Electrophysiological function during voiding after simulated childbirth injuries.

During vaginal delivery dual injuries of the pudendal nerve and the external urethral sphincter (EUS), along with other injuries, are correlated with later development of stress urinary incontinence. It is not known how combinations of these injuries affect neuromuscular recovery of the micturition reflex. We investigated the EUS electromyogram (EMG) and the pudendal nerve motor branch potentials (PNMBP) during voiding 4 days, 3 weeks or 6 weeks after injury; including vaginal distension (VD), pudendal nerve crush (PNC), both PNC and VD (PNC+VD), and pudendal nerve transection (PNT); and in controls. Pudendal nerve and urethral specimens were excised and studied histologically. No bursting activity was recorded in the EUS EMG during voiding 4 days after all injuries, as well as 3 weeks after PNC+VD. Bursting activity demonstrated recovery 3 weeks after either VD or PNC and 6 weeks after PNC+VD, but the recovered intraburst frequency remained significantly decreased compared to controls. Bursting results of PNMBP were similar to the EMG, except bursting in PNMBP 4 days after VD and the recovered intraburst frequency was significantly increased compared to controls after PNC and PNC+VD. After PNT, neither the EUS nor the pudendal nerve recovered by 6 weeks after injury. Our findings indicate bursting discharge during voiding recovers more slowly after PNC+VD than after either PNC or VD alone. This was confirmed histologically in the urethra and the pudendal nerve and may explain why pudendal nerve dysfunction has been observed years after vaginal delivery.

Efficacy of a standardized technique of trans-vaginal entry into the peritoneal cavity for post-hysterectomy vaginal vault suspension.

The aim of this paper is to describe the efficacy and safety of a standardized technique of trans-vaginal entry into the peritoneal cavity for post-hysterectomy vault prolapse and determine how well the pre-operative pelvic examination predicted successful peritoneal entry. A retrospective review of patients undergoing post-hysterectomy trans-vaginal apical suspensions using a standardized technique of peritoneal entry was employed in this study. A subset of patients underwent a standardized pre-operative evaluation to predict what organ was behind the vaginal cuff and posterior cul-de-sac. Peritoneal entry was attempted in 280 patients, and successfully achieved in 223(80%). One cystotomy and one proctotomy (0.3%) occurred during attempted entry. Of those who underwent the standardized pre-operative evaluation, peritoneal entry was successful 86% of the time when small bowel was predicted to lie behind the vaginal cuff or posterior cul-de-sac. Peritoneal entry can be safely achieved in the majority of post-hysterectomy prolapse patients. Pre-operative examination assists in predicting successful peritoneal entry.

Lower urogenital tract anatomical and functional phenotype in lysyl oxidase like-1 knockout mice resembles female pelvic floor dysfunction in humans.

Female pelvic floor dysfunction (FPFD) is a complex group of conditions that include urinary incontinence and pelvic organ prolapse (POP). In humans, elastin homeostasis has been implicated in the pathophysiology of FPFD. Lysyl oxidase-like 1 knockout (LOXL1-KO) mice demonstrate abnormal elastic fiber homeostasis and develop FPFD after parturition. We compared the lower urogenital tract (LUT) anatomy and function in LOXL1-KO mice with and without POP. LUT anatomy was assessed in LOXL1-KO mice over 28 wk. Pelvic visceral anatomy in LOXL1-KO was evaluated with a 7-Tesla magnetic resonance imaging (MRI) scanner. LUT function was assessed using conscious cystometry and leak point pressure (LPP) testing. Quantitative histological analysis of elastic fibers was performed on external urethral sphincter (EUS) cross sections. By 25 wk of age, 50% of parous LOXL1-KO mice developed POP. LOXL1-KO mice with POP had greater variability in the size and location of the bladder on MRI compared with mice without POP. Parity and POP were associated with lower LPP. Elastin clusters were significantly increased in the EUS of LOXL1-KO mice with POP. Because parity triggers POP in LOXL1-KO mice, LOXL1-KO mice with POP have variable internal pelvic anatomy, and both parity and POP are associated with a decrease in LPP, we conclude that LOXL1 LUT anatomical and functional phenotype resembles FPFD in humans. The increase in elastin clusters in the urethra of LOXL1-KO mice with POP suggests that elastin disorganization may lead to functional abnormalities. We conclude that LOXL1 warrants further investigation in the pathphysiology of FPFD.

Bowel symptoms 1 year after surgery for prolapse: further analysis of a randomized trial of rectocele repair.

OBJECTIVE: The purpose of this study was to analyze change in bowel function and its relationship to vaginal anatomy 1 year after rectocele repair and pelvic reconstruction in a randomized trial of 3 techniques of rectocele repair. STUDY DESIGN: The study is an ancillary analysis of data from a randomized trial of 3 techniques of rectocele repair: posterior colporrhaphy, site-specific repair, and site-specific repair with Fortagen graft augmentation. Pelvic examination and validated questionnaires were obtained at baseline, 6 months, and 1 year after surgery. Bowel symptoms included straining, splinting, incomplete emptying, painful defecation, fecal urgency, and fecal incontinence. Logistic regression was used to identify predictors of bothersome postoperative symptoms. RESULTS: One hundred six women with Stage > or = 2 POP, which included a rectocele, were enrolled in the study. Ninety-nine underwent prolapse surgery that included a rectocele repair and completed at least 1 follow-up visit. Ninety-six percent of subjects underwent concomitant prolapse surgery. No differences in change in bowel symptoms were noted between treatment groups. On average, all bowel symptoms evaluated were significantly improved 1 year after surgery. The development of new "bothersome" bowel symptoms after surgery was uncommon (11%). After controlling for age, treatment group, comorbidities, and preoperative bowel symptoms, corrected postoperative vaginal support (Stage 0/1) was associated with a reduced risk of postoperative straining (adj. OR 0.17 95% CI 0.03 to 0.9) and feeling of incomplete emptying (adj. OR 0.1 95% CI 0.01 to 0.52). Normal support of the posterior vaginal wall (Bp < or = -2) was associated with a reduced risk of bothersome incomplete emptying (OR 0.08 95% CI 0.004 to 0.58) but not with other symptoms. CONCLUSION: Resolution or improvement in bowel symptoms can be expected in the majority of women after rectocele repair and pelvic reconstruction. While all symptoms improved after surgery, a reduction in bothersome postoperative straining and incomplete emptying were specifically associated with cure of posterior vaginal wall prolapse.

De novo rectal prolapse after obliterative and reconstructive vaginal surgery for urogenital prolapse.

OBJECTIVE: The purpose of this study was to compare the incidence of de novo rectal prolapse after obliterative vaginal surgery with the incidence that was seen after reconstructive vaginal surgery for urogenital prolapse. STUDY DESIGN: A chart review was performed on subjects who underwent vaginal surgery for urogenital prolapse from Jan. 1, 2001, through Dec. 31, 2004, at the Cleveland Clinic. Diagnosis of postoperative rectal prolapse was identified with ICD-9 code 569.1. RESULTS: Nine hundred sixteen women underwent vaginal surgery for urogenital prolapse. Ninety-two percent of the women (n = 840) underwent reconstructive surgery, and 8% of the women (n = 76) underwent obliterative surgery. The incidence of postoperative full-thickness rectal prolapse in women who were > or = 65 years old who underwent obliterative surgery was 3 of 74 (4.1%; 95% CI, 1.4-11), with an estimated odds ratio of 22 (95% CI, 2.3-196; P < .002) compared with women who were > or = 65 years old who underwent reconstructive surgery. CONCLUSION: Obliterative surgery is associated with a substantially greater risk of de novo rectal prolapse than reconstructive vaginal surgery for urogenital prolapse.

Treatment of urinary tract endometriosis.

Endometriosis involving the urinary tract, although infrequent, can have significant impact on patients' symptoms, response to treatment, and urologic function. The purpose of this article is to review the epidemiology, pathophysiology, diagnosis, and management of endometriosis that affects the urinary tract.

The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for pelvic organ prolapse.

OBJECTIVE: The objective of the study was to determine the incidence of ureteral obstruction during vaginal surgery for pelvic organ prolapse and the accuracy and efficacy of intraoperative cystoscopy. STUDY DESIGN: The study was a retrospective review of 700 consecutive patients who underwent vaginal surgery for anterior and/or apical pelvic organ prolapse with universal intraoperative cystoscopy. RESULTS: Thirty-seven patients (5.3%) had no spillage of dye from 1 or both ureters intraoperatively. The false-positive and negative cystoscopy rates were 0.4% and 0.3%, respectively. Thus, the true incidence of intraoperative ureteral obstruction was 5.1%. Intraoperative cystoscopy was accurate in 99.3% of cases, with a sensitivity and specificity of 94.4% and 99.5%, respectively. Suture removal relieved ureteral obstruction in 88% of cases. Six subjects (0.9%) had true ureteral injuries. CONCLUSION: Vaginal surgery for anterior and/or apical pelvic organ prolapse is associated with an intraoperative ureteral obstruction rate of 5.1%. Intraoperative cystoscopy accurately detects ureteral obstruction and allows for relief of obstruction in the majority of cases.