Primary menouria due to a congenital vesico–vaginal fistula with distal vaginal agenesis: a rarity

We present the case of a female aged 16 years, suffering from cyclical menouria for the last 3 years. Clinical examination revealed the absence of a vagina. Cystoscopy performed while the patient was having menouria revealed an orifice (10 × 8 mm) in the supratrigonal region; blood clots were entering the urinary bladder through this orifice. Magnetic resonance imaging of the pelvis depicted a fluid-filled longitudinal tract distal to the uterus (which was the upper vagina), between the cervix and the bladder. Diagnostic laparoscopy confirmed the presence of a uterus, both ovaries, and the tubal structures. Exploratory laparotomy, correction of the fistulous tract, and sigmoid vaginoplasty were performed. The distal part of the fistulous tract (urinary bladder end) was anastomosed to the proximal end of the sigmoid neo-vagina. The patient is doing well as per her last follow-up at 6 months. She has started menstruating per neo-vagina.     

Is anatomical failure following anterior vaginal repair associated with weak native vaginal tissues? A biomechanical and immunohistochemical study

Introduction and hypothesis

This study was performed to determine whether anatomical recurrence of cystocoele 1 year after anterior vaginal repair is related to biomechanical properties and/or the content of collagen in the vaginal wall and epithelial tissues.

Methods

In this prospective, observational study in a UK teaching hospital, we assessed women undergoing surgery for symptomatic anterior compartment prolapse. Outcome measures were anatomical recurrence, biomechanical strength and collagen content in vaginal tissues. In part one of the study, 42 women underwent biomechanical testing of full-thickness anterior vaginal wall tissue samples to determine the elastic moduli and yield stress. In part two, 59 women underwent immunohistochemical testing of anterior vaginal wall tissue samples to determine tissue content of procollagen I; collagen types I, III, V; and matrix metalloproteinases 1 and 2 (MMP-1 and 2). Results were then compared with anatomical outcome at 1 year postsurgery.

Results

Differences in yield strain in all outcome groups (optimal, satisfactory and unsatisfactory) were not statistically significant. Considerable variation was found in collagen type I in both satisfactory and unsatisfactory groups. There was no difference or correlation with procollagen, collagen types III and V, and MMP-1 and recurrence of pelvic organ prolapse (POP) between groups. There was a weak correlation between collagen type I and higher yield stress in both groups.

Conclusions

Anatomical failure of anterior repair does not appear to be related to the biomechanical strength or collagen content of the anterior vaginal wall.     

Estrogen inhibits vaginal tropoelastin and TGF-β1 production

Introduction and hypothesis

The aim of this study was to quantify the effects of estrogen on vaginal smooth muscle cell (SMC) tropoelastin and transforming growth factor (TGF)-β1 production.

Methods

Primary SMC were incubated with estradiol, and cell proliferation was assessed by 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide (MTT) assay at 48 h. Supernatants were collected and tropoelastin and TGF-β1 levels measured.

Results

SMC proliferation was significantly increased by estradiol [relative cell number, mean ± standard error (SE), estradiol 0.1 μM 116?±?19 % of control (P?=?NS), 1 μM 127?±?13 % of control (P?<?0.05), 10 μM 153?±?26 % of control, (P?<?0.05)]. Tropoelastin production was significantly decreased by estrogen [mean ± SE, estradiol 0.1 μM 78?±?2 % of control (P?<?0.05), 1 μM 76?±?4 % of control (P?<?0.05), 10 μM 67?±?3 % of control, (P?<?0.05)]. In addition, TGF-β1 production was significantly decreased [mean ± SE, estradiol 0.1 μM 96?±?4 % of control (P?=?NS), 1 μM 84?±?6 % of control (P?<?0.05), 10 μM 70?±?6 % of control, (P?<?0.05)].

Conclusion

Estrogen increases vaginal SMC proliferation and inhibits tropoelastin and TGF-β1 production.     

Does vaginal size impact sexual activity and function?

Introduction and hypothesis

This study seeks to determine if total vaginal length (TVL) or genital hiatus (GH) impact sexual activity and function.

Methods

Heterosexual women?≥?40 years were recruited from urogynecology and gynecology offices. TVL and GH were assessed using the Pelvic Organ Prolapse Quantification exam. Women completed the Female Sexual Function Index (FSFI) and were dichotomized into either normal function (FSFI total?>?26) or sexual dysfunction (FSFI?≤?26).

Results

Five hundred five women were enrolled; 333 (67%) reported sexual activity. While sexually active women had longer vaginas than women who were not active (9.1 cm?±?1.2 versus 8.9 cm?±?1.3, p?=?0.04), significance was explained by age differences. GH measurements did not differ (3.2 cm?±?1.1 versus 3.1 cm?±?1.1, p?=?0.58). In sexually active women, TVL was weakly correlated with FSFI total score, but GH was not. TVL and GH did not differ between women with normal FSFI scores and those with sexual dysfunction.

Conclusions

Vaginal size did not affect sexual activity or function.     

Can pelvic floor dysfunction after vaginal birth be prevented?

Introduction and hypothesis

Significant breakthroughs in our understanding of pelvic floor dysfunction have occurred in the past two decades. The next step is to translate this understanding into effective preventative and early intervention strategies to minimize maternal morbidity from vaginal birth. We have learned enough to chart a course toward prevention.

Methods

This article outlines some major advances in understanding the pathophysiology of pelvic floor dysfunction and suggests strategies for future prevention research.

Results

Vaginal birth is the primary risk factor for the development of pelvic floor disorders and this is compounded by forceps use. Age, race, and genetics are also risk factors. Steps to prevent or minimize the development of pelvic floor problems include moderating forceps use and utilizing risk assessment tools to offer cesarean delivery to those at greatest risk.

Conclusion

These actions would represent one giant step forward in advancing the practice of obstetrics into the modern age of personalized medicine.

     

Female sexual dysfunction following vaginal surgery: Myth or reality?

This article reviews the mechanisms by which vaginal surgery affects female sexual function and related pathophysiology to potential causes. The anatomy, neurovascular supply of the clitoris and introitus, and intrapelvic nerve supply are discussed as they apply to vaginal surgery. Methods to avoid neurovascular damage during pelvic floor surgery have been corroborated by supporting literature. The incidence of female sexual dysfunction after various transvaginal procedures for indications such as stress urinary incontinence and pelvic organ prolapse, anterior/posterior colporrhaphy, perineoplasty, and vaginal vault prolapse has been discussed. Current literature regarding female sexual dysfunction following other procedures such as vaginal hysterectomy, Martius flap interposition, and vesicovaginal and rectovaginal fistula repair also are reviewed.     

Does the vaginal wall become thinner as prolapse grade increases?

Introduction and hypothesis

The pathophysiology of prolapse is not well understood. However, two main theories predominate: either the fibromuscular layer of the vagina develops a defect/tears away from its supports, or its tissues are stretched and attenuated. The aim of this study was to assess how vaginal wall thickness (VWT) is related to vaginal prolapse.

Methods

The study group comprised 243 women with symptomatic prolapse recruited from the Outpatient Department of a tertiary referral centre for urogynaecology. A history was taken and women were examined to determine their POP-Q score. Using a previously validated technique, ultrasonography was used to measure the mean VWT at three anatomical sites on the anterior and posterior walls. Scores were then compared using t tests, the Kruskal-Wallis test and the Friedman test.

Results

The mean age of the patients was 59.7 years (SD 12.0 years range 38?–?84 years). For each measurement VWT reduced as prolapse grade increased until the prolapse extended beyond the hymen. Women with grade 3 prolapse had a significantly higher mean VWT than women with grade 1 or 2 contained prolapse. Menopause status did not have a significant effect on the VWT.

Conclusions

VWT is lower in women with vaginal prolapse until the prolapse extends beyond the hymen and then VWT is thicker and comparable with women without prolapse. This may be explained by changes in the vaginal tissue including reduction of collagen, elastin and smooth muscle, as well as fibrosis in exposed tissues, rather than by defects in the vagina.

     

Posterior vaginal compartment prolapse and defecatory dysfunction: are they related?

While posterior vaginal compartment prolapse and defecatory dysfunction are highly prevalent conditions in women with pelvic floor disorders, the relationship between anatomy and symptoms, specifically obstructed defecation, is incompletely understood. This review discusses the anatomy of the posterior vaginal compartment and definitions of defecatory dysfunction and obstructed defecation. A clinically useful classification system for defecatory dysfunction is highlighted. Available tools for the measurement of symptoms, physical findings, and imaging in women with posterior compartment prolapse are discussed. Based on a critical review of the literature, we investigate and summarize whether posterior compartment anatomy correlates with function. Definitions of obstructed defecation and significant posterior compartment prolapse are proposed for future exploration.     

Mesh removal after vaginal surgery: what happens in the UK?

Introduction and hypothesis

There is little objective evidence regarding complication rates for mesh procedures outside clinical trials. Current coding poorly collects complications of prolapse and continence surgery using mesh. This survey was designed to identify surgeons performing mesh removal and reporting patterns in the UK.

Methods

An electronic questionnaire was sent to all members of the Royal College of Obstetricians and Gynaecologists and members of the Section of Female Neurological and Urodynamic Urology of the British Association of Urologists in the UK. The questionnaire aimed to identify the number of procedures performed for mesh complications and whether they were reported to the Medicines and Healthcare products Regulatory Agency (MHRA) and the patterns of referral and treatment

Results

Referral to a colleague in the same hospital was common practice (69 %). Only 27 % of respondents stated that they reported all removals to the MHRA. The numbers of surgical procedures were low, with most respondents performing between one and three procedures each year and many not performing any surgery for a specific mesh complication in the previous year.

Conclusions

Removal of exposed, eroded and/or painful vaginally inserted mesh is performed by many different surgeons in a variety of hospital settings in the UK.

     

Posterior vaginal compartment repairs: Where are the main anatomical defects?

Introduction and hypothesis

Traditionally, it has been believed that posterior vaginal compartment prolapse was largely due to defects in the rectovaginal fascia, with surgical repairs concentrating on addressing this defect. We aimed to determine the relative size of defects at the different vaginal levels (I–III) following a large number of posterior vaginal compartment repairs (PRs) to determine whether this traditional viewpoint is still appropriate.

Methods

In a cross-sectional study of 300 consecutive PRs, mostly following prior or concomitant hysterectomy, two sets of markers of posterior compartment prolapse were used to measure anatomical defects at levels I–III: (i) from Pelvic Organ Prolapse Quantification (POP-Q) system points C, Ap, Bp, and genital hiatus (GH), and from Posterior Repair Quantification (PR-Q) perineal gap (PG), posterior vaginal-vault descent (PVVD), midvaginal laxity (MVL)—vault undisplaced, and rectovaginal fascial laxity (RVFL).

Results

The largest defects were found at level I (PVVD: mean 6.0 cm; point C, mean minus 0.9 cm), and level III (PG, mean 2.9 cm; GH, mean 3.7 cm). Level II defects (MVL—vault undisplaced, mean 1.3 cm; RVFL, mean 1.1 cm; points Ap, Bp, both mean 1.0 cm) were relatively small.

Conclusions

This study suggests that the defects found at surgery for posterior vaginal compartment prolapse were more frequent at the vaginal vault (level I) and vaginal introitus (level III) than at midvagina (level II). These findings should have implications for surgical planning.

     

What are the risk factors of anal incontinence after vaginal delivery?

Fecal incontinence is one of the most feared complications of vaginal delivery. It may be the consequence of sphincter tears, of pudendal neuropathy, or of a combination of the two. Fecal incontinence occurs immediately following 13-54% of vaginal deliveries but its persistence in the mid and long term is poorly known. The incidence of perineal tear with anal sphincteric defect varies from 1-9% and the incidence of unrecognized sphincter injury may be as high as 18-35%. Half the women who undergo primary anal sphincter repair have short or long term continence problems. Pudendal neuropathy is caused by nerve stretch during pushing in the second stage of labor and descent of the fetal head; it may occur even with the first delivery. Risk factors for sphincter injury and pudendal neuropathy include forceps delivery, large neonatal size, and prolonged second stage of labor. The risk of fecal incontinence must be considered even during the first pregnancy. Routine episiotomy does not prevent sphincter injury and may even predispose to it. Pudendal neuropathy following delivery may lead to delayed fecal incontinence abetted by postmenopausal hormonal deficiency and tissue senescence. The possible benefit of early episiotomy for women at high risk of sphincter injury must be evaluated by prospective studies.     

Tension free vaginal tape: is the intra-operative cough test necessary?

The tension-free vaginal tape (TVT) procedure is recognised as an effective treatment for genuine stress incontinence. It was first described using local anaesthesia, with an intra-operative cough test helping to correctly position the tape. Many patients prefer general anaesthesia and often, patients with genuine stress incontinence do not leak when supine. This aim of this study was to compare the outcome in TVTs performed under general anaesthesia with those performed under spinal anaesthesia. Retrospective analysis of 105 patients, all of whom had urodynamically proven genuine stress incontinence and underwent TVT procedure, was performed: 52 under spinal anaesthesia and 53 under general anaesthesia. The primary and secondary outcome measures were the success or failure of the procedure and the complication rate, respectively. There was no significant difference in outcome or complication rate between the two groups. The type of anaesthetic used does not influence the outcome and we question the necessity of an intra-operative cough test. Editorial Comment: Many surgeons in the USA perform the tension-free vaginal tape (TVT) either alone or with other pelvic reconstructive procedures under general anesthesia. The cough stress test as originally recommended under regional or local anesthesia is performed with the patient in the recumbent position, theoretically lessening its validity and reliability at predicting success. This small retrospective study demonstrates equal efficacy in short-term follow-up when TVT sling tensioning is performed by surgeon judgment as with other pubovaginal slings, or by using the cough stress test when feasible under spinal anesthesia. It is hoped that future studies with larger number of patients and longer follow-up will confirm this.