Search

The pelvic floor guards the passage of the pelvic organs to the exterior. The near-epidemic prevalence of incontinence in women continues to generate interest in the functional anatomy of the pelvic floor. However, due to its complex architecture and poor accessibility, the classical 'dissectional' approach has been unable to come up with a satisfactory description, so that many aspects of its anatomy continue to raise debate. For this reason, we opted for a 'sectional' approach, using the Chinese Visible Human project (four females, 21-35 years) and the Visible Human Project (USA; one female, 59 years) datasets to investigate age-related changes in the architecture of the anterior and middle compartments of the pelvic floor. The puborectal component of the levator ani muscle defined the levator hiatus boundary. The urethral sphincter complex consisted of a circular proximal portion (urethral sphincter proper), a sling that passed on the vaginal wall laterally to attach to the puborectal muscle (urethral compressor), and a circular portion that surrounded the distal urethra and vagina (urethrovaginal sphincter). The exclusive attachment of the urethral sphincter to soft tissues implies dependence on pelvic-floor integrity for optimal function. The vagina was circular at the introitus and gradually flattened between bladder and rectum. Well-developed fibrous tissue connected the inferior vaginal wall with urethra, rectum and pelvic floor. With eight-muscle insertions, the perineal body was a strong, irregular fibrous node that guarded the levator hiatus. Only loose areolar tissue comprising a remarkably well developed venous plexus connecting the middle and superior parts of the vagina with the lateral pelvic wall. The posterolateral boundary of the putative cardinal and sacrouterine ligaments coincided with the adventitia surrounding the mesorectum. The major difference between the young-adult and postmenopausal pelvic floor was the expansion of fat in between the components of the pelvic floor. We hypothesize that accumulation of pelvic fat compromises pelvic-floor cohesion, because the pre-pubertal pelvis contains very little fibrous and adipose tissue, and fat is an excellent lubricant., (© 2017 Anatomical Society.)

Objectives: The primary objective was to evaluate the ability of different anatomic cut-off points, as established in specialist urogynecology populations, to identify clinically relevant prolapse in a population of postmenopausal women with pelvic floor symptoms recruited from primary care., Study Design: Cross-sectional study among 890 women (≥55 years) screened for pelvic floor symptoms., Main Outcome Measures: The Pelvic Floor Distress Inventory 20 was used to measure symptoms, and the Pelvic Organ Prolapse Quantification (POP-Q) system was used to assess prolapse. Areas under the curves, sensitivity, and specificity were calculated for the hymen as a cut-off point for symptomatic prolapse of the anterior and posterior vaginal wall. For the apical compartment, a cut-off point of -5cm relative to the hymen was used., Results: Vaginal bulging was the only symptom reported more often with increasing POP-Q stages. Areas under the curves (95% confidence intervals) to discriminate between women with and without vaginal bulging symptoms were 0.66 (0.61-0.72), 0.56 (0.50-0.63), and 0.61 (0.55-0.66) for the anterior (Ba), posterior (Bp) and apical (C) compartment, respectively. When the hymen was used as the cut-off point, Ba had a sensitivity of 38.1% and a specificity of 82.4%, and Bp had a sensitivity of 13.3% and a specificity of 96.5%. For C, the cut-off point of -5cm relative to the hymen had a sensitivity of 37.9% and a specificity of 73.1%., Conclusions: The anatomic cut-off points for clinically relevant prolapse established in the specialist urogynecology population cannot adequately identify symptomatic prolapse in a population of postmenopausal women with pelvic floor symptoms recruited from primary care., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Morphological information on the reproductive system allows the understanding of ecological and behavioural aspects of different species as well as supports the development of conservational strategies. Unfortunately, for many species, not enough relevant and precise information is available. In the present study, we describe for the first time the macroscopic and histological aspects of female genital organs and external female genitalia of Saimiri macrodon, Saimiri cassiquiarensis and Saimiri vanzolinii. We perform a comparison between these three peripatric species and investigate the possibility of their reproductive morphology to act as a factor of reproductive isolation. We have found that these species share many similarities in most of the analysed organs. Although some important differences were identified that may play an important role in the evolution of the components of the reproductive system of these species, those differences are not enough to compose a mechanism of reproductive isolation for these three species of Saimiri. The results of this study may be used to support the development of biotechnological approaches of reproduction and strategies for conservation programmes and management of threatened species of this genus, particularly S. vanzolinii, considered to be a vulnerable species to extinction., (© 2016 Blackwell Verlag GmbH.)

The anatomy of the uterus is defined with the angles of the vagina, cervix and uterine corpus. Hereunder there are angles of version and flexion. The cervical position observed during the vaginal speculum examination, may give information about the uterine anatomy. In this study, we investigated the place of the cervical position in the estimation of the uterine anatomy observed during the cervical examination. We enrolled 240 patients in our study, who applied to our routine gynecology outpatient clinic with various complaints. We divided these patients into two groups according to the cervical position (anterior cervical position and posterior cervical position) observed during the speculum examination. We recorded the uterine anatomy also with the transvaginal ultrasonography. During the speculum examination, we determined that 90% of the cases with posterior fornix position were anteverted and 10% retroverted; 64.2% of the cases with anterior fornix position were anteverted and 35.8% retroverted. According to these findings, cervical position observed during the speculum examination might be useful in the estimation of the uterine anatomy regarding the angles of the version. However, the ultrasonographic examination is essential for a definitive determination of the uterine anatomy. Clin. Anat. 30:404-408, 2017. © 2017 The Authors. Clinical Anatomy published by Wiley Periodicals, Inc. on behalf of American Association of Clinical Anatomists., (© 2017 The Authors. Clinical Anatomy published by Wiley Periodicals, Inc. on behalf of American Association of Clinical Anatomists.)

Pelvic organ prolapse is a fairly common condition that imposes significant symptoms, diminished quality of life, social burden, financial expense, and surgical risk on women. As evidence supporting the benefit of pelvic-floor muscle training in nonsurgical management of pelvic organ prolapse grows, physical therapists are becoming a provider of choice interacting with women affected by pelvic organ prolapse. This perspective article will review recent research on tissue characteristics of 3 key components of pelvic organ support: skeletal muscle, ligament, and vaginal wall. This information will be summarized as implications for physical therapists. An improved understanding of pelvic-floor tissue in women with and without pelvic organ prolapse will provide a more comprehensive appreciation of the interaction of multiple systems in the disorder., (© 2017 American Physical Therapy Association.)

Objective: To assess anatomic outcome and quality of life (QOL) after vaginal sacrocolporectopexy among patients with pelvic organ prolapse., Methods: A noncomparative observational study was conducted at Hanover Medical School, Germany, among patients who underwent vaginal sacrocolporectopexy for uterine or vaginal vault prolapse between May 1, 2006, and October 31, 2012. A validated German version of the Prolapse QOL (P-QOL) questionnaire was sent to eligible patients; respondents were invited for follow-up examination., Results: Overall, 128 patients were enrolled. Concomitant hysterectomy was performed among 82 (64.1%) patients, anterior colporrhaphy among 105 (82.0%), and posterior colporrhaphy among 58 (45.3%). After a mean interval of 26.5 months (range 1.0-81.3 months), seven patients exhibited recurrent vaginal vault prolapse of at least stage 2, giving a success rate of 92.3% (95% confidence interval 85.9%-96.5%). The P-QOL scores were either low (<40) or very low (<20), indicating high QOL. Regarding symptoms related to pelvic organ prolapse, patients reported little or no impact on QOL after vaginal sacrocolporectopexy., Conclusion: Vaginal sacrocolporectopexy seemed safe and feasible, leading to anatomically correct fixation of the vaginal apex, high anatomic success rates, and good QOL. This procedure might be considered as an alternative to laparoscopic or abdominal sacrocolpopexy., (© 2017 International Federation of Gynecology and Obstetrics.)

The vaginal vestibule has not been the subject of a dedicated journal article. Recent terminology has suggested its division into anterior and posterior components. The case for this division has not yet been assessed. Both components extend laterally from the hymen to the junction with the labia minora. The posterior vaginal vestibule is proposed to extend from the posterior aspect of the hymen to the anterior edge of the perineum whilst the anterior vestibule extends from the posterior aspect of the hymen to just below the clitoris. Anatomical considerations (differing layers) might firstly support the above division. The posterior vestibule, by necessity, is far more flexible with the superficial aspect (approximately 1.5 cm), anatomically and histologically, comprising skin and subcutaneous tissue, with perineal musculature deep to this. In turn, it is more likely to be subject to obstetric and surgical considerations than the anterior vaginal vestibule. Obstetric trauma, in particular, would tend to create defects, particularly at its posterior margin. Many dermatological and microbiological considerations may be common to both anterior and posterior vestibule. Any dermatological condition of the vestibule can result in sexual dysfunction and can be complicated by secondary muscular spasm. Congenital anomalies will differ anteriorly and posteriorly. Multiple considerations can be identified to support the case for division of the vaginal vestibule into anterior and posterior components. Neurourol. Urodynam. 36:979-983, 2017. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Objective: To investigate the role of MRI in the evaluation of both the new female anatomy and complications in male-to-female sex reassignment surgery (MtF-SRS)., Methods: 71 consecutive patients with MtF-SRS had 74 MRI [age range, 21-63 years; mean (±standard deviation) age, 36 ± 10 years; median age, 37 years]. In 47 patients, MRI was performed to rule out early post-operative complications after gender conversion (n = 40), vaginoplasty (n = 6) or remodelling of the labia majora (n = 1). In 27 patients, MRI was performed 1-20 years after MtF-SRS for late post-operative complications, pain or dysuria, inflammatory changes or poor cosmetic outcome. Three patients had MRI both before and after the operation., Results: MRI allowed investigation of the new female anatomy in all cases. Soon after MtF-SRS, a small amount of blood was identified in all patients around the neoclitoris, urethral plaque and labia. Post-operative complications were clinically significant fluid collections (n = 5), labial abscesses (n = 2), severe cellulitis (n = 3), partial neovaginal prolapse (n = 3), focal necrosis and dehiscence of the vaginal wall (n = 2) and hypovascularization of the neoclitoris (n = 1). After ileal vaginoplasty, three patients developed clinically insignificant haematomas, one a large rectovaginal fistula with dehiscence of the intestinal anastomosis and bowel perforation (n = 1). In the 27 patients investigated 1-20 years after MfF-SRS, MRI demonstrated cavernosal remnants (n = 10), spared testis (n = 1) neovaginal strictures (n = 8), fistulas and abscesses (n = 3) and prolapse (n = 2). Three of these patients also had fibrotic changes. In the remaining three patients, no pathological features were identified., Conclusion: After genital reconfiguration, MRI allows assessment of the post-operative anatomy and of post-operative complications. Advances in knowledge: Imaging features of the new anatomy and of surgical complications after SRS are discussed and illustrated.

Complex foldings of the vaginal wall are unique to some cetaceans and artiodactyls and are of unknown function(s). The patterns of vaginal length and cumulative vaginal fold length were assessed in relation to body length and to each other in a phylogenetic context to derive insights into functionality. The reproductive tracts of 59 female cetaceans (20 species, 6 families) were dissected. Phylogenetically-controlled reduced major axis regressions were used to establish a scaling trend for the female genitalia of cetaceans. An unparalleled level of vaginal diversity within a mammalian order was found. Vaginal folds varied in number and size across species, and vaginal fold length was positively allometric with body length. Vaginal length was not a significant predictor of vaginal fold length. Functional hypotheses regarding the role of vaginal folds and the potential selection pressures that could lead to evolution of these structures are discussed. Vaginal folds may present physical barriers, which obscure the pathway of seawater and/or sperm travelling through the vagina. This study contributes broad insights to the evolution of reproductive morphology and aquatic adaptations and lays the foundation for future functional morphology analyses.

In the present study, a detailed histological description of the female reproductive tract of South American fur seal (Arctophoca australis) pups has been conducted. The uterine tube was covered by cuboidal to columnar epithelium; nerve fibers were present in the mesosalpinx and beneath the muscular layer. The uterus was bipartitus; the endometrial surface of the horns was lined by a simple cuboidal or columnar epithelium with deep tubular glands; caudally ("the transition area"), the epithelium changed to pseudostratified columnar, few tubular glands were present and the myometrium increased in width. A bistratified epithelium internally coated the uterine body, whereas it changed to cylindrical stratified epithelium with a highly vascularized lamina propria and a strong muscular layer in the cervix; no endometrial glands were observed in this region. From the transition area of the uterus to the vagina there were several nerve fibers and ganglia belonging to the uterovaginalis plexus. In the vestibule, hymenal folds were poorly developed; adnexa structures included the major vestibular glands and a neurovascular structure similar to the vestibular bulb. Minor vestibular glands were associated with the clitoris. The skin of the perineum was lined by a keratinized stratified epithelium, pigmented, with sebaceous glands, sweat glands and hair follicles. This is the first detailed histological description of the reproductive tract of South American fur seal pups, including the glandular adnexa and nerve structures. These results contribute to the reproductive biology in Pinniped species, and give a better understanding of the utero-placental perfusion mechanism during diving. Anat Rec, 2017. © 2017 Wiley Periodicals, Inc. Anat Rec, 300:600-613, 2017. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Introduction: Women with pelvic floor dysfunction can have tender areas on vaginal examination, which can be treated with trigger-point injections. There are no publications to evaluate the accuracy of pelvic floor muscle injections., Methods: Trigger-point injections were performed on 2 fresh cadaveric pelvises using a curved nasal cannula guide and 7-in spinal needle. This was performed using our standard template of 2 sets of injections at the 1-, 3-, and 5-o'clock positions distally and proximally. The first pelvis was dissected to examine dye penetration. Based on these results, we modified our technique and repeated the injections on the second cadaver. We dissected the second pelvis and compared our findings., Results: The 1-o'clock proximal and distal injections stained the obturator internus and externus near the insertion at the ischiopubic ramus. The 3-o'clock injections stained the midbody of the pubococcygeus and puborectalis. The distal 5-o'clock position was too deep and stained the fat of the ischiorectal space. The proximal 5-o'clock injection stained the area of the pudendal nerve. Our goal at the distal 5-o'clock position was to infuse the iliococcygeus muscle, so we shortened the needle depth from 2 to 1 cm beyond the cannula tip. In our second dissection, the distal 5-o'clock injection again stained only the fat of the ischiorectal space., Conclusions: This is the first study to characterize the distribution of pelvic floor muscle injections in a cadaver model and confirms the ability to deliver medications effectively to the pelvic floor muscles.

Background: Pelvic organ prolapse affects half of vaginally parous women. Several animal models are used to study its pathophysiology and treatment. Sheep are interesting because they develop spontaneously prolapse with similar risk factors as women and can be used for vaginal surgery. This study describes ovine pelvis anatomy and compares it to women's pelvis to provide anatomical tools for translational researchers., Methods: MRI, pelvic dissections, and histology were used for detailed macro- and microscopic analysis of relevant anatomical structures in 6 nulliparous ewes., Results: Although sheep are quadrupeds, the gross and microscopic anatomies are similar to the female pelvis. Principal differences are the shape and its orientation, the absence of the sacrospinous ligament and the internal obturator. The levator ani (except for the puborectalis) and the coccygeus muscle are present, yet the latter is more developed - coinciding with the tail. The dimensions and morphology of the ovine vagina is comparable. The retropubic and the rectovaginal space are accessible transvaginally. There is a wide expression of estrogen receptors with low or absent immunoreactivity in the urethral epithelium, bladder, anus and internal anal sphincter., Conclusion: The ovine pelvic floor has many anatomical and ultrastructural similarities to the female pelvic floor., (© 2017 S. Karger AG, Basel.)

There is increasing concern about possible adverse effects of soy based infant formulas (SBIF) due to their high amount of isoflavones (ISO). The aim of the present study was to investigate effects of neonatal exposure to ISO on reproductive system of female Wistar rats. Animals were exposed to an ISO depleted diet or a diet enriched with an ISO extract (IRD; 508mg ISO/kg) during embryogenesis and adolescence. Pups of each group were fed daily by pipette with ISO-suspension (ISO+; 32mg ISO/kg bw) or placebo from postnatal day (PND) 1 until PND23 resulting in plasma concentrations similar to levels reported in infants fed SBIF. The visceral fat mass was reduced by long-term IRD. Vaginal epithelial height was increased at PND23 and vaginal opening was precocious in ISO+ groups. Later in life, more often irregular estrus cycles were observed in rats of ISO+ groups. In addition, FSH levels and uterine epithelial heights were increased at PND80 in ISO+ groups. In summary, the results indicate that neonatal ISO intake, resulting in plasma concentrations achievable through SBIF, has an estrogenic effect on prepubertal rats and influences female reproductive tract later in life., (Copyright © 2016. Published by Elsevier Ireland Ltd.)

Introduction and Hypothesis: The uterosacral (USL) and cardinal ligaments (CL) provide support to the uterus and pelvic organs, and the round ligaments (RL) maintain their position in the pelvis. In women with pelvic organ prolapse (POP), the connective tissue, smooth muscle, vasculature, and innervation of the pelvic support structures are altered. Rodents are commonly used animal models for POP research. However, the pelvic ligaments have not been defined in these animals. In this study, we hypothesized that the gross anatomy and histological composition of pelvic ligaments in rodents and humans are similar., Methods: We performed an extensive literature search for anatomical and histological descriptions of the pelvic support ligaments in rodents. We also performed anatomical dissections of the pelvis to define anatomical landmarks in relation to the ligaments. In addition, we identified the histological components of the pelvic ligaments and performed quantitative analysis of the smooth muscle bundles and connective tissue of the USL and RL., Results: The anatomy of the USL, CL, and RL and their anatomical landmarks are similar in mice, rats, and humans. All species contain the same cellular components and have similar histological architecture. However, the cervical portion of the mouse USL and RL contain more smooth muscle and less connective tissue compared with rat and human ligaments., Conclusion: The pelvic support structures of rats and mice are anatomically and histologically similar to those of humans. We propose that both mice and rats are appropriate, cost-effective models for directed studies in POP research.

The reproductive system of the female Ethusa mascarone was studied with a combination of histological and MRI-techniques. The study reveals a completely new type of eubrachyuran seminal receptacle. This receptacle consists of two largely separate chambers that engage with each other in a manner similar to shaking hands. One chamber facing the medial axis is lined by cuticle while the second chamber consists of a thick holocrine epithelium. Both chambers are connected by two openings of a unique structure. First, the glandular chamber opens ventro-laterally to the cuticle chamber via a laterally flattened connective duct that is lined by a highly folded cuticle. A second opening connects both chambers dorsally with the oviduct orifice. A distinct character is the cuticular hook-like projection that is situated in between the connection of oviduct opening, the glandular chamber and the cuticle chamber of the seminal receptacle. The complete seminal receptacle exhibits a combination of plesiomorphic and apomorphic characters. The arrangement of the receptacles featured in two separate chambers, including the ventro-lateral connection of the glandular chamber to the cuticle chamber, presumably reflects an early evolutionary stage of an eubrachyuran receptacle. In contrast, the dorso-lateral opening between both chambers, including the hook-like projection, appears to be an apomorphic character of at least E. mascarone. J. Morphol. 277:1497-1508, 2016. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Study Objective: To compare the effects of the laparoscopic approach versus the vaginal route for the management of vaginal cuff closure during total laparoscopic hysterectomy on female sexual function in premenopausal patients with benign gynecologic conditions., Design: A prospective study with a randomized, double-blind design (Canadian Task Force Classification I)., Setting: A university hospital., Patients: Patients who were scheduled to have total laparoscopic hysterectomy because of benign conditions., Interventions: Patients were randomized to vaginal cuff closure via the vaginal route versus the laparoscopic approach. The study included a total of 70 patients; 34 underwent the laparoscopic approach in the management of vaginal cuff closure, and 36 underwent the vaginal route., Measurements and Main Results: Female sexual function and vaginal length were measured. The duration of total surgery was significantly shorter in the laparoscopic approach group compared with the vaginal route group (112.2 ± 36.5 vs 122.7 ± 53.6, p < .05). The total Female Sexual Function Index scores preoperatively and 3 months postoperatively were similar between the laparoscopic approach and vaginal route groups (all p > .05). Vaginal lengths 3 months postoperatively were significantly longer in the laparoscopic approach group compared with the vaginal route group (8.39 ± 0.90 vs 7.34 ± 1.17, p < .05). The duration of cuff closure was significantly shorter in the vaginal route group compared with the laparoscopic approach group (8.92 ± 2.23 vs 7.51 ± 2.5, p < .05). Preoperative vaginal lengths were significantly longer in comparison with 3 months postoperatively both in the laparoscopic approach and the vaginal route groups (all p < .05). The preoperative total Female Sexual Function Index scores were significantly higher in comparison with 3 months postoperatively both in the laparoscopic approach and the vaginal route groups (all p < .05)., Conclusion: The results of this study indicate that the laparoscopic approach for vaginal cuff closure might be preferable because of better postoperative vaginal length and a shorter duration of total surgery time., (Copyright © 2016 AAGL. All rights reserved.)

Background: Aging, childbearing, and hormonal changes can lead to vulvovaginal laxity and mucosal atrophy that negatively affect a woman's quality of life. As more minimally and noninvasive options for genital rejuvenation become available in the outpatient setting, it becomes increasingly important for the dermatologic surgeon to be familiar with these popular procedures., Objective: To familiarize dermatologists with the nonsurgical options available for female genital rejuvenation, patient motivations for pursuing these procedures, relevant anatomy, and potential adverse events., Materials and Methods: A MEDLINE search was performed on nonsurgical female genital rejuvenation from 1989 to 2015, and results are summarized., Results: Reports of nonsurgical female genital rejuvenation procedures using fractional carbon dioxide lasers, nonablative lasers, monopolar radiofrequency devices, hyaluronic acid fillers, and fat transfer are concisely summarized for the practicing dermatologist., Conclusion: Review of the literature revealed expanding options for nonsurgical female genital rejuvenation.

Introduction and Hypothesis: We updated anatomic theories of pelvic organ support to determine pathophysiology in various forms of cystocele., Methods: PubMed/MEDLINE, ScienceDirect, Cochrane Library, and Web of Science databases were searched using the terms pelvic floor, cystocele, anatomy, connective tissue, endopelvic fascia, and pelvic mobility. We retrieved 612 articles, of which 61 matched our topic and thus were selected. Anatomic structures of bladder support and their roles in cystocele onset were determined on the international anatomic classification; the various anatomic theories of pelvic organ support were reviewed and a synthesis was made of theories of cystocele pathophysiology., Results: Anterior vaginal support structures comprise pubocervical fascia, tendinous arcs, endopelvic fascia, and levator ani muscle. DeLancey's theory was based on anatomic models and, later, magnetic resonance imaging (MRI), establishing a three-level anatomopathologic definition of prolapse. Petros's integral theory demonstrated interdependence between pelvic organ support systems, linking ligament-fascia lesions, and clinical expression. Apical cystocele is induced by failure of the pubocervical fascia and insertion of its cervical ring; lower cystocele is induced by pubocervical fascia (medial cystocele) or endopelvic fascia failure at its arcus tendineus fasciae pelvis attachment (lateral cystocele)., Conclusions: Improved anatomic knowledge of vaginal wall support mechanisms will improve understanding of cystocele pathophysiology, diagnosis of the various types, and surgical techniques. The two most relevant theories, DeLancey's and Petros's, are complementary, enriching knowledge of pelvic functional anatomy, but differ in mechanism. Three-dimensional digital models could integrate and assess the mechanical properties of each anatomic structure.

Background: Vaginal delivery and aging are key risk factors for pelvic floor muscle dysfunction, which is a critical component of pelvic floor disorders. However, alterations in the pelvic floor muscle intrinsic structure that lead to muscle dysfunction because of childbirth and aging remain elusive., Objectives: The purpose of this study was to determine the impact of vaginal deliveries and aging on human cadaveric pelvic floor muscle architecture, which is the strongest predictor of active muscle function., Study Design: Coccygeus, iliococcygeus, and pubovisceralis were obtained from younger donors who were ≤51 years old, vaginally nulliparous (n = 5) and vaginally parous (n = 6) and older donors who were >51 years old, vaginally nulliparous (n = 6) and vaginally parous (n = 6), all of whom had no history of pelvic floor disorders. Architectural parameters, which are predictive of muscle's excursion and force-generating capacity, were determined with the use of validated methods. Intramuscular collagen content was quantified by hydroxyproline assay. Main effects of parity and aging and the interactions were determined with the use of 2-way analysis of variance, with Tukey's post-hoc testing and a significance level of .05., Results: The mean age of younger and older donors differed by approximately 40 years (P = .001) but was similar between nulliparous and parous donors within each age group (P > .9). The median parity was 2 (range, 1-3) in younger and older vaginally parous groups (P = .7). The main impact of parity was increased fiber length in the more proximal coccygeus (P = .03) and iliococcygeus (P = .04). Aging changes manifested as decreased physiologic cross-sectional area across all pelvic floor muscles (P < .05), which substantially exceeded the age-related decline in muscle mass. The physiologic cross-sectional area was lower in younger vaginally parous, compared with younger vaginally nulliparous, pelvic floor muscles; however, the differences did not reach statistical significance. Pelvic floor muscle collagen content was not altered by parity but increased dramatically with aging (P < .05)., Conclusions: Increased fiber length in more proximal pelvic floor muscles likely represents an adaptive response to the chronically increased load placed on these muscles by the displaced apical structures, presumably as a consequence of vaginal delivery. In younger specimens, a consistent trend towards decrease in force-generating capacity of all pelvic floor muscles in the parous group suggests a potential mechanism for clinically identified pelvic floor muscle weakness in vaginally parous women. The substantial decrease in predicted muscle force production and fibrosis with aging represent likely mechanisms for the pelvic floor muscle dysfunction in older women., Competing Interests: The authors report no conflict of interest., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The female mouse estrous cycle is divided into four phases: proestrus (development of ovarian follicles), estrus (ovulation), metestrus (formation of corpora lutea), and diestrus (beginning of follicle development for next ovulation and elimination of previous oocytes). The appearance of the epithelium of the external genitalia is used to identify the stage of the estrous cycle of a female mouse. This is usually easier to see in strains with either no or only light skin pigmentation. By examining the color, moistness, and degree of swelling of the vagina, females in estrus can readily be identified. To set up the matings, females are examined in the afternoon, and those in estrus are placed into the cages with males (one or two females in each cage with one male). Usually, 50% or more of the selected females will mate. The presence of a vaginal copulation plug next morning indicates that mating has occurred, but it does not mean that a pregnancy will result even if proven breeder fertile males were used. It is important to check vaginal plugs early in the morning because they fall out or are no longer detectable ~12 h after mating or sometimes earlier., (© 2016 Cold Spring Harbor Laboratory Press.)

Recent studies have suggested that maternal characteristics can affect reproductive health of offspring, possibly through pre-natal hormonal influence. Anogenital distance (AGD) is an anthropometric measure which is a sensitive reproductive endpoint of masculinisation. It provides a read-out of pre-natal androgen exposure and has been associated with several reproductive health outcomes in humans. We studied AGD and stretched penile length (SPL) in a large, racially homogenous sample of consecutive newborns to understand their association with maternal and infant characteristics. A prospective cross-sectional study involving measurement of AGD and SPL at birth was performed by a single trained observer. A total of 1077 newborns (553 males and 524 females) were included in final anthropometric analysis. The mean AGD of males was 2.56 ± 0.31 cm, and the mean AGD of females was 1.54 ± 0.17 cm. The mean SPL of males was 3.31 ± 0.38 cm. On multiple regression analysis, for both males and females, birthweight (β = 0.229, P < 0.001 and β = 0.135, P < 0.001, respectively) was modest but significant predictor for AGD. For SPL, only gestational age (β = 0.054, P < 0.001) was found to be statistically significant predictor. There was no significant association observed for gravidity, parity and maternal age with both AGD and SPL. Thus, no maternal characteristics (age, gravidity, parity) influence AGD or SPL in human infants., (© 2015 Blackwell Verlag GmbH.)

Objectives: To identify a G-spot complex (GSC) in vivo in MRI examinations at 1.5 Tesla field strength., Design: Observational study., Setting: Single centre., Population: Twenty-one consecutive patients (January-March 2014)., Methods: Imaging analysis of routine imaging protocols for usual medical indications with and without concomitant opacification of the vaginal cavity with inert ultrasound gel. The gel distends the otherwise collapsed vaginal walls, allowing for an improved discrimination of anatomic features. The macroscopic and histological results recently derived from the dissections of fresh cadavers by Ostrzenski et al. were translated into imaging characteristics to be expected in the respective MRI sequences (e.g. T1- and T2-weighted) in search of an in vivo correlate of the GSC. Age, menopause status, medical indication and diagnosis were co-variables., Main Outcome Measures: To analyse primarily whether MRI imaging is able to depict a distinct morphological entity in vivo matching the GSC, based on anatomical descriptions published recently. The elaboration of an appropriate MRI-imaging protocol was a secondary aim., Results: A total of 21 studies were obtained. A GSC was identified within the anterior vaginal wall in 13/21 patients (62%). In all, 10/21 (48%) had vaginal gel opacification. We identified a GSC in 10/10 patients (100%) with opacification in all three planes of the T2 images. This was only true for 3/11 cases (27%) without opacification., Conclusions: There is evidence for an in vivo morphological correlate to the postmortem anatomical findings of a GSC described by Ostrzenski et al.; its visibility in MRI imaging can be significantly improved with vaginal opacification by ultrasound gel., Tweetable Abstract: Identification of G-spot by MRI with vaginal gel-opacification in 13/21 patients., (© 2016 Royal College of Obstetricians and Gynaecologists.)

Background: Recognition and assessment of apical vaginal support defects remains a significant challenge in the evaluation and management of prolapse. There are several reasons that this is likely: (1) Although the Pelvic Organ Prolapse-Quantification examination is the standard prolapse staging system used in the Female Pelvic Medicine and Reconstructive Surgery field for reporting outcomes, this assessment is not used commonly in clinical care outside the subspecialty; (2) no clinically useful and accepted definition of apical support loss exists, and (3) no consensus or guidelines address the degree of apical support loss at which an apical support procedure should be performed routinely., Objective: The purpose of this study was to identify a simple screening measure for significant loss of apical vaginal support., Study Design: This was an analysis of women with Pelvic Organ Prolapse-Quantification stage 0-IV prolapse. Women with total vaginal length of ≥7 cm were included to define a population with "normal" vaginal length. Univariable and linear regression analyses were used to identify Pelvic Organ Prolapse-Quantification points that were associated with 3 definitions of apical support loss: the International Consultation on Incontinence, the Pelvic Floor Disorders Network revised eCARE, and a Pelvic Organ Prolapse-Quantification point C cut-point developed by Dietz et al. Linear and logistic regression models were created to assess predictors of overall apical support loss according to these definitions. Receiver operator characteristic curves were generated to determine test characteristics of the predictor variables and the areas under the curves were calculated., Results: Of 469 women, 453 women met the inclusion criterion. The median Pelvic Organ Prolapse-Quantification stage was III, and the median leading edge of prolapse was +2 cm (range, -3 to 12 cm). By stage of prolapse (0-IV), mean genital hiatus size (genital hiatus; mid urethra to posterior fourchette) increased: 2.0 ± 0.5, 3.0 ± 0.5, 4.0 ± 1.0, 5.0 ± 1.0, and 6.5 ± 1.5 cm, respectively (P < .01). Pelvic Organ Prolapse-Quantification points B anterior, B posterior, and genital hiatus had moderate-to-strong associations with overall apical support loss and all definitions of apical support loss. Linear regression models that predict overall apical support loss and logistic regression models predict apical support loss as defined by International Continence Society, eCARE, and the point C; cut-point definitions were fit with points B anterior, B posterior, and genital hiatus; these 3 points explained more than one-half of the model variance. Receiver operator characteristic analysis for all definitions of apical support loss found that genital hiatus >3.75 cm was highly predictive of apical support loss (area under the curve, >0.8 in all models)., Conclusions: Increasing genital hiatus size is associated highly with and predictive of apical vaginal support loss. Specifically, the Pelvic Organ Prolapse-Quantification measurement genital hiatus of ≥3.75 cm is highly predictive of apical support loss by all study definitions. This simple measurement can be used to screen for apical support loss and the need for further evaluation of apical vaginal support before planning a hysterectomy or prolapse surgery., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Besides the basic role to flavor and color foods, several health benefits have been attributed to spices. The traditional Cameroonian food "Nkui" is prepared using several spices (Afrostyrax lepidophyllus Mildbr., Capsicum frutescens Linn., Fagara leprieurii Guill. et Perr., Fagara tessmannii Engl., Mondia whitei Hook. F. Skell., Pentadiplandra brazzeana Baill., Solanum gilo Raddi., Tetrapleura tetraptera Taub. and Xylopia parviflora A. Rich. Benthane) that are believed to have a positive impact on the female reproductive physiology. Aiming to determine the potential effect of this food on the female reproductive tract, we evaluated the estrogenic properties of aqueous and ethanol extracts of Nkui using a 3-day uterotrophic assay in ovariectomized (OVX) rats., Methods: OVX female Wistar rats were randomly separated in several groups of five animals each and submitted to a 3-day uterotrophic assay (per os). At the end of treatment, animals were sacrificed and uterus, vagina and mammary gland collected and fixed in 10 % formalin for histological analysis., Results: These extracts increased the uterine wet weight, the uterine and vaginal epithelial heights, and the lumen and diameter of alveoli in the mammary glands. They also altered the estradiol-induced increase of uterine wet weight. The dichloromethane and methanol fractions of the ethanol extract exhibited estrogenic properties as well by increasing uterine and vaginal endpoints., Conclusions: These results suggest that the spices of "Nkui" contain estrogenic phytoconstituents and this traditional food may be considered as functional.

Introduction: In the pelvis, the rectogenital septum (RGS) separates the urogenital compartment from the digestive compartment. In men, it corresponds to Denonvilliers' rectoprostatic fascia or rectovesical septum (RVS). Its purpose-and, indeed, its existence-are controversial in women. The purpose of this review was to update knowledge about the RGS in women and, in particular, to clarify its relationship to pelvic nerves in order to deduce practical consequences of pelvic surgery and compare it to the RVS in men., Methods: A review of the anatomical and surgical literature was undertaken. Evidence for embryological origin, composition, and surgical importance of the RGS in women and men is suggested., Results: This manuscript presents evidence of the existence of the RGS in both women (rectovaginal septum, RVaS) and men (rectovesical septum, RVS). It originates from the genital structures and extends from the rectogenital pouch to the perineal body. It is composed of connective tissue associated with bundles of smooth muscle cells and has lateral expansions in close contact with neurovascular bundles originating from the inferior hypogastric plexus. During pelvic surgery for carcinoma, preservation of nerve fibers of erectile bodies is necessary if possible. The RGS is thus an important surgical landmark during urogenital sinus surgery, prolapse surgery, and proctectomy in women as well as during proctectomy and prostatectomy in men., Conclusions: The RGS is present in women as well as in men, with great similarities between the two sexes. It represents an important surgical landmark during pelvic nerve-sparing surgery.

Evolutionary approaches are powerful tools for understanding human disorders. The composition of vaginal microbiome is important for reproductive success and has not yet been characterized in the contexts of social structure and vaginal pathology in non-human primates (NHPs). We investigated vaginal size, vulvovaginal pathology and the presence of the main human subtypes of Lactobacillus spp./ BV-related species in the vaginal microflora of baboons (Papio spp.). We performed morphometric measurements of external and internal genitalia (group I, n = 47), analyzed pathology records of animals from 1999-2015 (group II, n = 64 from a total of 12,776), and evaluated vaginal swabs using polymerase chain reaction (PCR) (group III, n = 14). A total of 68 lesions were identified in 64 baboons. Lactobacillus iners, Gardnerella vaginalis, Atopobium vaginae, Megasphaera I, and Megasphaera II were not detected. L. jensenii, L. crispatus, and L. gasseri were detected in 2/14 (14.2%), 1/14 (7.1%), and 1/14 (7.1%) samples, respectively. BVAB2 was detected in 5/14 (35.7%) samples. The differences in the vaginal milieu between NHP and humans might be the factor associated with human-specific pattern of placental development and should be taken in consideration in NHP models of human pharmacology and microbiology.

The lateral support of the vaginal wall depends on the integrity of the paravaginal section of the visceral pelvic fascia, levator ani, and their connection. Various defects of the muscle and fascia can result in identical clinical findings-ie, the descent of the lateral vaginal sulcus. In this study, we created a realistic scheme for classifying paravaginal defects, based on the complex relationship of the pelvic fascia with the levator ani. Surgical observations, cadaver examinations, and a complex magnetic resonance imaging (MRI)-based 3-dimensional (3D) model were used to analyze the spatial relationships of normal and defective anatomy of the female pelvic floor. Descent of the lateral vaginal sulcus can result from a defect in the paravaginal visceral pelvic fascia, levator ani, or both. The fascial defect can be partial or complete, and the muscle defect can vary in location. A detailed illustrated classification is presented. We present a new model of the pathology that underlies a common clinical finding., (© 2016 Wiley Periodicals, Inc.)

Present research was carried out in order to perform the monitoring of development, recognizes the type of tissue and describes histological and cellular changes of the vaginal closure membrane (VCM) throughout pregnancy in Galea spixii. The results showed that at 20 days of gestation (DG), the VCM occludes completely the external vaginal ostium. Microscopically, the VCM presented juxtaposed cells, derived from the stratum germinative of the stratified epithelium of vaginal mucosa at 20 DG and areas with cell clusters with the presence of intercellular spaces in the final stages of pregnancy (40-50 DG). At 0 DG, the stratified epithelium of vaginal mucosa presented all strata but at 20 DG presented stratified epithelium without the stratum corneum and stratum granular and showed communicant junctions by desmosomes and interdigitations in the cell membrane compound the VCM. Gradually from 40 to 50 DG the stratum germinative became barely perceptible. Many cells showed apoptotic nuclei and emerged many intercellular spacing. So, the interdigitations and desmosomes were not observed. Here, it was demonstrated for the first time that the VCM is formed after the extinction of the stratum granular and corneum of the vaginal mucosa epithelium, with the proliferation of the cells of stratum germinative and communication and junction through desmosomes and interdigitations of these cells. At the end of pregnancy, cellular apoptosis; the spread of stratum germinative; and, absence of cellular communication and junction may be responsible for the weakening of the VCM and may assist the process of rupture of this membrane., (© 2016 Wiley Periodicals, Inc.)

Purpose: To calculate vaginal doses during image guided brachytherapy with volume-based metrics and correlate with long-term vaginal toxicity., Methods and Materials: In this institutional review board-approved study, institutional databases were searched to identify women undergoing computed tomography and/or magnetic resonance-guided brachytherapy at the Duke Cancer Center from 2009 to 2015. All insertions were contoured to include the vagina as a 3-dimensional structure. All contouring was performed on computed tomography or magnetic resonance imaging and used a 0.4-cm fixed brush to outline the applicator and/or packing, expanded to include any grossly visible vagina. The surface of the cervix was specifically excluded from the contour. High-dose-rate (HDR) and low-dose-rate (LDR) doses were converted to the equivalent dose in 2-Gy fractions using an α/β of 3 for late effects. The parameters D0.1cc, D1cc, and D2cc were calculated for all insertions and summed with prior external beam therapy. Late and subacute toxicity to the vagina were determined by the Common Terminology Criteria for Adverse Events version 4.0 and compared by the median and 4th quartile doses, via the log-rank test. Univariate and multivariate hazard ratios were calculated via Cox regression., Results: A total of 258 insertions in 62 women who underwent definitive radiation therapy including brachytherapy for cervical (n=48) and uterine cancer (n=14) were identified. Twenty HDR tandem and ovoid, 32 HDR tandem and ring, and 10 LDR tandem and ovoid insertions were contoured. The median values (interquartile ranges) for vaginal D0.1cc, D1cc, and D2cc were 157.9 (134.4-196.53) Gy, 112.6 (96.7-124.6) Gy, and 100.5 (86.8-108.4) Gy, respectively. At the 4th quartile cutoff of 108 Gy for D2cc, the rate of late grade 1 toxicity at 2 years was 61.2% (95% confidence interval [CI] 43.0%-79.4%) below 108 Gy and 83.9% (63.9%-100%) above (P=.018); grade 2 or greater toxicity was 36.2% (95% CI 15.8%-56.6%) below 108 Gy and 70.7% (95% CI 45.2%-96.2%) above (P=.004); and grade 3 or worse toxicity was 9.9% (95% CI 0.0%-23.6%) below 108 Gy and 30.0% (95% CI 4.7%-55.3%) above (P=.025). This association was maintained on multivariate analysis, independent of covariates such as applicator type, age, and dose rate., Conclusions: Vaginal dose was associated with all grades of vaginal toxicity. Confirmation at other sites using this methodology will be necessary to establish reproducibility; however, the integration of routine calculation of vaginal dose may be warranted., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The goal was to increase pseudopregnant mice production by estrous cycle staging by visual examination before pairing and to determine the effect of such pseudopregnant recipients on embryo transfer. To compare methods of estrous cycle staging over 14 days, groups consisted of 10 females in proestrus-estrus and 10 vasectomized males; group 1: only daily visual observation; group 2: daily visual observation and cytological examination on day 1; group 3: daily visual observation and daily cytological examination. The average time to first vaginal plug was 1.8 days in group 1, 2.7 days in group 2, and 3.2 days in group 3, whereas the average time between consecutive vaginal plugs was 9.2 days (group 1), 10 days (group 2), and 9.25 days (group 3). The average time between consecutive estrous cycles was 9.7 days (group 1), 11.8 days (group 2), and 9.4 days (group 3). The congruence between visual and cytological examination in determining proestrus-estrus in group 2 was 100% and that for the four stages in group 3 was 79% with a range of 44% to 100%. From 162 plug-positive females originally selected in proestrus-estrus, 49%, 30%, 19%, and 2% were plug-positive on Day 1, Day 2, Day 3, and Day 4, respectively, showing that pseudopregnant mice production was significantly increased on the first 2 days. From 192 plug-positive females originally selected randomly, these values were 31%, 21%, 35%, 10%, and 3% on d1, d2, d3, d4, and d5, respectively. No significant differences were observed between groups with respect to embryo transfers with fresh or cryopreserved embryos although the number of pups born per litter was higher in group A with fresh (7.57 vs. 6.39) and cryopreserved-thawed embryos (5.0 vs. 4.38). Furthermore, the sex ratio and the genotype of the pups were not significantly affected., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The available literature describing the morphology of the female chinchilla's uterine cervix varies and includes phrases such as 'the cervical canal,' 'a single cervix,' and 'the cervix;' alternatively, some publications describe 2 cervices. In this report, we provide an anatomically correct and definitive description of the uterine cervical morphology of the laboratory chinchilla. We further propose revised, anatomically precise nomenclature to characterize the female chinchilla reproductive tract as a whole.

Vaginal evisceration can be defined as a defect in the vaginal wall resulting in prolapse of the intraperitoneal contents. This is a rare complication of hysterectomy, but may result in severe morbidity. We report the case of a postmenopausal woman with transvaginal evisceration of the sigmoid colon 1 year after an abdominal hysterectomy. An exploratory laparotomy was undertaken to reduce the prolapsed sigmoid colon through a combined vaginal-abdominal route. Repair of the defect of the vaginal vault was made using an absorbable running suture. Two years later, the patient presented at the emergency department with a transvaginal evisceration of the omentum. An exclusively vaginal approach was then chosen to repair the smaller vaginal defect and vaginal cuff was closed using non-absorbable sutures. As two different surgical approaches were used in this patient, a discussion of the different treatment options and also of the principles of prevention of vaginal cuff dehiscence is provided., (2016 BMJ Publishing Group Ltd.)

Objectives: The effect of hysterectomy on vesicourethral and sexual functions remains controversial. The primary objective of this study was to compare the effects of a laparoscopic hysterectomy and a total abdominal hysterectomy on lower urinary tract function. The secondary aims were to compare the two surgeries in terms of postoperative vaginal length and dyspareunia., Materials and Methods: This was a prospective randomized clinical study in which 292 women were assigned to either the laparoscopic hysterectomy (n = 146) or total abdominal hysterectomy (n = 146) groups. The vaginal length and urodynamic measurements were taken, and the patients were asked to grade the presence and severity of dyspareunia using a visual analog scale 3 weeks before and 12 weeks after the surgery. The relationship between the postoperative vaginal length and the incidence of dyspareunia was evaluated. The urodynamic procedures used included uroflowmetry and voiding cystometry to record the maximum flow rate (Q-max) and to assess the bladder capacity., Results: The preoperative vaginal length was similar between the groups, whereas the postoperative vaginal length was significantly longer in the laparoscopic hysterectomy group. When the 15 patients who developed postoperative dyspareunia were evaluated, no differences in the postoperative vaginal length were seen, but a significant difference in the change in the length of the vagina was found when compared with the other patients. No significant difference was found with regard to pre- and postoperative Q-max, bladder capacity, and change in bladder capacity between the study groups., Conclusions: The change in the length of the vagina was much more remarkable after total abdominal hysterectomy, compared with laparoscopic hysterectomy. It seems that the Q-max and the bladder capacity increase after hysterectomies, regardless of the surgical type. Further prospective randomized comparative studies are warranted to ascertain whether laparoscopic hysterectomies cause less damage to the pelvic floor, compared with abdominal hysterectomies.

Introduction: Female genital mutilation (FGM), the partial or total removal of the external genitalia for non-medical reasons, can affect female sexuality. However, only few studies are available, and these have significant methodologic limitations., Aim: To understand the impact of FGM on the anatomy of the clitoris and bulbs using magnetic resonance imaging and on sexuality using psychometric instruments and to study whether differences in anatomy after FGM correlate with differences in sexual function, desire, and body image., Methods: A cross-sectional study on sexual function and sexual anatomy was performed in women with and without FGM. Fifteen women with FGM involving cutting of the clitoris and 15 uncut women as a control group matched by age and parity were prospectively recruited. Participants underwent pelvic magnetic resonance imaging with vaginal opacification by ultrasound gel and completed validated questionnaires on desire (Sexual Desire Inventory), body image (Questionnaire d'Image Corporelle [Body Image Satisfaction Scale]), and sexual function (Female Sexual Function Index)., Main Outcome Measures: Primary outcomes were clitoral and bulbar measurements on magnetic resonance images. Secondary outcomes were sexual function, desire, and body image scores., Results: Women with FGM did not have significantly decreased clitoral glans width and body length but did have significantly smaller volume of the clitoris plus bulbs. They scored significantly lower on sexual function and desire than women without FGM. They did not score lower on Female Sexual Function Index sub-scores for orgasm, desire, and satisfaction and on the Questionnaire d'Image Corporelle but did report significantly more dyspareunia. A larger total volume of clitoris and bulbs did not correlate with higher Female Sexual Function Index and Sexual Desire Inventory scores in women with FGM compared with uncut women who had larger total volume that correlated with higher scores., Conclusion: Women with FGM have sexual erectile tissues for sexual arousal, orgasm, and pleasure. Women with sexual dysfunction should be appropriately counseled and treated., (Copyright © 2016 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to characterize pertinent anatomy relative to the sacral suture placed at time of robotic sacrocolpopexy using postoperative computed tomography and magnetic resonance imaging., Methods: A vascular clip was placed at the base of the sacral suture at the time of robotic sacrocolpopexy. Six weeks postoperatively, subjects returned for a computed tomography scan and magnetic resonance imaging., Results: Ten subjects completed the study. The middle sacral artery and vein coursed midline or to the left of midline in all the subjects. The left common iliac vein was an average of 26 mm from the sacral suture. To the right of the suture, the right common iliac artery was 18 mm away. Following the right common iliac artery to its bifurcation, the right internal iliac was on average 10 mm from the suture. The bifurcations of the inferior vena cava and the aorta were 33 mm and 54 mm further cephalad, respectively.The right ureter, on average, was 18 mm from the suture. The thickness of the anterior longitudinal ligament was 2 mm.The mean angle of descent of the sacrum was 70 degrees. Lastly, we found that 70% of the time, a vertebral body was directly below the suture; the disc was noted in 30%., Conclusions: We describe critical anatomy surrounding the sacral suture placed during robotic sacrocolpopexy. Proximity of both vascular and urologic structures within 10 to 18 mm, as well as anterior ligament thickness of only 2 mm highlights the importance of adequate exposure, careful dissection, and surgeon expertise.

Background: Depot-medroxyprogesterone acetate (DMPA) has been associated in some studies with increased HIV susceptibility in women. We used a pigtail macaque model to document the effects of repeated DMPA treatments and their potential contribution to increased SHIV susceptibility., Methods: Nine pigtails were administered 2.5, 1.5, or 0.5 mg/kg DMPA in study weeks one and four. Menstrual cycling, vaginal epithelial thickness, and other SHIV susceptibility factors were monitored for a mean of 24 study weeks., Results: All DMPA treatments suppressed menstrual cycling and increased vaginal pH. The vaginal epithelium thinned naturally during baseline menstrual cycles (from mean of 351 to 161 μm in late-luteal phase). Following DMPA, the non-nucleated layer was temporarily absent. Two weeks post-second DMPA injection, mean epithelial thickness was 53, 45, and 167 μm for the descending doses, respectively., Conclusions: All animals showed temporal vaginal epithelial thinning with loss of the non-nucleated layer, and vaginal pH changes post-DMPA injections., (Published 2015. This article is a U.S. Government work and is in the public domain in the USA.)

The vagina stands as an important alternative to the oral route for those systemic drugs that are poorly absorbed orally or are rapidly metabolized by the liver. Drug permeation through the vaginal tissue can be estimated by using in vitro, ex vivo and in vivo models. The latter ones, although more realistic, assume ethical and biological limitations due to animal handling. Therefore, in vitro and ex vivo models have been developed to predict drug absorption through the vagina while allowing for simultaneous toxicity and pathogenesis studies. This review focuses on available methodologies to study vaginal drug permeation discussing their advantages and drawbacks. The technical complexity, costs and the ethical issues of an available model, along with its accuracy and reproducibility will determine if it is valid and applicable. Therefore every model shall be evaluated, validated and standardized in order to allow for extrapolations and results presumption, and so improving vaginal drug research and stressing its benefits., (Copyright © 2015 Elsevier B.V. All rights reserved.)

This review presents and applies fundamental mass transport theory describing the diffusion and convection driven mass transport of drugs to the vaginal environment. It considers sources of variability in the predictions of the models. It illustrates use of model predictions of microbicide drug concentration distribution (pharmacokinetics) to gain insights about drug effectiveness in preventing HIV infection (pharmacodynamics). The modeling compares vaginal drug distributions after different gel dosage regimens, and it evaluates consequences of changes in gel viscosity due to aging. It compares vaginal mucosal concentration distributions of drugs delivered by gels vs. intravaginal rings. Finally, the modeling approach is used to compare vaginal drug distributions across species with differing vaginal dimensions. Deterministic models of drug mass transport into and throughout the vaginal environment can provide critical insights about the mechanisms and determinants of such transport. This knowledge, and the methodology that obtains it, can be applied and translated to multiple applications, involving the scientific underpinnings of vaginal drug distribution and the performance evaluation and design of products, and their dosage regimens, that achieve it., (Copyright © 2015 Elsevier B.V. All rights reserved.)

The appearance of the female external genitalia is key for understanding and diagnosing many diseases that women of all ages encounter. Alas, the normal appearance of the vulva is an elusive concept, scarcely represented in textbooks, and the growing number of vulvar cosmetic surgery calls for a review of the normal appearance of the vulva and its diversity. In this paper I will review vulvar embryology, anatomy, the current literature discussing vulvar appearance, and describe meticulous vulvar examination, including the diagnostic tools.

Objective: To evaluate morphological structure of uterosacral ligament (USL) and cardinal ligament (CL) in patients with severe pelvic organ prolapse (POP) by MRI technology, and to analysis and discuss its clinical significance., Methods: From November 2013 to February 2014 in Peking University People's Hospital, 26 elderly patients with III-IV degree of POP were selected as the POP group and 18 healthy elderly volunteers were selected as the control group during the same period. Pelvic MRI examination were performed in the two groups. The morphological characteristics of left and right side of the uterosacral-cardinal ligament on MRI and the attachment site of the starting and ending points between two group were described and compared., Results: In POP group, 25 cases of left USL starting point were located in the sacrospinous ligament/coccygeal muscle complex [58% (15/26)] or coccygeal muscle [38% (10/26)], ending point were located in the cervix and vagina [58% (15/26)] or cervix [38% (10/26)]; 24 cases of right USL starting point were located in the sacrospinous ligament/coccygeal muscle complex [31% (8/26)] or coccygeal muscle [62% (16/26)], 26 cases of right USL ending point were located in the cervix and vagina [62% (16/26)] or cervix [38% (10/26)]; the left and right CL in the POP group and the control group were both from the sacroiliac joint at the top of the greater sciatic foramen from the ipsilateral pelvic side wall; 1 case (4%, 1/26) of left CL in the POP group completely connected to the bladder, 10 cases (38%, 10/26) partly connected to the bladder; 14 cases (54%, 14/26) of right CL partly connected to the bladder, the rest ending points of left and right CL were located in cervix and (or) vagina. In the control group, 17 cases of left USL starting point were located in the sacrospinous ligament/coccygeal muscle complex (10/18) or coccygeal muscle (7/18), ending point were located in the cervix and vagina (12/18) or cervix (6/18); 18 cases of right USL starting point were located in the sacrospinous ligament/coccygeal muscle complex (10/18) or coccygeal muscle (8/18), ending point were located in the cervix and vagina (13/18) or cervix (5/18); 8 cases (8/18) of left CL partly connected to the bladder; 15 cases (15/18) of right CL partly connected to the bladder, the rest ending points of left and right CL were located in cervix and (or) vagina. There was no significant difference between the two groups on the starting and ending points (P > 0.05)., Conclusions: The observation of MRI could be consistent with the clinical anatomy on the starting and ending points, direction of travel in the uterosacral-cardinal ligament. The starting and ending points of the left and right side USL and the ending points of the left and right side CL are not completely symmetrical, the variation degree is large, some CL could be completely or partly inserted to the bladder.

Forest destruction has progressively hampered the survival of many species, and this is why it is so important to study of the lives of primates in captivity. This study aimed to describe the morphological aspects of the female reproductive tract of Sapajus apella. We used five animals obtained from the National Primate Center, Ananindeua - PA. The ovaries were paired, compact and symmetrical and had a smooth surface. The uterine tubes were bilateral and convoluted in adult animals and straight in young individuals. The uterus was simple and located in the pelvic region. The vagina was a long structure due to the position of the uterus. The external genitalia were located in the urogenital perineum and consisted of dark pigmented labia majora and labia minora, a vaginal vestibule as long as the vagina and a well-developed clitoris. The results showed that the genitals of S. apella resemble those of other Neotropical primates., (© 2014 Blackwell Verlag GmbH.)

Introduction and Hypothesis: Anterior vaginal wall length (AVL) is on average 6.1 ± 1.3 cm in women with normal support and lengthened in women with cystocele. We hypothesize that AVL is reduced after anterior repair and that women with larger cystoceles will have greater reduction in AVL., Methods: Demographic, clinical, and surgical data were collected for women undergoing hysterectomy and anterior repair in whom intraoperative vaginal wall measurements had been made between November 2009 and April 2014. In the operating room, AVL was defined preoperatively as the distance from the hymenal ring to the anterior cervicovaginal junction at the hysterectomy incision site, and postoperatively, from the hymenal ring to the same location on the anterior cuff. During the anterior repair the fibromuscular tissues were plicated using an interrupted technique., Results: Measurements were available for 40 women. Average age was 61.7 ± 10 years, median parity was 2.5 and median preoperative Pelvic Organ Prolapse Quantification System (POP-Q) point Ba was 3 cm distal to the hymen. On average, AVL was reduced after surgery by 2.5 cm. Mean postoperative AVL was similar to mean AVL in women with normal pelvic support (6.4 ± 0.8 cm vs 6.1 ± 1.3 cm, p = 0.15). Longer preoperative AVLs had greater AVL change (R (2) = 0.78, p = <0.0001)., Conclusions: In women undergoing anterior repair, mean AVL was reduced by 28 % and returned to the normal range after surgery. These data highlight a rarely discussed effect of anterior repair, which is restoration of normal anterior vaginal wall length.

As adolescence is often the first time a woman will see a gynecologist, it is important for health care providers to understand and be capable of explaining the changes that occur to a young woman during these years. Many adolescents and their caretakers who seek gynecologic care for what they consider vulvovaginal abnormalities may be misinterpreting completely normal changes; education and reassurance are the best treatment in these cases. Most medical literature on vulvovaginal health focuses on abnormalities and there is a paucity of information on what is considered "normal." This goal of this review is to describe normal anatomic and physiologic vulvovaginal changes that occur during the adolescent years, as well as to offer advice on how to educate and reassure young women during this vulnerable time., (Copyright © 2015 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Background: Studies on reproductive morphology are important to understand the reproductive cycle of non-human primates., Methods: This study describes the functional morphology of the adult female tubular genital organs in 41 Aotus (12.8 ± 6.8 years old, ranging from 3 to 25 years), with respect to reproductive status and number of parturitions., Results: In females with developing embryos, endometrial glands showed a higher secretion than other females, and the embryo implantation occupied this secretive endometrium. Changes in the thickening, number of layers, and keratinization in the vaginal epithelium suggest that vaginal cytology may be an indicator of the estrous cycle. Non-pregnant multiparous females had a larger uterine body than nulliparous females. Number of parturitions and reproductive state had an impact on tubular genital organs in female owl monkeys., Conclusions: These results can be useful for the development of biotechnologies of reproduction and for improvement of the management of this species., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Purpose: We prospectively tested five variations in vaginal gauze packing in an effort to improve contrast between the packing, cervix, and applicator for MRI-based intracavitary brachytherapy planning., Methods and Materials: Five patients enrolled on a prospective study from May 2013 to October 2013 received MRI-based intracavitary brachytherapy for cervical cancer with variations of impregnated gauze packing. Substances tested included antibiotic cream alone, antibiotic cream mixed with ultrasound gel, conjugated estrogens cream mixed with ultrasound gel, ultrasound gel alone, and gadolinium. Images from the T2-weighted pelvic MRI were used to obtain signal intensity measurements at points within the packing, cervix, and applicator. Signal intensity values were normalized using the signal-to-noise ratio and compared using an unpaired t-test., Results: Ultrasound gel-impregnated gauze allowed for the greatest contrast between the packing and the cervix with a difference in mean normalized signal intensity of 38.2 (p < 0.01). Conjugated estrogens cream mixed with ultrasound gel and gadolinium also provided contrast when compared with cervix, with differences in mean normalized signal intensity of 25.3 and -16.2, respectively (p < 0.01 for both). For all variations but gadolinium, the normalized mean signal intensity of the packing was found to be significantly different from the applicator, with the ultrasound gel again demonstrating the greatest contrast with a difference of 42.5 (p < 0.01)., Conclusions: Gauze impregnated with ultrasound gel, conjugated estrogens cream mixed with ultrasound gel, and gadolinium allowed for a significant difference in MRI signal intensity between the packing and the cervix. With respect to both the cervix and the applicator, ultrasoundgel-impregnated gauze provided the best contrast overall., (Copyright © 2015 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: Multiphoton microscopy (MPM) is a nonlinear, high-resolution laser scanning technique and a powerful approach for analyzing the spatial architecture within tissues. To demonstrate the potential of this technique for studying the extracellular matrix of the pelvic organs, we aimed to establish protocols for the detection of collagen and elastin in the vagina and to compare the MPM density of these fibers to fibers detected using standard histological methods., Methods: Samples of the anterior vaginal wall were obtained from nine patients undergoing a hysterectomy or cystocele repair. Samples were shock frozen, fixed with formaldehyde or Thiel's solution, or left untreated. Samples were imaged with MPM to quantify the amount of collagen and elastin via second harmonic generation and autofluorescence, respectively. In six patients, sample sections were also histologically stained and imaged with brightfield microscopy. The density of the fibers was quantified using the StereoInvestigator and Cavalieri software., Results: With MPM, collagen and elastin could be visualized to a depth of 100 μm, and no overlap of signals was detected. The different tissue processing protocols used did not result in significantly different fiber counts after MPM. MPM-based fiber quantifications are comparable to those based on conventional histological stains. However, MPM provided superior resolution, particularly of collagen fibers., Conclusions: MPM is a robust, rapid, and label-free method that can be used to quantify the collagen and elastin content in thick specimens of the vagina. It is an excellent tool for future three-dimensional studies of the extracellular matrix in patients with pelvic organ prolapse.

Purpose: A novel customized vaginal brachytherapy mould technique has been developed for clinical use. This image-guided technique provides a brachytherapy applicator solution for irregular vaginal vault configuration and/or a wide vaginal apex relative to the vaginal introitus that would be sub-optimally treated with standard cylinders., Methods: The customized vaginal applicator is generated by the following process: CT images are obtained with contrast-soaked vaginal packing in situ to highlight unique anatomical detail. A 3-dimensional digital model is developed from the images and subsequently converted into a custom applicator with the use of stereolithography, which is an additive manufacturing technique whereby layers 50-100 μm thick of resin are deposited and polymerized using a laser to create intricate 3-dimensional objects. The density of the applicator and the dose delivered using the custom applicator were both measured to ensure accurate dosimetry., Results: The CT-based densities of a clinical vaginal cylinder and the cylinder generated using stereolithography were 1.29 ± 0.06 g/cm(3) vs 1.28 ± 0.01 g/cm(3), respectively. The mean measured dose from a representative stereolithographed applicator normalized to dose measured for a single plastic catheter was 99.8 ± 4.2%. In patient dosimetric results indicate improved coverage of the lateral aspect of vaginal vault with the custom cylinder relative to the standard cylinder; 700 cGy vs 328 cGy, respectively, at a representative lateral vaginal dose point, while simultaneously achieving relatively narrow dose distribution in the anterior/posterior direction., Conclusions: Stereolithographic applicator production was available within a clinically acceptable timeframe, and its clinical feasibility and utility has been demonstrated., (Copyright © 2015 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether the use of vaginal progesterone in twin gestations with a cervical length (CL) of ≤2.5 cm is associated with a reduced risk of preterm delivery., Design: Retrospective cohort study., Setting: Tertiary-care medical centre in New York City., Population: Women with twin gestations undergoing sonographic cervical length screening., Methods: Women with twin gestations with a CL of ≤2.5 cm between 16 and 32 weeks of gestation, and who delivered at our centre between 2010 and 2013, were included. We evaluated the impact of vaginal progesterone on the risk of preterm delivery using a Cox proportional hazard model, adjusted for potential confounding factors. We then performed a propensity score analysis using inverse probability of treatment weights to account for treatment selection bias and confounding., Main Outcome Measure: Delivery prior to 35 weeks of gestation., Results: Of the 167 twin pregnancies analysed, 61 (35.7%) were treated with vaginal progesterone. The hazard ratio (HR) of delivery prior to 35 weeks of gestation in the vaginal progesterone group, compared with the no vaginal progesterone group, was 1.8 (95% confidence interval, 95% CI 1.5-3.1) in the unadjusted analysis, 1.4 (95% CI 0.7-3.2) following multivariable adjustment for confounding factors, and 1.5 (95% CI 1.1-2.3) using propensity score methods., Conclusion: Women with more risk factors for preterm delivery were more likely to be treated with vaginal progesterone. After statistically correcting for this with propensity score methods, we found that vaginal progesterone therapy in twin pregnancies with a CL ≤2.5 cm was associated with an increased risk of preterm delivery., (© 2014 Royal College of Obstetricians and Gynaecologists.)