Twelve Month Outcomes of Pelvic Organ Prolapse Surgery in Patients With Uterovaginal or Posthysterectomy Vaginal Prolapse Enrolled in the Multicenter Pelvic Floor Disorders Registry.

OBJECTIVE: The aim of the study was to compare 12-month subjective and objective outcomes between 3 approaches to apical pelvic organ prolapse (POP) surgery in patients presenting with uterovaginal or posthysterectomy vaginal prolapse enrolled in the Pelvic Floor Disorders Registry for Research. STUDY DESIGN: This was an analysis of a multicenter, prospective registry that collected both patient- and physician-reported data for up to 3 years after conservative (pessary) and surgical treatment for POP. Twelve-month subjective and anatomic outcomes for patients who underwent surgical treatment were extracted from the registry for analysis. Pelvic organ prolapse recurrence was defined as a composite outcome and compared between the 3 apical surgery groups (native tissue repair, sacrocolpopexy, colpocleisis) as well as the 2 reconstructive surgery groups (native tissue repair and sacrocolpopexy). RESULTS: A total of 1,153 women were enrolled in the registry and 777 (67%) opted for surgical treatment, of whom 641 underwent apical repair and were included in this analysis (404 native tissue repair, 187 sacrocolpopexy, and 50 colpocleisis). The overall incidence of recurrence was as follows: subjective 6.5%, anatomic 4.7%, retreatment 7.2%, and composite 13.6%. The incidence of recurrence was not different between the 3 surgical groups. When baseline patient characteristics were controlled for, composite POP recurrence between the native tissue and sacrocolpopexy groups remained statistically nonsignificant. Concurrent perineorrhaphy with any type of apical POP surgery was associated with a lower risk of recurrence (adjusted odds ratio, 0.43; 95% confidence interval, 0.25-0.74; P = 0.002) and prior hysterectomy was associated with a higher risk (adjusted odds ratio, 1.77, 95% confidence interval, 1.04-3.03; P = 0.036). CONCLUSION: Pelvic Floor Disorders Registry for Research participants undergoing native tissue apical POP repair, sacrocolpopexy, and colpocleisis surgery had similar rates of POP recurrence 12 months after surgery.

Urinary symptoms after bladder flap at the time of primary cesarean delivery: a randomized controlled trial (RTC).

INTRODUCTION AND HYPOTHESIS: The aim of this study was to evaluate urinary symptoms in the postpartum period after omission of the bladder flap at the time of primary cesarean delivery. METHODS: This was a single-blind parallel-group randomized comparison (bladder flap, no bladder flap) in women scheduled for a primary cesarean delivery at 37 weeks gestation or later. The primary outcome was urinary symptom scores at 6-8 weeks postpartum. Secondary outcomes included comparisons of preoperative and postoperative pelvic floor symptom scores and the proportions of symptom bother responses between the study groups. RESULTS: A total 43 women were available for analysis. Randomization was as follows: omission of the bladder flap (n = 22) and bladder flap (n = 21). Demographic characteristics and baseline pelvic floor symptom scores were similar between the groups. The primary outcome, urinary symptom scores at 6-8 weeks postpartum, did not differ significantly between the groups, but urinary symptom bother was significantly higher in women who received a bladder flap. Pelvic floor symptom scores improved significantly following delivery. CONCLUSIONS: Urinary symptom scores as measured by the UDI-6 did not differ between women randomized to bladder flap or omission of the bladder flap, but the proportion of women with urinary symptom bother was significantly higher among those who received a bladder flap.

Labial fusion causing recurrent cyst formation and a novel approach to surgical management.

BACKGROUND: Labial fusion may occur as a result of lichen sclerosus, lichen planus, genital mutilation, obstetric laceration, and atrophic vaginitis. Koebner phenomenon, or reformation of scar tissue over the clitoris after trauma to the involved tissue, may confound attempts at surgical management. CASE: A 22-year-old nulligravid patient presented with labia minora fusion that had been present since childhood. Her most bothersome symptoms were the recurrence of periclitoral pseudocysts with pain and discharge after spontaneous or needle drainage. Her symptoms and examination findings persisted despite a prolonged course of topical clobetasol, and she desired surgical intervention. A silastic vessel loop was placed through the tract between her clitoris and fused overlying labia. The ends of the vessel loop were brought together and tied in a fashion similar to cutting setons used to manage complex anal fistulae. Over the subsequent weeks, additional ties were used to sequentially tighten the loop and gradually divide the fused labia, ultimately exposing the patient's normal clitoris, which was uninjured by the procedure. Topical clobetasol was used throughout the process to prevent reagglutination of the labia. CONCLUSIONS: Our experience suggests that adaptation of a cutting seton may be used effectively in the surgical management of labial fusion to allow for gradual division of the skin bridge while minimizing the risk of recurrence of agglutination.

Surgical repair of recurrent prolapse after LeFort colpocleisis.

Recurrent pelvic organ prolapse occurs rarely after obliterative procedures. The optimal surgical approach for therapy is unknown. We describe a case of recurrent prolapse after LeFort colpocleisis. The patient presented with stage III prolapse through the lateral vaginal channel. At surgery, the prolapse was repaired using a modified repeat colpocleisis and repeat perineorrhaphy. Transvaginal revision via modified repeat colpocleisis should be considered for treatment of recurrent pelvic organ prolapse after LeFort colpocleisis.

Teaching subcuticular suturing to medical students: video versus expert instructor feedback.

OBJECTIVE: Given limitations in surgical educational resources, more efficient teaching methods are needed. We sought to evaluate 3 strategies for improving skills in subcuticular suturing-practice with an instructional video, practice with expert instructor supervision, and independent practice. DESIGN: Fifty-eight medical students volunteered for this research. Students viewed a video on subcuticular suturing then completed a pretest requiring closure of an incision in a plastic model. Students were randomized among 3 groups: practice with an instructional video (group A), practice with supervision by an expert instructor (group B), and independent practice (group C). After instruction, students completed a posttest, then a retention test 1 week later. Their performances were video recorded and evaluated using a validated scoring instrument composed of global and task-specific subscales. RESULTS: Performances measured using both subscales improved significantly from pretest to post-test only for group B. However, when comparing student performances between pretest and retention posttest, significant improvements on both subscales were seen only in group A. CONCLUSION: These results suggest that practice with an instructional video is an effective method for acquiring skill in subcuticular suturing.

Sexual complaints, pelvic floor symptoms, and sexual distress in women over forty.

INTRODUCTION: The American Psychiatric Association recommends considering sexually related personal distress when assessing female sexual dysfunction. Currently, there is little data regarding the impact of sexual complaints on sexual distress. AIM: To investigate the association between sexual complaints and perceived sexual distress in a population of ambulatory adult women. METHODS: Using the short forms of the Personal Experiences Questionnaire and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, we assessed sexual complaints among 305 women seeking outpatient gynecologic care. Depressive symptoms were quantified using the Center for Epidemiologic Studies Depression (CESD) score. Sexual distress was measured using the Female Sexual Distress Scale (FSDS). Using multivariable logistic regression, we compared sexual complaints between distressed and nondistressed women. MAIN OUTCOME MEASURES: Sexual distress, defined by FSDS score ≥15. RESULTS: FSDS scores were available for 292/305 participants. Seventy-six (26%) scores reflected distress. Distressed women were more likely to be younger (55.2±1.0 years vs. 56.7±0.8 years, P=0.017); have higher CESD scores (16.6 vs. 9.5, P=0.001); and report decreased arousal (56.8% vs. 25.1%, P=0.001), infrequent orgasm (54% vs. 28.8%, P=0.001), and dyspareunia (39.7% vs. 10.6%, P=0.001). Women with sexual distress were also more likely to report sexual difficulty related to pelvic floor symptoms, including urinary incontinence with sexual activity (9% vs. 1.3%, P=0.005), sexual avoidance due to vaginal prolapse (13.9% vs. 1%, P=0.001), or sexual activity restriction due to fear of urinary incontinence (14.9% vs. 0.5%, P=0.001). After multivariate analysis, sexual distress was significantly associated with dyspareunia (odds ratio [OR] 3.11, P=0.008) and depression score (OR 1.05, P=0.006), and inversely associated with feelings of arousal during sex (OR 0.19, P=0.001). CONCLUSION: Our results indicate that sexually related personal distress is significantly associated with dyspareunia, depressive symptoms, and decreased arousal during sexual activity. This contributes to our understanding of how sexual complaints may adversely affect women's quality of life.

Vaginal parity and pelvic organ prolapse.

OBJECTIVE: To investigate whether the odds of pelvic organ prolapse vary significantly with the number of vaginal births and whether cesarean birth is associated with prolapse. STUDY DESIGN: In this cross-sectional study of women over the age of 40, pelvic organ prolapse was defined as descent to or beyond the hymen. Logistic regression was used to estimate the relative odds of pelvic organ prolapse for each vaginal birth or cesarean birth, controlling for confounders. RESULTS: Two hundred ninety women underwent a pelvic organ prolapse quantification POPQ examination, and 72 were found to have pelvic organ prolapse. A single vaginal birth significantly increased the odds of prolapse (OR 9.73, 95% CI 2.68-35.35). Additional vaginal births were not associated with a significant increase in the odds of prolapse. Cesarean births were not associated with prolapse (OR 1.31, 95% CI 0.49-3.54). CONCLUSION: The odds of pelvic organ prolapse were almost 10 times higher after a single vaginal birth. The marginal impact of additional births on this association was small.

Anatomic outcomes of abdominal sacrocolpopexy with or without paravaginal repair.

INTRODUCTION AND HYPOTHESIS: We sought to compare rates of recurrent cystocele following sacrocolpopexy with and without paravaginal repair (PVR). METHODS: This retrospective cohort study compared outcomes for patients undergoing sacrocolpopexy with (group A) and without (group B) concomitant PVR. Defining anterior failure as point Ba > or = -1 cm, we compared anatomic outcomes and reoperation rates for recurrence of cystocele. RESULTS: One hundred seventy patients undergoing sacrocolpopexy had anterior wall prolapse at or beyond the hymen before surgery (62 in group A and 108 in group B). Ten (16.1%) patients in group A and 29 (26.9%) in group B experienced anterior wall prolapse to or beyond -1 cm (p = 0.13, power 0.38). Among these groups, one (1.6%) and five (4.6%) underwent reoperation for cystocele recurrence (p=0.42, power <0.3). CONCLUSIONS: Despite the trend toward improved clinical outcomes, we were unable to detect a statistically significant difference with inclusion of PVR with sacrocolpopexy.

Is there a pelvic organ prolapse threshold that predicts pelvic floor symptoms?

OBJECTIVE: The objective of this study was to determine the minimum threshold level at which maximum anatomic prolapse predicts bothersome pelvic floor symptoms. STUDY DESIGN: We performed a cross-sectional study of women older than 40 years undergoing gynecologic and urogynecologic examinations using Pelvic Organ Prolapse Quantification (POP-Q) examinations to assess support and Pelvic Floor Distress Inventory questionnaires to assess symptoms. Across the spectrum of prolapse severity, we calculated receiver operating characteristic (ROC) curves and areas under the curves (AUCs) for each symptom. RESULTS: Of 296 participants, age was 56.3 +/- 11.2 years, and 233 (79%) were white. POP-Q stage was 0 in 39 (13%), 1 in 136 (46%), 2 in 89 (30%), and 3 in 33 (11%). ROC analysis for each symptom revealed an AUC of 0.89 for bulging/protrusion; 0.81 for splinting to void; 0.55-0.62 for other prolapse and urinary symptoms; and 0.48-0.56 for bowel symptoms. Using a threshold of 0.5 cm distal to the hymen, the sensitivity (69%) and specificity (97%) were high for protrusion symptoms but poor for most other symptoms considered. CONCLUSION: Vaginal descensus 0.5 cm distal to the hymen accurately predicts bulging/protrusion symptoms; however, we could not identify a threshold of prolapse severity that predicted other pelvic floor symptoms.

Midurethral sling outcomes: tension-free vaginal tape versus Pelvilace.

We sought to compare the complications and efficacy of tension-free vaginal tape (TVT) and Pelvilace. Chart reviews and telephone questionnaires documented complications, urinary symptoms [Urogenital Distress Inventory short form (UDI-6) and Patient Global Impression of Improvement (PGII)], and re-operations. Failure was defined as PGII > or = 4 (no change or worse) or reoperation for urinary incontinence. There were 91 TVT and 22 Pelvilace slings. The TVT group had lower rates of urinary retention beyond 1 week (8% vs. 43%, p < 0.001) and reoperation for retention (1% vs. 19%, p < 0.001). Median changes in UDI-6 scores were -33.3 for the TVT group and -29.6 for the Pelvilace group (p = 0.21). Median PGII scores were 1 for the TVT group and 2 for the Pelvilace group (p = 0.024). Ten percent of the TVT group and 24% of the Pelvilace group (p = 0.095) were failures. Urinary retention was more common after Pelvilace than TVT slings. Symptomatic outcomes and failure rates were similar.

Diagnosis and management of hepatic ectopic pregnancy.

BACKGROUND: We present a case in which an adnexal mass caused symptoms that eventually lead to the identification of a primary hepatic pregnancy. CASE: A young woman presented with abdominal pain, a positive hCG test result, an empty uterus, and a pelvic mass. Diagnostic laparoscopy revealed a cystic adnexal mass. An exploratory laparotomy with ovarian cystectomy identified a mature teratoma but no evidence of pregnancy in the pelvis. Because the patient's quantitative hCG level continued to increase without evidence of an intrauterine pregnancy, a dilation and curettage was performed which yielded no products of conception. An ultrasound examination and magnetic resonance imaging identified an 11-week ectopic pregnancy with fetal cardiac activity located in the maternal liver. This was treated with fetal injections of methotrexate and potassium chloride under ultrasound guidance and subsequent maternal intramuscular injection of methotrexate. The patient tolerated these interventions well, and subsequent ultrasound examinations showed absent fetal cardiac activity and decreasing fetal size. Serial hCG tests were followed up to zero, and the patient's liver enzyme levels remained normal. CONCLUSION: With persistently rising hCG levels and no pregnancy identified in the uterus or pelvis, there should be a thorough evaluation of the entire pelvis and abdomen. Magnetic resonance imaging is a useful tool for locating such an ectopic pregnancy. Once identified, decisions regarding surgical versus medical management must take risk of adverse outcomes into consideration. This report reveals an 11-week hepatic pregnancy managed conservatively with fetal potassium chloride and maternal methotrexate administration.

Use of the placental perfusion model to evaluate transplacental passage of Trypanosoma cruzi.

OBJECTIVE: To determine whether Trypanosoma cruzi could be identified in placental cells in vitro and in placental tissue using a human ex vivo perfusion model. STUDY DESIGN: A placental cell line was incubated with trypomastigotes for progressive time periods. Trypomastigotes were also infused as a bolus into the maternal circulation of a placental perfusion model. Maternal and fetal perfusates, and placental tissue, were analyzed for parasitic DNA using polymerase chain reaction; perfused specimens were also examined histologically. RESULTS: Intracytoplasmic amastigotes were identified in trophoblast of the incubated cell line by 24-48 hours. Following placental perfusion, T cruzi DNA was identified in all postinoculation maternal perfusate samples and postinoculation placental tissue specimens; preinoculation controls were negative. CONCLUSION: This is the first description of the use of the human placental perfusion model to study congenital Chagas' disease, including the presence and time course of early parasitic invasion of the placenta.

Desquamating vaginal mucosa from chlorhexidine gluconate.

BACKGROUND: Chlorhexidine gluconate is a commonly used and effective antiseptic agent for preparing patients for surgery. CASE: A healthy premenopausal woman was taken to the operating room for a planned laparoscopically assisted vaginal hysterectomy. After vaginal, vulvar, perineal, and abdominal cleansing with chlorhexidine gluconate, the patient developed a desquamating vaginal reaction that was treated with intravenous corticosteroids, antihistamine, topical conjugated estrogen, and hydrocortisone cream. The planned surgery was aborted, and the patient recovered uneventfully overnight in the postanesthesia care unit. With continued application of conjugated estrogen cream, the patient's vaginal mucosa was well healed within 2 weeks. CONCLUSION: Although chlorhexidine gluconate has been used effectively to minimize surgical site infection in vaginal surgery, the possibility for adverse reaction should be considered.