Characterizing and reporting pelvic floor defects: the revised New York classification system.

The authors have devised a conceptual model and reporting system for characterizing, grading and staging pelvic floor defects. The system is user friendly and simple to learn and apply. It is based on commonly known anatomic landmarks and can be performed without memorizing or referring to a separate characterization and reporting plan. Completing the accompanying forms is self-explanatory and provides the information needed for proper comprehension and recording of anatomic defects. The model and reporting format have been used at our institutions for 5 years by medical students, residents, fellows and attendings. It has several advantages over the Pelvic Organ Prolapse Quantitation (POPQ) system: (1) it uses known anatomic landmarks rather than alphabetic labels; (2) it grades lateral wall defects which the POPQ system omits; (3) it recognizes and reports isolated defects or tears which present as bulges in the vaginal walls without downward linear descent (prolapse); (4) it uses a one-page reporting form and a one-page checklist and vaginal profile; (5) it can be done easily in both the supine and the standing positions; (6) it requires simple instruments and a disposable measuring tape available in most office settings; (7) it includes urethral hypermobility in its reporting scheme; (8) it includes cervical length, perineal descent and other measurements in its reporting scheme; and (9) it is similar enough to the POPQ system that easy conversion to, and integration with, the POPQ reporting form and vaginal profile is possible. Prospective trials testing the validity of this system and comparing it with the POPQ system for validity, reliability, reproducibility, test-retest analysis, and interobserver and intraobserver variance are warranted.

Krukenberg tumors: can management be improved?

OBJECTIVE: The Montefiore Medical Center experience with women with gastrointestinal (GI) cancer was reviewed to: (1) evaluate clinical parameters in patients with Krukenberg tumor (GI cancer metastatic to the ovaries) and (2) evaluate oophorectomy in GI cancer patients. METHODS: (1) Charts of all female patients admitted between 1985 and 1996 with gastric or colon cancer were reviewed. RESULTS: The frequency of Krukenberg tumor was 7/1,021 (0.7%). The median age at presentation was 39.5 years (range 35-80); 5 were premenopausal, 2 of whom were postpartum. Krukenberg tumor was significantly more common in the premenopausal patients with gastric cancer (p = 0.002), colon cancer (p = 0.001), and in both sites combined (p < 0.001). Our rate of pregnancy-associated Krukenberg tumors (28.6%) was significantly higher (p < 0.05) than that found in 4 of 5 large studies. The average survival of our 7 patients was 12.3 months (range 4 days to 26 months), with secondary debulking and chemotherapy offering 1 patient the longest longevity. Only 19/788 (2.4%) women had oophorectomy during their colon cancer surgery revealing 2 (10.5%) Krukenberg tumors, 6 (31.6%) benign solid or cystic ovarian tumors, and 11 (57.9%) normal or atrophic ovaries. CONCLUSIONS: Krukenberg tumors are rare. There is no uniformity of data reported in the literature. Krukenberg tumors were more common in premenopausal women with gastric or colon cancer compared to postmenopausal women. Our rate of pregnancy-associated Krukenberg tumors appeared to be higher compared to other studies. Prophylactic oophorectomy in pre- and postmenopausal women should be considered at the time of GI cancer surgery, and requires further study. A national registry combined with prospective, multisite studies are needed to gather data and evaluate treatment.

Paravaginal repair of lateral vaginal wall defects by fixation to the ischial periosteum and obturator membrane.

OBJECTIVE: The aim of the study was to evaluate the anatomic basis, efficacy, and safety of a technique for correcting lateral wall vaginal defects. STUDY DESIGN: Phase I was cadaveric dissection carried out to ascertain the strength and position of structures likely to support lateral vaginal wall defects. The ischial periosteum just anterior to the ischial spine was found to be strong tissue, relatively free of nerves and vessels. In phase II, paravaginal defects were repaired by placing sutures through the arcus tendineus and underlying obturator fascia, obturator membrane, and ischial periosteum. Other defects and urinary incontinence were corrected within the same surgical setting. Forty patients were followed up for an average of 39 months (range 7-52 months). Preoperative evaluation consisted of an extensive history, cough stress test, spontaneous uroflowmetry, postvoid residual urine determination, urethral axis determination, site-specific pelvic floor defect evaluation, and multichannel urodynamic studies. After the operation patients underwent evaluations at 3 months, at 6 months, and then annually. RESULTS: Objective site-specific re-examination of the 40 patients revealed the following recurrences: lateral wall in 1 of 40 procedures, anterior wall in 3 of 35 procedures, posterior wall in 1 of 36 procedures, and apical wall in 1 of 27 procedures. Thirty-four of 36 women (94.4%) with urodynamically confirmed genuine stress incontinence or potential incontinence achieved cure (P <.001). CONCLUSIONS: (1) The ischial periosteum and obturator membrane are consistently strong reattachment sites. (2) Repair of paravaginal defects with these tissues is effective and safe. (3) Urodynamic parameters were unchanged after the operation except for measures of incontinence, which were improved (P <.001). (4) Performing other pelvic procedures did not negatively alter the success rates of paravaginal repair. (5) The urethral axis was favorably altered after the operation (P <.01).

Antecedent history as a predictor of surgical cure of urgency symptoms in mixed incontinence.

OBJECTIVE: To determine the cure rate of urge incontinence after Burch colposuspension in patients with mixed incontinence diagnosed urodynamically, to determine if cure rates were different when the onset of urge symptoms antedated or postdated the symptoms of stress incontinence, and to propose appropriate preoperative counseling of patients based on this information. METHODS: Forty-six women with urodynamically diagnosed genuine stress incontinence and detrusor instability underwent Burch colposuspension. History of chronologic onset of stress incontinence or urge incontinence was recorded. Detailed history, clinical examination, and multichannel urodynamic and other functional studies were carried out on each patient preoperatively and postoperatively. Postoperative urodynamic studies were performed only in patients with persistent symptoms. Patients were assigned to the antecedent stress or antecedent urge group depending on which symptom(s) occurred first. Cure rates in each group were calculated and compared with history of incontinence. RESULTS: Fifty-eight of 82 patients with complaints of both stress and urge incontinence were diagnosed urodynamically as having mixed incontinence; 46 of them met the study criteria and underwent Burch colposuspension. Stress incontinence preceded urgency in 28 of the 46 patients (61%); urgency occurred first in the remaining 18 (39%). The cure rate of 78.6% (22 of 28) for urge incontinence was statistically significantly greater in the antecedent stress group compared with 22.2% (four of 18) in the antecedent urge group (P < .001). CONCLUSION: Patients with a primary presenting symptom of stress incontinence who later develop urge incontinence are 2.5 times more likely to be cured of urge incontinence by Burch colposuspension than patients whose primary presenting symptom is urge incontinence.

Postgraduate internship in gynecology and obstetrics for physician assistants: a 4-year experience.

Changes in the Hospital Code (405 Regulations) to limit the number of hours worked by residents have been implemented in New York state and may soon become a nation-wide policy. Although their goal is to guarantee quality of patient care and assure education for residents, the limitation of hours worked has increased manpower shortages, some of which could be resolved by using physician assistants with specialty training. To provide this training, a Postgraduate Internship in Gynecology and Obstetrics for Physician Assistants has been developed at the North Central Bronx Hospital and the Montefiore Medical Center. It is the first program of its kind at the postgraduate level to educate physician assistants specifically for practice in obstetrics and gynecology. The program consists of 3 months of didactic lectures to review and update knowledge on topics in medicine, surgery, gynecology, preoperative and postoperative care, cardiac and trauma life support, and critical care, followed by a clinical year similar to that of a rotating physician intern. We believe that such postgraduate educational opportunities in gynecology and obstetrics benefit both the individual physician assistant's growth and development and the level of care delivered, and may be an answer to staffing needs.

Abnormal cervical cytology leading to the diagnosis of gastric cancer.

There have been nine cases reported in the English literature in which the finding of malignant cells on cervical/vaginal cytology led to the diagnosis of primary gastric cancer. We report on a patient with gastric carcinoma, metastatic to the cervix, in which the diagnosis was suspected by the finding of signet ring cells on a Papanicolaou smear of the cervix. Prior to treatment of this patient, concordance of signet ring carcinoma on cervical and ascitic fluid cytology and on cervical and gastric biopsies was documented; this has not been reported previously. Thirty-four additional cases of gastric carcinoma metastatic to the cervix are reviewed. This paper is presented to remind the clinician that, however rare, metastases from the gastrointestinal tract to the uterine cervix do occur.

Primary ovarian pregnancy two years after bilateral tubal ligation. A case report.

This is the first documented case of intrafollicular ovarian pregnancy following bilateral tubal ligation. The patency of the previously ligated tube was demonstrated by hysterosalpinography. It appears that the incidence of ovarian pregnancy is not related to the rising incidence of tubal pregnancy.

Spontaneous clostridia gas gangrene of uterus associated with endometrial malignancy.

Only four patients with clostridia sepsis in association with gynecologic malignancy have been reported, all of whom had prior diagnostic or therapeutic intervention. Our patient is the first documented case of such clostridium sepsis that occurred spontaneously, i.e., without previous trauma, instrumentation, radiation or chemotherapy. The value of aggressive management is reviewed.

Cystic papillary hidradenoma of the vulva: case report and review of the literature.

Papillary hidradenoma of the vulva is a rare, benign neoplasm arising from apocrine sweat glands of the skin. Frequently, this lesion has been mistaken for carcinoma. The treatment of choice is local excision. The prognosis for patients with this tumor is excellent. We present a patient who is unique because she had a lesion which was the largest ever recorded, and which existed over twice as long as any previously described. This case is also presented to remind the clinician that, despite the gross appearance of the tumor which resembles carcinoma on sectioning, biopsy and histological diagnosis should guide the ultimate management of patients with such lesions. The findings in our patient support the view that no matter how large or how long in existence, hidradenoma remains benign.

Pararenal hematoma as a complication of vaginal hysterectomy. A case report.

Following a vaginal hysterectomy, a woman developed a pelvic hematoma that expanded in the retroperitoneum to the level of the right kidney. Such a complication, a pararenal hematoma after vaginal hysterectomy, has not been reported on previously. The cuff hematoma was demonstrated clearly by ultrasonography. However, the extent and dimensions of the retroperitoneal hematoma were disclosed only by computed tomographic (CT) scanning. We recommend that a the CT scan be considered in the evaluation of any large posthysterectomy pelvic hematoma.

Retroperitoneal hematoma from a ruptured tubal pregnancy as an unusual cause of a pelvic mass. A case report.

Retroperitoneal hematoma can result from a ruptured tubal pregnancy and present as a pelvic mass. Such a case has not been described previously.

Abdominal wall actinomycosis associated with an IUD. A case report.

Abdominal wall actinomycosis without pelvic organ involvement in users of intrauterine contraceptive devices (IUDs) has not been reported on previously. We encountered one such patient, whose uterine cervix was colonized superficially with Actinomyces. We suggest that systemic actinomycosis be included in the differential diagnosis of pain in IUD users when Actinomyces is found on Papanicolaou smears or in endocervical curettings. Such patients should be treated with appropriate antibiotic therapy, especially prior to any surgical intervention.

PIP: This paper presents the 1st reported case of actinomycosis of the subcutaneous tissues and abdominal wall without pelvic organ involvement in an IUD user. The patient, a 39-year old woman, para 4-0-1-4, presented with lower abdominal pain. Pap smear findings were reported as cervical intraepithelial neoplasia, grade I-II, and endocervical curettage showed colonies of Actinomyces species. A subsequent cone biopsy revealed carcinoma in situ but no evidence of Actinomyces. The final diagnosis was cervical intraepithelial neoplasia, leiomyomata, and actinomycotic abscesses of the abdominal wall. It is suggested that systemic actinomycosis be included in the differential diagnosis of pain in IUD users when Actinomyces is found on Pap smears or in endocervical curettings. Treatment of actinomycosis generally involves intravenous aqueous penicillin, 10-20 million units/day for 4-5 days, followed by 2-15 million units/day of oral penicillin for 3 weeks-1 year. Longterm antibiotic therapy is particularly important prior to any surgical intervention. If left untreated, actinomycosis can lead to infection, brain abscess, or death.

Paraganglioma complicating pregnancy and the puerperium.

A rare case of a paraganglioma (extraadrenal pheochromocytoma) that complicated both pregnancy and the puerperium is described. The patient presented a confusing clinical picture simulating pregnancy-induced hypertension, which, after delivery, masqueraded as intractable fever of unknown origin. Computed tomography precisely identified the presence and location of the mass, which had eluded detection despite exhaustive testing. Pheochromocytoma should be considered in the differential diagnosis of postpartum fever of unknown origin, especially if associated with paroxysmal hypertension.

Carcinoembryonic antigen levels in the diagnosis of malignant lesions of the abdominopelvic region.

The differential diagnosis of tumors of the abdominopelvic region can be difficult. The inability to differentiate carcinoma of the colon and rectum from carcinoma of the ovary, in particular, may result in inadequate surgical procedures and unnecessary complications. In this study, elevated pretreatment levels of carcinoembryonic antigen were used as an aid in distinguishing between extragenital and gynecologic tumors in 76 women. Levels below 10 nanograms per milliliter suggested a malignant tumor of the female reproductive tract or benign disease; levels above 20 nanograms per milliliter indicated carcinoma of an extragenital organ. In addition to other diagnostic studies, pretreatment values of carcinoembryonic antigen may enable the physical to anticipate the specificity of the tumor and the scope of the surgical problem more precisely and, thus, be better able to prepare the patient for optimum treatment.

Current concepts of defibrination in the pregnant woman.

The possible predisposing causes of difibrination in the pregnant woman are discussed. Coagulation profiles and qualitative and quantitative assessment of fibrinolytic activity during labor, delivery and the early puerperium in normal pregnancies are presented. These factors were also studied in patients with abruptio placentae and prolonged intrauterine fetal death and in women whose pregnancies were terminated with intraamniotic infusion of hypertonic saline or prostaglandin F2alpha. The findings suggest that a minor degree of physiologic defibrination develops during normal labor that is qualitatively similar to, but of much lesser magnitude than, the pathologic defibrination syndrome commonly associated with abruptio placentae or prolonged intrauterine fetal death. Some degree of defibrination occurs in women undergoing saline abortion, similar to that of women during normal parturition, but does not usually reach clinically significant levels. The coagulation changes seen during prostaglandin abortion suggest that a minor degree of defibrination occurs that is substantially less than that seen during saline abortion. The findings presented form a basis for the rational management of defibrination in the pregnant woman.

Defibrination in obstetrics. Modern concepts.

Coagulation profiles of serum fibrinogen, factors V and VIII and haemoglobin in normal pregnancies during labour, delivery and the early puerperium are presented. These factors were also studied in patients with abruptio placentae, in intra-uterine death, and in patients whose pregnancies were terminated with intra-amniotic saline and prostaglandin F2alpha. An assessment of fibrinolytic activity in these patients was made using qualitative (euglobulin lysis time) and quantitative (FR-antigen) tests. The coagulation findings presented form a basis for the rational management of defibrination in obstetrics.