Rectovaginal fistula model in the New Zealand white rabbit.

INTRODUCTION AND HYPOTHESIS: The purpose of this study was to create an animal model to study rectovaginal fistula repair. METHODS: Fourteen New Zealand white rabbits underwent surgical creation of a rectovaginal fistula. The technique was developed with a pilot study conducted on the first two animals, then standardized and performed on the remaining 12 rabbits. The standardized technique included making a defect in the rectovaginal septum using a 3-mm skin punch then splinting the defect with 6-mm tubing for 2 weeks. RESULTS: Using the standardized technique, a fistula was successfully created in all 12 rabbits ranging from 1 to 5 mm (mean = 2.8 mm, SD = 1.1). A 95% tolerance interval was calculated for the model and predicted that a successful fistula can be created ranging from 0.3 to 5.2 mm in 85% of attempts with the model. CONCLUSION: The New Zealand white rabbit is a promising animal model to study rectovaginal fistula repair.

Overactive bladder medication adherence when medication is free to patients.

PURPOSE: We examined overactive bladder medication compliance in a health care system in which patients do not pay for medication. MATERIALS AND METHODS: Pharmacy dispensing records were reviewed for antimuscarinic agents from January 2003 to December 2006 for the United States Military Health System National Capital Region. Medication nonpersistence, switching and adherence were examined. Kaplan-Meier survival analysis was done to compare medication persistence duration. RESULTS: Overactive bladder medications were dispensed to 7,879 adults. Tolterodine extended release (4,716 patients or 60%) and oxybutynin immediate release (2,003 or 25.5%) were most commonly prescribed. The medication nonpersistence rate, defined as the proportion of patients who never refilled a prescription for antimuscarinics during the study period, was 35.1% (2,760 of 7,858). Of 5,098 patients who refilled a prescription 1,305 changed the medication or dose at least once for a medication switch rate of 25.6%. The overall median medication possession ratio, defined as the total days of medication dispensed except for the last refill divided by the number of days between the first dispense date and the last refill date, was 0.82 in all cases. Men had a significantly higher median medication possession ratio than women (0.86 vs 0.81, p <0.001). Of patients who obtained at least 1 refill women remained on medication longer than men (median 606 vs 547 days, p = 0.01). Patients on tolterodine extended release had a higher medication nonpersistence rate than those on oxybutynin immediate release (0.89 vs 0.68, p <0.01). There was no difference between extended release medications. CONCLUSIONS: In a health care system in which patients do not pay for medications 35% of patients did not refill a prescription for overactive bladder medication, similar to previous reports. However, other measures of medication compliance were higher than those published previously in systems with copays.

Prophylactic Burch colposuspension at the time of abdominal sacrocolpopexy: a survey of current practice patterns.

INTRODUCTION: The purpose of this study was to determine the utilization of the prophylactic Burch procedure with abdominal sacrocolpopexy since the publication of the Colpopexy and Urinary Reduction Efforts (CARE) trial. METHODS: Using an Internet survey, 1,134 members of the American Urogynecological Society (AUGS) were contacted in May 2008 and questioned regarding their practice patterns to prevent de novo stress incontinence after sacrocolpopexy. RESULTS: Two hundred sixty-six responses were obtained for a 23% response rate. Of the 235 respondents actively performing sacrocolpopexies, 133 (57%) would not perform a prophylactic Burch colposuspension at the time of sacrocolpopexy in a woman without symptoms of stress urinary incontinence. Respondents were more likely to perform a prophylactic Burch if it had been more than 6 years since they completed residency or fellowship training. CONCLUSIONS: Prophylactic Burch colposuspension at the time of abdominal sacrocolpopexy has not been uniformly implemented into clinical practice by AUGS members since the publication of the CARE Trial.

The racial distribution of female pelvic floor disorders in an equal access health care system.

PURPOSE: We examined ethnic differences in female pelvic disorders in an equal access health care system. MATERIALS AND METHODS: An electronic medical record review was performed for patients with pelvic floor disorders at a military female pelvic medicine and reconstructive surgery division for a 1-year period. Primary diagnosis codes and patient reported race were reviewed. RESULTS: Mean +/- SD cohort age was 55 +/- 16.3 years. A total of 720 patients were identified, of whom 68.8% were white and 18.6% were black. Pelvic organ prolapse was the primary diagnosis in 34.2% of the women, while 19.7% had stress urinary incontinence and 10.8% had urge urinary incontinence. There was no difference in the prevalence of prolapse between black and white women. However, of patients with incontinence there was a statistically significant difference with urge incontinence in more black women (51.2%) and stress incontinence in more white women (66.2%) (chi-square p <0.05). CONCLUSIONS: There is a similar ethnic distribution of pelvic organ prolapse in an equal access health care system. Of women with incontinence there was a higher prevalence of urge urinary incontinence in black women and a higher prevalence of stress urinary incontinence in white women.

Utility of ultrasound in the combat theater: experiences of a gynecologist during Operation Iraqi Freedom/Operation Enduring Freedom.

OBJECTIVE: The purpose of this study was to evaluate the utility of ultrasound in a combat theater. METHODS: A retrospective review of gynecology visits was evaluated at Camp Doha, Kuwait, from August 2003 through April 2004. Of the 1,737 visits, 237 required pelvic ultrasound. Demographic information, as well as the indications, diagnosis, and disposition of the patients, was compiled. RESULTS: The average age of the patient requiring ultrasound was 28 +/- 8 years. The primary presenting complaint was pelvic pain. Forty percent with pelvic pain had no identifiable cause. The most common final diagnosis was pregnancy. Of the 237 visits, the use of ultrasound resulted in 136 return-to-duty dispositions. Of the 31% who were administratively redeployed, the majority were secondary to pregnancy. CONCLUSION: Gynecologic ultrasound was found to be a very useful tool in the combat theater. Ultrasound resulted in improved diagnostic ability and enhanced reassurance to both provider and patient.

Pregnancy during Operation Iraqi Freedom/Operation Enduring Freedom.

OBJECTIVE: The purpose of this study was to evaluate pregnancy during war-time deployment. METHODS: A retrospective review of gynecology visits was evaluated at Camp Doha, Kuwait, from August 2003 through April 2004. Of the 1,737 visits, 77 demonstrated a positive pregnancy test. These charts were evaluated for factors that may lead to important information for future deployments. RESULTS: The average age of the female soldier with a positive pregnancy test in theater was 27 +/- 7 years. The primary presenting complaint was amenorrhea. Ninety-two percent had an ultrasound. Fifty-four percent of visits were active duty, followed by Reserve, National Guard, and civilian government employees. Ninety-two percent were administratively redeployed. Seventy-seven percent of the soldiers became pregnant in country. Twenty-three percent arrived in country pregnant. CONCLUSIONS: Given the number of pregnancies before and during deployment, current screening procedures as well as new concepts in prevention need to be addressed.

Sexually transmitted diseases in Operation Iraqi Freedom/Operation Enduring Freedom.

OBJECTIVE: To identify the incidence of sexually transmitted diseases (STDs) in a female active duty population deployed in support of Operation Iraqi Freedom/Operation Enduring Freedom was the objective of this study. METHODS: Retrospective chart review was completed on all soldiers seeking outpatient gynecologic care at Camp Doha, Kuwait, from September 2003 through March 2004. Descriptive statistical analysis was performed on data from all patients identified as having an STD. RESULTS: Forty-four soldiers (2.5% of all encounters) were diagnosed with STDs during the study period. Genital herpes, Condyloma acuminata, and chlamydia were the most commonly identified infections accounting for 30, 25, and 21% of the diagnoses, respectively. CONCLUSION: Transmission of STDs in the deployed environment continues to be problematic. Viral infections were more commonly encountered than were bacterial infections. Patient education and prevention should be emphasized. Consideration should be given to STD screening upon redeployment.

Pelvic pain presenting in a combat environment.

OBJECTIVE: The objective was to identify the incidence of pain disorders in the deployed female active duty population in support of Operation Iraqi Freedom. METHODS: Retrospective chart review was completed on all patients who were seen for gynecologic services at Camp Doha, Kuwait, from September 2003 through March 2004. One thousand seven hundred thirty-seven patients were identified. Statistical analysis was performed. RESULTS: Of the 1,737 patients seen during the study period, 150 patients were identified as having a pelvic pain disorder. These patients accounted for 14% of all patients seen for gynecologic services. Mean age was 28 +/- 8 years (range, 15-53 years). Pelvic pain of unclear etiology and cystitis were the most common diagnoses made accounting for 19% and 16% of encounters. CONCLUSIONS: Acute pelvic pain disorders can be effectively managed in the combat environment. Optimization of predeployment regimens for management of pain is strongly recommended. Consideration should be given to making soldiers with chronic pelvic pain disorders that fail to respond to predeployment medical management nondeployable.

Complications after laparoscopic burch with hernia mesh and surgical tacks.

BACKGROUND: The Burch retropubic urethropexy for the repair of stress urinary incontinence can be performed laparoscopically. Advances in laparoscopic technique have led some surgeons to perform this procedure with hernia mesh and surgical tacks. CASE: A postmenopausal woman presented with complaints of lower abdominal pain, dyspareunia, dysuria, and urinary urgency and frequency after a laparoscopic Burch and paravaginal repair. Bimanual examination revealed tenderness over the pelvic floor muscles and anterior vaginal wall. Exploratory laparotomy revealed dense fibrous adhesions in the space of Retzius along with mesh, permanent suture, and 13 helical tacks. CONCLUSION: Laparoscopic procedures that use hernia mesh fastened with surgical tacks should not be used in the vagina or surrounding structures.

Acute dysuria among female soldiers.

OBJECTIVE: To assess behavior patterns among active duty female soldiers presenting to military care facilities for acute dysuria. METHODS: A self-administered questionnaire was developed. One hundred twelve female soldiers presenting with acute dysuria and one hundred twenty-six presenting for other reasons were surveyed. RESULTS: During regular duty hours, the dysuria group drank less than the control group (21% and 14%, respectively; p = 0.004). However, field duty appeared to compound this problem, with the dysuria group drinking considerably less than the control group (79% and 19%, respectively; p = 0.002). Both groups stated that they postponed urination during working hours. The dysuria group postponed urination more than did the control group during regular duty (75% and 53%, respectively; p = 0.006) and field duty (79% and 65%, respectively; p = 0.008). CONCLUSIONS: Female soldiers presenting with dysuria were more likely to report fluid restriction and to postpone voiding during duty, behaviors that were reported even more frequently during field duty. Fluid restriction and postponed urination may be significant factors in the development of acute dysuria among female soldiers.

Arcus tendineus fascia pelvis: a further understanding.

OBJECTIVE: The study was undertaken to further define the anatomy of the arcus tendineus fascia pelvis (ATFP). STUDY DESIGN: Thirty cadavers were dissected to find the average length, SD, and range of the ATFP. Comparisons were made to height and pelvis type. The average distance between the ischial spine and the attachment of the fascia of the rectovaginal septum (RVF) to the ATFP was measured. RESULTS: The average length, SD, and range in centimeters for the ATFP are 9.0, 0.70, and 7 to 10.5, respectively. The length of the ATFP increased with height. No associations could be made regarding pelvis type. The average distance between the ischial spine and the attachment of the RVF to the ATFP is 2.15 cm with a SD and range of 0.21 and 1.75 to 2.5, respectively. CONCLUSION: In this study, an average length for the ATFP is established and the distance between the ischial spine and the attachment of the RVF to the ATFP is redefined.

Evaluation of the effect of meconium on assessment of fetal lung maturity status by TDxFLM II testing.

OBJECTIVE: To evaluate the effect of meconium contamination on the TDxFLM II assay. METHODS: Amniotic fluid was collected from patients undergoing amniocentesis for obstetric indications between 31 and 40 weeks of gestation. A baseline TDxFLM II value was obtained and compared with amniotic fluid contaminated with 1%, 5%, and 10% meconium by weight. RESULTS: Twenty-one samples were studied, and in every case the TDxFLM II value decreased once the meconium was added. There was no consistent rate of decrease that correlated with the percentage of meconium added. CONCLUSION: Meconium contamination decreases the TDxFLM II value. A clinician who performs this test in the presence of meconium can be reassured that the contamination will not give an artificially elevated result. If the result is in the mature range, one can be confident that the result would only be higher if meconium were not present.