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The presacral space lies in the true pelvis anterior to the sacrum. Within the presacral space lies the anterior longitudinal ligament (ALL), which covers a portion of the anterior sacrum. Fixation to the ALL of the pelvic floor and reproductive tract in women has been performed for several decades as a treatment of pelvic organ prolapse (POP) (Fig. 18.1) [1]. The specific area of interest for the pelvic reconstructive surgeon lies caudal to the bifurcation of the great vessels and medial to the right ureter and sigmoid colon.

Objective This study aimed to establish descriptive data on the content, accuracy, and relevance of Internet-based information regarding pelvic organ prolapse and urinary incontinence. Methods Using the search terms, urinary incontinence, uterine prolapse, dropped uterus, cystocele, and dropped bladder, the first 20 Web sites that appeared in each of 3 highly used search engines were identified. Two experienced reviewers independently evaluated each site for specific content, relevance, and accuracy. Results A total of 220 individual sites were identified: government-, university-, and/or society-sponsored sites represented 14.1% of the identified sites. Private parties, community groups, or unknown sponsors represented 73.2% of the sites. Industry represented 12.7% of the sites. The year the site was created was displayed in 45.9% of the sites, although 66.4% of the sites contained a year of update. Overall, 45% of the sites were rated as mostly/completely relevant to the search term and 44% of the sites were rated as mostly/completely accurate. Government-, university-, and/or society-sponsored sites were significantly more likely to be rated mostly/completely relevant and mostly/completely accurate compared with all other site sponsors with P = 0.05 and P = 0.0003, respectively. Conclusions Government, university, and/or medical societies sponsor a minority of Web sites compared with other sponsors but provide more comprehensive content that is more relevant and accurate to the topics of pelvic organ prolapse and urinary incontinence.

We present the case of a 41-year-old woman who presented with gross hematuria, urinary urgency and frequency, and intermittent abdominal pain after vaginal hysterectomy 2 years prior. The presence of an adnexal mass was suspected by pelvic examination and confirmed by transvaginal pelvic ultrasonography. Cystoscopy with biopsy was consistent with an inflammatory bladder polyp, which was initially discovered by pelvic ultrasonography and noted to be contiguous with the adnexal mass. The patient underwent exploratory laparotomy, lysis of adhesions, left salpingoophorectomy, and transvesical resection of the bladder mass. Histology was consistent with ovarian abscess and chronic sinus tract formation that was contiguous with an inflammatory bladder polyp.

The aim of the study is to evaluate the impact of pelvic organ prolapse (POP) on sexual function in women with urinary incontinence (UI). In this retrospective, case-cohort study, we reviewed the medical records of all women evaluated for UI between March and November 2003. All patients completed the short forms of the Urogenital Distress Inventory, Incontinence Impact Questionnaire, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire. Women with stage two or greater POP, as determined by the pelvic organ prolapse quantification (POPQ) system, were compared to women with stage 0 or 1 POP. Sixty-nine women with POP and 47 women without POP were included. Patient demographics did not differ between the two groups. Women with POP were significantly more likely to report absence of libido (53% versus 30%, P=0.02), lack of sexual excitement during intercourse (46% versus 27%, P=0.05), and that they rarely experienced orgasm during intercourse (49% versus 30%, P=0.05). In conclusion, women with POP in addition to UI are more likely to report decreased libido, decreased sexual excitement, and difficulty achieving orgasm during intercourse when compared to women with UI alone.

Objectives To translate the previously described Pelvic Pain and Urgency/Frequency (PUF) questionnaire into Spanish using a back-translation technique and to validate the Spanish version in a group of bilingual women with symptoms consistent with interstitial cystitis or painful bladder syndrome. Methods Bilingual women with complaints of urinary urgency/frequency and/or pelvic pain were randomized to complete initially either the Spanish version or the original English version of the PUF questionnaire followed by the questionnaire in the other language. To evaluate retest reliability, subjects completed the Spanish version a second time 1 week later. Demographic information, including age, ethnic origin, and primary language, was obtained. Paired t tests and Wilcoxon signed rank tests for total PUF score, its two domain scores, and each item were used to assess the difference between the Spanish and English versions. Test and retest reliability of the Spanish version was similarly assessed. Agreement between the Spanish and English versions was assessed by weighted kappa statistics and 95% confidence intervals for each item. P values less than 0.05 were considered significant, and kappa values greater than 0.7 were considered to indicate good agreement. Results No statistically significant difference was found in the mean or median scores (ie, item, symptom, bother, total) between the English and Spanish versions. Good agreement between English and Spanish versions in all eight items was demonstrated by weighted kappa statistics. The Spanish version demonstrated retest reliability among total scores and seven of eight items when administered 1 week later. Conclusions The Spanish PUF questionnaire is a valid and reliable instrument for the evaluation and treatment of patients with interstitial cystitis or painful bladder syndrome.

Objectives To assess prospectively the degree of urethral mobility in the preoperative and postoperative periods after the transobturator tape procedure and correlate the findings with surgical outcome. Methods Thirty-six consecutive patients with stress urinary incontinence underwent the transobturator tape procedure. A cotton-swab test was performed before the procedure and at the 6-week postoperative follow-up visit to evaluate proximal urethral mobility. Cure was defined as the absence of leak during cough stress testing at cystometric capacity. Results Of the 36 patients, 26 were available for the complete follow-up evaluation. The mean preoperative and postoperative resting cotton-swab test values were 11.7° and 13.6°, respectively ( P = 0.347). The mean preoperative and postoperative straining cotton-swab test values were 57.3° and 48.4°, respectively ( P = 0.047). Of the 36 patients, 21 had a straining cotton-swab test result of 30° or greater after surgery, and 19 (90.4%) of these 21 patients were objectively cured by the procedure. Overall, 21 patients (84%) were objectively cured of stress urinary incontinence. Four patients had urinary leakage during stress testing at cystometric capacity. Three of these patients reported subjective cure and one noted improvement. Of the 5 patients with a negative cotton-swab test after surgery, 2 were cured (50%), 2 were not cured, and 1 did not undergo cough stress testing at cystometric capacity because of urgency at 200-mL limiting bladder filling. Conclusions The cure of urodynamic stress incontinence using the transobturator tape procedure does not require the correction of proximal urethral mobility.

BACKGROUND This report aims to describe urethral mesh erosion after a single-incision synthetic midurethral sling placement and to discuss possible causes for this complication. CASE A 41-year-old woman presented with recurrent stress urinary incontinence after an anchored single-incision midurethral sling placement. Cystourethroscopy and translabial pelvic ultrasonography demonstrated the size and location of the injury. Mesh removal, urethral reconstruction, and Martius transposition flap were performed. The entire mesh removed was 24% shorter than the product before insertion. CONCLUSION Mesh contraction may play an important role in delayed urinary tract injury especially after anchored synthetic midurethral sling placements.

Objective Anatomic differences among racial groups may contribute to observed differences in the occurrence of severe perineal lacerations at the time of vaginal delivery. The purpose of this study was to identify differences in perineal body length between racial groups. Methods Perineal body length was measured in primigravid women aged 18 to 45 years who were admitted in labor. Women were classified into 1 of 6 racial groups: White, Filipino, Japanese, Chinese, Native Hawaiian, or Micronesian. The primary outcome, perineal body length, was compared using analysis of variance. Results A total of 200 women were recruited. There were no significant differences in perineal body length (P = 0.42) and severe perineal lacerations (P = 0.82) between the different racial groups. The mean (SD) perineal body length of women who had a severe laceration was 3.9 (0.5) versus 3.9 (0.6) cm in women who did not have a severe laceration (P= 0.98). Conclusion Perineal body length does not seem to differ among the different racial groups studied and therefore an unlikely cause of racial variation in rates of severe perineal lacerations.

BACKGROUND Current evidence supports cervical preservation at the time of abdominal prolapse repair using synthetic mesh to minimize vaginal mesh extrusion. This report aims to describe management of benign cervical disease following laparoscopic sacrocervicopexy including successful trachelectomy performed vaginally. CASE A 70-year-old sexually active woman presented with symptomatic pelvic organ prolapse and stress urinary incontinence. Her Papanicolaou smears over several years were unremarkable, and she had a benign endocervical polyp removed in the office 3 months before surgery. She underwent an uncomplicated robotic-assisted laparoscopic supracervical hysterectomy and sacrocervicopexy. She presented 8 months after surgery with persistent vaginal spotting after intercourse and was found to have a recurrent endocervical polyp. Ultimately, she underwent uncomplicated trachelectomy performed vaginally with resolution of her symptoms. CONCLUSIONS Retention of the cervix at the time of mesh-augmented abdominal prolapse repairs introduces a unique set of evaluation and management considerations for benign cervical disease. Trachelectomy performed vaginally was successful and uncomplicated in this case.

We present a case of Actinomyces infection associated with the transobturator sling. The patient had a transobturator sling complicated only by a left vaginal sulcal perforation. She subsequently developed mesh erosion that led to two partial mesh resections performed in the operating room at 6 weeks and again at 6 months after the initial surgery. She subsequently required a groin dissection and removal of the entire left side of the sling due to persistent infection. The presence of a foreign body is believed to create an environment that makes growth of the bacteria more likely. With increased use of artificial mesh in incontinence and prolapse surgery, we may see increasing numbers of these types of infections.

We report an unusual case of rectal mesh erosion presenting 16 months after robotic sacrocolpopexy. The patient initially underwent a robotic sacrocolpopexy, lysis of adhesions, midurethral sling, and posterior colporrhaphy for symptomatic grade 2 pelvic organ prolapse and urodynamic stress incontinence. Her postoperative recovery was uneventful. Sixteen months later, an anterior 2 × 2-cm rectal mesh erosion was noted on the colonoscopy performed when she presented with hematochezia.

Neobladder substitution after radical cystectomy for invasive cancer has become commonplace as it preserves normal volitional voiding through the native urethra and avoids urinary diversion. Neobladder-vaginal fistula (NVF) is a rare postoperative complication of this procedure that results in decreased quality of life. We describe a case of vaginal repair of a NVF and present a review of the literature.

To determine whether preoperative urethral mobility is associated with success of the transobturator insertion of suburethral polypropylene slings.A cohort of women who underwent a transobturator insertion of a suburethral polypropylene sling for urodynamic stress incontinence between October 2003 and January 2005 was prospectively assessed.Of the 134 women in the study cohort, 107 (80%) provided postoperative data at a median followup interval of 10 months. Postoperatively, 92 (86%) reported complete resolution of stress urinary incontinence on the Urogenital Distress Inventory-6 questionnaire, and 15 (14%) reported persistent incontinence. The median preoperative urethral mobility was significantly decreased among women who were incontinent postoperatively compared to those who were continent (40 degrees [10-60] vs. 50 degrees [10-90], p=0.0049). Women with preoperative urethral mobility45 degrees were at least 4 times more likely to report postoperative incontinence compared with women with preoperative urethral mobilityor = 45 degrees (29.4% vs. 6.9%, RR 4.29, 95% CI 1.59-11.60, p = 0.005). In addition, women with preoperative urethral straining angles45 degrees from the horizontal were at least 5 times more likely to report postoperative incontinence compared with women with preoperative urethral straining anglesor = 45 degrees (41.7% vs. 8.7%, RR 5.21, 95% CI 1.88-14.42, p = 0.006). Neither patient age nor the concomitant performance of an anterior colporrhaphy affected these results.Women with preoperative urethral mobility or preoperative urethral straining angles45 degrees appear to be at higher risk for failure following a transobturator insertion of a suburethral polypropylene sling.

To review a series of women with endometriomas developing in the scar of the skin incision performed for cesarean section.A total of 37 patients diagnosed with incisional endometrioma at the time of surgical excision from 1975 to 2005 were identified from the comprehensive surgical database, which includes all operative procedures performed at this institution. The medical records of 33 of the 37 patients were available for review.The endometriomas ranged in size from a diameter of 1-12 cm and were initially observed to be present 6 months to 9 years (mean, 3.2) after the surgical procedure. Diagnosis was best made by needle aspiration of chocolate colored fluid from the mass. Medical therapy with a gonadotropin releasing hormone agonist, medroxyprogesterone acetate or combination oral contraceptives had been attempted in 14 patients without a change in lesion size. All patients were cured by surgical excision of the endometrioma.The overall incidence of incisional endometriomas following cesarean section during the 30-year period was 0.08%. Optimal treatment is by surgical excision. It is hypothesized that failure to close the parietal and visceral peritoneum with sutures at the time of cesarean section may markedly increase the postoperative occurrence of an endometrioma in the skin incision scar.

Objectives To estimate the prevalence of interstitial cystitis in women with detrusor overactivity refractory to anticholinergic medication using the potassium sensitivity test (PST). Methods Women with complaints of urinary frequency, urgency, and/or urge incontinence of 3 months’ duration or longer were referred to the urogynecology clinic. Between October 2003 and June 2004, 47 consecutive women were diagnosed with phasic, idiopathic detrusor overactivity after evaluation by history, physical examination, urinalysis, urine culture, urodynamic testing, and cystoscopy. Refractory detrusor overactivity was defined as a 50% or less improvement in urinary urgency, frequency, and/or urge incontinence episodes while taking anticholinergic medications. All women were offered the PST. Results All 47 women were included in the study; 18 (38.3%) had only detrusor overactivity incontinence and 29 (61.7%) also had concomitant urodynamic stress incontinence. Additionally, 19 women (40.4%) had pelvic pain. Of the 47 women, 31 agreed to undergo the PST. Of the 31 women, 25 had positive and 6 had negative PST result. Of the 31 women, 25 did not respond to therapy with one or more anticholinergic medications, and 24 (96%) of these 25 had had a positive PST. The remaining 6 women responded to treatment with oxybutynin, and only 1 (16.7%) had had a positive PST (P = 0.0002). The odds ratio of a positive PST for women in whom anticholinergic therapy failed compared with women in whom it did not was 120.0 (95% confidence interval 6.4 to 2257.5; P = 0.0002). Conclusions These preliminary findings suggest that there is a high prevalence of interstitial cystitis in women with detrusor overactivity that does not respond to anticholinergic medication.

OBJECTIVE This study aimed to determine whether the Pelvic Organ Prolapse Quantification (POPQ) system should be simplified based on its use in the peer-reviewed literature. METHODS The American Journal of Obstetrics and Gynecology, Obstetrics and Gynecology, and International Urogynecology Journal were used for this study. All articles relating to pelvic organ prolapse published in these journals from January 2005 to December 2010 were reviewed for their use of the POPQ system. The POPQ points described in the Materials and/or Results sections of these articles were recorded. RESULTS Two hundred eighty-three articles using the POPQ system were identified. One hundred thirty-two (47%) articles used the POPQ system but only to determine the stage of prolapse. Specific points were not mentioned. One hundred two (36%) articles evaluated specific POPQ points (Aa, Ba, Ap, Bp, C, D). Forty-nine (17%) articles evaluated points Gh, Pb, and Tvl. CONCLUSIONS The POPQ system, based on its use in the peer-reviewed literature, may need revisions. An abbreviated version of the system may be considered, allowing for more widespread use.

The new minimally invasive transobturator sling for surgical treatment of female genuine stress urinary incontinence is designed to reproduce the natural suspension of the urethral fascia while eliminating the need for retropubic needle passage. We report 3 cases of bladder perforation during the transobturator sling procedure. All injuries were identified intraoperatively by cystoscopy, and successful reinsertion of the mesh was accomplished. Transurethral bladder drainage with a Foley catheter was maintained for 5 to 7 days postoperatively. All 3 patients recovered uneventfully. Routine intraoperative cystoscopy is, therefore, recommended for the identification of bladder injuries during the transobturator sling procedure.

The purpose of this study was to calculate the number of cesarean deliveries needed to prevent 1 case of obstetric anal sphincter laceration associated with operative vaginal delivery in an at-risk cohort.An institutional, computerized database was used to analyze women with obstructed labor who could have been managed by either operative vaginal or cesarean delivery from September 2006 to March 2008. Women with 1 or more of the following diagnoses comprised the cohort: cephalopelvic disproportion (CPD), arrest of descent, maternal exhaustion, and fetal distress.Fifty (23.9%) out of a total of 209 women managed by operative vaginal delivery experienced an anal sphincter laceration compared to none of 254 women in the cesarean delivery group (P.0001). The ARR therefore was 23.9% (95% confidence interval, 18.1-29.7) and the NNT was 4.2 (95% confidence interval, 3.4-5.5).Five cesarean deliveries are needed to prevent 1 anal sphincter laceration associated with operative vaginal delivery in this cohort.

Voiding dysfunction after mid-urethral sling procedures is uncommon but not completely avoidable. We report on a method to adjust the transobturator mid-urethral sling under local anesthesia in the early postoperative period for postoperative voiding difficulty. At postoperative day 17 and 18, 2 women, who had undergone the transobturator tape procedure for stress incontinence, underwent successful loosening of the mesh through the previous vaginal incision, without the need to transect or remove the tape. Both patients had immediate resolution of their symptoms while maintaining urinary continence.