Pain Scores and Exposure Rates after Polypropylene Mesh for Pelvic Organ Prolapse.

OBJECTIVES: To characterize pain and exposure after Prolift placement and identify risk factors. METHODS: A case series of women who underwent Prolift vaginal mesh were surveyed. Pain was assessed using a visual analog scale. Exposure was evaluated clinically. RESULTS: Of 183 eligible patients, 160 completed the survey, and 45 returned for examination. Mean preoperative pain score was 0.97 and postoperative was 1.35 (P = 0.12). Pre- and postoperative pain scores by compartment were: anterior (1.34 vs 1.25, mean change -0.09, P = 0.84), posterior (1.30 vs 1.56, mean change 0.26, P = 0.72), and total (0.63 vs 1.34, mean change 0.71, P = 0.05). Graft exposure was confirmed in 23 of 183 patients (12.6%); however, because asymptomatic patients were not examined, the true exposure rate may be underestimated. Hematoma formation is independently associated with mesh exposure, adjusted odds ratio 18.4 (95% confidence interval 3.4-147.4, P = 0.01). CONCLUSIONS: Although pain scores did not increase overall, there was a trend toward increased pain score in the patients with total (anterior and posterior) Prolift. Hematoma formation was significantly associated with mesh exposure.

Modified Beef Tongue Model for Fourth-Degree Laceration Repair Simulation.

BACKGROUND: An existing model for fourth-degree laceration repair uses beef tongue with plastic or vinyl tubing. This modified model substitutes beef tripe for the anal mucosa and chicken leg muscles for the anal sphincter muscle analogs to create a realistic model. METHOD: Tripe is tunneled through the body of the trimmed beef tongue and sutured like an ostomy to simulate the anal canal. The tongue is incised toward the tripe "anal canal." Chicken leg muscles are tunneled from the incision out to the cut edges of the beef tongue to create anal sphincter muscle analogs. Procedures can be repeated on the opposite side. Two double-sided models can be made per tongue. EXPERIENCE: The model can be refrigerated or frozen and thawed before use. A fourth-degree laceration can be cut immediately before use. Materials were obtained at a local supermarket for $5-7 per half-tongue, double-sided model. Residents responded positively to the model and stated that animal tissue provided realistic haptic simulation. CONCLUSION: The modified beef tongue model utilizing tripe and chicken leg muscles as anal mucosa and anal sphincter muscle analogs, respectively, provided excellent perceived haptic fidelity. Moreover, it is an innovative, inexpensive, and well-received teaching tool to augment resident education.

Vaginal Swab Test Compared With the Urethral Q-tip Test for Urethral Mobility Measurement: A Randomized Controlled Trial.

OBJECTIVE: To assess whether use of a vaginal cotton-tipped swab is equivalent to the standard Q-tip test regarding urethral mobility. Secondarily, to examine whether both tests agree in hypermobility diagnosis, discomfort level, and patients' preference. METHODS: In this randomized crossover trial, women with stress urinary incontinence without prolapse beyond the hymen were randomized to undergo either a vaginal or urethral mobility test first followed by the alternate approach. The primary outcome was the difference in rotation angle, from resting to maximum strain, between tests. The equivalence margin was ±10°. The secondary outcome was agreement in hypermobility diagnosis using two definitions: 1) maximum straining angle of 30° or greater from the horizontal plane; and 2) rotation angle 30° or greater. Discomfort was assessed using a 0-10 visual analog scale. Using 90% power assuming a standard deviation of 20°, 36 and 139 patients were needed for 10° and 5° equivalence margins, respectively. RESULTS: From January 2014 to March 2015, 140 women were randomized. The mean difference between the two tests was 5.1° (95% confidence interval 3.2-6.9°), meeting the predefined equivalence criteria. In the hypermobility diagnosis, the urethral and vaginal tests had no disagreement using definition 1 (P=.23), whereas the two tests disagreed using definition 2 (P=.03). The urethral approach had a higher discomfort level (P<.001). The majority preferred the vaginal test (68% preferred vaginal, 32% no preference). CONCLUSION: The vaginal swab test is equivalent to the standard Q-tip test in measuring urethral mobility with less discomfort and is preferred by patients.

Low-dose 17-ß-estradiol cream for vaginal atrophy in a cohort without prolapse: Serum levels and vaginal response including tissue biomarkers associated with tissue remodeling.

OBJECTIVES: Describe the effect of 50 mcg vaginal 17-ß-estradiol (E2) cream on vaginal maturation, serum estrogen levels, atrophic symptoms, and biomarkers of oxidative stress and tissue remodeling in postmenopausal women without prolapse. METHODS: Seventeen women, 65 years or older, applied intravaginal E2 cream nightly for eight weeks, then twice weekly for eight weeks. Vaginal biopsies, serial blood draws, and atrophic symptoms were obtained at baseline, eight, and sixteen weeks. Changes in atrophic symptoms, vaginal maturation indices (VMI), and serum E2 were measured. Immunohistochemical staining characterized levels of transforming growth factor-beta (TGF-ß), nuclear factor kappa B (NFKB), inducible nitric oxide synthase (iNOS), endothelial nitric oxide synthase (eNOS), and thrombospondin (TSP). RESULTS: Serum E2 levels (pg/ml) were unchanged from baseline (mean (SD)) 7.7 (3.3) to eight 9.7 (5.7) and sixteen 8.7 (5.8) (p=0.24) weeks. VMI (mean (SD)) improved from baseline 34.2 (18.3) to eight 56.7 (13.1) and sixteen 54.5 (11.3) (p<0.001) weeks with no difference between eight and sixteen weeks. Vaginal dryness (p=0.03) and itching (p=0.02) improved. Tissue biomarker levels did not change (TGF-ß p=0.35, NFKB p=0.74, eNOS p=0.80, iNOS p=0.24, TSP p=0.80). DISCUSSION: Vaginal E2 improved atrophic symptoms and VMI without elevating serum E2. Tissue remodeling biomarkers did not change.

Life Space Assessment in Older Women Undergoing Non-Surgical Treatment for Urinary Incontinence.

OBJECTIVES: Urinary incontinence (UI) impacts all aspects of life activities. This study aims to characterize change in mobility within the community utilizing the Life Space Assessment (LSA) questionnaire in women undergoing non-surgical UI treatment. DESIGN: Prospective cohort study, performed from July 2007 to March 2009, which followed women seeking non-surgical UI treatment and assessed their mobility and symptoms using LSA, Urogenital Distress Inventory (UDI-6), and Incontinence Impact Questionnaire (IIQ-7) at baseline and 2, 6, and 12 months post-treatment. Estimated Percent Improvement (EPI) and Patient Satisfaction Question (PSQ) were obtained post-treatment. SETTING: Outpatient tertiary-care clinic. PARTICIPANTS: 70 ambulatory, community-dwelling women, aged 65 years or older, seeking non-surgical care for UI. INTERVENTION: Multi-component behavioral and/or pharmacologic therapies. MEASUREMENTS: We hypothesized LSA would improve with treatment. Repeated measures analysis with Tukey's HSD and backwards selection linear regression model were performed. RESULTS: LSA score decreased from baseline to 2 months (mean±SD; 63±29 to 56±28, p<0.001) and was sustained at 6 and 12 months (54±28, 54±28). UDI scores improved from 36±23 to 25±24, p<0.001, at 2 months, and improvement persisted at 6 and 12 months (22±22, 21±24). Improvements in UDI and patient perceived improvement in UI were not associated with LSA change. Age, race, and depression impacted LSA, which decreased 1-point for each additional year of age (p=0.004), 6-points for each point higher on the Geriatric Depression Scale (GDS) (p=0.002), and 6-points for African American race (p=0.048). CONCLUSION: Decreased mobility represented by LSA was related to age, depression, and race, but not UI symptom improvement.