Urogynecologic conditions: interstitial cystitis/painful bladder syndrome.

Interstitial cystitis, also known as painful bladder syndrome, is a debilitating condition. The diagnosis is difficult and often is one of exclusion. Cystoscopy is the best way to confirm the diagnosis, but treatment can be initiated based on symptoms alone. Most patients benefit from an array of different drugs, including pentosan polysulfate, amitriptyline, hydroxyzine, and cimetidine. These treatments must be tailored for each patient. If oral drugs are ineffective, intravesical therapy can be attempted with dimethyl sulfoxide, heparin, or an anesthetic therapeutic combination containing lidocaine. Fulguration typically is performed if Hunner ulcers are found on cystoscopy. Hydrodistention, sacral neuromodulation, and intradetrusor onabotulinumtoxinA are sometimes useful.

Urogynecologic conditions: pelvic organ prolapse.

Chronic pelvic pain is a commonly encountered condition that often is multifactorial. Etiologies include gynecologic, urologic, gastrointestinal, and neurologic conditions. Laboratory tests, imaging, and surgical intervention are not always helpful in identifying the etiology of pelvic pain. For appropriate management of this complex disease process, a detailed history and physical examination, and a multidisciplinary approach are needed. Pelvic pain may be caused by endometriosis, pelvic inflammatory disease, adenomyosis, interstitial cystitis/painful bladder syndrome, or other factors. Evaluation may include keeping a pain diary; laboratory tests, such as a pregnancy test, urinalysis, or tests for sexually transmitted infections; ultrasonography of abnormalities detected on physical examination; and laparoscopy. Specific first-line treatments include nonsteroidal anti-inflammatory drugs and oral contraceptives for endometriosis; progestins, gonadotropin-releasing hormone analogs, aromatase inhibitors, or hysterectomy for adenomyosis; and education, food avoidance, and behavioral modifications for interstitial cystitis/painful bladder syndrome. Surgical options include nerve transection procedures, laparoscopic uterosacral nerve ablation, and presacral neurectomy, although data on effectiveness are limited.

Diagnosis and surgical treatment of stress urinary incontinence.

Stress urinary incontinence (SUI) is a major problem affecting more than 20% of the nation's female population, with increasing prevalence as our population continues to age. Incontinence places a great burden on individuals, and the economic effect is large. Stress urinary incontinence occurs when there is involuntary leakage of urine during coughing, laughing, sneezing, or physical activity. It can be diagnosed during physical examination and by using low-cost office diagnostics. Although nonsurgical treatments provide some benefit, surgical interventions have demonstrated superiority with respect to subjective and objective cure and better long-term improvement. Corrective surgeries for SUI can be grouped into four categories: 1) slings (midurethral slings and slings placed at the ureterovesical junction), 2) retropubic urethropexy, 3) urethral bulking agents, and 4) artificial sphincters. The success and failure of each approach needs to be assessed in the context of individual patients and their circumstances. Slings and retropubic urethropexy are considered first-line surgical options. Since the advent of minimally invasive retropubic midurethral slings such as the tension-free vaginal tape, transobturator tension-free vaginal tape, and single-incision sling, retropubic urethropexy have fallen out of favor. Warnings about mesh use may contribute to a resurgence of retropubic urethropexy procedures such as the Burch procedure. A Burch procedure should still be considered for patients who have an aversion to mesh or if they are undergoing concurrent abdominal approach surgery. Urethral bulking agents are usually reserved for patients with a fixed, nonmobile urethra who cannot tolerate an operative experience or have failed previous antiincontinence procedures. Artificial sphincters should be considered an operation of last resort.

Mesh erosion following abdominal sacral colpopexy in the absence and presence of the cervical stump.

INTRODUCTION AND HYPOTHESIS: We compared the role of abdominal sacral colpopexy (ASCP) with concomitant supracervical hysterectomy to ASCP alone in patients with prior hysterectomy in the prevention of mesh erosion. MATERIALS AND METHODS: We performed a retrospective chart review of 277 consecutive patients who underwent ASCP with one surgeon. Patients were separated into two groups based on the presence of a uterus at the time of surgery. Group A comprised195 patients with a uterus who underwent ASCP and concomitant supracervical hysterectomy; group B comprised 82 patients with prior total hysterectomy who underwent ASCP. The outcome measures included peri- and postoperative findings, complications, and surgical success. Data were analyzed by t test and chi-square test using SPSS software. RESULTS: No significant difference was found between groups during surgery in terms of anesthesia type, total operative time, and estimated intraoperative blood loss. At mean postoperative follow-up of 7-8 months, there was no difference between groups in terms of de novo urinary symptoms, recurrent vaginal-wall prolapse, or dyspareunia and Pelvic Organ Prolapse Quantification (POP-Q) point C examination. Sling erosion was observed in four (4.2 %) patients in group A versus none in group B. Apical mesh erosion was diagnosed in one patient in group A (0.5 %) and two (2.4 %) patients in group B. These differences were not statistically significant. CONCLUSION: Concomitant supracervical hysterectomy with ASCP was associated with a low incidence of mesh erosion and had the same intraoperative course and postoperative outcome as ASCP with previous hysterectomy.

Long-term quality of life and pelvic floor dysfunction after bariatric surgery.

OBJECTIVE: To evaluate effects of bariatric surgery on pelvic floor mediated quality of life in morbidly obese women. STUDY DESIGN: Prospective cohort study of 44 women undergoing bariatric surgery. RESULTS: Thirty-six women gave data at baseline and at mean follow-up of 3.15 years following bariatric surgery. Although urinary impact questionnaire scores improved (-34.92, P = .0020), colorectal-anal impact questionnaire and pelvic organ prolapse impact questionnaire scores did not improve despite significant weight loss. Baseline female sexual function index scores were low (17.70 ± 8.38) and did not improve with weight loss (16.91 ± 9.75, P = .5832). Pelvic organ prolapse/urinary incontinence sexual questionnaire scores did improve (35.78 ± 6.06 preoperatively vs 38.22 ± 6.03 postoperatively, P = .0193). CONCLUSION: Bariatric surgery is associated with significant improvement in the impact of urinary incontinence on quality of life. Sexual function was poor, and improved only on the pelvic organ prolapse/urinary incontinence sexual questionnaire that evaluated urinary incontinence.

Magnetic resonance imaging of abdominal versus vaginal prolapse surgery with mesh.

INTRODUCTION AND HYPOTHESIS: We compared two surgical approaches in patients with symptomatic prolapse of the vaginal apex with normal controls by analyzing pelvic landmark relationships measured using magnetic resonance imaging (MRI) before and after surgery. METHODS: In this prospective multicenter pilot study involving 16 participants, nulliparous controls (n = 6) were compared with ten parous (3.0 ± 1.0) women with uterine apical prolapse equal to or greater than stage 2. Group A (n = 5) underwent abdominal sacral colpopexy with monofilament polypropylene mesh and group B (n = 5) with vaginal mesh kit repair (Total ProLift). Subtotal hysterectomy was performed in all group A and no group B women. All patients underwent preoperative and 3-month postoperative Pelvic Organ Prolapse Quantification (POP-Q) and dynamic MRI. Comparison of MRI pelvic angles and distances was performed and analyzed by Mann-Whitney rank sum test and chi-square test. RESULTS: Vaginal apical support is similar at 3 months for abdominal sacral colpopexy (ASCP) and ProLift by POP-Q examination and MRI analysis. In both treatment groups, the postoperative POP-Q point C and MRI parameters were similar to nulliparous controls at 3 months. CONCLUSIONS: Anatomic outcomes for ASCP compared with ProLift were similar at 3 months in terms of vaginal apical support by POP-Q and MRI analysis. Continued comparative analysis of postoperative support with objective imaging seems warranted.

Recognition of occult bladder injury during the tension-free vaginal tape procedure.

OBJECTIVE: To identify signs and the etiology of occult bladder injury during the tension-free vaginal tape sling procedure. METHOD: The charts of 140 women who underwent a tension-free vaginal tape procedure were reviewed, and complications were tabulated and analyzed. The tension-free vaginal tape procedure was performed in six fresh-frozen pelves to demonstrate the mechanism of the occult bladder injury. RESULTS: Occult bladder injury was suspected when cystoscopy instillation fluid flowed from the plastic sheath that covers the prolene tape after the extraction of the tension-free vaginal tape trocar. Three of six cases of intraoperative bladder injury had occult bladder injury identified on repeat cystoscopic inspection. The bladder injury caused by the rough edge at the point of attachment of the tension-free vaginal tape to the trocar was reproducible in three of 12 tension-free vaginal tape applications in fresh-frozen pelves. Traction on the tension-free vaginal tape reapproximates the injured bladder edges and potentially promotes spontaneous healing. CONCLUSION: Bladder injuries may go unrecognized during a tension-free vaginal tape procedure. Continuous seepage of water through the prolene plastic sleeve is suggestive of occult bladder injury and requires repeat cystoscopy to identify the potential site of injury.