The optimal cutoff value for levator-urethra gap measurements using tomographic ultrasound imaging in avulsion diagnosis is population specific.

AIMS: The levator-urethra gap (LUG), the distance between the urethral lumen center and levator insertion on the inferior pubic rami, can be used for diagnosing levator avulsion, with a previously suggested cutoff of LUG ≥2.5 cm. The aim of this study is to determine an optimal cutoff value for LUG measurements in a high-risk patient population. METHODS: Women followed prospectively after sustaining obstetric anal sphincter injury underwent an interview pelvic examination questionnaires and four-dimensional-transperineal ultrasound examination. Levator avulsion was diagnosed on contraction using tomographic ultrasound imaging. Ultrasound datasets were analyzed offline at a later time blinded to previous data. LUG was measured on each side of the three central slices, yielding six measurements and the highest available value was obtained on each side. Different cutoffs were evaluated using receiver-operating characteristics (ROC) curve analysis and Youden's test. The cutoff was validated against symptoms and signs, and sonographic findings using logistic regression analysis. RESULTS: A total of 618 complete datasets were available for analysis, median age 29 years, median body mass index of 23.4 kg/m2 , parity 1, and 26.4% instrumental deliveries. Youden's test and ROC curve analysis gave the best area under the curve of 0.869 for a cutoff of 2.305 (95% confidence interval, 0.839-0.9). Women diagnosed with avulsion based on this cutoff were more symptomatic, whereas using larger cutoffs missed more avulsion defects. CONCLUSION: LUG measurement is useful but should be individualized to the population studied, in our case, in a high-risk population, 2.305 cm was the optimal cutoff. Using larger cutoffs may be more specific but is likely to miss more cases.

[Female urethral diverticula--clinical and surgical aspects].

Urethral diverticula are a common cause of chronic genitourinary symptoms in women. They occur in 5% of women overall, with higher frequencies in selected populations of symptomatic women. The classical presentation is with recurrent urinary tract infections and post-micturition dribbling but almost any urinary symptom may be a presenting feature. Newer imaging modalities such as magnetic resonance imaging and perineal ultrasound are now widely available and urethral diverticula, that were previously unrecognized, can now be more easily detected. However, despite the availability of effective diagnostic techniques, diagnosis is often delayed. This is due to a lack of awareness among clinicians. These patients are often inappropriately treated for other conditions, significantly delaying the proper management of their condition. A high index of suspicion, a careful examination and referral for appropriate investigation will improve the number correctly diagnosed and lead to considerable benefit since most symptomatic cases can be cured by appropriate surgery. This review aims to summarize the presentation, investigation and management of female urethral diverticulum. Hopefully, greater awareness will lead to more timely diagnosis and appropriate treatment.

Transvaginal pelvic organ prolapse repair of anterior enterocele following cystectomy in females.

This study aims to highlight pelvic organ prolapse (POP) in females following radical cystectomy and to describe our experiences with their management. This is a retrospective case series of five women who had symptomatic POP following radical cystectomy and ileal conduit urinary diversion. All patients presented with a midline anterior enterocele with atrophic ulcerated vaginal skin. One patient presented with small bowel evisceration and required an emergency surgical repair. The average time for presentation was 10.6 +/- 6.5 months after cystectomy. In all cases, repair was done via a transvaginal approach. Three patients underwent fascial repair, one colpocleisis, and one bilateral iliococcygeal repair. In three cases, we had to use mesh for reinforcement. Two patients underwent ancillary procedures because of POP recurrence. Surgical repair of POP in women following radical cystectomy is challenging especially if vaginal length is to be maintained. Transvaginal repair is feasible and using synthetic mesh may be necessary.

Pelvis architecture and urinary incontinence in women.

OBJECTIVES: To examine anatomic features in the pelvic bones and muscles in women with urinary incontinence (UI). MATERIAL AND METHODS: Between October 2005 and January 2006, 212 consecutive women underwent pelvic computerized tomography in our center. Preceding the examination, all women completed a clinical and demographic questionnaire including detailed questions about UI. Several anatomic parameters using multiplanar reformation and three-dimensional techniques (volume rendering) were examined. We specifically evaluated different bony parameters, pelvic floor muscle angles, densities, and cross-sectional areas. Ninety-three women (46.5%) had UI; the remaining women served as the control group. A logistic regression model was used to evaluate risk factors for UI. RESULTS: The mean age was 55.5 yr (range: 19-90). Women who suffered from UI were older (60.97 vs. 50.77 yr, p<0.0001), had higher body mass index (27.65 vs. 25.49, p<0.01), had more previous hysterectomies (21.5% vs. 6.5%, p<0.005), underwent more pelvic irradiation (9.7% vs. 1.8%, p<0.05), and had more diabetes mellitus (31.2% vs. 13.1%, p<0.005). Patient's age and previous hysterectomy were found to be the major clinical risk factors for UI (OR: 1.029, p=0.002; OR: 2.94, p=0.024, respectively). Logistic regression analysis on all clinical and morphologic variables yielded the following risk factors: pelvic-inlet diameter (OR: 1.216, p<0.0001), pelvic-inlet anterior-posterior diameter (OR: 1.109, p=0.003), pelvic-outlet diameter (OR: 1.077, p=0.011) and transverse perineal muscle cross-section diameter (OR: 0.773, p<0.0001). CONCLUSIONS: Pelvic inlet and outlet dimensions are major risk factors for developing UI in women. These findings may lead to a better comprehension of the pathophysiology of UI in women.