Publications

BACKGROUND

Increased risk of pelvic organ prolapse in women with a history of bladder exstrophy poses difficult management owing to the absence of anterior support and pelvic angle. We present a case of recurrent prolapse in the setting of bladder exstrophy and discuss factors that may warrant consideration during the evaluation of such patients.

CASE

A 26-year-old nulliparous woman with a history of bladder exstrophy and pelvic organ prolapse initially repaired with a porcine graft sacral hysteropexy presented with suspected recurrent apical prolapse. After counseling, she elected to undergo second surgery. During exploration, cervical elongation rather than recurrent prolapse was noted. Therefore, the decision was made to perform a trachelectomy.

CONCLUSIONS

When recurrent pelvic organ prolapse is reported, especially in the setting of complicating factors such as a history of bladder exstrophy, other differential diagnoses for prolapse, such as cervical elongation, should be considered. Initial evaluation of such patients can be tailored to evaluate for other possible diagnoses, clarifying the choice of options for optimal medical or surgical management.

The International Classification of Sleep Disorders, Second Edition (ICSD-2) distinguishes 5 subtypes of central sleep apnea syndromes (CSAS) in adults. Review of the literature suggests that there are two basic mechanisms that trigger central respiratory events: (1) post-hyperventilation central apnea, which may be triggered by a variety of clinical conditions, and (2) central apnea secondary to hypoventilation, which has been described with opioid use. The preponderance of evidence on the treatment of CSAS supports the use of continuous positive airway pressure (CPAP). Much of the evidence comes from investigations on CSAS related to congestive heart failure (CHF), but other subtypes of CSAS appear to respond to CPAP as well. Limited evidence is available to support alternative therapies in CSAS subtypes. The recommendations for treatment of CSAS are summarized as follows: CPAP therapy targeted to normalize the apnea-hypopnea index (AHI) is indicated for the initial treatment of CSAS related to CHF. (STANDARD)Nocturnal oxygen therapy is indicated for the treatment of CSAS related to CHF. (STANDARD)Adaptive Servo-Ventilation (ASV) targeted to normalize the apnea-hypopnea index (AHI) is indicated for the treatment of CSAS related to CHF. (STANDARD)BPAP therapy in a spontaneous timed (ST) mode targeted to normalize the apnea-hypopnea index (AHI) may be considered for the treatment of CSAS related to CHF only if there is no response to adequate trials of CPAP, ASV, and oxygen therapies. (OPTION)The following therapies have limited supporting evidence but may be considered for the treatment of CSAS related to CHF after optimization of standard medical therapy, if PAP therapy is not tolerated, and if accompanied by close clinical follow-up: acetazolamide and theophylline. (OPTION)Positive airway pressure therapy may be considered for the treatment of primary CSAS. (OPTION)Acetazolamide has limited supporting evidence but may be considered for the treatment of primary CSAS. (OPTION)The use of zolpidem and triazolam may be considered for the treatment of primary CSAS only if the patient does not have underlying risk factors for respiratory depression. (OPTION)The following possible treatment options for CSAS related to end-stage renal disease may be considered: CPAP, supplemental oxygen, bicarbonate buffer use during dialysis, and nocturnal dialysis. (OPTION) .