Eva Grimaldi

The effects of mediolateral episiotomy on pelvic floor function after vaginal delivery.

OBJECTIVE: To evaluate the effect of mediolateral episiotomy on puerperal pelvic floor strength and dysfunction (urinary and anal incontinence, genital prolapse). METHODS: Five hundred nineteen primiparous women were enrolled 3 months after vaginal delivery. Puerperae were divided in 2 groups: group A (254 women) comprised the women who received mediolateral episiotomy and group B (265 women) the women with intact perineum and first- and second-degree spontaneous perineal lacerations. Each woman was questioned about urogynecological symptoms and examined by digital test, vaginal perineometry, and uroflowmetric stop test score. Data were subjected to Student t test and Fisher exact test to assess, respectively, the difference between the mean values and the proportions within the subpopulations. Using a simple logistic regression model to test an estimate of relative risk, we expressed the odds ratios of the variables considered with respect to the control population (group B). RESULTS: No significant difference was found with regard to the incidence of urinary and anal incontinence and genital prolapse, whereas dyspareunia and perineal pain were significantly higher in the episiotomy group (7.9% versus 3.4%, P = .026; 6.7% versus 2.3%, P = .014, respectively). Episiotomy was associated with significantly lower values, both in digital test (2.2 versus 2.6; P < .001) and in vaginal manometry (12.2 versus 13.8 cm water; P < .001), but not in uroflowmetric stop test. CONCLUSION: Mediolateral episiotomy does not protect against urinary and anal incontinence and genital prolapse and is associated with a lower pelvic floor muscle strength compared with spontaneous perineal lacerations and with more dyspareunia and perineal pain. LEVEL OF EVIDENCE: II-2

Perineal ultrasound evaluation of urethral angle and bladder neck mobility in women with stress urinary incontinence

Objectives 1. To assess the reproducibility of an electronic ultrasonographic technique for the measurement of urethral angulation; 2. To test the ability of measurement of the urethral angle and bladder neck mobility to predict genuine stress incontinence; 3. To compare ultrasound variables in stress incontinent women and in controls.

Postpartum urinary symptoms: prevalence and risk factors

OBJECTIVES To assess the prevalence of urinary symptoms, the relationship between urinary symptoms and vaginal descent, and the association between urinary symptoms and obstetric factors. STUDY DESIGN Five hundred and thirty-seven women were interviewed and underwent a urogynaecological evaluation 3 months after vaginal delivery. Quantitative-type variables were subjected to Students t test. Simple logistic regression analyses were carried out on the symptoms studied as a function of risk factors. RESULTS 8.2% of primiparae showed stress urinary incontinence and multiparae in 20% (P=0.0001); urge incontinence was present in 5.5% of primiparae and in 13% of multiparae (P=0.004). Significant correlations were found among operative vaginal delivery, dysuria (P=0.048) and frequency (P=0.036). Urinary incontinence appeared associated with induced labour with prostaglandins (P=0.018) and with general maternal factors, such as parity (P=0.001) and elevated weight at the beginning of pregnancy (P=0.019). CONCLUSIONS It is likely that the pathogenesis of postpartum urinary incontinence includes not only the effects of pelvic floor trauma on urethrovesical mobility under stress, but also a deficiency in urethral resistance caused by drugs, such as prostaglandins.

Visual function in menopause: the role of hormone replacement therapy

Objective To assess the effects of hormone replacement therapy (HRT) on visual function after menopause. Design This study was conducted on 80 postmenopausal women aged 52 to 70 years. Women were randomly divided into two groups: 40 women were treated by oral HRT (equine conjugated estrogens 0.625 mg/day + dydrogesterone 5 mg/day in a continuous combined regimen), and 40 women were not treated with hormones (control group). Each woman underwent a contrast sensitivity test, a Schirmer test, and an evaluation of intraocular pressure before starting the study and 1 year after the beginning of the study. Statistical analysis was performed by Students t test and Fishers exact test. Results Contrast sensitivity function was significantly improved in all spatial frequencies (1.5, 3, 6, and 12 cycles per degree) with the exception of 18 cycles per degree in the HRT group 1 year after the beginning of treatment, whereas the control group demonstrated significant impairment at the lowest spatial frequencies (1.5, 3, and 6 cycles per degree). Tear production was significantly improved in the HRT group 1 year after the beginning of treatment, and intraocular pressure was similar in the two groups before and after the beginning of the study. Conclusions HRT improves visual function, promoting a better contrast sensitivity and a higher tear production, but does not modify intraocular pressure.

Immediate postpartum perineal examination as a predictor of puerperal pelvic floor dysfunction.

OBJECTIVE To determine the relation between postpartum perineal trauma and the development of puerperal pelvic floor dysfunctions. METHODS A prospective study was conducted on 218 primiparae immediately after vaginal delivery. Women were divided in three groups according to perineal trauma: group A (n = 171) intact perineum or superficial tear, group B (n = 39) perineal muscle tears, group C (n = 8) anal sphincter tears with or without disruption of the rectal mucosa. Two months later, each woman was questioned about urogynecologic symptoms and examined by digital test, vaginal perineometry, and uroflowmetric stop test score. RESULTS No significant difference was found among the groups with regard to the incidence of stress incontinence, frequency/urgency, and urge incontinence, whereas anal incontinence was found more commonly in group C (group C versus group A: P =.003, odds ratio 18.78). No significant difference was found for digital test, perineometry, and uroflowmetric stop test. CONCLUSION Immediate postpartum perineal examination is not a good predictor of stress incontinence and pelvic floor weakness but could identify women at risk for anal dysfunctions: intact perineum does not exclude the appearance of symptoms related to perineal trauma after vaginal delivery.

The urine stream interruption test and pelvic muscle function in the puerperium

Objectives: This study assesses the role of the uroflowmetric urine stream interruption test (UST) in the evaluation of postpartum pelvic floor muscle function. Method: Two months after vaginal delivery, 492 women who underwent a digital test, vaginal manometry, and a UST were divided into two groups: continent and incontinent. Variables were subjected to the Students t‐test and to Fishers exact test to verify the difference between the two groups. Results: Digital test and vaginal manometry results were higher in the continent group, but only the UST showed significantly different values (P=0.001). All test results of incontinent puerperae who underwent rehabilitation were significantly improved after treatment. Conclusions: UST is low cost, non‐invasive, and can give objective information about pelvic floor performance after a vaginal delivery. It can be used for both routine clinical use and an outcome measure for women who undergo rehabilitation treatment.

Effects of epidural analgesia during labor on pelvic floor function after vaginal delivery

Background. Aims of this study were to determine the rate of symptoms related to perineal trauma (anal and stress urinary incontinence) and to assess pelvic floor muscle function in women who underwent epidural analgesia.

The treatment of Sjögren's syndrome with tibolone: a case report

We report the successful treatment with tibolone of a postmenopausal woman affected by primary Sjögrens syndrome. One year after the beginning of treatment, the woman does not need artificial tears and vaginal lubricants. This is the first report of an effective pharmacologic treatment for primary Sjögrens syndrome in humans.

Efficacy, tolerability and safety of a new medical device, Monurelle Biogel® vaginal gel, in the treatment of vaginal dryness: a randomized clinical trial in women of reproductive age

OBJECTIVE To prove the efficacy, tolerability and safety of Monurelle Biogel(®) (ZP-025) vaginal gel, which contains a purified, dialyzed, lyophilized bovine colostrum, in women of reproductive age suffering from vaginal dryness. DESIGN Randomized clinical trial (RCT) (Z7213M01). SETTING Five University Gynaecological Units. PATIENTS Ninety-five subjects were allocated at random to receive either ZP-025 (n=48) for about 23 intermenstrual days (1 or 2 times/daily intra-vaginally) or no treatment (lubricants on demand were allowed). MAIN OUTCOME MEASURES Change of Verbal Rating Scale (VRS) total and single score for vaginal symptoms, Vaginal Health Index (VHI) score, Female Sexual Function index (FSFI) and Female Sexual Distress Scale-revised (FSDS-R) scores. RESULTS A total number of 85 subjects was evaluable for primary analyses. Symptoms (VRS) of vaginal discomfort improved significantly already after 11 days, as compared to the control arm (p<0.0001). The mean VHI score was also significantly higher in ZP-025 group (p<0.001) at the end of the study. The analysis of covariance with the baseline value as covariate carried out on the FSFI Total Score showed a statistically significant difference in favour of the ZP-025 arm (p<0.032). A shift from presence to absence of sexual distress (≤11 points) was more prominent in the ZP-025 arm [10 subjects (40%) in the ZP-025 arm (p<0.0001) and 6 subjects (21.4%) in the control arm (p=0.01)]. Women reported a compliance rate of 100% for one ZP-025 application/day. Local tolerability of ZP-025 was excellent or good in 82.9% of the subjects. CONCLUSIONS The present multicentre RCT supports the use of Monurelle Biogel(®) in women of reproductive age reporting symptoms of vaginal dryness. A positive impact on vaginal health and sexual function was also evident.

Trattamento di irsutismo e androgenizzazione in menopausa

RiassuntoLa cessazione dell’attività ovarica che si verifica in menopausa comporta l’inversione del rapporto tra estrogeni e androgeni a favore di questi ultimi; ciò si traduce in una condizione di iperandrogenismo relativo e provoca delle ripercussioni sul profilo metabolico ed estetico, la cui espressione clinica è molto variabile ed è legata alla sensibilità individuale a tale squilibrio ormonale. La terapia estrogenica è in grado di ripristinare l’equilibrio endocrino mediante il supporto diretto degli estrogeni esogeni, ma anche attraverso una serie di effetti che riducono la biodisponibilità degli steroidi maschili. Tale risultato è più accentuato in seguito alla somministrazione di estrogeni per via orale. L’associazione del progestinico può contribuire ad antagonizzare gli effetti sfavorevoli dell’androgen izzazione quando si utilizzano preparati dotati di attività antiandrogenica. Soprattutto nelle fasi perimenopausali, quindi, la terapia ormonale sostitutiva, e in particolare l’impiego di progestinici dotati di attività antiandrogenica, ripristinando l’equilibrio endocrino, rappresenta un valido approccio alle forme di iperandrogenismo relativo. Durante la menopausa possono insorgere forme di iperandrogenismo assoluto di origine neoplastica o funzionale. Tra queste ultime, la più frequente è l’ipertecosi ovarica: nonostante l’approccio terapeutico classico e definitivo sia quello chirurgico, sono sempre più consistenti i dati sugli effetti della terapia medica basata sugli agonisti del GnRH, che rappresenta una valida alternativa soprattutto per quelle pazienti che non risultano delle candidate ottimali alla terapia chirurgica.