M. G. F. Sartori

Analysis of Collagen in Parametrium and Vaginal Apex of Women with and without Uterine Prolapse

Abstract: Our objective was to compare the amount of collagen in parametrium and vaginal apex between women with uterine prolapse at pre- and postmenopause, and in women without prolapse. The study included 22 premenopausal women without prolapse (group A), 10 premenopausal women with prolapse (group B), and 23 postmenopausal women with prolapse (group C) (total 55). Patients in group A underwent abdominal hysterectomy for uterine leiomyoma, and patients in groups B and C underwent vaginal hysterectomy. During the surgical procedure we obtained biopsies from the lateral parametrium and vaginal apex. The tissue was stained for histological analysis with picrosirius. We observed a lower amount of collagen in the parametrium of women with uterine prolapse, both in menacme and in postmenopause, than in the parametrium of women without prolapse. We observed no statistically significant difference in vaginal apex between the groups.

Effect of Estrogen–Progestogen Hormonal Replacement Therapy on Periurethral and Bladder Vessels

Abstract: This study assessed the effect of hormone replacement therapy using estrogens and/or progestogens on the number of vessels in the proximal and distal urethra, vesicourethral junction and bladder of castrated adult female rats. Forty-five virgin adult rats (Rattus norvegicus albinus) castrated for at least 30 days were used. They were assigned to five groups; group I (control) received no medication; the others received via the subcutaneous route, respectively, 17-β-estradiol (group II), medroxyprogesterone acetate (group III), a maize oil and benzyl acid solution – placebo (group IV) and 17-β-estradiol combined with medroxyprogesterone acetate (group V), for a minimum of 28 days. Increased vascularization throughout the urinary tract, except in the distal urethra, was found following estrogen replacement alone. In the group that received combined estrogens and progestogens, no increase was found. It was concluded that estrogen replacement in castrated rats significantly increased the number of vessels in the lower urinary tract.

Sexual steroids in urogynecology

The decline in sex hormone levels that accompanies the menopause has substantial effects on the tissues of the urogenital system, leading to atrophic changes. These changes can have negative effects on sexual and urinary function. The authors evaluate the repercussion of hypoestrogenism and sexual steroids on some elements of the pelvic floor and lower urinary tract. They summarize their research work and review significant published papers. They emphasize the changes in urinary mucosae, periurethral vessels, muscular layer, connective tissue, gene expression, autonomic nervous system receptors, as well as the main clinical aspects involved.

Changes in the Lower Urinary Tract in Continent Women and in Women with Stress Urinary Incontinence, According to Menopausal Status

Abstract: The aim of this study was to assess the impact of the postmenopausal period on clinical and urodynamic parameters and on the mobility of the bladder neck in continent women and in women with stress urinary incontinence. Fifty-seven postmenopausal women were studied: 30 were continent and 27 had stress urinary incontinence. They were subdivided according to postmenopausal stage into groups A (<5 years) and B (>5 years). Five years was a good marker to separate those women with mild and severe estrogen deficiency. Fifteen premenopausal incontinent women were selected for bladder neck ultrasound as controls. All underwent history, general physical and gynecologic examinations, LH and FSH determinations, type 1 urine and uroculture, circadian voiding diary, cotton-swab test, bladder neck ultrasound and urodynamic investigations. Analysis of the voiding diaries revealed a higher frequency of daytime micturition in both groups of incontinent patients than in the continent ones. Increased bladder neck mobility was also found, both in the cotton-swab test and an ultrasound, in group A and an ultrasound in the premenopausal incontinent women. Urodynamic investigation showed decreased bladder capacity at the first micturition urge, as well as decreased urinary volume in the group A patients compared to the continent ones. Decreased urethral closure maximum pressure was also found in group B patients in relation to the continent ones. We concluded that the effect of hypoestrogenism, manifested postmenopause, causes changes in the lower urinary tract of women, particularly those who are incontinent.

PUK23 VALIDATION OF A QUALITY OF LIFE QUESTIONNAIRE (KING'S HEALTH QUESTIONNAIRE) IN BRAZILIAN WOMEN WITH URINARY INCONTINENCE

Purpose: the proposal of the present study was to translate and to validate King s Health Questionnaire (KHQ) for Brazilian women with urinary incontinence. Methods: a hundred and thirty-four patients with urinary incontinence, confirmed by urodynamic study, were enrolled from the outpatient clinic of Uroginecology. Initially, we translated the KHQ into the Brazilian Portuguese language in agreement with international criteria. Due to language and cultural differences we performed a cultural, structural, conceptual, and semantic adaptation of the KHQ, in order to make sure that patients were able to fully understand the questions. All patients answered the KHQ twice on the same day, within an interval of 30 min, applied by two different interviewers. After 7 to 14 days, on a second visit, the questionnaire was applied again. Reliability (intraand interobserver internal consistency), construct and discriminative validity were tested. Results: several cultural adaptations were necessary until we reached the final version. The intra-observer internal consistency (alpha of Cronbach) of the several dimensions varied from moderate to high (0.77-0.90), and the interobserver internal consistency varied from 0.66 to 0.94. Moderate to strong correlation was detected among the specific KHQ urinary incontinence dominions and clinical Validacao do questionario de qualidade de vida (King’s Health Questionnaire) em mulheres brasileiras com incontinencia urinaria Validation of a quality of life questionnaire (King’s Health Questionnaire) in Brazilian women with urinary incontinence Eliana Suelotto Machado Fonseca1, Adriana Luciana Moreno Camargo2, Rodrigo de Aquino Castro3, Marair Gracio Ferreira Sartori4, Marcelo Cunio Machado Fonseca5, Geraldo Rodrigues de Lima6, Manoel Joao Batista de Castello Girao7 1 Enfermeira Responsavel do Ambulatorio de Uroginecologia e Mioma da Universidade Federal de Sao Paulo – Escola Paulista de Medicina (UNIFESP) 2 Fisioterapeuta Responsavel do Ambulatorio de Uroginecologia e Mioma da Universidade Federal de Sao Paulo – Escola Paulista de Medicina (UNIFESP) 3 Medico Chefe do Ambulatorio de Uroginecologia e Mioma da Universidade Federal de Sao Paulo – Escola Paulista de Medicina (UNIFESP) 4 Professora Adjunta; Chefe do Setor de Uroginecologia do Departamento de Ginecologia (Setor de Uroginecologia) da UNIFESP 5 Medico do Grupo de Pesquisa Clinica em Ginecologia da UNIFESP – Departamento de Ginecologia (Setor de Uroginecologia) da UNIFESP 6 Professor Titular; Departamento de Ginecologia (Setor de Uroginecologia) da UNIFESP 7 Professor Adjunto Livre Docente; Departamento de Ginecologia (Setor de Uroginecologia) da UNIFESP Correspondencia: Eliana Suelotto Machado Fonseca Rua Marques de Itu, 1007, apto 54 – Higienopolis – 01223-001 – Sao Paulo – SP – Fone: (11) 3825-5035 / 8208-7704 – e-mail: elianasfonseca@terra.com.br O questionario validado em portugues podera ser obtido por solicitacao a autora pelo e-mail elianasfonseca@terra.com.br Recebido em: 17/9/2004 Aceito com modificacoes em: 10/5/2005 Rev Bras Ginecol Obstet. 2005; 27(5): 235-42 236 Fonseca ESM, Camargo ALM, Castro RA, Sartori MGF, Fonseca MCM, Rodrigues de Lima G, Girao MJBC Rev Bras Ginecol Obstet. 2005; 27(5): 235-42 Introducao A perda da continencia urinaria pode afetar ate 50% das mulheres em alguma fase de suas vidas1. A vida social dessas pacientes passa a depender da disponibilidade de banheiros. Elas comumente relatam preocupacao e embaraco com o odor de urina. Apresentam dificuldade durante o intercurso sexual, por medo de perder urina ou de precisar interrompe-lo para urinar, alem de alteracoes do sono2,3. Entre 30 e 50% das pessoas que sofrem de incontinencia urinaria nao relatam espontaneamente esse fato ao medico ou a enfermeira, e so procuram o servico de saude apos o primeiro ano do inicio dos sintomas por acharem que a perda de urina e esperada com o evoluir da idade4. Elas, silenciosamente, tem reducao da auto-estima, tornando-se deprimidas, angustiadas e irritadas. O envolvimento do proprio paciente no seu tratamento e a necessidade de avaliacao mais ampla de como e quanto determinada doenca ou intervencao medica atinge a qualidade de vida sao fundamentais em qualquer servico de saude5. A mensuracao da qualidade de vida ajuda a selecionar e monitorar problemas psico-sociais de um paciente, demonstra a percepcao da populacao sobre diferentes problemas de saude e mede os resultados das intervencoes medicas5. Por isso, a Sociedade Internacional de Continencia (ICS) tem recomendado que um questionario de qualidade de vida seja incluido em todo e qualquer estudo sobre incontinencia urinaria6. O termo e o conceito de qualidade de vida surgiram com o crescimento e o desenvolvimento economico ocorridos apos a Segunda Guerra Mundial, nos Estados Unidos da America, para descrever efeito de aquisicao de diferentes bens na vida das pessoas7. A evolucao tecnologica e os conceitos de economia em saude tornaram necessaria a avaliacao nao so da eficacia e da toxicidade das intervencoes, mas tambem do seu impacto na qualidade de vida dos individuos7,8. O conceito de qualidade de vida e subjetivo e, portanto, sua definicao e variavel. Esta relacionado a percepcao do individuo sobre o seu estado de saude em grandes dominios ou dimensoes de sua vida5,9. O interesse em mensurar a qualidade de vida, em relacao aos cuidados de saude, tem aumentado nos ultimos anos, de tal modo que a WHO (World Health Organization) iniciou projeto de avaliacao internacional de qualidade de vida, levando em consideracao decisoes de tratamento, autorizacao para novos farmacos e politica de pesquisa10. Os instrumentos de medida de qualidade de vida sao, em sua maior parte, desenvolvidos em outras linguas e culturas que nao a nossa. Utilizam-se, na mensuracao da qualidade de vida, questionarios que tem por finalidade avaliar os diversos aspectos e dimensoes da vida da paciente, como o fisico (mobilidade, autocuidado, exercicios), o psicologico (depressao, ansiedade, preocupacao), o social (suporte, contato, atividades nas horas vagas), o desempenho geral (emprego, trabalhos domesticos, compras), a dor, o sono e sintomas especificos da doenca, por exemplo, perda urinaria6-11. Existem varios questionarios para se avaliar a qualidade de vida em mulheres incontinentes que tem semelhancas e diferencas entre si. Podem ser utilizados questionarios genericos ou especificos, que avaliam aspectos proprios da gravidade e do impacto dos sintomas na vida das pacientes12. Os genericos, como o SF-36, sao de facil administracao e compreensao, mas tem como inconveniente apresentar dimensoes gerais, que podem ser pouco sensiveis as alteracoes clinicas que as pacientes venham a apresentar. Ja os questionarios especificos avaliam aspectos proprios da gravidade e do impacto dos sintomas na vida das pacientes, como: Bristol Female Lower Urinary Tract Symptoms (BFLUTS), Quality of Life in Persons with Urinary Incontinence (I-QoL), Stress Incontinence Questionnaire (SIQ) e King’s Health Questionnaire (KHQ). O questionario Bristol Female Lower Urinary Tract Symptoms e, essencialmente, usado para medir o impacto dos sintomas da incontinencia urinaria. As questoes focam mais o grau de incomodo do que o problema causado aos pacientes12. Ja os questionarios Quality of Life in Persons with Urinary Incontinence (I-QoL) e Stress Incontinence Questionnaire (SIQ) medem o impacto dos sintomas urinarios de maneira geral. As questoes sao utilizadas para avaliar todos os dominios da qualidade de vida e as frases sao construidas para atingir urinary incontinence manifestations known to affect the quality of life of these patients. Conclusion: KHQ was adapted to the Portuguese language and to the Brazilian culture, showing great reliability and validity. It should be included and used in any Brazilian urinary incontinence clinical trial.