Experiences of Black Women With Pelvic Floor Disorders-A Qualitative Analysis Study.

IMPORTANCE: Disparities research in Black women with pelvic floor disorders (PFDs) has primarily focused on epidemiology or surgical outcomes, but little is known about the patient perspective on seeking PFD care. OBJECTIVE: To provide quality and equitable care to Black women with PFDs, we conducted a qualitative study to hear their perspectives and lived health care experiences. STUDY DESIGN: Black women seeking care for PFDs at a tertiary care institution were invited to participate in qualitative interviews. Open-ended questions explored participants' knowledge, attitudes, and health care experiences. Interviews were transcribed verbatim and coded line-by-line. Inductive content analysis was performed to identify key themes, and consensus was achieved among the research team. RESULTS: Eight Black women aged 21-83 years consented to participate. Patients noted a stigma surrounding PFDs, both among health care professionals and their community. They noted several barriers to care: financial, logistical, and racial bias. They cited difficulties in patient-health care professional communication, including not feeling heard or treated as an individual. They preferred gender and racial concordance with their physicians. These women expressed both a desire for more knowledge and to share this knowledge and advocate for other women. CONCLUSIONS: Black women expressed distinct obstacles in their PFD health care. They reported not feeling heard or treated as a unique individual. The themes derived from this study identify complex patient-centered needs that can serve as the basis for future quality improvement work and/or hypothesis-driven research. By grounding health disparities research in patient perspectives, we can improve the health care experiences of Black women.

Levels and drivers of burnout during the COVID-19 pandemic among a diverse group of resident physicians.

OBJECTIVES: Evidence has shown significant impacts of the COVID-19 pandemic on physicians. We hypothesized that these effects would impact surgical and non-surgical resident education differently, with non-surgical specialties being more heavily impacted by frontline work and surgical specialties losing elective cases. METHODS: We examined well-being and burnout among resident physicians in surgical and non-surgical specialties during the peak of the COVID-19 pandemic using the Mayo Physician Well-Being Index (WBI). RESULTS: Completed surveys were received from 110 residents, 55% of whom were in a surgical training program. 35% of respondents were identified as 'at risk' for burnout. Increased demands from work (adj. OR 3.79, 95% CI 1.50, 9.59, p = 0.005) was associated with an increased likelihood for being 'at risk' compared to those without increased demands. Odds of having increased stress level were higher amongst residents with fear/anxiety of the unknown (adj. OR 4.21, 95% CI 1.63, 10.90, p = 0.003) and more demands outside work (adj. OR 10.54, 95% CI 2.63, 42.16, p = 0.001) but lower amongst residents with more time for studying (OR 0.23, 95% CI 0.09, 0.64, p = 0.005). Risk for burnout was not significantly different between surgical and non-surgical specialties when adjusting for increased demands from work (adj. OR 1.43, 95% CI 0.60, 3.37, p = 0.0.418). CONCLUSION: Perceived effects of the COVID-19 pandemic upon residents' educational experience was mixed: reduced clinical volume had a negative impact, while increased time for study was perceived favorably. These findings suggest potential strategies and targets to mitigate the stress and burnout of a future crisis, whether large or small, among surgical and non-surgical trainees.

Robotic-Assisted Laparoscopic Removal of Mid-Urethral Mesh Slings Eroded into the Bladder.

INTRODUCTION AND OBJECTIVES: Depending on the indication, there are multiple surgical approaches for the removal of mid-urethral mesh slings (MUS): transvaginal, endoscopic, open abdominal, and robotic. We demonstrate the robotic approach to treat MUS that have eroded into the bladder. The robotic approach offers excellent exposure, visualization, and accessibility. Compared to endoscopic approaches, the entire arm of the sling can be removed from the bladder wall, the bladder repaired, and the foreign body completely eliminated. Robotic MUS excision is ideal in patients who would be best served by maximal removal of the mesh from the bladder to prevent future complications. METHODS: In this video, we display 2 different cases showing 2 unique approaches to robotic MUS excision depending on the location of mesh erosion: 1. If a retropubic sling is eroded through the anterior bladder, we begin by dropping the bladder and entering the space of Retzius to locate the mesh arm. 2. If the sling is eroded into the posterior bladder, a cystotomy is made on the anterior dome to visualize the posterior bladder wall. RESULTS: Once the mesh is identified, we follow the mesh graft carefully and dissect it away from surrounding tissues. The dissection is immediately close to the mesh, without fragmenting it, to allow for complete excision and protection of adjacent critical structures. The surgical principles and instrument techniques of robotic mesh excision mirror those utilized for transvaginal mesh excision. Complications of this surgical approach include a urinary leak that may require prolonged catheterization or re-operation and recurrent stress urinary incontinence, in addition to typical operative risks. CONCLUSION: For treatment of mesh erosion into the bladder, a robotic approach offers excellent visualization, is feasible, and well-tolerated. Compared to fragmenting the mesh using an endoscopic approach, the robotic approach has the advantage of excising the mesh definitively and preventing future recurrences of mesh erosion. Properly selected patients should be offered the robotic approach to mesh excision.

Spouses Speak Up: The Impact of Mesh Sling Complications on the Patient's Spouse-A Qualitative Analysis Study.

OBJECTIVE: To examine the perspectives, attitudes, and beliefs of the spouses of women with complications of mesh midurethral sling (MUS) surgery with the goal of increasing our understanding of the multidimensional nature of MUS surgery complications. METHODS: After IRB approval, the spouses of patients who underwent surgery for MUS complications at a single tertiary care institution participated in qualitative interviews. Using an interview guide with standardized prompts, semistructured interviews were conducted. Interviews were transcribed verbatim and reviewed line-by-line by two researchers independently. Inductive content analysis was used to code the transcripts and identify themes, and consensus was achieved by the research team. RESULTS: Seven male spouses participated in qualitative interviews, and several themes and subthemes were identified. First, spouses expressed feelings of regret. They described that their partner's dyspareunia detracted from their intimate relationship. The participants also reported the negative impact on their lives and their households. Due to the personal nature of the issue, couples would avoid involving friends and family, creating a sense of isolation. Finally, they expressed hope of finding a healthcare team experienced with mesh complications and invested in their spouse's improvement. CONCLUSION: Spouses of women who experience MUS complications serve as caregivers and provide support; they are impacted by adverse outcomes. It is important to acknowledge their role in patients' healthcare experiences and learn from their insights. Our study lays the foundation for future work and ultimately for improving the experiences of patients and their spouses with MUS surgery and potential complications.

Female pelvic medicine and reconstructive surgery fellows' case logs remained stable during the COVID-19 pandemic.

INTRODUCTION: During the COVID-19 pandemic and subsequent staffing shortages there was concern about the case volume, and thus competency, of graduating trainees due to reduced surgical volumes. Elective procedures were particularly affected, which includes Female Pelvic Medicine and Reconstructive Surgery (FPMRS) cases. To understand whether FPMRS fellows were affected, we assessed their case logs for changes during the pandemic. METHODS: The nationally aggregated case logs of graduating FPMRS fellows, both urology and obstetrics and gynecology (OBGYN), were obtained from the Accreditation Council for Graduate Medical Education. The available academic years (AYs) included 2018-2019, 2019-2020, and 2020-2021. Standard deviation for each index category was derived from the average and 90th percentile data. One-way analysis of variance was used to compare differences in case volumes for tracked index categories between AYs. RESULTS: Graduating fellows logged an average of 517.4 (standard deviation [SD] 28.6) and 818.0 (SD 37.9) cases, for urology and OBGYN respectively, over their fellowship training during the examined period. No significant differences in total surgical procedures were found for either specialty between pre-COVID AY 2018-2019 and COVID-affected AYs 2019-2020 and 2020-2021. For urology fellows, gastrointestinal (GI) procedures was the only index case category with a significant difference, and it was a decrease between the two COVID-affected AYs: 2020-2021 compared to 2019-2020 (8.9 vs. 4.2, p = 0.04). For both urology and OBGYN fellows, there was a statistically significant decrease in graft/mesh augmentation procedures from COVID-affected AY 2019-2020 to AY 2020-2021. This may be attributed to the reclassification of mesh removal cases from graft/mesh augmentation procedures to genital procedures in 2020-2021. There was not a significant decrease in these procedures from pre-COVID AY 2018-2019 to the COVID-affected AYs. There were no other statistically significant differences between AYs for OBGYN fellows. CONCLUSIONS: Surgical case volumes for FPMRS urology and OBGYN fellows who trained during the COVID-19 pandemic were comparable to those of their pre-pandemic peers. No significant differences between pre-COVID and COVID-affected years were found for either total surgical procedures or index case categories. Despite disruptions in health care nationwide, FPMRS trainee case volumes were largely unaffected.

"Vagina" Is Not a Bad Word: Historical and Contemporary Censorship of the Word "Vagina".

OBJECTIVE: To characterize instances of censorship of the word "vagina" to better understand perceptions and behaviors surrounding the word. METHODS: Internet and relevant database (PubMed, Academic OneFile, Proquest, Health Business Elite, etc) searches were conducted for the words "vagina," "censor," and related wildcard terms. Search results were filtered by three independent reviewers for relevance. Related articles were summarized and reviewed for common themes. In addition, interviews were conducted with three people who have personal experience with censorship of the word "vagina." Interviews were transcribed and also reviewed for common themes. RESULTS: Examples of censorship of the word "vagina" were compiled, and several themes were identified: (1) Policies surrounding censorship are unclear; (2) Policies appear highly variable; (3) There are differing standards between references to male and female genitalia; and (4) Objections often call the use of "vagina" overtly sexual, profane, or unprofessional. CONCLUSION: The word "vagina" is censored across multiple platforms and policies regarding censorship are inconsistent and unclear. Pervasive censorship of the word "vagina" perpetuates a culture of ignorance and shame about women's bodies. Until we normalize the word "vagina," we cannot make progress on women's pelvic health.

Outcomes of prostatic urethral lift in a medically complex population at a veterans affairs hospital.

Objective: The objective of this study is to report "real-world" outcomes of prostatic urethral lift (PUL) in a medically complex US military veteran population while employing liberalized procedural indications. Methods: A retrospective review was conducted of patients who underwent PUL at our institution. There were no prostatic size requirements, patients were accepted on anti-platelet/anticoagulant therapy, no benign prostatic hyperplasia (BPH) medication washout was required, and there was no maximum post-void residual PVR. Pre- and post-operative International Prostate Symptom Score (IPSS), uroflowmetry, and PVR were recorded. Statistical comparisons were performed using simple t tests. Results: From 2013 to 2019, 91 patients underwent PUL. Mean age was 70 (range 55-92) years. The majority of our patients were classified as American Society of Anesthesiologists (ASA) class 3 versus the general population at ASA class 2. Post-operatively, IPSS decreased by an average of 43% (23 to 13, p < 0.001). There was a mean 41% decrease in PVR (179 to 101 cc, p = 0.009), which was durable for a follow-up of up to 54 months. Maximum urinary flow rate improved by an average of 32% (9.3 to 12.3 cc/s, p = 0.003), which was also durable throughout follow- up. Forty-four patients required catheterization pre-operatively and 16 required catheterization post-operatively. Therefore, 27 patients (61.4%) were rendered catheter-free by PUL. Thirty-nine patients were taking antiplatelet medications peri-operatively, and 13 took anticoagulants. Only one patient (on warfarin) experienced hematuria requiring re-admission with catheter placement. Conclusions: PUL produced effective and durable results in our veteran population, including in patients with significant pre-operative bladder decompensation and those on antiplatelets/anticoagulants.

Innovative Approaches to Battling Resident Burnout in a Urology Residency Program.

INTRODUCTION: Data suggest many U.S. physicians experience burnout, affecting up to 65% of U.S. urology resident physicians. We implemented a multifaceted Urology Resident Wellness Curriculum and measured its effect on burnout reported among our trainees. METHODS: We created a 5-pronged Resident Wellness Curriculum: 1) faculty-sponsored Resident Wellness Fund, 2) social groups between 1 faculty and 2-3 trainees, 3) one-on-one structured mentorship, 4) resident-organized social outings using the Resident Wellness Fund, and 5) wellness education. We administered 2 validated burnout questionnaires, the Maslach Burnout Index-Human Services Survey and the Expanded Mayo Physician Well Being Index, to our resident physicians at 4 time points, immediately before and following curriculum implementation. At study conclusion, resident physicians were asked to rank the most meaningful interventions. RESULTS: At 4 timepoints over 3 academic years, 54 completed instruments were collected from 32 unique resident physicians. Initial Maslach Burnout Index survey data indicated high levels of Depersonalization and Emotional Exhaustion with moderate levels of Personal Accomplishment. Over the study period, there was improvement in Depersonalization from high to moderate (28% decrease, p=0.04), improvement in Emotional Exhaustion from high to moderate (20% decrease, p=0.15) and preserved moderate Personal Accomplishment. The average Physician Well Being Index score decreased by 52% (p=0.006), demonstrating decreased levels of distress. Resident-organized social outings were ranked as the most meaningful intervention, with 63% of participants ranking it first. CONCLUSIONS: Rates of urology resident physician burnout were observed to be high at baseline, but improved significantly after introduction of a purposeful Resident Wellness Curriculum.

Education Time Out and Debrief: Structured Implementation of Perioperative Resident Technical Education Discussion.

BACKGROUND: We designed a model for pre- and postoperative discussions between faculty and trainees to maximize educational yield of cases and accelerate residents' technical development. We sought to study its effect on surgical education via participant perceptions and longitudinal validated performance evaluations. STUDY DESIGN: Our model included preoperative collaborative technical goal-setting, specific to the resident, or "Time Out," and immediate postoperative granular feedback guided by validated evaluation tools, or "Debrief." We encouraged routine use for two 3-month rotations. We administered surveys with Likert scale and open-ended questions before and after implementation to assess adoption and perceptions. Likert scale survey data were analyzed using Mann-Whitney U tests; reported time durations were analyzed using t-tests. At 2 time points per rotation, designated faculty evaluated participating residents using the Objective Structured Assessment of Technical Skills (OSATS) for open/endoscopic cases or Global Evaluative Assessment of Robotic Skills (GEARS). OSATS and GEARS data were analyzed using paired t-tests. RESULTS: Before our intervention, we noted significant differences between attending and resident physicians' perceptions of the frequency, importance, and challenges of perioperative educational discussions. After our intervention, these disparities resolved. In addition, participants reported significantly improved satisfaction with pre- and postoperative educational discussions (p = 0.01). Use of the model did not require increased time per participants' report. Paired GEARS/OSATS were completed for 9 trainees during the intervention, with faculty ratings revealing significant improvement in resident technical skills (p = 0.03). CONCLUSIONS: Our structured model for perioperative educational discussions, consisting of the preoperative "Education Time Out" and postoperative "Education Debrief," significantly improved faculty and resident satisfaction and was associated with measurable improvements in resident technical skills without requiring significantly more time.

Outcomes of Prophylactic Mid-Urethral Sling at the Time of Robotic Sacrocolpopexy.

OBJECTIVE: To compare outcomes of patients who underwent robotic sacrocolpopexy (RSC) with and without concomitant mid-urethral sling (MUS) placement for prophylaxis or treatment of preoperative stress urinary incontinence (SUI) METHODS: We performed a retrospective review of all patients without prior incontinence procedures who underwent RSC with or without MUS placement by 3 surgeons (JA, LA, KE) at a single institution from 2012 to 2017 for treatment of pelvic organ prolapse. Patients had a MUS placed for either documented SUI or prophylaxis of SUI. We compared patient characteristics, operative details, postoperative outcomes, and complications between the groups. RESULTS: A total of 134 patients were identified. 58 (43%) had a MUS placed for documented SUI, 43 (32%) had prophylactic MUS, and 33 (25%) did not have a MUS placed. There were no differences in baseline characteristics between the 3 groups. Patients who did not have a MUS placed had less estimated blood loss (76.4 vs 63.8 vs 36.9 mL, P = .018) but no difference in operative time (P = .408), length of stay (P = .427), or postoperative urinary retention (P = .988). A total of 4 (7%) patients who had a MUS placed for SUI had persistent SUI postoperatively. There were 2 (5%) patients who had a MUS placed prophylactically and 4 (12%) patients who did not have a MUS that developed de novo SUI. CONCLUSION: In this series, we demonstrate the safety and efficacy of prophylactic MUS placement at the time of RSC. Randomized studies evaluating concomitant prophylactic sling at time of robotic sacrocolpopexy could further guide preoperative patient counseling and decision-making.

A 26-Year-old Woman With Dysuria and Hematuria.

In this case, we present imaging findings characteristic of chronic genitourinary schistosomiasis. Schistosoma haematobium, a blood fluke endemic to Africa and the Middle East, is a prominent cause of hematuria and bladder cancer in regions lacking adequate water sanitation. Luminal calcifications of the genitourinary tract, that is, of the bladder and/or ureters, from deposition of fluke eggs are a classic sign of chronic S. haematobium infection and should raise suspicion for the disease even when urine or serological tests are negative. It is important to recognize these findings on CT or, in resource-limited settings, plain film to allow for prompt, effective treatment.

The Prevalence and Treatment of Erectile Dysfunction in Male Solid Organ Transplant Recipients.

INTRODUCTION: Erectile dysfunction (ED) is a prevalent and under-recognized complaint among male solid organ transplant recipients. Most research on this topic has focused on kidney transplant recipients alone. In this review, we integrate current research on ED across all types of solid organ transplant recipients and assess the success of current methods of ED treatment in transplant populations. AIM: To review the current literature addressing the prevalence and treatment of ED in the male solid organ transplant population. METHODS: A literature search was conducted using PubMed to identify relevant studies. Search terms included "organ transplant" and "erectile dysfunction." Titles and abstracts were reviewed for relevance. References from identified articles were also searched and included, if appropriate. MAIN OUTCOME MEASURES: Review of peer-reviewed literature. RESULTS: The prevalence of ED among transplant recipients is higher than that in the general population: 39.8-86.2% in liver transplant recipients, 54-66% in renal transplant recipients, 71-78% in heart transplant recipients, and 79% in simultaneous pancreas-kidney transplant recipients. Phosphodiesterase-5 inhibitors have up to 80% efficacy in treating ED in kidney transplant recipients. Intracavernosal injections have been used with success rates of 60-70% in cardiac and renal transplant recipients. Penile prostheses have also been shown to be safe and effective across transplant types. A low incidence of infection has been reported in several case series, although there is concern for an increased rate of mechanical complications in pelvic organ transplant recipients. Accordingly, placement of a two-piece or malleable prosthesis or ectopic reservoir placement with a three-piece inflatable prosthesis is suggested in this population. CONCLUSION: ED is highly prevalent among male solid organ transplant recipients and should be routinely screened in this population. Current modalities of ED treatment used in the general population are safe and effective in solid organ transplant recipients, although success rates are often lower than those in the general population. Payne K, Popat S, Lipshultz LI, et al. The Prevalence and Treatment of Erectile Dysfunction in Male Solid Organ Transplant Recipients. Sex Med Rev 2021;9:331-339.

Para-aortic haemangioma mimics paraganglioma on MRI.

Here, we report a case of a 70-year-old man referred for an incidentally discovered left renal lesion with peri-aortic lymphadenopathy following a CT scan for back pain. A follow-up MRI scan demonstrated a Bosniak IIF left renal cyst and a T2-hyperintense para-aortic lesion concerning for extra-adrenal paraganglioma (EAP). [131I] Metaiodobenzylguanidine scintigraphy of the para-aortic lesion and urine catecholamines were equivocal. The mass was resected via a robotic approach. Histological examination revealed a haemangioma. Haemangiomas are benign vascular tumours frequently identified on imaging of the liver. Intra-abdominal haemangiomas outside of the liver, however, are rare and may have imaging characteristics that mimic EAP.

Is pain relief after vaginal mesh and/or sling removal durable long term?

INTRODUCTION AND HYPOTHESIS: This study was to review our experience of pain relief durability in women who experienced initial pain resolution after vaginal mesh and/or sling removal (VMSR). METHODS: A retrospective chart review of consecutive, nonneurogenic women who underwent VMSR for pain and reported persistent pain relief at the 6-month postoperative follow-up visit were assessed. Pre- and postoperative data collected were self-reported chief complaints, physical examination, other medical conditions associated with chronic pain, use of pain medications, Urogenital Distress Inventory-6 (in which question 6 specifically addresses pain), and the Numerical Pain Rating Scale (NPRS). Success was defined by continued resolution of pain assessed by score of 0 on NPRS (0 none to 10 terrible), (0-1 on the Urogenital Distress Inventory-6 (UDI-6) question 6, subjective report of pain-free status, and/or no chronic use of pain medications other than those prescribed for non-mesh-related pain. RESULTS: Between 2006 and 2015, 125 of 356 women met study criteria. Mean follow-up after VMSR was 3.5 (range 0.5-10) years. Among 25 women who did not meet success criteria by questionnaire answers or subjective report, 21 had causes unrelated to their original mesh/sling placement and were pain free after they were addressed. Four women experienced delayed mesh-related pain return at 28, 46, 47, and 54 months, respectively; two required mesh removal surgery. Involvement in lawsuits and chronic pain-related medical conditions did not affect the durability of pain relief. CONCLUSIONS: At a mean follow-up of 3.5 years, the original pain relief noted after VMSR was durably maintained.

Long-term management of luminal urethral stricture in women.

INTRODUCTION AND HYPOTHESIS: The objective was to report our long-term experience of luminal urethral stricture (LUS) in women treated with dilation under general anesthesia. METHODS: Following institutional review board approval, charts of women who underwent urethral dilation (UD) under general anesthesia for LUS and had over 6 months' follow-up were reviewed. LUS was confirmed by urethroscopy. UD was performed using female dilators with guidewire and Heyman dilators when required. Outcome measures included the number of UD procedures and the duration and frequency of clean intermittent catheterization (CIC). Success was defined as the ability to void without repeat UD and with no need for CIC 1 year after UD. Possible predictive variables were analyzed. RESULTS: Between 2000 and 2013, a total of 30 out of the 32 women who underwent UD for LUS met the inclusion criteria. Mean follow-up was 59 (range: 7 to 151) months. Thirteen women in the success group showed improvement in the mean maximum flow rate (pre 11 ml/s to post 27.8 ml/s) and post-void residual (pre 85 ml to post 43 ml). In the failure group of 17 patients, 2 required chronic CIC 1 year after a single UD. Fifteen opted for repeat UD. After second (n = 5), third (n = 2), and fourth (n = 2) UD, 9 patients came off CIC and reported durable satisfaction. Four women remained on regular CIC. Two required a permanent suprapubic catheter. CONCLUSION: At a mean follow-up of 5 years, UD for LUS produced durable resolution in 43 % of our patients. Another 30 % fully benefited from repeat UDs. Shorter duration of symptoms before presentation was significantly associated with success.

Long-term outcomes after the excision of horseshoe urethral diverticulum.

INTRODUCTION AND HYPOTHESIS: The objective was to report our long-term experience with horseshoe urethral diverticulum (HUD) excised using the urethral preservation technique. METHODS: Following IRB approval, charts of women who underwent HUD excision and had at least 6 months' follow-up were reviewed. HUD was defined as a bilateral posterior diverticulum that extended laterally and anteriorly past 3 and 9 o'clock on the left and right sides respectively. HUD was diagnosed by pre-operative MRI. Success was defined as no evidence of residual diverticulum on post-operative imaging and the reported resolution of diverticulum symptoms. RESULTS: Between 1998 and 2014, 12 out of 15 women who underwent HUD excision met the inclusion criteria. Mean follow-up was 81 (median: 52, range: 7-163) months. Presenting symptoms included urinary leakage (n = 8), dyspareunia (n = 6), dysuria (n = 6), frequency (n = 5), urgency (n = 5), and vaginal pain (n = 8). Two patients reported having all three symptoms of the historic triad: dysuria, dyspareunia, and post-void dribbling. Three patients had prior urological interventions, including excision of a unilateral diverticulum, a Spence procedure, and a Skene gland incision. Only 1 patient had a recurrent HUD confirmed by MRI 10 years later, which required reoperation. HUD symptoms resolved in the remaining 11 patients, with post-operative imaging showing no evidence of recurrent HUD, and no further therapy was needed. Of 4 women who reported stress urinary incontinence (SUI) pre-operatively, only 2 reported SUI symptoms post-operatively. There were no cases of post-operative urethro-vaginal fistula. CONCLUSION: At a mean follow-up of 6-7 years, excision of HUD with urethral preservation produced long-lasting resolution in the majority of patients.

While You Were Sleepwalking: Science and Neurobiology of Sleep Disorders & the Enigma of Legal Responsibility of Violence During Parasomnia.

In terms of medical science and legal responsibility, the sleep disorder category of parasomnias, chiefly REM sleep behavior disorder and somnambulism, pose an enigmatic dilemma. During an episode of parasomnia, individuals are neither awake nor aware, but their actions appear conscious. As these actions move beyond the innocuous, such as eating and blurting out embarrassing information, and enter the realm of rape and homicide, their degree of importance and relevance increases exponentially. Parasomnias that result in illegal activity, particularly violence, are puzzling phenomena for medicine and the law. Via a review of the pertinent medical literature, a general overview of the current scientific knowledge of parasomnias will be provided. Though this knowledge is far from complete, it can provide some neurobiological information about the nature of parasomnia, including conclusions about a sleepwalker's level of intention as well as factors that predispose one to such episodes. Although a parasomniac's complete lack of consciousness warrants acquittal from criminal liability, it does not exclude responsibility for subjecting oneself to exacerbating factors that result in these violent parasomnias. Individuals should be held accountable if they could be expected to control these factors. In addition, they should undergo appropriate treatment and management in order to prevent future parasomnia behaviors. Establishing a legal defense for parasomnia will prove difficult due to the strong potential for malingering, so specific criteria will be outlined in order to distinguish between true and fraudulent claims of crimes committed during parasomniac states.