bearing age, stress in­ lingering infection may be possible, and continance in adults with suprapubic, in cases where response is not good, de­ renal angle or perineal pain, .low backache tailed and extensive investigations may and irregular bowel habits. Urinalysis is be done. important as a base line to judge the There seems to be no definite termi­ response besides the diagnosis. There is nology assigned to this common condi­ also tendency to alkaline pH and micro­ tion, though most authors do make '1 scopic haematuria. Radiological investi­ passing mention of existance of such gations are usually not of much help condition and its treatment. But no de­ except to rule out other conditions .. tails are given, and definitely no status Erosion of cervix, external meatal ste­ as a disease entity has been given. Be­ nosis, excessive mucous fronds around l cause the organ involved is urethra and the meatus, definite or probable caruncle the pathology is obstructive, tentatively and senile vaginitis are other common suggested title could be "Chronic concurring features. Response to dilata- 13 364 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA

tion, in association with adjuvant therapy, Type II: is a factor invariably common to all the This includes most young and middle cases. aged women, almost all in child-bearing Though too early, an attempt is made age. However, the main point is not the now to subdivide the group into aetiolo­ age, but it is the gross infection in geni­ gical types. These compartments are not tal tract. The dischar ge from vagina i.:; watli!r tight and ther e may be combina­ overt and its inflammatory effect on the tion of the two types, as well as there external urinary meatus is visible. Most may be some cases which do not fall cases with mucosal fronds around thi:! in any of these subgroups. There is a lot meatus fall in this group. Whether the that is still unexplained .• Four types are fronds are the cause or the effect of vagi­ described. nal discharge and infection, is a matter of guesswork. Some of these patients Type I: have features of this conditions as well This describes infants and children as those of the type III to be described. under 10 to 12 years of age. Here it may All erosion cases are in this group. These be logical to believe that the infection patients have a tendency to recurrent in­ comes from fomites, but looking to the fection, pE,rineal pain and renal infection. narrowness of meatus, some congenital They require meticulous examination factor may be responsible. The obstruc­ and treatment of gynaecological condi­ tion is at the external meatus. Some tion. They may require repeated treat­ patients have been mistaken as '3 ment and m ore prolonged course of pro­ months' colic'. The straining and pain per antiinfective agent. All the patients while passing urine is unmistakable. The who develop symptoms in early months results are most dramatic to only one of married life and in whom the symp­ dilatation. Tendency to alkaline urine is toms become recurrent or chronic fall maximum in this condition. in this group. This is because, though the initial factor is irr itation, all the cases CASE REPORT with irritation alone, without infection, L. B. J., 4 year old girl had come to get cured with simple treatment, but India from Africa. She complained of those with pre-existing predisposing fac­ severe burning micturition, frequency and tors become chronic and therefore in­ crying everytime she passed urine. She cluded in this group. had frequent fever with rigor upto 103°F. Multiple urine cultures were done and CASE REPORT proper antibiotics were given, but with only temporary improvement. Her IVP Mrs. M. S. B., 22 yrs, married 5 yrs. done at Africa was normal. Urine was ago, had pain in the left renal angle, neutral and showed 100-150 pus cells/HPF. dysuria and occasional dribbling of urin0 On ~1-12-69 , a dilatation was done upto for last 2! years. She had fever off and number 13/ 16 french. The patient reported on, mild oedema over feet and frequency good improvement immediately, and fol­ of D / N: 10-12/ 6-7. She had leucorrhoea low up after 17 days and letter from Africa for last 3 years. She was wife of a doctor, after 18 months have shown that she is and was treated fo :r erosion of cervix 2 free from all complaints without any years ago and had consumed good amounts medications. of nitrofurantin, tetracyclines and anal­ gesics. She had suprapubic tenderness, and This type constitutes about 10 to 12 % urine showed 4-5 pus cells, but it was al­ of all the cases. kaline. Her residual urine was 2 ozs. CHRONIC OBSTRUCTIVE URETHRITIS IN FEMALES 365

There was· some impulse on the anterior R. B. C.s. It was acidic. I. V. P. showed vaginal wall on coughing. A cystoscopy chronic pyelonephritis, but not definitely was done and a very narrow stenosis of tuberculous. the external meatus was found and dilat­ A cystoscopy and full dilatation were ed. Immediate results were dramatic and done. Moderate stenosis of· the internal she was kept on nitrofurantin for 6 weeks. meatus was felt. The result was good, but A follow up upto 10 months was very the symptoms recurred after 6 months. satisfactory and she was off all the medi­ The degree of cystourethrocele was in­ cines. Reports from husband even uptill creasing. A dilatation again relieved the today are very satisfactory. 30% of cases patient completely but she was again fall in this group. stressed the importance of sphincter exer­ cises, which she was not doing. A follow Type III: up after 2 years showed that she had still This group includes mo";;t palients with mild stress incontinance, but no urinary symptoms. She has agreed for operation damaged bladder sphincter mechanism if symptoms recur. 25 to 30% of cases fall as the main pathology, with ensuing in­ in this variety. fection. Almost all are multiparous Type IV: women, but even virgins are not exempt. Besides signs of ascending urinary in­ This type includes all the cases past fection, they have stress incontinance, menopause or approaching mEnopause. not very severe leucorrhoea and the pain Again, some overlapping is possible. But is maximum at the end of voiding. These gross vaginal infection and sphincter in­ patients usually show vaginal outlet competance are not the main aetiological weakness and cystourethrocele is visi­ factors. The main complaints are supra­ ble. The obstruction is mostly at the in­ pubic pain and perineal pain, continu­ ternal meatus and the internal sphincter ous dysuria, burning and itching. The fails to close properly. The results de­ sense of obstruction is well marked. The pend mainly upon how much we can external meatus is small and flush and bring the sphincter mechanism to nor­ the mucosa is pale, dry and painful to mal. The stress incontinance disappears touch. The vagina is small without any by dilatation alone, in most of the early other pathology. The obstruction is in cases and in these patients it can be the whole length of the urethra, which kept from recurrence by exercise, but in is rather inelastic. Some of the young patients with severe damage, the incon­ patients in this group had hysterectomy tinance does not disappear and these in the past. Very severe obstructive patients usually require operation for cases usually come from this group, as permanent results. also patients with early. or obvious car­ nude. The response is less dramatic to CASE REPORT dilatation alone, but oestrogen for a Mrs. S. D. S., 28 years, had first attack period of 3 months gives very good! re­ . of urinary infection 11 years ago soon after sults. These patients do have a tendency her first delivery. Since then she used to get recurrent attacks of infection, for which to recurrance. Psychological overlay in many urine cultures were done and was symptoms is more common in such cases. treated accordingly. She was also suspec­ ted of having tuberculosis and was given CASE REPORT complete treatment twice. She had mark­ Mrs. V. H. S., 47 years old, was first seen ed stress incontinance and was cauterised on 16-2-69 for diminished flow of urine for erosion with good results 5 years ago. and in drops for 1 year. There was fre­ Her urine showed 8-10 pus cells and few quency and dysuria, and dyspnoea, fatigue

• 366 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA

and low fever. She was in menopause for in detail. These groups are illustrated the Jast 6 years and had no leucorrhoea whatsoever. She was treated by tetracy­ by one case report in each group. clines and sulpha. Her blood investiga­ Though there are many · points still un­ tions were normal, but urine was alkaline explained, and there are many cases with 10-12 pus cells and 2-3 R. B. C.s. per which have signs of more than one group HPF. I. V. P. showed normal upper tract, combined, the next project is to study but bladder showed diverticuli, which were confirmed by cystogram. A dilata­ such cases in individual groups seperate­ tion was done followed by introduction of ly. The treatment suggested is so simple No. 22 Foley catheter for 4 days. The and inexpensive that one is tempted to results were good for 18 months, but then give a therapeutic trial in almost all the she got some obstructive. sympoms, much cases, before performing detailed inves­ less compared to the previous one. She was kept on mandalamine for 6 weeks and tigations for other conditions like tuber­ oestrogens for 3 months. culosis, tumour, calculi, etc. WhEn this Recently a second dilatation was done, condition is identified, dilatation of and a cystogram just before that showed urethra becomes one of the sheet diverticuli were of the same size and urine anchors of treatment, without which showed only mild infection. This variety constitutes some 10 to 15% of all cases. the treatment is incomplete and the results are unsatisfactory. When Summary performed in a correct case, togather A series of 114 cases of nonspecific wih other adjuvant measures, it results urinary infection in females is analysed in satisfied and grateful patients. with a' view to study the basic reasons Acknowledgement for making the infection chronic and re­ current. The usual well known predis­ Shri N. N. Shah, final year M.B.B.S., posing causes are excluded. A common student h£ lped in collecting and analys­ obstructive factor is incriiminated for ing statistics. aetiology and an attempt is made to References rationalise the treatment on this basis 1. Brannan, W. et al, J. Urol. 101: 570, to get more permanent results. In doing 1969. so, it becomes necessary to recognise the 2. Savouret, J. Recurrent Urinary In- condition by a title and "Chronic Ob­ fections: Medicine en France: 17: structive Urethritis" has been suggested. 6, 2, 1969. Further analysis of basic pathology, cli­ 3. Emmett, J. L.: Clinical Urography, nical picture, investigations and treat­ 402-403, 1964. " 4. Rechardson, F. H.: J. Urol., 101: ment required besides dilatation, has 719, 1969. helped to subdivide the condition into 5. Kerr, w. S. Jr.: J. Urol., 102: 449, four subgroups, which are then described 1969.

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