Müllerian anomalies are relatively common. Accurate knowledge of the advantages and limitations of various diagnostic modalities, the limitations of the classification systems, the surgical options available where appropriate, and the obstetric outcomes after these surgeries will help in the optimal management of these patients.

Background Vaginal stones may form in the setting of mesh exposure with urinary incontinence. This report serves to help understand the presentation, evaluation, and management of vaginal urinary stones. Case A 68-year-old female presented with a vaginal calculus. She had a history of anterior and posterior polypropylene mesh placement for prolapse 7 years earlier and urinary incontinence. The stone was identified on a portion of exposed mesh and removed in office. Pathology confirmed urinary etiology. The exposed mesh resolved with topical estrogen. Cystourethroscopy excluded urinary fistula and bladder mesh erosion. Conclusions When identified, a vaginal calculus should be removed and evaluated for composition. Cystourethroscopy should be performed to assess potential urinary tract fistulas and mesh erosion. Additional imaging should be considered.

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INTRODUCTION: Surgical site infections (SSIs) represent approximately 17% of all hospital-acquired infections with an estimated 500,000 SSIs per year. Cesarean delivery is the primary contributor to SSIs, resulting in patient morbidity and increasing length of hospital stay and medical costs. Studies have shown a benefit to pre-operative antibiotics, but no studies have been done to determine the benefits of stratifying patients into risks categories to tailor management with the goal of preventing infection. METHODS: This is a prospective two-phase quality improvement study in which women undergoing cesarean delivery were categorized according to a risk stratification checklist into high and low-risk groups for developing SSIs. Management for the low risk group consisted of standard pre-operative intravenous antibiotics and a standard pressure dressing. Management for the high risk group consisted of 24 hours of intravenous antibiotics and a specialized Mepilex dressing. SPSS software was used for data analysis. RESULTS: The overall occurrence of SSIs in the low and high risk groups were 7.1% and 3.3% respectively, p-value <0.23. 20% of patients with SSIs had insulin-controlled diabetes, p-value <0.06. Logistic regression demonstrated that both diabetes and BMI were strong predictors of SSIs, p-value <0.01. The incidence of complex SSIs decreased 40% after initiation of the protocol. CONCLUSION: Our data suggest an overall decrease in SSIs after stratifying patients into high and low risk groups with the assigned antibiotics/dressing. Obesity and diabetes are the greatest predictors of SSIs. These risk factors should prompt consideration of use of prolonged antibiotics and a specialized dressing.

INTRODUCTION: Studies of the effectiveness of continuous local anesthetic administration for pain reduction after Cesarean delivery have provided inconsistent results. This study evaluated the effectiveness of this mode of administration on post-surgical pain and narcotic use. METHODS: Fifty women who had a Cesarean delivery were enrolled into a randomized double-blind, placebo controlled trial. The On-Q continuous abdominal wall and intraperitoneal wound irrigation system for local anesthetic administration was placed at the time of closure. Total post-operative narcotic use and patient reported pain scale scores were used to evaluate efficacy of treatment at 6, 12, 24 and 48 hours postoperatively. RESULTS: Forty patients completed the study. Repeated measures ANOVA revealed no significant difference in narcotic use or reported pain scores between the control group and those receiving local anesthetic for all time points. There was a trend towards reduced pain and narcotic use in the study group at the 6, 12, and 48-hour time points (group*time interaction p < 0.09). Regardless of group assignment, women who had a prior Cesarean section, versus primigravid women, had an increased total narcotic use (58.06 mg vs. 38.28 mg, respectively; p < 0.03). CONCLUSION: Dual catheter placement and infusion of bupivacaine has potential to decrease the use of narcotics and pain following Cesarean delivery; however, given the small sample size of the study, a significant difference between groups could not be delineated. Further study is indicated to investigate catheter placement and effects on pain control, narcotic use and other potential benefits such as shorter length of stay.