Kenneth Powers

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.

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.

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.

Inflammatory response to bovine pericardium: reply to letter by Davila

Dear editor, We read with interest the letter to the editor by G. Willy Davila. We respect the author’s vast experience, and we concur that there was no conclusive evidence in our case report [1] for an inflammatory response to the bovine pericardium. Nevertheless, we believe that the case highly suggests a reaction, albeit inflammatory, allergic, or foreign body, to the material used. We perform colpoperineorrhaphies in our center on a regular basis and have for years utilized various graft materials. In our experience, the postoperative course in this case was atypical in nature, and the potential for bovine pericardium to induce local reactions has been previously described [2, 3]. We respectfully disagree with several of the author’s assertions. First, the author claims that the induration observed was likely due to “normal healing from surgery.” We maintain that the reported severe spasm and swelling, and marked induration and tenderness are not likely manifestations of normal healing. Furthermore, the quick and favorable response to the nonsteroidal anti-inflammatory preparations suggests an inflammatory reaction. Second, the author asserts that severe pelvic floor spasm was more likely a result of the “routine perineorrhaphy.” We respectfully maintain that severe levator spasm to the point of prohibiting any attempt at a speculum examination, coupled with marked induration, severe tenderness and swelling over the graft site, and urinary retention are not likely a result of routine perineorrhaphy. This is particularly noteworthy, since we reported that levator plication was not performed in this patient to avoid dyspareunia. Third, we do not agree with the author’s assertion that the patient’s voiding dysfunction was “anything but commonly seen postoperative temporary voiding dysfunction.”Wemaintain that urinary retention of 2 weeks’ duration is not commonly seen following a routine perineorrhaphy. We reiterate, however, that our case does not provide conclusive evidence and caution should be exercised. Lastly, an isolated case report such as ours cannot and does not condemn the use of bovine pericardium. We abandoned its use in our center generally as a matter of preference and experience with other graft materials or approaches. The purpose of our case report was to describe our humble experience to possibly assist other clinicians in similar cases.

The role of cystourethroscopy in patients with previous pelvic surgery

Abstract Objectives: 1) To determine the frequency of lower urinary tract injury (LUTI) in patients with previous pelvic surgery and 2) to evaluate the role of routine cystourethroscopy (CUS) in these patients. Materials and Methods: The records of all women who had previous pelvic surgery without a documented intraoperative cystoscopy who later underwent postoperative office CUS at Montefiore Medical Center between January 1999 and May 2000 were retrospectively reviewed. All patients underwent a detailed urogynecologic history and physical examination, urine analysis, and urine culture. All patients then underwent routine office CUS. Results: Sixty-seven patients met the inclusion criteria. All but one had their primary surgery at other institutions. The mean age was 64 (range, 54–77). Previous surgical procedures included 35 abdominal hysterectomies, 5 vaginal hysterectomies, 1 hysteropexy, 9 suburethral slings, 10 anterior colporrhaphies, 2 retropubic suspensions, and 15 bladder repairs. The cystourethroscopic diagnoses were as follows: 54 with atrophic urethritis, 14 with interstitial cystitis, and 2 with intravesical sutures. The rate of LUTI was 3% (95% CI 0.2,7). Conclusions: The rate of LUTI is low. The use of CUS is essential to appropriate diagnosis and treatment for patients with lower urinary tract injury consequent to pelvic surgery. We suggest routine intraoperative CUS for patients undergoing pelvic surgery. Prospective studies are warranted.