Anatomy of the pudendal nerve in clinically important areas: a pictorial essay and narrative review.

PURPOSE: The pudendal nerve is an anatomical structure arising from the ventral branches of the spinal roots S2-S4. Its complex course may be affected by surrounding structures. This may result in irritation or entrapment of the nerve with subsequent clinical symptoms. Aim of this study is to review the anatomy of the pudendal nerve and to provide detailed photographic documentation of the areas with most frequent clinical impact which are essential for surgical approach. METHODS: Major medical databases were searched to identify all anatomical studies investigating pudendal nerve and its variability, and possible clinical outcome of these variants. Extracted data consisted of morphometric parameters, arrangement of the pudendal nerve at the level of roots, formation of pudendal nerve, position according to sacrospinal and sacrotuberal ligaments and its terminal branches. One female cadaver hemipelvis was dissected with common variability of separate course of inferior rectal nerve. During dissection photodocumentation was made to record course of pudendal nerve with focus on areas with recorded pathologies and areas exposed to iatrogenic damage during surgical procedures. RESULTS: Narrative review was done to provide background for photodocumentation. Unique photos of course of the pudendal nerve was made in areas with great clinical significance. CONCLUSION: Knowledge of anatomical variations and course of the pudendal nerve is important for examinations and surgical interventions. Surgically exposed areas may become a site for iatrogenic damage of pudendal nerve; therefore, unique picture was made to clarify topographic relations.

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.

[Anterior colporrhaphy under local anesthesia]. / Prední posevní plastika v lokální anestezii.

OBJECTIVE: To evaluate the advantage of the usage of local anesthesia for vaginal surgery in gerontological patients. DESIGN: Prospective study. SETTING: Charles University in Prague, 1st Medical Faculty and Hospital Bulovka, Department of Obstetrics and Gynaecology, Prague. METHODS: 43 patients over 60, 4 were younger, with diagnosed descent of anterior vaginal wall G II-III according to International Continence Society classification, were included into the study. They underwent anterior vaginal wall repair in the sole local anesthesia. For the assessment of the procedure, we used anamnestic data and quality of life questionnaires Visual analogue scale, International Consultation on Incontinence Questionnaire - Short Form, Pelvic Floor Distress Inventory - 20. RESULTS: The results of used questionnaires confirmed positive results of the local anesthesia. We demonstrated statistically significant improvement of the urinary incontinence too, as well as subjective perception of the descent. CONCLUSION: Excellent subjective assessment of usage of local anesthesia showed us new operative possibility in treatment applicable in high-risk patients.

[Anticipated efficacy of HPV vaccination in prophylaxis against nongenital cancers]. / Predpokládaná úcinnost HPV vakcinace v profylaxi nongenitálních karcinomu

BACKGROUND: There is a considerable number of studies on the efficacy HPV (human papillomavirus) vaccination against different cancers but relevant information is scattered in diverse journals. This paper is a review summarizing current knowledge of the potential of HPV vaccination against all HPV related cancers. AIM: HPV infection is probably the most frequent sexually transmitted disease. At least 13 HPV genotypes are classified as carcinogenic or probably carcinogenic in respect to cervical cancer. Almost 100% of cervical cancers are linked to HPV infection. HPV 16 and HPV 18 are the most frequently involved genotypes and account together for approximately 70% of cervical cancer in the world. Persistent high risk HPV infection is responsible for a significant proportion of vulvar, vaginal, anal and penile carcinomas. The virus has also been implicated in oncogenesis of head and neck cancers, including oropharyngeal cancers. HPV infection can play an important role in cancerogenesis of lung, esophagus, breast, and colon and rectum. On the contrary, published results indicate that HPV infection is not associated with prostate oncogenesis. Strong predominance of HPV 16 has been reported for all HPV associated cancer sites. Generally, it is estimated that approximately 5.2% of all cancers are associated with oncogenic HPV infection. Currently, there are two vaccines on the market; quadrivalent Silgard® (Gardasil®) and bivalent CervarixTM. Large trials for both vaccines have shown efficacy against HPV related infection and disease. Efficacy has been very high in HPV naive subjects to vaccine related types. While HPV vaccination is currently approved for the prevention of cervical cancer, it also has the potential in the prevention of all HPV associated malignancies. The Czech republic belongs to countries that cover HPV vaccination of girls at the age of 13- 14 years by general health insurance. Overall impact of this vaccination remains to be evaluated. The new issues of the role of HPV in oncogenesis, as well as the potential effect of HPV vaccination against HPV related nongenital cancers are discussed. CONCLUSION: Approximately 5.2% of all human cancers are associated with oncogenic human papillomavirus infection. HPV vaccination against the most risky HPV oncotypes may cause a significant reduction of these cancers mainly in the HPV naive population.

[The reasons of changes in revised staging for carcinoma of the vulva]. / Duvody zmen ve stagingu karcinomu vulvy.

BACKGROUND: Review of revised staging system for vulva, explaining the changes of staging and their impact on the prognosis of disease is presented. AIM: The main objectives of a reliable staging system include an assessment of prognosis, planning treatment, and the evaluation of their outcomes. A good staging system must meet three basic characteristics: validity, reliability and practicality. Since medical research and practice in the field of oncology have shown explosive growth, the staging of vulvar cancer and some other cancers did not give a good spread of prognostic groupings. Changes based on new findings were proposed in 2008 by the FIGO Committee on Gynecologic Oncology, approved, and published a year later the changes in the staging system for carcinoma of the vulva. Stage 0 was deleted, since it represents preinvasive lesion. Stage IA remained unchanged and stage I and II were combined. The number and morphology of the involved nodes were taken into account, and the bilaterality of positive nodes has been discounted. CONCLUSION: The purpose of a good staging system is to offer a classification of the extent of gynecological cancer, in order to provide a method of conveying ones clinical experience to others for the comparison of different treatment methods. As a result of the explosion of medical research in the field of oncology, the staging of some of the gynecological cancers became outdated and did not give a good spread of prognostic groupings. According to the revised staging for carcimona of the vulva, patients are divided to groups with similar prognosis. Therefore, exchange of relevant information between oncological centers is facilitated, thus disseminating knowledge and stimulating research in other parts of the world.

[A comparison of different types of suburethral slings in the treatment of urinary incontinence in geriatric patients]. / Srovnání ruzných typu pásek v lécbe inkontinence moci u gerontologických pacientek.

OBJECTIVE: Comparison of different types of tension free tapes in the treatment of urinary incontinence in institutionalized elderly patients. DESIGN: Prospective randomized study. SETTING: Charles University in Prague, 1st Medical Faculty and Hospital Bulovka, Department of Obstetrics and Gynaecology, Prague. METHODS: 43 patients of several gerontologic centres with prevailing stress urinary incontinence were included based on urinary dysfunction specific questionnaire (ICIQ) and cognitive functions objective estimation (MMSE). Three types of tapes, TVT-O, MiniArc and Ajust were used and patients were randomized into the groups and after an urogynaecologic examination, incl. ultrasound the operation was performed. RESULTS: The groups were - except of the age of the patients of group MiniArc - well outweighted concerning demographic parameters. High success rate of all techniques used evaluated by the QoL questionnaires was in all the groups comparable. No case of bleeding, bladder injury or postoperative pain was found. Higher frequency of OAB de novo and worsening of preexisting symptomatics could be explained by general very high prevalence of OAB in the elderly even without the operation. In whole our cohort only 1 case of failure to treat and of tape exposure was found. Our results confirming high success rate of all the types also in elderly and institutionalized patients are in consent with sporadic published data. CONCLUSION: Surgical treatment of cases of stress and mixed urinary incontinence is also in cases of elderly polymorbid nurcing facilities clients with regard to the high success rate. Secondary outcome of our report when accepting the conclusion is drop of the costs of antiincontinence pads thus having a significant economic effect.

Case report: pelvic actinomycosis.

A case of pelvic actinomycosis is presented. The patient is 42-year-old female with a 5 weeks history of pelvic pain. An intrauterine device (IUD) was taken out 3 weeks ago. There is a lump length 9 cm between rectus muscles. Ultrasound, magnetic resonance imaging (MRI) and histology are used to make the diagnosis. Actinomycosis can mimic the tumour disease. The definitive diagnosis requires positive anaerobic culture or histological identification of actinomyces granulas. A long lasting antibiotic therapy is performed.

[New Single-Incision Sling System MiniArc in treatment of the female stress urinary incontinence]. / První zkusenosti s novou minipáskou k lécbe stresové inkontinence moci u zen--MiniArc.

OBJECTIVE: The aim of this paper is to introduce the new Single-Incision Sling System MiniArc in treatment of the female stress urinary incontinence. SUBJECT: Prospective follow up. SETTING: Department of Obstetrics and Gynaecology, The First Faculty of Medicine, Charles University in Prague. SUBJECT AND METHOD: Prospective follow up of the first set of 38 patients treated with the new method MiniArc. CONCLUSION: We performed initial 38 cases of MiniArc under the local anesthesia. There was neither the complication during procedure, nor during the early postoperative period. No patient required urine derivation. Late postoperative period showed neither obstruction, nor ,,de novo urgency". One asymptomatic sub-urethral tape protrusion into the vagina was found. No late postoperative pain occurred. Subjective cure rate was investigated in 33 ladies with follow up from 6 weeks through 19 months. 23 females declared full dryness (i.e., 76.7%), 6 patients were very satisfied and declared improvement of more than 70% (i. e. 20.0%); thus we obtained efficacy in 29 cases of 30 (i. e. 96.7%). We have not seen any vanishing of the sling effect. Based on our initial experience we judge the new single incision tape as very promising.

[Prolene mesh comparing with sacrospinal fixation in the treatment of genital prolapse in women. Prospective multicentre randomized study]. / Alogenni prolenové implantáty ve srovnání se sakrospinální fixací v lécbe prolapsu; randomizovaná multicentrická prospektivní srovnávací studie.

OBJECTIVE: Polypropylene mesh in the treatment of genital prolapse in women was introduced at the turn of the millennium with the rationale of decreasing surgical invasiveness, reinforcing weak tissues and to possibly complement insufficient surgical techniques. Prospective randomized studies comparing traditional and modern operations are lacking. SUBJECT: Prospective multicentre randomized study. SETTING: Department of Obstetrics and Gynaecology, The First Faculty of Medicine, Charles University in Prague. SUBJECT AND METHOD: A prospective multicentre trial was approved by the Ministry of Health of the Czech Republic and registered with the FDA planning to recruit 500 patients with vaginal prolapse, 18 years of age and over, undergoing surgery at 5 major urogynaecologic centres. The patients were divided into three groups according to prolapse predominance. The surgical techniques used were: anterior and posterior prolift, and randomly allocated total prolift or sacrospinous fixation. The examination setup included lower urinary tract ultrasound, MRI, POP-Q assessment and QoL questionnaires before surgery and six and 24 month after the surgery. CONCLUSION: Preliminary analysis of partial data of 225 women showed an acceptable rate of complications and a better success rate in the mesh groups, whereas operation time and blood loss was lower in the classical operation group. Quality of life questionnaires documented that all the methods used have comparably good results. The surgical techniques used are acceptable methods for pelvic organ prolapse repair with low complication rates and excellent impact on the subjective perception of the patient's quality of life.

Adhesive bowel strangulation after caesarean section, the rare puerperal complication.

Caesarean section is the most frequent abdominal operation carried out in obstetric practice. Parturients undergoing this operation are still exposed to a substantial rate of short- and long-term complications. The incidence of re-laparotomy after caesarean section is 0.12-0.70%. The most common indication for re-laparotomy is intra-abdominal bleeding, uterine atony, eventration, haematoma in the muscle and intra-abdominal abscesses. We present the case report of an unusual life-threatening complication of caesarean section that led to re-laparotomy. Caesarean section rate has been continually increasing globally in the last few decades, thus we also have to take into account unusual complications e.g. intestinal complication.

[Abortion induction in IInd trimester]. / Indukce potratu ve II. trimestru na Gynekologicko porodnické klinice FN na Bulovce.

STUDY AIM: Analysis of the set of women that underwent the termination of pregnancy in IInd trimester at the OBGYN clinic, Teaching Hospital Na Bulovce at interval of years 2006-2007. We appreciated the effect of method and compared with references in the literature. TYPE STUDY: Retrospective descriptive study. SEATTING: OBGYN clinic of the 1st faculty of Charles University, teaching hospital Na Bulovce, Prague. METHOD: Retrospective analysis of the set of women that underwent termination of pregnancy in the IInd trimester. Data are obtained from medical documentation and statistically processed. The analysis treats with 50 cases, in all of them, cervix was prepared with hydrophile dilators. In 37 cases were subsequently handed up prostaglandins intraamnially, in two cases generally intravenously, in two cases vaginally and 9 pregnancies were finished directly by dilatation and curettage without endeavour about expulsion. RESULTS: From 37 women after intraamnial administration of prostaglandins, 35 (94.6%) aborted successfully. Average time from amniocentesis to expulsion was 13 hours 45 minutes, 23 women aborted to 24 hours (62.2%). Undesirable effects were present in 12 cases (32.4%). CONCLUSION: Our record of local intraamnial administration of prostaglandins appears to be effective method. On the other hand, other methods are described in recent literature, which appear to be more efficient and have smaller occurrence of adverse effects.

Unrecognized primary genital herpes infection (case report).

The authors present a case report of unrecognized herpes genitalis, which was caused by primary HSV-1 infection. The 28-year old female was examined by three board certified gynaecologist and initially treated as mycotic vulvitis. The authors point out the atypical course in the patient without anti-HSV-1 and HSV-2 antibodies. This infection is rather very painful, extensive and with complications. Thus, it is necessary to consider the diagnosis and to begin antiviral therapy as soon as possible.

[Analysis of a group of HIV positive women who gave birth in the Czech Republic]. / Analýza souboru HIV pozitivních rodicek v Ceské republice.

OBJECTIVE: An analysis of HIV positive women who gave birth between 1st January 1985 to 31st December 2006 in the Czech Republic. SUBJECT: A retrospective descriptive analysis. SETTING: Teaching Hospital Bulovka, 1st Faculty of Medicine, Charles University, Prague. SUBJECT AND METHODS: The study included HIV positive women that gave birth between 1st January 1985 to 31st December 2006 at Bulovka hospital. The group of 62 HIV positive women (including 7 secundiparae) gave birth to 71 new-borns (twice twins). The deliveries were performed by C-section. We interrupted breast-feeding by all these women. RESULTS: All new-borns were born alive, no one had Apgar score less than 7 at five minutes. No congenital disorders were found. Three new-borns were transfered to Intensive care unit for new-born babies, two due to dysmaturity and one due to abstinence syndrome. 3 new-borns out of total 71 new-borns were HIV positive (4.2%). CONCLUSION: Routine prenatal screening for HIV and high-quality cooperation between obstetricians and infection control doctors are the basic condition of low rate of vertical trasmission HIV infection in the Czech Republic.