C. Riccetto

Prevalence and correlates of stress urinary incontinence during pregnancy: a survey at UNICAMP Medical School, São Paulo, Brazil

The aim of this study was to evaluate the prevalence of stress urinary incontinence (SUI) in women in the third trimester of pregnancy. In total, 340 patients attending the Antenatal Clinic at the State University of Campinas (UNICAMP) were interviewed. Overall, 170 women (50%) presented SUI. Stress urinary incontinence did not correlate to either body mass index (BMI) or race. There was no correlation between parity and SUI, but when considering distinct types of effort, urine leakage on coughing (P=0.0478) and laughing (P=0.0046) were highly more frequent in multiparous women. One hundred eleven women had had only vaginal deliveries and 68 delivered by cesarean section. There was no difference between the two groups concerning incontinence, but multiparous women (≥4) who delivered exclusively vaginally demonstrated 2.0 times more chances to leak urine when compared to nulliparous women. This fact strongly suggests parity to be more relevant than delivery route as a risk factor to stress urinary incontinence. Nulliparous women presented with a high percentage (45.5%) of the symptom, emphasizing the elevated risk of SUI during first pregnancy.

Corrección transobturatoria de los cistoceles

Resumen Objetivo Presentar nuestra experiencia inicial con el sistema Perigee para la correccion de prolapsos de pared anterior vaginal. Material Y metodo 15 pacientes con prolapso de la pared anterior de la vagina (edad media: 62 anos) fueron intervenidas con el sistema Perigee compuesto de una tela para la correccion del defecto central y cuatro astas autofijables para la correccion del defecto lateral. La tecnica de implante consta de cuatro pasos: 1) diseccion lateral vaginal hasta rama isquiopubica; 2) realizacion de dos marcas superiores en el pliegue genito-femoral y dos inferiores a 2 cm lateralmente y 3 cm inferiormente en relacion a las primeras; 3) introduccion agujas superiores paralelas a la rama isquiopubica y conexion con los “brazos” del injerto e introduccion de agujas inferiores verticalmente con conexion a las “piernas” del injerto; 4) ajuste sin tension de la malla. La tasa de curacion fue medida objetivamente utilizando el sistema POP-Q. Resultados El punto Aa preoperatorio paso de 0.09 a -3.00 a las 6 semanas del postoperatorio y se mantuvo en -2.73 a los tres meses. El punto Ba preoperatorio era de 1.73 y paso a -2.82 a las 6 semanas y se mantuvo en -2.82 a los 3 meses. Las complicaciones no fueron significativas. No se produjeron danos vasculares ni sangrados significativos. Conclusiones La correccion transobturadora de los cistoceles es una opcion atrayente. Los buenos resultados iniciales prometen ser duraderos.

Evaluación de la función sexual femenina antes y después de un procedimiento para la corrección de la incontinencia urinaria de esfuerzo

The prevalence of urinary incontinence is around 20% of healthy middle-aged women. Incontinence causes a negative impact on the quality of life and sexuality. From August 2002 to January 2004, 30 patients (mean age 43 years) with stress urinary incontinence (59%), overactive bladder (15%) and mixed incontinence (26%) answered the ICIQ-SF(International Consultation on Incontinence Questionnarie-Short Form) and FSFI (Female Sexual Function Index) questionnaires before and after treatment for urinary incontinence. The follow - up ranged from 12 to 53 months. Mean ICIQ score was 17 and 7 before and after treatment respectivelly (p<0,001). Overactive bladder showed the worst scores in all domains. The patients who underwent surgery increased their scores of desire (p=0,02), satisfaction (p=0,05) and total score (p=0,02). Thirteen patients which ICIQ was zero increased: desire (p<0,01), satisfaction (p=0,05) and total score (p=0,01). Urinary incontinence significantly affects the quality of life. Therefore sexual evaluation in incontinence patients is recommended.

Aplicaciones clínicas de la teoría integral de la continencia

CLINICAL APPLICATIONS OF THE COMPREHENSIVE THEORY OF URINARY INCONTINENCE Currently, urinary incontinence cannot be treated without taking into consideration the comprehensive theory of urinary incontinence. According to this theory, stress incontinence, urge incontinence and alterations in bladder emptying result from alterations in the elements of suburethral support, ligaments and muscles of the pelvis floor. Alterations in the forces applied by muscles and ligaments to the fascia adjacent to the vaginal wall and the urethra cause the vesical neck and the urethra to open or close. Alterations in the forces applied to the vagina can also cause premature activation of the micturition reflex, triggering involuntary contractions of the detrusor muscle. Knowledge of the anatomic substrate of the upper, intermediate and lower layers of the pelvic floor and of the main pubourethral, urethropelvic and uterosacral ligamentous elements is essential before any surgical approach of incontinence can be attempted. Depending on the location of the fascial or ligamental muscle lesion and of the sensitivity of the local nerve endings, stress incontinence, urge incontinence, altered bladder emptying or combinations of these conditions can develop. There are 6 basic defects which should be systematically investigated: defect in the suburethral support (“Hammock”), tethered vagina syndrome, distended pubourethral ligaments, distended uterosacral ligaments and support of the vaginal apex, lesions of vaginal insertion of pubococcygeal muscles, lesions of the striated muscles of the pelvic floor levator plate.

Seguimiento a largo plazo del soporte uretral tendinoso: un enfoque anatómico para incontinencia urinaria de esfuerzo

Los procedimientos tipo sling han sido utilizados por decadas para el manejo de la incontinencia urinaria de esfuerzo (IUE) femenina, pero solo en la decada pasada han llegado a ser la tecnica de eleccion. Los procedimientos minimamente invasivos son el procedimiento de eleccion en algunos centros por su eficacia y baja morbilidad. El soporte uretral tendinoso (TUS) representa un enfoque anatomico que consiste en colocar una cincha de baja tension a nivel de la uretra media, anclada al arco tendineo de manera bilateral. De febrero 1999 a octubre 2000, 25 pacientes femeninas con IUE y con una edad media de 53 anos fueron intervenidas mediante TUS. De ellas, 23 pudieron evaluarse a largo plazo con un seguimiento un maximo 72 meses. Despues de 6 meses, 20 pacientes (87%) se encontraban secas, 2 (8,7%) mejoraron y 1 (4,3%) era incontinente. Sin embargo, al final del seguimiento, 15 pacientes estaban continentes (65,2%), 3 (13%) mejoraron y 5 (21%) seguian incontinentes. Por lo que, el TUS es un concepto que merece investigaciones adicionales.

Clinical and urodynamic experience with intravesical hyaluronic acid in painful bladder syndrome associated with interstitial cystitis

Abstract Introduction Few studies have been carried out on therapeutic options in patients with painful bladder syndrome associated with interstitial cystitis. The aim is to verify the safety and effectiveness of treatment with sodium hyaluronate through intravesical instillation in patients with painful bladder syndrome. Materials and methods A series of 18 female patients is presented, with a mean age of 51 years and prior diagnosis of painful bladder syndrome, who were treated by means of the weekly infusion of an intravesical solution of 40 mg of sodium hyaluronate in sterile solution, over a period of eight weeks. The patients were examined clinically and urodynamically prior to their inclusion in the study and eight months after the instillations had concluded. Results There was a statistically significant improvement in the urodynamic parameters and in the symptoms measured quantitatively by means of the questionnaire “Pelvic Pain and Urgency/Frequency” between the baseline situation and after the vesical instillation of sodium hyaluronate in patients with painful bladder syndrome. There was no toxicity arising from the treatment, given that no adverse effects were recorded in relation to it. Conclusion The clinical use of intravesical hyaluronic acid in patients with painful bladder syndrome possibly associated with interstitial cystitis has been demonstrated. The clinical improvement is also associated with an increase in the bladders capacity and sensitivity. Tolerance was excellent. Clinical tests that more profoundly evaluate the therapeutic potential of this drug in this type of patients are required.

Severe depression and anxiety in women with overactive bladder

Depression and anxiety are prevalent psychiatric conditions and are associated with overactive bladder. The objective of this study was to determine prevalence and severity of anxiety and depression associated with overactive bladder (OAB) in women.

Impact of sacrospinous vaginal vault suspension on the anterior compartment

OBJECTIVES A prospective study was conducted to assess the efficacy of sacrospinous vaginal vault fixation and its impact on the anterior compartment. The Pelvic Organ Prolapse Quantification (POP-Q) system was used to quantify pelvic organ prolapse in the apical and anterior vaginal compartments. METHODS Fifty-eight patients underwent a procedure to correct apical prolapse from March 2003 to February 2006. Mean preoperative and postoperative POP-Q scores were respectively: Aa (+0.74; -1.45); Ba (+3.17; -1.36); C (+3.41; -7.71) (p<0.001). RESULTS Cure rate was 93.1%. Preoperative and postoperative evaluation of the anterior vaginal compartment was respectively: stage 1 (5.2%; 48.3%), stage 2 (6.9%; 34.5%), stage 3 (74.1%; 5.2%), and stage 4 (13.8%; 0%). De novo cystocele occurred in 87.9% of cases. An improvement was seen in lower urinary tract symptoms of urgency, nocturia, and urge incontinence. CONCLUSIONS Sacrospinous vaginal vault suspension is effective for the treatment of apical prolapse and leads to formation of cystocele in most cases.

Anatomía tridimensional y cirugía virtual para procedimientos transobturatrizes

INTRODUCTION Stress Urinary Incontinence (SUI) may be managed by transobturator approach. We developed a three-dimensional model, for understanding the surgical anatomy and manual training as well, in order to reduce the learning curve for pelvic surgeries. OBJECTIVE To demonstrate in synthetic models, the anatomical basis for the management of SUI and cystocele. METHOD The anatomical model includes: pelvic bones, the main layers of the pelvic muscles, ligaments and fascias. The surgical devices were transobturator needles, synthetic slings and meshes for anterior vaginal wall repair. The workshop was carried out with an anatomical overview and hands-on training in this tridimentional models and finally surgery in animals. At the end, a questionnaire was applied to verify the impact of this tool in the learning process and trainee satisfaction. RESULTS As far as the anatomical concept, 90% (n=72) of the participants classified this model as very good and 10% (n=8) as good. As a tool for understanding the tridimentional pelvic floor anatomy applied to transobturator procedures there were 100% of approval. CONCLUSIONS This synthetic model allows for understanding the pelvic floor tridimentional anatomy and surgical procedures as well. Further skill is got in the animal model reducing the learning curve for transobturator procedures.Resumen Introduccion La Incontinencia Urinaria de Esfuerzo (IUE) se maneja quirurgicamente diferente siguiendo la Teoria Integral de la Continencia razon por la cual es importante el conocimiento de las estructuras anatomicas. Desarrollamos un modelo tridimensional basado en la anatomia de la pelvis para el entrenamiento manual de la cirugia y asi disminuir la curva de aprendizaje de urologos y ginecologos Objetivo Demostrar en modelos sinteticos, las bases anatomicas del manejo transobturatriz en la IUE, cistoceles y en IUE recidivante post tratamiento quirurgico Metodologia El modelo anatomico incluye: huesos pelvicos, las principales capas de los musculos pelvicos, ligamentos y fascias. Los dispositivos quirurgicos son agujas transobturatrizes en forma de “C” y helicoidales; un sling reajustable de acceso universal y una malla especial autofijable y el sling crossover. Fue realizado un entrenamiento con clases teoricas y practicas. Las clases practicas fueron realizadas con las pelvis y los dispositivos de la cirugia transobturatriz. A continuacion fueran realizadas cirugias transobturatrizes en ovejas. Al final, se aplico un cuestionario para verificar el impacto de esta herramienta en la curva de aprendizaje del acceso transobturatriz Resultados Con respecto al concepto anatomico, el 90% (n=72) de los participantes, clasifico el modelo como muy bueno y 10% (n=8) como bueno. Como herramienta para el aprendizaje de los procedimientos transobturatrizes, el 100% aprobo tanto el material escrito como el modelo anatomico tridimensional Conclusiones Este modelo sintetico permite entendery poner en practica las diversas tecnicas quirurgicas,substituyendo los modelos animales, las reconstrucciones tridimensionales computarizadas y las imagenes bidimensionales, contribuyendo asi de forma significativa en la curva de aprendizaje

Correlación entre la edad y los síntomas de vejiga hiperactiva en mujeres jóvenes en Brasil

UNLABELLED Overactive Bladder Syndrome (OAB) is defined by the ICS (International Continence Society) as urinary urgency, with or without urgency incontinence and frequently associated with increase of frequency and nocturia. PURPOSE The aim of the study was to establish a correlation between OAB symptoms and Age in women aged 20-45. MATERIALS AND METHODS We interviewed 1050 women aged 20-45 in the area of Campinas, Brazil, to investigate the prevalence of Overactive Bladder Symptoms. In this study we used the ICIQ-OAB questionnaire (ICS standard), in its validated Portuguese version and a specific questionnaire for the demographics. RESULTS Overall, women aged 35-45 years showed significantly higher scores in the ICIQ-OAB questionnaire than all other groups (P<.001). Older women (35-45) presented a significantly higher score than younger women (all other groups) (P<.0001) regarding urinary frequency. Regarding frequency, there was a significant difference between the age group 35-45 (higher score) and the age groups 20-22 and 23-27 (P<.0001). Women aged 35-45 presented significantly more nocturia than women in the age groups of 28-34, 23-27 and 20-22. Women in the group of 28-34 also presented more nocturia than women aged 20-22 (P<.0001). Women aged 35-45 experienced more urgency than those in the age groups of 28-34 and 23-27 (P<.0001). Women aged 35-45 had significantly more urgency incontinence than all the other groups, and women in group of 20-22 also presented more incontinence than those aged 23-27 (P<.0001). Significant differences were also found regarding symptom bother, women in group 35-45 years old presented higher scores than the other groups regarding frequency (P<.0001), nocturia (P=.0011), urgency (P=.0015) and urgency incontinence (P<.0001). CONCLUSIONS In conclusion, older women present more OAB symptoms and therefore a higher score than younger women.