Sarah A. Collins

Effects of Circumcision on Male Sexual Function: Debunking a Myth?

PURPOSE Claims of superior sexual sensitivity and satisfaction for uncircumcised males have never been substantiated in a prospective fashion in the medical literature. We performed such a study to investigate these assertions. MATERIALS AND METHODS The Brief Male Sexual Function Inventory (BMSFI) was administered to sexually active males older than 18 years before undergoing circumcision. After a minimum interval of 12 weeks after the operation, the survey was again administered. The 5 domains of the BMSFI (sexual drive, erections, ejaculation, problem assessment overall satisfaction) were each given a summed composite score. These scores before and after circumcision were then analyzed by Wilcoxon signed-rank testing. RESULTS All 15 men who participated in the study between September 1999 and October 2000 were available for followup. Mean patient age plus or minus standard deviation was 36.9 +/- 12.0 years. There was no statistically significant difference in the BMFSI composite scores of reported sexual drive (p >0.68), erection (p >0.96), ejaculation (p >0.48), problem assessment (p >0.53) or overall satisfaction (p >0.72). CONCLUSIONS Circumcision does not appear to have adverse, clinically important effects on male sexual function in sexually active adults who undergo the procedure.

The effect of pessaries on the vaginal microenvironment

OBJECTIVE The objective of the study was to evaluate the differences in vaginal culture, microscopy, and Gram stain between postmenopausal women who wear pessaries and those who do not to explain pessary-related, bothersome vaginal discharge. STUDY DESIGN Postmenopausal women not using exogenous estrogen who had either been wearing a pessary for at least 3 months or who were undergoing their first pessary fittings were approached for enrollment. Symptoms were assessed, and vaginal fluid was collected for culture, microscopy, and Gram stain. A cross-sectional analysis was performed, comparing the new and return pessary wearers. The new pessary users were also sampled at 2 weeks, 3 months, and 6 months after fitting. RESULTS Women who wore pessaries were more likely to be bothered by discharge (30.0% vs 2.1%, P < .001). They were also more likely to show microscopic evidence of vaginal inflammation and vaginitis. Prospective data showed that these changes developed during the first 2 weeks of pessary use. Aerobic and anaerobic organisms were nearly identical in women with and without bothersome vaginal discharge in the cross-sectional analysis and at all time points in the prospective analysis. CONCLUSION Pessary-related, bothersome vaginal discharge develops early and may be due to an inflammatory process in the vagina.

Complex sacral abscess 8 years after abdominal sacral colpopexy.

BACKGROUND: Sacral colpopexy is an effective, durable repair for women with apical vaginal or uterovaginal prolapse. There are few reports of serious complications diagnosed in the remote postoperative period. CASE: A 74-year-old woman presented 8 years after undergoing posthysterectomy abdominal sacral colpopexy using polypropylene mesh. Posterior vaginal mesh erosion had been diagnosed several months before presentation. She suffered severe infectious complications including an infected thrombus in the inferior vena cava, sacral osteomyelitis, and a complex abscess with presacral and epidural components. Surgical exploration revealed an abscess cavity surrounding the mesh. CONCLUSION: Although minor complications commonly occur after sacral colpopexy using abdominal mesh, serious and rare postoperative infectious complications may occur years postoperatively.

Regional heterogeneity in expression of the sphingosine-1-phosphate pathway in the female rat lower urinary tract.

OBJECTIVE We investigated the existence and regional distribution of sphingosine-1-phosphate regulatory enzymes and receptors in the lower urinary tract and determined the functional role of sphingosine-1-phosphate receptors in the bladder. STUDY DESIGN Lower urinary tract tissue from 10 female rats was harvested for real-time reverse transcriptase-polymerase chain reaction or organ bath physiology, whereas blood serum was obtained for high-performance liquid chromatography determination of sphingosine-1-phosphate levels. Statistical analysis included the Student t test and analysis of variance. RESULTS All 3 sphingosine-1-phosphate receptors and major enzymes were expressed throughout the lower urinary tract, but expression and physiologic force generation varied among regions. Sphingosine-1-phosphate was detected in serum. CONCLUSION We provide novel data that the sphingosine-1-phosphate signaling pathway regulatory proteins exist throughout the female rat lower urinary tract, but that relative expression exhibits regional heterogeneity corresponding with lower urinary tract contractile response to sphingosine-1-phosphate. Our study suggests that sphingosine-1-phosphate signaling is important in the lower urinary tract and identifies this pathway as a possible target for altering bladder smooth muscle tone.

Effect of surgical approach on physical activity and pain control after sacral colpopexy

OBJECTIVE We sought to compare recovery of activity and pain control after robotic (ROB) vs abdominal (ABD) sacral colpopexy. STUDY DESIGN Women undergoing ROB and ABD sacral colpopexy wore accelerometers for 7 days preoperatively and the first 10 days postoperatively. They completed postoperative pain diaries and Short Form-36 questionnaires before and after surgery. RESULTS At 5 days postoperatively, none of the 14 subjects in the ABD group and 4 of 28 (14.3%) in the ROB group achieved 50% total baseline activity counts (P = .283). At 10 days, 5 of 14 (35.7%) in the ABD group and 8 of 26 (30.8%) in the ROB group (P = .972) achieved 50%. Postoperative pain was similar in both groups. Short Form-36 vitality scores were lower (P = .017) after surgery in the ABD group, but not in the ROB group. CONCLUSION Women undergoing ROB vs ABD sacral colpopexy do not recover physical activity faster, and pain control is not improved.

Clinical and Molecular Epidemiology of Childhood Invasive Nontypeable Haemophilus influenzae Disease in England and Wales.

Introduction: In countries with established Haemophilus influenzae type b (Hib) immunization programs, nontypeable H. influenzae (NTHi) is now responsible for nearly all invasive H. influenzae cases across all age groups. Methods: Public Health England (PHE) conducts enhanced national surveillance of invasive H. influenzae disease in England and Wales. Invasive NTHi isolates submitted to Public Health England from children of ages 1 month to 10 years during 2003–2010 were characterized by multilocus sequence typing (MLST). Detailed clinical information was obtained for all laboratory-confirmed cases of invasive NTHi disease in children during 2009–2013. Results: In England and Wales, there were 7797 cases of invasive H. influenzae disease diagnosed during 2000–2013 and 1585 (20%) occurred in children aged 1 month to 10 years, where NTHi was responsible for 31–51 cases (incidence, 0.53–0.92/100,000) annually. Detailed clinical follow-up of 214 confirmed NTHi cases diagnosed in this age-group during 2009–2013 revealed that 52% (n = 111) occurred in <2-year-old and 52% (n=110) had comorbidity. Bacteremic pneumonia was the most common clinical presentation (n = 99, 46%), 16% (n = 34) required intensive care and 11% (n = 23) died. Characterization by biotyping and MLST of 316 NTHi strains from children with invasive disease during 2003–2010 revealed a genetically heterogeneous population (155 MLSTs) with diverse biotypes and no association with comorbidity status, clinical disease or outcome. Conclusions: The high level of genetic diversity in invasive NTHi strains highlights the difficulties in developing an effective vaccine against this pathogen.

Nerve injury during uterosacral ligament fixation: a cadaver study

Introduction and hypothesisThe objective of this study was to identify nerve(s) vulnerable to entrapment during uterosacral ligament fixation (USLF), which could cause postoperative lower extremity pain previously described in the literature.MethodsPreserved cadavers in a medical anatomy course were used. Before the students’ pelvic dissections, a 2-0 prolene suture was placed in the middle third of each left uterosacral ligament visualized. The sutures were re-evaluated at the end of the course.ResultsNine sutures remained in place after the course, and one entrapped a nerve. It was part of the inferior hypogastric plexus, included fibers from S2 and S3, and radiated to the bladder and rectum. The posterior femoral cutaneous nerve was lateral and posterior to this nerve.ConclusionsThe inferior hypogastric plexus is vulnerable during USLF. Entrapment of S2 and S3 fibers could cause pain in their respective dermatomes and could be responsible for the postoperative pain previously described.

Pneumococcal conjugate vaccine failure in children: A systematic review of the literature

BACKGROUND Pneumococcal conjugate vaccines (PCVs) are highly effective in preventing pneumococcal invasive disease (IPD) due to serotypes included in the vaccines. The risk of vaccine-type IPD in immunised children (i.e. vaccine failure) has not been systematically assessed in countries with established PCV programmes. METHODS We undertook a systematic review of the English literature published from January 2000 to April 2016 to evaluate the vaccine schedule, risk factors, serotype distribution, clinical presentation and outcomes of vaccine failure in children vaccinated with the 7-valent (PCV7), 10-valent (PCV10), and 13-valent (PCV13) vaccines. Data sources included MEDLINE, EMBASE, Cochrane library, and references within identified articles. RESULTS We identified 1742 potential studies and included 20 publications involving 7584 participants in children aged ⩽5year-olds: 5202 received 2 doses followed by a booster in 10 studies, (68.6%), 64 (0.8%) received 3 doses without a booster in 2 studies, and 2318 received a 3+1 schedule (30.6%) in 8 studies. A total of 159 vaccine failure cases were identified, representing 2.1% [95% CI: 1.8-2.4%] of the reported IPD cases. Most studies did not report clinical characteristics or outcomes. Among eight studies reporting comorbidities, 33/77 patients (42.9%) had an underlying condition. The main serotypes associated with vaccine failure were 19F (51/128 cases with known serotype; 39.8%), 6B (33/128; 25.8%), and 4 (10/128; 7.8%). Only five studies reported patient outcomes, with a crude case fatality rate of 2.4% (2/85; 95%CI: 0.3-8.5%). CONCLUSION Pneumococcal conjugate vaccines have been implemented in national immunisation programmes for more than a decade, yet there are only a few studies reporting vaccine failure. PCV failure is rare, irrespective of vaccine or schedule. Co-morbidity prevalence was high amongst vaccine failure cases but case fatality rate was relatively low. There is a need for more systematic reporting vaccine failure cases in countries with established pneumococcal vaccination programmes.

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.

Correlation of POP-Q posterior compartment measures with defecatory dysfunction

Introduction and hypothesisThe relationships of Pelvic Organ Prolapse Quantification (POP-Q) items pb and Bp with defecatory dysfunction were evaluated with the hypothesis that increased values for both items would correlate with symptoms of stool trapping.MethodsPelvic Floor Distress Inventory (PFDI-20) results and POP-Q exams from 1,663 urogynecology patients were compiled in a database. Rectocele was defined as POP-Q point Bp > −0.5 and perineocele as pb >3. PFDI-20 questions were used to compare defecatory symptoms and bother in women with and without rectocele and perineocele.ResultsWhile perineocele was not associated with symptoms or bother, women with isolated rectoceles had higher rates of splinting (p < 0.001) and incomplete evacuation (p = 0.001) and higher bother scores (p < 0.001) than those with neither rectocele nor perineocele.ConclusionsThe POP-Q Bp point, but not the pb measurement, correlates with symptoms of defecatory dysfunction.