The Effect of Aging on Pelvic Floor Pressure Measurements in Nulliparous Women

Aims: To investigate the correlation between age and 3-dimensional pelvic floor manometry parameters, sexual function, and urinary status in old post-menopausal versus young nulliparous women. Methods: This was a cross-sectional study. Two groups of young (18 - 40 years) and old (52 - 85 years) nulliparous volunteers completed Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), and Female Sexual Function Inventory (FSFI-19) and underwent a 3-dimensional pelvic floor manometry. Results: The study included 9 young participants with a mean age of 28.6, and 10 old participants with a mean age of 61.8. All the older participants were postmenopausal and all the young participants were premenopausal. Mean PFDI-20 score was significantly higher in the older group: 52 ± 12 versus 4 ± 4, p= 0.001. Urinary Distress Inventory score (UDI-6, part of PFDI questionnaire) was higher amongst the older group: 28 ± 26 versus 3 ± 8, p= 0.006. All young participants scored zero in their PFIQ-7 while the older participants averaged 31 out of maximal score of 300. While sexual activity was higher in the younger group (89% versus 60%), sexual function assessed through the FSFI-19, was not significantly different between the two groups. Valsalva pressures obtained from manometry measurements were significantly higher in the older group (mean 230 mm Hg versus 161, p= 0.015). Conclusions: Post-menopausal women have higher pelvic floor and urinary symptoms associated with increased Valsalva pressures as measured by vaginal manometry.

Utilization of Artificial Intelligence for Diagnosis and Management of Urinary Incontinence in Women Residing in Areas with Low Resources: An Overview

Urinary incontinence (UI) is a distressing condition involving involuntary loss of urine from the body. Urinary incontinence can negatively impact a person’s overall quality of life and lead them into stages of embarrassment and depression. It is an underrepresented and undertreated condition prevalent in women, especially in low socioeconomic regions where women may not be able to express their concerns due to unawareness of diagnosis and treatment/management options. There are different diagnostic and management protocols for UI;however, utilizing artificially intelligent systems is not standard care. This paper overviews the use of artificial intelligence in women’s health and as a means of cost-effectively diagnosing patients, and as an avenue for providing low-cost treatments to women that suffer from urinary incontinence in low-resource communities. Studies found that these systems, mainly utilizing artificial neural networks (ANNs) and convolutional neural networks (CNNs), served to be an effective method in diagnosing patients and providing an avenue for personalized treatment for improved patient outcomes. A simple artificial intelligence (AI) model utilizing Multilayer Perceptron (MLP) Networks was proposed to diagnose and manage urinary incontinence.

The “Mothers’ Pelvic Floor Support (RECOUP) Clinic” Referral Patterns in Washington DC Area of the United States

Introduction: Childbirth entails many physical, emotional, and societal changes and repercussions, including postpartum depression affecting 20% - 30%, postpartum blues, and post-traumatic stress disorder. We hypothesized that many physical and mental health manifestations of pelvic floor disorders might be masked by the ordinary course of postpartum recovery and not referred out for specialized evaluation. Leveraging our RECOUP (Mothers’ Pelvic Floor Support) Clinic, we explored the referral patterns to this clinic to test our hypothesis. Methods: The study is a single-center observational study including women who presented to the RECOUP Clinic. The clinic’s target patient population includes those with a perineal injury, instrumental delivery, urinary retention, urinary or fecal incontinence, pain, or pelvic pressure associated with childbirth. Results: One hundred and one women were evaluated in the RECOUP Clinic. 45/101 (45%) were not referred but found their way to the clinic through social media and the internet. Very few patients 4/101 (4%) were referred with anal sphincter injuries. (52/101, 51%) were referred after many requests by the patients. Conclusions: Over ninety percent of women evaluated at RECOUP Clinic are self-referred or referred upon the mother’s request. There is an opportunity for physicians and other providers to become more familiar with dedicated clinics for postpartum pelvic floor care. Enhancing such clinical services allows one to reach patients who otherwise will go unserved. Summary: Childbirth is an event with substantial ramifications that should be addressed, and we believe a specialized clinic is an optimal facility, so the RECOUP was founded. In this paper, we explored the referral patterns to our RECOUP clinic.

Resection of Vaginal Septum in Obstructed Hemivagina and Ipsilateral Renal Anomaly: Utility of Three Dimensional Intraoperative Ultrasound

Background: Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome is a rare congenital condition of the female urogenital tract, presenting intraoperative challenges. We demonstrate the utility of three dimensional intraoperative ultrasound to better delineate anatomy and aid in optimal resection of the vaginal septum. Case: A 12-year-old female was referred to pediatric and adolescent gynecology for irregular periods and evaluation of her gynecologic organs. Imaging studies confirmed OHVIRA syndrome. She underwent uncomplicated vaginal septum resection, guided by three dimensional intraoperative ultrasound. Summary and Conclusion: Intraoperative ultrasound can better delineate challenging anatomy. We show that three dimensional intraoperative ultrasound offers significant advantages over traditional two dimensional ultrasound and is a supplement to MRI, which may be helpful in complex anatomical cases like OHVIRA syndrome.

Preoperative Gabapentin Dosage Relationship to Length of Stay in Post-Anesthesia Care Unit in Patients Undergoing Pelvic and Breast Surgery

Background: Gabapentin is routinely prescribed preoperatively to decrease postoperative pain intensity. It is included in the enhanced recovery after surgery (ERAS) recommendations. Objective: To analyze correlation of gabapentin dosage and post anesthesia care unit (PACU) length of stay (LOS) and cost. Study Design: A retrospective chart review of patients who underwent general anesthesia and received preoperative oral gabapentin from June 2017 to August 2017 for pelvic and breast procedures. The main outcome was correlation between PACU LOS and gabapentin dosage in the outpatients. Financial analysis was performed to assess the cost to the hospital associated with increased LOS. Results: Of the 636 patients, 405 patients received 300 mg and 231 patients received 100 mg gabapentin. Mean dosage per kg (mg/kg ± SD) was 3.12 ± 1.51 (range: 0.86 to 6.12). PACU LOS was 96 ± 77 (minutes ± SD) in patients receiving 100 mg and 120 ± 96 in patients receiving 300 mg capsule (p = 0.001). Linear regression analysis, failed to show a statistically significant correlation between per kg dosage and PACU LOS (p = 0.13). Using multiple regression analysis, we calculated the correlation coefficient to be +1.71 minutes per 1mg/kg gabapentin (95% CI: -3.75 to +7.10, p = 0.54) after adjusting for confounders. Adding 3 mg/kg to pre-op gabapentin dosage of all outpatients cost on average, an extra $9794 per month in this cohort. Conclusion: Every 1mg/kg increase in gabapentin dosage adds an estimated 7.1 minutes to PACU LOS. A 3 mg/kg increase in gabapentin adds estimated 22 additional minutes in PACU LOS. Unfortunately, increase LOS is associated with increased hospital costs.

The Utility of Endovaginal Ultrasound in the Design of a Sacrospinous Ligament Anchoring Device in Patients with and without Pelvic Organ Prolapse

Objective: To determine whether endovaginal ultrasound is a reliable measure in visualization of the sacrospinous ligament among women with prolapse versus women without prolapse, and thus might be clinically applicable in the design of an ultrasound-guided device for performing sacrospinous ligament anchor placement as a treatment for pelvic organ prolapse. Methods: In the first phase of this study we performed a sacrospinous anchor placement in four normal fresh-frozen female pelves. Afterwards, an endovaginal ultrasound was performed to visualize the anchor localization which was validated by dissection of the cadaveric pelves. In the second phase of the study: two groups of volunteer females with and without pelvic organ prolapsed (POP-group, vs NON-POP group) were evaluated by endovaginal ultrasound to localize the sacrospinous ligament. Results: Cadaveric dissection demonstrated accurate anchor placement into the 8/8 sacrospinous ligament. We performed endovaginal ultrasound in a total of 17 N-POP and 10 (POP) patients. Among the N-POP group, the right and left ischial spines were visible in 6/17 (35%) and (6/17) 35% vs 0/10 (0%) for both right and left sides in POP group (p = 0.008). The right sacrospinous ligament was visualized in 4/17 (23%) N-POP subjects and 0/10 POP subjects (p = 0.27) and the left sacrospinous ligament was visualized in 7/17 (41%) N-POP subjects and 2/10 POP subjects (p = 0.48). Conclusions: Sacrospinous ligament and the ischial spines couldn’t be reliably visualized among women with or without pelvic organ prolapse using endovaginal ultrasound, although the structures are visualized more in some of the non-prolapsed women. The sacrospinous anchoring device demonstrated accurate placement by cadaveric dissections.

Vaginal Robotic Supracervical Hysterectomy in an Ovine Animal Model: The Proof of Concept

Objective: To gain insight into the feasibility and safety of a novel vaginal robot for performing supracervical hysterectomy in an ovine model. Introduction: The clinical application of transvaginal natural or fice transluminal endoscopic surgery (vNOTES) has broadened significantly. vNOTES reduces wound complications such as infection, hematoma formation, or herniation and is currently utilized for hysterectomy, adnexal surgery, myomectomy, and staging surgery for endometrial cancer. Robotic assistance has been proposed to overcome the current vNOTES mechanical obstacles. The implementation of the current robots has limited utility due to their bulk and inflexibility. Robotic Natural Orifice Transluminal Surgery (rNOTES) is the new frontier in advancement of surgical robots. In developing new task specific robots, it is important to utilize an accurate model for testing. A novel vaginal robot introduced through the posterior cul-de-sac to perform a complete retrograde hysterectomy is the subject of this study. Methods: The study was conducted at the animal lab, Asaf-Harofe hospital, Israel. The ovine model was preferred since the anatomical landmarks and vascular anatomy are comparable to the human except for a bicornuate uterus in sheep. A vaginal robotic supra-cervical hysterectomy was performed in a sheep. Results: A vaginal robotic supracervical hysterectomy was performed successfully in an ovine model. The uterus was extracted via the entry point in the pouch of Douglas. 20 cc of blood loss was reported and no complications were observed. Conclusions: Vaginal supracervical hysterectomy via a vaginal approach using a novel robotic system was found to be feasible.