George Lazarou

Innervation of the levator ani muscles: description of the nerve branches to the pubococcygeus, iliococcygeus, and puborectalis muscles

We described the innervation of the levator ani muscles (LAM) in human female cadavers. Detailed pelvic dissections of the pubococcygeus (PCM), iliococcygeus (ICM), and puborectalis muscles (PRM) were performed on 17 formaldehyde-fixed cadavers. The pudendal nerve and the sacral nerves entering the pelvis were traced thoroughly, and nerve branches innervating the LAM were documented. Histological analysis of nerve branches entering the LAM confirmed myelinated nerve tissue. LAM were innervated by the pudendal nerve branches, perineal nerve, and inferior rectal nerve (IRN) in 15 (88.2%) and 6 (35.3%) cadavers, respectively, and by the direct sacral nerves S3 and/or S4 in 12 cadavers (70.6%). A variant IRN, independent of the pudendal nerve, was found to innervate the LAM in seven (41.2%) cadavers. The PCM and the PRM were both primarily innervated by the pudendal nerve branches in 13 cadavers (76.5%) each. The ICM was primarily innervated by the direct sacral nerves S3 and/or S4 in 11 cadavers (64.7%).

Pessary use in advanced pelvic organ prolapse

The objective of this study was to review our experience with pessary use for advanced pelvic organ prolapse. Charts of patients treated for Stage III and IV prolapse were reviewed. Comparisons were made between patients who tried or refused pessary use. A successful trial of pessary was defined by continued use; a failed trial was defined by a patient’s discontinued use. Thirty-two patients tried a pessary; 45 refused. Patients who refused a pessary were younger, had lesser degree of prolapse, and more often had urinary incontinence. Most patients (62.5%) continued pessary use and avoided surgery. Unsuccessful trial of pessary resorting to surgery included four patients (33%) with unwillingness to maintain, three patients (25%) with inability to retain and two patients (17%) with vaginal erosion and/or discharge. Our findings suggest that pessary use is an acceptable first-line option for treatment of advanced pelvic organ prolapse.

Inflammatory reaction following bovine pericardium graft augmentation for posterior vaginal wall defect repair.

Graft augmentation for repair of recurrent pelvic organ prolapse is commonly used in reconstructive pelvic surgery. The reported complications are mainly late onset. We report a case of early-onset inflammatory reaction following bovine pericardium graft augmentation for posterior vaginal wall defect repair. A 49-year-old presented with a recurrent and symptomatic posterior vaginal wall defect. She underwent an uneventful site-specific repair and bovine graft augmentation. Her early postoperative course was complicated by inflammatory response to the graft presenting as intense pelvic floor spasm and urinary retention. The condition was managed conservatively and resolved subsequently. One year later, the patient continues to be asymptomatic. Transient intense pelvic floor spasm and urinary retention can be the result of inflammatory reaction following graft augmentation with bovine pericardium for posterior vaginal wall defect repair.

Gross and microscopic hematuria: guidelines for obstetricians and gynecologists.

Although gross hematuria is a relatively uncommon condition in general obstetrics and gynecology practice, microscopic hematuria is a common incidental finding during routine antepartum or gynecologic office visits. The proper evaluation and treatment options are understudied in females. In fact, work-up of females is controversial, and no consensus guidelines exist at this time. Pregnancy increases the number of potential diagnoses. The majority of published literature on hematuria in pregnancy is in the form of case reports, and esoteric diagnoses are disproportionately represented. The purpose of this review is to summarize existing literature regarding the evaluation, differential diagnosis, and treatment of hematuria in women, with special emphasis on pregnancy and the diagnosis and treatment of microscopic hematuria. Target Audience: Obstetricians & Gynecologists, Family Physicians Leaning Objectives: After completion of this article, the reader should be able to identify causes of microscopic hematuria in women, use a logical approach to the evaluation of women with microscopic hematuria, and select appropriate imaging modalities for pregnant and nonpregnant women with microscopic hematuria.

Delayed urethral erosion after tension-free vaginal tape.

Urethral erosions have been reported with various sling materials placed by means of various techniques. The patient often presents in the immediate postoperative period, although late presentations have been described. The diagnosis is made on cystoscopy, and mesh excision with urethral reconstruction is advocated. We present the cases of two patients with urethral erosion after mid-urethral polypropylene sling who presented 3 months after surgery with urethral pain, mid-urethral blockage and symptoms of bladder dysfunction. Urethroscopy revealed the mesh bridging the lumen of the urethra. Trans-vaginal mesh excision and layered urethral reconstruction was curative in both patients.

Late-onset allergic reaction to povidone-iodine resulting in vulvar edema and urinary retention.

BACKGROUND: Povidone-iodine, a surgical antiseptic, is associated with adverse side effects ranging from minor skin irritation to anaphylaxis, with symptoms occurring within minutes and up to 8 hours after contact. CASE: We report a case of a patient, with no history of allergy to povidone-iodine, who developed an allergic reaction 24 hours after intraoperative exposure to povidone-iodine, presenting with acute urinary retention secondary to extensive vulvar edema, which resolved after administration of antihistamines. CONCLUSION: Allergic reactions to povidone-iodine can be late in onset and, in vaginal surgeries, may present with atypical symptoms such as acute urinary retention secondary to vulvar edema. Prompt diagnosis and effective treatment requires strong clinical suspicion in patients presenting postoperatively with a known history of exposure.

Anatomy of the Pelvic Floor

Anatomy is to pelvic surgery as vocabulary is to language: The more detailed one’s knowledge is in anatomy, the more fluent and facile one becomes in the operating room.

Delayed small bowel obstruction after robotic-assisted sacrocolpopexy.

We report 2 unusual cases of partial bowel obstruction resulting from adherence to a barbed suture presenting 3 to 4 weeks after robotic-assisted sacrocolpopexy for uterovaginal prolapse. Both patients underwent an uncomplicated robotic-assisted supracervical hysterectomy and sacrocolpopexy. Immediate postoperative recovery was uncomplicated. Three to four weeks after surgery, both patients presented with symptoms of nausea, vomiting, and abdominal pain and were found to have small bowel obstructions requiring a return to the operating room. Upon surgical exploration, a loop of small bowel was found to be adhered to a segment of the barbed suture at the sacral promontory, which had been used to close the peritoneum over the mesh. Subsequent to release, both patients had an uneventful recovery.

Update on Urinary Tract Markers in Interstitial Cystitis/Bladder Pain Syndrome.

Abstract Interstitial cystitis (IC)/painful bladder syndrome/bladder pain syndrome (BPS) is a chronic hypersensory condition of unknown etiology. Moreover, the optimal modality for diagnosing IC remains disputed. Several urinary markers have been investigated that may have potential utility in the diagnosis or confirmation of IC/BPS. Thus, inflammatory mediators, proteoglycans, urinary hexosamines, proliferative factors, nitric oxide (NO), BK polyomavirus family, and urothelial proinflammatory gene analysis have been found to correlate with varying degrees with the clinical diagnosis or cystoscopic findings in patients with IC/BPS. The most promising urinary biomarker for IC/BPS is antiproliferative factor, a sialoglycopeptide that has demonstrated inhibitory effects on urothelial cell proliferation and a high sensitivity and specificity for IC/BPS symptoms and clinical findings. In this article, we review the urinary markers, possible future therapies for IC/BPS, and the clinical relevance and controversies regarding the diagnosis of IC/BPS.

Rare case of neglected pessary presenting with concealed vaginal hemorrhage.

Background Vaginal pessaries are commonly used for management of pelvic organ prolapse. Severe complications can occur in neglected cases. Case A 91-year old woman with significant comorbidities presented with large concealed vaginal bleeding and history of vaginal pessary placement 14 years before. On examination, an impacted Gellhorn pessary in the vagina was noted with some spotting. Serum blood tests revealed severe anemia and renal insufficiency. An abdominal and pelvic computed tomographic scan confirmed a Gellhorn pessary and a large vaginal accumulation of blood superior to impaction. The pessary was surgically removed vaginally under anesthesia. Recovery was uneventful, and the patient was discharged 1 week later. Conclusion Our case underlines the need of follow-up and compliance after pessary placement for early detection of complications.