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.

Neglected pessary causing a rectovaginal fistula: a 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%).

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.

Rupture of a tuboovarian abscess into the anterior abdominal wall: a case report.

BACKGROUND: Rupture of a tuboovarian abscess is a life-threatening emergency. The current standard of care is surgery to manage the onset of peritonitis and sepsis. CASE: A 34-year-old woman presented with gradually worsening abdominal pain over several weeks. She had fever, pelvic tenderness, an elevated white blood cell count and ultrasonographic evidence of a tuboovarian abscess. After 48 hours of triple antibiotic therapy without a clinical improvement, she underwent surgery, during which she was found to have an abscess that had ruptured into the abdominal wall. A supracervical hysterectomy/bilateral salpingo-oophorectomy and surgical debridement of the subcutaneous tissue was performed, with wet to dry dressing changes of the surgical wound. Over the following 18 months, the patient required extensive wound care for recurrent bouts of wound drainage. CONCLUSION: Rupture of a tuboovarian abscess usually presents with sudden worsening of the patient's condition. Delays in surgical debridement and drainage increase the rate of associated mortality. Atypical presentations may present as cases resistant to conventional medical therapy, with fewer of the associated risks of life-threatening peritonitis and subsequent sepsis. Our patient represents the first reported case of extraperitoneal spillage of abscess contents from rupture of a tuboovarian abscess into the anterior abdominal wall.

Incisional bladder hernia and refractory urinary urgency after pelvic surgery: a case report.

BACKGROUND: Isolated incisional herniation of the bladder is very rare following pelvic surgery and may present as suprapubic discomfort. We report a case of incisional bladder hernia following pelvic surgery presenting as refractory urinary urgency. CASE: A 70-year-old woman, para 2, presented with a long history of suprapubic tenderness and refractory urinary urgency following reconstructive pelvic surgery. Over the 3 years following her surgery, multiple physicians evaluated the patient but were unable to find a definitive source of her urgency. She had used multiple anticholinergic agents without relief of the symptoms. A complete urogynecologic evaluation, radiologic imaging and high clinical suspicion for incisional hernia revealed a bladder hernia. Surgical exploration confirmed the fascial defect and bladder hernia. Herniorrhaphy corrected the defect and relieved the patient's symptoms of refractory urgency. CONCLUSION: An incisional bladder hernia may present as refractory urinary urgency following reconstructive pelvic surgery. Strong clinical suspicion can allow earlier diagnosis and surgical treatment of this rare condition. Primary herniorrhaphy offers successful repair of the fascial defect and resolution of the urgency symptoms.

Delayed urethral erosion after tension-free vaginal tape.

Urethral erosions have been reported with various sling materials placed by means of various techniques. The patient often presents in the immediate postoperative period, although late presentations have been described. The diagnosis is made on cystoscopy, and mesh excision with urethral reconstruction is advocated. We present the cases of two patients with urethral erosion after mid-urethral polypropylene sling who presented 3 months after surgery with urethral pain, mid-urethral blockage and symptoms of bladder dysfunction. Urethroscopy revealed the mesh bridging the lumen of the urethra. Trans-vaginal mesh excision and layered urethral reconstruction was curative in both patients.

Fecal incontinence: a review of prevalence and obstetric risk factors.

Anal incontinence (AI) is a significant problem that causes social and hygienic inconvenience. The true prevalence of AI is difficult to estimate due to inconsistencies in research methods, but larger studies suggest a rate of 2-6% for incontinence to stool. There is a significant association between sonographically detected anal sphincter defects and symptoms of AI. The intrapartum factors most consistently associated with a higher risk of AI include: forceps delivery, third or fourth degree tears, and length of the second stage of labor. Fetal weight of > 4,000 g is also associated with AI. Repair of the sphincter can be performed in either an overlapping or an end-to-end fashion, with similar results for both methods. The role of cesarean delivery for the prevention of AI remains unclear, and further study should be devoted to this question.

Pessary use in advanced pelvic organ prolapse.

The objective of this study was to review our experience with pessary use for advanced pelvic organ prolapse. Charts of patients treated for Stage III and IV prolapse were reviewed. Comparisons were made between patients who tried or refused pessary use. A successful trial of pessary was defined by continued use; a failed trial was defined by a patient's discontinued use. Thirty-two patients tried a pessary; 45 refused. Patients who refused a pessary were younger, had lesser degree of prolapse, and more often had urinary incontinence. Most patients (62.5%) continued pessary use and avoided surgery. Unsuccessful trial of pessary resorting to surgery included four patients (33%) with unwillingness to maintain, three patients (25%) with inability to retain and two patients (17%) with vaginal erosion and/or discharge. Our findings suggest that pessary use is an acceptable first-line option for treatment of advanced pelvic organ prolapse.

Evaluation of the role of pudendal nerve integrity in female sexual function using noninvasive techniques.

OBJECTIVE: Using quantitative sensory testing and a validated questionnaire, we investigated the role of pudendal nerve integrity in sexual function among women. STUDY DESIGN: Participants completed the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ). Vibratory and pressure thresholds were measured at the S2 dermatome reflecting pudendal nerve distribution. RESULTS: A total of 56 women enrolled; 29 (51.8%) were asymptomatic and 27 (48.2%) had 1 or more forms of female sexual dysfunction (total sexual dysfunction) including: desire disorder 16.1%, arousal disorder 26.8%, orgasmic disorder 25%, and pain disorder 12.5%. Age, parity, menopausal status, and body mass index were similar between groups. PISQ scores were lower in symptomatic subjects compared with controls (P < .001). Decreased tactile sensation was found at the clitoris for women with total sexual dysfunction, desire disorder, and arousal disorder. Women with arousal disorder also had decreased tactile sensation at the perineum. CONCLUSION: Pudendal nerve integrity may play a role in female sexual dysfunction.

Inflammatory reaction following bovine pericardium graft augmentation for posterior vaginal wall defect repair.

Graft augmentation for repair of recurrent pelvic organ prolapse is commonly used in reconstructive pelvic surgery. The reported complications are mainly late onset. We report a case of early-onset inflammatory reaction following bovine pericardium graft augmentation for posterior vaginal wall defect repair. A 49-year-old presented with a recurrent and symptomatic posterior vaginal wall defect. She underwent an uneventful site-specific repair and bovine graft augmentation. Her early postoperative course was complicated by inflammatory response to the graft presenting as intense pelvic floor spasm and urinary retention. The condition was managed conservatively and resolved subsequently. One year later, the patient continues to be asymptomatic. Transient intense pelvic floor spasm and urinary retention can be the result of inflammatory reaction following graft augmentation with bovine pericardium for posterior vaginal wall defect repair.

Pessary reduction and postoperative cure of retention in women with anterior vaginal wall prolapse.

This study aimed to determine whether preoperative pessary reduction of anterior vaginal wall prolapse in patients with elevated postvoid residual (PVR) volumes relieves urinary retention, and if reconstructive pelvic surgery in these patients cures urinary retention. The records of all women with symptomatic anterior vaginal wall and urinary retention (PVR >or=100 cc) who underwent evaluation and surgical repair of the anterior vaginal wall at our institution between 1996 and 1999 were retrospectively reviewed. All patients underwent a detailed urogynecologic and urodynamic evaluation and had a pessary trial prior to surgery. Cure of urinary retention was defined as PVR <100 cc at 3 months postoperatively. Sensitivity, specificity, positive and negative predictive values for pessary reduction testing were calculated. Twenty-four patients met the inclusion criteria. Two patients (8%) had stage 2, eleven (46%) stage 3, and eleven (46%) stage 4 anterior vaginal wall prolapse. Preoperatively, the use of pessary was associated with relief of urinary retention in 75% patients. In predicting postoperative cure of urinary retention, pessary testing had a sensitivity of 89%, specificity of 80%, positive predictive value of 94%, and negative predictive value of 67%. Nineteen of 24 patients had a PVR <100 cc postoperatively, indicating a 79% cure rate for urinary retention. In women with symptomatic anterior vaginal wall prolapse and urinary retention, use of a pessary is associated with relief of retention in the majority of patients. Furthermore, pessary reduction testing has good sensitivity, specificity, and positive predictive value for postoperative voiding function.