Agnaldo L. Silva-Filho

Intensive supervised versus unsupervised pelvic floor muscle training for the treatment of stress urinary incontinence: a randomized comparative trial

Introduction and hypothesisPelvic floor muscle training (PFMT) is considered to be the first-line treatment for female stress urinary incontinence (SUI). There are few studies that have tested the efficacy of unsupervised PFMT. The aim of this study was to compare the effectiveness of intensive supervised PFMT to unsupervised PFMT in the treatment of female SUI.MethodsSixty-two women with SUI were randomized to either supervised or unsupervised PFMT after undergoing supervised training sessions. They were evaluated before and after the treatment with the Oxford grading system, pad test, quality of life questionnaire, subjective evaluation, and exercise compliance.ResultsAfter treatment, there were no differences between the two groups regarding PFM strength (p = 0.20), International Consultation on Incontinence Questionnaire-Short Form score (p = 0.76), pad test (p = 0.78), weekly exercise compliance (p = 0.079), and subjective evaluation of urinary loss (p = 0.145).ConclusionsBoth intensive supervised PFMT and unsupervised PFMT are effective to treat female SUI if training session is provided.

Computational modeling approach to study the effects of fetal head flexion during vaginal delivery

OBJECTIVE The purpose of this study was to investigate the influence of fetal head flexion during vaginal delivery with a 3-dimensional computational finite element model. STUDY DESIGN A finite element model of the pelvic skeletal structure, pelvic floor, and fetus was developed. The movements of the fetus during birth were simulated in engagement, descent, flexion, internal rotation, and extension of the fetal head. The opposite forces against the fetal descendent and the stress of the pelvic floor muscles were obtained on simulations with different degrees of head flexion. RESULTS The simulated increase in fetal head flexion is associated with lower values of opposite forces against the fetal descent. The descending fetus with abnormal head flexion also meets resistance in later stations. Lower stress on the pelvic floor was demonstrated with simulated increase in fetal head flexion during vaginal delivery. CONCLUSION This analytic evidence suggests that the fetal head flexion during vaginal delivery may facilitate birth and protect the pelvic floor.

The influence of pelvic muscle activation during vaginal delivery.

OBJECTIVE: To estimate the influence of pelvic floor muscle activation during vaginal delivery using a three-dimensional computational finite element model. METHODS: A computational finite element model of the pelvic skeletal structure, pelvic floor, and fetus was developed. The movements of the fetus during birth, in vertex position, were simulated; namely, the engagement, descent, flexion, internal rotation, and extension of the fetal head. The opposite forces against the fetal descent and the stress on the pelvic floor muscles were obtained in passive, 5%, 10%, and 15% pelvic floor muscle simulated activations. RESULTS: The increase in pelvic floor muscle activation was associated with higher values of forces against the fetal descent. The descending fetus encountered increasing resistance in higher stations with the increase in pelvic floor muscle activation. The maximum values of stress of the pelvic floor muscles were obtained in +4 station. The increase in pelvic floor muscle activation was also followed by higher values of pelvic floor stress. CONCLUSION: This study demonstrates the feasibility of using a computational modeling approach to study parturition. This experimental evidence suggests that the pelvic floor muscle activation during vaginal delivery may represent an obstacle to fetal descent and increase the risk for pelvic floor injuries. LEVEL OF EVIDENCE: III

Biomechanical Properties of Vaginal Tissue in Women with Pelvic Organ Prolapse

Background/Aims: To compare biomechanical properties of vaginal tissues between women with and without pelvic organ prolapse (POP) and investigate factors that may influence these properties. Methods: Forty patients submitted to POP surgery and 15 non-POP cadavers were evaluated. The tissue was excised from anterior and posterior middle third vagina. The biomechanical properties considered were stiffness (E) and maximum stress (Smax), and they were evaluated by means of uniaxial tension tests. Results: POP patients were associated with higher values of E (13.1 ± 0.8 vs. 9.5 ± 0.7 MPa; p < 0.001) and Smax (5.3 ± 0.5 vs. 3.2 ± 0.9 MPa; p < 0.001) in the anterior vaginal wall compared to the posterior wall. In contrast, non-POP women presented lower values of E (6.9 ± 1.1 vs. 10.5 ± 1.0 MPa; p = 0.01) and Smax (2.6 ± 0.4 vs. 3.5 ± 0.4 MPa; p = 0.043) in the anterior wall. The occurrence of POP was the only independent predictor of higher values of E and Smax in anterior vaginal samples (p = 0.003 and p = 0.008, respectively). Women with severe anterior vaginal prolapse presented higher levels of E and Smax in the anterior sample compared to those with lower POP stages (p = 0.001 and p = 0.01; respectively). Conclusion: Women with POP present significant changes of biomechanical properties in the vagina.

Quality of life in women with vulvar cancer submitted to surgical treatment: a comparative study

OBJECTIVES To investigate the occurrence and severity of lymphoedema of the lower extremities (LLE), quality of life (QoL), and urinary and sexual dysfunction in women with vulvar cancer submitted to surgical treatment. STUDY DESIGN Twenty-eight patients with vulvar cancer submitted to vulvectomy and inguinofemoral lymphadenectomy and 28 healthy, age-matched women (control group) were evaluated. The occurrence and severity of LLE were determined by Millers Clinical Evaluation. QoL, urinary function and sexual function were assessed by the EORTC QLQ-C30, SF-ICIQ and FSFI questionnaires, respectively. The differences between groups and correlations were assessed using Students t-test, Chi-squared test, Mann-Whitney U-test and Spearmans rho test. RESULTS The groups were similar in terms of marital status, educational status, menopausal status, hormone therapy and height. The occurrence and severity of LLE were higher in women with vulvar cancer compared with the control group (p<0.001 and p = 0.003, respectively). A significant association was found between the severity of LLE and advanced age (p = 0.04), and the severity of LLE and higher body mass index (BMI; p = 0.04) in patients with vulvar cancer. In the patients with vulvar cancer, there was a significant correlation between the severity of LLE and worse QoL in the following domains: physical, cognitive, emotional, social, fatigue, pain, sleep and financial questions (p < 0.05). There was no difference in urinary function between the two groups (p = 0.113). Age and number of deliveries were the only variables associated with the occurrence of urinary incontinence (p = 0.01). Urinary incontinence was present in women with a mean age of 74.9 ± 4.6 years and a mean of 7.3 ± 1.3 normal deliveries. There was no difference between the groups in terms of the sexual function. Multivariate analysis showed an association between sexual function and age (p = 0.01), and sexual function and being in a stable relationship (p=0.02). CONCLUSION Patients submitted to vulvectomy or inguinofemoral lymphadenectomy for vulvar cancer are at higher risk of developing LLE compared with healthy, age-matched women. This has a negative effect on QoL, but does not interfere with urinary or sexual function.

An approach on determining the displacements of the pelvic floor during voluntary contraction using numerical simulation and MRI.

The present study was conducted in order to establish a methodology based on the finite element method to simulate the contraction of the pelvic floor (PF) muscles. In the generated finite element model, a downward pressure of 90 cm H2O was applied, while actively contracting the PF muscles with different degrees of muscular activation (10, 50 and 100%). The finite element methodology of the active contraction behaviour proposed in this study is adequate to simulate PF muscle contraction with different degrees of muscular activation. In this case, in particular, for an activation of 100%, the numerical model was able to displace the pubovisceral muscle in a range of values very similar to the displacement found in the magnetic resonance imaging data. In the analysed case study, it would be possible to conclude that an intensity contraction of 50% would be necessary to produce enough stiffness to avoid possible urine loss.

Clinicopathological features influencing pelvic lymph node metastasis and vaginal and parametrial involvement in patients with carcinoma of the cervix

Purpose: This study was undertaken to evaluate clinical and pathologic findings that predicted pelvic lymph node metastasis and parametrial and vaginal involvement in patients with stage IB carcinoma of the cervix. Methods: 71 patients with diagnosis of stage IB (FIGO) cervical cancer were prospectively studied from December 1997 to August 2002. The patient’s age, clinical stage (IB1 or IB2), histological classification, grade of differentiation, tumor volume, and lymphatic vascular space invasion (LVSI) were evaluated. Statistical methods included χ2 test and Fisher’s exact test to evaluate significant differences between the groups. The level of significance was set at p < 0.05. Results: The clinical stage was IB1 in 51 patients (71.8%) and IB2 in 20 patients (28.2%). The histological classification identified squamous cell carcinoma in 60 patients (84.5%) and adenocarcinoma in 11 patients (15.5%). The average tumoral volume was 22.8 ± 24.3 cm3 (0.3–140.0 cm3). The tumor was well differentiated (G1) in 8 (11.3%), moderately differentiated (G2) in 40 (56.3%) and poorly differentiated in 23 (32.4%) of the cases. The presence of LVSI was detected in 14 patients (19.7%) and was associated with pelvic lymph node metastasis and vaginal and parametrial involvement (p = 0.002, p = 0.001 and p < 0.001; respectively). The average number of positive pelvic lymph nodes was significantly higher in the patients with LVSI compared with patients without LVSI (2.47 ± 2.8 vs. 0.33 ± 0.74; p = 0.001). There was no association of age, clinical stage, histological classification, grade of differentiation or tumor volume with pelvic lymph node metastasis and vaginal and parametrial involvement. Conclusion: The presence of LVSI is significantly associated with pelvic lymph node metastasis and vaginal and parametrial involvement in patients with stage IB cervical carcinoma.

Inflammatory Response Patterns in ICSI Patients: A Comparative Study Between Chronic Anovulating and Normally Ovulating Women

The aim of this study was to evaluate inflammatory response in chronic anovulating infertility women undergoing intracytoplasmic sperm injection. Thirteen infertile women with chronic anovulation and 23 normally ovulating women were prospectively evaluated. N-acetylglucosaminidase (NAG), myeloperoxidase (MPO), monocyte chemoattractant protein 1 (MCP-1), and C-reactive protein (CRP) concentrations were evaluated in serum and follicular fluid. Women with chronic anovulation presented higher NAG and MPO activity in follicular fluid when compared with normally ovulating women. Serum MPO activity was higher in the control group compared to the chronic anovulation group. Both serum and follicular fluid CRP concentrations were higher in women with chronic anovulation in comparison with the control group. Higher MCP-1 follicular fluid concentrations and serum levels of CRP were associated with the occurrence of ovarian hyperstimulation syndrome. Patients with chronic anovulation exhibited significantly higher follicle macrophage/neutrophil activation as well as unspecific inflammatory response by comparison with normally ovulating women.

Evaluation of N‐acetilglucosaminidase and myeloperoxidase activity in patients with endometriosis‐related infertility undergoing intracytoplasmic sperm injection

Aim:  Inflammation is as an important factor in ovulation with the active participation of leucocytes and their inflammatory mediators. The present study was performed to compare the activity of the inflammatory enzymes myeloperoxidase (MPO) and N‐acetylglucosaminidase (NAG) in patients with endometriosis‐related infertility and in normally ovulating women undergoing intracytoplasmic sperm injection (ICSI).

Translation of biomechanics research to urogynecology

IntroductionPelvic floor (PF) dysfunctions represent a frequent and complex problem for women. The interaction between the vagina and its supportive structures, that are designed to support increases in abdominal pressure, can be considered a biomechanical system. Recent advances in imaging technology have improved the assessment of PF structures. The aim of this paper is to review the applications of biomechanics in urogynecology.MethodsThe available literature on biomechanics research in urogynecology was reviewed.ResultsComputational models have been demonstrated to be an effective tool to investigate the effects of vaginal delivery and PF dysfunctions. Biomechanical analysis of PF tissues provides a better understanding on PF dysfunctions etiology. These studies are also important for the development of synthetic prostheses utilized in PF surgery.ConclusionAn interdisciplinary and multidisciplinary collaborative research, involving bioengineers and clinicians, is crucial to improve clinical outcomes in patients with PF dysfunctions.