Omero Benedicto Poli Neto

Importance of pelvic muscle tenderness evaluation in women with chronic pelvic pain.

OBJECTIVE To determine the prevalence of pelvic muscle tenderness in women with chronic pelvic pain (CPP) and to assess the importance of evaluating muscle tenderness in such women. DESIGN Observational study of 48 healthy female volunteers and 108 women with CPP, who were clinically evaluated for pelvic muscle tenderness by two researchers blinded to all clinical data. RESULTS The frequency of clinically detected pelvic muscle tenderness was significantly higher in women with CPP than in healthy volunteers (58.3% vs 4.2%, P < 0.001). Among women with CPP, those with pelvic muscle tenderness had higher Beck Depression Index scores (22 [6-42] vs 13 [3-39], P = 0.02) and higher rates of dyspareunia (63.5% [40/63] vs 28.9% [13/45], P < 0.004) and constipation (46.0% [29/63] vs 26.7% [12/45], P = 0.05) than those without pelvic muscle tenderness. CONCLUSION Tenderness of pelvic muscles was highly prevalent among women with CPP and was associated with higher BDI scores and higher rates of dyspareunia and constipation. Determination of pelvic muscle tenderness may help in identifying women who require more intense treatment for CPP.

High prevalence of chronic pelvic pain in women in Ribeirão Preto, Brazil and direct association with abdominal surgery

INTRODUCTION: Chronic pelvic pain is a disease that directly affects the social and professional lives of women. OBJECTIVE: To estimate the prevalence of this clinical condition and to identify independent factors associated with it in women living in Ribeirão Preto, Brazil. METHODS: A one-year cross-sectional study was conducted in a population sample of 1,278 women over the age of 14 years. The target population was predominantly composed of women who are treated by the public health system. The questionnaire was administered by interviewers who were not linked to the city health care programs. The prevalence of the morbidity was estimated. First, we identified the significant variables associated with pelvic pain (p<0.10) and then we attributed values of 0 or 1 to the absence or presence of these variables. Logistic regression analysis was used to identify and estimate the simultaneous impact of the independent variables. The results were expressed by odds ratio and their 95% confidence interval with p<0.05. RESULTS: The disease was found in 11.5% (147/1,278) of the sample. The independent predictors were dyspareunia, previous abdominal surgery, depression, dysmenorrhea, anxiety, current sexual activity, low back pain, constipation, urinary symptoms, and low educational level. CONCLUSION: The prevalence of chronic pelvic pain in Ribeirão Preto is high and is associated with conditions that can usually be prevented, controlled, or resolved by improvement of public health policies and public education.

Oxidative-Stress Biomarkers in Patients with Pulmonary Hypertension

This controlled, prospective, nonrandomized clinical investigation has as its chief strength the fact that it was done in humans with active disease and apparently on fairly modest therapeutic regimens. The aim was to present the results of oxidative-stress biomarkers in humans suffering from pulmonary artery hypertension (PAH). Inflammation and oxidative stress are essential in PAH with increased lipid peroxidation and reduced antioxidant defenses. Twenty-four adult patients of both sexes, with a mean age of 21 years, were subdivided into 2 groups: a control group of 12 healthy, nonsmoking volunteers and a PAH group (PAHG) of 12 volunteers with PAH receiving outpatient treatment. Oxidative stress was evaluated by plasma activity of reduced glutathione (GSH); lipid peroxidation was expressed by malondialdehyde (MDA) and lipid hydroperoxide (ferrous oxidation of xylenol orange [FOX] assay); vitamin E was measured by high-performance liquid chromatography and tumor necrosis factor-α (TNF-α) by enzyme-linked immunosorbent assay. Statistical analyses showed significant differences for (1) the TNF-α measure, with highest values in PAHG patients; (2) the plasma GSH, with lowest values in PAHG patients; (3) vitamin E, with the lowest concentrations in PAHG patients; (4) MDA measure, with highest values in PAHG patients; and (5) the lipid hydroperoxide FOX measure, with highest values in PAHG patients. In conclusion, inflammation and oxidative stress are present in patients with PAH, as confirmed by increased lipid peroxidation, reduced GSH, and low concentrations of vitamin E.

Hysteroscopy as a standard procedure for assessing endometrial lesions among postmenopausal women

CONTEXT AND OBJECTIVES Endometrial cancer is the most prevalent type of malignant neoplasia of the genital tract. The objective of this study was to calculate the sensitivity, specificity, accuracy and positive and negative predictive values for diagnostic hysteroscopy, in comparison with histopathological tests, for all lesions of the endometrial cavity. DESIGN AND SETTING Retrospective descriptive study at the public tertiary-level university hospital of Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo. METHODS Diagnostic hysteroscopy was indicated in the following instances: endometrial thickness > 4 mm in asymptomatic patients; postmenopausal bleeding; and irregular endometrium or endometrium difficult to assess from ultrasound, with or without vaginal bleeding. Ultrasound evaluations were carried out no more than three months prior to hysteroscopy. RESULTS There were 510 patients, with a mean age of 61.1+/-2.0 years and mean time elapsed since the menopause of 12.7+/-2.5 years. Endometrial biopsies were performed on 293 patients (57.5%). Histopathological analysis showed that 18 patients presented endometrial carcinoma or typical or atypical hyperplasia, and none of them presented endometrial thickness of less than 8 mm. No significant differences were found between the median thicknesses of the various benign lesions (p > 0.05). In our data, the sensitivity, specificity, accuracy and positive and negative predictive values for cancer or hyperplasia were 94.4%, 97.0%, 96.8%, 68% and 99.6%, respectively. CONCLUSIONS Our results suggest that hysteroscopy is valuable as a diagnostic tool for malignant/hyperplastic and benign lesions, except for submucous myomas, for which the sensitivity was only 52.6%.

Abordagem da dor pélvica crônica em mulheres

Chronic pelvic pain is a debilitating and highly prevalent disease with a major impact on quality of life and work productivity, beyond significant costs to health services. The dilemma of managing patients with chronic pelvic pain continues to frustrate physicians confronted with these complaints, in part because its pathophysiology is poorly understood. Consequently, its treatment is often unsatisfactory and limited to temporary symptom relief. In the present revision, we discuss the adequate management of chronic pelvic pain. We point out that a comprehensive medical history and physical examination should include special attention to gastrointestinal, urological, gynecological, muscle-skeletal, neurological, psychiatric, and endocrine systems. Thus, a multidisciplinary approach is recommended. Additionally, we emphasize that, although useful, specific surgical procedures, such as laparoscopy, should be indicated only to selected patients, mainly after excluding irritable bowel syndrome and pain of myofascial origin.

Thiele massage as a therapeutic option for women with chronic pelvic pain caused by tenderness of pelvic floor muscles

AIMS AND OBJECTIVES Musculoskeletal system has been found to be involved in genesis and perpetuation of chronic pelvic pain (CPP) and has strong evidences that up to 80% of women with CPP present dysfunction of the musculoskeletal system. In this study, we report a series of women with CPP caused by tenderness of pelvic floor muscles successfully treated with Thiele massage. METHODS Were included in this study six women with CPP caused by tenderness of the levator ani muscle that underwent transvaginal massage using the Thiele technique, over a period of 5 minutes repeated once a week for 4 weeks. After 1 month, the women returned for follow-up. RESULTS The median tenderness score for the six women evaluated was 3 at the first evaluation and 0 after 1 month of follow-up (P < 0.01). The mean Visual Analogue Scale and McGill Pain Index scores were 8.1 and 34, respectively, at the first evaluation, and 1.5 and 16.6 at follow-up (P < 0.01). CONCLUSION Thiele massage appears to be very helpful for women with CPP caused by tenderness of the levator ani muscle. However, these results are preliminary and a larger number of women are necessary to obtain more conclusive results.

Conservative management of large uterine arteriovenous malformation: case report.

Uterine arteriovenous malformation is a rare condition that may be associated with uterine bleeding. Eventually morphologic aspects of the lesions induce unnecessary aggressive surgery; we report here a case of successful expectant management.

Endometriose umbilical sem cirurgia pélvica prévia

PURPOSE: to present a series of cases of umbilical endometriosis in patients in reproductive age, with no previous pelvic surgery. METHODS: four patients aged between 33 and 43 years were included in the study. They all presented umbilical bleeding associated or not with pelvic pain, and medical history varied from two months to four years. Abdominal wall ultrasound was performed for diagnosis support before surgical excision of the umbilical lesions, and histological examination was also performed. RESULTS: the ultrasonographic evaluation of the four patients showed hypoechogenic umbilical lesion suggestive of endometriosis. All patients were submitted to surgical excision and histological examination of the lesions. CA-125 serum levels were measured in three of the patients, but they were within normal ranges (from 6.8 to 10.1 U/mL). In addition to umbilical surgery, laparoscopy was performed in all patients, but only one presented concomitant pelvic endometriosis. In a one-year follow-up, patients maintained asymptomatic and there was no recurrence of the lesions. CONCLUSIONS: umbilical endometriosis is a rare entity, but it may be remembered as a possibility in cases of umbilical nodulations or bleeding, even if there is no previous history of pelvic surgery with endometrial manipulation. Its treatment is always surgical and, in general, it is enough to promote complete elimination of the lesion and of the symptoms.

Expression of p63 differs in peritoneal endometriosis, endometriomas, adenomyosis, rectovaginal septum endometriosis, and abdominal wall endometriosis.

CONTEXT Although there is evidence that endometriosis results from basal endometrium dislocation, the underlying biology is not fully understood. One protein that plays an important role in regulating epithelial proliferation and differentiation is the 63-kDa membrane protein (p63), which is also a marker of basal and reserve cells in the female genital tract. OBJECTIVE To determine whether p63 is expressed differently in peritoneal endometriosis, endometriomas, and adenomyosis, as well as in deep endometriotic nodules of the rectovaginal septum and abdominal wall. DESIGN This study includes a prospective series of consecutive patients (Canadian Task Force classification II-2) from a tertiary care university hospital. Specimens collected from 83 patients (15 peritoneal endometriosis specimens, 22 endometrioma specimens, 36 adenomyosis specimens, and 10 rectovaginal septum/abdominal wall specimens) were evaluated. Diagnostic and operative laparoscopies or laparotomies were performed, and tissue samples were obtained. Immunohistochemistry was used to evaluate p63 expression. RESULTS Positivity for p63 was detected in 93.3% of the peritoneal endometriosis specimens, 81.8% of the endometrioma specimens, 36.1% of the adenomyosis specimens, and none of the rectovaginal/abdominal wall endometriosis specimens (P < .001). Distribution of p63 immunostaining in the positive specimens was homogeneous. CONCLUSIONS Endometriotic lesions express p63 differently, and some retain the basal/reserve cell immunophenotype. Nevertheless, it remains unclear whether the lack of p63 expression in some lesions is related to the extent of the disease, to its clinical behavior, or to exacerbation of the accompanying symptoms.

Reduction of Pain Sensitivity is Associated with the Response to Treatment in Women with Chronic Pelvic Pain

OBJECTIVE The objective of this study was to evaluate whether pain thresholds to electrical stimulation of the skin change in the response to treatment in women with chronic pelvic pain (CPP). METHODS Fifty-eight women with persistent pelvic pain for at least 6 months, from a tertiary care setting, were included in this study. All women were evaluated before the therapeutic intervention and at 6 months of multidisciplinary treatment. To estimate the pain threshold, we used transcutaneous electrical nerve stimulation on the anterior surface of the nondominant arm. The intensity of clinical pain was estimated by a visual analog scale and by the McGill questionnaire. RESULTS The mean of pain threshold increased from 14.2 to 17.4 after 6 months of treatment (P < 0.0001). The effect sizes of the increase of electrical pain threshold were 0.86 (95% CI, 0.38 to 1.34) in the group with pain reduction and 0.53 (95% CI, -0.08 to 1.15) in the group without pain reduction. CONCLUSION The sensitivity to experimental pain was reduced after 6 months of multidisciplinary treatment for CPP. Our data provided additional evidence of central sensitization in women with CPP.