Quantification of pelvic organ prolapse in mice: vaginal protease activity precedes increased MOPQ scores in fibulin 5 knockout mice

Two mouse models of pelvic organ prolapse have been generated recently, both of which have null mutations in genes involved in elastic fiber synthesis and assembly (fibulin 5 and lysyl oxidase-like 1). Interestingly, although these mice exhibit elastinopathies early in life, pelvic organ prolapse does not develop until later in life. In this investigation we developed and validated a tool to quantify the severity of pelvic organ prolapse in mice, and we used this tool prospectively to study the role of fibulin 5, aging, and vaginal proteases in the development of pelvic organ prolapse. The results indicate that >90% of Fbln5(-/-) mice develop prolapse by 6 mo of age, even in the absence of vaginal delivery, and that increased vaginal protease activity precedes the development of prolapse.

Regulation of elastolytic proteases in the mouse vagina during pregnancy, parturition, and puerperium

Recent evidence indicates that failure of elastic fiber assembly and synthesis is involved in the pathophysiology of pelvic organ prolapse in mice. It has been long been hypothesized that parturition-induced activation of proteases in the vaginal wall and its supportive tissues may contribute to pelvic organ prolapse in women. In this investigation, we determined the expression of matrix metalloproteases with elastase activity (matrix metalloproteinase [MMP] 2, MMP9, and MMP12) and their inhibitors in the vaginal wall of nonpregnant, pregnant, and postpartum mice. Data obtained using mRNA levels and enzyme activity measurements indicate that MMP2, MMP9, and 21- to 24-kDa caseinolytic serine proteases are regulated in vaginal tissues from pregnant and postpartum mice. Although suppressed during pregnancy and the early postpartum time period, MMP2 and MMP9 enzyme activities are increased after 48 h, a time when mRNA levels of protease inhibitors (tissue inhibitor of MMP2 [Timp2], cystatin C [Cst3], and alpha-1 antitrypsin [Serpina1]) are decreased. We conclude that recovery of the vaginal wall from pregnancy and parturition requires increased elastic fiber assembly and synthesis to counteract the marked increase in elastolytic activity of the postpartum vagina.

Pelvic organ prolapse in fibulin-5 knockout mice: pregnancy-induced changes in elastic fiber homeostasis in mouse vagina

Pelvic organ prolapse is strongly associated with a history of vaginal delivery. The mechanisms by which pregnancy and parturition lead to failure of pelvic organ support, however, are not known. Recently, it was reported that mice with null mutations in lysyl oxidase-like 1 (LOXL1) develop pelvic organ prolapse. Elastin is a substrate for lysyl oxidase (LOX) and LOXL1, and LOXL1 interacts with fibulin-5 (FBLN5). Therefore, to clarify the potential role of elastic fiber assembly in the pathogenesis of pelvic organ prolapse, pelvic organ support was characterized in Fbln5-/- mice, and changes in elastic fiber homeostasis in the mouse vagina during pregnancy and parturition were determined. Pelvic organ prolapse in Fbln5-/- mice was remarkably similar to that in primates. The temporal relationship between LOX mRNA and protein, processing of LOXL1 protein, FBLN5 and tropoelastin protein, and desmosine content in the vagina suggest that a burst of elastic fiber assembly and cross linking occurs in the vaginal wall postpartum. Together with the phenotype of Fbln5-/- mice, the results suggest that synthesis and assembly of elastic fibers are crucial for recovery of pelvic organ support after vaginal delivery and that disordered elastic fiber homeostasis is a primary event in the pathogenesis of pelvic organ prolapse in mice.

Vascular anatomy over the superior pubic rami in female cadavers

OBJECTIVE

The objective of the study was to characterize the vascular anatomy over the superior pubic ramus.

STUDY DESIGN

Detailed dissections of the retropubic space were performed in 15 fresh female cadavers. Vessels crossing the superior pubic rami were inspected for width, course, communications, and relationship to the midline of the pubic symphysis and the obturator canal.

RESULTS

Vessels 1 mm or greater in width connecting the obturator vessels and inferior epigastric or external iliac vessels were noted in 10 of 15 (66.7%) cadavers: 9 (60%) had veins, 5 (33.3 %) had arteries, and 4 (26.7%) had both. In all specimens, the vessels crossed over the superior pubic rami lateral to or at the level of the obturator canal, which was on average 5.4 cm from the midline of the pubic symphysis.

CONCLUSION

Communicating vessels crossing the superior pubic rami were present in the majority of specimens. Understanding this anatomy should aid the surgeon in avoiding vascular complications.

Actinomyces associated with persistent vaginal granulation tissue

BACKGROUND: We report a case of symptomatic actinomycosis associated with vaginal suture erosion and granulation tissue refractory to conservative management, in an outpatient setting. CASE: Three months after total vaginal hysterectomy and uterosacral ligament vaginal vault suspension, a woman complained of painless, intermittent vaginal discharge and spotting. Despite cauterization of granulation tissue, vaginal spotting persisted for another month. On re-examination, braided polyester suture that was found underlying the granulation tissue was removed. Recurrent symptoms, together with a biopsy revealing actinomycetes, prompted a trial of oral penicillin VK. With persistent symptoms and discomfort during attempts in the outpatient clinic, the woman eventually required suture removal in the operating room. Her symptoms subsequently resolved without recurrence, and no further antibiotic treatment was required. CONCLUSIONS: Actinomyces may be associated with persistent granulation tissue and vault suspension suture material. In rare circumstances, when tissue debridement and suture removal in the clinic is unsatisfactory, surgical intervention in the operating room may be necessary. Ten days of antibiotic therapy alone did not eradicate the granulation tissue, and symptoms resolved only after complete removal of the underlying permanent suture.