Tajnoos Yazdany

Review of the diagnosis, management and treatment of fecal incontinence.

Abstract Fecal incontinence is a common problem affecting women but is underreported because of patients’ reluctance to discuss their symptoms and an inconsistent use of screening tools by physicians. Obstetric injury from vaginal delivery is the principal cause of fecal incontinence among young women. Prevalence rates are highest in the elderly, especially those with declining cognitive function. There are multiple diagnostic tests including anal manometry, endosonography, defecography, and pudendal nerve latency testing to assist physicians in the workup of patients and aid in the selection of appropriate treatment options. After patient identification and workup, most patients can be offered conservative measures including dietary measures and biofeedback. Surgery is indicated for specific abnormalities such as rectal prolapse, fistula, and recent obstetrical sphincter injury repair. Management of refractory cases may include sacral nerve stimulation and percutaneous tibial nerve stimulation. Fecal diversion or an artificial bowel sphincter may be considered when all else has failed. Primary care physicians, gynecologists, and specialists in female pelvic medicine should screen women for fecal incontinence. Initial conservative therapy may be directed by the primary health provider, and those resistant to this approach should be referred to specialist care.

Patient beliefs regarding hysterectomy in women seeking surgery for pelvic organ prolapse: findings in a predominantly Hispanic population.

Objective This study aimed to determine the proportion of women who opt for hysterectomy when seeking care for pelvic organ prolapse and the factors important in their decision making. Methods One hundred twenty-four patients from July 2011 through August 2012 seeking care for pelvic organ prolapse were recruited to complete a questionnaire regarding their beliefs about uterine preservation at the time of prolapse repair, as well as the PFDI-7 and PSIQ-12. Patients completed a questionnaire before physician consultation that included demographic data, beliefs regarding the social, sexual, and emotional impact of hysterectomy, and sources of information. Results The women were predominantly Hispanic (77.4%), postmenopausal (65.3%), and sexually active (42.7%). Almost half of the women had a limited education level, defined as no high school degree (49.2%), and the majority of the women had an annual income of less than

Sacrospinous ligament fixation for pelvic organ prolapse in the era of vaginal mesh kits.

25,000 (66.9%). Thirty-one percent of patients desired to retain their uterus at the time of prolapse repair when given the choice. Most patients received information from their health care provider and family members, very few from the Internet or media sources. Conclusions Thirty-one percent of the largely Hispanic women with lower income in this study would choose to preserve their uterus at the time of prolapse repair, a proportion lower than what was reported from previous studies performed in white women with higher income.

Resection of a vulvar arteriovenous malformation in a premenarchal patient.

Purpose of review To examine the sacrospinous ligament as a point of attachment for pelvic organ prolapse procedures, including vaginal mesh kits. Recent findings Pelvic surgeons are increasingly employing the sacrospinous ligament as a point of attachment for biologic grafts and synthetic mesh kits during uterovaginal prolapse repairs. These techniques may have introduced a novel set of complications (mesh extrusion, erosion) in addition to those already known to occur in traditional sacrospinous ligament fixations. Except for limited short-term results, little data are available in the literature regarding surgical outcomes and complications for mesh and graft augmented repairs attached to the sacrospinous ligament. Summary The sacrospinous ligament fixation is a well tolerated and effective procedure for suspension of the vaginal apex. Mesh augmentation using the sacrospinous ligament may improve objective prolapse recurrence, but complications still occur, including those specific to mesh placement.

Association of depression and anxiety in underserved women with and without urinary incontinence.

BACKGROUND: Arteriovenous malformation of the vulva is described in only a few case reports in the literature. Given the complex anatomy of the vulva, arteriovenous malformations in this location present a particularly challenging treatment dilemma. CASE: An 11-year-old premenarchal girl with a large vulvar arteriovenous malformation was monitored for several years. After three episodes of bleeding, despite conservative management with embolization, she was taken urgently to the operating room for resection of the lesion. A multidisciplinary team participated in the 12-hour procedure. Several months after the initial surgery, the patient is without complaints and adjusting well. Labial reduction will be required once she is fully grown. CONCLUSION: Arteriovenous malformations of the vulva require treatment before the onset of menarche because of the potential for massive hemorrhage. If first-line conservative treatment with embolization fails, a multidisciplinary team should be assembled for surgical treatment.

Women's Perception of Their Vulvar Appearance in a Predominantly Low-Income, Minority Population

Objectives Depression and anxiety are found in increasing rates in those with lower urinary tract disease. The manner in which this association further impacts underserved women has not been fully evaluated. Methods For this study, 429 patients were included from general gynecology and female pelvic medicine and reconstructive surgery clinics between the ages 18 and 80 years at a Los Angeles County teaching hospital. Patients who met the study criteria completed the following questionnaires: the Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory, Pelvic Floor Distress Inventory Short From, Pelvic Floor Impact Questionnaire Short Form, and the SF-12 Health Survey. Data analyses included descriptive statistics, tests of mean difference, correlations, and regression models to compare with categories of incontinent and continent women. Results Of the 429 patients, 71.8% were Hispanic with a mean age of 46.6 years (range, 18–80 years) and median parity of 2.83 (0–17). Among the patients with incontinence, 34.1% reported mild, moderate, or severe depression on the BDI-II compared with 21% patients without incontinence (P = 0.003). In addition, 20.4% of the incontinent group had severe depression (BDI-II, >20), whereas only 8.2% in the continent group had severe depression (P = 0.001). The higher Urinary Distress Inventory scores did correlate with the worsening Patient Health Questionnaire (r = 0.263; P = 0.0001), BDI-II (r = 0.209; P = 0.002), and SF-12 Health Survey mental scores (r = −0.140; P = 0.04). Conclusions Current findings show that approximately one third of the women reporting incontinence in our sample had depression. Underserved patients seeking medical care for incontinence in publically funded hospitals may have depression and anxiety at rates higher than those reported in the general population.

The use of infection prevention practices in female pelvic medicine and reconstructive surgery.

Objectives The aim of this study was to investigate the effect of certain predictors, such as age and media exposure, on a womans perception of her vulva anatomy. Methods We recruited 346 female visitors from a county teaching hospital to complete questionnaires that determine the following: demographics, satisfaction with their vulvar appearance, whether they consider their vulvar anatomy to be normal, exposure to media (namely having had Internet access or learned about genitalia from the Internet or any type of pornography), and consideration of cosmetic vulvar surgery for themselves. The participants were divided into 2 age groups; group I (45 years or older) and group II (18–44 years). Personal satisfaction, self-perceived normality, and ones consideration of cosmetic vulvar surgery were then compared between the 2 groups. Results A large percentage of women considered their vulva to be “normal,” 93.1% of group I versus 96.0% of group II (P = 0.24). For group I, 87.5% were satisfied with their vulva versus 91.5% of group II (P = 0.24). The participants with media exposure report self-perceived normal-appearing vulvas at higher rates than those not exposed to media (96.7% vs 90.8%, respectively; P = 0.03). Of those who were satisfied with their vulvar appearance, 92.3% were exposed to media, whereas 84.5% were not exposed (P = 0.03). However, of the participants who reported consideration of vulvar surgery, 74.4% of them had exposure to media, whereas 25.6% had no media exposure (P = 0.034). Conclusions Age does not play a significant role in determining a womans acceptance of the appearance of her vulvar anatomy. However, media exposure was a significant determinant for self-perception, satisfaction, and desire for cosmetic vulvar surgery.

Uterine Conservation at the Time of Pelvic Organ Prolapse Treatment: the Options for Patients and Providers

Purpose of review This review discusses recently published and relevant data on the preventive techniques used to reduce perioperative infections in urogynecologic procedures. Recent findings The consequences of postprocedural and postsurgical infections in Female Pelvic Medicine and Reconstructive Surgery can be challenging. Infections can range from a simple urinary tract infection to a devastating infection of vaginally implanted mesh that requires multiple subsequent reoperations. Measures taken to reduce the chances of postprocedural or postsurgical infections may provide better outcomes, with lower costs and less litigation. Recent studies on the outcomes of specific practices used in urology and urogynecology to prevent infectious complications can help guide clinicians through the decision-making process on which new practices to adopt. Summary Good evidence-based practices to reduce or prevent infectious complications after procedures in female urology and urogynecology will save time, lower morbidity, reduce costs, and improve patient outcomes and satisfaction. However, there is still a great need for more level I evidence on infection prevention practices utilized in female urology and urogynecology.

Chronic 3rd Degree Laceration Repair

Surgical management of pelvic organ prolapse (POP) is a growing field. POP surgery has traditionally involved performing a hysterectomy at the time of repair for apical compartment prolapse. In recent years, providers and patients have called the medical necessity of this practice into question. There is growing evidence that uterine conservation may be a viable option during the time of prolapse repair. This article will review the historical perspective of uterine conservation, patient selection, conservative management, as well as surgical techniques and recent supporting literature of uterine-sparing procedures for POP. As women seek more minimally invasive approaches for prolapse repair, we anticipate that uterine conservation will continue to gain popularity.

Determining outcomes, adverse events, and predictors of success after sacral neuromodulation for lower urinary disorders in women

A 54-year-old Korean woman was referred to my department because PETCT scan showed a hypermetabolic spot on the aortocaval area. She underwent radical abdominal hysterectomy with bilateral salpingooophorectomy, appendectomy, and bilateral pelvic lymphadenectomy followed by concurrent chemo-radiation because of pelvic lymph node metastasis and parametrial involvement in other hospital a few years ago. We performed laparoscopic excision of para-aortic metastatic lymph nodes on Jul 16, 2013. The final histopathological report showed that aortocaval lymph node was metastatic squamous cell carcinoma which greatest size was 2.6cm with extranodal extension. Six of all retrocaval lymph node was metastatic squamous cell carcinoma. After surgery, she received adjuvant chemotherapy and she is healthy without evidence of disease recurrence.