Search

The failure of the levator hiatus (LH) and urogenital hiatus (UGH) to remain closed is not only associated with pelvic floor disorders, but also contributes to recurrence after surgical repair. Pregnancy and vaginal birth are key events affecting this closure. An understanding of normal and failed hiatal closure is necessary to understand, manage, and prevent pelvic floor disorders.This narrative review was conducted by applying the keywords "levator hiatus" OR "genital hiatus" OR "urogenital hiatus" in PubMed. Articles that reported hiatal size related to pelvic floor disorders and pregnancy were chosen. Weighted averages for hiatal size were calculated for each clinical situation.Women with prolapse have a 22% and 30% larger LH area measured by ultrasound at rest and during Valsalva than parous women with normal support. Women with persistently enlarged UGH have 2-3 times higher postoperative failure rates after surgery for prolapse. During pregnancy, the LH area at Valsalva increases by 29% from the first to the third trimester in preparation for childbirth. The enlarged postpartum hiatus recovers over time, but does not return to nulliparous size after vaginal birth. Levator muscle injury during vaginal birth, especially forceps-assisted, is associated with increases in hiatal size; however, it only explains a portion of hiatus variation-the rest can be explained by pelvic muscle function and possibly injury to other level III structures.Failed hiatal closure is strongly related to pelvic floor disorders. Vaginal birth and levator injury are primary factors affecting this important mechanism.

Introduction and hypothesis Pelvic organ prolapse quantification by means of upright magnetic resonance imaging (MRI) is a promising research field. This study determines the angle for the pelvic inclination correction system (PICS) for upright patient position, which is hypothesized to deviate from the supine PICS angle. The necessity of different PICS angles for various patient positions will also be discussed. Methods Magnetic resonance scans of 113 women, acquired in an upright patient position, were used to determine the upright PICS angle, defined as the angle between the sacrococcygeal–inferior pubic point (SCIPP) line and the horizontal line. The difference and correlation between the upright and supine PICS angles were calculated using the paired Student’s t-test and the Pearson’s correlation coefficient (r) respectively. The effect of the difference between the upright and supine PICS angle on the measured pelvic organ extent was calculated using goniometry. Results The mean (interquartile range) PICS angles were 29° (26–35°) for the upright and 33° (30–37°) for the supine patient position. They were significantly different (pr = 0.914, p Conclusions The PICS angle for the upright patient position is 29°. The use of a dedicated PICS angle for different patient positions allows for more accurate pelvic organ extent analysis in patients with prolapse.

We aimed to develop a deep learning-based multi-label classification model to simultaneously diagnose three types of pelvic organ prolapse using stress magnetic resonance imaging (MRI).Our dataset consisted of 213 midsagittal labeled MR images at maximum Valsalva. For each MR image, the two endpoints of the sacrococcygeal inferior-pubic point line were auto-localized. Based on this line, a region of interest was automatically selected as input to a modified deep learning model, ResNet-50, for diagnosis. An unlabeled MRI dataset, a public dataset, and a synthetic dataset were used along with the labeled image dataset to train the model through a novel training strategy. We conducted a fivefold cross-validation and evaluated the classification results using precision, recall, F1 score, and area under the curve (AUC).The average precision, recall, F1 score, and AUC of our proposed multi-label classification model for the three types of prolapse were 0.84, 0.72, 0.77, and 0.91 respectively, which were improved from 0.64, 0.53, 0.57, and 0.83 from the original ResNet-50. Classification took 0.18 s to diagnose one patient.The proposed deep learning-based model were demonstrated feasible and fast in simultaneously diagnosing three types of prolapse based on pelvic floor stress MRI, which could facilitate computer-aided prolapse diagnosis and treatment planning.

Dissection reveals elegant simplicity in pelvic floor structure. So, why are so many of us confused about the pelvic floor? The pelvic floor is in an invisible region between what we see from above and below, so our experience does not help. It is confusing because there is conflict between existing illustrations, so we do not know which are false and which are true. To resolve conflicts in pelvic anatomy we must: recognize the Vesalian principle that truth lies in the body, not necessarily in books; commit to focusing on structures rather than words; and overcome "theory-induced blindness," the psychological principle that discounts what is seen when it contradicts a theory we believe. We should revive century-old standards that require accuracy in anatomical illustration analogous to the p value in statistics. Committing to anatomical accuracy will ensure that we no longer navigate in surgery and research using a flawed map.

We present a methodology for subtyping of persons with a common clinical symptom complex by integrating heterogeneous continuous and categorical data. We illustrate it by clustering women with lower urinary tract symptoms (LUTS), who represent a heterogeneous cohort with overlapping symptoms and multifactorial etiology. Data collected in the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN), a multi-center observational study, included self-reported urinary and non-urinary symptoms, bladder diaries, and physical examination data for 545 women. Heterogeneity in these multidimensional data required thorough and non-trivial preprocessing, including scaling by controls and weighting to mitigate data redundancy, while the various data types (continuous and categorical) required novel methodology using a weighted Tanimoto indices approach. Data domains only available on a subset of the cohort were integrated using a semi-supervised clustering approach. Novel contrast criterion for determination of the optimal number of clusters in consensus clustering was introduced and compared with existing criteria. Distinctiveness of the clusters was confirmed by using multiple criteria for cluster quality, and by testing for significantly different variables in pairwise comparisons of the clusters. Cluster dynamics were explored by analyzing longitudinal data at 3- and 12-month follow-up. Five clusters of women with LUTS were identified using the developed methodology. None of the clusters could be characterized by a single symptom, but rather by a distinct combination of symptoms with various levels of severity. Targeted proteomics of serum samples demonstrated that differentially abundant proteins and affected pathways are different across the clusters. The clinical relevance of the identified clusters is discussed and compared with the current conventional approaches to the evaluation of LUTS patients. The rationale and thought process are described for the selection of procedures for data preprocessing, clustering, and cluster evaluation. Suggestions are provided for minimum reporting requirements in publications utilizing clustering methodology with multiple heterogeneous data domains.

Test the hypotheses that (1) cardinal ligament (CL) straightening and lengthening occur with parity and prolapse, (2) CL straightening occurs before lengthening, and (3) CL length is correlated with level III measures.We performed a secondary analysis of MRIs from women in three groups: (1) nulliparous with normal support, (2) parous with normal support, and (3) uterine prolapse (POP-Q point C - 4 and Ba1 cm). The 3D stress MRI images at rest and maximal Valsalva were analyzed. CLs were traced from their origin to cervico-vaginal insertions. Curvature ratio was calculated as curved length/straight length. Level III measures included urogenital hiatus (UGH), levator hiatus (LH), and levator bowl volume (LBV), and their correlations with CL length were calculated.Ten women were included in each group. Compared to the nulliparous group, CL length was 18% longer in parous controls (p = .04) and 59% longer with prolapse (p .01) at rest, while at Valsalva, CL length was 10% longer in parous controls (p = .21) and 49% longer with prolapse (p .01). Curvature ratios showed 18% more straightening in women with prolapse compared to parous controls (p .01). Curved CL length and level III measures were moderately to strongly correlated: UGH (rest: R = 0.68, p .01; Valsalva: R =0.80, p .01), LH (rest: R = 0.60, p .01; Valsalva: R = 0.78, p .01), and LBV (rest: R = 0.71, p .01; Valsalva: R =0.89, p .01).Our findings suggest that the CLs undergo three times as much lengthening with prolapse as with parity; however, straightening only occurs with prolapse. Strong correlations exist between level I and level III support.

INTRODUCTION AND HYPOTHESIS: Intraabdominal pressure acts on the pelvic floor through an aperture surrounded by bony and muscular structures of the pelvis. A small pilot study showed the area of the anterior portion of this plane is larger in pelvic organ prolapse. We hypothesize that there is a relationship between prolapse and anterior (APA) and posterior (PPA) pelvic cross-sectional area in a larger, more diverse population. STUDY DESIGN: MRIs from 30 prolapse subjects and 66 controls were analyzed in this case-control study. The measurement plane was tilted to approximate the level of the levator ani attachments. Three evaluators made measurements. Patient demographic characteristics were compared using Wilcoxon Rank-Sum and Fisher’s exact tests. A multivariable logistic regression model identified factors independently associated with prolapse. RESULTS: Controls were 3.7 years younger and had lower parity, but groups were similar in terms of race, height, and BMI. Cases had a larger APA (p

The Latzko transvaginal vesicovaginal fistula repair is a highly effective treatment for even complex fistulae. Our video demonstrates the Latzko repair technique and its application in a variety of circumstances that include fistula management concurrent with treatment of uterovaginal prolapse, after complex urologic surgery, and in the postpartum setting after urologic injury. The technique of the procedure varies only slightly in these diverse conditions. The basic steps begin with hydro-dissecting the epithelium from the underlying fascia surrounding the fistula tract, followed by denuding the epithelium within a circumscribing incision around the fistula. The fistula is then closed with a purse-string suture placed just outside the epithelialized tract. Next, several layers of imbricating sutures are placed to close the defect. Finally, the vaginal epithelium is closed.

Stress urinary incontinence is a symptom that arises from damage to the muscles, nerves, and connective tissue of the pelvic floor. Urethral support, vesical neck function, and function of the urethral muscles are important determinants of continence. The urethra is supported by the action of the levator ani muscles through their connection to the endopelvic fascia of the anterior vaginal wall. Damage to the connection between this fascia and muscle, loss of nerve supply to the muscle, or direct muscle damage can influence continence. In addition, loss of normal vesical neck closure can result in incontinence despite normal urethral support. Although the traditional attitude has been to ignore the urethra as a factor contributing to continence, it does play a role in determining stress continence since in 50% of continent women, urine enters the urethra during increases in abdominal pressure, where it is stopped before it can escape from the external meatus. Perhaps one of the most interesting yet least acknowledged aspects of continence control concerns the coordination of this system. The muscles of the urethra and levator ani contract during a cough to assist continence, and little is known about the control of this phenomenon. That operations cure stress incontinence without altering nerve or muscle function should not be misinterpreted as indicating that these factors are unimportant.

One postulated cause of post-prostatectomy incontinence is urethral and bladder neck hypermobility. The objective of this study was to determine the magnitude of anatomical differences of urethral and bladder neck position at rest and with valsalva in continent and incontinent men post-prostatectomy based on dynamic MRI.All subjects underwent a dynamic MRI protocol with valsalva and non-valsalva images and a standard urodynamic evaluation. MRI measurements were taken at rest and with valsalva, including (1) bladder neck to sacrococcygeal inferior pubic point line (SCIPP), (2) urethra to pubis, and (3) bulbar urethra to SCIPP. Data were analyzed in SAS using two-tailed t tests.A total of 21 subjects (13 incontinent and 8 continent) had complete data and were included in the final analysis. The two groups had similar demographic characteristics. On MRI, there were no statistically significant differences in anatomic position of the bladder neck or urethra either at rest or with valsalva. The amount of hypermobility ranged from 0.8 to 2 mm in all measures. There were also no differences in the amount of hypermobility (position at rest minus position at valsalva) between groups.We found no statistically significant differences in bladder neck and urethral position or mobility on dynamic MRI evaluation between continent and incontinent men status post-radical prostatectomy. A more complex mechanism for post-prostatectomy incontinence needs to be modeled in order to better understand the continence mechanism in this select group of men.

Over a period of 30 months, 200 patients were seen in the combined gynecology/urology clinic of the University of Michigan Medical Center. Nintey-nine patients (49.5%) were referred by urologists and 86 (43%) by gynecologists. The mean number of visits by patients to the clinic was 1.7, with a range of 1–3; 78 patients (39%) visited the clinic on just one occasion; 116 patients (58%) had undergone previous gynecologic and/or urologic surgery. At least one diagnosis was confirmed in 183 patients (91.5%). A total of 151 operations were performed, 43 (28.5%) by gynecologists and urologists working together.

Functional tests have demonstrated minimal loss of vaginal closure force with age. So we tested the null hypotheses that age neither affects the maximum cross-sectional area (CSA) nor the volume of the levator muscle. Corresponding hypotheses were also tested in the adjacent obturator internus muscle, which served as a control for the effect of age on appendicular muscle in these women.Magnetic resonance images of 15 healthy younger (aged 21-25 years) and 12 healthy older nulliparous women (aged63 years) were selected to avoid the confounding effect of childbirth. Models were created from tracing outlines of the levator ani muscle in the coronal plane, and obturator internus in the axial plane using 3D Slicer v. 3.4. Muscle volumes were calculated using Slicer, while CSA was measured using Imageware™ at nine locations. The hypotheses were tested using repeated measures analysis of variance with P 0.05 being considered significant.The effect of age did not reach statistical significance for the decrease in levator ani muscle maximum CSA or the decrease in volume (4.3%, P = 0.62 and 10.9%, 0.12, respectively). However, age did significantly adversely decrease obturator internus muscle maximum CSA and volume (24.5% and 28.2%, P 0.001, respectively). Significant local age-related changes were observed dorsally in both muscles.Unlike the adjacent appendicular muscle, obturator internus, the levator ani muscle in healthy nullipara does not show evidence of significant age-related atrophy.

L. L. Wall 1 and J. O. L. DeLancey 2 1Section of Gynecology, The Emory Clinic, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA; 2Division of Gynecology, Department of Obstetrics and Gynecology, University of Michigan Medical Center, Ann Arbor, MI, USA 'And this, he said, is the reason why the cure of many diseases is unknown to the physicians of Hellas, because they disregard the whole, which ought to be studied also; for the part can never be well unless the whole is well.' Socrates, in Plato's Charmides [1] Pelvic floor dysfunction, particularly as manifested by genital prolapse and urinary or fecal incontinence, remains one the the largest unaddressed issues in women's health care today. These problems result in substantial social embarrassment, emotional distress and physical discomfort, and are the cause of tens of thousands of surgical operations each year. However, many women with these afflictions continue to bear them stoically in resigned silence, regarding them as normal and inevitable parts of aging - which they are not. The economic costs of these problems are also immense and similarly unappreciated. At at consensus development conference held in October 1988, for example, the National Institutes of Health estimated the total direct and indirect costs of managing adult urinary incontinence alone at $10.3 billion per year- far more than the current costs of the AIDS epidemic [2]. While the public at large has remained oblivious to these facts, the paper products industry has launched a multi- million-dollar campaign to promote the sales of a vast array of absorbent pads, panty-liners, and undergar- ments in hope of opening up this gigantic source of *This paper has been reproduced from Perspectives in Biology and Medicine 1991 ;34(4):486-96 with kind permission of the University of Chicago. ( 9 1991 the University of Chicago. All rights reserved). Correspondence and offprint requests to: Dr L. Lewis Wall, Section of Gynecology, The Emory Clinic, 1365 Clifton Road NE, Atlanta, GA 30322, USA. potential profits. Despite the enormity of these problems and our longstanding clinical experience in treating them, however, prolapse recurring after an attempt at surgical repair remains a significant clinical problem, and the approach to uterine prolapse by gynecologic surgeons appears to have changed little in 60 years. Why? What has led to such an impasse? Why has our thinking about these problems remained so narrow and so unfruitful? We propose that this is largely due to the compartmentalization of the pelvic floor into unnatural spheres of influence by competing medical specialities, with resultant neglect of the interrelationships among the pelvic organ systems. Over the past 2000 years western medicine has dramatically narrowed its focus and changed its pre- occupations. Greek medicine, which dominated medical thought in many ways until the 17th and 18th centuries, viewed illness largely as a disruption of generalized bodily processes, an imbalance among four humors whose interrelationships constituted the foun- dations of human pathology. The rise of empiric and experimental science gradually replaced this conception of illness with one which saw it as arising from specific disease processes in a local group of tissues or organs. This reorganization of medicine around the 'anatomic idea' led to the development of specialties dealing with disorders of specific organ systems: ophthalmology, cardiology, gastroenterology, urology, gynecology etc. [3-5]. In the 20th century this process has been hastened by the development of techniques which permit specia- lized examination of discrete organ systems - and which also allow large professional fees to be collected by the specialists capable of performing these procedures [6]. This financial factor has created a 'territorial impera

The association of dysfunctional bowel elimination with lower urinary tract symptoms is well known in children, but not in adults. It was our objective to assess lower urinary tract symptoms (LUTS) in women who report difficult defecation (DD).This is a secondary analysis of 2,812 women, aged 35-64, who participated in a telephone interview. All subjects were asked "When you move your bowels, does the stool come out easily?" DD was considered present in those answering "no." All subjects were queried regarding LUTS, urinary infections in the past year, self-perceived health status, medical history, and demographics. Symptoms of stress incontinence (five items), urge incontinence (five items), and the impact of these symptoms on their quality of life were solicited from subjects reporting more than 12 episodes of incontinence in 1 year.DD was reported by 10.4% (290/2,790) of women. Women with DD had higher LUTS than those who did not: nocturia (mean 1.8 ± 0.1 vs. 1.3 ± 0.0), urgency (47.6% vs. 29.2%), increased daytime frequency (mean 8.2 ± 0.3 vs. 7.2 ± 0.1), dysuria (22.9% vs. 13.7%), and a sensation of incomplete bladder emptying (55.6% vs. 28.2%). DD women were more often menopausal, reported a fair or poor self-reported health status, and had a higher number of comorbidities, less formal education, and lower annual household income.Women with symptoms of DD have an increased rate of LUTS, consistent with the diagnosis of overactive bladder without incontinence. The pathophysiology underlying this association is worthy of future research.

The origin of the pubovisceral muscle (PVM) from the pubic bone is known to be at elevated risk for injury during difficult vaginal births. We examined the anatomy and histology of its enthesial origin to classify its type and see if it differs from appendicular entheses.Parasagittal sections of the pubic bone, PVM enthesis, myotendinous junction, and muscle proper were harvested from five female cadavers (51-98 years). Histological sections were prepared with hematoxylin and eosin, Masson's trichrome, and Verhoeff-Van Gieson stains. The type of enthesis was identified according to a published enthesial classification scheme. Quantitative imaging analysis was performed in sampling bands 2 mm apart along the enthesis to determine its cross-sectional area and composition.The PVM enthesis can be classified as a fibrous enthesis. The PVM muscle fibers terminated in collagenous fibers that insert tangentially onto the periosteum of the pubic bone for the most part. Sharpey's fibers were not observed. In a longitudinal cross-section, the area of the connective tissue and muscle becomes equal approximately 8 mm from the pubic bone.The PVM originates bilaterally from the pubic bone via fibrous entheses whose collagen fibers arise tangentially from the periosteum of the pubic bone.

We frequently associate pelvic floor injury with parity, ageing, hysterectomy, and chronic straining. Exactly what structures are injured remains the focus of intense research. Therefore, basic understanding of pelvic floor anatomy is essential to effective communication between pelvic floor specialists. The goal of the current chapter is to lay a firm anatomic foundation for interpreting different imaging modalities by emphasizing pelvic floor innervations, morphology of the levator ani muscle by origin-insertion pairs, and fascial and muscular support of the anterior and posterior compartments.

There is a surprising lack of prospective data on genital and pelvic prolapse and the relation of these conditions to incontinence. Several abnormalities may be important: uterine prolapse, rectoceles, enteroceles, total vaginal eversion, and cystoceles. The authors describe their experience in 65 cases of various etiologies.

Stress continence depends upon three factors: proximal urethral support, vesical neck closure, and urethral contractility. The position of the vesical neck is not static but mobile and under voluntary control. Its support depends upon connections of the urethrovaginal endopelvic fascia to the medial aspect of the levator ani. In addition, these fasciae are attached to the arcus tendineus fasciae pelvis which supports the urethra during levator relaxation, and probably during stress. Levator contraction supports the proximal urethra and also pulls the vesical neck anteriorly against a band of endopelvic fascia which is suspended between the arcus tendinei, compressing it closed. Relaxation of the muscles allows the vesical neck to descend, and facilitates its opening. The connective tissue and smooth muscle of the trigonal ring encircles the vesical neck's lumen, and may contribute to closure of this area. The striated urogenital sphincter muscle can contract to assist in maintaining continence in continent women whose vesical neck is not competent. It has a circular sphincteric portion from 20 to 60% of urethral length. From 60 to 80% it has a considerable bulk of muscle which forms an arch at the perineal membrane that would compress the urethra from above.

Stress continence depends upon three factors: proximal urethral support, vesical neck closure, and urethral contractility. The position of the vesical neck is not static but mobile and under voluntary control. Its support depends upon connections of the urethrovaginal endopelvic fascia to the medial aspect of the levator ani. In addition, these fasciae are attached to the arcus tendineus fasciae pelvis which supports the urethra during levator relaxation, and probably during stress. Levator contraction supports the proximal urethra and also pulls the vesical neck anteriorly against a band of endopelvic fascia which is suspended between the arcus tendinei, compressing it closed. Relaxation of the muscles allows the vesical neck to descend, and facilitates its opening. The connective tissue and smooth muscle of the trigonal ring encircles the vesical neck's lumen, and may contribute to closure of this area. The striated urogenital sphincter muscle can contract to assist in maintaining continence in continent women whose vesical neck is not competent. It has a circular sphincteric portion from 20 to 60% of urethral length. From 60 to 80% it has a considerable bulk of muscle which forms an arch at the perineal membrane that would compress the urethra from above.

We examine racial differences in urinary incontinence prevalence, frequency, quantity, type, and risk factors in a population based sample of community dwelling black and white women.Women 35 to 64 years old were sampled from telephone records from 3 southeast Michigan counties. Women self-identifying as black or white race completed a telephone interview that assessed demographics, health history, lifestyle factors and urinary incontinence experience. Statistical analysis included descriptive statistics, factor analysis and multivariable logistic regression to determine adjusted odds of urinary incontinence. Estimates were weighted to reflect probability and nonresponse characteristics of the sample, and to increase generalizability of the findings.Interviews were completed by 1,922 black and 892 white women (response rate = 69%). The overall prevalence of urinary incontinence was 26.5%. By race, urinary incontinence prevalence was 14.6% for black women and 33.1% for white women (p0.001). Among incontinent women there was no difference by race in the frequency of urinary incontinence. However, black women reported more urine loss per episode (p0.05). A larger proportion of white women with incontinence (39.2%) reported symptoms of pure stress incontinence compared to black women (25.0%), whereas a larger proportion of black women (23.8%) reported symptoms of pure urge incontinence compared to white women (11.0%). Risk factors for urinary incontinence were generally similar for white and black women.In this population based study we observed racial differences in prevalence, quantity and type of urinary incontinence. Frequency of and risk factors for urinary incontinence were generally similar for white and black women.

To analyze the quantity and distribution of intramuscular nerves within the striated urogenital sphincter and test the hypothesis that decreased nerve density is associated with decreased striated sphincter muscle and cadaver age.Thirteen cadaveric urethras (mean age 47 years, range 15-78 years) were selected for study. A sagittal histologic section was stained with S100 stain to identify intramuscular nerves. The number of times that a nerve was seen within the striated urogenital sphincter (nerve number) was counted. The number of axons within each nerve fascicle was also counted. Regression analysis of nerve density against muscle cell number and age was performed.Remarkable variation was found in the quantity of intramuscular nerves in the striated urogenital sphincter of the 13 urethras studied. The number of nerves ranged from 72 to 543, a sevenfold variation (mean 247.1 +/- standard deviation 123.2), and the range of number of axons was 431 to 3523 (2201 +/- 1152.6). The larger nerve fascicles were seen predominantly in the distal (13.1 +/- 5.7 axons per nerve) compared with the proximal part of the striated urogenital sphincter (1.2 +/- 2). Reduced nerve density throughout the striated urogenital sphincter correlated with fewer muscle cells (P =.02). Nerve density also decreased with advancing age (P =.004).Remarkable variation in the quantity of intramuscular nerves was found. Women with sparse intramuscular nerves had fewer striated muscle cells. Intramuscular nerve density declined with age.

OBJECTIVES: To test the hypothesis that selected older women with mild-to-moderate stress urinary incontinence (SUI) can learn to demonstrate significantly reduced urine loss in 1 week by intentionally contracting the pelvic floor muscles before and during a cough (a skill we have termed “The Knack”). DESIGN: A prospective, randomized, single-blind interventional study. SETTING: The Older American Independence Center, a federally sponsored research program affiliated with the University of Michigan in Ann Arbor, Michigan. PARTICIPANTS: Twenty-seven women with a mean (SD) age of 68.0 (5.5) years, self-reported SUI, and demonstrable urine loss during a deep cough. INTERVENTION: Women were randomized to an immediate intervention group (Group I: n = 13) who were taught the Knack after their first clinic visit, or a wait-listed control group (Group II: n = 14) who were taught the Knack after 1 month. MEASUREMENTS: At 1 week after instruction, we tested the efficacy of the Knack in a standing stress test by (1) comparing the volumes of cough-related urine loss leaked by all subjects, with and without use of the Knack, and (2) comparing the volumes of cough-related urine loss leaked by Group I, using the Knack, with Group II, which had not yet been taught the Knack. RESULTS: Intra-individual results showed that at 1-week follow-up, the Knack was used to reduce urine loss resulting from a medium cough by an average of 98.2%, compared with that of a similar cough performed 1 minute before without the Knack (P =.009); likewise urine loss was reduced by an average of 73.3% (P =.003) in a deep cough. Reduction in urine loss was not significantly correlated with a digital measure of pelvic floor muscle strength. CONCLUSION: Within 1 week, selected older women with mild-to-moderate SUI can acquire the skill of using a properly-timed pelvic floor muscle contraction to significantly reduce urine leakage during a cough.

We studied prospectively 62 women with cystoceles by video-urodynamics before and after operative repair. Of 29 women with grades 1 and 2 cystoceles 8 had residual urine, 14 had urge incontinence and 24 had symptoms of stress urinary incontinence. Of these women 23 had urodynamic evidence of stress incontinence, as did 3 of 5 without stress incontinence symptoms. Of 33 women with large cystoceles 22 had symptoms of stress urinary incontinence but 10 more had urodynamic evidence of stress urinary incontinence. Of these 33 women 18 had significant residual urine and 24 had urge incontinence. Operative repair resolved stress incontinence in 51 of 54 women, urge incontinence in 33 of 38 and residual urine in 24 of 26. Cystoceles recurred in 3 patients, and enteroceles developed in 3 and recurred in 2. These findings indicate that cystoceles may cause voiding dysfunction and lack of symptoms of stress incontinence is unreliable in patients with cystoceles. In addition, cystoceles are associated with other symptoms, most of which actually resolve after operative repair.

Background Vulvar vestibulitis and interstitial cystitis are enigmatic and controversial conditions. They are increasingly recognized as important causes of genitourinary pain in young women. This report proposes an etiologic association between the two conditions. Cases We report three patients with both vulvar vestibulitis and interstitial cystitis. Although an association between these conditions has previously been proposed, these are the first case reports of the coexistence of these conditions in the same patient. Conclusion Because both the vestibule of the vulva and the bladder are derived from the urogenital sinus, we propose that the coexistence of vulvar vestibulitis and interstitial cystitis in some patients represents a generalized disorder of urogenital sinus-derived epithelium.