Elena Tunitsky-Bitton

Pyogenic spondylodiscitis associated with sacral colpopexy and rectopexy: report of two cases and evaluation of the literature

Pyogenic spondylodiscitis includes a spectrum of spinal infections such as discitis, osteomyelitis, epidural abscess, meningitis, subdural empyema, and spinal cord abscess. This is a rare complication of sacral colpopexy, but can lead to devastating consequences for the patient. We present two cases of pyogenic spondylodiscitis following sacral colpopexy. In addition, we discuss 26 cases of pyogenic spondylodiscitis reported in the literature from 1957 to 2012. Techniques to decrease rates of infection include proper identification of the S1 vertebra, awareness of the suture placement depth at the level of the sacrum and at the vagina, and early treatment of post-operative urinary tract and vaginal infections. Awareness of symptoms, timely diagnosis and multidisciplinary approach to management is essential in preventing long-term complications.

Prediction models for postpartum urinary and fecal incontinence in primiparous women.

Objectives This study aimed to develop and internally validate a nomogram that facilitates decision making between patient and physician by predicting a woman’s individual probability of developing urinary (UI) or fecal incontinence (FI) after her first delivery. Methods This study used Childbirth and Pelvic Symptoms Study data, which estimated the prevalence of postpartum UI and FI in primiparous women after vaginal or cesarean delivery. Two models were developed using antepartum variables, and 2 models were developed using antepartum plus labor and delivery variables. Urinary incontinence was defined by a response of leaking urine “sometimes” or “often” using the Medical, Epidemiological, and Social Aspects of Aging Questionnaire. Fecal incontinence was defined as any involuntary leakage of mucus, liquid, or solid stool using the Fecal Incontinence Severity Index. Logistic regression models allowing nonlinear effects were used and displayed as nomograms. Overall performance was assessed using the Brier score (zero equals perfect model) and concordance index (c-statistic). Results A total of 921 women enrolled in the Childbirth and Pelvic Symptoms Study, and 759 (82%) were interviewed by telephone 6 months postpartum. Two antepartum models were generated, which discriminated between women who will and will not develop UI (Brier score = 0.19, c-statistic = 0.69) and FI (Brier score = 0.10, c-statistic = 0.67) at 6 months and 2 models were generated (Brier score = 0.18, c-statistic= 0.68 and Brier score = 0.09, c-statistic = 0.68) for predicting UI and FI, respectively, for use after labor and delivery. Conclusions These models yielded 4 nomograms that are accurate for generating individualized prognostic estimates of postpartum UI and FI and may facilitate decision making in the prevention of incontinence.

Neuroanatomy, neurophysiology, and dysfunction of the female lower urinary tract: A review

Abstract The 2 major functions of the lower urinary tract are the storage and emptying of urine. These processes are controlled by complex neurophysiologic mechanisms and are subject to injury and disease. When there is disruption of the neurologic control centers, dysfunction of the lower urinary tract may occur. This is sometimes referred to as the “neurogenic bladder.” The manifestation of dysfunction depends on the level of injury and severity of disruption. Patients with lesions above the spinal cord often have detrusor overactivity with no disruption in detrusor-sphincter coordination. Patients with well-defined suprasacral spinal cord injuries usually present with intact reflex detrusor activity but have detrusor sphincter dyssynergia, whereas injuries to or below the sacral spinal cord usually lead to persistent detrusor areflexia. A complete gynecologic, urologic, and neurologic examination should be performed when evaluating patients with neurologic lower urinary tract dysfunction. In addition, urodynamic studies and neurophysiologic testing can be used in certain circumstances to help establish diagnosis or to achieve better understanding of a patient’s vesicourethral functioning. In the management of neurogenic lower urinary tract dysfunction, the primary goal is improvement of a patient’s quality of life. Second to this is the prevention of chronic damage to the bladder and kidneys, which can lead to worsening impairment and symptoms. Treatment is often multifactorial, including behavioral modifications, bladder training programs, and pharmacotherapy. Surgical procedures are often a last resort option for management. An understanding of the basic neurophysiologic mechanisms of the lower urinary tract can guide providers in their evaluation and treatment of patients who present with lower urinary tract disorders. As neurologic diseases progress, voiding function often changes or worsens, necessitating a good understanding of the underlying physiology in question.

Ultrasound Evaluation of Midurethral Sling Position and Correlation to Physical Examination and Patient Symptoms

Objective The primary objective was to evaluate the position and angle variation between 3 different midurethral slings (MUSs) using 3-dimensional ultrasound (US) technology. The secondary objective was to compare differences in findings on physical examination and symptoms of incontinence and sexual dysfunction between subjects. Methods This was a cross-sectional study of 61 subjects who had undergone MUS placement without concomitant anterior or apical compartment prolapse surgery (21 retropubic [RP], 19 out-to-in transobturator [TOT], 21 in-to-out transobturator [TVT-O]). Subjects completed validated questionnaires (Sandvik Incontinence Severity Index, Urogenital Distress Inventory 6) and underwent a pelvic examination and standardized 2-dimensional and 3-dimensional ultrasonography evaluation. Results On translabial US, the median RP sling angle was 108.2 degrees (72.6–135.9), significantly more acute than the angle of TOT and TVT-O slings (119.3 degrees [72.3–140.4, P = 0.02] and 118.5 degrees [99.0–154.7, P = 0.004]). There was no difference in the sling angles between the TOT and TVT-O slings (P = 0.86). No difference was noted in the position of the sling along the urethra (P = 0.82). The TOT sling was more often palpable (57.8%, P = 0.02) compared with the RP or TVT-O groups. Fifteen patients (4 RP, 5 TOT, 6 TVT-O) reported discomfort during intercourse that they attributed to the MUS. Three of 19 TOT subjects reported that their partner experienced pain with intercourse because of the sling. However, sexual function and urinary symptoms were not statistically different between the 3 groups. Conclusions On 3-dimensional US, RP sling angle was found to be significantly more acute than the angles of the TOT and TVT-O slings, and there was no difference between the 2 transobturator slings. The TOT sling was more often palpable on examination, but this finding did not correlate with increased pain on palpation.

Phenazopyridine for Evaluation of Ureteral Patency: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the usefulness of phenazopyridine for confirmation of ureteral patency during intraoperative cystoscopy. METHODS: We conducted a randomized controlled trial comparing use of phenazopyridine with no medications for evaluation of ureteral patency during intraoperative cystoscopy in women undergoing pelvic surgery. The primary study outcome was time to visualize ureteral urine efflux. To detect a 3-minute difference with &agr; of 0.05 using a two-sided, two-sample t test and &bgr; 0.80 required 98 patients equally divided into two groups. RESULTS: A total of 104 women were randomized from April to December 2015. Patients in the treatment group tended to be older (P=.02); otherwise, study groups were similar. Time to visualize ureteral urine efflux did not differ between study groups with a mean time of 2 minutes 40 seconds (±2 minutes 38 seconds) in the control group and 2 minutes 53 seconds (±4 minutes 35 seconds) in the treatment group (P=.77). Regarding the surgeon survey, surgeons felt less frustrated and impatient in visualization of ureteral urine efflux in the treatment group compared with the control group (mean response 1.5±0.8 in treatment compared with 2.0±1.0 in control, P=.007), and surgeons felt that the cystoscopy took too long more often in the control than in the treatment group (1.7±0.9 in treatment compared with 2.1±1.0 in control, P=.02). Trial of void result differed significantly between groups with fewer patients in the treatment group failing a void trial (P=.04). There were no adverse events related to phenazopyridine use. CONCLUSION: Preoperative phenazopyridine is a useful and cost-saving medication for use in planned cystoscopy for evaluation of ureteral patency. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, https://clinicaltrials.gov/, NCT02424149.

Primary Ewing Sarcoma Presenting as a Vulvar Mass in an Adolescent: Case Report and Review of Literature

BACKGROUND Extraosseous Ewing sarcoma (ES) tumors presenting in the genitourinary tract are highly uncommon. Few cases of primary vulvar and vaginal cases of ES have been published. CASE A 15-year-old adolescent presented with a bothersome 5-cm mass located on her left labium minorum. Following excision, a diagnosis of a primary ES was made. The patient was treated with multiagent chemotherapy and was doing well 20 months after treatment completion. SUMMARY AND CONCLUSION Based on the few available case reports and our reported case, it appears that extraosseous ES arising in superficial sites such as the vulva have better prognosis and should be treated with complete excision and multiagent chemotherapy.