Symptomatic vulvar mucinous cyst: A case report and review of the literature.

BACKGROUND: Vulvar mucinous cysts are rare, benign, noninvasive masses. They can be mistaken for cysts of Bartholin gland, Skene gland, vestibular, or canal of Nuck. Generally, they may be left untreated, but observed. However, if symptomatic, they may require surgical removal. CASE: We report a large vulvar mucinous cyst in a 29-year-old woman with no contributory medical history. Excision of the mass was performed because its size had begun to cause symptoms. The diagnosis of a mucinous cyst was based on radiological and clinicopathologic features. The patient developed a post-operative vulvar hematoma and was discharged 2 days after the surgery with a Foley catheter in place. Continued follow-up was maintained for the hematoma, which drained spontaneously and resolved without incident. There has been no recurrence of the cyst after completion of short-term surgical follow-up. CONCLUSION: Vulvar mucinous cysts are rare masses. We present the diagnosis and treatment of a large vulvar mucinous cyst. The cyst was completely removed during surgery, but long-term surveillance for recurrence is currently being conducted.

Symptomatic Epidermoid Cyst Presenting as a Paravaginal Mass.

BACKGROUND: Ischioanal fossa epidermoid cysts are uncommon masses of epithelial origin and are believed to be either congenital or the result of trauma. Surgical excision is preferred as opposed to incision and drainage because these masses may enlarge, recur, become infected, or undergo malignant transformation. CASE: This report describes a case of a 62-year-old woman who presented for evaluation of vaginal and perineal discomfort and fullness. Physical examination and computed tomography scan revealed a 7.1-cm cystic mass in the left ischioanal space. Transgluteal surgical excision was performed and pathology revealed an epidermoid cyst. The patient recovered with symptomatic improvement. CONCLUSIONS: This report demonstrates a rare case of ischioanal fossa epidermoid cyst. In cases of rectal masses, cystic lesions should be considered. Thorough physical examination, imaging studies, and proper surgical management of these masses can improve patient symptomatology, prevent recurrence, and also decrease the risk of malignant transformation.

Complete procidentia: temporizing treatment with an obstetric balloon.

BACKGROUND: Pelvic organ incarceration resulting from complete uterovaginal prolapse is rare. Unique management and treatment of this condition are presented. CASE: A 66-year-old multigravid woman presented with increasing abdominal pain, 1-day history of urinary retention, and 30-day history of obstipation. She exhibited complete procidentia, and an attempt to reduce the prolapse immediately was unsuccessful. After fecal disimpaction in the operating room, an obstetric balloon was used for temporary reduction. CONCLUSION: Incarcerated complete procidentia is treated in a stepwise process, initially reducing the prolapse to relieve acute incarceration symptoms. Typically, reduction is accomplished with the aid of a pessary. However, because of this patient's condition, an obstetric balloon was used for temporary reduction to allow subsequent surgical treatment after tissue rest and medical stabilization. This method should be considered in similar situations.

XerC-mediated DNA inversion at the inverted repeats of the UU172-phase-variable element of Ureaplasma parvum serovar 3.

Phase variation of the UU172 phase-variable element of Ureaplasma parvum is governed by a DNA inversion event that takes place at short inverted repeats. The putative tyrosine recombinase XerC of Ureaplasma has been suggested as a mediator in the proposed site-specific recombination event. Here, we provide evidence that XerC mediates DNA inversion at the inverted repeats located on a synthetic locus that was introduced into the model organism Escherichia coli. Synthetic loci were created by exchanging the genes UU171 and UU172 with the two reporter genes gfp (green fluorescent protein) and mrfp1 (monomeric red fluorescent protein 1) either containing or missing the inverted repeats of the UU172 phase-variable element. E. coli was transformed with these loci and also co-transformed with the expression vector pBAD24 that contained the xerC gene behind the arabinose inducible pBAD promoter. Upon XerC expression, DNA inversion was observed only in the locus that contained the inverted repeat regions. We also demonstrate that XerC can process the recombination event with both an N-terminal maltose binding protein tag and a C-terminal 6×His tag in E. coli. A XerC mutant, where the proposed catalytic tyrosine residue 228 was exchanged with an alanine, did not process the recombination event.

Considerations to improve the evidence-based use of vaginal hysterectomy in benign gynecology.

Vaginal hysterectomy fulfills the evidence-based requirements as the preferred route of hysterectomy for benign gynecologic disease. Despite proven safety and effectiveness, the vaginal approach for hysterectomy has been and remains underused in surgical practice. Factors associated with underuse of vaginal hysterectomy include challenges during residency training, decreasing case numbers among practicing gynecologists, and lack of awareness of evidence supporting vaginal hysterectomy. Strategies to improve resident training and promote collaboration and referral among practicing physicians and increasing awareness of evidence supporting vaginal hysterectomy can improve the primary use of this hysterectomy approach.

A simple agar plate preparation for effective transfer of Ureaplasma colonies onto nitrocellulose membranes for colony immunoblotting.

A simple method for preparing agar plates is presented, which allows an efficient transfer of Ureaplasma colonies to nitrocellulose membranes for subsequent immunological detection. This simple and reproducible procedure was used to demonstrate antigenic variation in the phase-variable mba-locus of Ureaplasma parvum serovar 3.

Interaction of the putative tyrosine recombinases RipX (UU145), XerC (UU222), and CodV (UU529) of Ureaplasma parvum serovar 3 with specific DNA.

Phase variation of two loci ('mba locus' and 'UU172 phase-variable element') in Ureaplasma parvum serovar 3 has been suggested as result of site-specific DNA inversion occurring at short inverted repeats. Three potential tyrosine recombinases (RipX, XerC, and CodV encoded by the genes UU145, UU222, and UU529) have been annotated in the genome of U. parvum serovar 3, which could be mediators in the proposed recombination event. We document that only orthologs of the gene xerC are present in all strains that show phase variation in the two loci. We demonstrate in vitro binding of recombinant maltose-binding protein fusions of XerC to the inverted repeats of the phase-variable loci, of RipX to a direct repeat that flanks a 20-kbp region, which has been proposed as putative pathogenicity island, and of CodV to a putative dif site. Co-transformation of the model organism Mycoplasma pneumoniae M129 with both the 'mba locus' and the recombinase gene xerC behind an active promoter region resulted in DNA inversion in the 'mba locus'. Results suggest that XerC of U. parvum serovar 3 is a mediator in the proposed DNA inversion event of the two phase-variable loci.

Clinical findings associated with bladder trabeculations in women.

INTRODUCTION AND HYPOTHESIS: This study evaluated whether bladder trabeculations are associated with advanced prolapse, urinary urgency, or detrusor overactivity among women undergoing office cystoscopy. It is well established that bladder trabeculations are associated with bladder outlet obstruction (BOO) in men; however, the clinical significance of trabeculations in women is unclear. Whereas an analogous relationship has been proposed between prostatic obstruction in men and advanced pelvic organ prolapse (POP) in women, little data in the medical literature supports this theory. METHODS: A retrospective cohort study was conducted using Current Procedural Terminology (CPT) codes (52000, 52204) to identify all women who underwent office cystoscopy at our urogynecology center between January 2008 and May 2011. The 551 women identified were grouped by the presence or absence of bladder trabeculations. Multivariable logistic regression was used to estimate the association between trabeculations and the primary aim, increasing stage of prolapse, and the secondary aims: bladder outlet obstruction, detrusor overactivity, or urge urinary incontinence (UUI). RESULTS: Of the 551 women meeting inclusion criteria, 86 had trabeculations. Controlling for age, the odds of bladder trabeculations were eightfold greater for women with stage IV POP when compared with women with stage 0 prolapse [odds ratio (OR) 8.2, 95% confidence interval (CI) 1.6-43.1]. The odds of bladder trabeculations were twofold greater for women with detrusor overactivity (OR 2.3, 95% CI 1.3-4.0) found on urodynamic study and also as reflected subjectively by answers to Pelvic Floor Distress Inventory (PFDI) item number 16 (OR 4.2, 95% CI 1.3-14.5). CONCLUSION: In this study, bladder trabeculations were associated with stage IV prolapse in the anterior compartment as well as with detrusor overactivity and UUI.

Two-/three-dimensional transperineal sonography of complicated tape and mesh implants.

Transperineal sonography (TPS) affords dynamic evaluation of suburethral slings using tensionless vaginal tape and mesh implants used to treat complications associated with surgical procedures of the pelvic floor. This review describes and illustrates the TPS findings in postoperative complications such as recurrent prolapse, cystocele, enterocele, and rectocele. The potential use of live 3-dimensional TPS to delineate the dynamics aspects of pelvic floor disorder is also mentioned.

Factors associated with exposure of transvaginally placed polypropylene mesh for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: This study evaluates potential risk factors for mesh exposure following transvaginal placement of polypropylene mesh for pelvic organ prolapse requiring reoperation. METHODS: We performed a case-control study. Cases had mesh exposure requiring surgical revision; controls had no mesh exposures and were chosen for similar surgical date and type of mesh. RESULTS: We identified 48 cases and 48 controls. The adjusted odds ratio of having a bleeding complication at the time of mesh implantation was 7.25 [95% confidence interval (CI) 1.47-35.66], smokers versus nonsmokers was 3.17 (95% CI 0.59-17.12), and being 1 year older was 0.96 (95% CI 0.92-1.0), among women with mesh exposure. CONCLUSIONS: We identified bleeding complications at the time of mesh implantation as a risk factor for mesh exposure requiring reoperation. Despite being one of the largest studies on this topic, our data were inconclusive regarding the impact of other possible factors on mesh exposure.

Ureaplasma antigenic variation beyond MBA phase variation: DNA inversions generating chimeric structures and switching in expression of the MBA N-terminal paralogue UU172.

Phase variation of the major ureaplasma surface membrane protein, the multiple-banded antigen (MBA), with its counterpart, the UU376 protein, was recently discussed as a result of DNA inversion occurring at specific inverted repeats. Two similar inverted repeats to the ones within the mba locus were found in the genome of Ureaplasma parvum serovar 3; one within the MBA N-terminal paralogue UU172 and another in the adjacent intergenic spacer region. In this report, we demonstrate on both genomic and protein level that DNA inversion at these inverted repeats leads to alternating expression between UU172 and the neighbouring conserved hypothetical ORF UU171. Sequence analysis of this phase-variable 'UU172 element' from both U. parvum and U. urealyticum strains revealed that it is highly conserved among both species and that it also includes the orthologue of UU144. A third inverted repeat region in UU144 is proposed to serve as an additional potential inversion site from which chimeric genes can evolve. Our results indicate that site-specific recombination events in the genome of U. parvum serovar 3 are dynamic and frequent, leading to a broad spectrum of antigenic variation by which the organism may evade host immune responses.

Anterior, posterior and apical vaginal reconstruction with and without bolsters.

Pelvic-organ-prolapse repair presents unique challenges to the pelvic surgeon. Historically, the unacceptable failure rates with traditional procedures have instigated the many conceptual and technique changes. Critical analysis of the biomechanics of normal and altered anatomy has shifted the primary focus of surgeries from the midline of the distal vagina to the interspinous diameter. In addition, just as surgeons in other fields have begun to incorporate bolsters into various types of repairs, the field of prolapse repair has seen a proliferation of materials that are available to help strengthen repairs. Much effort, time and significant resources have been invested in improving these repairs, but much remains to be learned. The rapid pace of change has prevented the development of the type of evidence-based data that are needed to analyse accurately the specific risks and benefits of the various available approaches. Conceptual changes in the aetiology of pelvic organ prolapse, pelvic biodynamics and the specific nature of connective tissue damage have helped to fuel the rapid pace of change.

Alternate phase variation in expression of two major surface membrane proteins (MBA and UU376) of Ureaplasma parvum serovar 3.

Ureaplasma urealyticum and Ureaplasma parvum are commensals and pathogens of the human urogenital tract and of newborn infants. There are four distinct U. parvum serovars and 10 distinct U. urealyticum serovars. Both species possess a distinct immunodominant variable surface protein, the multiple banded antigen (MBA), which shows size variability among isolates as a result of changes in the number of C-terminal repeating units. Adjacent to the MBA gene (UU375) lies UU376, which was annotated as 'Ureaplasma-specific conserved hypothetical gene'. In four different strains of U. parvum serovar 3, we demonstrated expression of UU376 by Western blot analysis and phase variation between UU376, here designated Upvmp376 (Ureaplasma phase-variable membrane protein 376), and MBA after application of selective pressure with hyperimmune antisera directed against either protein. By Southern blot analysis, we found that the switch between MBA and Upvmp376 expression is associated with a DNA inversion event in which the nonrepetitive region of the MBA gene and its putative promoter region are opposed to either the repetitive region of MBA or UU376. We propose that in U. parvum serovar 3, and presumably in all U. parvum and U. urealyticum, an inversion event at specific sites effects an alternate ON/OFF switching of the genes UU375 and UU376.

Using improved technology for filter paper-based blood collection to survey wild Sika deer for antibodies to hepatitis E virus.

Recent reports from Japan implicated wild Sika deer (Cervus nippon) in the zoonotic transmission of hepatitis E to humans. Seroprevalence studies were performed to determine if imported feral populations of Sika deer in Maryland and Virginia posed a similar risk of transmitting hepatitis E virus (HEV). Hunters collected blood on filter paper discs from freshly killed deer. The discs were desiccated and delivered to a collection point. The dried filters were weighed to estimate the amount of blood absorbed and were eluted and collected in one tube via a novel extraction system. The procedure was quantified and validated with negative and positive serum and blood samples obtained from domestic Sika deer before and after immunization with HEV recombinant capsid protein, respectively. None of the 155 tested samples contained antibody to HEV, suggesting that Sika deer in these populations, unlike those in Japan, do not pose a significant zoonotic threat for hepatitis E. However, the new method developed for collecting and eluting the samples should prove useful for field studies of many other pathogens.