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Objectives Obstetric anal sphincter injury (OASIS) is a potentially serious complication of vaginal delivery and can lead to both short-term and long-term sequelae. This study sought to identify health care seeking patterns of women who developed pelvic floor symptoms including pelvic pain after OASIS. It also identified demographic and clinical factors associated with seeking subspecialty care from a pelvic floor specialist and demographic and clinical factors associated with seeking care for pelvic pain after OASIS. Methods This study is a retrospective cohort study of 69 women who developed pelvic floor disorders after OASIS. Results For women diagnosed with a pelvic floor symptom, the mean time to follow-up was 2.4 years, the mean number of visits until diagnosis was 2.2 visits, and 2.9 visits were needed for treatment. The most common diagnoses were pelvic pain, lower urinary tract symptoms including incontinence, and defecatory dysfunction. Twenty-five percent of the cohort received treatment from a pelvic floor specialist. These women were more likely to be older and have urinary incontinence. Women with pain were more likely to be seen by a primary care provider and have longer time to diagnosis. Conclusions The study showed that multiple visits were needed to both diagnose and treat pelvic floor disorders (PFD) after OASIS. Pelvic pain was the most common primary PFD after OASIS. There should be a high level of suspicion for pelvic floor disorders, especially pain disorders, in women who have sustained a third- or fourth-degree laceration.

Aims The aim of this study was to compare the expression of urinary nerve growth factor (NGF), brain derived neurotrophic factor (BDNF), substance P (SP), and calcitonin-gene related peptide (CGRP) in women with and without overactive bladder (OAB). We sought to determine factors associated with higher expression of these neuropeptides. Methods Participants with OAB and age-matched controls were enrolled. Symptom severity was assessed with validated questionnaires. Urinary neurotrophin levels, symptom scores, and clinical data were compared between the groups. Multivariate analysis determined independent factors associated with urinary neurotrophin levels. Results Sixty-seven women (38 OAB, 29 controls) were included. Women with OAB and controls were similar in age, race, body mass index, parity, and smoking status. Women with OAB were more likely to report a history of pelvic pain and pelvic surgery. Neurotrophic factor levels normalized to urinary creatinine did not differ between the groups. Increasing age was associated with greater urinary levels of BDNF and NGF (β = 0.23, 95%CI 0.11–0.34 and 0.75, 95%CI 0.17–1.33, respectively, P

OBJECTIVE To evaluate trends in annual rates of vaginal birth, cesarean delivery, and obstetric anal sphincter injury at a single institution before and after the designation of obstetric anal sphincter injury as a measure of obstetric quality and safety. METHODS This was a retrospective cohort study of women undergoing a singleton vaginal delivery and diagnosed with obstetric anal sphincter injury over a 16-year period. International Classification of Diseases, 9th Revision codes for perineal lacerations were used as identifiers. Trends in annual cesarean delivery, perineal laceration, and obstetric anal sphincter injury rates were assessed in a linear regression model. The data were divided into two time periods (1998-2005 and 2006-2013) based on the year (2006) in which obstetric anal sphincter injury was designated as a quality marker and compared. RESULTS A total of 1,366 women had obstetric anal sphincter injury, and 1,360 were included for analysis. There was a 12.1% decline in annual vaginal delivery rates (from 77.1% to 67.8%) and a 40.6% increase in annual cesarean delivery rate (from 22.9% to 32.2%; P

The objective was to report patterns of sling and transvaginal mesh-related complications using the IUGA/ICS classification of prosthesis-related complications. This was a retrospective chart review of all patients who underwent surgical removal of sling, transvaginal mesh, and sacrocolpopexy for mesh-related complications from 2011 to 2013 at three tertiary referral centers. The International Urogynecological Association (IUGA)/International Continence Society (ICS) classification system was utilized. We identified 445 patients with mesh complications, 506 pieces of synthetic mesh were removed, and 587 prostheses-related complications were classified. 3.7 % of patients had viscus organ penetration or vaginal exposure as their presenting chief complaint and 59.7 % were classified as not having any vaginal epithelial separation or category 1. The most common category was spontaneous pain (1Be: 32.5 %) followed by dyspareunia (1Bc: 14.7 %). The sling group was 20 % more likely to have pain compared with the pelvic organ prolapse (POP) mesh group (OR 1.2, 95 % CI 0.8–1.6). The most commonly affected site (S2) was away from the suture line (49 %). Compared with the sling group, the POP group had a higher rate of mesh exposure, which mostly occurred at the suture line area. The majority of patients presented with mesh-related complications more than 1 year post-insertion (T4; average 3.68 ± 2.47 years). Surgeons should be aware that patients with vaginal mesh complications routinely exhibit complications more than 1 year after the implantation with pain as the most common presenting symptom.

Although the surgical restoration of apical support has been shown to decrease reoperation rates, it is unclear whether this has been incorporated into current practice. The aims of this study were to determine the rate of concomitant apical suspensory procedures in women with anterior vaginal wall prolapse undergoing surgical repair in 2011 and to identify associated factors. This cross-sectional study queried the Nationwide Inpatient Sample for women with a primary diagnosis of cystocele who underwent prolapse repair in 2011. The study cohort was analyzed for demographics, concomitant procedures, and hospital characteristics. The rate of apical suspensory procedures was determined. Factors potentially associated with receiving concomitant apical suspensory procedure were evaluated using univariate analysis and multivariate logistic regression. A total of 2,900 women in the database had a primary diagnosis of cystocele and underwent surgical prolapse repair in 2011. 925 (31.9 %) subjects underwent a concomitant apical suspensory procedure. The mean age in the study cohort was 61.9 ± 12.8 years. Hysterectomies were performed in 11.1 % of subjects. 61.1 % were performed vaginally, 26.5 % laparoscopically, and 12.5 % abdominally. On multivariate analysis, age greater than 50 years, Caucasian race, concomitant hysterectomy, and an urban teaching hospital setting were independently associated with receiving concomitant apical suspensory procedure in 2011. Despite evidence that the restoration of apical support is important for optimal anterior support, the overall rate of concomitant apical suspensory procedures is low. Several factors may play a role in whether or not women receive an apical suspensory procedure. This study highlights opportunities to improve the quality of surgical care provided to women with anterior vaginal prolapse.

Introduction and Hypothesis We evaluated the anatomical success and complications of Perigee® with porcine dermis Graft in the repair of anterior vaginal wall prolapse (AVWP) Materials and Methods After Institutional Review Board (IRB) approval, the charts of all patients who underwent AVWP repair using the Perigee/InteXen® kit from July 2005 to July 2009 were reviewed. Patients who had less than 6-month follow-up were excluded. Preoperative data including patient age, previous AVWP repairs, hysterectomy status, preoperative dyspareunia and pertinent physical findings were collected and recorded. Postoperative success was defined as anatomical stage 0 or I using the Pelvic Organ Prolapse Quantification (POP-Q) scoring system. Graft related complications were also recorded. Results Out of 89 patients, 69 completed at least 6-month follow-up. Median follow-up was 13 (6-48) months. Seventeen patients (25%) had previous AVWP repair and 32 (46%) had previous hysterectomy. Preoperatively, AVWP stage II was found in 9 (13%), stage III in 27 (39%) and stage IV in 33 (48%) patients. Anatomic success was found in 48 (69%) patients, with 23 (33%) having stage 0 and 25 (36%) stage I AVWP. Intraoperative complications included incidental cystotomy in one patient and bladder perforation in one. Postoperative complications included vaginal exposure and dyspareunia in one case, wound dehiscence in one and tenderness over the graft arm with dyspareunia in one. conclusions The use of porcine dermis in AVWP repair is safe with minimal graft related complications; however, anatomical success is lower than that reported with the use of synthetic grafts.

1) Evaluate the most common indication for sling removal in patients with synthetic mesh slings; 2) identify the location of pain for each of the three types of synthetic sling procedures including retropubic (RP) sling, transobturator (TOT) sling, and single incision slings (SIS), and 3) describe the surgical approach to each of the above and its associated complications.A retrospective chart review of all patients who underwent surgical removal of a sling due to a mesh-related complications from 2011 to 2013 at three referral centers.There were 337 sling complications followed by the IUGA/ICS mesh complication classification. RP slings were more likely to have urinary tract complications (category 4) and intra-abdominal site complications (S5). Of those, 286 slings were removed, 106 (37.1%) were RP, 131 (45.8%) TOT, and 44 (15.4%) SIS. Vaginal pain was the most common reason for sling removal. Twenty-one percent of the TOT had groin pain which was a five times higher risk than RP (OR 5.3, 95% CI 1.5-18.7), and the RP was three times more likely to have suprapubic pain than the TOT (OR 2.97, 95% CI 1.3-7.0). Fifteen percent of the TOT had either unilateral or bilateral groin mesh removal.The most common indication for sling removal was vaginal pain. RP sling had a higher risk of suprapubic pain and TOT sling had a higher risk of groin pain. Patients with a history of SIS had a higher incidence of urethral erosion. TOT removal had the highest intraoperative complication rate.

Synthetic mesh utilized to treat stress urinary incontinence (SUI) and pelvic organ prolapse (POP) can often result in postoperative complications. The objectives of this study were to determine: 1) the most common indications for mesh removal; 2) the incidences of the removal of specific mesh procedures (such as suburethral sling [SUS], transvaginal mesh [TVM], or sacrocolpopexy); and 3) the idences and types of surgical complications associated with mesh removal.This was a retrospective study. Design Classification: Canadian Task Force II-3.Three tertiary referral centers in the United States.We examined data from all patients at the three centers who underwent surgical removal of synthetic materials from previous SUS, TVM, and sacrocolpopexy procedures for mesh-related complications from 2011 to 2013.Patients underwent vaginal, intra-abdominal, and inguinal mesh revisions by cutting, partial removal, or total removal of the mesh for mesh-related complications.Overall, 445 patients with complications underwent mesh removal laparoscopically, via groin dissection and/or transvaginally. There were a total of 506 mesh products removed. Of these, 56.5% were slings and 43.5% were for pelvic organ prolapse (POP). Synthetic mesh removed from patients included: transvaginal mesh (TVM) anterior for anterior vaginal prolapse, TVM posterior for posterior vaginal prolapse, sacrocolpopexy mesh, and suburethral slings (SUS) for stress urinary incontinence. Synthetic SUS removed included: retropubic (RPS), transobturator (TOT), and single-incision slings (SIS). TOT was the most common type of sling removed. Patients with a sling who only complained of vaginal pain with or without intercourse underwent a vaginal approach for surgical revision/removal of the sling (86.6%). Patients with an RPS with lower abdominal/suprapubic pain and vaginal pain underwent a vaginal and laparoscopic approach for sling removal (18.4%). Patients with a TOT sling who complained of vaginal and groin pain underwent a vaginal and inguinal approach for sling removal (4.3%). In patients who had POP mesh removal, 42.3% had an anterior TVM, 30.6% had a posterior TVM, 14% had both anterior and posterior TVMs, and 13.1% underwent sacrocolpopexy mesh removal. Complications encountered during mesh revision/removal surgery were: two blood transfusions from complete RPS removal (vaginal and laparoscopic approach), three urethral injuries during TOT sling removal (vaginal approach), two ureteral injuries during anterior vaginal wall mesh removal, and two rectal injuries during posterior vaginal wall mesh removal. All injuries were repaired at the time of mesh removal without recurrence.In our study, the most common indication for mesh removal was pain with or without intercourse. The most common mesh procedure resulting in removal was the TOT sling. Use of a vaginal approach only for sling removal had the lowest incidence of intraoperative complications. Laparoscopic RPS removal had the highest incidence of required blood transfusions, anterior TVM had the highest incidence of ureteral injury, and posterior TVM had the highest incidence of rectal injury. Overall, sling, TVM, and sacrocolpopexy mesh removal are safe procedures when performed by experienced surgeons.

OBJECTIVE To evaluate the use and effect of early administration of vaginal estrogen via a continuous low-dose estradiol vaginal ring placed immediately after pelvic reconstructive surgery. METHODS This was a randomized controlled trial of 65 postmenopausal women undergoing vaginal reconstructive surgery. The subjects were randomly assigned to receive an estradiol-releasing vaginal ring, placebo vaginal ring, or control without vaginal ring for 12 weeks immediately after vaginal reconstructive surgery. The primary outcome was tissue quality based on vaginal maturation 3 months postoperatively. Secondary outcome measures were subjective and objective signs of atrophy; vaginal pH; the presence of granulation tissue, microscopic inflammation, and major healing abnormalities; and the ability to tolerate an intravaginal ring. RESULTS At 12 weeks, the estradiol ring group had a significantly improved maturation value (P

This study aims to compare the efficacy of porcine graft-augmented anterior prolapse repair with and without underlying pubocervical fascia plication.Women with symptomatic anterior prolapse who underwent transvaginal repair, using biologic graft via transobturator approach, were retrospectively studied. An initial cohort had the graft placed without fascial plication. A second cohort had graft placement as an overlay to fascial plication.Between March 2005 and September 2008, 65 subjects underwent anterior repair with biologic graft; 35 without fascial plication and 30 as an overlay to plication. At 6 months follow-up, anatomic recurrence (Ba/= -1) was significantly higher in the non-plicated group (18/35, 51%) compared with the plicated group (2/30, 7%) p0.01. Five (5/35, 14%) in the non-plicated group compared with none (0/30) in the plicated group underwent further treatment (p = 0.06).When using a non-crosslinked biologic graft for repair of anterior vaginal prolapse, we recommend the addition of concomitant midline fascial plication to enhance anatomic outcome.

We set out to evaluate anatomical outcomes of recurrent vs. primary prolapse surgery, focusing on anterior colporrhaphy (AC).A retrospective study was performed comparing patients who underwent AC for recurrent cystocele (group I) and a matched control group who underwent primary AC (group II).Thirty-one patients were included in each group. Median follow-up was 22 (5-55) months. Successful anterior vaginal support was obtained in 18/23 (78.2%) patients in group I and 17/21 (81%) patients in group II at 1 year (p = 1.000) and in 9/21 (42.8%) patients in group I and in 15/21 (71.4%) patients in group II at 2-year follow-up (p = 0.031).Recurrent cystocele repair has a higher anatomic failure rate than primary repair at 2-year follow-up. Alternative surgical techniques that provide better long-term durability may be beneficial in repair of recurrent anterior wall prolapse.

The aim of this study was to compare the expression of urinary nerve growth factor (NGF), brain derived neurotrophic factor (BDNF), substance P (SP), and calcitonin-gene related peptide (CGRP) in women with and without overactive bladder (OAB). We sought to determine factors associated with higher expression of these neuropeptides.Participants with OAB and age-matched controls were enrolled. Symptom severity was assessed with validated questionnaires. Urinary neurotrophin levels, symptom scores, and clinical data were compared between the groups. Multivariate analysis determined independent factors associated with urinary neurotrophin levels.Sixty-seven women (38 OAB, 29 controls) were included. Women with OAB and controls were similar in age, race, body mass index, parity, and smoking status. Women with OAB were more likely to report a history of pelvic pain and pelvic surgery. Neurotrophic factor levels normalized to urinary creatinine did not differ between the groups. Increasing age was associated with greater urinary levels of BDNF and NGF (β = 0.23, 95%CI 0.11-0.34 and 0.75, 95%CI 0.17-1.33, respectively, P 0.02). Higher urinary NGF was associated with increasing BMI (β = 0.81, 95%CI 0.05-1.57, P = 0.04) while pain was associated with elevated urinary SP (β = 0.21, 95%CI 0.09-0.33, P = 0.001).Our data does not support a relationship between urinary neurotrophin levels and OAB in age-matched postmenopausal women. Further research is necessary to elucidate the role of urinary neurotrophins in the diagnosis and management of OAB. Neurourol. Urodynam. 36:740-744, 2017. © 2016 Wiley Periodicals, Inc.

OBJECTIVES The primary aim of this study was to compare the proportion of concomitant apical procedures in women undergoing hysterectomy for uterovaginal prolapse in 2001 and 2011. The secondary aim was to identify factors associated with receiving concomitant apical procedures in 2001 and 2011. METHODS The Nationwide Inpatient Sample database was queried for women with a primary diagnosis of uterovaginal prolapse who underwent hysterectomy in 2001 and 2011. The study cohort was analyzed for demographics, clinical factors, and concomitant procedures. Factors potentially associated with receiving concomitant apical procedure were evaluated using univariable analysis and multivariate logistic regression. RESULTS A total of 14,647 women were identified (5867 in 2001 and 8780 in 2011). In 2001, 26.9% women received a concomitant apical procedure, and this proportion increased to 48.2% in 2011 (odds ratio, 2.53; 95% confidence interval, 2.36-2.72; P < 0.0001). In 2001, the mean (SD) age was 53.8 (14.1) years compared with 56.8 (13.3) years in 2011. Although vaginal hysterectomy was most common in both years, a concomitant apical procedure was more likely to be performed with abdominal hysterectomy (P < 0.001). On multivariate analysis, age older than 50 years (P = 0.0001), abdominal route of hysterectomy (P < 0.0001), and undergoing hysterectomy at an academic teaching hospital (P < 0.0001) were independently associated with concomitant apical procedures in both 2001 and 2011. CONCLUSIONS Although the proportion of concomitant apical repair was higher in 2011 compared with 2001, it is still low given the existing data demonstrating the importance of a concomitant apical procedure at the time of hysterectomy for uterovaginal prolapse.

BACKGROUND Bladder calculi are rare in women and are associated with irreducible pelvic organ prolapse. We report a case of irreducible uterine procidentia and bladder calculi that was surgically managed with a complete transvaginal approach. CASE A 76-year-old woman presented with irreducible complete uterine procidentia. Bladder stones were appreciated on examination and confirmed with imaging. The patient was managed surgically with transvaginal cystolithotomy, uterus-sparing Lefort colpocleisis, and perineorrhaphy under spinal anesthesia. The patient had an uncomplicated postoperative course without recurrent prolapse or urinary retention at 3-month follow-up. CONCLUSION The presence of bladder calculi should be considered in the setting of irreducible pelvic organ prolapse. A complete transvaginal approach with cystolithotomy and concomitant obliterative procedure without hysterectomy is a safe and effective alternative to the traditional approach.

Abdominal pseudocyst formation is a rare adult complication associated with ventriculoperitoneal (VP) shunts. Presenting symptoms are primarily abdominal and include distention, pain and anorexia, and secondarily neurological with signs and symptoms of shunt malfunction. We describe a case of VP shunt-related pseudocyst formation presenting as symptomatic pelvic organ prolapse with stage 4 enterocele 4 years after VP shunt placement. The patient's vaginal enterocele enlarged and became more symptomatic as intra-abdominal cyst formation expanded. Symptomatic relief of pelvic floor symptomatology including resolution of exteriorized prolapse was established by conservative measures and eventual VP shunt revision and removal. VP shunt malfunction may present as symptomatic pelvic organ prolapse and may require shunt removal or revision for resolution of symptoms.

The presacral space contains a dense and complex network of nerves that have significant effects on the innervation of the pelvic viscera and support structures. The proximity of this space to the bony promontory of the sacrum has lead to its involvement in an array of corrective surgical procedures for pelvic floor disorders including sacrocolpopexy and rectopexy. Other procedures involving the same space include presacral neurectomy which involves intentional transection of the contained neural plexus to relieve refractory pelvic pain and resection of retrorectal or presacral tumors. Potential complications of these procedures are postoperative constipation and voiding dysfunction.Our aim was to review the current published literature on outcomes following a variety of procedures involving the presacral space and review postoperative bowel and urinary function. We also include an overview of the functional and structural anatomy of the presacral space and its corresponding neural plexi.We conclude that quality data are lacking on the short-term and long-term rates for bowel and bladder dysfunction following surgical procedures involving the presacral space.

BACKGROUND: Synthetic materials are being used increasingly in reconstructive pelvic surgery. Multifilament polypropylene mesh in particular has been associated with healing abnormalities and other postoperative complications. This article describes an atypical infection presenting as a draining sinus tract to the lower extremity after intravaginal slingplasty. CASE: An otherwise healthy 75-year-old-woman presented with recurrent leg cellulitis 18 months after posterior intravaginal slingplasty for vaginal vault prolapse. A 35-cm fistulous tract draining from the pelvis to the lower thigh was identified. The patient underwent surgical debridement and was treated with 12 weeks of intravenous antibiotics with complete healing and no recurrence of symptoms. CONCLUSION: Complications associated with the multifilament mesh used in the intravaginal slingplasty tunneler device include pain, erosion, localized abscess, and genitourinary fistula.

The objective of this study was to evaluate whether a history of previous pelvic surgery is associated with lower urinary tract (LUT) injury at the time of pelvic reconstructive surgery (PRS).A retrospective analysis of patients undergoing pelvic reconstructive surgery from 2006 to 2011 was performed. Patients were divided into two groups: those with previous pelvic surgery and those without previous pelvic surgery. A sample size analysis was performed to determine the number needed to detect at least a 3-fold difference in the rate of LUT injury. Demographic, historical, clinical, intraoperative, and postoperative data were analyzed. Associations between LUT injury and demographics, previous pelvic surgery, or other clinical risk factors were assessed using univariate and multivariate analyses.685 women were included in the analysis: 514 (74.9%) with and 171 (25.1%) without prior pelvic surgery. The overall rate of LUT injury was 6%. Of the injuries, 3.2% were cystotomies, and 1.9% were ureteral obstructions. Previous pelvic surgery did not significantly affect the rate of LUT injury (OR 0.76, 95%CI 0.38-1.54). A diagnosis of prolapse, concurrent hysterectomy, anterior repair, and apical repair were significantly associated with LUT injury. After controlling for age and race, a diagnosis of prolapse remained significantly associated with LUT injury (OR 3.38, 95% CI 1.11-14.75).Prior pelvic surgery does not affect the rate of LUT injury in pelvic reconstructive surgery. The diagnosis of prolapse is a risk factor for LUT injury in women undergoing pelvic reconstructive surgery.

Our goal was to compare outcomes of repeat vs. primary synthetic slings in patients with stress urinary incontinence (SUI) with intrinsic sphincter deficiency (ISD).We reviewed patients who underwent a sling for SUI with ISD from 2003 to 2010. The patients were divided into two groups according to whether they underwent primary or repeat sling. Surgical success was defined as no incontinence and no reintervention (i.e., urethral bulking) during follow-up. Statistical analysis included the unpaired t test, Wilcoxon rank sums test, chi-squared/Fisher's exact tests, and logistic regression to identify risk factors associated with failure.Six hundred and thirty-seven patients with ISD underwent a sling procedure at our institution; 557 (87 %) a primary sling and 80 (13 %) a repeat sling. Patient demographics were similar. Preoperatively, patients with recurrent SUI reported more subjective bother. Mean follow-up was 66.5 weeks (24-374). Success was achieved in 81 % of primary compared with 55 % of repeat slings (p0.0001). Repeat patients were 3.4 times more likely to fail surgery [odds ratio (OR) =3.43, 95 % confidence interval (CI) 2.1-5.6]. Additionally 30 % of the repeat group underwent urethral bulking postoperatively compared with 8.6 % in the primary group (OR=4.4, 95 % CI 2.5-7.7). Prior incontinence procedures, a positive supine stress test, and transobturator sling were independent risk factors for failure. Among the types of slings placed (transobturator, retropubic, tensioned pubovaginal), pubovaginal slings were most successful (OR=2.7, 95 % CI 1.4-5.2).In women with ISD, repeat slings are associated with lower success rates compared with primary slings. Pubovaginal slings resulted in the highest success rate compared with both transobturator and retropubic slings.

Background Rectovaginal fistula is a rare complication of inflammatory bowel disease, obstetric trauma, pelvic surgery, radiation, and trauma. We present a rectovaginal fistula occurring after an excision of a Bartholin gland. Case A healthy 43-year-old woman presented with flatus per vagina immediately after a Bartholin gland excision. She had a history of recurrent Bartholin abscess and had undergone multiple incision and drainage procedures of this cyst over the past 6 years. On rectovaginal examination, the patient was found to have a rectovaginal fistula and subsequently underwent successful transvaginal repair. Conclusion Rectovaginal fistula can occur after excision of a Bartholin gland. This case report illustrates a rare and serious complication to a commonly performed gynecologic procedure.

Study Objective To determine prognostic factors related to successful salpingo-oophorectomy in menopausal women at the time of vaginal hysterectomy. Design Retrospective cohort study (Canadian Task Force Classification II-2). Setting Tertiary care center. Patients A total of 309 postmenopausal ≥60 years old with pelvic floor disorders. Interventions Vaginal hysterectomy with attempted prophylactic salpingo-oophorectomy. Measurements Factors associated with ability to achieve vaginal salpingo-oophorectomy. Main Results 203 (65.7%) achieved successful removal of 1 or both ovaries, and 106 (34.3%) were not amenable to removal. Younger age and shorter cervical length were predictors of salpingo-oophorectomy. Cervical elongation of ≥7 cm, exteriorized cervical/uterine prolapse, and anterior vaginal wall prolapse beyond the hymen were associated with lower likelihood of achieving salpingo-oophorectomy. Conclusions Patient age and cervical length are independent factors that influence the success of accomplishing salpingo-oophorectomy at the time of vaginal hysterectomy.

This study aims to evaluate clinical outcomes of concomitant suburethral sling with LeFort colpocleisis including its effect on postoperative voiding.We performed a retrospective review of all LeFort colpocleisis procedures from our institution. We reviewed demographics, symptoms of stress urinary incontinence, incontinent events/day, pads usage/day, urodynamic parameters, and presence of voiding dysfunction.Two hundred ten patients underwent colpocleisis during the study period. Mean age was 82.2 ± 4.9 and median follow-up was 22 weeks (2-169). Preoperatively, 73 (35%) complained of stress urinary incontinence (SUI) symptoms, and an additional 105 (50%) were diagnosed with occult SUI. One hundred sixty-one (77%) patients underwent concurrent suburethral sling. Overall, sling placement resulted in a 92.5% subjective stress continent rate. Fifty-six patients presented with voiding dysfunction (VD). Postoperatively, VD resolved in 91%. De novo VD occurred in two patients (1.9%) and one (0.6%) required sling revision.Sling placement at time of colpocleisis is associated with high continence rates with minimal risk of postoperative voiding dysfunction.

Introduction: Synthetic mesh utillzed in the treatment of stress urine incontinence (SUI) and pelvic organ prolapse (POP) can often result in patients with postoperative mesh complications. Complications most often cited include: pain, mesh erosion into viscus organs, mesh extrusion into the vaginal epithelium, and infections. Patients are often treated with surgery for mesh and scar revision as well as mesh removal in an attempt to address complications. Patients who have surgery to remove the mesh are subjected to the risk of a new surgery as well as the potential complications of removing the mesh. At our institutions, we have a high volume of patients with mesh related complications who have undergone surgical mesh removal. Objectives: The objective of this study is: 1) to determine the most common indications for mesh removal 2) to determine the most common complications attributed to the surgical mesh and 3) evaluate the incidence of surgical complications associated with the removal of a specific type of mesh sling and POP mesh. Methods: This was a retrospective chart review of all patients who underwent surgical removal of synthetic materials from previous suburethral sling, transvaginal mesh, and sacrocolpopexy for mesh related complications from 2011 to 2013 at three tertiary referral centers in the Southeast United States. We included all women who underwent mesh/sling removal. The database was queried to identify potential subjects. Data was analyzed by using chi-square test for categorical data, and Student’s t-test and Wilcoxon Rank Sum test for continuous data. Results: A total of 445 patients with complications underwent mesh removal either laparoscopically, via groin dissection and/or transvaginally during the study period. There were a total of 506 mesh products removed. The mean patient age was 53.8±11.2 year and parity 2.5±1.2. The majority of patients were caucasian (82.0%), postmenopausal (72.8%), sexually active (52.1%), and and insured (76.4%). 82.9% had previous hysterectomy and 92.6% had previously been seen by a different physician(s). 28% had previous surgery for sling/mesh revision or removal. Of the 445 patients, 373 (83.3%) had a synthetic midurethral sling for SUI, 178 (40%) had transvaginal mesh and 38 (8.5%) had a sacral colpopexy (SC) inserted for treatment of POP. These slings can be categorized into retropubic slings (RP), transobturator (TOT) slings and single incision slings (SIS). The transvaginal mesh (TVM) are categorized into anterior vaginal wall mesh and posterior vaginal wall mesh. The most common indications for sling and mesh revision/removal were pain, dyspareunia, pressure symptoms, erosion/extrusion, and vaginal discharge. Of the 506 mesh products removed, 56.5% were slings (RP 20.9%, TOT 22.3%, and SIS 15.4%) and 43.5% were mesh for POP (TVM 37.4% and SC 5.7%). Among the 3 types of synthetic slings, TOT was the most common type of sling removed. TOT group was 60% more likely to have pain than RP (OR 1.6, 95% CI 0.9-2.7). Patients with sling who complained of vaginal pain with or without intercourse were subjected only to a vaginal approach to surgical removal of the sling (86.6%). Patients with lower abdominal /suprapubic pain and vaginal pain that had a RP underwent a vaginal and laparoscopic approach to sling removal (18.4%). Patients who complained of vaginal and groin pain that had a TOT sling underwent a vaginal and inguinal approach to sling removal (4.3%). For patients requiring vaginal wall mesh removal, 42.3% of the patients had mesh removal from the anterior vaginal wall only, 30.6% posterior vaginal wall only and 14.0% both anterior and posterior 2/3/2014 Oasis, The Online Abstract Submission System http://www.abstractsonline.com/submit/SubmitPrinterFriendlyVersion.asp?ControlKey=%7BA9E8EBCB%2D76D6%2D4249%2DAC80%2D24A161440D01%7D... 2/3 INTERNATIONAL UROGYNECOLOGICAL ASSOCIATION 2030 M Street NW, Suite 701 Washington, DC 20036 33301 USA Email: office@iuga.org Web Site: www.augs-iuga2014.org Phone: +1-202-733-3234

The objective of this study was to compare the results of the Pelvic Organ Prolapse Quantification (POP-Q) examination by visual estimation to measurement.Women with pelvic organ prolapse underwent both "eyeball"/estimated and measured POP-Q examinations by two trained examiners in a randomized order. POP-Q points and stage were analyzed using the paired t test, chi-square, Pearson's correlation, and kappa statistics.Fifty subjects had a mean age of 60, mean BMI 27.8, and median parity of 2. The POP-Q stages by the measured technique were 18% (9/50) stage 1, 38% (19/50) stage 2, 44% (22/50) stage 3, and 0% (0/50) stage 4. The POP-Q stages based on estimation and measurement were highly associated (p0.05). Individual points did not differ significantly between the techniques and did not differ significantly between examiners (all p0.05).Among examiners who routinely perform POP-Q examinations, there is no significant difference between "eyeball"/estimated and measured POP-Q values and stage.

This study aimed to validate a symptom questionnaire to assess presence and patient bother as related to common pelvic floor disorders. The validation of the Pelvic Floor Bother Questionnaire (PFBQ) included evaluation of internal reliability, test-retest reliability, and validity of the items. A total of 141 patients with mean age of 61.8 ± 13.2 were included in the study. Twenty-four percent of patients complained of stress urinary incontinence, 14.9% mixed incontinence, 14.9% urge incontinence, 10% fecal incontinence, 5.7% obstructed defecation, 28.4% pelvic organ prolapse, and 2.1% dyspareunia. The PFBQ demonstrated good reliability (α = 0.61-0.74; ICC = 0.94). There was a strong agreement beyond chance observed for each question (k = 0.77-0.91). PFBQ correlated with stage of prolapse (ρ = 0.73, p

Case notes A healthy 68-year-old woman who had had 3 viable offspring and who had undergone hysterectomy had a 3-year history of mild vaginal prolapse. The condition was not bothersome. Afterbeingdiagnosedwithtemporalarteritis,herrheumatologist began treating her with oral prednisone, 100 mg daily. Within 1monthofcorticosteroidinitiation,sheexperiencedcomplete vaginal-vault eversion. The vaginal wall quickly became ulcerated, and she was unable to ambulate because of terrible pain thatwasrelatedtothemassiveprolapse.Twomonthslater,she was severely debilitated and confined to a scooter. During this time period, she also experienced steroid-induced diabetes mellitus and osteopenia. On examination, total eversion of the vaginal vault was noted.Deepulcerationscoveredapproximately60%ofthevagina and were more prominent along the dependent portions of the prolapse (Figures 1 and 2). The genital hiatus measured 3.9 in (10 cm); the vaginal length measured 4.3 in (11 cm). Placement of a size-8 Gellhorn pessary (3.5) failed. Subsequently, the patient was instructed to coat the vagina with estrogen cream and cover the medication with an occlusive dressing (plastic wrap) each night. Because the ulcerations were not infected, no oral or topical antibiotics were prescribed. Conclusions Support of the pelvic floor is maintained by connective tissue, ligaments, and muscles. 1 These supportive structures (ie, the endopelvicfasciaandcardinal-uterosacralligaments)arecomposed of varying compositions of collagen, elastin, smooth muscle, fibroblasts, and vascular structures. 2 Collagen and elastin help provide both strength and flexibility to the pelvic