Satisfactory urethral coitus in a patient with vaginal stenosis: case report

Urethral coitus is a very rare sexual disorder seen in women either with intact or anomalous vagina such as vaginal agenesis or imperforate hymen. Only about 25 cases have been reported in the literature. We report a case of urethral coitus in a patient with surgically corrected ambiguous genitalia due to congenital adrenal hyperplasia. The patient had megalourethra and stenotic vaginal introitus. Megalourethra was corrected by plication technique. Correction of megalourethra with this technique has not been reported in literature up to now. To the best of our knowledge, the present case is the 26th of total cases with urethral coitus reported so far and the first case of urethral coitus associated with a stenotic vaginal introitus developing due to surgically corrected ambiguous genitalia.     

Pelvic fracture urethral injuries in girls

PURPOSE: Injuries to the female urethra associated with pelvic fracture are uncommon. They may vary from urethral contusion to partial or circumferential rupture. When disruption has occurred at the level of the proximal urethra, it is usually complete and often associated with vaginal laceration. We retrospectively reviewed the records of a series of girls with pelvic fracture urethral stricture and present surgical treatment to restore urethral continuity and the outcome. MATERIALS AND METHODS: Between 1984 and 1997, 8 girls 4 to 16 years old (median age 9.6) with urethral injuries associated with pelvic fracture were treated at our institutions. Immediate therapy involved suprapubic cystostomy in 4 cases, urethral catheter alignment and simultaneous suprapubic cystostomy in 3, and primary suturing of the urethra, bladder neck and vagina in 1. Delayed 1-stage anastomotic repair was performed in 1 patient with urethral avulsion at the level of the bladder neck and in 5 with a proximal urethral distraction defect, while a neourethra was constructed from the anterior vaginal wall in a 2-stage procedure in 1 with mid urethral avulsion. Concomitant vaginal rupture in 7 cases was treated at delayed urethral reconstruction in 5 and by primary repair in 2. The surgical approach was retropubic in 3 cases, vaginal-retropubic in 1 and vaginal-transpubic in 4. Associated injuries included rectal injury in 3 girls and bladder neck laceration in 4. Overall postoperative followup was 6 months to 6.3 years (median 3 years). RESULTS: Urethral obliteration developed in all patients treated with suprapubic cystostomy and simultaneous urethral realignment. The stricture-free rate for 1-stage anastomotic repair and substitution urethroplasty was 100%. In 1 girl complete urinary incontinence developed, while another has mild stress incontinence. Retrospectively the 2 incontinent girls had had an associated bladder neck injury at the initial trauma. Two recurrent vaginal strictures were treated successfully with additional transpositions of lateral labial flaps. CONCLUSIONS: This study emphasizes that combined vaginal-partial transpubic access is a reliable approach for resolving complex obliterative urethral strictures and associated urethrovaginal fistulas or severe bladder neck damage after traumatic pelvic fracture injury in female pediatric patients. Although our experience with the initial management of these injuries is limited, we advocate early cystostomy drainage and deferred surgical reconstruction when life threatening clinical conditions are present or extensive traumatized tissue in the affected area precludes immediate ideal surgical repair.     

Glanuloplasty with scrotal flap for partial penectomy

PURPOSE: To our knowledge the physiological mechanisms involved in sexual intercourse have not been completely explored. We hypothesized that vaginal distention induced by penile thrusting may affect the function of the bladder and urethra. To verify this supposition we assessed the effect of vaginal distention on vesical and urethral pressure. No relevant reports in the literature were identified. MATERIALS AND METHODS: The response of vesical and urethral pressure to vaginal distention was recorded in 26 healthy women volunteers with a mean age plus or minus standard deviation of 36.7 +/- 9.8 years. A condom was introduced into the vagina and inflated with carbon dioxide in increments of 10 ml. up to 80 ml. Vesical and urethral pressure was measured by a 2-channel microtip catheter connected to a transducer. The vesicourethral pressure response to vaginal distention was also tested after individual anesthetization of the bladder, urethra and vagina. RESULTS: No vesicourethral pressure response was recorded with 10 and 20 ml. of vaginal distention. At 30 and up to 80 ml. of distention bladder pressure decreased and urethral pressure increased (p <0.05). There was no significant difference when the volume of vaginal distention was increased. Mean duration of the pressure response was 4.2 +/- 0.6 seconds. Pressure returned to normal after a latency period of 5.2 +/- 1.1 seconds, although the vagina was continuously distended. Vaginal distention during anesthetization of the bladder, urethra or vagina did not evoke a pressure response. CONCLUSIONS: The vesicourethral response to the inserted condom, which by inflation adopts the shape of the erect penis, seems to simulate the response of the vagina when it is distended by the erect penis during coitus. The constant vesicourethral pressure response to vaginal distention postulates a reflex relation, which we call the vagino-vesicourethral reflex. This reflex is apparently evoked during coitus, leading to momentary vesical dilatation and increased urethral sphincter activity, which most likely acts to prevent urinary leakage during coitus. Reflex disorders may explain urinary leakage during coitus in some neuropathic conditions.     

Delayed vaginal and urethral mesh exposure: 10 years after TVT surgery

Delayed mesh exposure after tension-free vaginal tape (TVT) procedure is rare. We report a case of mesh exposure into the vagina and urethra that developed 10 years after TVT surgery. A 58-year-old postmenopausal woman presented with mixed urinary incontinence. She was investigated, and her stress urinary incontinence was cured with a TVT procedure 10 years ago. She was then scheduled follow-up annually. Two years postsurgery, a granulation tissue was observed and excised at the vaginal incision site. Vaginal examination 10 years postsurgery showed vaginal mesh erosion 0.5 cm from urethral meatus. Cystoscopy revealed concomitant urethral erosion at the posterior urethral wall. Mesh excision was performed, and urethra and vagina were repaired in layers. Postoperative recovery was uneventful. This finding shows that, although rare, complications can occur even after 10 years of TVT surgery.     

Single-stage correction of urinary incontinence and vaginoplasty in a case of urethral coitus with vaginal agenesis

Urethral coitus is a very rare entity which usually presents as urethral incontinence during intercourse and is most commonly seen with intact vagina. Only about 24 cases have been reported in the literature. A presentation in vaginal agenesis is exceedingly rare and poses the surgical challenge of restoring continence without interfering with sex life. Here we report a case of urethral intercourse with vaginal agenesis presenting with incontinence that we treated with McIndoe's vaginoplasty and urethral plication in a single stage, with satisfactory result. To the best of our knowledge, this method of reconstruction has not yet been reported for this condition.     

A magnetic device for increasing the urethral resistance to flow: an experimental study in female dogs

OBJECTIVE: To test a new magnetic device for increasing the urethral resistance to flow in a dog model, and thus provide a potential mechanical device for the treatment of incontinence in women. MATERIALS AND METHODS: The study comprised 12 female mongrel dogs; three dogs were used to study the effect on urethral resistance of inserting a vaginal magnet (control experiment) and five were assessed in a urodynamic study. With the animals under general anaesthesia, the bladder and the urethra were exposed by a low midline incision. One magnet, embedded in a silicon layer, was placed on the anterior side of the urethra 3 cm distal to the bladder neck and fixed with a few sutures. To increase the urethral resistance as required, a second magnet was inserted into the vagina and the device activated. Urethral pressure profiles and leak-point pressures were recorded in the anaesthetized animals under resting conditions and after the urethra was compressed between the magnets. Recordings were also made after pharmacological blockade of the urethral musculature. In four additional dogs, chronic experiments were conducted to evaluate the effect of continuous compression of the urethra and the vaginal wall for 14 days. RESULTS: Urethral compression between the magnets resulted in a doubling of the maximal pressure in the proximal urethra and in a threefold increase of the leak-point pressure. After pharmacological denervation of the urethra the differences between the control pressures and those after activating the device were even greater, although not significantly so. After 2 weeks of continuous compression of the vaginal wall and the urethra between the magnets there was no detectable tissue damage. CONCLUSION: These results suggest that the magnetic device can efficiently increase urethral pressure and that prolonged compression caused no apparent damage to the urethra or vagina. It may therefore be a useful potential method of providing urinary continence in women.     

The split labium minus flap graft technique

The split labium minus flap graft technique was used to restore tissue volume and therefore elasticity into the bladder neck area of vagina in eight patients. Three full-thickness vaginal incisions were made, a longitudinal incision extending from external urethral meatus to 3–4 cm beyond the bladder neck, and two transverse incisions, one just below the external urethral meatus and the other at the level of the bladder neck. The vagina, urethra and bladder neck were mobilized widely and the suburethral flaps rotated downwards, leaving a bare area below the urethra. A transverse incision was made across the base of one labium minus (LM) and the incision carried up on each side to the ridge of the LM. The inner wall was dissected clear of the outer wall, creating a flap. This was then rotated into the bare area formed by dislocation of the suburethral vagina. The flap was attached to the pubococcygeus muscles laterally, to the external meatus superiorly and to the vaginal skin inferiorly. All the cut surfaces of the vagina and LM were joined with 00 Dexon sutures. Postoperative pain was minimal. All patients were discharged within 48 h, and there was excellent anatomical restoration at 6 weeks follow-up. The technique works well in patients with adequately large labia minora, and has potential uses for patients who have deficient vaginal tissue in the hammock or bladder neck areas of the vagina.Abbreviations LM Labium minus Editorial Comment: Tethering of the vagina during vaginal repair may cause overcorrection of the support under the bladder neck. Using a full-thickness graft from the labia minora permits the release of the vagina under the urethra and bladder neck and allows for the closure of the vaginal mucosa without tension.     

Role of the pelvic floor in Bladder neck opening and closure II: Vagina

The aim of the study was to examine the role of vaginal stretching during bladder neck opening and closure. The study group comprised 12 patients with GSI and 4 controls. The position of the bladder neck relative to the vagina was assessed in the resting, straining and ‘squeezing’ positions using video-radiological studies. Radio-opaque dye was instilled into the bladder, vagina, rectum and levator plate. Vascular clips applied to the midurethral, bladder neck and bladder base parts of the anterior vaginal wall assisted in determining differential movements of these parts of the vagina during bladder neck opening and closure. The suburethral vagina (hammock) was shown to stretch downwards and forwards during straining, and downwards and backwards during micturition. The bladder neck, upper part of the vagina and the rectum were stretched backwards and downwards in an identical manner during straining and micturition, apparently in response to backward contraction of the levator plate and downward angulation of its anterior lip. All organs were stretched upwards and forwards during ‘squeezing’. The findings support the hypothesis that, during stress and micturition, selective pelvic floor contractions stretch the vagina against intact pubourethral and uterosacral ligaments to assist opening and closure of the urethra and bladder neck. EDITORIAL COMMENT: The authors propose a new theory for the mechanism of micturition and continence. The new ‘Integral Theory’ describes the role of the vagina and three pelvic floor muscles, the levator plate, the anterior portion of the pubococcygeus (PCM) and the longitudinal muscles of the anus (LMA) in the opening and closing of the urethra. Unlike the ‘hammock hypothesis’, proposed by Delancey, the authors believe it is the forward movement of the vagina around its attachment to the pubourethral ligaments via contraction of the PCM that closes off the urethra, and not increased abdominal pressure transmission to the proximal urethra. Their proposed mechanism for incontinence is laxity of the vaginal hammock and decreased forward motion, and less compression of the urethra. This theory is also in contrast to Shafik’s ‘common sphincter’ concept of continence, which stresses the importance of the puborectalis and external urethral sphincter as the main mechanism for continence, with no significance given to the role of the anterior vaginal wall or its attachment and movement around the pubourethral ligament. This new integral theory is based on findings of muscle movements using cadaveric dissection, video X-ray studies, digital palpation, EMG and dynamic urethral pressure measurements. This is an interesting theory which again emphasizes the role of the pelvic floor muscles, not only in their support function but also in their role of active movements of the viscera within the bony pelvis.     

Our experience with salvage genitourinary fistulae repair: technique and outcomes

Objectives The objectives are to present the long-term results of vaginal reconstructive operations using the labial fat pad flap (Martius flap) interposition. Patients and methods Eight women, 27–65 years old (mean 40), suffering from urinary fistulae (five urethrovaginal and three vesicovaginal) who failed primary repair underwent salvage vaginal reconstruction for damaged urethra or bladder. Urethral or bladder and vaginal defect was closed and a Martius fat flap was interposed between urethra or bladder and vaginal wall flap to secure a watertight separation of the structures. A Martius flap was also used successfully for salvage vaginal reconstruction in three more women, two with extensive injury of their urethra and bladder neck and one with vaginal leakage, after a rectosigmoid neobladder diversion following cystectomy. Results The repair was successful in all eight patients with urinary fistulae and in the one with rectovaginal leakage. The patient with the traumatically injured urethra and bladder neck developed an anastomotic stricture treated with urethral dilatations and internal urethrotomy. The older one developed a vesicovaginal fistula due to bladder neck closure, and this was repaired with a second transvaginal closure. Conclusion Martius labial fat flap is an easy to prepare, well-vascularized tissue that can be most helpful in achieving a long-lasting favorable outcome in vaginal reconstructive surgery.     

Mechanical properties of the urethra in females with genuine stress incontinence: Static measurements in the resting urethra

The pressure (P_ura)-cross-sectional area (CA) relationship in the resting urethra was examined in 30 females with genuine stress incontinence (GSI). Measurements were performed at the bladder neck, in the high-pressure zone, and in the distal part of the urethra. From the two variables urethral elastance (dP_ura/dCA) and hysteresis were calculated. The results were compared with those obtained in normal females. Urethral elastance, hysteresis, and urethral pressure showed significant differences at the three sites of measurement. Urethral elastance was significantly decreased at the bladder neck in patients with GSI as compared to normal women, while the urethral pressure was significantly decreased all along the urethra. It is suggested that both mechanical weakness all along the urethra and decreased deformability of the urethral wall may be of pathophysiologic importance in GSI.     

Urethral and paraurethral leiomyomas in the female patient

Urethral leiomyomas in women arise from the smooth muscle of the urethra and are rare, benign urethral tumors seen primarily in women. We present three cases of urethral leiomyomas identified over a 30-year period at our institution. A 45-year old woman presented with a 1 year history of frequency, nocturia, and hesitancy and was found to have both a 2-cm proximal urethral and a 3-cm posterior bladder leiomyoma. She developed stress urinary incontinence postoperatively and was treated with a Burch colposuspension. A 33-year old woman with hematuria was found to have both a 3-cm urethral and a 3-cm paraurethral leiomyoma at the bladder neck. A 21-year old without urinary complaints was found to have a 3-cm leiomyoma at the urethral meatus. Urethral leiomyomas must be differentiated from paraurethral leiomyomas, which are often asymptomatic and may be removed without disrupting the urethral mucosa or smooth muscle. The removal of urethral myomas may be complicated by the development stress urinary incontinence or urethral stricture.     

Use of atresic vagina as a urethra to repair iatrogenic incontinence, secondary to a complete longitudinal urethral incision

Vaginal atresia is a rare congenital anomaly. Patients with this pathology commonly present with amenorrhea, or an inability to have sexual intercourse. A dorsal urethral wall incision was performed in a woman who complained of difficulty with coitus. Her gynecologist intended to expand the vagina, thinking the diagnosis was a vaginal septum. We report a repair technique for total urinary incontinence following a longitudinal complete urethral incision, which also involved the bladder neck. The vaginal reconstruction consisted of an ileal segment, whereas the urinary incontinence was corrected using a rectus fascial sling. To our knowledge, this is the first case of this kind reported in the literature.     

Single vaginal ectopic ureter via Gartner's duct cyst spontaneously perforating into the bladder

We report on a girl with a rare variant of single vaginal ectopic ureter via Gartner's duct cyst, which ruptured spontaneously into the bladder leading to aggravation of urinary incontinence. The patient also had a megalovagina, and a fistula between the distal urethra and vagina. She became continent after removal of a dysplastic kidney, unroofing of the cyst and closure of the fistulas.     

Severe genital prolapse and its relationship to detrusor instability

Twelve women with severe genital prolapse through the vaginal introitus were evaluated urodynamically with and without a properly fitted vaginal ring pessary in order to evaluate the relationship between severe genital prolapse and detrusor instability in women. Provocative retrograde medium-fill urethrocystometry confirmed detrusor instability in all patients. Seven women showed resolution of uninhibited detrusor contractions during provocative maneuvers after pessary placement. Nine women underwent vaginal hysterectomy and vaginal repair operation; a bladder neck suspension was performed if indicated. Five women returned postoperatively for urodynamic evaluation. Three of 4 women who responded to pessary placement with resolution of uninhibited detrusor contractions had a stable bladder and no uregency symptoms postoperatively. One patient who did not respond to pessary placement continued to have symptomatic motor urge incontinence after a vaginal repair procedure. The data suggest that genital prolapse may provoke uninhibited bladder contraction by increasing urethral resistance, and that vaginal pessary placement may be useful in predicting which patient with genital prolapse and uninhibited detrusor contractions during cystometry will have a stable bladder after vaginal repair operation.Editorial Comment: Prostatic urethral obstruction in men has long been implicated in the genesis of detrusor instability due to outlet obstruction or to sensory stimuli from the altered prostatic urethra. The relationship of urethral obstruction to the occurrence of detrusor instability in women has not been studied adequately. The preliminary study of 12 patients indicates that there may be a relationship which can be studied by pessary placement, since 7 of the 12 women demonstrated resolution of the instability after pessary placement. Unfortunately only 5 women returned for urodynamic studies postoperatively, but of these 75% who responded to pessary placement also responded to surgery. This study should serve as a stimulus to others to study this further and attempt to elucidate the relationship of the obstruction caused by the prolapse to the occurrence of detrusor instability.     

女童陈旧性尿道外伤的治疗

目的 提高女童陈旧性尿道外伤的疗效。方法 总结44例女童尿道外伤病例资料。其中陈旧性43例,尿道阴道瘘40例,阴道闭锁积脓2例,阴道结石1例,膀胱结石1例。28例带膀胱造瘘,15例为尿失禁。平均年龄8岁。手术分3类：尿道贯通7例,其中3例再经阴道修瘘;经阴道修瘘1例;经耻骨联合切除入路修复尿道及瘘35例。结果 40例随访6个月－16年,排尿正常29例,发生不全尿失禁11例。结论 除短段病例可用尿道贯通及大女孩阴道修瘘外,多需经耻骨入路、栽剪膀胱三角区瓣修复尿道狭窄及尿道阴道瘘。     

Urethral duplication with single bladder and multiple genitourinary abnormalities: an example of continent urinary diversion

A 13-year-old girl with multiple genitourinary malformations, incomplete bladder exstrophy, urethral duplication with single bladder, septate vagina, and total urinary incontinence is presented. Prior to admission she had undergone surgery for teratoma and calculi of the bladder and partial fecal incontinence. A continent urinary diversion was done by bladder augmentation using a cecal-colonic segment and by surgical closure of the bladder neck. The distal end of the appendix was brought to the skin as an inconspicuous, easily catheterizable, watertight stoma, our modification of the Mitrofanoff procedure. Excision of the vaginal septum, creation of an introitus, and unification of the split clitoris improved the cosmetic appearance of the external genitalia and improved the outlook for a normal sexual life and pregnancy.     

Large urethral prolapse formation after calcium hydroxylapatite (Coaptite) injection

A 67-year-old woman who had failed two prior anti-incontinence surgeries presented with stress urinary incontinence and intrinsic sphincteric deficiency. Calcium hydroxylapatite (Coaptite(R)) was injected cystoscopically into the bladder neck and proximal urethra and resolved her incontinence. Seven months later, she presented with difficulty in voiding and a urethral mass. Physical examination revealed a large prolapse of the urethral mucosa obstructing the external urethral meatus. Surgical exploration revealed local migration of calcium hydroxylapatite particles from the site of injection (bladder neck and proximal urethra) to the distal urethra. The prolapsed urethral mucosa was incised and marsupialized. Improper injection techniques likely contributed to urethral prolapse in this complication. Meticulous attention to injection techniques is the key to treatment success of urethral bulking agents, particularly in patients who have a scarred/fixed urethra or have multiple urethral/vaginal surgeries.     

Posttraumatic complete and partial loss of urethra with pelvic fracture in girls: an appraisal of management

PURPOSE: Urethral injury in girls accompanying fracture of the pelvis is rare. We present our experience with 5 such complex cases and review the literature to define the types of problem and determine appropriate management. MATERIALS AND METHODS: We report on 5 girls with posttraumatic urethral injuries and pelvic fracture resulting in stricture as well as management based on the site and length of urethral stricture. Associated injuries and results are discussed. RESULTS: Of the 5 girls who presented with stricture 4 had undergone suprapubic cystostomy as initial treatment, whereas in 1 primary repair had failed. Urethral reconstruction using a bladder flap tube and distal urethrotomy into the vagina were performed in 3 and 1 cases, respectively. These 4 girls were continent although 1 required clean intermittent catheterization for a short period. The 3 patients with complete urethral loss had a more severe degree of pelvic fracture, including 1 treated with core through internal urethrotomy. CONCLUSIONS: Posttraumatic urethral injury accompanying pelvic fracture in young girls results in challenging management situations. More severely displaced pelvic fracture is associated with greater urethral loss and requires more complex repair. Cases of partial urethral injury or urethral transection without much displacement are better managed by primary repair of the transected urethra, which decreases morbidity. Primary repair may not be feasible in patients with extensive injury, who should be treated with secondary appropriate reconstruction after preliminary suprapubic cystostomy. Complete urethral loss may be managed by bladder flap tube neourethra creations with effective continence and excellent outcomes. Short segment distal urethral strictures may be treated with meatotomy or core through internal urethrotomy.     

Four-corner bladder and urethral suspension for moderate cystocele

The classical approach to cystocele repair involves the approximation of lax pubocervical fascia through the anterior vaginal wall with narrowing of the bladder neck and proximal urethra by the Kelly-type plication. This procedure corrects the prolapse but when performed for the treatment of incontinence it has a high failure rate because the bladder neck and urethra are not placed into a high, supported, nonobstructed retropubic position. Furthermore, due to elevation of the bladder base without simultaneous elevation of the bladder neck and urethra, de novo stress urinary incontinence may occur. We developed a transvaginal needle suspension operation for the bladder and urethra that repairs anterior vaginal wall prolapse with excellent support of the bladder base and repositions the bladder neck in the high retropubic position, all during a simple and rapid operation that is tolerated well by the patient.     

Traumatic rupture of female urethra

Complete avulsion of the female urethra secondary to blunt trauma is uncommon. It is associated with pelvic fractures, and because of the close association of the urethra and vagina a vaginal laceration also occurs. The paucity of lesions associated with pelvic fracture may be explained by the relative mobility and shortness of the urethra in the female. The treatment of urethral trauma in females has not been established. Vaginal, transpubic, or retropubic approaches have been used successfully. We report on 3 cases of urethral trauma with anterior vaginal lacerations treated by retropubic approach with good results.