Wilma Markus Greston

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%).

Krukenberg Tumors:Can Management Be Improved? 1

Objective: The Montefiore Medical Center experience with women with gastrointestinal (GI) cancer was reviewed to: (1) evaluate clinical parameters in patients with Krukenberg tumor (GI cancer metastatic to the ovaries) and (2) evaluate oophorectomy in GI cancer patients. Methods: (1) Charts of all female patients admitted between 1985 and 1996 with gastric or colon cancer were reviewed. Results: The frequency of Krukenberg tumor was 7/1,021 (0.7%). The median age at presentation was 39.5 years (range 35–80); 5 were premenopausal, 2 of whom were postpartum. Krukenberg tumor was significantly more common in the premenopausal patients with gastric cancer (p = 0.002), colon cancer (p = 0.001), and in both sites combined (p < 0.001). Our rate of pregnancy-associated Krukenberg tumors (28.6%) was significantly higher (p < 0.05) than that found in 4 of 5 large studies. The average survival of our 7 patients was 12.3 months (range 4 days to 26 months), with secondary debulking and chemotherapy offering 1 patient the longest longevity. Only 19/788 (2.4%) women had oophorectomy during their colon cancer surgery revealing 2 (10.5%) Krukenberg tumors, 6 (31.6%) benign solid or cystic ovarian tumors, and 11 (57.9%) normal or atrophic ovaries. Conclusions: Krukenberg tumors are rare. There is no uniformity of data reported in the literature. Krukenberg tumors were more common in premenopausal women with gastric or colon cancer compared to postmenopausal women. Our rate of pregnancy-associated Krukenberg tumors appeared to be higher compared to other studies. Prophylactic oophorectomy in pre- and postmenopausal women should be considered at the time of GI cancer surgery, and requires further study. A national registry combined with prospective, multisite studies are needed to gather data and evaluate treatment.

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.

Characterizing and Reporting Pelvic Floor Defects: the Revised New York Classification System

Abstract: The authors have devised a conceptual model and reporting system for characterizing, grading and staging pelvic floor defects. The system is user friendly and simple to learn and apply. It is based on commonly known anatomic landmarks and can be performed without memorizing or referring to a separate characterization and reporting plan. Completing the accompanying forms is self-explanatory and provides the information needed for proper comprehension and recording of anatomic defects. The model and reporting format have been used at our institutions for 5 years by medical students, residents, fellows and attendings. It has several advantages over the Pelvic Organ Prolapse Quantitation (POPQ) system: (1) it uses known anatomic landmarks rather than alphabetic labels; (2) it grades lateral wall defects which the POPQ system omits; (3) it recognizes and reports isolated defects or tears which present as bulges in the vaginal walls without downward linear descent (prolapse); (4) it uses a one-page reporting form and a one-page checklist and vaginal profile; (5) it can be done easily in both the supine and the standing positions; (6) it requires simple instruments and a disposable measuring tape available in most office settings; (7) it includes urethral hypermobility in its reporting scheme; (8) it includes cervical length, perineal descent and other measurements in its reporting scheme; and (9) it is similar enough to the POPQ system that easy conversion to, and integration with, the POPQ reporting form and vaginal profile is possible. Prospective trials testing the validity of this system and comparing it with the POPQ system for validity, reliability, reproducibility, test–retest analysis, and interobserver and intraobserver variance are warranted.

Management of Krukenberg tumors: an 11-year experience and review of the literature.

Purposes: The Montefiore Medical Center (MMC) experience with Krukenberg tumors (gastrointestinal cancer metastatic to the ovary) was reviewed 1) in order to determine whether it could be used to make clinical management recommendations, eg, differences in treatment based on menopausal status, secondary debulking, prophylactic oophorectomy; 2) to compare the MMC experience to the reported literature, since one of our patients survived 1912 months beyond the generally accepted mean of this rare tumor.Methods: 1) Prospective study from January 1985-April 1996 of 5 patients followed at MMC with a diagnosis of gastrointestinal (GI) cancer metastatic to the ovary; 2) retrospective chart review of all female patients admitted to MMC with a diagnosis of GI cancer during the same time period; 3) computerized literature review from 1966 to 1996.Results: Five patients were followed prospectively. Retrospective chart review identified 1,016 female patients admitted with gastric (231) or colon (785) cancer, 2 additional cases of Krukenberg tumor were identified. Of the 7 patients with Krukenberg tumors the primary tumor was colon in 5 and gastric in 2. The average age at presentation was 49.3 years (range 35-80); 5 were premenopausal, 2 were postmenopausal, and 2 (28.6%) were postpartum. The average survival of these 7 patients was 12.3 months (range 4 days to 26 months). The 5 patients who had ovarian metastases removed at first laparotomy survived an average of 10.8 months. The 1 patient who had a secondary debulking survived longest (26 months). The 1 patient who had no surgery lived 6 months. These numbers are not statistically significant, but do suggest that further study is warranted. Including the prospectively studied patients, 1,021 patients were evaluated. Seven of 1,021 (0.7%) had Krukenberg tumors. Two of 11 (18.2%) premenopausal gastric cancer patients had a Krukenberg tumor, whereas none of the 222 postmenopausal gastric cancer patients did. Similarly, 3 of 41 (7.3%) premenopausal colon cancer patients had a Krukenberg tumor compared to 2 of 747 (0.3%) postmenopausal colon cancer patients. This difference in menopausal status is significant by Fishers Exact test (P <.001). Nineteen patients underwent oophorectomy at the time of primary colon cancer surgery: 11 had normal or atrophic ovaries, 2 thecomas, 4 simple cysts, and 2 Krukenberg tumors. Three of 19 (15.8%) were premenopausal.Conclusions: Review of the literature has identified a number of diagnostic and management issues that appear to impact on survival. These include timing of definitive diagnosis of Krukenberg tumors, ie, before, after, or at the same time as diagnosis of the GI primary tumor; menopausal status; concurrent pregnancy; role of debulking; prophylactic oophorectomy. The prognosis worsens when the primary tumor is identified after the metastasis to the ovary is discovered. Krukenberg tumor is more common in premenopausal women than in postmenopausal women. The number of patients with Krukenberg tumors discovered postpartum in our study was significantly increased compared to the other series in the literature. The number of patients who received prophylactic oophorectomy or secondary debulking in our study was inadequate to draw conclusions regarding a benefit of these procedures. However, a benefit may be suggested for debulking, as survival appears to be increased. More importantly, there may be a role for prophylactic oophorectomies in both pre- and postmenopausal patients, as this would eliminate the need for a repeat laparotomy. A randomized trial is needed to evaluate the role of prophylactic oophorectomy and debulking. Since the clinical and pathologic details in the literature vary widely, it is extremely difficult to compare studies, particularly the treatment and survival of patients with Krukenberg tumors. Reports should include age, site of GI primary, time from diagnosis of primary to ovarian metastasis, and overall survival as well as survival from the time of diagnosis and treatment of the Krukenberg. We wish to alert the clinician that persistent GI symptoms always warrant investigation. Pelvic inflammatory disease, pregnancy, and postpartum endometritis may mask the GI symptoms. Delays in diagnosis should be avoided. During surgery, the gynecologic surgeon must do a complete upper abdominal exploration, and the general surgeon must do a complete pelvic evaluation. Since Krukenberg tumors are rare, a national registry should be started to gather information on these patients; this might lead to better diagnosis and treatment.

Spontaneous clostridia gas gangrene of uterus associated with endometrial malignancy

Only four patients with clostridia sepsis in association with gynecologic malignancy have been reported, all of whom had prior diagnostic or therapeutic intervention. Our patient is the first documented case of such clostridium sepsis that occurred spontaneously, i.e., without previous trauma, instrumentation, radiation or chemotherapy. The value of aggressive management is reviewed.

Abnormal cervical cytology leading to the diagnosis of gastric cancer

Abstract There have been nine cases reported in the English literature in which the finding of malignant cells on cervical/vaginal cytology led to the diagnosis of primary gastric cancer. We report on a patient with gastric carcinoma, metastatic to the cervix, in which the diagnosis was suspected by the finding of signet ring cells on a Papanicolaou smear of the cervix. Prior to treatment of this patient, concordance of signet ring carcinoma on cervical and ascitic fluid cytology and on cervical and gastric biopsies was documented; this has not been reported previously. Thirty-four additional cases of gastric carcinoma metastatic to the cervix are reviewed. This paper is presented to remind the clinician that, however rare, metastases from the gastrointestinal tract to the Uterine Cervix do occur.

Cystic papillary hidradenoma of the vulva: Case report and review of the literature

Papillary hidradenoma of the vulva is a rare, benign neoplasm arising from apocrine sweat glands of the skin. Frequently, this lesion has been mistaken for carcinoma. The treatment of choice is local excision. The prognosis for patients with this tumor is excellent. We present a patient who is unique because she had a lesion which was the largest ever recorded, and which existed over twice as long as any previously described. This case is also presented to remind the clinician that, despite the gross appearance of the tumor which resembles carcinoma on sectioning, biopsy and histological diagnosis should guide the ultimate management of patients with such lesions. The findings in our patient support the view that no matter how large or how long in existence, hidradenoma remains benign.

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.