Imaging of the female urethral diverticulum.

Female urethral diverticulum is a localized out-pouching of the urethra that is becoming increasingly prevalent, but often poses a diagnostic challenge. Traditionally, conventional voiding cystourethrography has been used to make the preoperative diagnosis. With the development of higher-resolution images acquired through ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI), the anatomy and various abnormalities of the female urethra can be better elucidated. This article focuses on the imaging features of female urethral diverticulum, with emphasis on diagnostic pearls, particularly using MRI. Female urethral diverticulum can be best identified by their location in the posterolateral urethra and by their communication with the urethral lumen. Improved imaging techniques combined with increased physician awareness of urethral diverticulum will lead to more prompt and accurate diagnosis of this entity, leading to better treatment of affected patients.

Obstetric fistulas: a clinical review.

A high proportion of genitourinary fistulas have an obstetric origin. Obstetric fistulas are caused by prolonged obstructed labor coupled with a lack of medical attention. While successful management with prolonged bladder drainage has occasionally been reported, mature fistulas require formal operative repair, and it is crucial that the first repair is done properly. The literature reports 3 approaches to fistula repair: vaginal, abdominal, and combined vaginal and abdominal. Many authors report high success rates for the surgical closure of obstetric fistulas at the time of hospital discharge, without further evaluation of the repair's effect on urinary continence or subsequent quality of life. Data on obstetric fistulas are scarce, and thus many questions regarding fistula management remain unanswered. A standardized terminology and classification, as well as a data reporting system on the surgical management of obstetric fistulas and its outcomes, are critical steps that need to be taken immediately.

Complex obstetric fistulas.

Obstetric fistulas are rarely simple. Most patients in sub-Saharan Africa and parts of Asia are carriers of complex fistulas or complicated fistulas requiring expert skills for evaluation and management. A fistula is predictably complex when it is greater than 4 cm and involves the continence mechanism (the urethra is partially absent, the bladder capacity is reduced, or both); is associated with moderately severe scarring of the trigone and urethrovesical junction; and/or has multiple openings. A fistula is even more complicated when it is more than 6 cm in its largest dimension, particularly when it is associated with severe scarring and the absence of the urethra, and/or when it is combined with a recto-vaginal fistula. The present article reviews the evaluation methods and main surgical techniques used in the management of complex fistulas. The severity of the neurovascular alterations associated with these lesions, as well as inescapable limitations in staff, health facilities, and supplies, make their optimal management very challenging.

Obstetric vesico-vaginal fistulas at the National Hospital of Niamey, Niger.

OBJECTIVE: To determine the epidemiologic and therapeutic characteristics of obstetric vesico-vaginal fistulas at the National Hospital of Niamey, Niger. METHODS: From December 2003 to February 2005, 111 consecutive patients with vesico-vaginal fistulas presenting for treatment were included and prospectively followed up. Demographic and clinical data were collected. The patients were re-evaluated 3 months after surgery. RESULTS: Among the 104 patients treated surgically 87% were aged between 15 and 36 years; 84% were married before they were 19 years old; 51% were divorced; and 80% did not live with their husbands. The fistula was caused by the first delivery in 43% of the patients; 93% were in labor for more than 24 hours; 35% were delivered at home; and perinatal death was 100%. The overall cure rate was 73%. CONCLUSION: These epidemiologic characteristics provide data towards the development of an obstetric fistula prevention program in Niger.

Thyrotropin-releasing hormone-induced contraction of urethral and vaginal muscle.

Pressure studies were carried out in 10 women to determine whether TRH stimulates muscular contractions in the genitourinary system. TRH (500 micrograms) or saline was administered iv as a bolus injection. Whereas saline had no effect, TRH increased intraurethral pressures in all women, vaginal pressure in 7, and bladder pressure in none. These findings suggest that TRH, acting centrally, peripherally, or both, may play a role in initiating muscular contractions in the female genitourinary tract.

Suburethral diverticulum: classification and therapeutic considerations.

The records of 70 patients with a suburethral diverticulum were reviewed. Cases were classified according to their anatomic site of origin in an attempt to rationalize the appropriate therapeutic approach. It is suggested that suburethral diverticulum arising in the lower third of the urethra be preferably treated by marsupialization with tissue excision for histologic confirmation, and those diverticula arising in the upper two thirds of the urethra be treated by excision. In those cases in which multiple diverticula are suspected, an anterior vaginoplasty should be carried out in an attempt to reduce the morbidity associated with excision only.

Adenocarcinoma arising in adenomyosis detected by atypical cytology.

Adenocarcinoma in adenomyosis is unusual and in most cases is associated with adenocarcinoma in the surface endometrium. In the latter, the diagnosis is made in the removed specimen because of the finding of adenocarcinoma in curettings. In contrast, adenocarcinoma arising in adenomyosis without surface endometrial changes is extremely rare and presents major diagnostic problems. The two cases reported herein demonstrate the significance of atypical vaginal cytology in the recognition of such lesions.

Rectal serosal hematoma: an unusual complication of culdocentesis.

Culdocentesis is currently a widely used diagnostic technique in gynecology. Although associated with numerous theoretical risks, few complications have been documented in anecdotal reports. Rectal serosal hematoma, an unusual complication of culdocentesis, is described.

Carcinoma in situ of the vulva.

Of 106 patients with carcinoma in situ (CIS) of the vulva, 102 have been followed from 1 to 15 years. The average age of the patient was 47 years; however, 40% were under the age of 41. Twenty-seven percent had associated cervical malignancy. Only 4 patients developed invasive cancer. Of these, 2 were postmenopausal and the 2 younger patients had been immunosuppressed because of systemic disease; thus the subsequent invasive cancer. The incidence of recurrence was essentially the same whether the patient was treated by vulvectomy or wide local excision. In view of the uncertainties about the invasive potential of CIS of the vulva in young patients and the absence of a proved need for an extensive procedure, it is suggested that this entity be treated only by local excision.

Mucinous cystadenocarcinoma of the ovary.

Reports of 78 cases of mucinous cystadenocarcinoma of the ovary were collected from the Emil Novak Ovarian Tumor Registry and the files of the Gynecologic Pathology Laboratory of the Johns Hopkins Hospital between the years 1942 and 1966. Two-year and 5-year followups were available for 91 and 83% of the cases, respectively. The prognosis was related to the most aggressive area of the tumor as the histologic grade was based on the maximum number of mitoses per high-powered field. In view of the clinical and histopathologic differences between these lesions and the serous and endometrioid varieties, it is suggested that each tumor be considered on its own merits in order to offer an accurate prognosis.

The morphology of the earliest invasive cell in low genital tract epidermoid neoplasia.

The light and electron microscopic characteristics of the distinct eosinophilic microinvasive cell in the lower genital tract epidermoid neoplasia are described. The eosinophilic quality of the invasive cell is associated with an accumulation of contractive protein seen at the ultrastructural level. The presence of these differentiated cells near the basement membrane should be viewed with more concern as they contain the cytoplasmic machinery with which to invade.

Primary, papillary peritoneal neoplasia.

Subsequent to the recognition of the intraperitoneal tumors of low malignant potential, clinicians have repeatedly faced the ambiguities inherent in a disease that seems aggressive on the basis of its wide distribution in the peritoneal cavity but benign on the basis of its histopathology and clinical course. Whereas the occasional case has been associated with extensive local reaction and ascites, except for a rare exception these tumors result in prolonged survival and in an absence of extraabdominal extension. The current review of 154 cases followed from 2 to 40 years, performed in an attempt to understand this perplexing disease, leads to the following conclusions: 1) Whereas frequently beginning on the ovary and showing a predilection for the pelvis, there are examples of widely disseminated peritoneal disease with minimal, if any, ovarian involvement; 2) the outcome without adjunctive therapy is excellent and thus such therapy is contraindicated in view of the death of only 2 of the 154 patients with disease, 1 of whom had had adjunctive intraperitoneal isotope therapy; and 3) this disease is best understood as a diffuse primary peritoneal tumor probably developing on the basis of irritating agents' reaching the abdominal cavity from the lower genital canal, a process similar to that proposed for the genesis of endometriosis. Such a low-grade primary in situ tumor that may involve the entire peritoneal cavity is compatible with prolonged survival.

Anatomy of pelvic arteries adjacent to the sacrospinous ligament: importance of the coccygeal branch of the inferior gluteal artery.

OBJECTIVE: To describe the arterial vascular anatomy in the area of the sacrospinous ligament. METHODS: Cadaver pelvises were dissected to reveal the anatomy of the sacrospinous ligament with emphasis on vascular and neuroanatomy. Flexible rulers were used to measure the coccygeal branch in five hemipelvises. RESULTS: The pudendal vessels and nerve pass immediately medial and inferior to the ischial spine (within 0.5 cm of the spine) and behind the sacrospinous ligament. The pudendal artery lies anterior to the sacrotuberous ligament, which passes behind the ischial spine to its attachment at the posterior ischial tuberosity. The inferior gluteal artery originates from the posterior or the anterior branch of the internal iliac artery to pass behind the sciatic nerve and the sacrospinous ligament. There is a 3- to 5-mm window in which the inferior gluteal vessel is left uncovered above the top of the sacrospinous ligament and below the lower edge of the main body of the sciatic nerve plexus. The coccygeal branch of the inferior gluteal artery passes immediately behind the midportion of the sacrospinous ligament and pierces the sacrotuberous ligament in multiple sites. The main body of the inferior gluteal artery leaves the pelvis by passing posterior to the upper edge of the sacrospinous ligament and following the inferior portion of the sciatic nerve out of the greater sciatic foramen. CONCLUSION: Sutures placed through the sacrospinous ligament at least 2.5 cm from the ischial spine along the superior border of the sacrospinous ligament and without transgressing the entire thickness are in an area generally free of arterial vessels.

Vulvar carcinoma with hypercalcemia.

Hypercalcemia associated with nonmetastatic malignancy has been reported most frequently with lung or kidney tumors, while among gynecologic malignancies, the ovary has been the most common primary site. The pertinent clinicopathologic features of 2 cases of nonmetastatic vulvar carcinoma producing hypercalcemia are described in the present report. Including 3 previously reported cases, the vulva is seen to be the second most common site in the female genital tract for production of this paraendocrine syndrome. The clinician should be aware of the association of hypercalcemia and mental confusion with bulky vulvar tumors, so that surgery will not needlessly be delayed in a futile attempt to correct the hypercalcemia medically,

The histopathology of the developing tubal ectopic pregnancy.

Examination of histopathologic sections taken of tubal ectopic pregnancies and gross dissections of these specimens suggest that, in the majority of cases, the growth of the developing trophoblast takes place in a largely extratubal site and that the common clinical impression that the mass associated with the tubal ectopic pregnancy is a dilated fallopian tube is largely erroneous.

Radiography, sonography, and magnetic resonance imaging for stress incontinence. Contributions, uses, and limitations.

Imaging has increased our ability to understand stress incontinence and prolapse and has advanced our existing concepts of pathophysiology. Once these conceptual contributions have been made, imaging modalities may fade from current use, but the lessons learned will remain. It is the relationship of clinical imaging to conceptual development that is important. Conventional radiographic studies are well understood and can be obtained in most facilities. Sonographic units are currently available in many urologic and gynecologic clinics and offices and can be adapted for stress incontinence studies. The benefits of real-time studies and soft-tissue detail at the urethrovesical junction and office-based convenience make this an attractive new technique. The global pelvic approach offered by MR imaging offers spectacular imaging possibilities, which can help in complex cases and in future concepts in the field. MR imaging is rapidly evolving and may continue to offer new insights as technology permits. In accordance with Hodgkinson's earlier observations, imaging should not be routinely required in all patients undergoing evaluation for stress incontinence, but should certainly be considered in failed operations, complex prolapse, and when clinical diagnosis is in doubt. It is always better to use an imaging technique, no matter how expensive, than to end up with a bad surgical result.

Anatomic goals in the correction of female stress urinary incontinence.

The goal of stress incontinence surgery is to prevent opening of the urethra during increases in intra-abdominal pressure. Greater refinements in the understanding of the pathophysiology of incontinence and experience with newer treatments have extended surgical thinking beyond the familiar paradigm "to place the urethra in a high retropubic position." When incontinence is associated with vaginal hypermobility, vaginal support may be sufficient to restore continence if the suburethral vaginal wall is sufficiently strong, an evaluation which must often be made by physical examination alone. However, when the vaginal wall is weak, the urethra will require an alternative form of support, usually a sling. If the urethra is intrinsically deficient, vaginal support may not be sufficient to prevent opening during increased intra-abdominal pressure, and coaptation by sling obstruction or periurethral bulking injection may be required. Most laparoscopic approaches to stress incontinence use Burch's method, which offers excellent urethral stability provided the suburethral vaginal wall is strong. Newer insights into the relation between vaginal mobility and urethral closure are discussed, as well as anatomic aspects of the Burch suspension relevant to laparoscopic repair.

Endometriosis and perimenarchal tubal torsion. A case report.

Tubal torsion and endometriosis were present in conjunction in a perimenarchal girl.

Stress incontinence observed with real time sonography and dynamic fastscan magnetic resonance imaging--insights into pathophysiology.

Our concepts of pathophysiology of stress urinary continence have been greatly shaped by developments in radiographic imaging. Simple radiographs with and without contrast initially revealed the importance of urethral descent in pathogenesis. More recently, magnetic resonance imaging (MRI) and real time ultrasonography are showing soft tissue detail within both a global pelvic and a local urethral context. Careful examination of these studies can extend our concepts of pathophysiology and lead us beyond existing paradigms. We propose a unified theory of stress incontinence based on our dynamic fastscan MRI and real time ultrasonograms of stress incontinence, incorporating known details of pelvic anatomy, sphincteric location and function. The hypothesis introduces the concept of a continence threshold at which the urethra is subjected simultaneously to both shearing and explusive forces. If these forces are sufficient to overcome urethral coaptation at threshold, leakage results. The model proposes an anatomical sequence of changes through which the incontinent urethra cycles between periods of rest and increased abdominal pressure, and suggests a way in which repeated episodes of prolpase and urethral traction by shearing forces exerted by the vagina on the urethra may contribute to the development of intrinsic sphincteric deficiency.