Vaginal Insertion Research Articles

A case of an ectopic ureter with vaginal insertion diagnosed in adulthood

Ectopic ureter which is one of the causes of urinary incontinence in adults is a rarely seen entity. In this case, diagnosis and treatment of urinary incontinence in a female patient thought to originate from an ectopic ureter will be evaluated. On magnetic resonance (MR) urograms double collecting system in both kidneys and also grade 3 hydroureteronephrosis in the collecting system which drained the upper pole of the right kidney were seen. The ureter draining the upper pole of the right kidney was seen to open into a 24 mm-wide cystic pouch inside the right lateral wall of the vaginal cuff. During vaginal examination an orifice of 3 mm was observed on the right wall of the vagina. Right ureteroneocystostomy was performed. Ureters with ectopic orifices are very rarely seen causes of urinary incontinence. To establish the diagnosis, this pathology must be recognized, should be kept in mind, and appropriate diagnostic methods must be used.

A systematic review and meta-analysis of the impact of native tissue repair for pelvic organ prolapse on sexual function.

The aim of this review was to investigate the impact of native tissue repair for pelvic organ prolapse (POP) on overall sexual function and dyspareunia. Cochrane Incontinence Group Specialized Register of Controlled Trials, The Cochrane Central Register of Controlled Trials, MEDLINE, and Embase were searched for trials of prolapse surgery assessing sexual function and dyspareunia before and after surgery. We assessed observational studies and randomized controlled trials investigating the impact of surgical correction of POP on sexual function. Surgical interventions assessed were anterior and/or posterior repair with or without a vaginal hysterectomy. Studies including patients undergoing concurrent incontinence surgery or vaginal mesh insertion were excluded from the analysis. Dyspareunia was analyzed separately. We identified 674 potential citations, of which 14 articles assessed sexual function and/or dyspareunia before and after traditional prolapse surgery. The results suggest evidence for significant improvement in sexual function postsurgery, with a standardized mean difference of -0.55, 95 % confidence interval (CI) -0.68 to -0.43 in favor of surgical correction. Dyspareunia rates were also significantly improved postoperatively, with overall odds ratio of at least 2.5 times as likely as the chances of deterioration. Sexual function is significantly improved and dyspareunia significantly reduced following native tissue prolapse surgery. There were several methodological problems with the quality of the primary research, particularly related to study heterogeneity, use of different outcome measures, and absence of well-designed randomized controlled trials.

Vaginal Insertion of Kidney and Robotic Assisted Laparoscopic Kidney Transplantation: The First World Experience.

Introduction: Following laparoscopic or robotic assisted living donor nephrectomy kidney retrieval through vagina are reported. Here we present our initial experience of insertion of kidney through vagina and robotic assisted laparoscopic kidney transplantation (RKT). Material and methods: Permission of IRB was obtained. Major inclusion criteria were at least one normal vaginal delivery and good capacity of vagina on examination. Exclusion criteria were active vaginal infection or atrophic vagina. Antibiotic prophylaxis was used. Total 3 transplants carried out. Recipient surgery: In 30 degree Trendelenberg and Lithotomy position six ports were placed; one camera port, three robotic ports, one assistant port and one port for suction and irrigation. External iliac vessels were dissected. Robot was undocked. Gynecologist placed an incision in posterior fornix of vagina and kidney was inserted into abdomen. Wound of posterior fornix was closed and vagina packed. Robot was re-docked and kidney brought close to previously dissected external iliac vessels. Vascular anastomosis was carried out by Gore Tex CV6 suture. Ureteric reimplantation was performed using 4/0 vicryl without stent. Results: There was no injury to kidney parenchyma, no delayed graft function and no infection. Mean anastomosis time, rewarming time and blood loss were 51 min., 72 min., 67.5 ml respectively. Six months graft and patient survival is 100%. Conclusion: Vaginal insertion of kidney and RKT is feasible and safe. Larger studies are required for confirmation of these findings.

Vaginal Insertion of Kidney and Laparoscopic Kidney Transplantation: An Initial Experience.

Introduction: Minimally invasive surgery (MIS) for kidney transplantations are performed either by small incision during open surgery, laparoscopically or robotically. Following MIS, specimen retrieval through vagina is well known. Following laparoscopic or robotic assisted living donor nephrectomy kidney retrieval through vagina are reported. Here we present our initial experience of insertion of kidney through vagina and laparoscopic kidney transplantation (LKT). Material and methods: Permission of IRB was obtained. Major inclusion criteria were at least one normal vaginal delivery and good capacity of vagina on examination. Exclusion criteria were active vaginal infection or atrophic vagina. Antibiotic prophylaxis was used. Total 8 transplants carried out. Recipient surgery: In 20 degree Trendelenbergh position five ports are placed. External iliac vessels were dissected. Subsequently, lithotomy postion was given and gynecologist manipulated uterus and vagina. Laparoscopically incision in posterior fornix of vagina was made and kidney was inserted into abdomen. Posterior fornix was closed and vagina packed. Both legs were straightened and pneumoperitoneum was restrored. Kidney was brought close to iliac vessels. Laparoscopic free hand vascular anastomosis and ureteric reimplantation was performed. Results: Mean time for cold ischemia, anastomosis, re-warming, and operation was 103 min., 40 min., 59.5 min., 255 min. respectively. No DGF. No infection. One year graft and patient survival is 100%. Conclusion: Vaginal insertion of kidney and laparoscopic kidney transplantation are safe and effective. Larger studies are required for confirmation of these findings

Nerves supplying the internal anal sphincter: an immunohistochemical study using donated elderly cadavers

Nerves serving the internal anal sphincter (NIAS) have been described as the lower rectal branches of the pelvic autonomic nerve plexus. However, their topographical anatomy and fiber components have remained unclear. Using histological sections from ten elderly donated cadavers, we investigated the topographical anatomy and composite fibers of the NIAS using immunohistochemistry for S100 protein, neuronal nitric oxide synthase (nNOS), vasoactive intestinal polypeptide (VIP) and tyrosine hydroxylase (TH). At the 2-3 o'clock position in the lower rectum, the NIAS originated from nerves at the posterolateral corner of the prostate in males or in the lower paracolpium in females. The nerves ran inferiorly along the internal aspect of the levator ani muscle, and joined branches of the myenteric plexus at a level slightly above the epithelial junction. The NIAS contained both nNOS-positive parasympathetic nerve fibers and TH-positive sympathetic fibers, but VIP-positive fibers were few in number. The origin of the NIAS at the posterolateral corner of the prostate as well as in the lower paracolpium might be sacrificed or damaged during radical prostatectomy or tension-free vaginal tape insertion. Low anterior resection of rectal cancer will most likely render damage to the NIAS because of its intersphincteric course. Although the nerve composition of the NIAS is characterized by a higher proportion of sympathetic nerve fibers than the myenteric plexus in the large intestine, their role is unclear. However, evaluation of sphincteric function after surgery would appear to be difficult because of the complex control mechanism independent of nerve supply.

Measuring Adherence by Visual Inspection of Returned Empty Gel Applicators in the CAPRISA 004 Microbicide Trial

In the CAPRISA 004 trial, adherence was estimated as the proportion of reported sex acts covered by two gel doses, which was assessed by counting returned empty gel applicators. The returned empty applicators were inspected visually in a standardized manner for residue on the outside of the applicator, as an indicator of vaginal insertion. Over 15 months, spanning 11,839 study visits by 838 women, a total of 59,800 returned empty applicators were inspected. By visual assessment, 77.5 % of these applicators appeared to have been inserted. To test the accuracy of the assessment we fitted a Cox model and found that the risk for HIV infection was doubled when less than half of the returned empty applicators had been assessed as not inserted in the vagina. Visual inspection enhanced both the accuracy of the adherence measurement and aided identification of mechanical problems with applicator use experienced by women in the trial.

Vaginal Misoprostol versus Vaginal Estradiol in Overcoming Unsatisfactory Colposcopy

Background: Unsatisfactory colposcopy, an inability to visualize the entire transformation zone, is found in about 10-20% of the patients undergoing the procedure. These patients usually require conization for a comprehensive evaluation of the cervix. Our study aims to compare the efficacy and safety of vaginal misoprostol versus vaginal estradiol in overcoming unsatisfactory colposcopy. Methods: We studied 48 women with unsatisfactory colposcopy. They were randomized into two groups: group I (n = 24) received 200 µg misoprostol vaginally and colposcopy was repeated after 6 h, while the subjects in group II (n = 24) were prescribed a 7-day course of 50 µg estradiol for vaginal insertion followed by a repeat colposcopy. The efficacy and safety of these two drugs were compared. Results: Repeat colposcopy was satisfactory in 70.8% of the women given vaginal misoprostol compared to 82.6% of the women who used vaginal estradiol. The difference was not statistically significant. The adverse effects were reported more often by the women in the misoprostol group (41.6%) as compared to those in estradiol group (13%) (p = 0.04). Conclusion: Both estradiol and misoprostol were comparable in overcoming unsatisfactory colposcopy. However, a higher incidence of adverse effects was noted with misoprostol as compared to estradiol.

Morphometry of the Pelvic Floor Muscles in Women With and Without Provoked Vestibulodynia Using 4D Ultrasound

It has been suggested that pelvic floor muscles (PFMs) play an important role in provoked vestibulodynia (PVD) pathophysiology. Controversy in determining their exact contribution may be explained by methodological limitations related to the PFM assessment tools, specifically the pain elicited by the measurement itself, which may trigger a PFM reaction and introduce a strong bias. The aim of this study was to compare PFM morphometry in women suffering from PVD to asymptomatic healthy control women using a pain-free methodology, transperineal four-dimensional (4D) ultrasound. Fifty-one asymptomatic women and 49 women suffering from PVD were recruited. Diagnosis of PVD was confirmed by a gynecologist following a standardized examination. All the participants were nulliparous and had no other urogynecological conditions. The women were evaluated in a supine position at rest and during PFM maximal contraction. Transperineal 4D ultrasound, which consists of a probe applied on the surface of the perineum without any vaginal insertion, was used to assess PFM morphometry. Different parameters were assessed in sagittal and axial planes: anorectal angle, levator plate angle, displacement of the bladder neck, and levator hiatus area. The investigator analyzing the data was blinded to the clinical data. Women with PVD showed a significantly smaller levator hiatus area, a smaller anorectal angle, and a larger levator plate angle at rest compared with asymptomatic women, suggesting an increase in PFM tone. During PFM maximal contraction, smaller changes in levator hiatus area narrowing, displacement of the bladder neck, and changes of the anorectal and of the levator plate angles were found in women with PVD compared with controls, which may indicate poorer PFM strength and control. Using a reliable and pain-free methodology, this research provides sound evidence that women with PVD display differences in PFM morphometry suggesting increased tone and reduced strength.

Acute kidney injury from herbal vaginal remedy in Ilorin: a case report

The use of traditional herbal remedy is very common worldwide, and it is associated with complications such as acute kidney injury. Herbal remedy accounts for 35% of acute kidney injury in Africa. As with orthodox medicines, herbal remedies are administered orally in the majority of cases but other routes such as topical and rectal administrations may be used. Vaginal route of administration is a rare practice used as arbortifacients in some parts of southern Africa. One case of AKI that resulted from vaginal administration of a herbal product used as a treatment of infertility has been reported previously in Nigeria. We describe a similar case of a young female who developed AKI three days after vaginal insertion of a herbal remedy for treatment of secondary infertility. She was managed conservatively and recovered full renal function. The case suggests that the unusual socio-cultural practice of vaginal herbal therapy leading to AKI may be underreported and therefore the need for surveillance and public awareness of the harmful effect of this practice, and the use of unstandardized herbal products.Key words: Acute kidney injury, herbal vaginal remedy, nephrotoxins, Nigeria

Use of the dye stain assay and ultraviolet light test for assessing vaginal insertion of placebo-filled applicators before and after sex.

Applicator dye staining and ultraviolet (UV) light have been used in trials to measure adherence, but not in the setting of before and after sex gel dosing (BAT-24). This study was designed to determine if semen or presex gel dosing impacts the sensitivity and specificity of a dye stain assay (DSA) for measuring vaginal insertion of placebo-filled applicators with BAT-24 dosing. Healthy monogamous couples received Microlax-type applicators (Tectubes, Åstorp, Sweden) filled with hydroxyethylcelluose placebo gel. Women were instructed to vaginally insert 1 dose of gel before and a second dose after sex and to return applicators within 48 hours after sex. Applicators were stained to detect semen, followed by UV then DSA, and scored by 2 readers. Positive and negative controls were randomly included in applicator batches. Fifteen couples completed the study. Each woman returned at least 6 applicators over a 30-day period. The sensitivity for insertion of postsex applicators was higher for UV (97%) compared with DSA (90%), and the specificity was similar (≥96%). For presex applicators, the sensitivity and specificity were higher for DSA (100%) compared with UV testing (87% sensitivity, 96% specificity). Among returned postsex applicators, 95% tested positive by UV compared with 87% by DSA. Agreement between readers was significantly better on the presex applicators for DSA than for UV, and for postsex readings, agreement was less than half that for UV, although the results were not statistically significant. Applicator tests are feasible for measuring adherence in trials with gel dosing before and after sex.

Outcome of the Laparoscopic Two-Team Sling Procedure, Tension-Free Vaginal Tape Insertion, and Transobturator Tape Insertion in Women With Recurrent Stress Urinary Incontinence

ObjectiveAlthough the surgical treatment of primary stress urinary incontinence (SUI) has been well studied, the optimal treatment of persistent or recurrent SUI represents a significant challenge to the surgeon, and there are limited relevant published data. The aim of this study was to document outcome data for various surgical techniques used at our centre for the treatment of recurrent SUI, and to assess the immediate and long-term complications associated with these procedures. MethodsThis retrospective study assessed the outcome of the laparoscopic two-team sling procedure, tension-free vaginal tape (TVT) insertion, and transobturator tape (TOT) insertion in the treatment of recurrent SUI in women. Data collected included patient demographics, urodynamic data, postoperative subjective cure and objective cure (negative cough stress test), and intraoperative and postoperative complications. ResultsForty-six women with recurrent SUI were included in the study: 24 had had laparoscopic two-team sling procedures, 15 had had TVT insertion, and 7 had had TOT insertion. For each procedure, objective cure rates were 91.7%, 73.3%, and 85.7%, respectively, and subjective cure rates were 79.2%, 60%, and 57.1% respectively. In the laparoscopic two-team sling group, one woman developed an infected hematoma and one required surgery for a small bowel obstruction. ConclusionThe laparoscopic two-team sling procedure or TVT or TOT insertion may be used in experienced hands for surgical management of patients with recurrent stress urinary incontinence. We found no statistically significant differences in outcomes between the three groups, possibly because of the small sample size. Larger sample size and longer follow-up within prospective randomized trials are warranted to identify any possible differences.

SU‐C‐500‐02: Comparison of a Commercial Electronic Brachytherapy Source and Ir‐192/Co‐60 HDR Source for Endometrial and Cervical Cancers

Purpose: To evaluate the dosimetric differences between Iridium‐192, Co‐60 based HDR plans and plans generated by electronic brachytherapy source (EBS) for cervical and endometrial cancers. Material/Methods: Our institution uses volume based planning for each tandem and ovoid (T&O) or vaginal cylinder insertion and treatment. We attempt to characterize the differences between the three sources (Ir‐192, Co‐60 and EBS). For vaginal cylinder cases, patients receive 6 Gy x3 prescribed to a depth 5 mm. For T&O cases, the prescription is 8Gy x3 to point A. Organs at risk (OARs) contoured were rectum, bladder, sigmoid & small bowel. Our planning protocol requires adjustment of source dwell times and positions to keep doses to the OARs below 70% of the prescription dose. For vaginal cylinder, dose coverage is optimized to a line drawn 5mm from the vaginal cylinder surface. This is a retrospective study of previously planned Ir‐192 treated patients. Results: There is no difference between the Co‐60 and Ir‐192 plans but plans generated using the EBS offer better sparing of OARs as evaluated using the dose to highest 2cc of the organ at risk but the differences are not statistically significant. However, there are significant differences in the DVH between EBS and the other two sources. There was a reduction of up to 50% between EBS and other two sources using v15%, v25%, v50% v75% (% of volume getting 15, 50, 75 percent of the prescription dose). Conclusion: All three sources are suitable for HDR Brachytherapy but the use of EBS can reduce the organ at risk dose while achieving similar dose coverage. Even though D2cc is the recommended dose volume point for HDR plans evaluation, V15%, V25%, V50% and V75% are also useful indicator of the plan quality as they characterize the lower dose region of the DVH curves more adequately

Vaginoplasty using the inner surface or mucosa of the prepuce in children with congenital adrenal hyperplasia

ObjectiveTo describe and present the results of the use of the inner surface or mucosa of the prepuce in vaginoplasty for ambiguous genitalia. Patients and MethodsThis technique can be used alone in low vaginal insertion or associated with a total urogenital mobilization in cases of high vagina. During the past 7 years, we have performed 18 vaginoplasties using the described technique in 46, XX DSD (female pseudohermaphroditism). All patients had 21-hydroxylase deficiency; four had the simple virilizing form and 14 had additional salt loss. The age of the patients at surgery varied from 4 to 28 months (average 11.2). ResultsThe final cosmetic results were considered good by the parents and surgeon for the majority of our patients, and satisfactory in three cases. Clinical examination revealed stenosis of vaginal introitus in only one patient (which responded very well to one dilatation) and one urethra-vaginal fistula. ConclusionThis technique of vaginoplasty, simple in its realization and answering the purpose of treatment with few complications, can be used in the feminizing genitoplasty of young children with 46,XX DSD, ovotesticular DSD (true hermaphroditism), mixed gonadal dysgenesis and dysgenetic male pseudohermaphroditism.

PROGRAMMED REPRODUCTION IN SHEEP OUTSIDE THE MATING SEASON

The ewes follow the seasonal reproductive pattern which in the climate conditions of Kosovo means that the sexual activity is manifested from Junе to August. We assessed the efficiency of two hormonal protocols for the oestrus synchronization in ewes out of the sexual season (during March–April 2012). For this reason two experimental groups, each comprised of 50 Sharr breed ewes, are formed. The both groups had the same breeding and physiological status (all are over 60 days after parturition) as well as management conditions. The treatment for the first group was comprised of progestаgen vaginal sponge insertion (Fluor Geston Acetate, 40 mg, Intervet®) for 14 days and the 500 IU of eCG (equine Chorionic Gonadotropin), Foligon (Intervet®), i/m were applied at the time of vaginal sponge removal. The second group followed the similar protocol, but they were additionally treated with 0.1 mg/ewe gonadotropin releasing hormone (GnRH; Fertagyl, Intervet®) 36 h after the eCG application. The oestrus was detected by presentation of the ewes to ram 48 h after the vaginal device was removed. The presented ewes were mated twice in the interval of 12 hours. From the data of the study we have the rate that induced oestrus for the both groups was 94 % and 96 % respectively (P>0.05). We believe that combining hormonal treatment following an accurate methodology delivers very good results in inducing and synchronizing the estrus out of the mating season in sheep.

Graft‐related complications and biaxial tensiometry following experimental vaginal implantation of flat mesh of variable dimensions

To compare the occurrence of graft-related complications (GRCs) and biomechanical properties of meshes implanted vaginally and abdominally. In vivo animal experiment. Centre for Surgical Technologies, Medical Faculty, KU Leuven, Belgium. Twenty adult parous Texel ewes. Sheep were implanted with Gynemesh M, a 28-g/m² polypropylene mesh reinforced with polyglecaprone fibres, under general anaesthesia. Dissection into the rectovaginal septum was performed to accommodate a flat 50 × 50 mm (n = 10) or 35 × 35 mm (n = 10) mesh, which was sutured to the underlying tissues. A 50 × 50 mm mesh was laid over a primarily sutured, full-thickness, 40-mm longitudinal abdominal wall incision. Sacrifice was at 60 days (n = 10) or 90 days (n = 5). The occurrence of exposure, the degree of contraction and examination of the biomechanical properties of explants with a minimum radius of 32 mm via biaxial tensiometry. Insertion of a 50 × 50 mm mesh led to exposures in 30% (3/10) of cases, and the average contraction rate was 52 ± 14%. In the 35 × 35 mm implants, there were no exposures, and the contraction rate was 25 ± 26.3%. Vaginal explants with no GRCs and of sufficient size had biomechanical properties that were comparable with those of abdominal explants. Vaginal mesh insertion is associated with GRCs, such as exposure and contraction. Although other factors probably play a role, this study illustrates that mesh size may also induce these complications. In a vaginal surgery model, clinically occurring GRCs can be reproduced. In addition, biomechanics of uncomplicated vaginal explants are comparable with those measured on abdominal explants.

A Phase 3, Placebo Controlled Study of the Safety and Efficacy of Avanafil for the Treatment of Erectile Dysfunction After Nerve Sparing Radical Prostatectomy

We evaluated the safety and efficacy of 100 and 200 mg avanafil for the treatment of adult males with erectile dysfunction after bilateral nerve sparing radical prostatectomy. This was a double-blind, placebo controlled, parallel group, phase 3 study in males age 18 to 70 years with a history of erectile dysfunction of 6 months or more after bilateral nerve sparing radical prostatectomy. Patients were randomized to 100 or 200 mg avanafil or placebo (taken 30 minutes before sexual activity) for 12 weeks. Primary end points included successful vaginal insertion (Sexual Encounter Profile [SEP] question 2), successful intercourse (SEP3) and change in score on the erectile function domain of the International Index of Erectile Function (IIEF-EF) questionnaire. A total of 298 patients were randomized and 84.6% completed the study. At baseline 16.1% were age 65 years or older and 71.5% had severe erectile dysfunction (mean overall IIEF-EF domain score 9.2). After 12 weeks there were significantly greater increases in SEP2 and SEP3 and change in mean IIEF-EF domain score with 100 and 200 mg avanafil vs placebo (p <0.01). Following dosing with avanafil 36.4% (28 of 77) of sexual attempts (SEP3) at 15 minutes or less were successful vs 4.5% (2 of 44) for placebo (p <0.01). Avanafil was generally well tolerated. No serious adverse events were reported and fewer than 2% of patients discontinued the study due to an adverse event. Avanafil in 100 and 200 mg doses was effective and well tolerated in improving erectile function after prostatectomy. Results suggest a rapid onset of action and sustained duration of effect, with all 3 primary end points being achieved at both dose levels.

Organ at Risk Interfraction Dose Variance in Relationship to Insertion Angle of a Vaginal Cylinder for HDR Brachytherapy

In HDR vaginal cylinder brachytherapy, an individualized treatment plan is generated on an initial planning CT and then used for subsequent fractions regardless of changes in interfraction anatomy and cylinder insertion angle. In this study, we analyzed the variance in bladder and rectal doses by comparing the planned received dose (PRD) to the actual received dose (ARD) per fraction in relationship to the vaginal cylinder insertion angle.

Laparoscopic Repair for Recurrent Lateral Enterocele and Rectocele

It is difficult to determine what types of procedures should be attempted in patients who have recurrent prolapse. We present a case of recurrent lateral enterocele and rectocele after the patient had undergone multiple surgeries for pelvic organ prolapse (POP), including a vaginal hysterectomy, bladder-neck suspension, anterior colporrhaphy, site-specific rectocele repair, apical mesh implant, iliococcygeus vault suspension, and transobturator suburethral sling procedure. With recurrence, the patient underwent robot-assisted laparoscopic sacral colpopexy, tension-free vaginal tape transobturator sling insertion, rectocele repair, and perineorrhaphy with cystoscopy. She then presented with defecatory outlet obstruction and constipation and subsequently was treated with a stapled transanal rectal resection. The patient returned with continued defecatory dysfunction and a recurrent lateral enterocele and rectocele. The recurrence was treated laparoscopically using a lightweight polypropylene mesh. The postoperative period was uneventful. Two years later, the patient reported decreased defecatory symptoms and no further symptomatic prolapse.

Dyeing to Know

Dyeing to Know

Trypan Blue Staining to Determine Vaginal Exposure in Two Types of Plastic Vaginal Applicators Containing Two Different Microbicide Formulations

Dye staining of applicators has been shown to be a reliable and objective method to test vaginal insertion in clinical microbicide trials, but different plastics, dyes, and product formulations may impact the accuracy of this method. Reportedly used applicators returned from 3 clinical trials were stained with 1% trypan blue. In a phase 1 study (VivaGel), using gel-filled HTI polypropylene applicators, 1271 (97%) of applicators stained positive. In a phase 1 and a phase 2a study (LACTIN-V) using linear low-density polyethylene applicators to deliver a dry powder formulation, 57 (95%) and 135 (86%) tested positive, respectively. Dye staining of vaginal applicators is an objective low-cost measure suitable for low-resource settings.