Fabio Amicarelli

Prevalence of anal incontinence in women with symptoms of urinary incontinence and genital prolapse

OBJECTIVE To investigate risk factors and prevalence of anal incontinence among women with pelvic floor dysfunctions. METHODS We evaluated 881 women with symptoms of urinary incontinence and/or genital prolapse. Each completed a bowel questionnaire and underwent a detailed medical, surgical, obstetric, and gynecologic history, and a pelvic examination. Additional testing, when indicated, included office cystometry or multichannel urodynamic evaluation. Multivariable analysis using logistic regression was used to test the overall significance of all variables significantly associated with anal incontinence, using univariate analysis. RESULTS A total of 178 women had anal incontinence (20%). These patients were on average older, had a greater body mass index, and had larger birth weight infants than their anal‐continent counterparts; 511 were diagnosed with urinary incontinence, and 122 (24%) also had anal incontinence. Women with urinary incontinence were more likely to report anal incontinence events than women continent of urine (24% versus 15%, P = .002). The following associations were found with anal incontinence: infant with birth weight 3800 g or greater (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1, 2.2), rectocele greater than grade 2 (OR 1.9, 95% CI 1.1, 3.3), urinary incontinence (OR 1.9, 95% CI 1.3, 2.8), hemorrhoidectomy (OR 2.7, 95% CI 1.1, 7.0), irritable bowel syndrome (OR 6.3, 95% CI 3.5, 11.5). CONCLUSION Among women with symptoms of urinary incontinence and pelvic organ prolapse, the prevalence of anal incontinence was 20%. Urinary incontinence and severe rectocele were found to be associated with anal incontinence.

The Sacrospinous Vaginal Vault Suspension: Critical Analysis of Outcomes

Abstract: One hundred and three women with a preoperative diagnosis of a pelvic support defect underwent right sacrospinous fixation of the vaginal apex. The procedure was performed either therapeutically (in 63 subjects with vaginal vault eversion) or prophylactically (40 patients with severe uterovaginal prolapse), and was associated with other reconstructive procedures to repair the coexisting cystocele, enterocele or rectocele. Preoperative and postoperative assessments of each vaginal site were compared and the results in the cure of stress urinary incontinence, if present, were evaluated with regard to the type of surgery performed. The overall rate of satisfactory results in the repair of the superior vaginal defect was 94%, and good anatomic results were achieved in the repair of either enterocele or rectocele. Conversely, the repair of the anterior vaginal wall was not as good as in the posterior and superior vaginal sites. Stress urinary incontinence was successfully managed in 72% of the women using different anti-incontinence procedures.

Ureteral and vesical endometriosis. Two different clinical entities sharing the same pathogenesis.

Ureteral or vesical endometriotic lesions affect about 1% of women with endometriosis. The diagnosis may be difficult when specific symptoms are lacking. A delay in diagnosis can lead to significant morbidity. An adequate comprehension of the circumstances in which ureteral and vesical endometriosis present or should be suspected, aided by advances in imaging techniques and laparoscopic surgery, may allow a significant progress in the treatment of these conditions. The pathogenesis, diagnosis, and treatment of ureteral and vesical endometriosis are reviewed, with the aim of increasing the degree of awareness of the clinicians and helping in devising an adequate clinical management plan for the lesser understood aspects of the disease. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this educational activity, the participant should be better able to explain the most likely pathogenesis of ureteral and vesical endometriosis, recall the clinical presentation and risk factors for endometriosis of the bladder and ureter, and summarize treatment strategies for endometriosis of the bladder and ureter.

Effects of oral and transdermal hormone replacement therapy on lipoprotein(A) and lipids: A randomized controlled trial

Objective:Our purpose was to compare the effect of oral and transdermal hormone replacement therapy on lipoprotein(a) and other plasma lipids in healthy postmenopausal women. Design:A total of 120 postmenopausal women were enrolled in a prospective randomized controlled study, and allocated either to transdermal 17β-estradiol (50 μg/day) or to oral conjugated estrogen (0.625 mg/day). Forty-one age-matched women were used as the reference group. Plasma lipids and lipoproteins were determined every 3 months and differences were sought by statistical analysis. Results:Plasma lipoprotein(a) dropped after 3 months of treatment either with transdermal estradiol (p < 0.01) or oral estrogen (p < 0.01). Lipoprotein(a) was reduced by 12% and 22%, respectively. No further decreases were seen later on. Plasma total and low-density lipoprotein (LDL) cholesterol concentrations were decreased significantly with both treatments after 3 months of therapy. No difference was seen in the lowering effect on lipoprotein(a), LDL and total cholesterol concentrations between regimens. Plasma high-density lipoprotein (HDL) cholesterol and triglyceride concentrations increased throughout the study only in patients treated with oral estrogen. Conclusions:These data demonstrate that hormone replacement therapy reduces the concentration of lipoprotein(a) when given both orally and transdermally. The lowering effect is achieved quickly because the maximal effect is observed after 3 months of therapy.

Changes in Sex Hormone-Binding Globulin Plasma Concentrations Induced by Body Weight and Estrogen Status in Perimenopausal Years

A cross-sectional study was conducted on 562 healthy perimenopausal women, with a mean age of 52.6 years, to follow perimenopausal changes in sex hormone-binding globulin (SHBG) plasma levels during the perimenopausal years. According to menstrual history and follicle-stimulating hormone (FSH) levels, 398 women were considered postmenopausal, and 164 were premenopausal. Women with a body mass index (BMI) of <25 were considered to be of average weight, and those with a BMI > 25 were thought to be overweight. To study the effect of oral hormone replacement therapy, 153 women in the postmenopausal group were given 0.625 mg/day of oral conjugated estrogen plus medroxyprogesterone acetate, 10 mg/day, for 12 days every 3 months. SHBG levels were assayed at baseline and after 12 months of therapy. SHBG was positively associated with 17 β-estradiol plasma levels (r = 0.09, p < 0.05), and there was a strong negative correlation with BMI (r = −0.27, p < 0.001). After menopause, SHBG plasma levels dropped significantly (p < 0.05), but only in lean women. Similarly, hormone replacement therapy increased SHBG plasma levels in lean postmenopausal women (p < 0.001) but not among overweight treated women. These findings indicate that circulating estrogens are the main factor in SHBG metabolism in lean women, while obesity apparently abolishes the hormonal influence of ovarian estrogen and of hormone replacement therapy.

Effects of Hormone Replacement Therapy on Lipids and Lipoproteins in Dyslipidemic Postmenopausal Women: A Comparison Between Transdermal and Oral Estrogen

The physiologic effects of combination hormone replacement therapy are less well established than the effects of estrogen alone. Recently the Postmenopausal Estrogen/ Progestin Interventions (PEPI) Trial [1] offered the most definitive conclusion that estrogen alone or in combination with a progestin decreased low density lipoprotein (LDL) cholesterol and increased high density lipoprotein (HDL) cholesterol. The higher levels of triglycerides, although potentially detrimental, seem to be related to an increased production of large very low density lipoproteins (VLDL), which are less atherogenic than small VLDL. Reports of the metabolic effect of transdermal estrogen are conflicting. Overall, it seems that transdermal estradiol is less effective than oral estrogen on LDL and HDL cholesterol, whereas a fall in triglycerides has been reported [2]. Recently, the National Cholesterol Education Program Adult Treatment Panel II Guidelines suggested hormone replacement therapy an alternative to standard treatments for dyslipidemic postmenopausal women [3].

Lipoprotein(a) Changes in Perimenopausal Years

Several publications, over the last decade, reported the influence of sex hormones on lipoprotein(a) plasma levels. We studied Lp(a) changes in perimenopausal years and the effect of two different schedules of hormone replacement therapy (HRT) on Lp(a) plasma levels. According to menstrual history and FSH plasma levels, 424 women were divided in two groups: 112 were in premenopause and 312 were postmenopausal women with a mean time since last period of 5 years. No difference in Body Mass Index (BMI) was seen between groups, but postmenopausal women were older than premenopausal ones. Lp(a) plasma levels were significantly higher after menopause (p<.01); no significant difference was seen with aging but, at any age considered, premenopausal women have lower Lp(a) plasma levels than the postmenopausal counterpart.