Are there age-related changes in the measurements of the urethral sphincter complex in nulliparous women? A three-dimensional ultrasound assessment.

INTRODUCTION AND HYPOTHESIS: The objective was to determine age-related changes in measurements of urethral sphincter complex components in asymptomatic nulliparous women. METHODS: Eighty nulliparous women ≥18 years underwent 3D ultrasound of the anterior pelvic compartment in a cross-sectional study. Measurements of the urethral sphincter components (smooth muscle sphincter [SMS] and striated urinary sphincter [SUS]) and urethra including area, length, width, and distance of the SUS and SMS from the urethrovesical junction were obtained. The women were grouped into four age groups: < 30 years (group A), 30 to < 45 (group B), 45 to < 60 (group C), and ≥ 60 years (group D). Age-related differences in the measurements were determined. Inter-rater and intra-rater agreement were performed for 20 nulliparous women. RESULTS: There were 24, 18, 26, and 12 women in groups A, B, C, and D respectively. None of the urethral sphincter complex measurements was significantly associated with age (p > 0.05). No differences were found between the groups for any measurements using one-way ANOVA and multiple comparison pairwise comparison (p > 0.05) other than width of SMS (C > A), urethral length (C > A), and distance of SUS from urethrovesical junction (C > D). Inter-rater and intra-rater agreement were moderate for area, length, and width of SUS (intraclass correlation 0.6) and good (intraclass correlation above 0.8) for the remaining measurements. CONCLUSION: Other than width of SMS, urethral length, and distance of SUS from urethrovesical junction, the dimensions of urethral sphincter complex components, as visualized by 3D endovaginal ultrasound, do not vary with age.

Updates on the diagnostic tools for evaluation of pelvic floor disorders.

PURPOSE OF REVIEW: Pelvic floor disorders are common and cause significant morbidity for women. Recent advances in the evaluation of women with pelvic floor dysfunction have improved diagnostic accuracy and, with the development and use of validated patient-reported outcomes, has improved measurement of outcomes important to patients. We describe recent advances in the evaluation and measurement of pelvic floor disorders (PFDs). RECENT FINDINGS: We describe recent developments in pelvic floor assessment of women with pelvic floor dysfunction. SUMMARY: Complex integration of multiple anatomic structures and their function are necessary for pelvic floor function. Although the pillars of a complete assessment are a thorough history and physical exam, diagnostic tools can aid in fleshing out the correct and complete analysis of the patient suffering from PFDs.

Levator ani defects in patients with stress urinary incontinence: three-dimensional endovaginal ultrasound assessment.

INTRODUCTION AND HYPOTHESIS: To determine the prevalence of levator ani (LA) muscle subdivision defects in patients with SUI using three-dimensional endovaginal ultrasound (3D EVUS). METHODS: This is a prospective cohort study of 100 patients with pure or predominant urodynamic SUI who underwent 3D EVUS. The 3D cubes obtained were analyzed and the LA muscle was divided into three subgroups: the puboperinealis/puboanalis, the puborectalis, and the iliococcygeus/pubococcygeus. Each LA muscle subdivision was individually scored on each side (0: no defect, 1: ≤50 % muscle loss, 2: > 50 % muscle loss, and 3: total absence of the muscle) and a cumulative score, categorized as 0 (no defect), mild (total score 1-6), moderate (7-12), and severe (≥13) was calculated. RESULTS: The number of women with no LA muscle defect or a mild defect was significantly higher than the number of those with a moderate or severe defect (p < 0.001). Apart from the small inverse relationship of the total puborectalis muscle score and the cumulative subdivision score with maximal urethral closure pressure (r value > -0.3; p < 0.05), the muscle defect scores were not found to correlate with urodynamic parameters (p > 0.05). Although all muscle subdivisions contributed to the overall LA muscle defect score, the association was strongest for the puborectalis component (r = 0.9; p < 0.001). The prevalence of the LA muscle defect in patients with intrinsic sphincter deficiency (ISD) was not significantly different from that in patients without ISD. CONCLUSION: Patients with SUI have a higher prevalence of no or mild LA defect compared with a moderate or severe LA defect.

Dynamic assessment of sling function on transperineal ultrasound: does it correlate with outcomes 1 year following surgery?

INTRODUCTION AND HYPOTHESIS: To correlate dynamic assessment of sling function using 2D and 3D transperineal ultrasound with outcomes following transobturator sling surgery. METHODS: This is an unmatched case-control study of 100 patients who underwent transobturator sling surgery at our center between 2009 and 2012. Group A (n = 50) patients had successful outcomes and group B (n = 50) patients had suboptimal outcomes 1 year following surgery. The patients underwent 2D dynamic and 3D transperineal ultrasound. The two groups were compared with regard to the deformability of the sling on Valsalva, the concordance of urethral movement with the sling, and location of the sling. RESULTS: When compared with group B, group A had a significantly greater number of patients in whom the sling deformed at Valsalva (flat at rest, curving into a c-shape at Valsalva), the urethral movement was concordant with the sling and the sling had a midurethral location (p < 0.0001). In all 17 patients in group B in whom the urethra moved in a concordant manner with the sling (34%), the sling did not deform on Valsalva maneuver and was located proximally. In all 15 patients in group A in whom the sling remained either flat or curved (30%), the urethra moved concordant with the sling and the sling was in midurethral location. CONCLUSIONS: On 2D and 3D transperineal ultrasound, the best outcomes following transobturator sling surgery are associated with concordance of urethral movement with the sling, midurethral location, and deformability of the sling on dynamic assessment.

Transobturator versus single incision slings: 1-year results of a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: To compare 1-year surgical outcomes following transobturator (TO) sling placement and single incision (SI) sling placement for the treatment of stress urinary incontinence (SUI). METHODS: We performed a randomized trial at a single institution. Patients with urodynamically proven SUI were offered participation and randomized to placement of a TO sling (Monarc™) or a SI sling (MiniArc™) between 2008 and 2011. The primary outcome measure was urinary leakage during standardized cough stress test (CST). Forty subjects in each group were required to achieve 80 % power to detect an effect size of 0.25. RESULTS: A total of 98 patients were randomized with 49 patients in the TO group and 49 patients in the SI group. Preoperative demographics were similar between the groups (Table 1). The TO group had a significantly longer sling operative time (10.7 ± 4.8 min vs. 7.8 ± 4.9 min, p < 0.001) and greater estimated blood loss (31.6 ± 26.6 mL vs. 22.9 ± 22.1 mL, p = 0.02). At the 1-year follow-up, there was no difference in the primary outcome with 9 TO patients (21 %) and 12 SI patients (29 %) having a positive CST (p = 0.5). A composite measurement of 'failure', defined as patient-reported SUI and a positive CST, showed no difference between the TO group (17 %) and the SI group (27 %; p = 0.3). CONCLUSIONS: The SI sling provides comparable objective efficacy to the TO sling at 1 year.

De novo stress urinary incontinence after pelvic organ prolapse surgery in women without occult incontinence.

INTRODUCTION AND HYPOTHESIS: There is a paucity of data evaluating the risk of de novo stress urinary incontinence (SUI) after surgery for pelvic organ prolapse (POP) in women with no preoperative occult SUI. We hypothesized that apical suspension procedures would have higher rates of de novo SUI. METHODS: This was a retrospective database review of women who had surgery for POP from 2003 to 2013 and developed de novo SUI at ≥6 months postoperatively. Preoperatively, all patients had a negative stress test and no evidence of occult SUI on prolapse reduction urodynamics. The primary objective was to establish the incidence of de novo SUI in women with no objective evidence of preoperative occult SUI after POP surgeries at ≥6 months. RESULTS: A total number of 274 patients underwent POP surgery. The overall incidence of de novo SUI was 9.9 % [95 % confidence interval (CI) 0.07-0.14]. However, the incidence of de novo SUI in those with no baseline complaint of SUI was 4.4 % (95 % CI 0.03-0.1). There was no difference in de novo SUI rates between apical [9.7 % (n = 57)] and nonapical [10.5 %, (n = 217] procedures (p = 0.8482). Multivariate logistic regression identified sacrocolpopexy [adjusted odds ratio (OR) 4.54, 95 % CI 1.2-14.7] and those with a baseline complaint of SUI (adjusted OR 5.1; 95 % CI 2.2-12) as risk factors for de novo SUI. CONCLUSIONS: The incidence of de novo SUI after surgery for POP without occult SUI was 9.9 %. We recommend counseling patients about the risk of de novo SUI and offering a staged procedure.

Obliterative LeFort colpocleisis in a large group of elderly women.

OBJECTIVE: To report on anatomical and functional outcomes, patient satisfaction, and associated morbidity and mortality in patients undergoing LeFort colpocleisis. METHODS: This was a retrospective case series of LeFort colpocleisis performed from January 2000 to October 2011. Data obtained from a urogynecologic database included demographics, comorbidities, medications, and urinary and bowel symptoms. Prolapse was quantified using the pelvic organ prolapse quantification (POP-Q) examination. Operative characteristics were recorded. All patients underwent pelvic examination and POP-Q assessment at follow-up visits. Patients also were asked about urinary and bowel symptoms as well as overall satisfaction. All intraoperative and postoperative surgical complications were recorded. RESULTS: Three hundred twenty-five patients underwent LeFort colpocleisis. Fifteen patients were excluded from the analysis because of incomplete data. The mean age was 81.3±5.3 years. Comorbidities were common, with 74.1% of the patients having at least one concomitant medical condition. The procedure was performed under spinal anesthesia in 67%. Additional procedures at the time of colpocleisis included incontinence procedures (79%) and dilation and curettage (46%). Mean follow-up was 45 (range 2-392) weeks. Anatomical success rate was 98.1% and patients were highly satisfied, with 92.9% reported being "cured" or "greatly improved." Complication and mortality rates were 15.2% and 1.3%, respectively. CONCLUSION: Colpocleisis is an effective and low-risk procedure with high anatomical success rates and patient satisfaction. Associated morbidity and mortality related to the procedure are low. Colpocleisis remains an excellent surgical option for the elderly patient with advanced pelvic organ prolapse. LEVEL OF EVIDENCE: III.

Endoscopic transurethral resection of urethral mesh erosion with the use of a pediatric nasal speculum.

BACKGROUND: A rare but challenging complication of midurethral slings is erosion of mesh tape through the urethral wall. CASES: In this report, we describe two cases in which a pediatric nasal speculum provided exposure for transurethral resection of eroded mesh. Exposure was sufficient for complete mesh resection endoscopically as well as with use of traditional surgical instruments. Since having surgery there has been no recurrence of mesh erosion and the irritative voiding symptoms have resolved. CONCLUSION: Urethral mesh erosion can be managed from a transurethral approach. Furthermore, use of a pediatric nasal speculum improves visualization and efficiency.

Repeat versus primary slings in patients with intrinsic sphincter deficiency.

INTRODUCTION AND HYPOTHESIS: Our goal was to compare outcomes of repeat vs. primary synthetic slings in patients with stress urinary incontinence (SUI) with intrinsic sphincter deficiency (ISD). MATERIALS AND METHODS: We reviewed patients who underwent a sling for SUI with ISD from 2003 to 2010. The patients were divided into two groups according to whether they underwent primary or repeat sling. Surgical success was defined as no incontinence and no reintervention (i.e., urethral bulking) during follow-up. Statistical analysis included the unpaired t test, Wilcoxon rank sums test, chi-squared/Fisher's exact tests, and logistic regression to identify risk factors associated with failure. RESULTS: Six hundred and thirty-seven patients with ISD underwent a sling procedure at our institution; 557 (87 %) a primary sling and 80 (13 %) a repeat sling. Patient demographics were similar. Preoperatively, patients with recurrent SUI reported more subjective bother. Mean follow-up was 66.5 weeks (24-374). Success was achieved in 81 % of primary compared with 55 % of repeat slings (p<0.0001). Repeat patients were 3.4 times more likely to fail surgery [odds ratio (OR) =3.43, 95 % confidence interval (CI) 2.1-5.6]. Additionally 30 % of the repeat group underwent urethral bulking postoperatively compared with 8.6 % in the primary group (OR=4.4, 95 % CI 2.5-7.7). Prior incontinence procedures, a positive supine stress test, and transobturator sling were independent risk factors for failure. Among the types of slings placed (transobturator, retropubic, tensioned pubovaginal), pubovaginal slings were most successful (OR=2.7, 95 % CI 1.4-5.2). CONCLUSION: In women with ISD, repeat slings are associated with lower success rates compared with primary slings. Pubovaginal slings resulted in the highest success rate compared with both transobturator and retropubic slings.

Three-dimensional endovaginal ultrasound examination following injection of Macroplastique for stress urinary incontinence: outcomes based on location and periurethral distribution of the bulking agent.

INTRODUCTION AND HYPOTHESIS: Our aim was to use three-dimensional enodovaginal ultrasound (3D EVUS) to identify sonographic parameters that are associated with successful outcomes following injection of Macroplastique. METHODS: Three hundred and sixty degree 3D EVUS was performed in 100 treatment-naïve patients following Macroplastique injection. The location, volumes, periurethral distribution, and distance of the hyperechoic densities from the urethrovesical junction were assessed. The patients were divided into two groups: group A (n = 72): patients who had good clinical outcome and group B (n = 28): patients who were not improved or worsened. The two groups were compared with respect to the ultrasound parameters measured. RESULTS: Group A had a greater proportion of women with Macroplastique located in the proximal urethra, while midurethral location was found to be significantly more frequent in group B (p = 0.036). The odds of a circumferential periurethral distribution in group A were 13.62 times the odds in group B (95% CI: 5.12-56.95). When the location of the injection and the type of periurethral distribution were considered together, it was found that when the site of injection was proximal, the odds of circumferential distribution in group A was significantly greater than those in group B (odds ratio [95% CI]: 22 [3.05-203.49]; p < 0.001). CONCLUSION: Proximally located Macroplastique and circumferential periurethral distribution of Macroplastique are individually associated with successful outcomes following the injection. The combination of circumferentially distributed and proximally located Macroplastique is associated with the best short-term clinical outcomes.

Reattachment of the endopelvic fascia to the apex during anterior colporrhaphy: does the type of suture matter?

INTRODUCTION AND HYPOTHESIS: We aimed to determine if the use of permanent suture for the apical fixation during traditional anterior colporrhaphy results in improved outcomes compared to delayed absorbable suture. METHODS: A retrospective case-control study was performed in patients who underwent traditional non-grafted anterior colporrhaphy with reattachment of the anterior endopelvic fascia to the apex/cervix comparing permanent (group 1) or absorbable suture (group 2). Patients were matched based on age, body mass index, and presenting stage of prolapse. The primary outcome assessed was anterior wall vaginal prolapse recurrence defined as Pelvic Organ Prolapse Quantification (POP-Q) points Aa or Ba ≥ -1 cm. Secondary outcome measures included overall prolapse stage, subjective reporting of satisfaction, and any healing abnormalities or complications resulting from suture type. RESULTS: A total of 230 patients were reviewed (80 in group 1 and 150 in group 2) and median follow-up was 52 (24-174) weeks. A statistically significant improvement in anterior wall anatomy was seen in group 1 compared to group 2 [(Aa -2.70 ± 0.6 cm vs -2.5 ± 0.75 cm, p = 0.02) and Ba (-2.68 ± 0.65 cm vs -2.51 ± 0.73 cm, p = 0.03), respectively]. Comparing prolapse stage, there were no observed differences between the groups. Exposure of the permanent suture occurred in 12 patients (15 %) and 5 (6.5 %) required suture trimming to treat the exposure. CONCLUSIONS: Reattachment of endopelvic fascia to the apex at the time of anterior colporrhaphy results in low recurrence rates. Use of permanent suture for apical fixation is associated with improved anatomic correction at the expense of increased suture exposures.

A randomized clinical trial of the impact of local estrogen on postoperative tissue quality after vaginal reconstructive surgery.

OBJECTIVE: To evaluate the use and effect of early administration of vaginal estrogen via a continuous low-dose estradiol vaginal ring placed immediately after pelvic reconstructive surgery. METHODS: This was a randomized controlled trial of 65 postmenopausal women undergoing vaginal reconstructive surgery. The subjects were randomly assigned to receive an estradiol-releasing vaginal ring, placebo vaginal ring, or control without vaginal ring for 12 weeks immediately after vaginal reconstructive surgery. The primary outcome was tissue quality based on vaginal maturation 3 months postoperatively. Secondary outcome measures were subjective and objective signs of atrophy; vaginal pH; the presence of granulation tissue, microscopic inflammation, and major healing abnormalities; and the ability to tolerate an intravaginal ring. RESULTS: At 12 weeks, the estradiol ring group had a significantly improved maturation value (P<0.01) and objective atrophy assessment (P<0.01) compared with the placebo ring and control arms. Granulation tissue was increased in the placebo ring arm (P<0.01). Subjective atrophy scores did not differ among the groups (P=0.39). CONCLUSIONS: Early administration of vaginal estrogen after vaginal surgery via an estradiol-releasing ring is feasible and results in improved markers of tissue quality postoperatively compared to placebo and controls.

Predictors of successful salpingo-oophorectomy at the time of vaginal hysterectomy.

STUDY OBJECTIVE: To determine prognostic factors related to successful salpingo-oophorectomy in menopausal women at the time of vaginal hysterectomy. DESIGN: Retrospective cohort study (Canadian Task Force Classification II-2). SETTING: Tertiary care center. PATIENTS: A total of 309 postmenopausal ≥60 years old with pelvic floor disorders. INTERVENTIONS: Vaginal hysterectomy with attempted prophylactic salpingo-oophorectomy. MEASUREMENTS: Factors associated with ability to achieve vaginal salpingo-oophorectomy. MAIN RESULTS: 203 (65.7%) achieved successful removal of 1 or both ovaries, and 106 (34.3%) were not amenable to removal. Younger age and shorter cervical length were predictors of salpingo-oophorectomy. Cervical elongation of ≥7 cm, exteriorized cervical/uterine prolapse, and anterior vaginal wall prolapse beyond the hymen were associated with lower likelihood of achieving salpingo-oophorectomy. CONCLUSIONS: Patient age and cervical length are independent factors that influence the success of accomplishing salpingo-oophorectomy at the time of vaginal hysterectomy.

LeFort colpocleisis and stress incontinence: weighing the risk of voiding dysfunction with sling placement.

INTRODUCTION AND HYPOTHESIS: This study aims to evaluate clinical outcomes of concomitant suburethral sling with LeFort colpocleisis including its effect on postoperative voiding. METHODS: We performed a retrospective review of all LeFort colpocleisis procedures from our institution. We reviewed demographics, symptoms of stress urinary incontinence, incontinent events/day, pads usage/day, urodynamic parameters, and presence of voiding dysfunction. RESULTS: Two hundred ten patients underwent colpocleisis during the study period. Mean age was 82.2 ± 4.9 and median follow-up was 22 weeks (2-169). Preoperatively, 73 (35%) complained of stress urinary incontinence (SUI) symptoms, and an additional 105 (50%) were diagnosed with occult SUI. One hundred sixty-one (77%) patients underwent concurrent suburethral sling. Overall, sling placement resulted in a 92.5% subjective stress continent rate. Fifty-six patients presented with voiding dysfunction (VD). Postoperatively, VD resolved in 91%. De novo VD occurred in two patients (1.9%) and one (0.6%) required sling revision. CONCLUSIONS: Sling placement at time of colpocleisis is associated with high continence rates with minimal risk of postoperative voiding dysfunction.

Biologic grafts for cystocele repair: does concomitant midline fascial plication improve surgical outcomes?

INTRODUCTION AND HYPOTHESIS: This study aims to compare the efficacy of porcine graft-augmented anterior prolapse repair with and without underlying pubocervical fascia plication. METHODS: Women with symptomatic anterior prolapse who underwent transvaginal repair, using biologic graft via transobturator approach, were retrospectively studied. An initial cohort had the graft placed without fascial plication. A second cohort had graft placement as an overlay to fascial plication. RESULTS: Between March 2005 and September 2008, 65 subjects underwent anterior repair with biologic graft; 35 without fascial plication and 30 as an overlay to plication. At 6 months follow-up, anatomic recurrence (Ba>/= -1) was significantly higher in the non-plicated group (18/35, 51%) compared with the plicated group (2/30, 7%) p < 0.01. Five (5/35, 14%) in the non-plicated group compared with none (0/30) in the plicated group underwent further treatment (p = 0.06). CONCLUSIONS: When using a non-crosslinked biologic graft for repair of anterior vaginal prolapse, we recommend the addition of concomitant midline fascial plication to enhance anatomic outcome.

Validation of a global pelvic floor symptom bother questionnaire.

INTRODUCTION AND HYPOTHESIS: This study aimed to validate a symptom questionnaire to assess presence and patient bother as related to common pelvic floor disorders. METHODS: The validation of the Pelvic Floor Bother Questionnaire (PFBQ) included evaluation of internal reliability, test-retest reliability, and validity of the items. RESULTS: A total of 141 patients with mean age of 61.8 +/- 13.2 were included in the study. Twenty-four percent of patients complained of stress urinary incontinence, 14.9% mixed incontinence, 14.9% urge incontinence, 10% fecal incontinence, 5.7% obstructed defecation, 28.4% pelvic organ prolapse, and 2.1% dyspareunia. The PFBQ demonstrated good reliability (alpha = 0.61-0.74; ICC = 0.94). There was a strong agreement beyond chance observed for each question (k = 0.77-0.91). PFBQ correlated with stage of prolapse (rho = 0.73, p < 0.0001), number of urinary and fecal incontinence episodes (rho = 0.81, p < 0.0001; rho = 0.54, p < 0.0001), and obstructed defecation (rho = 0.55, p < 0.0001). CONCLUSION: The PFBQ is a useful tool that can be easily used for identification and severity or bother assessment of various pelvic floor symptoms.

"Eyeball" POP-Q examination: shortcut or valid assessment tool?

INTRODUCTION AND HYPOTHESIS: The objective of this study was to compare the results of the Pelvic Organ Prolapse Quantification (POP-Q) examination by visual estimation to measurement. METHODS: Women with pelvic organ prolapse underwent both "eyeball"/estimated and measured POP-Q examinations by two trained examiners in a randomized order. POP-Q points and stage were analyzed using the paired t test, chi-square, Pearson's correlation, and kappa statistics. RESULTS: Fifty subjects had a mean age of 60, mean BMI 27.8, and median parity of 2. The POP-Q stages by the measured technique were 18% (9/50) stage 1, 38% (19/50) stage 2, 44% (22/50) stage 3, and 0% (0/50) stage 4. The POP-Q stages based on estimation and measurement were highly associated (p < 0.05). Individual points did not differ significantly between the techniques and did not differ significantly between examiners (all p > 0.05). CONCLUSION: Among examiners who routinely perform POP-Q examinations, there is no significant difference between "eyeball"/estimated and measured POP-Q values and stage.

Primary versus recurrent prolapse surgery: differences in outcomes.

INTRODUCTION AND HYPOTHESIS: We set out to evaluate anatomical outcomes of recurrent vs. primary prolapse surgery, focusing on anterior colporrhaphy (AC). METHODS: A retrospective study was performed comparing patients who underwent AC for recurrent cystocele (group I) and a matched control group who underwent primary AC (group II). RESULTS: Thirty-one patients were included in each group. Median follow-up was 22 (5-55) months. Successful anterior vaginal support was obtained in 18/23 (78.2%) patients in group I and 17/21 (81%) patients in group II at 1 year (p = 1.000) and in 9/21 (42.8%) patients in group I and in 15/21 (71.4%) patients in group II at 2-year follow-up (p = 0.031). CONCLUSIONS: Recurrent cystocele repair has a higher anatomic failure rate than primary repair at 2-year follow-up. Alternative surgical techniques that provide better long-term durability may be beneficial in repair of recurrent anterior wall prolapse.

Combined trans- and periurethral injections of bulking agents for the treatment of intrinsic sphincter deficiency.

The purpose of this study was to compare Contigen combined with Durasphere to Contigen injections alone for the treatment of stress urinary incontinence (SUI) with intrinsic sphincter deficiency (ISD). Subjective and objective incontinence outcomes were compared at 2 weeks and 6 months. We compared rates of urinary retention and future incontinence surgery between groups. Thirty-three women underwent combined injections, and 51 underwent Contigen injections. Two weeks postoperatively, more women in the combined group were cured (72.7 vs. 39.2%, P = 0.003), but this difference diminished at 6 months (33.3 vs. 29.4%, P = 0.70). Retention was more common in the combined group (P = 0.002, odds ratio [OR] = 0.062 [95% confidence interval (CI) = 0.007, 0.52]). Twenty-three women in the Contigen and ten in the combined group underwent subsequent incontinence surgery (P = 0.17, OR = 2.03 [95% CI = 0.80, 5.1]). Combining Contigen and Durasphere injections to treat SUI with ISD does not improve outcomes compared to Contigen injections alone.

Pyometra necessitating hysterectomy after colpocleisis in an extremely elderly patient.

As the number of women more than the age 65 increases, so will the need for treatment of pelvic organ prolapse and the comorbidities that come with surgical treatment of an aging population gain significance. Colpocleisis is an option for women failing or refusing conservative prolapse management and not desiring sexual function. The advantages of colpocleisis are decreased operative time, low complication rate, and ability to use local or regional anesthesia. We report a case of a 95-year-old woman whose procidentia was treated with colpocleisis. Endometrial evaluation with dilation and curettage was performed at the time of colpocleisis. Postoperative course was complicated by pyometra necessitating total abdominal hysterectomy and bilateral salpingoopherectomy, leading to further complications including deep vein thrombosis, anemia, atrial fibrillation, and pleural effusions. Preoperative versus intraoperative endometrial evaluation may decrease the risk of developing pyometra after colpocleisis and, therefore, diminish the possibility of multiple complications.