Factors influencing long-term pessary use.

INTRODUCTION AND HYPOTHESIS: We aimed to identify factors contributing to successful pessary use for over 1 year. METHODS: A chart review was conducted composed of 150 women at Montefiore Medical Center, using a pessary for over 1 year. Characteristics of those who continued pessary usage were compared with those who discontinued use by using Chi-square, Fisher's exact test, logistic regression model, receiver-operator characteristic curve, and Kaplan-Meier survival curves. RESULTS: Thirty-five women (23%) discontinued using pessaries (DP) after a year, while 115 women (77%) continued (CP). There was no difference in multiple characteristics. The DP group had more patients with stress incontinence, p = 0.17. Older age at pessary insertion showed higher continued use (OR = 1.083, CI: 1.033-1.136). Patients with a history of prolapse repair surgery were more likely to discontinue pessary use. CONCLUSIONS: Age greater than 72 years was associated with continued pessary use and history of hysterectomy or prolapse surgery, and stress incontinence were associated with discontinuation.

Effects of menstrual cycle and oral contraceptive use on serum levels of lipid-soluble antioxidants.

OBJECTIVE: The purpose of this study was to examine the influence of menstrual cycle and oral contraceptive use on serum levels of lipid-soluble antioxidants. STUDY DESIGN: In this cross-section study, nonfasting blood samples were collected twice from 10 healthy premenopausal women during the follicular phase (between days 8 and 11) and the luteal phase (between days 18 and 22) of their same menstrual cycle. In addition, blood samples from 15 premenopausal women who used oral contraceptive for at least 6 months and 40 women who did not use oral contraceptive were collected randomly at any day of the menstrual cycle. Serum levels of coenzyme Q10, alpha-tocopherol, gamma-tocopherol, beta-carotene, alpha-carotene, and lycopene were determined using high pressure liquid chromatography. RESULTS: Serum coenzyme Q10 and alpha-tocopherol levels were significantly lower during the follicular phase compared with the luteal phase of the same menstrual cycle (P < .05). Oral contraceptive use also significantly decreased coenzyme Q10 and alpha-tocopherol (P < .001). Other antioxidant levels were comparable. CONCLUSION: Alterations in coenzyme Q10 and alpha-tocopherol levels during the menstrual cycle and in oral contraceptive users should be taken into consideration, concerning the future antioxidant research in premenopausal women. Further studies are needed to investigate the potential role of endogenous and exogenous ovarian hormones on oxidative stress in women.

Incisional bladder hernia and refractory urinary urgency after pelvic surgery: a case report.

BACKGROUND: Isolated incisional herniation of the bladder is very rare following pelvic surgery and may present as suprapubic discomfort. We report a case of incisional bladder hernia following pelvic surgery presenting as refractory urinary urgency. CASE: A 70-year-old woman, para 2, presented with a long history of suprapubic tenderness and refractory urinary urgency following reconstructive pelvic surgery. Over the 3 years following her surgery, multiple physicians evaluated the patient but were unable to find a definitive source of her urgency. She had used multiple anticholinergic agents without relief of the symptoms. A complete urogynecologic evaluation, radiologic imaging and high clinical suspicion for incisional hernia revealed a bladder hernia. Surgical exploration confirmed the fascial defect and bladder hernia. Herniorrhaphy corrected the defect and relieved the patient's symptoms of refractory urgency. CONCLUSION: An incisional bladder hernia may present as refractory urinary urgency following reconstructive pelvic surgery. Strong clinical suspicion can allow earlier diagnosis and surgical treatment of this rare condition. Primary herniorrhaphy offers successful repair of the fascial defect and resolution of the urgency symptoms.

Effects of menopause and hormone replacement therapy on serum levels of coenzyme Q10 and other lipid-soluble antioxidants.

The present study examines the influence of menopause and hormone replacement therapy (HRT) on serum levels of coenzyme Q(10) and other lipid-soluble antioxidants in normal women. Serum levels of coenzyme Q(10), alpha-tocopherol, gamma-tocopherol, beta-carotene and lycopene in 50 premenopausal women (not using oral contraceptives), 33 healthy postmenopausal and 15 postmenopausal women on HRT ("Prempo"; combination of 0.625 mg conjugated estrogen and 2.5 mg medroxyprogesterone acetate) were measured by high-pressure liquid chromatography. Lipid profiles were also analyzed. Significantly higher serum coenzyme Q(10) and alpha-tocopherol levels were detected in postmenopausal compared with premenopausal women (P < 0.05, and < 0.001); whereas, in postmenopausal subjects on HRT, we detected a significant decrease in coenzyme Q(10) and gamma-tocopherol levels (P < 0.001, and < 0.05) and increased alpha-tocopherol levels (P < 0.05). Serum levels of beta-carotene, lycopene, LDL, HDL, cholesterol and triglyceride were comparable among the study groups. Coenzyme Q(10) is postulated to be involved in preventing cardiovascular disease (CVD) because of its bioenergetics role in the mitochondrial respiratory chain and its antioxidant properties at the mitochondrial and extramitochondrial levels. The decrease in serum concentrations of coenzyme Q(10), produced by HRT, may promote oxygen free radical-induced membrane damage and may, thus alter cardiovascular risk in postmenopausal women. HRT-induced reductions in lipid-soluble antioxidant(s) levels, and its potential consequences on CVD, needs to be further investigated.

Impact of hormones on female sexual function and dysfunction.

The female sexual response cycle is a complex system composed of physiologic changes, psychological, and cultural factors. Female sexual dysfunction (FSD) encompasses a variety of sexual problems, including low desire or interest, diminished arousal, difficulties with orgasm, and dyspareunia. Research in female sexual function and dysfunction has lagged significantly behind males despite our current knowledge that FSD can occur in as many of 80% of the female population. Basic science research exists but also identifies serious gaps in our fundamental knowledge of this area. The purpose of this article was to review our current understanding of the effects of hormones on normal physiologic sexual responses in women, female sexual function and dysfunction, and the available treatment options for the various components of FSD.

Effects of oral, vaginal, and transdermal hormonal contraception on serum levels of coenzyme q(10), vitamin e, and total antioxidant activity.

The use of the transdermal contraceptive patch is associated with greater bioavailability of ethinyl estradiol (EE) compared with contraceptive vaginal ring or oral contraceptives (OC). We compared the influences of three contraceptive methods (OC, vaginal ring, and transdermal patch) on serum levels of coenzyme Q(10), alpha-tocopherol, gamma-tocopherol and total antioxidant capacity in premenopausal women. Blood samples from 30 premenopausal women who used hormonal contraception for at least 4 months were collected. Forty subjects who did not use any contraception were studied as control. Serum levels of coenzyme Q(10), alpha-tocopherol and gamma-tocopherol were measured by high-pressure liquid chromatography. Serum samples were also assayed for total antioxidant capacity (TAOC). Serum levels of coenzyme Q(10) and alpha-tocopherol were found to be significantly lower (P < .05) in all three contraceptive users compared with controls. Contraceptive patch users had the lowest levels of coenzyme Q(10) levels compared with normal subjects. Serum TAOC levels were significantly lower (P < .05) among the contraceptive user groups. Alterations in coenzyme Q(10) and alpha-tocopherol induced by hormonal contraception and the potential effect(s) of exogenous ovarian hormones should be taken into consideration in future antioxidant research.

Nerve injury during uterosacral ligament fixation: a cadaver study.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to identify nerve(s) vulnerable to entrapment during uterosacral ligament fixation (USLF), which could cause postoperative lower extremity pain previously described in the literature. METHODS: Preserved cadavers in a medical anatomy course were used. Before the students' pelvic dissections, a 2-0 prolene suture was placed in the middle third of each left uterosacral ligament visualized. The sutures were re-evaluated at the end of the course. RESULTS: Nine sutures remained in place after the course, and one entrapped a nerve. It was part of the inferior hypogastric plexus, included fibers from S2 and S3, and radiated to the bladder and rectum. The posterior femoral cutaneous nerve was lateral and posterior to this nerve. CONCLUSIONS: The inferior hypogastric plexus is vulnerable during USLF. Entrapment of S2 and S3 fibers could cause pain in their respective dermatomes and could be responsible for the postoperative pain previously described.

Gross and microscopic hematuria: guidelines for obstetricians and gynecologists.

Although gross hematuria is a relatively uncommon condition in general obstetrics and gynecology practice, microscopic hematuria is a common incidental finding during routine antepartum or gynecologic office visits. The proper evaluation and treatment options are understudied in females. In fact, work-up of females is controversial, and no consensus guidelines exist at this time. Pregnancy increases the number of potential diagnoses. The majority of published literature on hematuria in pregnancy is in the form of case reports, and esoteric diagnoses are disproportionately represented. The purpose of this review is to summarize existing literature regarding the evaluation, differential diagnosis, and treatment of hematuria in women, with special emphasis on pregnancy and the diagnosis and treatment of microscopic hematuria.

Human immunodeficiency virus (HIV) antigens and RNA in HIV-seronegative women with cervical intraepithelial neoplasia.

While investigating whether proteins retrieved by cervicovaginal lavages (CVL) from women with cervical intraepithelial neoplasia (CIN) might correlate with risk of progression to invasive cervical cancer, we unexpectedly identified HIV gag and env glycoprotein in CVL from women with HIV-negative serology. HIV antigens were consistently identified by mass spectrometry (MS) in CVL from 4 women but were absent in CVL from the remaining 16 women. HIV serologies of all 20 patients were negative for both HIV-1 and HIV-2 antibodies. To validate the unexpected MS findings we performed Western blot (WB) and immunoaffinity chromatography (IC) analysis of CVL for HIV proteins, viral load assays of paired CVL and blood samples, and immunohistochemical HIV p24 expression in cervical biopsy specimens. WB analysis of CVL for prostate-specific antigen (PSA) was performed to exclude semen contamination as the source of HIV proteins. WB and IC results demonstrated the presence of HIV-1 gp41 and p24 antigens in four CVL that were identified by MS to have the HIV proteins. Despite negative serology, HIV RNA in CVL and HIV p24 in cervix biopsies were detected in patients with HIV antigen-positive CVL. HIV p24-positive CVL were PSA negative. All 20 subjects remained HIV seronegative throughout the study. Women with HIV proteins and RNA were comparatively older. Our findings suggest that CVL HIV proteins in women with CIN could be markers for unrecognized HIV exposure or subclinical infection. Proteomic screening of cervical secretions may be useful in identifying seronegative women exposed to HIV and/or at risk for AIDS.

Anatomic variations of the pelvic floor nerves adjacent to the sacrospinous ligament: a female cadaver study.

Our objective was to document variations in the topography of pelvic floor nerves (PFN) and describe a nerve-free zone adjacent to the sacrospinous ligament (SSL). Pelvic floor dissections were performed on 15 female cadavers. The course of the PFN was described in relation to the ischial spine (IS) and the SSL. The pudendal nerve (PN) passed medial to the IS and posterior to the SSL at a mean distance of 0.6 cm (SD = +/-0.4) in 80% of cadavers. In 40% of cadavers, an inferior rectal nerve (IRN) variant pierced the SSL at a distance of 1.9 cm (SD = +/-0.7) medial to the IS. The levator ani nerve (LAN), coursed over the superior surface of the SSL-coccygeus muscle complex at a mean distance of 2.5 cm (SD = +/-0.7) medial to the IS. Anatomic variations were found which challenge the classic description of PFN. A nerve-free zone is situated in the medial third of the SSL.

Innervation of the levator ani muscles: description of the nerve branches to the pubococcygeus, iliococcygeus, and puborectalis muscles.

We described the innervation of the levator ani muscles (LAM) in human female cadavers. Detailed pelvic dissections of the pubococcygeus (PCM), iliococcygeus (ICM), and puborectalis muscles (PRM) were performed on 17 formaldehyde-fixed cadavers. The pudendal nerve and the sacral nerves entering the pelvis were traced thoroughly, and nerve branches innervating the LAM were documented. Histological analysis of nerve branches entering the LAM confirmed myelinated nerve tissue. LAM were innervated by the pudendal nerve branches, perineal nerve, and inferior rectal nerve (IRN) in 15 (88.2%) and 6 (35.3%) cadavers, respectively, and by the direct sacral nerves S3 and/or S4 in 12 cadavers (70.6%). A variant IRN, independent of the pudendal nerve, was found to innervate the LAM in seven (41.2%) cadavers. The PCM and the PRM were both primarily innervated by the pudendal nerve branches in 13 cadavers (76.5%) each. The ICM was primarily innervated by the direct sacral nerves S3 and/or S4 in 11 cadavers (64.7%).

Pessary use in advanced pelvic organ prolapse.

The objective of this study was to review our experience with pessary use for advanced pelvic organ prolapse. Charts of patients treated for Stage III and IV prolapse were reviewed. Comparisons were made between patients who tried or refused pessary use. A successful trial of pessary was defined by continued use; a failed trial was defined by a patient's discontinued use. Thirty-two patients tried a pessary; 45 refused. Patients who refused a pessary were younger, had lesser degree of prolapse, and more often had urinary incontinence. Most patients (62.5%) continued pessary use and avoided surgery. Unsuccessful trial of pessary resorting to surgery included four patients (33%) with unwillingness to maintain, three patients (25%) with inability to retain and two patients (17%) with vaginal erosion and/or discharge. Our findings suggest that pessary use is an acceptable first-line option for treatment of advanced pelvic organ prolapse.

Comparison of preoperative and postoperative pressure transmission ratio and urethral pressure profilometry in patients with successful outcome following the vaginal wall patch sling technique.

AIMS: We studied preoperative and postoperative pressure transmission ratio (PTR) and urethral pressure profilometry in patients undergoing the vaginal wall patch sling technique as a first surgical approach for genuine stress incontinence (GSI) with urethral hypermobility. The specific aims were to determine the exact urodynamic parameters, if any, that may be improved postoperatively and to report the urodynamic outcome of the vaginal wall patch sling technique in successful cases. METHODS: Preoperatively, all patients had a positive standing stress test, urethral hypermobility on Q-tip testing, and normal postvoid residual volume. On urodynamics, all patients had equalization of maximum urethral closure pressure (MUCP) on cough profilometry, and absence of detrusor contractions on subtracted cystometry. The PTR for each cough was calculated. Cough spikes were assigned locations in the first, second, third, or fourth quartile of the functional urethral length (FUL). Urethral pressure profilometry was performed at bladder capacity in the sitting position. All urodynamic tests were repeated 3-6 months postoperatively. A two-tailed t-test was used for statistical analysis. RESULTS: Forty-eight patients demonstrated successful outcome at initial follow up and constituted the study population. There was a statistically significant increase in MUCP at stress as well as a statistical increase in PTR in the first, second, and third quartiles of the FUL postoperatively. CONCLUSIONS: The vaginal patch sling technique appears to restore continence both by buttressing the urethra at times of stress as well as repositioning the proximal urethra into the intra-abdominal pressure zone, thus, enhancing pressure transmission to the proximal urethra.

Inflammatory reaction following bovine pericardium graft augmentation for posterior vaginal wall defect repair.

Graft augmentation for repair of recurrent pelvic organ prolapse is commonly used in reconstructive pelvic surgery. The reported complications are mainly late onset. We report a case of early-onset inflammatory reaction following bovine pericardium graft augmentation for posterior vaginal wall defect repair. A 49-year-old presented with a recurrent and symptomatic posterior vaginal wall defect. She underwent an uneventful site-specific repair and bovine graft augmentation. Her early postoperative course was complicated by inflammatory response to the graft presenting as intense pelvic floor spasm and urinary retention. The condition was managed conservatively and resolved subsequently. One year later, the patient continues to be asymptomatic. Transient intense pelvic floor spasm and urinary retention can be the result of inflammatory reaction following graft augmentation with bovine pericardium for posterior vaginal wall defect repair.

The effects of hormone replacement on the biomechanical properties of the uterosacral and round ligaments in the monkey model.

OBJECTIVE: The purpose of this study was to determine effects of ovariectomy (OVX) and conjugated equine estrogens plus medroxyprogesterone acetate (CEE/MPA), or ethinyl estradiol plus norethindrone acetate (EE/NA) on biomechanics of uterosacral (USL) and round (RL) ligaments in postmenopausal (PMP) monkeys. STUDY DESIGN: This was a randomized, triple blind, placebo-controlled study. OVX monkeys received 12 months no treatment (Pbo) (n = 19), CEE/MPA (n = 19), or EE/NA (n = 21). USL and RL step strains and stress-relaxation data were curve-fitted, giving strain-dependent tensile modulus (TM) from 0% to 30%. RESULTS: (1) USL: TM for both treatment groups was greater than Pbo for strains from 0% to 12% (P < .04). (2) RL: TM for both treatment groups was smaller than Pbo for strains from 12% to 30% (P < .05). No differences were found between treatment regimens. CONCLUSION: CEE/MPA and EE/NA both affect functional biomechanical properties by increasing tensile stiffness in the USL and decreasing it in the RL.

Plasma uric acid levels in women with cervical intraepithelial neoplasia.

The objective of this study was to determine the association of plasma levels of uric acid, an endogenous antioxidant, in women with cervical intraepithelial neoplasia (CIN), while controlling for the confounding effects of human papillomavirus (HPV) infection, age, smoking, and use of oral contraception. Plasma-reduced and oxidized uric acid levels were determined in 650 women by high-performance liquid chromatography, employing electrochemical technique. The findings demonstrated that 1) plasma-reduced uric acid (PRUA) levels in women with CIN (n = 311) were significantly lower (P < 0.05) compared with women in a control group (n = 339); 2) according to multiple logistic regression analysis, PRUA levels were negatively (P = 0.0113) and HPV infection were positively associated (P < 0.0001) with CIN, after controlling for the confounding effects of the studied factors; 3) according to multiple regression analysis, there was a 31% decrease in CIN risk for each incremental increase of 1mg/dl of PRUA; and 4) according to polychotomous logistic regression analysis, independent of HPV infection, PRUA level was inversely associated with the histopathological graded severity of CIN. We have previously reported decreased plasma levels of exogenous antioxidants, for example, vitamins C and E, in women with CIN independent of HPV infection. The data suggest that plasma deficiencies of several antioxidants in HPV-infected uterine cervical tissue may create an oxidative environment that renders the tissue susceptible to free radical damage. It may be speculated that chronic free radical-induced tissue damage in the context of persistent HPV infection may be involved in the pathogenesis of CIN.

Lipid-soluble antioxidants and pregnancy: maternal serum levels of coenzyme Q10, alpha-tocopherol and gamma-tocopherol in preeclampsia and normal pregnancy.

It has been hypothesized that in preeclampsia, the antioxidant-deficient state may facilitate increased attacks of free radicals, which may result in endothelial cell damage. The purpose of this study was to investigate the association of three lipid-soluble antioxidants, coenzyme Q10, alpha-tocopherol and gamma-tocopherol, with preeclampsia and normal pregnancy. Serum levels of all three antioxidants in 42 women with normal pregnancies, 25 with mild preeclampsia and 28 with severe preeclampsia were measured by high-pressure liquid chromatography. A significant decrease was observed in serum levels of coenzyme Q10 and alpha-tocopherol (p < 0.001 for each by the Kruskal-Wallis rank test) in women with preeclampsia compared to levels in normal pregnancy. gamma-Tocopherol levels were comparable among the different groups. Logistic regression analysis revealed significant association between grades of preeclampsia and both serum coenzyme Q10 and alpha-tocopherol levels (p = 0.000 and 0.030, respectively). Coenzyme Q10 and alpha-tocopherol are potent antioxidants, and the decreased levels of these two antioxidants in preeclampsia may alter the normal redox balance, thereby reducing the ability of antioxidant defenses to protect against free radical damage. This could be a factor in the endothelial cell damage observed in preeclampsia.

Alpha-tocopherol and alpha-tocopheryl quinone levels in cervical intraepithelial neoplasia and cervical cancer.

OBJECTIVE: alpha-Tocopherol is a potent antioxidant that protects cell membranes against oxidative damage. Red blood cell alpha-tocopherol levels reflect membrane alpha-tocopherol concentrations, and altered levels may suggest membrane damage. The objective of this study was to determine the levels of alpha-tocopherol and alpha-tocopheryl quinone, the oxidized product of alpha-tocopherol, in plasma and red blood cells that were obtained from control subjects and patients with cervical intraepithelial neoplasia and cervical cancer. STUDY DESIGN: In this cross-sectional study, 72 women, (32 African American and 40 Hispanic) were recruited. Among these subjects, 37 women had cervical intraepithelial neoplasia; 14 women had cervical cancer, and 21 women were considered control subjects, who had normal Papanicolaou test results. alpha-Tocopherol and alpha-tocopheryl quinone levels were determined in red blood cell and plasma by high-pressure liquid chromatography. RESULTS: Plasma levels of alpha-tocopherol and alpha-tocopheryl quinone were decreased significantly (P=.012 and=.005, respectively, by Kruskal-Wallis test) in study groups compared with the control group; red blood cell levels of alpha-tocopherol and alpha-tocopheryl quinone were not altered significantly. CONCLUSION: The lower alpha-tocopherol level that was observed in this study is consistent with our previous reports of decreased antioxidant concentrations and increased oxidative stress in women with cervical intraepithelial neoplasia. Unaltered red blood cell alpha-tocopherol and alpha-tocopheryl quinone levels suggest undamaged cell membrane. Further studies are needed to investigate the potential role of oxidative stress in cervical intraepithelial neoplasia.

Pessary reduction and postoperative cure of retention in women with anterior vaginal wall prolapse.

This study aimed to determine whether preoperative pessary reduction of anterior vaginal wall prolapse in patients with elevated postvoid residual (PVR) volumes relieves urinary retention, and if reconstructive pelvic surgery in these patients cures urinary retention. The records of all women with symptomatic anterior vaginal wall and urinary retention (PVR >or=100 cc) who underwent evaluation and surgical repair of the anterior vaginal wall at our institution between 1996 and 1999 were retrospectively reviewed. All patients underwent a detailed urogynecologic and urodynamic evaluation and had a pessary trial prior to surgery. Cure of urinary retention was defined as PVR <100 cc at 3 months postoperatively. Sensitivity, specificity, positive and negative predictive values for pessary reduction testing were calculated. Twenty-four patients met the inclusion criteria. Two patients (8%) had stage 2, eleven (46%) stage 3, and eleven (46%) stage 4 anterior vaginal wall prolapse. Preoperatively, the use of pessary was associated with relief of urinary retention in 75% patients. In predicting postoperative cure of urinary retention, pessary testing had a sensitivity of 89%, specificity of 80%, positive predictive value of 94%, and negative predictive value of 67%. Nineteen of 24 patients had a PVR <100 cc postoperatively, indicating a 79% cure rate for urinary retention. In women with symptomatic anterior vaginal wall prolapse and urinary retention, use of a pessary is associated with relief of retention in the majority of patients. Furthermore, pessary reduction testing has good sensitivity, specificity, and positive predictive value for postoperative voiding function.

A modified vaginal wall patch sling technique as a first-line surgical approach for genuine stress incontinence with urethral hypermobility: long-term follow up.

We describe our long-term outcome for patients with genuine stress incontinence (GSI) and urethral hypermobility using a modified vaginal wall patch sling technique. Fifty-three patients were studied. Preoperatively, all patients had a positive standing stress test and urethral hypermobility on Q-tip testing. On urodynamics, all patients had absence of detrusor contractions on subtracted cystometry. The mean age of the patients was 45+10.2 years. Forty-four patients demonstrated complete symptomatic and urodynamic improvement. Five patients had a noticeable failure observed within the first 12 months of follow up and four patients developed later recurrence despite initial success. The overall success rate after 5 years of follow up was 83% (n=44/53). The modified vaginal wall patch sling technique appears to have a good long-term success rate with low operative morbidity and minimal postoperative voiding dysfunction. The patch sling can be used as a first-line surgical approach for GSI with urethral hypermobility and be combined with other vaginal surgery.