Cesarean scar ectopic pregnancy is becoming increasingly common at tertiary care hospitals around the world. It is a condition in which the embryo implants within the myometrium at the site of a previous cesarean hysterotomy, and it can occur in women with only one prior cesarean delivery. We present four cases of cesarean scar ectopic pregnancy diagnosed within a 6-month period between 2007 and 2008. Their initial presentations and management are discussed, followed by a review of the published literature summarizing both diagnostic and management recommendations.

Objective To evaluate racial and ethnic differences in knowledge about preventative and curative treatments for pelvic floor disorders (PFD). Methods The is a secondary analysis of responses from 416 community-dwelling women, aged 19-98 years, living in New Haven County, Connecticut, who completed the Prolapse and Incontinence Knowledge Questionnaire. Associations between race/ethnicity (categorized as White, African American, and Other Women of Color [OWOC, combined group of Hispanic, Asian or ‘Other’ women] and knowledge proficiency about modifiable risk factors and treatments for PFD were evaluated. Associations were adjusted for age, marital status, socioeconomic status, education, working in a medical field, and PFD history. Results Compared to White women, African American women were significantly less likely to recognize childbirth as a risk factor for UI and POP, to know that exercises can help control leakage, and to recognize pessaries as a treatment option for POP. OWOC were also significantly less likely to know about risk factors, preventative strategies and curative treatment options for POP and UI; however, these findings may not be generalizable given the heterogeneity and small size of this group. Conclusions Significant racial disparities exist in women's baseline knowledge regarding risk factors and treatment options for POP and UI. Targeted, culturally-sensitive educational interventions are essential to enhancing success in reducing the personal and economic burden of PFD, which have proven negative effects on women's quality of life.

Pelvic organ prolapse (POP) is a common, debilitating disorder affecting millions of women. Uterosacral ligaments (USLs) are the main supportive structures of the uterus and vagina and are often attenuated in women with POP. Although the mechanical strength of USLs is known to be dependent on collagen synthesis and catabolism and the degradation protein MMP2 has been implicated in POP, the molecular mechanisms involved in the development of POP are currently unknown. Homeobox (HOX) genes are transcriptional regulators that orchestrate embryonic development of the urogenital tract. We demonstrated here that HOXA11 was essential for organogenesis of the USL by showing that USLs were absent in Hoxa11-null mice. We compared expression of HOXA11, collagen type I, collagen type III, MMP2, and MMP9 in USLs of women with and without POP. Expression of HOXA11 and both collagens was dramatically decreased while MMP2 was increased in women with POP. Constitutive expression of Hoxa11 in murine fibroblasts resulted in significantly increased expression of collagen type III and decreased expression of MMP2. These results identified HOXA11 as an essential gene for the development of the USL and suggested that women with POP might have weakened connective tissue due to changes in a signaling pathway involving HOXA11, collagen type III, and MMP2. IntroductionPelvic organ prolapse (POP) is a common, costly, and debilitating disorder that negatively impacts the quality of life in many women. It entails the downward descent of the pelvic organs (uterus, vagina, bladder, and rectum) in women, causing symptoms including urinary and fecal incontinence, pelvic pain, and sexual dysfunction (1). The prevalence of POP has been estimated at 30%-50% of the population and increases with advancing age (2). It has been cited as one of the most common diagnoses for performing a hysterectomy, and over 300,000 procedures for POP are performed yearly in the United States (3, 4). Unfortunately, the recurrence rate for POP is very high, and approximately 30% of women undergoing surgical repair of POP will require reoperation for recurrent prolapse (4). Direct costs of this surgery exceed 1 billion dollars annually in the United States, and it is estimated that the rate of women seeking treatment for POP will double over the next 30 years as the elderly population rapidly expands (5, 6).While increasing age, parity, menopause, and BMI have been consistently implicated as risk factors for the development of POP, the molecular mechanisms responsible for the maintenance of the pelvic organ support structures are poorly characterized (1, 7-9). It has been proposed that alterations in remodeling of the pelvic floor after childbirth trauma, compounded by the risk factors cited above, lead to gradual weakening of the pelvic support system. In women with POP, biochemical analyses of the supportive structures of the pelvic floor (endopelvic fascia and uterosacral ligaments [USLs]) have demonstrated alterations in

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Introduction Bicycling is associated with neurological impairment and impotence in men. Similar deficits have not been confirmed in women. Aim To evaluate the effects of bicycling on genital sensation and sexual function in women. Methods Healthy, premenopausal, competitive women bicyclists and runners (controls) were compared. Main Outcome Measures (1) Genital vibratory thresholds (VTs) were determined using the Medoc Vibratory Sensation Analyzer 3000. (2) Sexual function and sexually related distress were assessed by the Dennerstein Personal Experience Questionnaire (SPEQ) and the Female Sexual Distress Scale (FSDS). Results Forty-eight bicyclists and 22 controls were enrolled. The median age was 33 years. The bicyclists were older, had higher body mass indices (BMIs), were more diverse in their sexual orientation, and were more likely to have a current partner. Bicyclists rode an average of 28.3 ± 19.7 miles/day (range 4–100), 3.8 ± 1.5 days/week, for an average of 2.1 ± 1.8 hours/ride. The mean number of years riding was 7.9 ± 7.1 years (range 0.5–30). Controls ran an average of 4.65 ± 2.1 miles/day (range 1.5–8) and 5.0 ± 1.2 days/week. On bivariate analysis, bicyclists had significantly higher VTs than runners, indicating worse neurological function at all sites (P < 0.05). Multivariate analysis found significant correlations between higher VTs and bicycling at the left and right perineum, posterior vagina, left and right labia. Increasing VTs at the clitoris, anterior vagina, and urethra were associated with age. In bicyclists, there were no correlations between VTs and miles biked per week, duration of riding, or BMI. Composite SPEQ scores indicated normal sexual function in all sexually active subjects. Neither group suffered from sexually related distress. Conclusion There is an association between bicycling and decreased genital sensation in competitive women bicyclists. Negative effects on sexual function and quality of life were not apparent in our young, healthy premenopausal cohort.

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Synthetic mesh use in transvaginal POP surgery decreased after the 2011 FDA safety update, but synthetic mesh use for transabdominal POP repair and sling procedures and overall biologic graft use in POP surgery did not decrease.

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