Background Female sexual dysfunction, including female orgasm disorder, has been reported following mid-urethral sling (MUS) surgery to treat bothersome stress urinary incontinence. Anterior vaginal wall-female periurethral tissue (AVW-FPT) likely contains autonomic and sensory innervation involved in the female sexual response, and injury to these nerves may result from MUS implantation. Aim To characterize, using fresh cadaveric tissue, autonomic and sensory nerves in AVW- FPT using immunohistochemistry (IHC), and to assess their proximity to an implanted MUS. Methods AVW-FPT was excised following careful dissection from four fresh cadavers. Prior to dissection, one cadaver underwent simulation of the MUS procedure by a urogynegologist, using a fascial sling. All samples were paraffin embedded, sectioned, and stained with hematoxylin. Serial sectioning and IHC were performed to identify nerves. IHC markers were used to characterize the sensory and autonomic innervation. Outcomes IHC localization of autonomic and sensory nerve markers consistent with neural tissue within the region of MUS implantation. RESULTS IHC of AVW-FPT using protein gene product 9.5 (PGP9.5), a general nerve stain, revealed innervation throughout the region targeted by the MUS implantation. More specifically, immunoreactivity for both autonomic (tyrosine hydroxylase, TH) and sensory (Nav1.8 and S100ß) nerves were found in close proximity (<1 mm) to the implanted MUS. In addition, a subset of S100ß positive nerves also showed immunoreactivity for calcitonin gene-related peptide (CGRP). Combining the IHC findings with the surgical simulation of the MUS implantation revealed the potential for damage to both autonomic and sensory nerves as a direct result of the MUS procedure. Clinical Translation The identified autonomic and sensory nerves of the AVW-FPT may contribute to the female sexual response, and yet are potentially negatively impacted by MUS procedures. Given that surgeries performed on male genital tissue, including the prostate, may cause sexual dysfunction secondary to nerve damage, and that urologists routinely provide informed consent regarding this possibility, urogynaecologists are encouraged to obtain appropriate informed consent from prospective patients undergoing the MUS procedure. Strengths & Limitations This is the first study to characterize the sensory and autonomic innervation within the surgical field of MUS implantation and demonstrate its relationship to an implanted MUS. The small sample size is a limitation of this study. CONCLUSION The present study provides evidence of potential injury to autonomic and sensory innervation of AVW-FPT as a consequence of MUS implantation, which may help explain the underlying mechanisms involved in the reported post-operative female sexual dysfunction in some women.

Background There is evidence of glandular tissue in the region of the anterior vaginal wall–female periurethral tissue (AVW-FPT) that has similar morphology and immunohistochemistry to the prostate in men. Surgical injury to this tissue has been suggested as a potential cause of sexual dysfunction following midurethral sling (MUS) procedures. However, the anatomy and embryology of these glands have not been fully resolved. This has led to difficulties in classifying this tissue as a prostate and defining its clinical significance related to MUS procedures. Aim To describe the histological and immunohistochemical characteristics of the female periurethral glands using markers of prostate tissue and innervation and to examine their anatomical relationships to an implanted MUS. Methods Using gross and fine dissection, the AVW-FPT was dissected from 9 cadavers. Prior to dissection, 2 cadavers underwent simulation of the MUS procedure by a urogynecologist. Samples were paraffin embedded and serially sectioned. Immunohistochemistry was performed using markers of prostate tissue and innervation. Outcomes Redundant immunohistochemical localization of markers for prostatic tissue and innervation of the glandular tissue of the AVW-FPT, including the region of MUS implantation. Results Female periurethral glands were immunoreactive for markers of male prostatic tissue, including prostate-specific antigen, androgen receptor, HOXB13, and NKX3.1. Markers of innervation (protein gene product 9.5, choline acetyl transferase, and vasoactive intestinal polypeptide) also localized to certain regions of the glandular tissue and associated blood supply. Surgical simulation of the MUS procedure demonstrated that some periurethral glands are located in close proximity to an implanted sling. Clinical Translation The AVW-FPT contains glandular tissue in the surgical field of MUS implantation. Iatrogenic damage to the female periurethral glands and the associated innervation during surgery could explain the negative impacts on sexual dysfunction reported following MUS procedures. Strengths and Limitations This is the first study to characterize the female periurethral glands using markers of prostatic tissue in concert with markers of general and autonomic innervation and characterize their anatomical relationships within the surgical field of MUS implantation. The small sample size is a limitation of this study. Conclusion We provide further evidence that the AVW-FPT contains innervated glands that are phenotypically similar to the male prostate and may share a common embryonic origin. The microscopic and immunohistochemical features of the periurethral glands may be indicative of their functional capacity in sexual responses. The location of these glands in the surgical field of MUS procedures underscores the clinical significance of this tissue.

Background and Aims Multiple‐choice questions (MCQ) in the anatomical sciences are often perceived to be targeting recall of facts and regurgitation of trivial details. Moving away from this assumption requires the design of purposeful multiple‐choice questions that focus on higher‐order cognitive functions as opposed to rote memorization. In order to develop such questions, it was important to first understand the strategies that students use in solving multiple‐choice questions. Using the think‐aloud protocol, this study seeks to understand strategies students use in solving multiple‐choice questions. Specifically, it seeks to uncover patterns in the reasoning process and tactics used when solving higher and lower order MCQ in anatomy. The research also provides insights onto how these strategies influence the student's probability of answering questions correctly. Methods Multiple‐choice questions were created at three levels of cognitive functioning based on the ideas, connections, extensions (ICE) learning framework. The think‐aloud protocol was used to unravel problem‐solving strategies used by 92 undergraduate anatomy students as they solved multiple‐choice questions. Results Sixteen strategies were identified through the oral and written think‐alouds that students used to solve MCQ. Eleven of these have been described and supported by the literature, while the rest were utilized by our students when solving MCQ in anatomy. Domain‐specific strategies of visualizing and recalling had the highest use. Personal connection was a strategy that allowed students to achieve success in all ICE levels in the oral think‐alouds and in the I and E levels in the written think‐alouds. Conclusions This research argues that it is upon us as educators to make learning visible to our students, specifically through the use of think‐alouds. It also raises awareness that when educators facilitate the process of students making personal connections, it aids students in new knowledge being integrated effectively and retrieved accurately.

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