The Application of Shear Wave Elastography to Determine the Elasticity of the Levator Ani Muscle and Vaginal Tissue in Patients With Pelvic Organ Prolapse

OBJECTIVES

The changes of the extracellular matrix of the connective tissue have significantly contributed to the incidence of pelvic organ prolapse (POP). It seems reasonable that sonoelastography could be a useful tool to evaluate the elasticity of pelvic floor tissue in patients with POP and compare it to those without POP. The main aim of this pilot study was to determine if there are differences in the elasticity of the levator ani muscle (LAM) and vaginal tissue between patients with and without POP.

METHODS

Prospective observation study, including 60 patients (30 with POP and 30 without POP). Sonoelastography was performed to evaluate the elasticity (in kilopascals, kPa) of the following regions of interest: vagina at the level of middle third of the urethra; vagina at the level of the bladder trigone; vagina in the anterior and posterior fornix; vagina at the level of middle third of the anorectal canal; posterior third of the LAM.

RESULTS

A total of 60 patients completed the study (30 with POP, 30 without POP). In the POP group, 18/30 (60%) had an anterior vaginal wall prolapse, 3/30 (10%) a uterine prolapse, 15/30 (50%) a rectocele, and 6/30 (20%) a enterocele. Patients with POP had higher elasticity in all anatomical study areas, with statistically significant differences in the anterior fornix (13.6 vs 11.2 kPa; P: .012). A multiple regression (controlling age, menopausal stage, and parity) allowed to detect statistically significant differences in the elasticity of the middle third of the urethra (P: .03) and the middle third of the anorectal canal (P: .019).

CONCLUSION

It is possible to evaluate the elasticity of the LAM and vaginal tissue using sonoelastography, detecting a higher elasticity in patients with POP than in those without POP.

Key drivers of hysterectomy among women of reproductive age in three states in India: comparative evidence from NFHS-4 and NFHS-5

PURPOSE

According to the 4th and 5th rounds of National Family Health Survey (NFHS), there is high prevalence of hysterectomies in the three states of Andhra Pradesh Telangana and Bihar. The three said states have more than double the number of hysterectomies taking place than the national average. Our purpose is to analyse whether these rates are increasing, decreasing or have stabilized and their reasons thereof. Such an analyses will help the policy makers in recommending good clinical practices within their states.

MATERIAL AND METHODS

We used data from NFHS-4 (2015-16) and NFHS-5 (2019-2021) rounds. We calculated the differences in predicted probabilities for various factors, performed a Fairlie Decomposition analyses to quantify the positive and negative contributors in the prevalence of hysterectomy across the three states over two time points, and assessed the association of various socio-demographic characteristics to hysterectomy through a multilevel logistic regression model.

RESULTS AND CONCLUSION

The results show that out of a total of 80,976 eligible respondents from the states under study, 5826 respondents self-reported that they had a hysterectomy done. It was found that older age, living in rural areas, belonging to other backward classes and higher wealth quintile, and higher parity positively contributed to the increased prevalence of hysterectomies in the three states. Higher educational attainment and previous use of family planning methods acted as protective factors. Characteristics at the household level had the highest intra-class correlation value in the prevalence of hysterectomy among women, followed by the Primary Sampling Unit and District levels, indicating high clustering in the prevalence of hysterectomy at the household level in all three states. Heavy menstrual bleeding/pain was the leading cause of hysterectomies in all three states, followed by fibroids/cysts in Andhra Pradesh and Telangana and Uterine disorder/ prolapse in Bihar. Over 80% of hysterectomies took place in the private hospitals.

RECOMMENDATIONS

The study recommends better, more efficient and accountable hysterectomy surveillance to ensure more sustainable woman's reproductive health services in India. Government should adopt and implement standard regulatory guidelines to prevent provider-driven avoidable hysterectomies. Moreover, we recommend informing primary care professionals about the long-term health effects of hysterectomy and promoting alternate therapies for treating uterine fibroids and heavy bleeding.

Is the Presence of Levator Ani Muscle Avulsion Relevant for the Diagnosis of Uterine Prolapse?

OBJECTIVE

To determine if the addition of the assessment of levator ani muscle (LAM) avulsion to the measurement of the difference in the pubis-uterine fundus distance between rest and with the Valsalva maneuver could increase the diagnostic capacity of ultrasound for uterine prolapse (UP).

METHODS

This multicenter, observational and prospective study included 145 patients. Ultrasound assessment was performed, establishing the diagnosis of UP as a difference between the pubic-uterine fundus distance at rest and during the Valsalva maneuver ≥15 mm (standard technique), while LAM avulsion was defined as an abnormal LAM insertion in three central slices using multislice ultrasound. A binary multivariate logistic regression model was made using nonautomated methods to predict surgical UP (general population, premenopausal, and postmenopausal patients), including the difference between the pubis-uterine fundus distance at rest and with the Valsalva maneuver as well as LAM avulsion.

RESULTS

A total of 143 patients completed the study. The addition of LAM avulsion criteria to the standard dynamic distance-based protocol for the diagnosis of UP resulted in a higher sensitivity for the general population (79.7 vs 68.1%) as well as for premenopausal (89.3 vs 79.9%) and postmenopausal patients (76 vs 66.1%). In contrast, the standard technique showed a higher specificity than the model based on the standard technique associated with LAM avulsion for the general population (89.2 vs 74.3%) and premenopausal women (91.7 vs 63.2%). For postmenopausal patients, the model based on the standard technique associated with LAM avulsion had a higher sensitivity (76 vs 66.1%) and specificity (91.7 vs 86.8%) than the ultrasound diagnosis of UP.

CONCLUSION

The implementation of the assessment of LAM avulsion in the ultrasound diagnosis of UP is useful in postmenopausal patients, increasing sensitivity and specificity relative to the ultrasound assessment based only on the difference between the pubis-uterine fundus distance at rest and with the Valsalva maneuver.

Pathologic copulatory lock in a genetically engineered laboratory mouse breeding pair

A breeding pair of genetically engineered laboratory mice (Mus musculus) presented in apparent copulatory lock (coital tie). After anesthetizing the animals, gentle traction was used to separate the pair at which point a vaginal prolapse was detected and the penis was covered with black, firm, dry crusts and noted to have a solid pale, tan, firm cylindrical mass adhering to its glans. The vaginal prolapse was reduced and the female was returned to its cage. The male mouse had a severely distended bladder which could not be expressed and was euthanized. Histopathologic examination of the distal two-thirds of the penis revealed diffuse, acute coagulative necrosis. The mass adhered to the distal penis was a homogenous granular eosinophilic material consistent with a copulatory plug. While copulatory plugs and locks have been described in some rodent species, they have not been reported in laboratory mice. While the cause of the adherence of the plug to the penis could not be determined, we hypothesize that its adherence to both the penis and the vagina led to the lock and subsequently to ischemic necrosis of the distal penis.

Evaluation of sexual function and vaginal prolapse after radical cystectomy in women: a study to explore an under-evaluated problem

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate sexual function, vaginal prolapse, and quality of life (QoL) in women after radical cystectomy (RC) using validated questionnaires and pelvic organ prolapse quantification (POP-Q) measurement.

METHODS

Female bladder cancer patients who underwent RC at our tertiary care center were included (January 2008 to March 2022). Patients received three validated questionnaires (International Consultation on Incontinence Questionnaire Vaginal Symptoms [ICIQ-VS] Part A, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire IUGA revised [PISQ], European Organization for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC] C30/BLM30). Patients who consented were examined with vaginal POP-Q measurement.

RESULTS

Out of 322 patients, 193 were still alive, 54 patients were lost to follow-up, and 43 were excluded, resulting in 96 patients who received the questionnaire. Finally, 35 patients were included, of whom 17 patients consented to vaginal examination. Complaints due to vaginal symptoms were low (ICIQ-VS 6.17 + 5.37). Sexual activity was reported by 12 patients (34.3%); 23 patients (65.71%) were not sexually active. No apical prolapse was found in POP-Q measurement; 6 patients (35.3%) had anterior, and 14 patients (82.4%) posterior prolapse; the highest prolapse stage was 2. No significant differences were found regarding POP stages, sexual function, and QoL (all p > 0.05) when comparing continent and incontinent urinary diversions. Comparing the vaginal approach (no sparing vs sparing), significant differences were found in only two PISQ subscales (significantly higher scores after vagina sparing, p = 0.01 and p = 0.02).

CONCLUSIONS

The type of urinary diversion, POP-Q stages, and tumor stages did not show significant differences regarding sexual function, QoL, and prolapse complaints in women after RC, whereas a vagina- sparing approach showed significant differences only in two subscales without clinical relevance.

Missing data imputation, prediction, and feature selection in diagnosis of vaginal prolapse

BACKGROUND

Data loss often occurs in the collection of clinical data. Directly discarding the incomplete sample may lead to low accuracy of medical diagnosis. A suitable data imputation method can help researchers make better use of valuable medical data.

METHODS

In this paper, five popular imputation methods including mean imputation, expectation-maximization (EM) imputation, K-nearest neighbors (KNN) imputation, denoising autoencoders (DAE) and generative adversarial imputation nets (GAIN) are employed on an incomplete clinical data with 28,274 cases for vaginal prolapse prediction. A comprehensive comparison study for the performance of these methods has been conducted through certain classification criteria. It is shown that the prediction accuracy can be greatly improved by using the imputed data, especially by GAIN. To find out the important risk factors to this disease among a large number of candidate features, three variable selection methods: the least absolute shrinkage and selection operator (LASSO), the smoothly clipped absolute deviation (SCAD) and the broken adaptive ridge (BAR) are implemented in logistic regression for feature selection on the imputed datasets. In pursuit of our primary objective, which is accurate diagnosis, we employed diagnostic accuracy (classification accuracy) as a pivotal metric to assess both imputation and feature selection techniques. This assessment encompassed seven classifiers (logistic regression (LR) classifier, random forest (RF) classifier, support machine classifier (SVC), extreme gradient boosting (XGBoost) , LASSO classifier, SCAD classifier and Elastic Net classifier)enhancing the comprehensiveness of our evaluation.

RESULTS

The proposed framework imputation-variable selection-prediction is quite suitable to the collected vaginal prolapse datasets. It is observed that the original dataset is well imputed by GAIN first, and then 9 most significant features were selected using BAR from the original 67 features in GAIN imputed dataset, with only negligible loss in model prediction. BAR is superior to the other two variable selection methods in our tests.

CONCLUDES

Overall, combining the imputation, classification and variable selection, we achieve good interpretability while maintaining high accuracy in computer-aided medical diagnosis.

Identification of Surgical Uterine Prolapse in Premenopausal Patients With Clinical or Ultrasound Criteria? A Multicenter Comparative Study

OBJECTIVES

It is unknown whether diagnosing uterine prolapse (UP) via ultrasound or surgical criteria is superior. Our objective is to determine whether the diagnostic capacity of ultrasound with surgical criteria differs from that of surgical criteria only.

METHODS

This was a multicenter prospective observational study with 54 premenopausal patients with surgical criteria for a dysfunctional pelvic floor pathology who were consecutively recruited for 1 year. Clinical UP with surgical criteria was defined when UP stage II-IV was identified (during pelvic floor consultation), and UP diagnosed by ultrasound with surgical criteria was established when a difference ≥15 mm was found between rest and Valsalva applied to the pubis-uterine fundus. The sensitivity, specificity and positive and negative predictive values were determined to evaluate clinical and ultrasound methodologies as diagnostic tests.

RESULTS

UP diagnosed by ultrasound with surgical criteria presented better sensitivity (78.57 vs 35.71%), specificity (92.11 vs 81.58%), positive predictive value (61.83 vs 23.99%), and negative predictive value (96.35 vs 11.37%) than UP diagnosed by surgical criteria only.

CONCLUSION

Ultrasound with surgical criteria is superior to surgical criteria alone when diagnosing UP.

Effect of Vitamin D analog supplementation on levator ani strength and plasma Vitamin D receptor expression in uterine prolapse patients

Uterine prolapse is a pathological condition that can negatively impact women's quality of life. It is caused by weakening of the pelvic floor muscles. Function of levator ani muscle and other striated muscles is thought to be influenced by Vitamin D levels. Vitamin D exerts its biological effects by adhering to Vitamin D receptors (VDRs) present in striated muscles. We aim to analyze the effect of Vitamin D analog supplementation on levator ani muscle strength in uterine prolapse patients. This was a quasi-experimental study with a pre-post design on 24 postmenopausal women diagnosed with grade III and IV uterine prolapse. Vitamin D levels, VDR, levator ani muscle, and hand grip muscle strength were measured before and after three months of Vitamin D analog supplementation. We found that Vitamin D level, VDR serum level, levator ani muscle strength, and hand grip muscle strength all significantly increase (p < 0.001) following Vitamin D analog supplementation. The correlation coefficient between levator ani muscle and handgrip muscle strength was 0.616 and with p value of 0.001. To conclude, Vitamin D analog supplementation can significantly increase levator ani muscle strength in uterine prolapse patients. We propose that determining Vitamin D level in postmenopausal women and replenishing its deficiency with Vitamin D analog supplementation might aid in preventing POP progression.

Six-year follow-up outcomes of the P(LLA-CL)/Fg bio-patch for anterior vaginal wall prolapse treatment

INTRODUCTION AND HYPOTHESIS

There were few data about the long-term outcomes of bio-compatible patches for pelvic organ prolapse (POP). The efficacy of poly (L-lactide-co-caprolactone) blended with fibrinogen [P(LLA-CL)/Fg] bio-patches were investigated for anterior vaginal wall prolapse treatment in a 6-year follow-up.

METHODS

The P(LLA-CL)/Fg bio-patch was fabricated through electrospinning. Nineteen patients with symptomatic anterior prolapse (Pelvic Organ Prolapse Quantification [POP-Q] stage ≥ 2) were treated with anterior pelvic reconstruction surgery using a P(LLA-CL)/Fg bio-patch and were followed up at 1, 2, 3, 6 months, and 6 years. The primary outcome was objective anatomical cure (anterior POP-Q stage ≤ 1). Secondary outcomes included complications, MRI evaluation, and scores of the Pelvic Floor Impact Questionnaire-7 (PFIQ-7) and the Pelvic Floor Distress Inventory-20 (PFDI-20).

RESULTS

The micro-morphology of the bio-patch resembled the extracellular matrix, which was suitable for the growth of fibroblasts. Sixteen (84.2%) patients were finally assessed, with a mean follow-up of 6.08 ± 0.18 years. The cure rate without anterior prolapse recurrence was 93.8% at 6 years. Compared with baseline, the POP-Q measurements of Aa, Ba, and C points and scores of PFIQ-7 and PFDI-20 manifested significant differences at all times (all p < 0.05). One (5.26%) case of bio-patch-related infection, 1 (5.26%) case of urinary retention, and no exposures and erosion occurred. MRI evaluation showed that the bio-patch gradually degraded to fragments at 1 month and was completely absorbed at 3 months.

CONCLUSIONS

Among long-term follow-ups, anterior pelvic reconstruction surgery with a P(LLA-CL)/Fg bio-patch demonstrated significant improvements in anatomical correction of anterior pelvic prolapse and pelvic function without severe morbidity.

Surgical excision of vaginal cysts presenting as pelvic organ prolapse: a case series

Vaginal cysts are rare, benign, predominantly cystic lesions of the anterior vaginal wall, with a prevalence of 1 in 200 women. Large vaginal cysts can occasionally present as symptomatic genital prolapse; these cases may be challenging to diagnose due to their rare clinical appearance. In symptomatic large vaginal cysts, surgical excision via vaginal approach is the recommended management with good anatomical results and patient satisfaction. The series of three consecutive adult women were referred for bothersome bulging prolapse. They were found to have a sizeable vaginal cyst at the anterior wall, associated with other symptoms. All patients (mean age 37±8.5 years) underwent total trans-vaginal surgical excision of the lesion. They were followed up in the out-patient department at six weeks and six months with no recurrences mentioned. Vaginal cysts are usually solitary, small, and asymptomatic; however, they can increase in size, easily mimic other pathologies, and are misdiagnosed as cystocele. Therefore, complete surgical vaginal excision of the symptomatic vaginal lesion is feasible and constitutes a good management option.

A modified technique for paravaginal repair of cystocele with paravaginal defect: A retrospective study

OBJECTIVE

We aimed to determine the efficacy and safety of a modified protocol for paravaginal repair of symptomatic paravaginal defects and cystocele.

METHODS

This study was an observational case series of 98 consecutive female patients, referred to our hospital between June 2014 and May 2018, with symptomatic grade II to IV paravaginal defects and cystocele. Our modified technique for paravaginal repair is based on the conventional protocol but incorporates reverse bridge repair and the cross-stitching of bilateral sutures. The curative effect of this new technique was evaluated subjectively and objectively during postoperative follow-up.

RESULTS

All operations were successful. Patients were followed up for 12 to 48 months, until June 2019; the mean follow-up period was 32.4 months. Three months after surgery, the rate of success was 100% (98/98 cases); in each case, the top of the vagina lay above the level of the sciatic spine. The rate of success was 94.9% (93/98 cases) at 12 months after surgery, 91.0% (61/71 cases) at 24 months after surgery, and 76.2% (16/21 cases) at 48 months after surgery. Four cases required a second surgery; three of these cases were treated with sacrocolpopexy, and one case was treated with sacrospinous ligament fixation.

CONCLUSION

Our modified technique for paravaginal repair was safe and effective for anterior vaginal prolapse and cystocele, as confirmed by the results observed over a mean follow-up period of 32.4 months.

A randomized control trial comparing vaginal and laparoscopically-assisted vaginal hysterectomy in the absence of uterine prolapse in a South African tertiary institution

OBJECTIVES

The primary objectives of this study were to estimate blood loss, operation time and cost differences in patients undergoing vaginal hysterectomy (VH) versus laparoscopically-assisted vaginal hysterectomy (LAVH). The secondary objectives were to determine differences in hospital stay, need for postoperative analgesia, intra- and immediate post-operative complications, and the rate of conversion to laparotomy. VH was hypothesized to be the preferred route for hysterectomy for benign uterine conditions.

STUDY DESIGN

A randomized control study was undertaken at the Department of Obstetrics and Gynaecology of the Charlotte Maxeke Johannesburg Academic Hospital and included the women admitted between January 2017 and December 2019 for hysterectomy due to benign conditions, meeting the inclusion criteria (vaginally accessible uterus, estimated uterine size ≤ 12 weeks of gestation or ≤ 280 g on ultrasound examination and pathology confined to the uterus). Surgical procedures were performed by the residents in training under the supervision of specialists with large experience. The patient demographic characteristics, uterine weight, operative time, estimated blood loss(expressed as the difference between preoperative and postoperative day one serum haemoglobin),direct surgery-associated costs, intra- and immediate post-operative complications and the length of hospital stay were recorded and comparatively analysed among patients randomly placed in VH and LAVH group.

RESULTS

A total of 227 women were included (151 patients underwent VH and 76 LAVH, upon 2:1 randomization, performed on this way to reflect the previous pattern of operating of the unit). The patients were matched with respect to age, parity and body mass index. No significant differences between two groups were found in mean uterine weight and also in mean serum haemoglobin shift, intra- and immediate post-operative complications, and convalescence period duration. There were statistically significant differences in operating time and in cost between the two procedures. On average, LAVH took longer than VH to be performed (62.8 ± 9.3 vs 29.9 ± 6.6 min, p < 0.0001) and it was more costly, mainly due to the longer operating time and required disposables. An amount of 15698.20 South African Rand (ZAR) or 1145.85 United States Dollar (USD) more were needed to perform LAVH in comparison to VH. All VHs and LAVHs were successfully accomplished without major complications or conversation to laparotomy.

CONCLUSION

Our data indicate that VH is a feasible and safe alternative for a large group of women with benign pathology and non-prolapsed uteri, being a faster and less costly procedure than LAVH.

Differential diagnosis of middle compartment pelvic organ prolapse with transperineal ultrasound

INTRODUCTION AND HYPOTHESIS

The objective was to identify the best parameter (pubis-cervix measurement, pubis-uterine fundus measurement or pubis-pouch of Douglas measurement) on transperineal ultrasound, based on the difference between measurements taken at rest and with the Valsalva maneuver, for presurgical differential diagnosis between uterine prolapse (UP) and cervical elongation (CE) without UP.

METHODS

A prospective observational study of 60 consecutively recruited patients who underwent corrective surgery of the middle compartment (UP or CE without UP). A transperineal ultrasound was performed, and the descent of the pelvic organ was measured in relation to the posteroinferior margin of the pubis in the midsagittal plane, referencing the uterine fundus, pouch of Douglas and the cervix at rest and with the Valsalva test.

RESULTS

Receiver operating characteristic (ROC) curves were constructed for the three evaluated measures, based on the difference between rest and Valsalva, for the diagnosis of UP. For the pubis-cervix distance, an area under the curve (AUC) of 0.59 was obtained; for the pubis-uterine fundus distance, the AUC was 0.81; and for the pubis-pouch of Douglas distance, the AUC was 0.69. Based on the best AUC (the difference in the pubis-uterine fundus distance at rest and with the Valsalva maneuver), a cut-off point of 15 mm was established for the diagnosis of UP (sensitivity: 75%; specificity: 95%; positive predictive value: 86%; and negative predictive value: 89%).

CONCLUSION

A difference of ≥15 mm in the pubis-uterine fundus distance at rest and with the Valsalva maneuver is useful for differentiating UP from CE without UP by ultrasound.

Short-term outcomes of sacrospinous hysteropexy through an anterior approach

INTRODUCTION AND HYPOTHESIS

The posterior approach to sacrospinous hysteropexy has been well studied but little is known about the anterior approach. This study assessed the efficacy and complications of an anterior approach to sacrospinous hysteropexy compared to hysterectomy with apical repair. We hypothesized that anterior sacrospinous hysteropexy has similar efficacy and fewer complications.

METHODS

This retrospective cohort study compared patients who underwent native-tissue anterior sacrospinous hysteropexy (cases) with those who underwent hysterectomy with apical repair (controls). Composite success was defined as (1) leading edge of prolapse not beyond the hymen and apex not descended > 1/3 total vaginal length; (2) no vaginal bulge symptoms; (3) no prolapse retreatment. Descriptive and bivariate statistics were performed as well as a Cox regression analysis for time to failure.

RESULTS

Fifty cases and 97 controls were compared. The median follow-up time was 7.6 months. Operative time was shorter in the hysteropexy group (110.7 vs. 155.9 min, p < 0.001). The composite success was 92% for both cases and controls (p = 1.000) with no difference in time to surgical failure (p = 0.183). There were no serious intraoperative complications in the hysteropexy group and six in the control group (3 transfusions, 1 conversion to laparotomy, 1 ureteral injury, 1 cystotomy; p = 0.101). There was no difference in the number of postoperative complications (22.0% vs. 30.9%, p = 0.203).

CONCLUSIONS

For primary uterine prolapse, anterior sacrospinous hysteropexy has similar short-term efficacy compared to hysterectomy with apical repair with shorter operative time and a trend towards fewer serious complications.

Gynecologists' perspectives on two types of uterus-preserving surgical repair of uterine descent; sacrospinous hysteropexy versus modified Manchester

INTRODUCTION AND HYPOTHESIS

The modified Manchester (MM) and sacrospinous hysteropexy (SSH) are the most common uterus-preserving surgical procedures for uterine descent. Little is known about gynecologists' preferences regarding the two interventions. The study's aim was to identify which factors influence Dutch (uro)gynecologists when choosing one of these techniques.

METHODS

This qualitative study consists of ten semi-structured interviews with Dutch (uro)gynecologists using predetermined, open explorative questions, based on a structured topic list. An inductive content analysis was performed using Atlas.ti.

RESULTS

For SSH, the majority (6/10 gynecologists) reported the more dorsal change of direction of the vaginal axis as a disadvantage and expected more cystocele recurrences (7/10). The most reported disadvantage of MM was the risk of cervical stenosis (7/10). Four gynecologists found MM not to be appropriate for patients with higher stage uterine prolapse. The quality of the uterosacral ligaments was related to the chance of recurrence according to five gynecologists. Patient counseling was biased toward one of the uterus-preserving operations (7/10). Four gynecologists stated they make the final decision while two let patient-preference lead the final decision.

CONCLUSIONS

Preference for one of the uterus-preserving interventions is mainly based on the gynecologist's own experience and background. The lack of information regarding these two uterus-preserving procedures hampers evidence-based decision making, which explains the practice pattern variation. In conclusion, further research is needed to improve evidence-based counseling and shared decision making regarding the choice of procedure.

Surgical repair of vaginal vault prolapse; a comparison between ipsilateral uterosacral ligament suspension and sacrospinous ligament fixation-a nationwide cohort study

INTRODUCTION AND HYPOTHESIS

Hysterectomy is frequently performed and associated with increased risk of subsequent genital prolapse including vaginal vault prolapse. Ipsilateral uterosacral ligament suspension (IUSLS) and sacrospinous ligament fixation (SSLF) are two commonly performed surgical techniques to treat vaginal vault prolapse. There is no consensus on the ideal operation technique. The aim of this study was to compare IUSLS and SSLF to treat vaginal vault prolapse based on the number of repeat surgeries.

METHODS

Previously hysterectomized patients operated on with IUSLS or SSLF in Denmark in 2010-2016 were included in this nationwide register-based cohort study and followed until June 2017. Data were obtained from Danish National Databases, to which reporting is mandatory by law, entailing high validity and completeness of data. Data were analyzed using Cox proportional hazard regression analysis adjusted for age, preoperative prolapse stage, smoking, BMI, and previous prolapse surgery.

RESULTS

In total, 744 patients were included; 384 underwent IUSLS while 360 underwent SSLF. After 5 years, 6.5% of patients operated on with IUSLS and 21.8% operated on with SSLF had a repeat surgery in the apical compartment and 12.4% and 30.6% in any compartment, respectively. The risk of repeat surgery was 4.8 times higher after SSLF compared to IUSLS [confidence interval (CI): 2.7-8.4] in the apical compartment and 2.4 times higher (CI: 1.2-5.1) in the anterior compartment. No difference was seen in the posterior compartment.

CONCLUSIONS

This study finds significantly higher numbers of repeat surgeries after SSLF compared to after IUSLS in a Danish nationwide cohort.

Association between overactive bladder and serum nerve growth factor concentrations in women with high-grade uterine prolapse

INTRODUCTION AND HYPOTHESIS

The association between overactive bladder (OAB) and uterine prolapse remains unclear. The extent of the role of serum nerve growth factor (NGF) levels in this relationship is also not known. Therefore, our study evaluated the association among OAB, high-grade uterine prolapse and serum NGF levels.

METHODS

A total of 90 patients participated in our study and were grouped as follows. Group I included patients with high-grade uterine prolapse and OAB, group II included patients with only high-grade uterine prolapse, and group III included healthy women without uterine prolapse or OAB. Serum NGF level analysis was performed in all groups.

RESULTS

Serum NGF levels varied greatly among the three groups, with significantly higher levels in group 1 than in groups 2 and 3 (p < 0.001). Serum NGF levels with a cutoff point of 120.49 pg/ml identified women with significant OAB symptoms to discriminate among groups with a sensitivity of 80%, specificity of 86.7%, positive predictive value of 75.0%, negative predictive value of 89.7% and positive likelihood ratio of 6.01 (p < 0.001).

CONCLUSIONS

Our study showed that NGF-related pathways may play an active role in the pathophysiology of OAB with high-grade uterine prolapse patients based on obstruction hypothesis.

[EFFICACY OF VAGINAL AND LAPAROSCOPIC SACROCOLPOPEXY, A DUAL APPROACH TO UTERO-VAGINAL PROLAPSE, COMPARED WITH LAPAROSCOPIC SACROCOLPOPEXY ALONE]

INTRODUCTION

Sacrocolpopexy (SCP) is one of the most successful operations for correcting utero-vaginal prolapse and achieving a functional vaginal reconstruction. The operation, which classically calls for an open abdominal approach, can be performed laparoscopically, but it is time-consuming and requires experienced laparoscopists. A few years ago, we introduced a dual vaginal-laparoscopic technique, in which we combined the ease of vaginal suturing with the advantages of laparoscopic SCP. We now evaluate the efficacy of this dual approach in comparison to the primary laparoscopic operation.

METHODS

We compared the efficacy and short-term results of 68 patients who had the dual operation to that of 28 classical Laparoscopic SCP patients. The study was retrospective and included analysis of patients' records. We also called the patients and encouraged them to come for a follow-up examination. We managed to examine 11 of the 28 Laparoscopic SCP patients (39%), 3-7 years after the operation, and 40 of the 68 patients who had the dual operation (59%), 1-5 years after the procedure.

RESULTS

The short-term results of the dual operation showed that it was faster, without compromising the wellbeing of the patients. For the long term results we examined the patients available and found that the subjective cure rate was 73% for the Laparoscopic SCP patients and 87% for the dual operation. However, we observed some degree of vaginal prolapse in 82% (9/11) of the Laparoscopic SCP operations, mainly cystocele or rectocele grade 1 or 2, but only 30% of the patients with the dual operation had such prolapse. There were no mesh erosions or exposures in any of the groups.

CONCLUSIONS

The dual operation combined the ease and accuracy of a vaginal operation with the benefits to the patient from a laparoscopic approach. It also enabled a convenient approach to add vaginal procedures that improved the surgical results, or complied with the patients' wishes.

Vaginal Dialogues: The Trials and Tribulations of Mesh in the Repair of Prolapse

Media reports suggest that between 2005 and 2014 an estimated 8,500 patients were injured (including 170 deaths) in Australia by defective medical devices. An Australian representative action against two manufacturers and a supplier of certain medical devices used for the treatment of stress urinary incontinence and pelvic organ prolapse by three women representing over 700 registered class members alleging serious complications of vaginal mesh repair gave rise to a judgment in favour of the plaintiffs in late 2019. The judgment suggests that replacing a set of suspensory components of the levator ani muscle with a rigid matrix of mesh which provided strong support at the expense of flexibility may have been a misguided choice.

Outcomes of native tissue transvaginal apical approaches in women with advanced pelvic organ prolapse and stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

Limited data exist comparing different surgical approaches in women with advanced vaginal prolapse. This study compared 2-year surgical outcomes of uterosacral ligament suspension (ULS) and sacrospinous ligament fixation (SSLF) in women with advanced prolapse (stage III-IV) and stress urinary incontinence.

METHODS

This was a secondary analysis of a multicenter 2 × 2 factorial randomized trial comparing (1) ULS versus SSLF and (2) behavioral therapy with pelvic floor muscle training versus usual care. Of 374 subjects, 117/188 (62.7%) in the ULS and 113/186 (60.7%) in the SSLF group had advanced prolapse. Two-year surgical success was defined by the absence of (1) apical descent > 1/3 into the vaginal canal, (2) anterior/posterior wall descent beyond the hymen, (3) bothersome bulge symptoms, and (4) retreatment for prolapse. Secondary outcomes included individual success outcome components, symptom severity measured by the Pelvic Organ Prolapse Distress Inventory, and adverse events. Outcomes were also compared in women with advanced prolapse versus stage II prolapse.

RESULTS

Success did not differ between groups (ULS: 58.2% [57/117] versus SSLF: 58.5% [55/113], aOR 1.0 [0.5-1.8]). No differences were detected in individual success components (p > 0.05 for all components). Prolapse symptom severity scores improved in both interventions with no intergroup differences (p = 0.82). Serious adverse events did not differ (ULS: 19.7% versus SSLF: 16.8%, aOR 1.2 [0.6-2.4]). Success was lower in women with advanced prolapse compared with stage II (58.3% versus 73.2%, aOR 0.5 [0.3-0.9]), with no retreatment in stage II.

CONCLUSIONS

Surgical success, symptom severity, and overall serious adverse events did not differ between ULS and SSLF in women with advanced prolapse. ClinicalTrials.gov Identifier: NCT01166373.

[An interaction between an obstetrician-gynecologist and a urologist in the gynecological practice]

The article is devoted to the interaction of a gynecologist and a urologist in a gynecological hospital, based on the experience of the gynecological department at the Clinic of obstetrics and gynecology of the Clinical Center of Sechenov University. The most common clinical scenarios were identified when the participation of a urologist in evaluation and treatment is urgently needed, including large pelvis mass, endometriosis with an involvement of pelvic organs, genital prolapse, small pelvis adhesions as a result of previous surgical procedures and postoperative urinary disorders. A close interaction between two specialties, which are dedicated to pelvic organs disorders, namely gynecology and urology, is extremely popular in modern clinical practice and allows to significantly reduce the number of intra- and postoperative complications, carry out a comprehensive examination and determine individual treatment tactics in a gynecological hospital, which increases quality of medical care.

Bladder rupture after a fall on the ground in a patient with total uterine prolapse

OBJECTIVE

The aim of this work is to present a case of traumatic bladder rupture in a patient with total uterine prolapse. Additionally, we provide a brief description of this issue.

DESIGN

Case report.

SETTING

Department of Obstetrics and Gynaecology, 3rd Faculty of Medicine, Charles University and Královské Vinohrady University Hospital, Prague; Departement of Radiology, 3rd Faculty of Medicine, Charles University and Královské Vinohrady University Hospital, Prague.

RESULTS

We present a case report of a patient with a total uterine prolapse that has been examined for a lower abdominal pain, hematuria and difficulties with urination. The problems arose suddenly after the fall on the ground. These symptoms are typical for bladder rupture, but other more frequent causes have to be ruled out. CT scan showed a contrast agent leak from the bladder. The patient was indicated for surgical revision and suture of the bladder wall.

CONCLUSION

Separately, rupture of the bladder occurs rarely. Most often, this injury is part of a wider trauma - especially after car crashes. However, our case report suggests that this option should be considered.

[Relevance between expectations before treatment, new symptoms and satisfaction after treatment in patients with pelvic organ prolapse]

OBJECTIVE

To investigate the relevance between expectations before treatment, new symptoms and satisfaction after treatment of the pelvic organ prolapse (POP) patients.

METHODS

Made a collection of 75 cases of POP patients at Peking University Third Hospital, who were affected by the POP symptoms and came to our clinic for treatment from January to December in 2013. Prospectively investigate the patients' expectations before treatment, which were the most troubling symptoms to be solved. According to treatment we divided the patients into surgery and pessary groups. Two groups were followed up with the degree to achieve the desired goals using patient global impression of improvement (PGI-I), new symptoms and satisfaction after treatment, try to find the relevance between expectations before treatment, new symptoms and satisfaction after treatment.

RESULTS

There were 47 (63%, 47/75) patients in the surgical group and 28 (37%, 28/75) patients in the pessary group. The top three problems for patients were friction when walking (25%, 19/75), dysuria (23%, 17/75) and the feeling of vaginal prolapse (19%, 14/75). The follow-up rate was of 93% (70/75), follow-up time was (5 ± 4) months. Satisfaction score after treatment of surgical group was higher than that of pessary group [(4.9 ± 0.4) versus (4.0 ± 1.3) scores, P < 0.01]. There was no statistically significant difference between two groups of PGI-I score [(6.7 ± 0.6) versus (6.6 ± 0.9) scores, P = 0.886]. The top three new symptoms after treatment were increased secretion, urinary incontinence and dysuria. PGI-I and satisfaction scores was relevant (P = 0.021). The availability of new symptoms and satisfaction scores was relevant (P = 0.001).

CONCLUSION

When achieving higher expectations to the treatment and no more new symptoms, the satisfaction score after treatment is higher.

A Comparative Study of Abdominal Hysterectomy versus Vaginal Hysterectomy in Non Descent Cases

Abdominal and vaginal hysterectomies are the two main operative modalities for various uterine conditions; however the indications for selecting a particular procedure in any setting may not be optimally defined. The present study was done with the objective to study the comparative risks of complications of abdominal and vaginal hysterectomies during intra-operative and post-operative period thereby improve the proportion of hysterectomies done vaginally. This randomized comparative study was carried out in the Department of Gynaecology and Obstetrics, Bangabandhu Sheikh Mujib Medical University, during the period from January 2012 to December 2012. Sixty subjects were equally divided into vaginal hysterectomy (Group A) and abdominal hysterectomy (Group B), thirty in each group for non-prolapsed cases with good uterine mobility and uterine size less than 12 weeks. Intra-operative blood loss, mean operating time was more in Group A than in Group B (250 ml, 72.97 ± 9.27 min) and (200 ml, 55.27 ± 1.80 min) respectively. Postoperative fever (17% & 7%), bleeding requiring transfusion (72% & 28%) and abdominal wound infection (13%, 0%) was more common in Group A as compared to Group B. From the study results it can be concluded that patients requiring hysterectomy for benign non prolapsed cases be offered the option of vaginal route which is less invasive, minimal or no complications, more economical and effective. In our centre, it is likely to replace abdominal hysterectomy as the operation of choice.

[Comparison of levator ani muscles in three-dimensional MRI-based models in women with and without pelvic organ prolapse at rest]

OBJECTIVE

Comparison of the levator ani muscles in three-dimensional (3D) MRI-based models in women with and without pelvic organ prolapse at rest to analyze the morphological characteristics of levator ani muscles in women with POP.

METHODS

Twenty-five women with POP and 22 women with normal pelvic support were selected from Nanfang Hospital of Southern Medical University. Axial, sagittal, and coronal T2-weighted pelvic magnetic resonance scans were obtained with the women in the supine position.The 3D models were reconstructed from the source images. Morphological changes was compared within the two groups of levator ani muscles, and the 3D models were measured to determine the levator ani muscle volume (LVOL), levator plate angle (LPA), levator hiatus width (LH-W) and length (LH-L), distance between symphysis and levator sling muscle (LSG).

RESULTS

There were no puborectalis avulsions in control, in POP, 3 cases of avulsions just in left, 3 cases of avulsions just in right, 7 cases in bilateral. The shape of iliococcygeus were all dome-shaped in control, 11 cases were U-shaped and 14 cases were dome-shaped in POP. The shape of levator hiatus were 7 cases of U-shape, 12 cases of V-shape, 3 cases of irregular in control; 5 cases of U-shape, 4 cases of V-shape, 16 cases of irregular in POP. POP versus control: LH-L: (68.0 ± 8.9) versus (61.6 ± 7.2) mm (P < 0.05); LH-W: (41.4 ± 3.9) versus (38.0 ± 3.2) mm (P < 0.05); LSG-L: (29.6 ± 7.4) versus (24.6 ± 3.7) mm (P < 0.05); LSG-R: (28.4 ± 6.8) versus (23.9 ± 3.2) mm (P < 0.05); LPA: (51.0 ± 11.3)° versus (40.6 ± 6.3)° (P < 0.05); LVOL: (23.7 ± 5.8) versus (24.6 ± 5.0) cm³ (P > 0.05).

CONCLUSIONS

It is possible to assess the morphologic changes of levator ani by using 3D MRI models objectively, our 3D data demonstrate larger in LVOL, LPA, LH-W, LH-L, LSG, and the changes in shape. It is helpful to diagnose and assess the specific situation of patients POP in clinic.

Utero-vaginal prolapse complicating pregnancy: a case report

BACKGROUND

Uterovaginal prolapse in pregnancy is an infrequent but potentially harmful condition when not properly handled. There is no standard guideline on its management; however discretion is used to treat individual case on its merit. Vaginal delivery is possible but elective caesarean section seems a better alternative.

METHOD

We present the case records of 24 year old Gravid 2 Para 1 + 0 (alive) who presented in labour with a second degree uterovaginal prolapse at term. Literature review using medline and manual library search was done.

RESULT

She tested positive to HIV I and II: and had emergency caesarean section for dystocia with the delivery of a live 3.5kg female baby. She was managed conservatively on bed rest, local antiseptics and physiotherapy. She was however lost to follow up.

CONCLUSION

Uterovaginal prolapsed in pregnancy is rare. Opinion is divided on delivery options but most are agreed on caesarean delivery and conservative follow up post partum. Prevention of pelvic organ prolapsed through antenatal care, supervised delivery, physiotherapy and fertility regulation remains key to favourable out-come.

[Clinical study on pubococcygeal line determined by dynamic magnetic resonance imaging used in evaluating pelvic organ prolapse]

OBJECTIVE

To investigate clinical value of pubococcygeal line (PCL) determined by dynamic magnetic resonance imaging (MRI) used in evaluating pelvic organ prolapse (POP), and investigate the relationship of pelvic organ prolapse quantitation (POP-Q) stage and pubococcygeal line (PCL) for the patient with POP.

METHODS

Twenty patients with POP were evaluated by POP-Q stage and pelvic dynamic MRI examination simultaneously. Sagittal MRI images were acquired at rest and during maximal Valsalva using a fast gradient echo sequence two-dimensional fast low angle shot (FLASH) T(1) weighted image. The degree of prolapsed anterior vaginal wall, uterus and posterior vaginal wall were measured by PCL and compared with POP-Q system.

RESULTS

There were 20 cases with cystocel diagnosed by POP-Q staging system, in which bladder neck or bladder base of 17 patients were under the PCL during maximum Valsalva. The concordance rate was 85% (17/20) between PCL and POP-Q stage. There were 19 cases with rectocele diagnosed by POP-Q, in which the anorectal junction of 4 patients' PCL descent below more than 2.5 cm. The concordance rate was 4/19 between PCL and POP-Q stage. There were 14 cases with uterine prolapse diagnosed by POP-Q staging system, in which uterine cervix of all descent below PCL. The concordance rate was 14/14 between PCL and POP-Q stage. However, it was noted that 5 cases did not reach POP-Q staging and their lowest uteri cervix were below or above PCL but less than 1 cm at maximal Valsalva.

CONCLUSIONS

Compared with POP-Q staging system, the reference line of PCL determined by dynamic MRI could diagnose uterine prolapse accurately and anterior vaginal wall with greater clinical value, however it was limited in diagnosing posterior vaginal wall prolapse effectively. Therefore, the clinical value of PCL should be further studied for evaluating POP.

Parity negatively impacts vaginal mechanical properties and collagen structure in rhesus macaques

OBJECTIVE

The purpose of this study was to determine the impact of parity on mechanical behavior of the vagina and to correlate these findings with alterations in collagen structure.

STUDY DESIGN

Mechanical properties of 5 nulliparous and 6 parous rhesus macaques were derived from uniaxial tensile tests. Collagen ratios and alignment were quantified by quantitative fluorescent microscopy and picrosirius red staining. Outcomes were compared by the Student t test or Mann Whitney U test (P < .05) and Spearman's rho for correlation coefficients.

RESULTS

Mechanical properties were inferior in a parous vs nulliparous vagina with decreased tangent modulus (P = .03), tensile strength (P < .001), and strain energy density (P = .006). Although no difference in collagen ratios (P = .26) were observed, collagen alignment decreased with parity (P = .06). Worsening pelvic organ support negatively correlated with decreasing collagen alignment (r(2) = -0.66) and mechanical properties (r(2) = -0.67).

CONCLUSION

Vaginal parity is associated with inferior tissue mechanics and loss of collagen alignment. Such behavior likely predisposes to the development of pelvic organ prolapse.

Impact of urodynamic based incontinence diagnosis on quality of life in women

AIMS

To characterize the effect of urodynamic diagnosis on degree of incontinence related bother and health related quality of life in a large, multi-ethnic population of women.

METHODS

Effects of multichannel urodynamic diagnosis, urethral competency, and other patient characteristics on abbreviated Urogenital Distress Inventory (UDI6) and Incontinence Impact Questionnaire (IIQ7) composite scores were analyzed retrospectively.

RESULTS

Six hundred eleven patients were included. Mean UDI6 and IIQ7 scores were significantly higher among patients with mixed incontinence, detrusor overactivity, urinary stress incontinence with overactive bladder, and negative studies compared to those with stress incontinence without OAB. The relative composite UDI6 and IIQ7 mean scores did not significantly differ between the mixed incontinence, detrusor overactivity, stress incontinence with OAB and negative study groups. UDI6 and IIQ7 scores were significantly higher among stress incontinent patients with intrinsic sphincter deficiency, but similar among mixed incontinent patients with intrinsic sphincter deficiency.

CONCLUSION

Urodynamic diagnoses of detrusor overactivity, mixed incontinence, and stress incontinence with overactive bladder are associated with significantly worse incontinence related bother and health related quality of life when compared to those with stress incontinence without OAB. These conditions appear to have similar degree of impact on incontinence related bother and quality of life. Patients presenting with symptoms of incontinence can suffer a similar compromise in quality of life despite a negative MCUD study.

Spanish language translation of pelvic floor disorders instruments

The purpose of the study is to translate existing measures of pelvic symptoms and quality of life from English into Spanish, facilitating research participation of Hispanic/Latina women. The forward-backward translation protocol was applied then adjudicated by a concordance committee. The measures included the Pelvic Floor Distress Inventory (PFDI), Pelvic Floor Impact Questionnaire (PFIQ), Medical, Epidemiological, and Social Aspects of Aging (MESA) Questionnaire, Hunskaar Severity Measure, Fecal Incontinence Severity Index and modified Manchester Questionnaire, Pelvic Organ Prolapse/Urinary Incontinence Sexual Functioning Questionnaire (PISQ), and the Life Orientation Test (LOT). English and Spanish versions were administered to 50 Hispanic/Latina women with pelvic symptoms. Kappa correlations of items and correlation coefficients for scales were computed. Psychometric testing for translations demonstrated good (0.80-0.89), very good (0.90-0.95), or excellent (>0.95) correlations for primary scales of the PFDI, PFIQ, MESA, Hunskaar, PISQ, and LOT. Strict translation techniques and testing yielded valid Spanish translations of instruments assessing pelvic symptoms/functional life impact in women with pelvic floor disorders.

Natural history of pelvic organ prolapse in postmenopausal women

OBJECTIVE

To describe the natural history of pelvic organ prolapse and risk factors for changes in vaginal descent in older women.

METHODS

This 4-year prospective observational study included 259 postmenopausal women with a uterus enrolled at one Women's Health Initiative clinical site who completed at least two annual pelvic organ prolapse quantification (POP-Q) examinations. We calculated 1-year and 3-year incidence and resolution risks for prolapse (defined as maximal vaginal descent to or beyond the hymen) and estimated progression and regression rates (1 cm or greater and 2 cm or greater changes in maximal vaginal descent) and risk factors.

RESULTS

Mean age was 68.1+/-5.5 years, and median vaginal parity was 4. Seventy-three (28%) women had four exams, 128 (49%) had three exams, and 58 (22%) had two exams. Prolapse waxed and waned yearly in individual women. Overall 1-year and 3-year prolapse incidences were 26% (95% confidence interval [CI] 20-33%) and 40% (95% CI 26-56%); 1-year and 3-year prolapse resolution risks were 21% (95% CI 11-33%) and 19% (95% CI 7-39%). Rates of any change in maximal vaginal descent over time varied depending on baseline measurements. Over 3 years, the maximal vaginal descent increased by at least 2 cm in 11.0% (95% CI 4.9-20.5%) of the women and decreased by at least 2 cm in 2.7% (95% CI 0.3-9.5%). Increasing body mass index and grand multiparity increased the risk for vaginal descent progression.

CONCLUSION

Prolapse progresses and regresses in older women, although rates of vaginal descent progression are slightly greater than regression overall. Obesity is a risk factor for progression in vaginal descent.

LEVEL OF EVIDENCE

III.

Vaginal hysterectomies in patients without uterine prolapse: a local perspective

OBJECTIVE

To review the results of vaginal hysterectomies in patients without uterine prolapse.

DESIGN

Retrospective chart review.

SETTING

University affiliated hospital, Hong Kong.

PATIENTS

Patients who had vaginal hysterectomies in the absence of uterine prolapse, from 1999 to 2005 inclusive.

MAIN OUTCOME MEASURES

The number, indications, operative procedures, and complications of such hysterectomies.

RESULTS

A total of 94 patients who underwent vaginal hysterectomy fulfilled the inclusion criteria. They accounted for 4.3 to 8.2% of all hysterectomies performed annually for benign diseases in the department, over the inclusive period 2000 to 2004. The incidences of complications, except bladder injuries, were comparable to those reported in other studies. The incidence of vault haematoma decreased as each surgeon's experience increased and more attention was paid to 'bleeders' at the 'four and eight o'clock areas' and more cephalic regions of the vaginal incision. Increased size of the uterus was an important determinant of the risk of complications.

CONCLUSIONS

Vaginal hysterectomy is an underutilised approach in Hong Kong. With more experience and better patient selection, complication rates can be further reduced. Further evaluation is suggested for the role of bleeders at 'four and eight o'clock regions' as potential causes of vault haematoma.

Patterns of constipation in urogynecology: clinical importance and pathophysiologic insights

OBJECTIVE

We have analyzed the prevalence and patterns of constipation in women with urinary symptoms and/or genital prolapse.

STUDY DESIGN

Seven hundred and eighty-six consecutive urogynecologic patients underwent a questionnaire and structured clinical assessment. Comparison between constipated and nonconstipated women was made. Fisher exact test, Wilcoxon rank sum test, and logistic regression were used for statistical analysis (P < .05 for significance).

RESULTS

Thirty-two percent of women were constipated (172 difficult stool passage, 13 reduced stool frequency, 64 both). A genital prolapse > or = 2 degree Half Way System (HWS) was present in 44% of women. A posterior colpocele was more frequent in constipated women (35% vs 19%; P < .0001), resulting in a risk factor for constipation (OR 2.31; 95% CI 1.63-3.27). By contrast, higher degrees of anterior colpocele appeared to protect against constipation (OR 0.80; 95% CI 0.66-0.96). No differences in prevalence of constipation were observed for urinary symptoms or urodynamic diagnosis.

CONCLUSION

Bowel dysfunction correlates exclusively with posterior aspects of the pelvic floor support.

Ehlers-Danlos syndrome in the parturient: an uncommon disorder--common dilemma in the delivery room

DESCRIPTION

Ehlers-Danlos syndrome (EDS) is a rare genetically transmitted connective tissue disorder, non-specific to pregnancy.

CONCLUSION

Because of multi-organ involvement and the varied presentations of this disease, no uniform obstetric and anesthetic recommendations regarding the peripartum care of these parturients can be made.

Metastatic colon carcinoma found within an enterocele sac: a case report

The incidental finding of cancer in a hernial sac is rare, but there are many case reports in the literature. There has never been a report of carcinoma found in an enterocele sac. We present the case of a 77-year-old female with symptomatic pelvic organ prolapse who presented for reconstructive pelvic surgery and was found to have metastatic adenocarcinoma contained within an enterocele sac. Incidental diagnosis of asymptomatic carcinoma found on typically discarded tissue from surgical procedures is rare. However, routine pathologic review of all tissue removed from a patient may save a life if carcinoma is found early.

L’élévation du taux de césariennes : un progrès nécessaire de l’obstétrique moderne

During the last 10 Years, the cesarean section (CS) rate was increased despite of the recommendations of the World Health Organization to keep it below 10-15%. The purpose of this review of the literature was to demonstrate how the concept of CS rate limitation has become obsolete. The increase in the CS rate is mainly justified by the decrease in maternal mortality and morbidity following elective CS: surgery-related risks have decreased and the confusion that was made between the risks of vaginal delivery and those of trial of labor has to be clarified to show that maternal mortality and morbidity are not increased by elective CS. However, instrumental delivery and CS during labor remain two situations at high risks both for the mother and her fetus. There is also an association between the increase in the CS rate and the decrease in perinatal mortality and morbidity, but this effect would only become clinically significant after a dramatic increase in the CS rate: this is the preventile principle of "marginal death". Numerous articles have been published reporting on the effects of vaginal delivery for the pelvic floor: urinary incontinence, pelvic organ prolapse, and especially fecal incontinence. All these publications concluded that CS has a protective effect. The rising duty to provide information to patients in high risk obstetrical situations such as a history of CS also contributes to the overall increase in CS rate mainly through the elective CS rate. Indeed, when faced with the alternative choices of potentially severe complications either for themselves or their child, women are likely to choose what appears to be the safest mode of delivery for their child and thus to opt for a CS. Finally, widespread delivery of information to the patients about trial of labor itself and the risks of vaginal delivery is the first step towards a "principle of preference", which consists in giving an important place to the patient's choice in the decision-making process, and thus to recognize her right to ask for an elective CS.

Vaginal evisceration long after vaginal hysterectomy

BACKGROUND

Vaginal evisceration can take place many years after vaginal surgery.

CASE

An 87-year-old woman presented with evisceration of small bowel through the vagina, 15 years after she underwent a vaginal hysterectomy. On physical examination, her vital signs were normal. Forty centimeters of small bowel was visible emerging from the vagina, appearing viable and nonedematous. Because of the high surgical risk, the bowel was replaced and the defect in the vaginal wall was repaired transvaginally.

CONCLUSION

Vaginal evisceration can be treated by a transvaginal surgical approach. Factors such as the medical condition of the patient and the viability of the herniated viscus should dictate the optimal approach in each case.