Low CD4(+) T cell responses to the C-terminal region of the malaria merozoite surface protein-1 may be attributed to processing within distinct MHC class II pathways.

The C-terminal fragment of merozoite surface protein-1 (MSP-1) of the mouse malaria parasite Plasmodium chabaudi chabaudi (AS) stimulates a weak CD4 T cell response when compared to the response to a more structurally simple region of the molecule. The tertiary structure of the C-terminal region of MSP-1 is maintained by five disulfide bonds. A peptide from this region could only be processed and loaded onto newly synthesized MHC class II molecules, whereas a peptide from the structurally simple region was available for loading onto recycling MHC class II. CD4(+) T cell hybridomas took longer to recognize an epitope derived from the disulfide-bonded region whether native parasite or recombinant MSP-1 antigen was used. Reduction of disulfide bonds in the C-terminal region subsequently allowed peptides to be loaded onto recycling MHC class II and greatly enhanced the rapidity of the T cell response. These data demonstrate that differential processing occurs intramolecularly in MSP-1, which may be responsible for the observed weak CD4 T cell responses against this region. The consequences of this in vivo may be that limited T cell help is available for protective antibody production which has important implications for designing vaccines based on MSP-1.

Pelvic prolapse: diagnosing and treating cystoceles, rectoceles, and enteroceles.

The current generation of women is maintaining a healthier and more active lifestyle into an older age. Treatable conditions such as stress urinary incontinence and pelvic prolapse detract from this active lifestyle. In many cases, an improved quality of life can be maintained by treating pelvic prolapse conditions with relatively minor surgical procedures. Optimal treatment requires a knowledge of pelvic floor anatomy, an understanding of the various pelvic floor defects, and experience in selecting the appropriate procedure. The unequivocal diagnosis of pelvic prolapse conditions can only be made on physical examination. Each section of the vagina -- anterior, posterior, lateral, and apex -- must be inspected and evaluated separately to define the true nature and degree of prolapse. The examination should be performed with a moderate amount of urine in the bladder, and the patient must strain forcefully during the procedure. In some cases, this requires that the patient stand or sit upright during part of the examination to allow all areas of prolapse to become manifest. When the proper procedures are performed, excellent long-term results can be anticipated. The successful treatment of cystoceles requires an evaluation for both lateral and central defects, as inadequate treatment of either defect will lead to recurrences. The treatment of rectoceles is more controversial: Most clinicians would repair symptomatic rectoceles, but many choose not to treat asymptomatic rectoceles because there is little documented benefit to justify the risk of postoperative dyspareunia. Small asymptomatic enteroceles may be treated with a pessary; however, large symptomatic enteroceles usually require surgery.

Pelvic prolapse: diagnosing and treating uterine and vaginal vault prolapse.

Uterine prolapse is often associated with a concomitant rectocele, cystocele, and/or an enterocele. Moderate degrees of prolapse are often associated with a feeling of pelvic heaviness or fullness or low back pain. The symptoms usually worsen with exertion and ease with bed rest. In severe prolapse, the cervix may descend outside the vaginal introitus, and patients may complain that a "mass" is protruding from the vagina. Bleeding from mucosal ulcerations or from the cervical os may occur due to rubbing of the prolapsed tissue against the patient's clothing. The commonly associated problems of cystoceles and rectoceles may lead the patient to complain of difficulty voiding, recurrent urinary infections, and/or "splinting" to defecate. Mild cases of uterine prolapse do not require therapy unless the patient is symptomatic; in most cases of second- or third-degree prolapse, however, patients may be quite uncomfortable and desire therapy. Nonsurgical options, such as a pessary, are usually tried first if the patient desires conservative therapy. Operative repair for uterine prolapse is usually approached vaginally if the uterus is small. An abdominal approach may be preferred if the uterus is large or if the woman has had multiple previous pelvic procedures or has extensive endometriosis or other processes that may obliterate the cul-de-sac. In either approach, the uterosacral and cardinal ligaments must be carefully ligated and tied together, and the cul-de-sac must be obliterated to reduce the risk of subsequent enterocele and to properly suspend the vaginal vault.

Our experience with pubovaginal slings in patients with stress urinary incontinence.

PURPOSE: Pubovaginal slings successfully treat stress urinary incontinence in women with intrinsic sphincter deficiency. Because of its durability, it has been an attractive procedure in select patients with urethral hypermobility. We examine our experience with pubovaginal sling. MATERIALS AND METHODS: A total of 150 patients were evaluated for pelvic prolapse and urinary incontinence. An abdominal leak point pressure was determined in all patients. Of patients with type II stress urinary incontinence, 36 patients (80%) underwent additional gynecological procedures at the time of the pubovaginal sling, compared to 29% with intrinsic sphincter deficiency and 33% with coexisting urethral hypermobility and intrinsic sphincter deficiency. RESULTS: The overall cure rate was 93% with a mean followup of 22 months. At 1 week postoperatively spontaneous voiding was accomplished by 56% of the patients with urethral hypermobility and 57% with intrinsic sphincter deficiency. Only 2.8% of patients required surgical therapy for prolonged urinary retention. De novo urgency/urge incontinence occurred in 19% of women with a 3% incidence of persistent urge incontinence. CONCLUSIONS: Pubovaginal slings are effective and durable. Voiding dysfunction is uncommon and is temporary in most patients.

Transvaginal urethrolysis for urethral obstruction after anti-incontinence surgery.

PURPOSE: Urethral obstruction following a stress incontinence procedure occurs in 5 to 20% of patients. We examine the success of transvaginal urethrolysis in resolving voiding dysfunction. MATERIALS AND METHODS: A retrospective chart review was performed on 39 patients who had undergone transvaginal urethrolysis for urethral obstruction following an anti-incontinence procedure. Preoperatively, a history was taken, and pelvic examination and either video urodynamics or cystoscopy were done. RESULTS: All 39 patients complained of urge incontinence, 13% had urinary retention, 51% had incomplete bladder emptying and 36% voided to completion but had irritative voiding symptoms. Previous surgery included retropubic urethropexy in 41% of the cases, pubovaginal sling in 38% and bladder neck suspension in 21%. Mean length of followup after urethrolysis was 16 months. Of the 39 patients 33 (85%) had resolution of urge incontinence but 5 still required occasional intermittent catheterization. The remaining 6 patients had continued urge incontinence. An augmentation procedure was performed in 4 patients with improvement of symptoms. CONCLUSIONS: Our data support transvaginal urethrolysis for the treatment of iatrogenic urethral obstruction. It is a rapid, effective and minimally invasive technique that should be considered if voiding dysfunction does not resolve spontaneously.

The incidence of Helicobacter pylori in patients with interstitial cystitis.

PURPOSE: The cause of interstitial cystitis is unknown. We evaluated the incidence of Helicobacter pylori antibodies in patients with interstitial cystitis to determine whether such infection may be a causative factor. MATERIALS AND METHODS: We obtained serum samples from 23 patients with interstitial cystitis and 23 control subjects. Samples were analyzed for the presence of H. pylori IgG antibodies. RESULTS: The incidence of positive tests for H. pylori antibodies was 22% in the interstitial cystitis group and 35% in controls. CONCLUSIONS: The incidence of infection with H. pylori is not increased in interstitial cystitis, and so it is unlikely to be a causative factor.

A followup on transurethral collagen injection therapy for urinary incontinence.

PURPOSE: Transurethral collagen injection therapy has been used successfully in treating stress urinary incontinence due to intrinsic sphincter deficiency since United States Food and Drug Administration approval in October 1993. MATERIALS AND METHODS: Telephone interview and chart review were performed on 139 women with intrinsic sphincter deficiency documented using video urodynamics, of whom 73% had grade 3 incontinence (leakage without effort). Median followup was 18 months (range 6 to 36). Median patient age was 72 years. RESULTS: A total of 103 patients (74%) was substantially improved after collagen therapy, 29 (20%) were improved and 7 had no improvement. Of the substantially improved group 72% obtained continence after 2 or fewer injections. Of the patients 11% required a "booster" injection more than 6 months after initial treatment. Complications, such as hematuria, urinary tract infections or transient urinary retention, were rare. CONCLUSIONS: Our results confirm the safety and efficacy of transurethral collagen. Once continence is achieved further collagen therapy is rarely necessary.

Ovarian abscess 15 months after vaginal hysterectomy. A case report.

BACKGROUND: Ovarian abscess is a primary infection of ovarian parenchyma. Since 1869, only 44 cases after vaginal hysterectomy have been reported in the medical literature. The pathophysiology of bacterial infection in these cases is different from the traditional ascending mechanism. CASE: A 28-year-old woman presented with complaints of lower abdominal pain and fever 15 months after transvaginal hysterectomy. Her white blood cell count was 22,700/mm3, with 90% neutrophils. Bimanual examination revealed a tender mass in the cul-de-sac, and computed tomography showed a large, multiloculated pelvic mass. Laparotomy, pathologic examination and microbiologic study confirmed the diagnosis of ovarian abscess. CONCLUSION: Our case represents another rare posthysterectomy ovarian abscess. Most of these cases were managed by surgery and antibiotic treatment.

Treatment results using pubovaginal slings in patients with large cystoceles and stress incontinence.

PURPOSE: We determined the efficacy of performing a pubovaginal sling concurrently with a formal cystocele repair in patients with grade III to IV cystoceles. MATERIALS AND METHODS: We studied 42 women with grade III to IV cystoceles diagnosed by physical examination and video urodynamics. Of the patients 9 (22%) had intrinsic sphincter deficiency diagnosed by an abdominal leak point pressure of less the 60 cm. water, and 24 (57%) had type II stress incontinence with urethral hypermobility and an abdominal leak point pressure greater than 90 cm. water. A pubovaginal sling and anterior colporrhaphy were performed and, if indicated, other vaginal procedures were done at that time. RESULTS: A total of 36 patients (86%) was available for postoperative pelvic examinations performed at 3-month intervals, for a mean followup of 20.4 months (range 12 to 39). Only 3 patients had symptomatic grade III cystoceles and 2 had enteroceles. Two patients required collagen injections and 2 underwent a repeat pubovaginal sling. Therefore, all patients were continent at the time of followup. CONCLUSIONS: This study confirms that in patients with large cystoceles and stress urinary incontinence a pubovaginal sling and anterior colporrhaphy effectively treat the incontinence and reduce the cystocele. In addition, the fascial sling appears to provide additional support to the bladder base, improving the durability of the anterior colporrhaphy.

Pubovaginal fascial slings.

The first pubovaginal fascial sling was reported in 1907, however, until recently this procedure was rarely utilized except after other incontinence procedures had failed. Currently, a pubovaginal sling is indicated as the primary incontinence procedure if intrinsic sphincter deficiency or coexisting intrinsic sphincter deficiency and urethral hypermobility are diagnosed preoperatively. Additionally, incontinence secondary to urethral hypermobility should be treated with a pubovaginal sling if the patient has a high risk of postoperative failure due to obesity, chronic cough, or repetitive strenuous activity. Pubovaginal slings are relatively easy to perform and yield reliably good results with minimal morbidity. We describe our current technique and results using pubovaginal slings for stress incontinence in women.

Modified Ingelman-Sundberg bladder denervation procedure for intractable urge incontinence.

PURPOSE: We determined the efficacy of the modified Ingelman-Sundberg procedure in women with urge incontinence and intractable detrusor instability. MATERIALS AND METHODS: Women with urge incontinence and detrusor instability, in whom medical and behavioral therapy failed, received transvaginal local anesthesia to block the terminal pelvic nerve branches to the bladder. Urge incontinence resolved temporarily in 25 patients, who subsequently underwent modified Ingelman-Sundberg transvaginal bladder denervation. All patients underwent preoperative urodynamic evaluation but documented detrusor instability was not a requirement for surgery. RESULTS: Of the patients 16 (64%) were cured of urge incontinence with substantial relief of detrusor instability, 2 (8%) had temporary improvement and 7 (28%) had no change. No patient who was cured required further surgery (mean followup 14.8 months, range 4 to 30). Use of anticholinergic agents also decreased dramatically: 5 patients used no, 9 used 1 and 2 used 2 medications. Detrusor instability was documented in 44% of the patients and was not predictive of operative outcome. There were no major complications of the procedure. Operative time was approximately 15 minutes. CONCLUSIONS: In patients with urge incontinence and medically refractory detrusor instability, with few simple choices for treatment, the modified Ingelman-Sundberg procedure is an excellent surgical option that yields good results with minimal morbidity.

Videourodynamic studies.

Videourodynamic evaluation that incorporates radiographic imaging with simultaneous measurement of bladder and urethral pressure is the most precise method available for diagnosing complex incontinence and voiding disorders. In addition, videourodynamics has been instrumental to the development of our present knowledge about urethral and bladder function including the concepts of detrusor and abdominal leak point pressures. Although these studies are more expensive and time consuming, the authors have found videourodynamic evaluation indispensable when the diagnosis remains in question after simple urodynamics and when the studies and clinical scenario do not agree.

Galactosemia: evaluation with MR imaging.

The cerebral findings at magnetic resonance imaging in 67 transferase-deficient galactosemic patients (36 female, 31 male; median age, 10 years) are reported. Twenty-two patients had mild cerebral atrophy, eight had cerebellar atrophy, and 11 had multiple small hyperintense lesions in the cerebral white matter on T2-weighted images. The classic galactosemic patients (those without measurable transferase activity) older than 1 year of age did not show the normal dropoff in peripheral white matter signal intensity on intermediate- and T2-weighted images. The authors postulate that this abnormal signal intensity is due to altered myelin formation secondary to the inability to make sufficient and/or normal galactocerebroside.