Pessaries and rectovaginal fistulae: consequences of delayed clinical follow-up in the Covid-19 pandemic
INTRODUCTION AND HYPOTHESIS:While 2017 guidelines from The American College of Obstetricians & Gynecologists called for pessary replacement every 3 to 4 months, a recent study in Obstetrics and Gynecology suggested that uninterrupted pessary use up to 6 months is not an independent risk factor for development of pessary-related complications. METHODS:Our recent experience throughout the Covid-19 pandemic highlights the potential ramifications of delayed clinical follow-up. RESULTS:During the Covid-19 pandemic, 3 of our patients developed rectovaginal fistulae secondary to Gellhorn pessary erosion in the context of delayed clinical follow-up. Our patients had previously attended routine appointments every 3 months without complications until missed appointments secondary to the pandemic led to fistulae formation. CONCLUSION:We believe that delayed clinical follow-up of pessary management beyond 3 months due to the Covid-19 pandemic may lead to fistula complications in elderly women with Gellhorn pessaries.
Improved Understanding of Female Pelvic Medicine and Reconstructive Surgery Concepts Through Targeted Case-Based Educational Intervention: A Pilot Study
OBJECTIVES/OBJECTIVE:Given the complex anatomy and pathophysiology of urogynecologic disorders, obstetrics and gynecology residents can have difficulty learning the subject's principles. There are no standardized resources for educators in this subspecialty. We hypothesized that our case-based educational intervention was associated with enhanced knowledge and greater resident satisfaction versus traditional urogynecology lectures. METHODS:This is a prospective study involving 19 obstetrics and gynecology residents at a single institution. Residents participated in three 1-hour case-based lectures, which included prelecture and postlecture topic knowledge assessments. Nonparametric Wilcoxon signed-rank tests were used to compare the before and after responses. Resident satisfaction was assessed using a 5-point Likert scale questionnaire. RESULTS:The median scores for the pretraining and posttraining assessments of resident urogynecology subject knowledge were 8 (5-10) and 10 (8-10), respectively. A stratified analysis was performed based on postgraduate year (PGY) and median prelectures and postlectures scores showed statistically significance (P < 0.001). Analysis of the PGY subgroups demonstrated statistical significance in PGY1 (P = 0.004), PGY2 (P = 0.008), and PGY3 (P = 0.03). However, the PGY4 subgroup (P = 0.06) did not reach statistical significance.All residents regardless of PGY level either agreed or strongly agreed that the case-based educational intervention enhanced resident knowledge, engagement, and clarity of the relevant teaching points and decreased resident stress about urogynecology topics. CONCLUSIONS:The case-based educational intervention significantly improved resident knowledge in urogynecology and enhanced resident satisfaction with this teaching method versus traditional lectures.
Outcomes of stress urinary incontinence in women undergoing TOT versus Burch colposuspension with abdominal sacrocolpopexy
INTRODUCTION AND HYPOTHESIS/OBJECTIVE:To compare postoperative rates of stress urinary incontinence (SUI) in patients with pelvic organ prolapse and SUI undergoing abdominal sacrocolpopexy (ASC) with Burch colposuspension or a transobturator tape (TOT) sling. METHODS:In this retrospective cohort study, medical records of 117 patients who underwent ASC with Burch (nâ€‰=â€‰60) or TOT (nâ€‰=â€‰57) between 2008 and 2010 at NYU Winthrop Hospital were assessed. Preoperative evaluation included history, physical examination, cough stress test (CST), and multichannel urodynamic studies (MUDS). Primary outcomes were postoperative continence at follow-up up to 12Â weeks. Patients considered incontinent reported symptoms of SUI and had a positive CST or MUDS. Secondary outcomes included intra- and postoperative complications. Associations were analyzed by Fisher's exact, McNemar's and Wilcoxon-Mann-Whitney tests. RESULTS:The groups were similar regarding age, BMI, parity, Valsalva leak point pressure (VLPP), and prior abdominal surgery (pâ€‰=â€‰0.07-0.76). They differed regarding preoperative SUI diagnosed by self-reported symptoms, CST, or MUDS (TOT 89.5-94.7%, Burch 60.7-76.3%, pâ€‰<â€‰0.0001-0.007). The TOT group had lower rates of postoperative SUI (TOT 12.5%, Burch 30%, ORâ€‰=â€‰0.15, 95% CI 0.04, 0.62). Relative risk reduction (RRR) in postoperative SUI for the TOT group compared with the Burch group was 79%-86%. There were no differences concerning intra- and postoperative complications. The Burch group had a higher rate of reoperation for persistent/recurrent SUI (Burch 25%, TOT 12% pâ€‰=â€‰0.078). CONCLUSIONS:The TOT group experienced a greater reduction in postoperative incontinence, and the Burch group underwent more repeat surgeries. The TOT sling may be superior in patients undergoing concomitant ASC.
Percutaneous tibial nerve stimulation associated with occipital headaches: a review of the adverse effects of percutaneous tibial nerve stimulation
Impact of Obesity on Robotic-Assisted Sacrocolpopexy
STUDY OBJECTIVE:To compare operative time in women stratified by body mass index (BMI) undergoing robotic-assisted sacrocolpopexy (RASC). Secondary objectives included characterizing perioperative characteristics and reoperation rates. DESIGN:Retrospective cohort study (Canadian Task Force classification II-2). SETTING:University-affiliated teaching hospital. PATIENTS:One hundred seventy-nine consecutive patients who underwent RASC by a single surgeon from 2009 throughÂ 2013. INTERVENTIONS:RASC. MEASUREMENTS AND MAIN RESULTS:). Overweight patients were significantly older, more parous, more frequently postmenopausal, and more frequently underwent concomitant salpingo-oophorectomy. Median operative times were 202, 206, and 216Â minutes in the normal-weight, overweight, and obese groups, respectively (pÂ =Â .53). CONCLUSION:Obese women undergoing RASC have similar operative time and procedural characteristics as normal-weight and overweight patients. Longer term outcomes are needed to ensure comparable surgical and anatomic success.
Update on Urinary Tract Markers in Interstitial Cystitis/Bladder Pain Syndrome
Interstitial cystitis (IC)/painful bladder syndrome/bladder pain syndrome (BPS) is a chronic hypersensory condition of unknown etiology. Moreover, the optimal modality for diagnosing IC remains disputed. Several urinary markers have been investigated that may have potential utility in the diagnosis or confirmation of IC/BPS. Thus, inflammatory mediators, proteoglycans, urinary hexosamines, proliferative factors, nitric oxide (NO), BK polyomavirus family, and urothelial proinflammatory gene analysis have been found to correlate with varying degrees with the clinical diagnosis or cystoscopic findings in patients with IC/BPS. The most promising urinary biomarker for IC/BPS is antiproliferative factor, a sialoglycopeptide that has demonstrated inhibitory effects on urothelial cell proliferation and a high sensitivity and specificity for IC/BPS symptoms and clinical findings. In this article, we review the urinary markers, possible future therapies for IC/BPS, and the clinical relevance and controversies regarding the diagnosis of IC/BPS.
Obstetric fistulae in West Africa: patient perspectives
OBJECTIVE: The objective of this study is to gain insight into the nature of obstetric fistulae in Africa through patient perspectives. STUDY DESIGN: At l'Hopital Saint Jean de Dieu in Tanguieta, Benin, 37 fistula patients underwent structured interviews about fistula cause, obstacles to medical care, prevention, and reintegration by 2 physicians via interpreters. RESULTS: The majority of participants (43%) thought their fistulae were a result of trauma from the operative delivery. Lack of financial resources (49%) was the most commonly reported obstacle to care, and prenatal care (38%) was most frequently reported as an intervention that may prevent obstetric fistulae. The majority (49%) of the participants requested no further reintegration assistance aside from surgery. CONCLUSION: Accessible emergency obstetric care is necessary to decrease the burden of obstetric fistulae in Africa. This may be accomplished through increased and improved health care facilities and education of providers and patients.
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.
Neglected pessary causing a rectovaginal fistula: a case report [Case Report]
BACKGROUND: Pessaries, properly maintained, have been shown to be safe for long-term care of symptomatic vaginal prolapse. Complications from neglected pessaries include impaction, erosion and fistula formation. Vesicovaginal fistulas have been described, but literature reports of rectovaginal fistulas are scarce. CASE: A 70-year-old woman, referred for pessary management, was found to have an impacted pessary that could not be removed due to pain. Examination under anesthesia revealed a Gellhorn pessary in the lumen of the rectum. It was removed transanally, leaving a large rectovaginal fistula. The patient was scheduled for reparative surgery in conjunction with colorectal surgery, but she cancelled the day before. CONCLUSION: For patients with a rectovaginal fistula resulting from an impacted vaginal pessary, a 2-stage procedure is required. The first stage, done under anesthesia, includes removal of the pessary and an examination to assess the size and location of the fistula. The second stage is operative management of the rectovaginal fistula, preceded by adequate bowel preparation. The clinician must stress proper pessary maintenance in order to avoid the serious consequences of a neglected pessary.
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%).