Vesical Calculus: A Complication of Intravesical Migration of Intrauterine Contraceptive Device

Intravesical migration of an intra-uterine contraceptive device (IUCD) in a 28-year-old woman resulted in recurrent urinary tract infections. She received antibiotic treatment from her general practitioner but had no investigations done. Later on she became pregnant and investigations revealed that the thread of IUCD was missing and there was a vesical calculus. After she had delivered the baby, a pelvic X-ray was taken and showed a vesical calculus on the IUCD. Both calculus and IUCD were removed cystoscopically. Correspondence and offprint requests to: Dr Muhammad Rafique, 5, Altaf Town, Tariq Road, Multan, Pakistan. E-mail: rafiqanju@hotmail.com/mrafiqanjum@yahoo.com     

Intravesical Foreign Body and Vesicovaginal Fistula: A Rare Complication of a Neglected Pessary

A silicone Gellhorn pessary, 3 inches in diameter, neglected for several years in an elderly woman, eroded through the anterior vaginal wall, ultimately to lie entirely within the bladder. General anesthesia and bilateral deep full-length Schuchardt’s incisions were required to remove it. A Latzko procedure was done at a later date to close the large vesicovaginal fistula; similar Schuhardt’s incisions were again used.     

Laparoscopic Management of Recurrent Vesicovaginal Fistula

Vesicovaginal fistula repair is most commonly undertaken via a transvaginal approach. We report a recurrent case of vesicovaginal fistula which was ultimately repaired using a laparoscopic approach. The fistula followed a hysterectomy and persisted despite two operations using the Latzko partial colpocleisis and prolonged catheterization. The fistulous tract was ultimately repaired by closing the vagina and bladder with an interposing omental flap utilizing a laparoscopic approach.     

Postirradiation Vesicovaginal Fistula Completely Resolved with Conservative Treatment

Postirradiation vesicovaginal fistulae (VVF) pose a great challenge for the urologist. The poorly vascularized radiated tissue surrounding the fistula impairs healing and makes operative repair technically demanding. Conservative treatment for postirradiation VVF is considered inappropriate, and to our knowledge has never previously been described. We present a case of a woman with postirradiation VVF that was resolved after transurethral coagulation and 3 weeks of catheterization.     

Laser Welding of Vesicovaginal Fistula

The management of vesicovaginal fistula remains a source of debate, despite extensive literature on the subject. It is difficult to prove the superiority of one surgical technique over another by randomized trials, given the variabilities of fistula etiology, the location and clinician expertise. Small epithelized fistulae following conservative treatment and residual or recurrent cases following transabdominal or transvaginal repair pose a therapeutic challenge. A case of a small vesicovaginal fistula following abdominal hysterectomy is presented, in which a successful outcome was achieved using endoscopic Nd-YAG laser fulguration.     

Posthysterectomy Vault Eversion with a Large Retroperitoneal Mass

A woman with complete vaginal eversion was found to have a large pelvic mass, extending from the rectovaginal septum to the presacral space. This 66-year-old woman with posthysterectomy vaginal eversion complained of pelvic fullness. A pessary provided relief of the prolapse, but the symptom of fullness persisted. Physical examination did not identify a pelvic mass. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a 9 cm tumor of the rectovaginal septum, extending to the presacral space. At laparotomy the patient had a massive neurofibroma arising from the anterior rectal wall. This case is of interest because the complete vaginal prolapse obscured the diagnosis of this large pelvic tumor. CT and MRI were useful in identifying and characterizing the mass. To our knowledge, this is the first reported case of vaginal prolapse with a large pelvic mass.     

Rectovaginal Fistula Repair Utilizing a Cadaveric Dermal Allograft

Rectovaginal fistula repair is commonly performed through the vagina. When recurrent fistulae occur, healthy tissue such as a muscle or fat pad may be interposed to facilitate healing and prevent recurrence. A woman developed a postpartum rectovaginal fistula after her third-degree perineal laceration failed to heal completely. Two subsequent fistula repairs were performed, with recurrence following each procedure. The fistula was ultimately repaired by performing a layered closure and interposing a cadaveric dermal allograft between the rectovaginal septum and vaginal epithelium. Allogenic cadaveric graft may be a viable alternative to traditional autologous flaps for the repair of recurrent or complicated rectovaginal fistulae.     

The obstetric fistula and peroneal nerve injury: An analysis of 947 consecutive patients

Peroneal nerve injury, resulting in leg weakness and foot drop, is seen frequently after long, obstructed labor that has caused an obstetric vesicovaginal fistula. Nine hundred and forty-seven consecutive patients treated in northern Nigeria for obstetric fistulas were reviewed for the presence of peroneal nerve trauma. The first 470 patients were reviewed retrospectively, and 25 (5.3%) were noted to have presented with significant motor weakness. The next 470 patients were prospectively evaluated by both history and physical examination. In this group, 311 (64.9%) women had either a history or current signs of peroneal nerve injury at the time of admission for fistula repair. Injuries were more common on the right side and were more commonly apparent in the first 2 years after the obstetric trauma causing the fistula.     

Thomas Addis Emmet, the Vesicovaginal Fistula, and the Origins of Reconstructive Gynecologic Surgery

Thomas Addis Emmet (1828–1919), the foremost pupil of J. Marion Sims and his successor as chief surgeon at The Woman’s Hospital in New York City, was probably the pre-eminent American gynecological surgeon of the last quarter of the 19th century. Among his many achievements were the first critical study of vescovaginal fistula repair, authorship of the first modern scientific textbook of gynecology, the invention of numerous special surgical instruments, pioneering the use of surgical scissors in vaginal operations, and the development of ‘staged’ procedures for surgical reconstruction of the vagina. He was an active writer, a renowned collector of American historical documents and memorabilia, a devout Catholic and a steadfast Irish patriot. This article reviews his life and contributions to gynecologic surgery.     

Vault Prolapse I: Dynamic Supports of the Vagina

The relative contributions of muscle forces and vaginal suspensory ligaments to the anatomical support of the vagina have been long disputed. The aim of this study was to gain further insights into the role of striated muscle forces. Fifty consecutive patients presenting to a pelvic floor clinic were tested with perineal ultrasound, lateral X-rays at rest and on straining, 10 ml of radio-opaque dye having been injected into bladder, vagina, rectum and, in 12 patients, into the levator plate also. The relevance of muscle forces to the three anatomical levels of support, the cardinal/uterosacral ligament complex (level 1), the rectovaginal fascia (level 2) and the perineal body (level 3), was analyzed. Biopsies of the suspensory ligaments were performed per vaginam. During effort, the upper part of the vagina was stretched backwards and downwards against the perineal body. Compression of level 2 on standing lateral X-ray appeared to be related to the angle of the upper vagina to the horizontal at rest. In 23 patients in whom the angle was 45° or more to the horizontal, only 2 demonstrated significant angulation of the upper vagina and therefore compression of level 2 on straining. In contast, all 27 patients with an angle less than 45° to the horizontal demonstrated both vaginal angulation and compression. Histology demonstrated smooth muscle and nerves in the suspensory ligaments, indicating an active contractile role for these structures. Analysis of the directional forces suggests that inability ot angulate the vagina sufficiently may predispose to herniations of the walls of the vagina owing to the twin influences of gravity and downward muscle forces exerted by the levator muscles.     

A Rare Complication with TVT: Vaginal Protrusion of the Tape

The authors report a rare postoperative complication of TVT. A 38-year-old woman, suffering from genuine stress incontinence, presented 3 weeks after surgery with a 1 cm protrusion of the TVT across the median vaginal scar. A fastening point on the tape and covering it with the vaginal skin was unsuccessful. Three weeks later, we found a 5 mm protrusion of the tape. At this time we decided to resect the protruding fibers but without interrupting the tape. Regular clinical checks showed good local cicatrization, and 4 weeks later the vaginal epithelium covered the tape completely and the patient no longer suffered from genuine stress incontinence.     

Bladder Cancer in Women

In women bladder cancer usually occurs above the age of 60 and comprises 3% of all female cancers. The hallmark of presentation is hematuria, which must be investigated by radiological imaging and cystoscopy. The best prognostic indicators are grade and stage. Stage divides the disease into two separate entities, superficial and invasive disease. Approximately 70%–80% of patients will present with superficial disease, 10% will fail treatment or progress to invasive disease, and 20% present with invasive disease. Superficial disease is managed by transurethral resection and additional intravesical therapy when high-risk parameters for recurrence or progression exist. Overall survival is good and the morbidity acceptable. Invasive bladder cancer carries a worse prognosis, with an average of 50% 5-year survival. Management of invasive disease warrants extensive surgery, which is the best single treatment modality. Chemotherapy and radiotherapy are implemented in the management of progression or metastasis.     

Biomechanical Properties of Prolapsed Vaginal Tissue in Pre- and Postmenopausal Women

The aim of this study was to biomechanically assess vaginal tissue from pre- and postmenopausal women with symptomatic prolapse. Vaginal tissue was collected at the time of surgery in women with symptomatic prolapse. Tissue specimens were biomechanically assessed by a purpose-built tissue puller system and stress–strain curves were digitally recorded. Tissue was stretched at a constant rate of 0.8 mm/s to an elongation of 8 mm. A force–stiffness relationship was obtained. All data were normalized for length and cross-sectional area of the specimens. Tissues from the anterior vaginal wall were analyzed in 10 postmenopausal and 8 premenopausal women. The mean age of the postmenopausal women was 69 years, compared to 41 years for premenopausal women. Pre- and postmenopausal groups show very little or no difference regarding elongation or long-term tissue deformation. A significantly higher elastic modulus was observed in postmenopausal vaginal tissue. This is most likely an age-related phenomenon. Apart from this, pre- and postmenopausal vaginal tissue showed few differences in biomechanical assessment.     

Transurethral Suture Cystorrhaphy for Repair of Vesicovaginal Fistulas: Evolution of a Technique

Technical difficulties in the initially described transurethral repair of vesicovaginal fistulas have led to several modifications in technique. In an uncontrolled trial, these modifications included the use of a suprapubic tract, along with an arthroscope for visualization of the fistula. A large-caliber port is passed per urethram for transurethral instrumentation access. New-generation laparoscopic needle driver technology markedly improves the ease of transurethral suturing. Three previously unreported vesicovaginal fistula patients have had successful resolution of their fistulas after undergoing transurethral repair. Small-diameter vesicovaginal fistulas in selected patients can be successfully repaired by a minimally invasive transurethral suture technique.     

Do Pessaries Prevent the Progression of Pelvic Organ Prolapse?

Pessaries are used for the management of pelvic organ prolapse, but it is unknown whether a pessary will prevent progression of this condition. The purpose of this study was to describe the course of pelvic organ prolapse among women using a pessary for at least 1 year. Among 56 consecutive women fitted with a pessary, 19 (33.9%) continued its use under our care for at least 1 year. We compared baseline and follow-up examinations, using the Pelvic Organ Prolapse Quantitation examination system. At baseline, 16 (84.2%) had stage 3 or 4 prolapse. After 1 year we observed a significant improvement in the stage of disease (P = 0.045, Wilcoxon signed rank test). Four women (21.1%, 95% confidence interval −0.2, 43.7%) had an improvement in stage. No women had worsening in stage of prolapse. These data suggest that there may be a therapeutic effect associated with the use of a supportive pessary. Correspondence and offprint requests to: Dr V. L. Handa, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, 600 North Wolfe Street, Harvey 319, Baltimore, MD 21287, USA. Tel: (410) 614-4495; Fax: (410) 955-1003; Email: vhanda1@jhmi.edu     

Diagnosis and Management of Post-cesarean Ureterouterine Fistulae

Urinary leakage following obstetric or gynecologic surgery is a dreaded complication, most often caused by a urogenital fistula. Of these, ureterouterine fistulae are relatively rare and pose a diagnostic and therapeutic dilemma. A 29-year-old woman presented with paradoxical incontinence of urine for 3 months. She had developed vaginal leakage of urine 2 weeks following an uneventful cesarean section. Conservative measures in the form of catheterization and bed rest did not relieve her symptoms. Subsequent examination and investigations revealed that she had a ureterouterine fistula. The case is discussed as well as the diagnostic modalities and treatment options.     

Long-term Assessment of the Incontinence Ring Pessary for the Treatment of Stress Incontinence

A prospective cohort of 38 women who presented with predominantly stress incontinence symptoms were fitted with an incontinence ring pessary. They had documented stress incontinence on multichannel urodynamic testing. Nine women (24%) were not leaking by subjective measures. Six women (16%) continued using the pessary. This group of women had no statistically identifiable parameters that distinguished them from women who had not wanted to continue using the pessary. There was a trend showing that successfully fitted women were younger (41 vs 52 years old), had less pelvic surgery and leaked less on semiquantitative pad testing (10.7 g vs 19.2 g). In women who chose to continue using the pessary there was a trend showing a decrease in the semiquantitative pad score (1.2 g from 10.7 g) and 7-day voiding diary (1.5 episodes from 4.1). In conclusion, the incontinence pessary was successful in a small proportion of women with stress incontinence.     

Study of the Effect of Straining on the Bulbocavernosus Muscle with Evidence of a Straining–Bulbocavernosus Reflex and its Clinical Significance

The bulbocavernosus muscle (BCM) surrounds the vaginal introitus and covers the vestibular bulb. Its role in erection is known. However, as it surrounds the vaginal introitus, it may also have a role in intravaginal pressure regulation and in the pathogenesis of uterovaginal prolapse. We investigated the effect of increased intra-abdominal pressure (IAP) on the BCM, aiming to assess its possible function in supporting the uterus, vagina and anorectum. The intrarectal (representative of the IAP) and intravaginal pressures were measured by manometric catheters in 19 healthy women volunteers (mean age 46.2 ± 10.4 years). The EMG activity of the BCM and its response to straining at different pressures were recorded by a concentric needle electrode. Two types of straining were tested: sudden momentary and slow sustained. The procedure was repeated in 11 of the women after individual anesthetization of the BCM, rectum and vagina. Sudden straining (coughing) produced a significant increase in intrarectal (P<0.0001) and intravaginal (P<0.0001) pressure as well as BCM EMG activity. Slow straining effected a similar but lower response: the BCM responded gradually with pressure elevation, whereas the latency exhibited a gradual decrease. The BCM did not react to straining after individual anesthetization of the BCM, vagina and rectum, but did respond to saline administration. The results were reproducible. BCM contraction on straining postulates a reflex relationship, which we call the ‘straining–bulbocavernosus reflex’. We hypothesized that this reflex is evoked by straining and results in BCM contraction and closure of the vaginal introitus. The vagina is believed to become a closed cavity, counteracting the increased intra-abdominal pressure and the uterine tendency to prolapse. The high pressure in the closed vaginal cavity presumably supports the rectovaginal septum against the high intrarectal pressure, and is suggested to share in the prevention of rectocele. The role of BCM in the pathogenesis of uterovaginal prolapse and rectocele needs further study.     

Vaginal Configuration on MRI after Abdominal Sacrocolpopexy and Sacrospinous Ligament Suspension

An MRI study was conducted to compare the vaginal configuration of women who had undergone sacrospinous fixation with transvaginal needle suspension or abdominal sacrocolpopexy with retropubic colposuspension with that of normal controls. MRI examination demonstrated that in normal controls the lower vagina formed an acute angle (mean 53°) with the pubococcygeal line and intersected the upper vagina at a mean angle of 145°. In the abdominal repair group the lower vagina intersected the pubococcygeal line at a mean angle of 57° and joined the upper segment at a mean angle of 137°. In the vaginal repair group the lower vagina intersected the pubococcygeal line at a mean angle of 54° and joined the upper segment at a mean angle of 220°. Our study demonstrated that abdominal sacrocolpopexy with retropubic colposuspension more closely restored the vagina to its normal configuration, whereas sacrospinous fixation with transvaginal needle suspension creates an abnormal vaginal axis.     

Anatomic and Functional Outcome of Vaginal Paravaginal Repair in the Correction of Anterior Vaginal Wall Prolapse

Over a 2-year period 45 patients with bilateral paravaginal support defects underwent vaginal paravaginal repair. Postoperative evaluations were conducted and anatomic outcome was determined by vaginal examination, with grading of vaginal wall support. Functional outcome was assessed by a standardized quality of life questionnaire, voiding dairy and standing stress test with a full bladder. Thirty-five patients had long-term follow-up with a mean of 1.6 years (range 1–85). The recurrence rates for displacement cystocele, enterocele and rectocele were 3% (1/35), 20% (7/35) and 14% (5/35), respectively. In no patients did vault prolapse develop or recur. Subjective or objective evidence of persistent stress urinary incontinence was found in 57% of patients (12/21). Vaginal paravaginal repair is a safe and effective technique for the surgical correction of anterior vaginal wall prolapse but has limited applicability in the surgical correction of genuine stress incontinence.