Montserrat Espuña

Patología del suelo pélvico

Resumen La incontinencia fecal y urinaria estan frecuentemente asociadas, junto con el prolapso de los organos pelvicos. El parto vaginal y el estrenimiento cronico son los factores de riesgo mas importantes en la patologia del suelo pelvico. Sea cual sea el sintoma por el que acude la paciente al especialista, es necesario investigar la existencia de sintomas de otros compartimentos, porque las pacientes raramente los refieren de forma espontanea. Las pacientes con una enfermedad del suelo pelvico deberian ser evaluadas por un grupo multidisciplinario de especialistas. Se recomienda, en la mayoria de los casos, una evaluacion completa que incluya urodinamica, manometria anal, ecografia endoanal y estudios neurofisiologicos del suelo pelvico, dado que las afecciones del suelo pelvico tienen una compleja patofisiologia multifactorial, y deben detectarse todas las anormalidades anatomicas y funcionales para proporcionar el tratamiento mas adecuado. El tratamiento conservador permite la curacion o mejoria de un gran numero de pacientes con sintomatologia le-ve-moderada. La cirugia debe indicarse en pacientes seleccionadas y correctamente evaluadas, de forma que se hayan identificado preoperatoriamente todos los defectos anatomicos y funcionales que puedan ser corregidos quirurgicamente. Identificar factores de riesgo, conocer mejor la prevalencia y la patofisiologia de este problema de salud, permitira establecer estrategias preventivas y mejorar los resultados terapeuticos.

Electrophysiologic Studies and Clinical Findings in Females With Combined Fecal and Urinary Incontinence: A Prospective Study

PurposeSeveral clinical, urodynamic, and manometric findings suggest neurologic damage as a contributing factor in the development of combined fecal and urinary incontinence. In this study, we wanted to test the hypothesis of pudendal nerve neuropathy being a more frequent lesion in patients with double incontinence compared with patients with isolated fecal incontinence.PatientsNinety-three females with combined fecal and urinary incontinence and 36 females with isolated fecal incontinence were investigated. All patients underwent anal manometry, endoanal ultrasound, electromyography, and pudendal nerve terminal motor latency.ResultsNo statistically significant differences were found in the age, history of vaginal delivery, and chronic straining between both groups. However, the rate of postmenopausal females was higher in the combined fecal and urinary incontinence group (85 vs. 67 percent; P = 0.02). Menopause was an independent risk factor of having double incontinence (odds ratio, 1.4; P = 0.02). Concentric needle electromyography of the external anal sphincter revealed increased duration of the motor unit potentials in 43 and 53 percent of patients with combined fecal and urinary incontinence and isolated fecal incontinence, respectively (P = 0.28). An increased number of polyphasic motor unit potentials was detected in 52 and 58 percent (P = 0.6). There was no statistically significant difference in the prevalence of bilateral (20 vs. 27 percent) or unilateral (23 vs. 14 percent) prolonged mean pudendal nerve terminal motor latency between both groups (P = 0.3).ConclusionsPudendal neuropathy is not a distinct characteristic of patients with double incontinence. The prevalence of pudendal neuropathy in these patients is similar to that observed in patients with isolated fecal incontinence. Others factors should be investigated to explain the common association of both types of incontinence.

Comparison between laparoscopic sacral hysteropexy and subtotal hysterectomy plus cervicopexy in pelvic organ prolapse: A pilot study.

The primary outcome was to evaluate the subjective success rates of two laparoscopic POP operation techniques: uterine‐sparing surgery versus a subtotal hysterectomy plus cervicopexy.

Pubic Bone Anchoring Devices for the Surgical Treatment of Urinary Stress Incontinence in Patients with Severe Genital Prolapse

Abstract The aim of this study was to test a surgical technique for the treatment of stress urinary incontinence associated with genital prolapse through a transvaginal suspension anchored to the pubic bone. Thirty-seven patients with severe genital prolapse and urodynamically proven stress incontinence were operated on with this procedure from February 1998 to May 2000. Preoperatively a detailed history, pelvic examination and urodynamic studies were carried out. The degree of prolapse was assessed pre- and postoperatively in the lithotomy position in accordance with the classification proposed by Baden and Walker [8]. Two titanium bone screws with no. 1 polypropylene sutures attached to them and a battery-operated screw inserter are used to fix the vaginal sutures to the pubic bone bilaterally. The procedure is performed transvaginally with no abdominal or suprapubic incisions. Objective outcomes were assessed by symptom assessment, clinical examination and a full urodynamic evaluation at 6 months postoperatively, and annually by clinical evaluation. Subjective outcomes were assessed by directly interviewing the patients about their postoperative urinary symptoms and asking them to classify their level of satisfaction. An objective cure rate (no objective loss of urine during coughing in the absence of a simultaneous detrusor contraction) at the 6-month postoperative urodynamic evaluation was observed in 23 of 37 patients (62%). Recurrent anterior vaginal wall prolapse (grade 2) had developed in 7 of 37 patients (27%). Subjectively, 73% of the patients expressed satisfaction with the procedure. Early results using two bone screws into the pubis to fix the periurethral and perivesical tissues and vagina to the posterior surface of the pubic bone were disappointing. Based on our results we have abandoned the use of this procedure to correct stress incontinence associated with severe genital prolapse.

Tratamiento farmacológico de la incontinencia urinaria de esfuerzo

Resumen La incontinencia urinaria de esfuerzo (IUE) es la perdida involuntaria de orina asociada a un esfuerzo fisico que provoca un aumento de la presion abdominal (toser, reir, correr o incluso andar). Se estima que, en aproximadamente el 50% de las mujeres con incontinencia urinaria (IU), su sintoma principal es la IUE. La uretra en si misma tiene un importante papel en el conjunto de los mecanismos de continencia, recibe inervacion triple: simpatica, parasimpatica y somatica. El estimulo somatico llega a la uretra desde el nucleo de Onuf, situado en la medula sacra, a traves del nervio pudendo, la estimulacion de receptores nicotinicos, en el musculo estriado uretral provoca la contraccion refleja y tambien la voluntaria del esfinter uretral. En estudios experimentales, se ha comprobado la implicacion de la serotonina en el control central del aparato urinario inferior, aunque ha resultado dificil establecer el tipo de accion, la mayoria de estudios reconoce que la activacion central dependiente de la serotonina produce una inhibicion en los mecanismos sensoriales y la estimulacion de la actividad somatica motora del esfinter estriado uretral. Mediante tecnicas inmunohistoquimicas, se ha podido observar que las neuronas del nucleo de Onuf que van al esfinter estriado uretral, estan rodeadas de numerosos terminales adrenergicos y serotoninergicos y, por tanto, sensibles a los efectos de un inhibidor de la recaptacion de serotonina (5-HT) y norepinefrina (NE). El incremento de serotonina y noradrenalina en la zona del nucleo de Onuf, provoca un aumento de actividad neural que trae como consecuencia un estimulo que favorece una contraccion prolongada del esfinter uretral. Segun esta observacion, cualquier farmaco que actue en el sistema nervioso central (SNC) y produzca un incremento en el aporte de serotonina y noradrenalina tiene un efecto que puede potenciar la continencia. La duloxetina es un inhibidor combinado de la recaptacion de 5-HT y NE. Los ensayos clinicos realizados en un total de 1.913 mujeres con IU de predominio de esfuerzo, con duloxetina frente a placebo y el metaanalisis de estos, proporcionan datos consistentes y de peso que apoyan la seguridad y la eficacia de la duloxetina para el tratamiento de la IUE. Esta forma de tratamiento se podra ofrecer como primera opcion terapeutica, al igual que la reeducacion muscular del suelo pelvico a mujeres con diagnostico de IUE. Los estudios de extension y el uso del farmaco en la practica clinica, indicaran el lugar exacto que ocupara el tratamiento farmacologico de la IUE en el contexto de la atencion a la IU en la mujer.