Anna Virginia Franco

Avulsion injury and levator hiatal ballooning: two independent risk factors for prolapse? An observational study.

Objective. To study whether avulsion and ballooning are independent risk factors for symptoms and/or signs of pelvic organ prolapse. Design. Retrospective analysis of data obtained in clinical practice. Setting. Tertiary urogynecology unit. Population. Seven hundred and sixty‐one consecutive women with symptoms of pelvic floor dysfunction. Methods. Evaluation included history, vaginal examination and four‐dimensional translabial ultrasound. Ultrasound analysis was performed off‐line, blinded against clinical data. Hiatal dimensions were measured at the plane of minimal hiatal dimensions. Puborectalis avulsion was identified using tomographic imaging. Main outcome measures. Symptoms and objective signs of prolapse (ICS POP‐Q stage 2+). Results. Owing to previous surgery 156 women were excluded, leaving 605, of whom 258 (43%) had prolapse symptoms. Significant prolapse (International Continence Society Prolapse Quantification System grade 2+) was identified as follows: cystocele in 222 (37%) women, rectocele in 159 (27%) and apical in 40 (8%), while 110 (18%) had an avulsion. There was a strong association between avulsion, hiatal ballooning and symptoms/signs of prolapse (p < 0.001). On multivariable backwards stepwise logistic regression, puborectalis avulsion was associated with an increased risk of symptoms and signs of prolapse, even after allowing for the degree of levator ballooning. The presence of avulsion did not modify the relation between hiatal area and symptoms of prolapse. Conclusions. Puborectalis avulsion injury and levator hiatal ballooning are independent risk factors for symptoms and signs of prolapse. The role of avulsion in the pathogenesis of prolapse is not fully explained by its effect on hiatal dimensions. It is likely that avulsion implies not only muscular trauma but also damage to structures impossible to assess clinically or by imaging, i.e. myofascial and connective tissue.

Is there an alternative to pad tests? Correlation of subjective variables of severity of urinary loss to the 1‐h pad test in women with stress urinary incontinence

To compare the 1‐h pad test in women who have urodynamically confirmed stress incontinence (USI) with a patient‐based 3‐point symptom severity scale and validated quality of life (QoL) questionnaires.

Vesicouterine fistula following Cesarean delivery—ultrasound diagnosis and surgical management

Vesicouterine fistulae are uncommon, with most units reporting 1–5 cases over 5–15‐year periods. To date there has been a paucity of case reports regarding this problem and only a few case series. In this report we outline the presentation and management of a vesicouterine fistula complicating a repeat Cesarean delivery, specifically describing the role of transvaginal ultrasound. Copyright

High uterosacral ligament vault suspension at vaginal hysterectomy: Objective and subjective outcomes of a modified technique

Aims:  To evaluate the outcomes of a modified high uterosacral ligament suspension (HUSLS) performed at vaginal hysterectomy for uterine prolapse.

Vaginal wind—the cube pessary as a solution?

Dear Editor, We read with interest the articles by Hsu [1] and Krissi et al. [2] regarding the management of the uncommon but distressing symptom of vaginal wind. By way of a case report, we present an alternative treatment. A 55-year-old woman presented with the symptom of passing wind vaginally. This occurred a few times a day and was exceptionally embarrassing. Examination did not reveal any vaginal prolapse. An intensive course of pelvic floor physiotherapy did not alleviate her symptoms and surgery was recommended. The patient underwent an anterior colporrhaphy in an attempt to reduce the vaginal capacity and eliminate the valve effect that often serves as the aetiology of this problem [2]. Unfortunately, at follow-up 6 months later, her symptoms were as yet unrelieved. A ring pessary was then inserted but this was also unsuccessful. Finally, a cube pessary was inserted and on follow-up 4 weeks later, she was completely asymptomatic for vaginal wind. Krissi et al. [2] suggests the use of a modified ‘Bard’ pessary to treat vaginal wind whereas Hsu [1] reports a case successfully treated by daily insertion of a tampon. We believe a cube pessary is simple, and universally available approach to this problem should be considered early in the treatment options for these women.

Continence outcomes following partial excision of vaginal mesh exposure after mid-urethral tape insertion

OBJECTIVE To assess the incidence of recurrent stress urinary incontinence (SUI) following vaginal excision of exposed mid-urethral tape (MUT). STUDY DESIGN This was a retrospective observational study in a tertiary urogynaecology unit of an inner city teaching hospital. The population consisted of 41 consecutive women seen with a vaginal mesh exposure following MUT insertion between 2000 and 2009, which failed to resolve with conservative measures. The primary outcome measure was the presence of symptoms of stress urinary incontinence following surgical excision of exposed mesh. RESULTS The incidence of recurrent SUI following tape excision was 34.1%. Type of mid-urethral tape, menopausal status, and the time interval between tape insertion and excision were not found to be significantly associated with the risk of recurrent SUI. CONCLUSIONS Over a third of women experience recurrent SUI after surgical management of vaginal mesh exposure following MUT insertion. Risk factors may be more comprehensively studied using prospectively collected cohorts.