Aversion to Mesh Use in Pelvic Floor Surgery in a Latina Population at the U.S.-Mexico Border.

IMPORTANCE: Limited studies have examined patient aversion to mesh use in pelvic surgery, especially in Latinas. OBJECTIVE: This study aimed to assess aversion to pelvic surgery with mesh for urinary incontinence and pelvic organ prolapse in a sample of Latinas on the U.S.-Mexico border. STUDY DESIGN: This was a cross-sectional study of self-identified Latinas with symptoms of pelvic floor disorders, recruited at their initial consultation visit at a single, academic urogynecology clinic. Participants completed a validated survey to assess perceptions of mesh use in pelvic surgery. Participants also completed questionnaires assessing the presence and severity of pelvic floor symptoms and level of acculturation. The primary outcome was aversion to mesh surgery, as indicated by a response of "yes" or "maybe" to the question "Based on what you already know, would you avoid surgery using mesh?" Descriptive analysis, univariate relative risk, and linear regression analysis were completed to identify characteristics associated with mesh avoidance. Significance was assessed and considered at P values <0.05. RESULTS: Ninety-six women were included. Only 6.3% had prior pelvic floor surgery using mesh. Sixty-six percent indicated that they would be likely to avoid pelvic surgery that uses mesh. Only 9.4% indicated that they obtained information regarding mesh directly from medical professionals. Levels of concern regarding the use of mesh varied widely (29.2% not worried, 19.1% somewhat worried, 16.9% very worried). Higher percentages of "more acculturated" participants indicated a desire to avoid mesh surgery (58.7% vs 27.3%, P < 0.05). CONCLUSIONS: In this Latina population, a majority of patients indicated an aversion to using mesh in pelvic surgery. Few patients obtained information regarding mesh directly from medical professionals, relying instead on nonmedical sources.

Perceptions of Mesh Use for Pelvic Floor Surgery in Latinas: Face Validity of a Spanish Questionnaire.

OBJECTIVE: The aim of the study was to validate a Spanish-translated survey assessing patients' perceptions of mesh use in pelvic floor surgery. METHODS: An English-language survey evaluating perceptions of mesh use underwent a process of Spanish translation and validation, using a forward-backward translation validation protocol. Self-identified bilingual Latinas with symptoms of pelvic floor disorders were recruited to participate in cognitive interviews after completing the survey in English and Spanish. κ coefficient and Cronbach α were calculated for measurement of reliability and internal consistency in responses. A P value of 0.05 was considered statistically significant. RESULTS: A total of 30 women were randomized to complete the initial survey in either English or Spanish. Demographics for the 2 cohorts were similar. For the Spanish-translated survey overall, 86% described the questions as "somewhat easy" or "very easy" to understand, and 93% reported that it was "clear" or "very clear" that the survey aimed to investigate their thoughts regarding mesh use. Approximately 63% of the participants expressed confusion over the use of the Spanish medical term "cabestrillo," translated for "sling." There were no significant differences in the responses on cognitive interview between the 2 groups. Overall, the responses between English and Spanish versions of the survey demonstrated good reliability and internal consistency. CONCLUSIONS: This study demonstrated face validity of a Spanish-translated survey assessing perceptions of mesh use in pelvic surgery in a Latina population. Participants' feedback was crucial to optimizing the quality of the survey for future studies that will evaluate Spanish-speaking patients' views of mesh implants in pelvic reconstructive surgery.

A Structured, Hybrid Cystoscopy Simulation Curriculum for Obstetrics/Gynecology Residents.

OBJECTIVES: This study aimed to assess the subjective and objective cystoscopy skills of gynecology residents before and after implementation of a comprehensive simulation curriculum. METHODS: Residents in an obstetrics/gynecology program at a single academic institution participated in a 6-week cystoscopy simulation course. Residents attended an initial orientation and didactic presentation, and then weekly 20- to 30-minute training sessions using a water balloon model and a virtual reality simulator. Pretesting and posttesting were performed, including (1) subjective self-assessments, (2) a written quiz, and (3) objective structured assessment of technical skills. Paired t test was used to assess the differences in residents' objective assessment scores before and after simulation training. RESULTS: A total of 16 residents were recruited. Residents reported significant subjective improvements in comfort, confidence, and proficiency in performing cystoscopy after completing the curriculum. Their overall objective assessment improved, including written quiz scores (mean score, 49% vs 78%; P < 0.001), efficiency in cystoscope assembly (means score, 0 vs 4; P < 0.001), overall bladder survey score (56% vs 86%, P < 0.001), and global rating score (mean score, 15 vs 24; P < 0.001). Residents tended to prefer the water-balloon model compared with the virtual reality simulator (75% vs 25%). CONCLUSIONS: Obstetrics/gynecology residents demonstrated significant improvements in subjective and objective measures of skill after completion of a 6-week cystoscopy simulation training course using a combination of low- and high-fidelity models. Although universal cystoscopy at the time of hysterectomy for benign indications remains controversial, cystoscopy simulation should remain an important part of resident training.

Decision Aid Video for Treatment Selection in Latinas With Symptomatic Pelvic Organ Prolapse: A Randomized Pilot Study.

OBJECTIVES: To assess impact of a decision aid video in Latina patients with symptomatic pelvic organ prolapse (POP) on knowledge, satisfaction and decisional conflict related to initial treatment selection. METHODS: Pilot study with randomized prospective design. Thirty Latina women with symptomatic POP were randomized to a decision aid intervention plus standard care (N = 15) or standard care alone (N = 15) group. Decision aid intervention consisted of a 10-minute video presented at time of initial evaluation for POP. Outcome measures included the Prolapse and Incontinence Knowledge Quiz ("Knowledge"), the Satisfaction with Decision ("Satisfaction") and Decisional Conflict (DCS) scales, and were assessed at 4 different timepoints: after initial visit, and at 1, 3 and 6 months after. Data was analyzed using repeated-measures ANOVA and pairwise between-group comparisons. RESULTS: Demographic and baseline data were similar between groups. There was a significant interaction between groups and time on the Knowledge scores (P = 0.03). Knowledge scores were higher at the initial visit in the intervention group (10.6 ± 0.8 vs 9.53 ± 1.4, P = 0.014). Satisfaction scores were lower in the intervention group on longitudinal analysis, indicating higher satisfaction (P = 0.02). There was no difference on overall Decisional Conflict scores between groups. The intervention group had lower scores on the "effective decision" DCS subscale at 3 and 6 months and "informed" DCS subscale at 3 months. CONCLUSIONS: A decision aid video intervention in Latina women with POP used at the time of initial evaluation may help the patient make a more informed treatment decision by increasing condition-related knowledge and lead to greater long-term satisfaction.

Qualitative Analysis of Knowledge, Attitudes, and Beliefs About Pessary Use Among Spanish-Speaking Women on the US-Mexico Border.

OBJECTIVES: To explore the knowledge, attitudes, and beliefs related to pessary use in Spanish-speaking women along the US-Mexico border. METHODS: Spanish-speaking women with symptoms of vaginal bulge were recruited from the urogynecology/gynecology clinics at Texas Tech University Health Sciences Center El Paso to participate in moderated focus groups. Discussion topics included knowledge of prolapse/pessaries, pros/cons of pessaries, alternatives, and prolapse surgery. Audio-recorded group discussions were transcribed verbatim, and qualitative analysis completed by independent review using grounded theory methodology. Common themes were identified and then aggregated to form consensus concepts, agreed upon by the reviewers. RESULTS: Twenty-nine Spanish-speaking women participated in 6 focus group discussions. Approximately half of women reported little or no prior knowledge about pessaries. Three main themes were identified from analysis: knowledge/perceptions, misinformation/misconceptions, and surgery-related concerns. Concepts identified from common themes included limited knowledge of pessaries, confusing "pessary" with "mesh," willingness to try pessaries in order to avoid surgery, desire to try pessary if it was recommended by physician, limited efficacy or complications of surgery, and mesh-related concerns. Interestingly, some women reported that pessaries appear to be a treatment more often offered in the United States rather than in Mexico. CONCLUSIONS: Most participants showed a willingness to try a pessary for symptoms of pelvic organ prolapse in an effort to avoid surgery, despite expressing limited knowledge about this treatment. Physician recommendations and risks of pessary use influence their likelihood of trying a pessary. These concepts serve as focus points for effective pessary counseling to help improve education and informed decision making in this patient population.

Staged repair of concomitant rectovaginal fistula and pelvic organ prolapse after removal of a neglected pessary.

Rectovaginal fistulas are a rare complication of neglected pessaries and can pose challenges in managing pelvic organ prolapse. We describe a 66-year-old woman with uterine procidentia who presented with a neglected Gellhorn pessary in place for 5 years. She complained of constipation and persistent vaginal bulge. On examination, the pessary stem eroded through the mid-posterior vaginal wall and anterior rectal wall. Staged surgical treatment included (1) pessary removal and development of ileostomy, (2) rectovaginal fistula repair, and (3) vaginal hysterectomy, uterosacral ligament suspension, and ileostomy reversal. Short-term follow-up did not demonstrate evidence of fistula or recurrence of prolapse. Rectovaginal fistulae resulting from neglected pessaries pose challenges in managing concomitant vaginal prolapse. A staged approach to fistula and prolapse repair is possible with the potential for good outcomes.

Posterior Vaginal Compartment Anatomy: Implications for Surgical Repair.

OBJECTIVES: To examine the gross and histologic anatomy of the proximal, mid, and distal posterior vaginal compartment and discuss implications for surgical repair. STUDY DESIGN: In this cadaver study, pelvic organs were resected en bloc, immersed in formalin solution, and transected in the mid sagittal plane. Measured distances included: posterior vaginal wall length, cervicovaginal junction or vaginal cuff to posterior peritoneal reflection, peritoneal reflection to proximal edge (apex) of perineal body, and perineal body apex to hymenal remnant (height). The posterior vaginal wall was divided into 3 segments along the midsagittal plane and submitted in whole tissue blocks for staining. Histologic analysis included that of 2 young nulliparous women whose tissue was harvested within 12 hours of death. RESULTS: Eleven cadavers were examined. Median (interquartile range [IQR]) posterior vaginal length was 7.6 (2.2) cm. The peritoneum attached to the posterior vaginal wall a median (IQR) of 1.3 cm (0.5 cm) distal to the cervicovaginal junction (n = 8). The rectovaginal space, spanning from the peritoneal reflection to perineal body apex, had a median (IQR) length of 4.7 cm (2.1 cm). Microscopic examination of the mid segment revealed a layer of loose fibroadipose tissue between the vaginal/rectal walls, with no distinct dense fibroconnective tissue layer. The median (IQR) perineal body height was 2.3 cm (1.2 cm). No discrete fibrous capsule was seen surrounding the external anal sphincter muscle. CONCLUSIONS: These findings support evidence showing absence of a rectovaginal fascia. The anal sphincter lacks a fibrous capsule, which is important during closure of third-/fourth-degree obstetric lacerations.

Spanish Language Pelvic Floor Disorders Patient Information Handouts: How Readable Are They?

OBJECTIVE: This study aimed to determine the readability of commonly available patient information materials for pelvic floor disorders written in Spanish and compare their readability based on type of content and source. METHODS: Spanish patient information handouts, including pamphlets from the National Institutes of Health, International Urogynecology Association, American Congress of Obstetricians and Gynecologists, online printable handouts, and industry-sponsored brochures were assessed for readability. Online materials for patients were obtained from Google searches using key words (pelvic floor disorders, urogynecology, patient information handouts, Spanish). Reading difficulty was assessed using INFLESZ v1.0, (Barrio-Cantalejo IM, Spain) a free software developed to calculate the readability of Spanish written texts. Three index scales were used: Flesch-Szigriszt Index, Word correlation Index, and the Fernandez-Huerta Index. RESULTS: Forty patient information handouts were analyzed. All pamphlets analyzed had readability scores within the "average" to "very difficult" reading difficulty levels as per the index scales used. None of the analyzed pamphlets met the sixth grade reading level criteria suggested by the National Institutes of Health and American Medical Association, including government-developed materials. There were no differences in readability scores between type of leaflet content or source. CONCLUSIONS: Current available free, industry-, organization-, and government-provided reading materials in Spanish do not serve the Spanish-speaking only or low English-speaking literacy population. Future work should aim to simplify the language in such documents to the suggested sixth grade reading level.

Thermosensitive hydrogels deliver bioactive protein to the vaginal wall.

The pathophysiology and natural history of pelvic organ prolapse (POP) are poorly understood. Consequently, our approaches to treatment of POP are limited. Alterations in the extracellular matrix components of pelvic support ligaments and vaginal tissue, including collagen and elastin, have been associated with the development of POP in animals and women. Prior studies have shown the protease MMP-9, a key player of ECM degradation, is upregulated in vaginal tissues from both mice and women with POP. On the other hand, fibulin-5, an elastogenic organizer, has been found to inhibit MMP-9 in the vaginal wall. Hence, we hypothesized that prolonged release of fibulin-5 may delay progression of POP. To test the hypothesis, oligo (ethylene glycol)-based thermosensitive hydrogels were fabricated, characterized and then used to deliver fibulin-5 to the vaginal wall and inhibit MMP-9 activity. The results indicate that hydrogels are cell and tissue compatible. The hydrogels also prolong the ½ life of fibulin-5 in cultured vaginal fibroblasts and in the vaginal wall in vivo. Finally, fibulin-5-containing hydrogels resulted in incorporation of fibulin-5 into the vaginal matrix and inhibition of MMP-9 for several weeks after injection. These results support the idea of fibulin-5 releasing hydrogel being developed as a new treatment for POP.

Effects of vaginal conjugated equine estrogens and ospemifene on the rat vaginal wall and lower urinary tract.

Although the positive effects of vaginal estrogens and the selective estrogen receptor modulator, ospemifene (OS), on the vaginal epithelium are well recognized, less is known regarding the effects of these therapies on the lower urinary tract or vaginal muscularis. Clinical evidence suggests that vaginally administered estrogen may improve overactive bladder-related symptoms. The objective of this study was to compare the effects of OS, vaginal conjugated equine estrogens (CEE), or both on the vaginal wall and lower urinary tract in a rat model of menopause. Contractile force of the bladder neck, dome, and external urethral sphincter at optimal field stimulation did not differ significantly among treatment groups. Pharmacologic responses to atropine, carbachol, and potassium chloride were similar among groups. Vaginal epithelial thickness and differentiation were differentially regulated by CEE or OS. Ospemifene altered epithelial differentiation pathways in vaginal epithelium in a unique way, and these effects were additive with local CEE. Unless contraindicated, the beneficial effects of vaginal CEE on the vaginal wall outweigh those of OS.

Knowledge, Perceptions, and Attitudes Toward Pelvic Organ Prolapse and Urinary Incontinence in Spanish-Speaking Latinas.

OBJECTIVES: The aim of the study was to explore individual views and perceptions of Spanish-speaking Latinas living on the US/Mexico border toward pelvic organ prolapse (POP) and urinary incontinence (UI), including awareness of conditions, implications of diagnoses, knowledge, and attitudes toward available treatment options. METHODS: Spanish-speaking Latina women were recruited from clinics at Texas Tech University Health Sciences Center El Paso. Focus group discussions were conducted, addressing topics including female pelvic anatomy, perceived etiology and course of POP and UI, and attitudes toward treatment options. Discussions were transcribed and qualitative analysis performed to identify common themes and concepts. RESULTS: Twenty-four women participated in 5 focus groups as follows: 2 groups of women diagnosed with POP/UI, 2 groups of women with POP/UI symptoms, and 1 group of asymptomatic women. Mean age of participants was 52 years. Participants had a good basic understanding of pelvic organs and function. The following 3 common themes were derived from our analysis: culture, barriers, and misconceptions. Concepts identified from common themes included views of POP/UI as "abnormal" conditions; perceptions that providers may downplay or ignore symptoms of POP/UI; fear of doctor; views of cancer as a common POP complication; embarrassment; views of "massage" therapy as an effective treatment for POP; and willingness to consider all available treatment options for POP and UI, including pessary. CONCLUSIONS: Findings suggest need for patient reassurance about the prevalence and benign course of POP and UI upon initial assessment, with continued reinforcement of basic concepts after diagnosis, and need for increased awareness and information resources for healthcare providers and Spanish-speaking Latina women regarding these common pelvic floor disorders.

Distance From Cervicovaginal Junction to Anterior Peritoneal Reflection Measured During Vaginal Hysterectomy.

OBJECTIVE: To quantify the distance of the dissection plane from the cervicovaginal junction to the anterior peritoneal reflection for vaginal hysterectomy. METHODS: This is a descriptive study examining the dissection plane for anterior colpotomy in 22 surgical patients undergoing vaginal hysterectomy and in nine cadaver specimens. Intraoperatively, the distance from the vaginal incision to the anterior peritoneal reflection was measured on the uterus after removal. In nine of these patients, this distance was also measured before anterior peritoneal incision. Embalmed cadavers with intact pelvic viscera were dissected and the distance of the same dissection plane was measured. RESULTS: Median (interquartile range) surgical patient age was 51.5 (42-63) years and the main surgical indications were abnormal uterine bleeding and pelvic organ prolapse. In these patients, the median (interquartile range) distance from cervicovaginal incision to anterior peritoneal reflection was 3.4 (2.6-3.7) cm. In cadavers, the median (interquartile range) age was 81 (72-86) years with a measured distance of 2.7 (2.4-2.9) cm. CONCLUSION: When performing a vaginal hysterectomy, surgeons can expect a median (range) dissection distance of 3.4 (1.8-4.6) cm from initial incision to the peritoneal reflection for anterior colpotomy.

Pelvic Organ Support in Animals with Partial Loss of Fibulin-5 in the Vaginal Wall.

Compromise of elastic fiber integrity in connective tissues of the pelvic floor is most likely acquired through aging, childbirth-associated injury, and genetic susceptibility. Mouse models of pelvic organ prolapse demonstrate systemic deficiencies in proteins that affect elastogenesis. Prolapse, however, does not occur until several months after birth and is thereby acquired with age or after parturition. To determine the impact of compromised levels of fibulin-5 (Fbln5) during adulthood on pelvic organ support after parturition and elastase-induced injury, tissue-specific conditional knockout (cKO) mice were generated in which doxycycline (dox) treatment results in deletion of Fbln5 in cells that utilize the smooth muscle α actin promoter-driven reverse tetracycline transactivator and tetracycline responsive element-Cre recombinase (i.e., Fbln5f/f/SMA++-rtTA/Cre+, cKO). Fbln5 was decreased significantly in the vagina of cKO mice compared with dox-treated wild type or controls (Fbln5f/f/SMA++-rtTA/Cre-/-). In controls, perineal body length (PBL) and bulge increased significantly after delivery but declined to baseline values within 6-8 weeks. Although overt prolapse did not occur in cKO animals, these transient increases in PBL postpartum were amplified and, unlike controls, parturition-induced increases in PBL (and bulge) did not recover to baseline but remained significantly increased for 12 wks. This lack of recovery from parturition was associated with increased MMP-9 and nondetectable levels of Fbln5 in the postpartum vagina. This predisposition to prolapse was accentuated by injection of elastase into the vaginal wall in which overt prolapse occurred in cKO animals, but rarely in controls. Taken together, our model system in which Fbln5 is conditionally knock-downed in stromal cells of the pelvic floor results in animals that undergo normal elastogenesis during development but lose Fbln5 as adults. The results indicate that vaginal fibulin-5 during development is crucial for baseline pelvic organ support and is also important for protection and recovery from parturition- and elastase-induced prolapse.

Risk factors for ureteral occlusion during transvaginal uterosacral ligament suspension.

INTRODUCTION AND HYPOTHESIS: To determine any risk factors associated with ureteral occlusion during transvaginal uterosacral ligament suspension (USLS). METHODS: A retrospective query to identify patients that underwent transvaginal USLS at a teaching hospital from 2008 to 2013 was performed. Patients in which ureteral occlusion was identified by cystoscopy were identified (cases), and compared with those without occlusion (controls). Medical records were reviewed for data abstraction. Variables compared between cases and controls included demographics, medical history/examination, concomitant procedures, number of suspension sutures placed, estimated blood loss and length of hospital stay. Univariate analyses were performed to identify potential risk factors for ureteral occlusion, followed by multivariate regression analysis to estimate odds ratios for identified predictors. RESULTS: A total of 144 USLS procedures were performed. Thirteen cases of ureteral occlusion were identified (9%). Baseline prolapse stage, body mass index, parity, previous hysterectomy or pelvic surgery of the groups were similar (all P > 0.05). Univariate analysis identified age (P = 0.04), concomitant anterior colporrhaphy (P = 0.01), and use of a suture-capturing device for suture placement (P = 0.04) as significant factors. On multivariate logistic regression analysis, concomitant anterior colporrhaphy increased ureteral occlusion risk (OR 10.5, 95%CI 2.37-74.99, P = 0.001), while use of a suture-capturing device decreased it (OR 0.1, 95%CI 0-0.41, P = 0.01). The mean number of suspension sutures placed per side was similar in the two groups (2.6 [range 2-4] for cases and 2.4 [range 1-4] for controls, P = 0.15). CONCLUSIONS: During transvaginal USLS, performance of a concomitant anterior colporrhaphy increased the risk of ureteral occlusion, while the use of a suture-capturing device for suspension suture placement was associated with decreased risk.

Myogenic stem cell-laden hydrogel scaffold in wound healing of the disrupted external anal sphincter.

OBJECTIVE: To evaluate the effect of myogenic stem cell-laden hydrogel scaffold on contractile function and histomorphology of the external anal sphincter (EAS) after transection without repair. METHODS: Eighty female rats underwent anal sphincter transection without repair. After 2 weeks, animals were injected at the transection site with: nothing (non-repaired control, NRC group); a polyethylene glycol-based hydrogel matrix scaffold combined with phosphate-buffered saline (PBS/hydrogel group); a hydrogel matrix scaffold combined with myogenic stem cells (stem cell/hydrogel group): or type I collagen (collagen) group. 4 (n = 40) or 12 (n = 40) weeks later, the anal sphincter complexes were dissected out and analyzed for contractile function, disruption, and striated muscle volume. Time-matched unoperated controls (UOC) were utilized for each of the two time points (n = 20). RESULTS: After 4 weeks, maximal electrical field-stimulated (EFS) contractions were significantly decreased in all four non-repaired treatment groups compared with UOC. However, EFS-stimulated contractions, tetanic force generation, and twitch tension were improved in non-repaired EAS injected with stem cell/hydrogel group relative to the NRC, PBS/hydrogel, or collagen groups. NRC and sphincters injected with PBS/hydrogel deteriorated further by 12 weeks, while those receiving stem cell/hydrogel maintained improved contractile function at varying frequencies and voltages. Striated muscle volume increased from 4 to 12 weeks for PBS/hydrogel and stem cell/hydrogel animals. At 12 weeks, stem cell/hydrogel animals had greater sphincter striated muscle volumes compared with all other treatment groups. CONCLUSION: In this animal model, sustained improvement of contractile responses in non-repaired EAS treated with biogel scaffold and myogenic stem cells suggests that a biologically compatible matrix may facilitate stem cell survival, differentiation, or function leading to recovery of contractile function even after persistent disruption.

Obturator neuropathy after retropubic tension-free vaginal tape placement.

BACKGROUND: We report a case of obturator neuropathy associated with retropubic midurethral sling. CASE: After retropubic tension-free vaginal tape (TVT) placement, a 36-year-old woman reported right inguinal region and thigh pain, both exacerbated with internal rotation and adduction. Neurologic examination was remarkable for two-fifths strength with right thigh adduction and an involuntary lateral drift of her right thigh with straight leg raise. Radiologic evaluation was unrevealing. With persistence of motor symptoms and pain, partial sling removal on the right was performed. Symptoms subsided postoperatively, and the patient ultimately recovered with no residual neurologic sequelae. CONCLUSION: Recognition of an atypical complication, obturator neuropathy, of retropubic TVT placement with prompt partial right sling removal on postoperative day 2 resulted in complete recovery of neurologic sequelae.

Clitoral Pain Following Retropubic Midurethral Sling Placement.

INTRODUCTION: Although uncommon, postprocedural pain with associated sexual dysfunction may be seen in patients after retropubic midurethral sling placement for treatment of stress urinary incontinence. AIMS: To describe a report of a woman who developed localized severe, persistent periclitoral pain after placement of a retropubic midurethral sling. METHODS: A healthy 41-year-old underwent an uncomplicated retropubic midurethral sling procedure. She developed persistent postoperative clitoral pain with worsening associated with arousal, impairing sexual function. Symptoms resolved with time and a course of steroid medication. MAIN OUTCOME MEASURES: To report a case of clitoral pain following midurethral sling surgery, and to provide a discussion about clitoral innervation, possible pain etiologies, and management options. RESULTS: We report a case of clitoral pain associated with sexual dysfunction and provide a review of clitoral innervation as well as potential mechanisms of nerve injury associated with a retropubic sling procedure. CONCLUSION: Clitoral pain symptoms following placement of a retropubic midurethral sling should be evaluated and promptly addressed, given the potential negative impact on the patient's sexual function. Christofferson M, Barnard J, and Montoya TI. Clitoral pain following retropubic midurethral sling placement. Sex Med 2015;3:346-348.

Effect of vaginal or systemic estrogen on dynamics of collagen assembly in the rat vaginal wall.

The objective of this study was to compare the effects of systemic and local estrogen treatment on collagen assembly and biomechanical properties of the vaginal wall. Ovariectomized nulliparous rats were treated with estradiol or conjugated equine estrogens (CEEs) either systemically, vaginal CEE, or vaginal placebo cream for 4 wk. Low-dose local CEE treatment resulted in increased vaginal epithelial thickness and significant vaginal growth without uterine hyperplasia. Furthermore, vaginal wall distensibility increased without compromise of maximal force at failure. Systemic estradiol resulted in modest increases in collagen type I with no change in collagen type III mRNA. Low-dose vaginal treatment, however, resulted in dramatic increases in both collagen subtypes whereas moderate and high dose local therapies were less effective. Consistent with the mRNA results, low-dose vaginal estrogen resulted in increased total and cross-linked collagen content. The inverse relationship between vaginal dose and collagen expression may be explained in part by progressive downregulation of estrogen receptor-alpha mRNA with increasing estrogen dose. We conclude that, in this menopausal rat model, local estrogen treatment increased total and cross-linked collagen content and markedly stimulated collagen mRNA expression in an inverse dose-effect relationship. High-dose vaginal estrogen resulted in downregulation of estrogen receptor-alpha and loss of estrogen-induced increases in vaginal collagen. These results may have important clinical implications regarding the use of local vaginal estrogen therapy and its role as an adjunctive treatment in women with loss of vaginal support.

Venous thromboembolism in women undergoing pelvic reconstructive surgery with mechanical prophylaxis alone.

INTRODUCTION AND HYPOTHESIS: The objective of this study was determine the frequency of symptomatic perioperative venous thromboembolism (VTE) and risk factor(s) associated with VTE occurrence in women undergoing elective pelvic reconstructive surgery using only intermittent pneumatic compression (IPC) for VTE prophylaxis. METHODS: A multi-center case-cohort retrospective review was conducted at six clinical sites over a 66-month period. All sites utilize IPC as standard VTE prophylaxis for urogynecological surgery. VTE cases occurring during the same hospitalization and up to 6 weeks postoperatively were identified by ICD9 code query. Four controls were temporally matched to each case. Information collected included demographics, medical history, route of surgery, operative time, and intraoperative characteristics. Univariate and multivariate backward stepwise logistic regression analyses were performed to identify potential risk factors for VTE. RESULTS: Symptomatic perioperative VTE was diagnosed in 27 subjects from a cohort of 10,627 women who underwent elective urogynecological surgery (0.25 %). Univariate analysis identified surgical route (laparotomy vs others), type of surgery ("major" vs "minor"), history of gynecological cancer, surgery time, and patient age as risk factors for VTE (P < 0.05). Multivariate analysis identified increased frequency of VTE with laparotomy, age ≥ 70, and surgery duration ≥ 5 h. CONCLUSIONS: In our study cohort, the frequency of symptomatic perioperative VTE was low. Laparotomy, age ≥ 70 years, and surgery duration ≥ 5 h were associated with VTE occurrence.

Estrogen alters remodeling of the vaginal wall after surgical injury in guinea pigs.

Loss of pelvic organ support (i.e., pelvic organ prolapse) is common in menopausal women. Surgical reconstruction of pelvic organ prolapse is plagued with high failure rates. The objective of this study was to determine the effects of estrogen on biomechanical properties, lysyl oxidase (LOX), collagen content, and histomorphology of the vagina with or without surgical injury. Nulliparous ovariectomized guinea pigs were treated systemically with either 50 µg/kg/day estradiol (E2,) or vehicle. After 2 wk, vaginal surgery was performed, and animals were treated with either beta-aminopropionitrile (BAPN, an irreversible LOX inhibitor), or vehicle to determine the role of LOX in recovery of the vaginal wall from injury with or without E2. Estradiol resulted in (i) significant growth, increased smooth muscle, and increased thickness of the vagina, (ii) increased distensibility without compromise of maximal force at failure, and (iii) increased total and cross-linked collagen. In the absence of E2, BAPN resulted in decreased collagen and vaginal wall strength in the area of the injury. In contrast, in E2-treated animals, increased distensibility, maximal forces, and total collagen were maintained despite BAPN. Interestingly, LOX mRNA was induced dramatically (9.5-fold) in the injured vagina with or without E2 at 4 days. By 21 days, however, LOX levels declined to near baseline in E2-deprived animals. LOX mRNA levels remained strikingly elevated (12-fold) at 21 days in the estrogenized vagina. The results suggest that prolonged E2 induced increases in LOX, and collagen cross-links may act to sustain a matrix environment that optimizes long-term surgical wound healing in the vagina.