Vaginal Laceration as a Result of Blunt Vehicular Trauma

BackgroundSexual abuse often is the primary diagnosis considered when prepubertal girls present with vaginal trauma. Although sexual abuse is very concerning and should remain high in the differential diagnosis, a variety of accidental injuries also can cause genital injury.CaseA 5-year-old girl presented to the emergency department with genital bleeding after a vehicle rolled over her pelvis. She had isolated vaginal lacerations on exam.Summary and ConclusionExtreme pelvic compression is an adequate mechanism of injury in a child presenting with vaginal laceration.     

Laparoscopic Posthysterectomy Vaginal Vault Excision for Chronic Pelvic Pain and Deep Dyspareunia

Study ObjectiveTo evaluate the outcome of posthysterectomy laparoscopic vaginal vault excision and its long-term effects on chronic pelvic pain, dyspareunia, quality of life, and patient satisfaction.Materials and MethodsThis is a retrospective cohort study (Canadian task force classification II–3) incorporating case note review and a postal questionnaire. It describes 22 consecutive patients who underwent laparoscopic vaginal vault excision for posthysterectomy dyspareunia and chronic pelvic pain. At laparoscopy, full thickness vaginal vault was excised along with scar tissue or any cyst. The vaginal cuff was closed laparoscopically. The patients were sent a validated questionnaire to assess their pain scores, general health, quality of life, and satisfaction with the surgery. The mean interval from vaginal vault excision and to questionnaire distribution was 1.8 years. The statistical analysis was performed with SPSS 15.ResultsThe mean age of the women was 40 years. All women had vaginal vault tenderness on examination and underwent laparoscopic vaginal vault excision. The only intraoperative complication was 1 puncture injury of the bladder, which was produced by 10-Veres needle during manipulation. A single or a combination of additional procedures was performed at the same time. The patient satisfaction questionnaires were received from 16 (72.7%) women. Of the 16 (72.7%) respondents, 13 (81.25%) confirmed improvement in dyspareunia. The mean pain scores decreased, and quality of life and general health improved significantly after vaginal vault excision (p <.05, t test).ConclusionLaparoscopic vaginal apex excision is a safe and effective management option after carefully excluding other causes of deep dyspareunia and chronic pelvic pain. It also provides an opportunity to detect and surgically excise previously undiagnosed endometriosis and other disease.     

Perioperative Complications in Vaginal Mesh Procedures Using Trocar in Pelvic Organ Prolapse Repair

Introduction and Hypothesis

This study aimed to document intraoperative and early postoperative complications associated with the use of vaginal mesh with trocar in pelvic organ prolapse (POP) repair.

Methods

This is a retrospective review of 120 cases of vaginal repair of POP using vaginal mesh. Of the 120 patients, 31 underwent anterior mesh repair (Light mesh 10, Avaulta 1, Perigee 1, and Prolift 19); 35 underwent posterior mesh repair (Light mesh 2, Posterior IVS 17, and Prolift 16); and 54 underwent anterior and posterior mesh (total) repair (Light mesh 8, Prolift 32, and Prolift M 14).

Results

Three bladder injuries (2.5%) and one distal rectal injury (0.8%) occurred during dissection. Three of four organ injuries (75%) had previous prolapse repair. Overall four patients (3%) required transfusion. Urinary retention exceeding 5 days occurred in four patients. Three of them (60%) also underwent TVT-O. Groin pain occurred in two patients one of whom underwent TVT-O. Gluteal pain occurred in one patient. Early mesh exposure occurred in the vaginal cuff of a patient who underwent hysterectomy.

Conclusions

The vaginal mesh procedures may be done with relatively few perioperative complications. However, there is a need for more randomized controlled trials with long-term follow-up to clarify its postoperative long-term complications and morbidities.     

Pelvic Neuroanatomy: An Overview of Commonly Encountered Pelvic Nerves in Gynecologic Surgery

ObjectiveThis video tutorial identifies key anatomic landmarks useful in identifying the path of the most commonly encountered pelvic nerves in benign gynecologic surgery.DesignThis is a narrated overview of commonly encountered pelvic nerves during benign gynecology, their origin, sensory, and motor function, as well as sequelae related to injury.SettingThe unintended injury of pelvic neural connections can be a complication of any pelvic surgery, however, surgery for malignancy or endometriosis may increase the likelihood of encountering these nerves. The majority of focus surrounding surgical nerve injury, however, relates to patient positioning [1]. Injury to the pelvic nerves can lead to lifelong sexual, bladder, and defecatory dysfunction [2].InterventionsWe review the Genitofemoral, Lateral Femoral Cutaneous, Ilioinguinal, Obturator, Superior and Inferior Hypogastric nerves, Pelvic Splanchnic nerves, and the Sacral nerves. Surgical illustrations are used (Fig. 1) alongside real-time narrated video to help viewers recognize the normal course of commonly encountered pelvic nerves at the time of gynecologic surgery (Figs2–3).ConclusionThe surgical management of complex pelvic disease can unfortunately carry significant patient morbidity [3]. The neural pathways traveling through the pelvis via the hypogastric nerves are responsible for proprioception, vaginal lubrication, and proper functioning or the urethral and anal sphincters [4]. Sparing these nerves during pelvic surgery, and especially when anatomic planes are distorted by pelvic disease, requires surgical expertise and an immense understanding of pelvic neuroanatomy [4,5]. Preservation of the pelvic neural pathways is necessary to deliver the best patient outcomes while minimizing unwanted surgical complications. This video tutorial also highlights the origin of these nerves, their anatomic location, procedures in which these nerves may be encountered, and what sequelae occur from their unintended injury.     

The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery

OBJECTIVE: Our goal was to evaluate the role of intraoperative cystoscopy during surgery for pelvic organ prolapse and urinary incontinence. STUDY DESIGN: Charts of 224 consecutive patients who had intraoperative cystoscopy performed after urogynecologic surgery were reviewed. RESULTS: Nine injuries occurred that were unsuspected before cystoscopy, for an incidence of 4%. Six ureteral ligations occurred, four after Burch cystourethropexy and two after vaginal culdoplasty. Intravesical sutures were noted after two Burch procedures, and another injury occurred with passage of fascia lata through the bladder during a pubovaginal sling procedure. Eight injuries were managed by removal and replacement of the suture or sling with only one requiring ureteroneocystotomy. When patients with injuries were compared with those without, there were no statistical differences in demographic or surgical parameters. CONCLUSIONS: The potential for damage to the lower urinary tract is significant with complex urogynecologic surgery. Because of the increased and delayed morbidity associated with unrecognized injury, intraoperative surveillance cystoscopy should be considered a part of all such procedures.(Am J Obstet Gynecol 1997;177:71)     

Laparoscopic Resection of a High Grade Serous Ovarian Cancer that Recurred at the Vaginal Stump with Extensive Pelvic Adhesions after Complete Surgical Staging

Study ObjectiveTo show laparoscopic resection of a high grade serous ovarian cancer that recurred at the vaginal stump with extensive pelvic adhesions after complete surgical staging.DesignStepwise demonstration of the procedure with narrated video footage.SettingUniversity hospital.InterventionsWe reported a case of a 62-year-old woman with a history of complete surgical staging of high grade serous ovarian cancer staged IIB, which consisted of hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, and omentectomy, about 18 months before this admission. She received 6 courses of carboplatin/paclitaxel combination therapy after complete surgical staging and achieved complete remission. About 12 months after the last course of chemotherapy, she visited the local clinic because of irregular vaginal bleeding. Physical examination revealed a 3 × 3 × 2 cm³ mass at the vaginal vault. Biopsy of the mass was performed under colposcopy, and pathological reports showed recurrent high grade serous cancer. Her serum cancer antigen 125 level was in normal range. Positron emission tomographic/computed tomographic imaging (PET/CT) showed no evidence of disease dissemination. A diagnosis of recurrent high grade serous ovarian cancer was made. After the biopsy of the recurrent mass, there were no visible lesions, which made us believe that laparoscopy management would not contribute to intraperitoneal spread of the tumors. Therefore, laparoscopic resection of the vaginal stump was scheduled. The key steps of the procedure were summarized as follows. First, the bowels were released from the side abdominal wall to expose bilateral external iliac vessels. Second, bilateral ureters were identified and mobilized to avoid incidental ureter injuries. Third, we opened the rectovaginal space and detached the rectum from the posterior vaginal wall. Fourth, the posterior vesical wall was separated from the vaginal stump. After exposure of the key anatomic landmarks, laparoscopic resection of the vaginal stump was performed safely. Final pathologic report showed recurrent high grade serous ovarian cancer. The patient received 6 courses of carboplatin/paclitaxel combination therapy, and maintenance therapy with olaparib was suggested, but the patient refused to accept this suggestion. She is still in complete remission 8 months after surgery.ConclusionLaparoscopic resection of a high grade serous ovarian cancer that recurred at the vaginal stump with extensive pelvic adhesions after complete surgical staging was achieved successfully in a logical way. The critical point of the procedure is to expose the key anatomic landmarks of the pelvis to avoid incidental injuries [1].     

Laparoscopic nerve-sparing radical vaginectomy in patients with vaginal carcinoma: surgical technique and operative outcomes

Study ObjectivesTo describe our technique for laparoscopic nerve-sparing radical vaginectomy and to assess the feasibility and safety of the procedure via operative outcomes.DesignRetrospective study (Canadian Task Force classification II-2).SettingMajor university teaching hospital in Chongqing, China.PatientsTwelve consecutive patients with early stage vaginal carcinoma.InterventionsLaparoscopic radical parametrectomy/vaginectomy with pelvic/paraaortic lymphadenectomy.Measurements and Main ResultsNerve-sparing radical vaginectomy was completed laparoscopically without conversion to laparotomy in 12 patients with early stage vaginal cancer. Mean (SD) operative time was 158.5 (36.7) minutes, and estimated blood loss was 135.2 (62.8) mL. No intraoperative complications occurred, and no patients required blood transfusion. The number of pelvic nodes obtained was 21.2 (9.8), and of para-aortic nodes was 13. All nodes were negative for malignancy. Histologic analysis confirmed the absence of any residual cancer tissue in the margins of the parametrial tissue and vagina. The median (range) time before Foley catheter removal was 9.76 (3–14) days, and bladder void function recovery to grade 0–I was observed in 11 patients (91.7%). Neither long-term bladder voiding dysfunction nor any other long-term complications were reported. The median duration of follow-up was 28 months. One patient with stage II vaginal cancer received pelvic regional radiation therapy; the other patients did not require adjuvant therapy after the operation. All patients were included in the follow-up protocol, and there was no recurrence of disease in any patients.ConclusionsLaparoscopic radical parametrectomy/vaginectomy with pelvic/para-aortic lymphadenectomy is a therapeutic option for early stage vaginal carcinoma. Nerve-sparing radical surgery in indicated patients may lead to optimal preservation of bladder function. The technique described in this preliminary study seems to be safe and feasible, and was relatively easy to perform in our study population.     

Sexual Dysfunction in Women after Traumatic Pelvic Fracture Negatively Affects Quality of Life and Mental Health

BackgroundWhile the impact of female sexual dysfunction (FSD) on mental health and overall health-related quality of life (HrQOL) has been previously documented, no prior work has evaluated this relationship in women following traumatic pelvic injuries.AimThis study aims to understand the relationship of FSD with HrQOL and depression in women with a history of traumatic pelvic fracture.MethodsData were collected with an electronic survey that included queries regarding mental and sexual health. Inverse probability weighting and multivariate regression models were utilized to assess the relationships between sexual dysfunction, depression and HrQOL.OutcomesStudy outcome measures included the Female Sexual Function Index (FSFI) to evaluate sexual functioning, the 8-item patient health questionnaire (PHQ-8) to assess depression symptoms, and the visual analog scale (VAS) component of the EuroQol 5 Dimensions Questionnaire (EQ-5D) to determine self-reported HrQOL.ResultsWomen reporting FSD had significantly higher PHQ-8 scores with a median PHQ-8 score of 6 (IQR 2, 11) relative to those without FSD who had a median score of 2 (IQR 0, 2) (P < .001). On multivariate linear regression, presence of FSD was significantly associated with higher PHQ-8 scores (β = 4.91, 95% CI 2.8–7.0, P < .001). FSFI score, time from injury, and age were all independently associated with improved HrQOL, with FSFI having the largest effect size (β = 0.62, 95% CI 0.30–0.95, P < .001).Clinical ImplicationsThese results underscore importance of addressing not just sexual health, but also mental health in female pelvic fracture survivors in the post-injury setting.Strengths and LimitationsThis study is one of the first to examine women with traumatic pelvic fractures who did not sustain concomitant urinary tract injuries. Study limitations include low response rate and the inherent limitations of a cross-sectional study design.ConclusionPatients with persistent, unaddressed FSD after pelvic fracture are at unique risk for experiencing depression and reporting worse health-related quality of life due to complex biopsychosocial mechanisms.Gambrah HA, Hagedorn JC, Dmochowski RR, et al. Sexual Dysfunction in Women after Traumatic Pelvic Fracture Negatively Affects Quality of Life and Mental Health. J Sex Med 2022;19:1759–1765.     

Postcoital Vaginal Rupture in a Young Woman with No Prior Pelvic Surgery

IntroductionReports of postcoital vaginal rupture in the literature are limited to cases involving women who are postmenopausal, have recently undergone pelvic surgery, or have suffered genitourinary trauma.AimWe report a case of postcoital vaginal rupture in a 23‐year‐old woman with no prior surgical history who complained of acute onset, severe vaginal pain after consensual intercourse.ResultsExamination under anesthesia revealed a 6‐cm laceration of the posterior fornix, which extended into the abdominal cavity. The laceration was repaired using a combined vaginal and laparoscopic approach.ConclusionsCoitus‐induced vaginal rupture in a reproductive aged woman with no prior pelvic surgery or other risk factors is a rare clinical presentation. Prior reports of rupture in premenopausal women have recommended repair via laparotomy. This case documents successful transvaginal and laparoscopic repair, and reviews the etiological mechanisms for coitus‐induced injury. Austin JM, Cooksey CM, Minikel LL, and Zaritsky EF. Postcoital vaginal rupture in a young woman with no prior pelvic surgery. J Sex Med 2013;10:2121–2124.     

Barriers to Care of Sexual Health Concerns in Men Following Traumatic Pelvic Fractures

IntroductionTraumatic pelvic fractures are associated with sexual dysfunction in men. However, how men are counseled and access care for sexual health following injury remains unknown.AimThe purpose of this study was to identify factors associated with accessing and obtaining care for sexual health concerns following traumatic pelvic fracture in men.MethodsMen treated for traumatic pelvic fractures at a level 1 trauma center were invited to participate in an online cross-sectional survey. The survey addressed multiple demographic and sexual function domains, as well as the postinjury sexual health care experience. De novo sexual dysfunction following injury was ascertained and reasons for not seeking care examined. Inverse probability weighting was utilized to adjust for nonresponse. Multivariable logistic regression was performed to identify factors associated with discussion of sexual health with providers after injury.OutcomesThe primary outcome was discussion of sexual health with health care providers after injury. Secondary outcomes included prevalence of self-reported sexual dysfunction, classification of sexual dysfunction experienced, and perceived barriers to accessing or obtaining care for sexual health concerns.Results277 men completed the survey. After adjustment, 46.3% (95% CI = 39.4%–53.0%) reported de novo sexual dysfunction after injury, with erectile dysfunction the most common symptom (27.9%). Only 20.4% (95% CI = 15.1%–26.0%) recalled having discussions or being asked about their sexual health following injury, and of these conversations 70.7% were patient-initiated. The most common perceived barriers to discussing sexual health with providers were the belief that sexual dysfunction would resolve with time (26.1%), and a lack of knowledge about their condition and treatment options (21.5%). On multivariate analysis, the presence of postinjury sexual dysfunction (adjusted odds ratio [aOR] = 3.42), private insurance (aOR = 2.17), and being married or in a partnership (aOR = 3.10) were independently associated with likelihood of having had sexual health discussions.Clinical ImplicationsDespite the high prevalence of sexual dysfunction in men following pelvic trauma, sexual health concerns are inadequately addressed due to both patient and provider factors.Strengths & LimitationsThe major strengths include large sample size, detailed reporting of subject experience, and new information in a previously understudied area of pelvic trauma survivorship. The primary limitations are low survey response rate, lack of representativeness of survey participants to whole pelvic fracture cohort, single-center experience, and cross-sectional study design.ConclusionSexual health concerns after pelvic fracture are common but inadequately addressed by health care providers. Improved postinjury, survivorship-model care pathways need to be designed to better address sexual health after injury.Johnsen NV, Lang J, Wessells H, et al. Barriers to Care of Sexual Health Concerns in Men Following Traumatic Pelvic Fractures. J Sex Med 2019;16:1557–1566.     

Clinical Presentation,Treatment, and Challenges in the Management of Child Sexual Assault at a Tertiary Care Referral Center in India

BackgroundChild Sexual Assault (CSA) is not an uncommon but an under-reported crime. Along with social and psychological critical issues, there are multiple challenges faced by the surgical team for the treatment of complex perineal injuries associated with CSA. This study was conducted to find clinical presentation and management of CSA along with its problems and challenges encountered by the pediatric surgical team.Materials and MethodsThis was a retrospective study from 2010 to 2019, conducted in the department of pediatric surgery at a tertiary referral center. All-female patients with a definitive history of sexual assault were included in the study.ResultsSeven patients fulfilled the inclusion criteria and the mean age was 5.3 years. After a primary survey, all patients were taken up for examination under anesthesia (EUA). Three patients were managed by the primary repair of the wound and did well during follow-up. Four patients had grade 4 perineal injury and required stage reconstruction. As a first stage, repair of rectal tear, vaginal tear, and the perineal body reconstruction was done along with diversion colostomy. One patient required redo repair of the perineal body and one had developed a rectovaginal fistula. Three patients completed all stages and they are fully continent.ConclusionThe spectrum of injuries varies widely in CSA and more chances of high-grade perineal injuries in children due to distinctive local anatomy. EUA is crucial to assess the extent of the injury and to decide the course of management. Meticulous anatomical repair and diversion stoma is the key for successful complex repair and excellent long-term outcomes in terms of continence for the severe grade of perineal injuries.     

Obstetric and gynecological outcome in a patient with traumatic pelvic fracture and perineal injuries

A 19-year-old woman presented with pelvic trauma following a road accident. She was hemodynamically stable. Examination revealed perineal injuries and type C pelvic fracture, which was stabilized with an external fixator. The broken ends of the pubic bone were brought together by an orthopedic wire. The detached vaginal wall and torn anal sphincter were surgically repaired after making a diverting colostomy. The postoperative period was uneventful. Colostomy was reversed after 3 months. Postoperatively the patient developed a cystocele, dyspareunia and vaginal pain. She conceived spontaneously and was planned for an elective cesarean at 37 weeks gestation; however, she presented in labor at 36 weeks and had a normal vaginal delivery. Pelvic fractures may be associated with genitourinary and anal sphincter injuries, which require management by a multidisciplinary team. On recovery the patient may develop prolapse, dyspareunia and persistent local pain. Spontaneous conception and normal vaginal delivery are nevertheless possible.     

An Arterial Vaginal Bleed Resulting from Short-Term Pessary Use: A Case Report

BackgroundPessaries are commonly used for the management of pelvic organ prolapse. Complications are rare, with major complications usually related to long-term use and neglect. Complications related to short-term pessary use, as well as complications requiring surgical intervention, are even less common.CaseWe present the case of a 58-year-old postmenopausal woman who presented with acute, arterial vaginal bleeding requiring surgical intervention 3 weeks after being fitted for a pessary for management of pelvic organ prolapse.ConclusionSevere, short-term complications are rare, but can occur with pessary management of pelvic organ prolapse. To our knowledge, this is the first case to describe an acute arterial hemorrhage requiring surgical intervention following short-term placement of a vaginal pessary.     

Morbidity of a Single Incision Transvaginal Mesh to Correct Apical Prolapse

Study ObjectiveTo determine complications and related reintervention rates associated with use of the Uphold Vaginal Support System (Boston Scientific, Boston, MA) for symptomatic vaginal apical prolapse.DesignA multicenter retrospective study.SettingTwo teaching hospitals.PatientsFifty-nine women with symptomatic vaginal apical prolapse.InterventionVaginal apical prolapse surgery using the Uphold Mesh Kit system with or without other concomitant procedures.Measurements and Main ResultsA chart review was performed, including the following parameters: perioperative and postoperative complications, repeat surgery, and recurrence rate. A total of 59 patients met the criteria for inclusion in the study. Bladder perforation occurred perioperatively in 1 patient. Postoperative voiding difficulties were observed in 16 patients (27.1%), including 9 women (15.2%) who left the hospital with an indwelling catheter in place. There were 5 cases (8.5%) of transient groin pain, all of which resolved spontaneously. One patient developed a vaginal hematoma. Nine women (15%) required reoperation, including 4 (6.7%) because of recurrent prolapse and 1 (2%) for pelvic pain considered related to the mesh. Three patients (5%) required release of a midurethral sling (MUS) that had been placed concomitantly with the Uphold system. Two patients (3%) required a MUS for de novo stress incontinence.ConclusionUse of the Uphold Vaginal Support System for symptomatic vaginal apical prolapse was associated with a significant risk of obstructed micturition. In our study population, 15% required repeat surgery, mainly for recurrent pelvic organ prolapse and de novo stress urinary incontinence. No surgical-related complication resulted in long-term morbidity.     

Case Series: Vaginal Rupture Injuries after Sexual Assault in Children and Adolescents

BackgroundVaginal rupture after sexual assault is a rare but life-threatening occurrence requiring prompt recognition and treatment. Herein, we describe four such cases in children. Our purposes are to increase clinicians' awareness of the physical trauma that a sexual abuse victim can suffer and increase recognition that these victims require immediate trauma services.CasesEach patient had obvious hymenal and vaginal lacerations with a vaginal apical rupture injury and secondary acute blood loss. None of the four victims sustained infectious sequelae.Summary and ConclusionProviders should have a low threshold for managing sexual abuse victims as trauma cases when they have obvious hymenal and vaginal lacerations and genital bleeding, proceeding expeditiously to examination using general anesthesia when appropriate.     

Brachial plexus injury complicating the labor: mother is the victim at this time

Abstract

Objective: Postpartum nerve injuries are rare complications of labor and the lower extremity peripheral nerves are the frequently affected ones. In this case report, we are presenting a patient who developed brachial plexus injury after a forceful vaginal delivery.

Case report: The patient is a 28-year-old woman with right upper extremity pain, numbness and weakness, whose symptoms started just after labor. According to the clinical evaluation, electrodiagnostic study and magnetic resonance imaging, it was diagnosed as the brachial plexus injury.

Conclusion: We concluded that similar to the ones seen after some surgeries, brachial plexus may be injured also during delivery and the labor positions should be considered.     

Robotic Vesicovaginal Fistula Repair

Study ObjectiveTo illustrate a technique of robotic vesicovaginal fistula repair in a patient with a previous history of pelvic radiation therapy and multiple abdominal surgeries.DesignStepwise demonstration of the technique with narrated video footage.SettingThis 59-year-old woman presented with vesicovaginal fistula. She had a history of rectosigmoidectomy followed by pelvic radiotherapy for stage III colon cancer 23 years earlier and subsequent robotic hysterectomy, bilateral salpingo-oophorectomy, and omentectomy with bilateral pelvic and para-aortic lymphadenectomy for stage II mixed cell endometrial carcinoma, which required surgical reintervention because of a pelvic hematoma and complete vaginal cuff dehiscence.InterventionsWe performed a robotic approach to vesicovaginal fistula with several key steps to repair the fistula and maintain the integrity of the abdominopelvic structures: (1) careful bowel adhesiolysis involving multiple segments of the intestine to the abdominal and pelvic peritoneum; (2) cystotomy with vaginal probe guidance; (3) fistulectomy by monopolar scissors after ureteral orifice visualization; (4) dissection of the retropubic space of Retzius, relieving bladder tension; (5) transverse sutures to coapt the raw surfaces on the vaginal side and the bladder in 2 layers with minimal tension; and (6) transurethral instillation of methylene blue into the bladder.ConclusionsTraditionally, patients with vesicovaginal fistula after pelvic radiation therapy and multiple abdominal surgeries are managed by laparotomy. This video demonstrates a feasible robotic approach to vesicovaginal fistula repair, with superior imaging affording 3-dimensional visualization and stabilization of instruments, allowing wrist-like movements.     

Massive Vaginal Hematoma — A Complication of In Vitro Fertilization

Background

The rates of serious complications from IVF with transvaginal oocyte retrieval are low. However, as the usage of IVF continues to increase, more complications are presenting to acute care and physicians should be aware of management issues.

A New Device for Simultaneous Measurement of Pelvic Floor Muscle Activity and Vaginal Blood Flow: A Test in a Nonclinical Sample

IntroductionDyspareunia in women, defined as persistent or recurrent genital pain associated with sexual intercourse, is hypothesized to be related to (fear associated) pelvic floor hyperactivity and to diminished sexual arousal. Psychophysiological research to support these hypotheses is scarce and concentrates mostly on the role of either pelvic floor activity or sexual arousal. To investigate both factors, a measurement device that enables simultaneous assessment of pelvic floor muscle activity and genital sexual arousal would be most optimal.AimThe aim of this study was to test a new vaginal device—a vaginal photoplethysmograph with build‐in surface electromyography (EMG)—that allows simultaneous assessment of pelvic floor muscle activity and vaginal blood flow.Main Outcome MeasuresGenital arousal measured as vaginal pulse amplitude (VPA) and vaginal surface EMG.MethodsThirty‐six sexually functional women participated. To investigate the sensitivity of the device for changes in genital blood flow and involuntary changes in pelvic floor activity, VPA and vaginal surface EMG were monitored during exposure to sexual and anxiety‐evoking film clips. In addition, vaginal surface EMG was monitored during voluntary flick and hold contractions.ResultsVPA increased in response to the sexual film, and EMG values were significantly higher in response to the anxiety‐evoking film. Higher EMG values in response to the anxiety film were associated with lower VPA. EMG during the instructed 3‐second hold pelvic floor contractions showed, as expected, higher values during pelvic floor contractions with support of surrounding muscle groups, compared with pelvic floor muscles alone.ConclusionThe device is sensitive to changes in vaginal blood flow in response to sexual stimuli, and it is able to pick up small, involuntary changes in pelvic floor activity associated with anxiety. Also, the device is able to record changes in pelvic floor activity during voluntary pelvic floor contractions. This new device will be a valuable tool in further research on superficial dyspareunia. Both S, van Lunsen R, Weijenborg P, and Laan E. A new device for simultaneous measurement of pelvic floor muscle activity and vaginal blood flow: A test in a nonclinical sample. J Sex Med 2012;9:2888–2902.     

Uterine perforation by a cystoperitoneal shunt, an unusual cause of recurrent vaginal discharge

BackgroundWe describe the first reported case of uterine perforation by a cystoperitoneal shunt. The mechanism of this unusual complication is unclear.CaseA 17-year-old patient had a cystoperitoneal shunt for a porencephalic cyst. She presented with recurrent watery vaginal discharge. A pelvic ultrasound examination showed that the uterus had been perforated by the distal tip of the shunt. The cystoperitoneal shunt was converted to a ventriculo-atrial shunt, and the vaginal discharge subsequently resolved.ConclusionThe appearance of light and clear vaginal discharge in a patient with a cystoperitoneal shunt raises the possibility of uterine perforation. This can be confirmed by ultrasound and analysis of the discharge. Removal of the shunt leads to spontaneous closure of the uterine defect.