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Leiomyomas can develop after hysterectomy and, when located in the bladder, can result in voiding dysfunction and incontinence.Fifty years after a hysterectomy, a 77-year-old woman presented with a 1-year history of urinary retention requiring self-catheterization and bothersome urinary incontinence. Multiple imaging modalities demonstrated a well-circumscribed 2-cm mass abutting the bladder beneath the trigone. After ureteral stent placement, we excised the nonpalpable mass using ultrasound guidance. We identified a 1.5-cm incidental cystomy and repaired it in layers. After the repair, we placed a suprapubic catheter. Pathologic examination of the mass revealed a leiomyoma. Postoperatively, we confirmed the integrity of the bladder, removed the ureteral stents, and reviewed postvoid residuals, which were minimal before removing the suprapubic catheter. Six weeks after her operation, the patient voided spontaneously with significant improvement of her urinary incontinence.Vaginal resection with ureteral stenting represents a safe surgical approach for resection of a symptomatic, benign bladder mass.

The aim of this study was to evaluate urinary symptoms in the postpartum period after omission of the bladder flap at the time of primary cesarean delivery. This was a single-blind parallel-group randomized comparison (bladder flap, no bladder flap) in women scheduled for a primary cesarean delivery at 37 weeks gestation or later. The primary outcome was urinary symptom scores at 6–8 weeks postpartum. Secondary outcomes included comparisons of preoperative and postoperative pelvic floor symptom scores and the proportions of symptom bother responses between the study groups. A total 43 women were available for analysis. Randomization was as follows: omission of the bladder flap (n = 22) and bladder flap (n = 21). Demographic characteristics and baseline pelvic floor symptom scores were similar between the groups. The primary outcome, urinary symptom scores at 6–8 weeks postpartum, did not differ significantly between the groups, but urinary symptom bother was significantly higher in women who received a bladder flap. Pelvic floor symptom scores improved significantly following delivery. Urinary symptom scores as measured by the UDI-6 did not differ between women randomized to bladder flap or omission of the bladder flap, but the proportion of women with urinary symptom bother was significantly higher among those who received a bladder flap.

Pyoderma gangrenosum is a rare dermatologic disorder that can occur on the vulva.A 25-year-old woman, gravida 2 para 1 abortus 1, had development of pain and subsequent ulceration at the location of her previously healed vulvar obstetric laceration. The ulceration and pain continued to worsen despite wound management. Once the diagnosis of vulvar pyoderma gangrenosum was made, cyclosporine was started and the wound rapidly healed.Vulvar pyoderma gangrenosum should be considered when a vulvar wound is not healing with conservative measures. Cyclosporine can be considered as an alternative to steroids for treatment.

The purpose of this study was to histologically chronicle wound healing following cystotomy repair using a small animal model. Thirty female Sprague–Dawley rats were included in this study. Twenty-eight rats underwent a vertical cystotomy in the bladder dome, which was repaired in a single continuous fashion. Two rats served as histological controls. Following cystotomy repair, groups of three to four rats were studied at single day intervals for 4 days, then at 2-day intervals until 10 days post-repair. The animal bladders were harvested and examined for inflammation, scar formation, and bladder healing. Thirty rat bladders were histologically examined. An inflammatory wound phase was observed during the first 4 days after wounding. Transition from acute to chronic inflammation was observed at day 2 with chronic inflammation persisting through day 10. Inflammation severity peaked 4 days post-wounding without regression through day 10. Evidence of proliferative phase wound healing was first observed 4 days post-wounding. Early increases in wound healing are due to inflammatory events such as fibrin plugging of the wound. Later developments after day 4 are due to wound proliferation, collagen deposition, and re-epithelialization. Additionally, wound healing in the rat bladder is observed on a continuum and not necessarily in discrete stages observed on precisely the same postoperative day in each animal.

Background: We sought to compare the pullout strengths of the sacral end of the sacrocolpopexy mesh when attached using one suture at the first versus second sacral vertebral level (S1 vs. S2) in female cadaveric pelvises. Methods: The sacral vertebrae were isolated in 9 unembalmed female cadavers, and segments of polypropylene mesh were attached to the sacrum using stitches at either the S1 or S2 level. The free end of the mesh was pulled at a constant rate. Maximum tension prior to system failure was recorded for each specimen. Suture pullout strengths between the two groups were compared using the two-sample Wilcoxon rank-sum test. Results: In all but one specimen, failure of the system occurred at the point of suture attachment to the anterior longitudinal ligament. Among the nine specimens, median pullout strengths were 7.49 lb (interquartile range 7.95) at S1 and 3.15 lb (interquartile range 2.975) at S2 (p = 0.028). Conclusion: The pullout strength of sutures used to attach the sacrocolpopexy mesh to the sacrum is significantly higher at the S1 level than at the S2 level.

Objective Given limitations in surgical educational resources, more efficient teaching methods are needed. We sought to evaluate 3 strategies for improving skills in subcuticular suturing—practice with an instructional video, practice with expert instructor supervision, and independent practice. Design Fifty-eight medical students volunteered for this research. Students viewed a video on subcuticular suturing then completed a pretest requiring closure of an incision in a plastic model. Students were randomized among 3 groups: practice with an instructional video (group A), practice with supervision by an expert instructor (group B), and independent practice (group C). After instruction, students completed a posttest, then a retention test 1 week later. Their performances were video recorded and evaluated using a validated scoring instrument composed of global and task-specific subscales. Results Performances measured using both subscales improved significantly from pretest to post-test only for group B. However, when comparing student performances between pretest and retention posttest, significant improvements on both subscales were seen only in group A. Conclusion These results suggest that practice with an instructional video is an effective method for acquiring skill in subcuticular suturing.

The American Psychiatric Association recommends considering sexually related personal distress when assessing female sexual dysfunction. Currently, there is little data regarding the impact of sexual complaints on sexual distress.To investigate the association between sexual complaints and perceived sexual distress in a population of ambulatory adult women.Using the short forms of the Personal Experiences Questionnaire and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, we assessed sexual complaints among 305 women seeking outpatient gynecologic care. Depressive symptoms were quantified using the Center for Epidemiologic Studies Depression (CESD) score. Sexual distress was measured using the Female Sexual Distress Scale (FSDS). Using multivariable logistic regression, we compared sexual complaints between distressed and nondistressed women.Sexual distress, defined by FSDS score ≥15.FSDS scores were available for 292/305 participants. Seventy-six (26%) scores reflected distress. Distressed women were more likely to be younger (55.2±1.0 years vs. 56.7±0.8 years, P=0.017); have higher CESD scores (16.6 vs. 9.5, P=0.001); and report decreased arousal (56.8% vs. 25.1%, P=0.001), infrequent orgasm (54% vs. 28.8%, P=0.001), and dyspareunia (39.7% vs. 10.6%, P=0.001). Women with sexual distress were also more likely to report sexual difficulty related to pelvic floor symptoms, including urinary incontinence with sexual activity (9% vs. 1.3%, P=0.005), sexual avoidance due to vaginal prolapse (13.9% vs. 1%, P=0.001), or sexual activity restriction due to fear of urinary incontinence (14.9% vs. 0.5%, P=0.001). After multivariate analysis, sexual distress was significantly associated with dyspareunia (odds ratio [OR] 3.11, P=0.008) and depression score (OR 1.05, P=0.006), and inversely associated with feelings of arousal during sex (OR 0.19, P=0.001).Our results indicate that sexually related personal distress is significantly associated with dyspareunia, depressive symptoms, and decreased arousal during sexual activity. This contributes to our understanding of how sexual complaints may adversely affect women's quality of life.

We sought to compare rates of recurrent cystocele following sacrocolpopexy with and without paravaginal repair (PVR). This retrospective cohort study compared outcomes for patients undergoing sacrocolpopexy with (group A) and without (group B) concomitant PVR. Defining anterior failure as point Ba ≥ −1 cm, we compared anatomic outcomes and reoperation rates for recurrence of cystocele. One hundred seventy patients undergoing sacrocolpopexy had anterior wall prolapse at or beyond the hymen before surgery (62 in group A and 108 in group B). Ten (16.1%) patients in group A and 29 (26.9%) in group B experienced anterior wall prolapse to or beyond −1 cm (p = 0.13, power 0.38). Among these groups, one (1.6%) and five (4.6%) underwent reoperation for cystocele recurrence (p = 0.42, power

We sought to compare the complications and efficacy of tension-free vaginal tape (TVT) and Pelvilace. Chart reviews and telephone questionnaires documented complications, urinary symptoms [Urogenital Distress Inventory short form (UDI-6) and Patient Global Impression of Improvement (PGII)], and re-operations. Failure was defined as PGII > or = 4 (no change or worse) or reoperation for urinary incontinence. There were 91 TVT and 22 Pelvilace slings. The TVT group had lower rates of urinary retention beyond 1 week (8% vs. 43%, p < 0.001) and reoperation for retention (1% vs. 19%, p < 0.001). Median changes in UDI-6 scores were -33.3 for the TVT group and -29.6 for the Pelvilace group (p = 0.21). Median PGII scores were 1 for the TVT group and 2 for the Pelvilace group (p = 0.024). Ten percent of the TVT group and 24% of the Pelvilace group (p = 0.095) were failures. Urinary retention was more common after Pelvilace than TVT slings. Symptomatic outcomes and failure rates were similar.

Objective To determine whether Trypanosoma cruzi could be identified in placental cells in vitro and in placental tissue using a human ex vivo perfusion model. Study design A placental cell line was incubated with trypomastigotes for progressive time periods. Trypomastigotes were also infused as a bolus into the maternal circulation of a placental perfusion model. Maternal and fetal perfusates, and placental tissue, were analyzed for parasitic DNA using polymerase chain reaction; perfused specimens were also examined histologically. Results Intracytoplasmic amastigotes were identified in trophoblast of the incubated cell line by 24–48 hours. Following placental perfusion, T cruzi DNA was identified in all postinoculation maternal perfusate samples and postinoculation placental tissue specimens; preinoculation controls were negative. Conclusion This is the first description of the use of the human placental perfusion model to study congenital Chagas' disease, including the presence and time course of early parasitic invasion of the placenta.

Recurrent pelvic organ prolapse occurs rarely after obliterative procedures. The optimal surgical approach for therapy is unknown. We describe a case of recurrent prolapse after LeFort colpocleisis. The patient presented with stage III prolapse through the lateral vaginal channel. At surgery, the prolapse was repaired using a modified repeat colpocleisis and repeat perineorrhaphy. Transvaginal revision via modified repeat colpocleisis should be considered for treatment of recurrent pelvic organ prolapse after LeFort colpocleisis.

Background Labial fusion may occur as a result of lichen sclerosus, lichen planus, genital mutilation, obstetric laceration, and atrophic vaginitis. Koebner phenomenon, or reformation of scar tissue over the clitoris after trauma to the involved tissue, may confound attempts at surgical management. Case A 22-year-old nulligravid patient presented with labia minora fusion that had been present since childhood. Her most bothersome symptoms were the recurrence of periclitoral pseudocysts with pain and discharge after spontaneous or needle drainage. Her symptoms and examination findings persisted despite a prolonged course of topical clobetasol, and she desired surgical intervention. A silastic vessel loop was placed through the tract between her clitoris and fused overlying labia. The ends of the vessel loop were brought together and tied in a fashion similar to cutting setons used to manage complex anal fistulae. Over the subsequent weeks, additional ties were used to sequentially tighten the loop and gradually divide the fused labia, ultimately exposing the patient's normal clitoris, which was uninjured by the procedure. Topical clobetasol was used throughout the process to prevent reagglutination of the labia. Conclusions Our experience suggests that adaptation of a cutting seton may be used effectively in the surgical management of labial fusion to allow for gradual division of the skin bridge while minimizing the risk of recurrence of agglutination.

Pubic symphysis diastasis during obstetric delivery occurs rarely. Symptoms usually respond to conservative management. A nulliparous 39-year-old delivered spontaneously with an audible pop noted. Pubic symphysis diastasis of 4.6 cm was diagnosed on pelvic X-ray. She developed severe pain with ambulation and stress urinary incontinence. After neither of these symptoms improved significantly in response to conservative management, the patient underwent open reduction internal fixation with plating of her pubic symphysis, and bladder neck sling placement using autologous rectus fascia. Postoperatively she experienced urinary retention, which resolved with continuous bladder drainage for 1 week. Both her urinary incontinence and pain resolved, and she had resumed normal activities 3 months following her surgery. Pubic symphysis diastasis is a rare obstetric complication with a paucity of literature to guide its management. A coordinated multidisciplinary approach to management is necessary when multiple organ systems are involved.

Objective To collect evidence for the validity and reliability of an assessment tool for simulated subcuticular suturing. Study Design Three subjects were videotaped while closing a simulated incision in a plastic model. The 3 trials were viewed independently by 7 faculty examiners masked to subject identity. Global rating and task-specific scales were used to assess subject competence. The mean scores were compared among the 3 subjects and 7 evaluators using analysis of variance. Results Significant differences were found among the mean global rating scores for the 3 subjects but not among the evaluators. Similarly, significant differences were found between mean task-specific scale scores for the 3 subjects but not among the evaluators. Cronbach's alpha for global rating (0.89) and task-specific (0.93) scores suggested high internal consistency for each scale. Conclusions These findings provide evidence for the discriminant validity, internal consistency, and inter-rater reliability of both the global rating and task-specific scales of our assessment tool.

Objective The objective of this study was to determine the minimum threshold level at which maximum anatomic prolapse predicts bothersome pelvic floor symptoms. Study Design We performed a cross-sectional study of women older than 40 years undergoing gynecologic and urogynecologic examinations using Pelvic Organ Prolapse Quantification (POP-Q) examinations to assess support and Pelvic Floor Distress Inventory questionnaires to assess symptoms. Across the spectrum of prolapse severity, we calculated receiver operating characteristic (ROC) curves and areas under the curves (AUCs) for each symptom. Results Of 296 participants, age was 56.3 ± 11.2 years, and 233 (79%) were white. POP-Q stage was 0 in 39 (13%), 1 in 136 (46%), 2 in 89 (30%), and 3 in 33 (11%). ROC analysis for each symptom revealed an AUC of 0.89 for bulging/protrusion; 0.81 for splinting to void; 0.55-0.62 for other prolapse and urinary symptoms; and 0.48-0.56 for bowel symptoms. Using a threshold of 0.5 cm distal to the hymen, the sensitivity (69%) and specificity (97%) were high for protrusion symptoms but poor for most other symptoms considered. Conclusion Vaginal descensus 0.5 cm distal to the hymen accurately predicts bulging/protrusion symptoms; however, we could not identify a threshold of prolapse severity that predicted other pelvic floor symptoms.

In abdominal sacrocolpopexy (ASC), a graft is used to secure the apex of the prolapsed vagina to the anterior longitudinal ligament of the sacrum. This retrospective cohort study enrolled women having ASC (abdominal sacrohysteropexy or abdominal sacral colpoperineopexy) in the years 2001–2005. Synthetic mesh was used in 52% of 259 ASC procedures; porcine dermis (Pelvicol) in 39%; and autologous fascia in 9%. Patients in whom synthetic mesh was used were older than others, more likely to have had hysterectomy, and likelier to be postmenopausal. Concomitant surgery was performed least often in the synthetic mesh group. Postoperative follow-up averaged 1.1 years. The primary outcome was anatomical failure of ASC at the apical compartment. Rates of apical failure were 11% when Pelvicol was used, 7% with autologous fascia, and 1% with synthetic mesh. All 7 reoperations necessitated for apical prolapse were in the Pelvicol group. Intraoperative and immediate postoperative complications were comparably frequent in the 3 treatment groups. Intraoperative problems included cystotomy in 6% of patients, enterotomy in 1.5%, and a single ureteral injury. Erosions occurred in 11% of the Pelvicol group. Similar numbers of reoperations for graft-related complications were required in all groups. The most common such complications were granulation tissue formation and erosion. These results show that ASC is likelier to fail when Pelvicol is used rather than synthetic mesh or autologous fascia. In addition, using Pelvicol did not lessen the risk of graft-related complications in this study population.

Background We present a case in which an adnexal mass caused symptoms that eventually lead to the identification of a primary hepatic pregnancy. Case A young woman presented with abdominal pain, a positive hCG test result, an empty uterus, and a pelvic mass. Diagnostic laparoscopy revealed a cystic adnexal mass. An exploratory laparotomy with ovarian cystectomy identified a mature teratoma but no evidence of pregnancy in the pelvis. Because the patient's quantitative hCG level continued to increase without evidence of an intrauterine pregnancy, a dilation and curettage was performed which yielded no products of conception. An ultrasound examination and magnetic resonance imaging identified an 11-week ectopic pregnancy with fetal cardiac activity located in the maternal liver. This was treated with fetal injections of methotrexate and potassium chloride under ultrasound guidance and subsequent maternal intramuscular injection of methotrexate. The patient tolerated these interventions well, and subsequent ultrasound examinations showed absent fetal cardiac activity and decreasing fetal size. Serial hCG tests were followed up to zero, and the patient's liver enzyme levels remained normal. Conclusion With persistently rising hCG levels and no pregnancy identified in the uterus or pelvis, there should be a thorough evaluation of the entire pelvis and abdomen. Magnetic resonance imaging is a useful tool for locating such an ectopic pregnancy. Once identified, decisions regarding surgical versus medical management must take risk of adverse outcomes into consideration. This report reveals an 11-week hepatic pregnancy managed conservatively with fetal potassium chloride and maternal methotrexate administration.

Background Chlorhexidine gluconate is a commonly used and effective antiseptic agent for preparing patients for surgery. Case A healthy premenopausal woman was taken to the operating room for a planned laparoscopically assisted vaginal hysterectomy. After vaginal, vulvar, perineal, and abdominal cleansing with chlorhexidine gluconate, the patient developed a desquamating vaginal reaction that was treated with intravenous corticosteroids, antihistamine, topical conjugated estrogen, and hydrocortisone cream. The planned surgery was aborted, and the patient recovered uneventfully overnight in the postanesthesia care unit. With continued application of conjugated estrogen cream, the patient's vaginal mucosa was well healed within 2 weeks. Conclusion Although chlorhexidine gluconate has been used effectively to minimize surgical site infection in vaginal surgery, the possibility for adverse reaction should be considered.

Background Pregnancy and parasitic infection are globally prevalent conditions that frequently coexist. Most pregnant patients with intestinal parasitic infections may be managed without antiparasitic chemotherapy. Case Shortly after a visit to her nation of origin, a 22-year-old native of Ethiopia presented during her first trimester with gastrointestinal complaints and worms in her stool, which were identified as Taenia. Microscopic examination of her stool also demonstrated Strongyloides stercoralis larvae, likely the residue of an infection that had occurred several years prior to her presentation. She was treated with appropriate antihelmenthic agents, and her subsequent prenatal course has been uncomplicated. Conclusion The ability of Strongyloides to sustain an intestinal infection through autoinvasion and to cause serious disease (hyperinfection syndrome) among certain hosts makes it unique among intestinal helminths. In this case, the patient was treated to manage her symptoms and prevent subsequent Strongyloides hyperinfection.

Summary A case of ischemia of the splenic flexure of the colon is presented. This is believed to be the first reported case in which the diagnosis was confirmed preoperatively by percutaneous selective inferior mesenteric angiography. The potentiality of this technic for improved diagnosis and understanding of mesenteric vascular patterns is discussed. Preoperative distinction between bowel ischemia, segmental ulcerative colitis, and regional enteritis may be clarified by use of selective mesenteric angiography.

Although the incidence of trauma to the pancreas is increasing, few collected series have appeared in recent years. Exceptions are a brief report of 42 cases by Berne and Walters 1 and 2 surveys of the experience at Baylor University and its affiliated hospitals. 2,4 It is felt timely to report the cases from another institution in view of the difficulties, either initially or as complications, that these injuries present. During the 13-year period ending Dec. 31, 1961, a total of 62 cases of pancreatic trauma were treated surgically at Grady Memorial Hospital (Table 1). Fifty-six injuries were due to penetrating wounds, and an additional 6 were secondary to blunt trauma. Over-all, there was a mortality of 21% and morbidity of 71%. All patients herein reported survived long enough to undergo surgical exploration. Penetrating Wounds Shootings and stabbings led to 56 of these injuries (Table 1). Forty-one were gunshot wounds.