Lieschen H. Quiroz

Levator ani deficiency and pelvic organ prolapse severity.

OBJECTIVE: To estimate whether levator ani deficiency severity is a predictor of clinically significant pelvic organ prolapse (POP) and to determine whether there is a levator ani deficiency threshold above which POP occurs. METHODS: Two-hundred twenty three-dimensional ultrasound scans performed on urogynecologic clinic patients were reviewed, and each levator ani muscle subdivision was individually scored (0=no defect, 1=50% or less defect, 2=more than 50% defect, 3=total absence of the muscle) on each side. A levator ani deficiency score was calculated and categorized as mild (score 0–6), moderate (score 7–12), and severe (score more than 13). Clinically significant prolapse was defined as stage 2 or higher. RESULTS: The mean age was 56.50 (standard deviation ±15.58) and median parity was 2 (range 0–6). A mild positive correlation was demonstrated between levator ani deficiency category and prolapse stage (rs=0.44; P<.001). Score distribution significantly differed by prolapse stage (P<.001). No patients with stage 3 prolapse had a levator ani score less than 6, and no patients with stage 4 prolapse had a levator ani score less than 9. In patients with prolapse, those with moderate levator ani deficiency had 3.2 times the odds of POP compared with patients with a minimal defect; those with severe levator ani deficiency had 6.4 times the odds of prolapse than those with minimal deficiency. CONCLUSIONS: Levator ani deficiency severity is associated with clinically significant prolapse. LEVEL OF EVIDENCE: II

Mothers' Satisfaction with Planned Vaginal and Planned Cesarean Birth

We sought to describe maternal satisfaction with childbirth among women planning either cesarean or vaginal birth. We enrolled primiparous women planning cesarean birth and a comparison group planning vaginal birth. After delivery, the maternal subjective experience was assessed with a visual analogue satisfaction scale and the Salmon questionnaire, with scale scores for these aspects of the maternal experience of birth: fulfillment, distress, and difficulty. The sample included 160 women planning vaginal birth and 44 women planning cesarean. Eight weeks postpartum, women planning cesarean reported higher satisfaction ratings ( P = 0.023), higher scores for fulfillment ( P = 0.017), lower scores for distress ( P = 0.010), and lower scores for difficulty ( P < 0.001). The least favorable scores were associated with unplanned cesarean ( N = 48). Women planning cesarean reported a more favorable birth experience than women planning vaginal birth, due in part to low satisfaction associated with unplanned cesarean. Maternal satisfaction with childbirth may be improved by efforts to reduce unplanned cesarean, but also by support for maternal-choice cesarean.

Surgical reconstitution of a unilaterally avulsed symptomatic puborectalis muscle using autologous fascia lata.

BACKGROUND: The puborectalis muscle is an important muscle for the maintenance of fecal continence. We present a novel surgical technique for repair of symptomatic avulsed puborectalis muscle. CASE: This woman presented with dyspareunia and fecal incontinence since the vaginal birth of her child 2 years before. The diagnosis of an avulsed right puborectalis was made by physical examination and confirmed by magnetic resonance imaging and three-dimensional ultrasonography. Fascia lata was harvested from the patient’s thigh and used to reconstitute the missing portion of the puborectalis muscle. At 12 months postoperatively, the patient was continent of stool and relieved of dyspareunia. CONCLUSION: The patient’s dyspareunia and fecal incontinence were alleviated by restoring normal anatomy.

The Significant Morbidity of Removing Pelvic Mesh From Multiple Vaginal Compartments

OBJECTIVE: To investigate perioperative complications of mesh removal performed in the operating room from a single-site, tertiary care center with a large volume of referrals for mesh removal and to compare the morbidity associated with single-compartment mesh removal compared with removal from multiple vaginal compartments. METHODS: A retrospective review was performed on all patients who underwent mesh removal from January 2008 to April 2014. Patients were identified based on Current Procedural Terminology codes for removal of vaginal mesh or sling. Summary statistics were calculated for the patient population. Complications were compared between single-compartment mesh removal surgery and multicompartment mesh removal surgery. A P value of <.05 was considered significant for all analyses. RESULTS: During a 75-month period, a total of 398 procedures were performed for the removal of vaginally placed mesh. A total of 326 (82%) patients underwent single-compartment surgery, 48 (12%) underwent multicompartment surgery, and in 26 (6%), the type of surgery was unclear. The indications for mesh removal included: pain (63%), dyspareunia (57%), mesh exposure (54%), and voiding dysfunction (39%). The mean length of mesh removed was 4 cm (standard deviation±2.8). Those with multicompartment surgery had approximately three times higher estimated blood loss compared with single-compartment surgery (P<.001). The odds of blood transfusion after multicompartment surgery were more than nine times higher than the odds of transfusion after a single-compartment surgery (odds ratio 9.7, 95% confidence interval 2.1–44.6; P<.01). CONCLUSION: Bleeding complications are higher with concomitant removal of mesh from multiple vaginal compartments. LEVEL OF EVIDENCE: III

Age effects on pelvic floor symptoms in a cohort of nulliparous patients.

Objectives This study aimed to investigate the effects of age on pelvic floor symptoms (PFSs) in nulliparous women. Methods Eighty community-dwelling nulliparous women, aged 21 to 70 years, were recruited. Pelvic floor support was assessed with pelvic organ prolapse quantification system. Participants completed the Pelvic Floor Distress Inventory 20 and Pelvic Floor Impact Questionnaire 7. Sexual function was assessed with the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire 12 and health status with the Short-Form Health Survey. The correlation between age and questionnaire scores was evaluated using Pearson coefficient. Logistic regression assessed predictors associated with PFS. Results Participants had a median age of 47 years, average body mass index of 28.3 kg/m2, and most were white; 52.5% were healthy and 30% were postmenopausal. The most common stage of prolapse was stage I. Age was associated with slightly higher Pelvic Floor Distress Inventory-20 scores (r = 0.41, P = 0.002), corresponding to more bothersome PFS, and lower Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-12 scores, corresponding to worsening sexual function with advancing age (r = −0.41, P = 0.0012). There was no association between age and overall Pelvic Floor Impact Questionnaire scores (P = 0.12). For symptomatic patients, logistic regression showed age to be associated with increased odds of having PFS [odds ratio (OR), 1.881; 95% confidence interval (CI), 1.216–2.91]. Menopausal status was not associated with increased odds of reporting symptoms (OR, 3.05; 95% CI, 0.80–11.62). When age and age by menopause were incorporated in the model, age remained a significant predictor of having PFS (OR, 1.78; 95% CI, 1.13–2.78). Conclusions In this population of community-dwelling nulliparous women, age was associated with worsening sexual function and slightly increased odds of reporting symptoms of pelvic floor disorders.

Pain management strategies for urogynecologic surgery: a review.

Objectives The objectives of this study were to review the recent literature on surgical pain management strategies and to identify those pertinent to urogynecologic surgery. Methods A literature search using Pubmed and MEDLINE was performed for trials on pain management in gynecologic surgery. Evidenced-based recommendations for preoperative, intraoperative, and postoperative pain control strategies for gynecologic procedures by various surgical routes were identified. Articles specifically describing urogynecologic procedures were sought, but quality, randomized trials on pain management modalities in other gynecologic procedures were also included. Results Although few randomized trials on pain management strategies in urogynecologic surgery exist, quality evidence suggests that several preemptive and multimodal analgesia strategies reduce pain and opioid-related adverse events in abdominal, laparoscopic, and vaginal surgery. Evidence supporting these strategies is outlined. Many are likely applicable to urogynecologic procedures. Conclusions Evidence guiding pain management in specific urogynecologic procedures is sparse and should be sought in future studies. When possible, procedure-specific strategies, including preemptive and multimodal techniques, should be implemented.

Levator Plate Upward Lift on Dynamic Sonography and Levator Muscle Strength

To compare digital palpation with levator plate lift measured by endovaginal and transperineal dynamic sonography.

In Vivo Ultrasound Characteristics of Vaginal Mesh Kit Complications

Objective The objective of this study was to investigate the ultrasound characteristics of vaginal mesh in women with vaginal mesh complications. Methods This was a cross-sectional study of women presenting with extrusion complications from vaginal mesh kit for prolapse at our tertiary care center between years 2009 and 2014. We included women who concurrently underwent a 3-dimensional endovaginal ultrasound (EVUS) as part of the clinical evaluation. We excluded women with incomplete charts and poor imaging quality. Subjects were categorized by the presence or absence of associated pelvic pain. Based on ultrasound findings, we compared the location of mesh, the appearance of mesh pattern (flat, folding, prominence, convoluted), and other EVUS characteristics of mesh. Results Forty-six women with vaginal mesh complications and good image quality were included. When comparing mesh length between posterior and anterior compartments, the posterior meshes were significantly longer than the anterior meshes (42.1 [SD, 11.9] mm vs 25.8 [SD, 9] mm; P < 0.0001) and more often associated with pain. In the posterior compartment, the mean mesh length seen on EVUS was significantly longer in women with pain than in women without pain (46.5 [SD, 9] mm vs 31.8 [SD, 12.1] mm; P = 0.0001). There was also a higher proportion of a “flat” mesh pattern, 14 (58.3%) of 25, in the posterior compartment associated with the presence of pain (P = 0.013). In the posterior compartment, a smaller distance between the distal edge of the mesh and the anal sphincter was significantly associated with the presence of pain (8 mm [0–37] vs 21 mm [8–35], P = 0.024). In both compartments, the EVUS had 100% sensitivity for detection of mesh extrusions. Conclusions In this population of patients presenting with mesh complications, the posterior meshes were more often visualized as a “flat” pattern with a higher frequency of pain. Mesh complications of the anterior compartment had a higher frequency of folding and shrinkage.

Is a new high-resolution probe better than the standard probe for 3D anal sphincter and levator ani imaging?

The aim of our study was to determine the accuracy of a new three-dimensional (3D) endoluminal ultrasound probe in assessing the levator ani muscle and anal sphincter complex. A total of 85 patients who had undergone concurrent 3D endovaginal (EVUS) and 3D endoanal (EAUS) ultrasound with both the standard BK 2052 probe and the new high-definition BK 8838 probes were included. For EVUS volumes, the levator ani deficiency (LAD) scores were calculated for each probe. For the EAUS volumes, any defects in the external anal sphincter (EAS) and the internal anal sphincter (IAS) visualized with each probe were recorded. The 3D volumes were evaluated in a blinded fashion. Appropriate statistics were utilized to assess absolute agreements between each pair of imaging modalities. The mean age of the patient population was 59 years (SD ± 10.76), the mean body mass index (BMI) was 28.36 (SD ± 5.99), and the median parity was 2 (range 1, 7). In all, 93% of the patients were Caucasian, 31% had stage 0 or 1 prolapse, while 59% had stage 2 prolapse. The mean total LAD score obtained on EVUS with the standard and the new probes were 11.49 (SD ± 4.94) and 11.53 (SD ± 5.01), respectively, p = 0.3778. Among the 53 patients who had EAUS with both probes, exact agreement for visualization of EAS and IAS for the standard and the new probes was 83% and 98%, respectively. Both transducers can be used for endovaginal imaging of the levator ani muscles interchangeably. Both transducers can be used for endoanal imaging of anal sphincter complex interchangeably.

Long-term impact of abdominal sacral colpoperineopexy on symptoms of obstructed defecation

Objective: To determine the long-term impact of abdominal sacral colpoperineopexy on symptoms of obstructed defecation. Methods: This is a long-term retrospective cohort study. We included women who underwent abdominal sacral colpoperineopexy at our institution between 2001 and 2005. We compared preoperative and postoperative symptoms using the Pelvic Floor Distress Inventory Short Form 20. Postoperative status was assessed on a mailed postal questionnaire. Obstructed defecation was defined using items from the colorectal-anal obstructive subscale. We also assessed patient satisfaction. Descriptive statistics were computed using standard methods for mean, median and proportions. Results: The study includes 38 women (21 completed both preoperative and postoperative questionnaires). Of 27 women completing the postoperative questionnaire at a median follow-up of 65 months (range 35-90 months), 23 (85%) reported obstructed defecatory symptoms and 12 (52%) reported bothersome symptoms. Sixty-three percent were satisfied with the results of their surgery. Conclusions: Abdominal sacral colpoperineopexy is unlikely to eliminate symptoms of obstructed defecation, although two-thirds of the participants remain satisfied with their surgery at 5 years.