PrEP-aring the General Gynecologist to Offer HIV Pre-exposure Prophylaxis.

It is estimated that 450,000 American women are at increased risk of infection with human immunodeficiency virus (HIV), and yet only 7% have a prescription for pre-exposure prophylaxis (PrEP). PrEP is a safe and effective method of HIV infection prevention via a daily use of an oral combination antiretroviral pill or longer-acting intramuscular injections. Gynecologists are experts in women's sexual health, and provide over half of annual preventative health visits, but are not yet routinely providing PrEP to patients, citing lack of knowledge as a major barrier. The authors aim to provide the general gynecologist with the skills to expertly provide PrEP to their patients to reduce HIV infection.

Liposomal bupivacaine efficacy for postoperative pain following posterior vaginal surgery: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Effective postoperative pain management is a crucial component of recovery following surgery. Narcotics are a cornerstone of postoperative analgesia, but can require a redosing requirement, encompass a lengthy list of side effects and adverse reaction risks, as well as carry a dependency potential. The national focus on decreasing opioid use has directly impacted postoperative pain management. Previous studies have reported the beneficial use of a single intraoperative injection of extended-release liposomal bupivacaine in postoperative pain management, however the same results have not been extensively studied in the urogynecology literature. OBJECTIVE: We sought to evaluate cumulative postoperative vaginal pain on days 1 and 3 after posterior vaginal wall surgery comparing study medication (extended-release liposomal bupivacaine) to placebo (saline). Secondary aims were to evaluate vaginal pain on postoperative day 7 and total morphine-equivalent narcotic usage on days 1, 3, and 7. STUDY DESIGN: This is a randomized, double-blinded, placebo-controlled trial with 100 subjects recruited from Walter Reed National Military Medical Center urogynecology clinic. All subjects were age >18 years and scheduled for surgery involving the posterior vaginal wall or muscularis (including posterior colporrhaphy, colpocleisis, sphincteroplasty, perineorrhaphy), excluding those with regular narcotic usage or concurrent pain management requiring the use of epidural anesthesia. A sample size of 96 patients was calculated. Subjects were randomized to receive either 20 mL of extended-release liposomal bupivacaine (Exparel) (Pacira Pharmaceuticals Inc, Parsippany, NJ) or 20 mL of placebo (saline) at the end of surgery. Concealed syringes were used and injected immediately postoperative into the lateral vaginal wall/levator muscle area and perineal body. In-house morphine-equivalent narcotic usage was recorded along with the postoperative day 1 pain scores. Patients were contacted by telephone on postoperative days 3 and 7. Vaginal pain scores were evaluated using the Defense and Veterans Pain Rating Scale, cumulatively and on days 1, 3, and 7. Overall morphine-equivalent narcotics were compared between the 2 groups. RESULTS: From October 2014 through August 2017, 100 patients were enrolled and completed the study; 49 (49%) of the patients were randomized to the study group and 51 (51%) were in the placebo group. There was no significant difference between vaginal pain scores between the study group and the placebo group (postoperative day 1: study medication median score 1 [interquartile range 0-3], placebo median score 1 [interquartile range 0-3] [P = .59]; postoperative day 3: study medication median score 2 [interquartile range 0-3], placebo median score 1 [interquartile range 0-3] [P = .20]; postoperative day 7: study medication median score 3 [interquartile range 1-4], placebo median score 1.5 [interquartile range 0-3] [P = .06]). Cumulative pain scores postoperative day 1-7 were also not significant (study medication median score 6 [interquartile range 1-10], placebo median score 4 [interquartile range 1-8] [P = .14]). Multivariate model for the presence of vaginal pain was calculated and after controlling for body mass index, age, and combined laparoscopy surgery, there was no significant difference between the study and the placebo groups (P = .62). There was no statistically significant difference in morphine equivalents for the 2 groups: study medication 112.5 (interquartile range 45-207) and placebo 101.5 (interquartile range 37.5-195), P = .81. CONCLUSION: The use of extended-release liposomal bupivacaine in posterior vaginal wall surgeries, injected into the lateral posterior vaginal wall and perineal body, does not provide a significant decrease in postoperative pain or decrease narcotic medication usage when compared to saline.

Overactive bladder medication adherence when medication is free to patients.

PURPOSE: We examined overactive bladder medication compliance in a health care system in which patients do not pay for medication. MATERIALS AND METHODS: Pharmacy dispensing records were reviewed for antimuscarinic agents from January 2003 to December 2006 for the United States Military Health System National Capital Region. Medication nonpersistence, switching and adherence were examined. Kaplan-Meier survival analysis was done to compare medication persistence duration. RESULTS: Overactive bladder medications were dispensed to 7,879 adults. Tolterodine extended release (4,716 patients or 60%) and oxybutynin immediate release (2,003 or 25.5%) were most commonly prescribed. The medication nonpersistence rate, defined as the proportion of patients who never refilled a prescription for antimuscarinics during the study period, was 35.1% (2,760 of 7,858). Of 5,098 patients who refilled a prescription 1,305 changed the medication or dose at least once for a medication switch rate of 25.6%. The overall median medication possession ratio, defined as the total days of medication dispensed except for the last refill divided by the number of days between the first dispense date and the last refill date, was 0.82 in all cases. Men had a significantly higher median medication possession ratio than women (0.86 vs 0.81, p <0.001). Of patients who obtained at least 1 refill women remained on medication longer than men (median 606 vs 547 days, p = 0.01). Patients on tolterodine extended release had a higher medication nonpersistence rate than those on oxybutynin immediate release (0.89 vs 0.68, p <0.01). There was no difference between extended release medications. CONCLUSIONS: In a health care system in which patients do not pay for medications 35% of patients did not refill a prescription for overactive bladder medication, similar to previous reports. However, other measures of medication compliance were higher than those published previously in systems with copays.

Interposition grafts for rectovaginal fistula repair in the New Zealand white rabbit.

INTRODUCTION AND HYPOTHESIS: The objective was to use an animal model to study different types of interposition grafts for rectovaginal fistula repair. METHODS: Twelve New Zealand white rabbits underwent surgical creation of a rectovaginal fistula, followed by repair. Four repair techniques were studied; three with interposition grafts and one control group without a graft. Animals were euthanized at 4-week intervals and underwent gross and histologic analysis. RESULTS: The mean rectovaginal wall thickness was greatest in the control group (5.6 mm) and thinnest in the autologous rectus fascia (4.2 mm) and porcine small intestine submucosa (5.1 mm) groups. The polypropylene graft had a mean thickness of 5.4 mm and elicited a strong, protracted inflammatory response. All fistulas were successfully closed except one porcine small intestine submucosa repair. CONCLUSIONS: There is no benefit from interposition graft use for rectovaginal fistula repair in our New Zealand white rabbit model.

Rectovaginal fistula model in the New Zealand white rabbit.

INTRODUCTION AND HYPOTHESIS: The purpose of this study was to create an animal model to study rectovaginal fistula repair. METHODS: Fourteen New Zealand white rabbits underwent surgical creation of a rectovaginal fistula. The technique was developed with a pilot study conducted on the first two animals, then standardized and performed on the remaining 12 rabbits. The standardized technique included making a defect in the rectovaginal septum using a 3-mm skin punch then splinting the defect with 6-mm tubing for 2 weeks. RESULTS: Using the standardized technique, a fistula was successfully created in all 12 rabbits ranging from 1 to 5 mm (mean = 2.8 mm, SD = 1.1). A 95% tolerance interval was calculated for the model and predicted that a successful fistula can be created ranging from 0.3 to 5.2 mm in 85% of attempts with the model. CONCLUSION: The New Zealand white rabbit is a promising animal model to study rectovaginal fistula repair.

The racial distribution of female pelvic floor disorders in an equal access health care system.

PURPOSE: We examined ethnic differences in female pelvic disorders in an equal access health care system. MATERIALS AND METHODS: An electronic medical record review was performed for patients with pelvic floor disorders at a military female pelvic medicine and reconstructive surgery division for a 1-year period. Primary diagnosis codes and patient reported race were reviewed. RESULTS: Mean +/- SD cohort age was 55 +/- 16.3 years. A total of 720 patients were identified, of whom 68.8% were white and 18.6% were black. Pelvic organ prolapse was the primary diagnosis in 34.2% of the women, while 19.7% had stress urinary incontinence and 10.8% had urge urinary incontinence. There was no difference in the prevalence of prolapse between black and white women. However, of patients with incontinence there was a statistically significant difference with urge incontinence in more black women (51.2%) and stress incontinence in more white women (66.2%) (chi-square p <0.05). CONCLUSIONS: There is a similar ethnic distribution of pelvic organ prolapse in an equal access health care system. Of women with incontinence there was a higher prevalence of urge urinary incontinence in black women and a higher prevalence of stress urinary incontinence in white women.

Sacral neuromodulation in the treatment of vulvar vestibulitis syndrome.

BACKGROUND: Vulvar vestibular syndrome is a chronic pain syndrome that typically results in pain and irritation of the vulvar vestibule and has few effective options for treatment. CASE: A 42-year-old woman presented with symptoms consistent with chronic vulvar vestibular syndrome that was refractory to multiple attempted therapies. The patient was offered sacral neuromodulation for treatment. She underwent a standard two-phase surgical implantation with good result at 2 years postimplantation. CONCLUSION: Sacral neuromodulation was shown to be a valid treatment option for this patient and resulted in excellent patient satisfaction at 2-year follow-up. Although the exact mechanism of action is unknown, sacral neuromodulation may be a viable option for the management of chronic pain syndromes of the vulva and vagina.

Ureteral stents and retrograde studies: a primer for the gynecologist.

PURPOSE OF REVIEW: To review basic techniques and recent advances in endourology for the practicing gynecologist. RECENT FINDINGS: New ureteral stent designs are available to improve comfort and reduce some of the complications of indwelling ureteral stents. A large prospective study failed to show a significant benefit of prophylactic ureteral catheterization prior to major gynecological surgery to reduce the risk of ureteral injury. There is a shift in the management of some iatrogenic ureteric injuries from surgical reimplantation to more conservative endoscopic management by interventional radiologists and urologists. SUMMARY: The indications, techniques, and complications of advanced endourology techniques including the use of indwelling ureteral stents and retrograde pyelography are reviewed. Indwelling ureteral stents are used to establish and maintain patency of the ureters for many indications, including specific gynecological indications such as iatrogenic ureteral injury, ureteric fistula, extrinsic compression from tumor, and prophylactically to prevent ureteric injury. Retrograde pyelography is a very useful technique to image the renal collecting system with particular utility in patients with contraindications to intravenous contrast and to investigate suspected iatrogenic ureteral injuries.

Hemolytic activity of Trichomonas gallinae isolates does not correspond with clinical virulence.

The hemolytic activity of 22 Trichomonas gallinae isolates was investigated using an 18h erythrocyte hemolysis assay which has been shown to correlate with the clinical virulence of T. vaginalis. Absorbance of the assay supernatants was measured at 540nm and expressed as percentage of complete hemolysis. Mean hemolytic activity of the T. gallinae isolates ranged from 3.5% to 53.4% and did not correspond with clinical virulence. The results of this investigation suggest hemolytic activity is not a useful in vitro virulence assay for T. gallinae.

An extract of Hydrilla verticillata and associated epiphytes induces avian vacuolar myelinopathy in laboratory mallards.

Avian vacuolar myelinopathy (AVM) is a neurological disease affecting bald eagles (Haliaeetus leucocephalus), American coots (Fulica americana), waterfowl, and other birds in the southeastern United States. The cause of the disease is unknown, but is thought to be a naturally produced toxin. AVM is associated with aquatic macrophytes, most frequently hydrilla (Hydrilla verticillata), and researchers have linked the disease to an epiphytic cyanobacterial species associated with the macrophytes. The goal of this study was to develop an extraction protocol for separating the putative toxin from a hydrilla-cyanobacterial matrix. Hydrilla samples were collected from an AVM-affected reservoir (J. Strom Thurmond Lake, SC) and confirmed to contain the etiologic agent by mallard (Anas platyrhynchos) bioassay. These samples were then extracted using a solvent series of increasing polarity: hexanes, acetone, and methanol. Control hydrilla samples from a reference reservoir with no history of AVM (Lake Marion, SC) were extracted in parallel. Resulting extracts were administered to mallards by oral gavage. Our findings indicate that the methanol extracts of hydrilla collected from the AVM-affected site induced the disease in laboratory mallards. This study provides the first data documenting for an "extractable" AVM-inducing agent.

Molecular characterization of the Trichomonas gallinae morphologic complex in the United States.

Forty-two Trichomonas gallinae isolates were molecularly characterized to determine whether isolates differed in genetic sequence of multiple gene targets depending on host species or geographical location. The 5.8S ribosomal RNA (rRNA) and flanking internal transcribed spacer (ITS) gene regions were amplified by polymerase chain reaction, and the sequences were analyzed phylogenetically. The results of the sequence analysis strongly suggest at least 2 species may exist within the T. gallinae morphologic complex. Based on ITS sequences, one group demonstrated high nucleotide identity to the 3 T. gallinae sequences available in GenBank, whereas the second group was more closely related to T. vaginalis (98%) than to T. gallinae (92%). Two common ground-dove (Columbina passerina) isolates shared a 95% identity with T. vaginalis and a 92% identity with T. gallinae and T. tenax. Sequence analysis of both the 18S rRNA and alpha-tubulin genes from a subset of the isolates supports the 5.8S-ITS sequence results. All of the T. vaginalis-like isolates originated from Arizona, California, or Texas, whereas T. gallinae isolates were found in all sampled states. Both T. vaginalis-like and T. gallinae isolates were involved in trichomoniasis outbreaks in California and Arizona.

Establishing a mean postvoid residual volume in asymptomatic perimenopausal and postmenopausal women.

OBJECTIVE: To estimate mean postvoid residual (PVR) volumes among perimenopausal and postmenopausal women without significant lower urinary tract or pelvic organ prolapse symptoms. METHODS: Patients presenting for well-women encounters were offered study participation. Women with a history of urinary incontinence greater than twice per week, urinary retention, symptomatic pelvic organ prolapse, or neurologic disorders were excluded. Pelvic relaxation, if present, was characterized according to the pelvic organ prolapse quantification system. Within 10 minutes of spontaneously voiding, PVR volume was assessed with bladder ultrasonography. RESULTS: A total of 96 patients were enrolled; mean age was 60+/-11 years. The majority (80%) were postmenopausal; 30% had a previous hysterectomy. Most women (92%) had some degree of prolapse; the median stage was one, most commonly involving the anterior compartment (70%). The median PVR volume was 19 mL (range 0-145 mL); the mean PVR volume was 24+/-29 mL. Only 15% of patients had a PVR volume greater than 50 mL, and 95% had a PVR volume 100 mL or less. Only age 65 years or older was associated with a higher mean PVR volume; hormone therapy, vaginal atrophy, parity, and stage of asymptomatic prolapse did not affect PVR volumes. CONCLUSION: Most asymptomatic perimenopausal and postmenopausal women had a PVR volume less than 50 mL, which was unaffected by multiple factors that were thought to potentially affect bladder function. Establishing "normal" volumes in this population may aid in developing recommendations regarding appropriate bladder function and retention criteria for women who are symptomatic or those who have had pelvic floor surgery.

Necropsy findings and arbovirus surveillance in mourning doves from the southeastern United States.

Mourning doves (Zenaida macroura) are the most abundant and widespread native member of the columbid family, as well as a major migratory game species, in the United States. However, there is little information on mortality factors in mourning doves. Records of necropsy accessions at the Southeastern Cooperative Wildlife Disease Study (SCWDS) from 15 southeastern states, from 1971 through 2005, were reviewed. One hundred thirty-five mourning doves were submitted from nine states during the 35-yr period. Trichomonosis constituted 40% (n = 54) of all diagnoses and was the most frequent diagnosis. Toxicoses and avian pox constituted 18.5% (n = 25) and 14.8% (n = 20) of all diagnoses, respectively. Remaining diagnoses included trauma, suspected toxicosis, Ascaridia columbae infection, suspected tick paralysis, and undetermined. Adults were observed more frequently with trichomonosis (94.1%) and toxicoses (68%) as compared to juveniles, but a gender predisposition was not apparent for either disease. Age and gender predilections were not apparent for cases of avian pox. The majority of the trichomonosis and avian pox cases were observed in the spring-summer, whereas the majority of the toxicosis cases were observed in the winter-spring. Additionally, the Georgia Department of Human Resources-Division of Public Health and West Virginia Department of Health and Human Resources submitted 809 mourning doves to SCWDS from 2001 through 2005 for West Nile virus surveillance efforts. West Nile virus was isolated from 2.1% (n = 17) and eastern equine encephalitis virus (EEEV) was isolated from 0.2% (n = 2) of the submitted birds.

Investigation of the link between avian vacuolar myelinopathy and a novel species of cyanobacteria through laboratory feeding trials.

Avian vacuolar myelinopathy (AVM) is a neurologic disease affecting Bald Eagles (Haliaeetus leucocephalus), American Coots (Fulica americana), and other birds in the southeastern United States. The cause of the disease has not yet been determined, although it is generally thought to be a natural toxin. Previous studies have linked AVM to aquatic vegetation, and the current working hypothesis is that a species of cyanobacteria growing epiphytically on that vegetation is producing a toxin that causes AVM. Surveys of epiphytic communities have identified a novel species of cyanobacteria in the order Stigonematales as the most likely suspect. The purpose of this study was to further examine the relationship between the suspect Stigonematales species and induction of AVM, by using animal feeding trials. Adult Mallards and domestic chickens were fed aquatic vegetation from two study sites containing the suspect cyanobacterial epiphyte, as well as a control site that did not contain the Stigonematales species. Two trials were conducted. The first trial used vegetation collected during mid-October 2003, and the second trial used vegetation collected during November and December 2003. Neither treatment nor control birds in the first trial developed AVM lesions. Ten of 12 treatment Mallards in the second trial were diagnosed with AVM, and control birds were not affected. This study provides further evidence that the novel Stigonematales species may be involved with AVM induction, or at the least it is a good predictor of AVM toxin presence in a system. The results also demonstrate the seasonal nature of AVM events.

Detection of Wellfleet Bay Virus Antibodies in Sea Birds of the Northeastern USA.

Wellfleet Bay virus (WFBV) is a recently described orthomyxovirus isolated from the tissues of Common Eiders (Somateria mollissima) collected during recurrent mortality events on Cape Cod, Massachusetts, US. Coastal Massachusetts is the only location where disease or mortality associated with this virus has been detected in wild birds, and a previous seroprevalence study found a significantly higher frequency of viral exposure in eiders from this location than from other areas sampled in North America. This suggests that coastal Massachusetts is an epicenter of WFBV exposure, but the reason for this is unknown. Opportunistic sampling of sympatric species and testing of banked serum was used to investigate potential host range and spatiotemporal patterns of WFBV exposure. Antibodies were detected in Herring Gulls (Larus argentatus), Ring-billed Gulls (Larus delawarensis), a White-winged Scoter (Melanitta fusca), and a Black Scoter (Melanitta nigra). These findings demonstrate the likely occurrence of fall/winter transmission, expand our understanding of the host range of the virus, and provide further insight into the epidemiology of WFBV in the northeastern US.

PREVALENCE AND DISTRIBUTION OF WELLFLEET BAY VIRUS EXPOSURE IN THE COMMON EIDER (SOMATERIA MOLLISSIMA).

Between 1998 and 2014, recurrent mortality events were reported in the Dresser's subspecies of the Common Eider ( Somateria mollissima dresseri) on Cape Cod, Massachusetts, US near Wellfleet Harbor. The early die-offs were attributed to parasitism and emaciation, but beginning in 2006 a suite of distinct lesions was observed concomitant with the isolation of a previously unknown RNA virus. This novel pathogen was identified as an orthomyxovirus in the genus Quaranjavirus and was named Wellfleet Bay virus (WFBV). To assess evidence of exposure to this virus in Common Eiders, we conducted a longitudinal study of the prevalence of WFBV antibodies at multiple locations from 2004-14; we collected 2,258 serum samples from six locations and analyzed each using a microneutralization assay. Results corroborate the emergence of WFBV in 2006 based on the first detection of antibodies in that year. Significantly higher prevalence was detected in Common Eiders sampled in Massachusetts compared to those in Maine, Nova Scotia, and Québec. For birds breeding and wintering in Massachusetss, viral exposure varied by age, sex, and season of sampling, and prevalence by season and sex were highly interrelated with greater numbers of antibody-positive males in the autumn and females in the spring. No evidence of viral exposure was detected in the Northern subspecies ( Somateria mollissima borealis). Among the locations sampled, Massachusetts appears to be the epicenter of Common Eider exposure to WFBV. Further research is warranted to understand the factors controlling the epidemiology of WFBV in Massachussetts, including those that may be limiting geographic expansion of this virus.

Avian vacuolar myelinopathy outbreaks at a southeastern reservoir.

Avian vacuolar myelinopathy (AVM) is a neurologic disease of unknown etiology that affects bald eagles (Haliaeetus leucocephalus), American coots (Fulica americana), and several species of waterfowl. An unidentified neurotoxin is suspected as the cause of AVM, which has been documented at several reservoirs in the southeastern United States. We conducted diagnostic and epidemiologic studies annually during October-March from 1998-2004 at Clarks Hill/Strom Thurmond Lake on the Georgia/South Carolina border to better understand the disease. Avian vacuolar myelinopathy was confirmed or suspected as the cause of morbidity and mortality of 28 bald eagles, 16 Canada geese (Branta canadensis), six American coots, two great-horned owls (Bubo virginianus), and one killdeer (Charadrius vociferus). Active surveillance during the outbreaks yielded annual average prevalence of vacuolar lesions in 17-94% of coots, but not in 10 beavers (Castor canadensis), four raccoons (Procyon lotor), and one gray fox (Urocyon cinereoargenteus) collected for the study. Brain lesions were not apparent in 30 Canada geese collected and examined in June 2002. The outbreaks at this location from 1998-2004 represent the most significant AVM-related bald eagle mortality since the Arkansas epornitics of 1994-95 and 1996-97, as well as the first confirmation of the disease in members of Strigiformes and Charadriiformes.

Sacral Neuromodulation for the Treatment of Persistent Genital Arousal Disorder.

BACKGROUND: Patients affected with persistent genital arousal disorder report unprovoked, excessive, and unremitting genital arousal unrelated to sexual desire. Those afflicted experience severe physical and psychological distress with significant feelings of shame, guilt, and frustration. Definitive treatment options for this disorder are limited. CASE: We present the case of a 32-year-old woman, gravida 1 para 1, with persistent genital arousal disorder after treatment of an uncomplicated urinary tract infection while in a military-deployed environment. After numerous treatment modalities failed, she responded to an implanted sacral neuromodulator. CONCLUSION: Persistent genital arousal disorder may be the result of upregulated sacral nerve pathways. We report the use of sacral neuromodulation using unique program settings, which may be an effective alternative in the treatment of this distressing disorder.

MORTALITY OF SELECTED AVIAN ORDERS SUBMITTED TO A WILDLIFE DIAGNOSTIC LABORATORY (SOUTHEASTERN COOPERATIVE WILDLIFE DISEASE STUDY, USA): A 36-YEAR RETROSPECTIVE ANALYSIS.

To determine the relative importance of mortality factors for birds and to assess for patterns in avian mortality over time, we retrospectively examined data of birds submitted to the Southeastern Cooperative Wildlife Disease Study (SCWDS; http://vet.uga.edu/scwds ), US, from 1976 to 2012. During this period, SCWDS, a wildlife diagnostic laboratory, received 2,583 wild bird specimens, from the taxonomic orders Apodiformes, Caprimulgiformes, Cuculiformes, Passeriformes, and Piciformes, originating from 22 states. Data from 2,001 of these birds were analyzed using log-linear models to explore correlations between causes of mortality, taxonomic family, demography, geographic location, and seasonality. Toxicosis was the major cause of mortality, followed by trauma, bacterial infection, physiologic stress, viral infection, and other (mortality causes with low sample numbers and etiologies inconsistent with established categories). Birds submitted during fall and winter had a higher frequency of parasitic infections, trauma, and toxicoses, whereas birds submitted during the spring and summer were more likely to die of an infectious disease, physiologic stress, or trauma. We noted a decrease in toxicoses concurrent with an increase in bacterial infections and trauma diagnoses after the mid-1990s. Toxicosis was the most commonly diagnosed cause of death among adult birds; the majority of juveniles died from physiologic stress, trauma, or viral infections. Infectious agents were diagnosed more often within the families Cardinalidae and Fringilidae, whereas noninfectious etiologies were the primary diagnoses in the Bombycillidae, Parulidae, Sturnidae, Turdidae, and Icteridae. There are important inherent limitations in the examination of data from diagnostic labs, as submission of cases varies in timing, frequency, location, and species and is often influenced by several factors, including media coverage of high-profile mortality events. Notwithstanding, our data provide a rare opportunity to examine long-term, regional, and temporal patterns in causes of avian mortality, and they allow for the analysis of novel and rare mortality factors.

Chronic urinary retention and pelvic floor hypertonicity after surgery for endometriosis: a case series.

OBJECTIVE: The purpose of this study was to evaluate 4 cases of chronic urinary retention and pelvic floor muscle spasms after surgery for endometriosis. STUDY DESIGN: These patients underwent a complete history, physical exam, and diagnostic work- up. The results were analyzed with regards to type and extent of inciting surgery, diagnostic findings, postoperative recovery, and treatment success. RESULTS: The patients' mean age was 39.5 years and all had undergone various surgical interventions for endometriosis. In addition to urinary retention, all developed debilitating pelvic floor muscle spasm postoperatively. Physical exam revealed pelvic floor hypertonicity and urodynamics indicated hypoactive detrusor contractility. Neurodiagnostic testing gave evidence of neuropathy in all subjects. CONCLUSION: Extensive endometriosis surgery may pose a risk for postoperative bladder dysfunction and pelvic floor muscle spasm.