Paulo Cezar Feldner

Valor da Queixa Clínica e Exame Físico no Diagnóstico da Incontinência Urinária

Objetivo: analisar a prevalencia das queixas clinicas uroginecologicas correlacionando-as com o diagnostico definitivo apos o exame urodinâmico e comparar o sinal clinico de perda urinaria com o estudo urodinâmico. Metodos: foram analisadas, retrospectivamente, 114 pacientes atendidas no periodo de junho de 2000 a janeiro de 2001. Todas as pacientes foram avaliadas por meio de anamnese padronizada, exame fisico e estudo urodinâmico, sendo classificadas de acordo com o queixa clinica, presenca do sinal de perda urinaria durante o exame ginecologico e diagnostico urodinâmico. Utilizou-se a analise estatistica dos dados amostrais, por meio da determinacao interna de um teste diagnostico, para calcular a sensibilidade, especificidade e os valores preditivos positivo e negativo do sinal clinico. Resultados: a media de idade foi de 51 anos (19-80), sendo que 61 encontravam-se no menacme (53,5%) e 53 (46,5%) na pos-menopausa. Destas, 10 (18,8%) faziam uso da terapia de reposicao hormonal. Do total de pacientes, 25 (21,9%) haviam se submetido a cirurgias previas para incontinencia. A queixa de perda urinaria isolada foi referida por 41 pacientes (36,0%), a urgencia/urge-incontinencia isolada por 13 (11,4%) e os sintomas mistos por 60 (52,6%). Das pacientes com perda isolada, observou-se, a avaliacao urodinâmica, que 34 (83%) tinham incontinencia urinaria de esforco (IUE), nenhuma paciente apresentava instabilidade do detrusor (ID), 2 (4,9%) incontinencia urinaria mista (IUM) e em 5 (12,1%) o estudo foi normal. Daquelas com queixa de urgencia/urge-incontinencia isolada, observamos na avaliacao urodinâmica que nenhuma tinha IUE, 5 (38,5%) ID, 1 (7,7%) IUM e em 7 (53,8%) o estudo foi normal. Daquelas com sintomas mistos, identificamos na avaliacao urodinâmica 25 com IUE (41,6%), 10 com ID (16,7%), 10 IUM (16,7%) e em 15 o estudo foi normal (25,0%). O sinal clinico de perda ao exame fisico foi identificado em 50 (43,9%) pacientes. Destas, 35 (70%) tinham diagnostico urodinâmico de IUE, 6 (12%) IUE e outro diagnostico e 9 (18%) nao tinham IUE. O sinal clinico estava ausente em 64 (56,1%) mulheres. Destas, 23 (35,9%) tinham diagnostico urodinâmico de IUE, 7 (11%) IUE e outro diagnostico e 34 (53,1%) nao tinham IUE. Conclusoes: a historia clinica associada ao exame fisico tem importância no manejo da incontinencia urinaria; porem, nao devem ser utilizados como unico criterio para o diagnostico. Os testes objetivos estao disponiveis e devem ser utilizados em conjunto com os dados clinicos.

Pregnancy after uterine arterial embolization

OBJECTIVE: To evaluate pregnancy outcomes, complications and neonatal outcomes in women who had previously undergone uterine arterial embolization. METHODS: A retrospective study of 187 patients treated with uterine arterial embolization for symptomatic uterine fibroids between 2005-2008 was performed. Uterine arterial embolization was performed using polyvinyl alcohol particles (500-900 µm in diameter). Pregnancies were identified using screening questionnaires and the study database. RESULTS: There were 15 spontaneous pregnancies. Of these, 12.5% were miscarriages (n = 2), and 87.5% were successful live births (n = 14). The gestation time for the pregnancies with successful live births ranged from 36 to 39.2 weeks. The mean time between embolization and conception was 23.8 months (range, 5–54). One of the pregnancies resulted in twins. The newborn weights (n = 14) ranged from 2.260 to 3.605 kg (mean, 3.072 kg). One (7.1%) was considered to have a low birth weight (2.260 kg). There were two cases of placenta accreta (12.5%, treated with hysterectomy in one case [6.3%]), one case of premature rupture of the membranes (PRM) (6.3%), and one case of preeclampsia (6.3%). All of the patients were delivered via Cesarean section. CONCLUSION: In this study, there was an increased risk of Cesarean delivery. There were no other major obstetric risks, suggesting that pregnancy after uterine arterial embolization is possible without significant morbidity or mortality.

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.

Treatment of anterior vaginal wall prolapse with and without polypropylene mesh: a prospective, randomized and controlled trial - Part I

OBJECTIVE To compare the use of polypropylene mesh (PM) and the traditional anterior vaginal wall colporraphy in women with anterior vaginal wall prolapse (AVWP) using objective and subjective tests and evaluation of quality of life (QoL). MATERIALS AND METHODS One hundred women were randomly distributed in two preoperatory groups. The first group (mesh) (n = 45) received a PM implant and the control group (n = 55) was submitted to traditional colporraphy. Postoperatory follow-up was done after 12 months. The primary objective was the correction of the Ba point ≤ -2 POP-Q (Pelvic Organ Prolapse Quantification System) and the secondary objective was the improvement of vaginal symptoms and QoL through ICIQ-VS (International Consultation on Incontinence Questionnaire - Vaginal Symptoms). Complications related to the use of PM or not were also described. RESULTS There was a significant difference between all POP-Q measures of pre- and postoperatory periods of each group in particular. There was a significant difference of the Ba point of the postoperatory period between the Mesh and Control group. The mean of Ba point in the Mesh group was statistically lower than of the Control group, depicting the better anatomical result of the first group. Both techniques improved vaginal symptoms and QoL. The most frequent complication of the Mesh group was prepubic hematoma in the perioperative period. In 9.3% of the cases treated with mesh it was observed PM exposition at the anterior vaginal wall after 12 months, being most of them treated clinically. CONCLUSION The treatment of AVWP significantly improved the Ba point in the Mesh group in comparison to the Control group. There were no differences of the vaginal symptoms and QoL between the two groups after 12 months. There were few and low grade complications on both groups.

Prevalence of and quality of life related to anal incontinence in women with urinary incontinence and pelvic organ prolapse

OBJECTIVE To investigate the prevalence of anal incontinence (AI) in woman with urinary incontinence (UI) and pelvic organ prolapse (POP). We also evaluated the impact on quality of life (QoL). STUDY DESIGN One hundred and ninety patients with UI or POP and 73 controls were recruited. AI was investigated by the Wexner index and the prevalence rates were obtained in all groups. Patients with AI completed the Fecal Incontinence Quality of Life questionnaire (FIQL). QoL was assessed using the Medical Outcome Study 36-item Short Form Health Survey (SF-36). RESULTS AI prevalence was 40.54% in the UI group and 27.91% in the POP group (p<0.0001). In the UI and POP groups correlations were found between the Wexner score and the domains of the FIQL and SF36. CONCLUSION The UI group had higher prevalence of AI than the other groups. The AI adversely affected the QoL of patients.

Sling retropúbico e transobturatório no tratamento da incontinênca urinária de esforço

OBJECTIVE: The aim of this study was to compare results of retropubic and transobturator sling for surgical treatment of female stress urinary incontinence (SUI). METHODS: Thirty randomized patients with SUI were divided in two groups, twenty who underwent the transobturator sling and ten the retropubic sling procedure. .Patients were assessed before and after one, six and twelve months of treatment by clinical history, physical examination, quality of life questionnaire (Kings Health Questionnaire), pad test and urodynamic parameters. At preoperative both groups were homogenous. RESULTS: One year after surgery, incontinence and quality of life questionnaire parameters had improved significantly in both groups and there was no difference between them. There was significant reduction in the pad test in both groups. Concerning urodynamic evaluation, one year after surgery cure rates were 84.2% for the transobturator group and 88.8% for the retropubic,. Subjective cure rate was 85% in the transobturator group and 88.8% in the retropubic. No statistical difference was found in complications rates. CONCLUSION: Retropubic and transobturator slings were effective in treatment of female SUI at one-year follow-up. Both techniques had significant cure rates and improved the quality of life with few complications.

Impact of HTLV-I in quality of life and urogynecologic parameters of women with urinary incontinence.

OBJECTIVE To assess the impact of urinary incontinence in quality of life, epidemiological data, symptoms, findings of gynecological/neurological examination and urodynamic of HTLV-I seropositive women compared with HTLV-I negative women. STUDY DESIGN 43 incontinent women were divided in two groups: 24 seropositives and 19 seronegatives for HTLV-I. We used Kings Health Questionnaire (KHQ), standardized recorded data and urodynamics. Data were compared using Mann-Whitney test or Chi-squared test. RESULTS Quality of life was significantly worse in seropositive incontinent women in the following parameters: general perception of health, impact of incontinence, limitation of daily life activities, social relations, sleep and disposition. Also, the following gynecological/neurological symptoms were more prevalent in seropositives: pain on vesical filling, dyspareunia, parestesis in inferior members, increased perineal sensitivity, pain in vaginal palpation, increased vaginal tonus, gait alteration, increased patellar reflex, Babinski reflex positive and increased tonus in inferior members. CONCLUSION Poor quality of life and physical abnormalities were identified in incontinent HTLV-I seropositive women when compared with incontinent HTLV-I seronegative women.

Sulfated glycosaminoglycans of the vagina and perineal skin in pre- and postmenopausal women, according to genital prolapse stage

The aim of this study was to analyze the amount and types of sulfated glycosaminoglycans (GAGs) of the extracellular matrix (ECM) in the posterior vaginal wall and perineal skin in menacme and postmenopausal women, according to genital prolapse stage. Samples of vaginal tissue and perineal skin were obtained from 40 women who underwent vaginal surgery. Sulfated glycosaminoglycans were extracted by extensive tissue maxatase digestion, submitted to electrophoresis on agarose gel, and their concentrations were determined by densitometry. Dermatan sulphate (DS) was the predominant GAG, followed by chondroitin sulfate (CS) and heparan sulfate (HS). In the vagina there was a significant decrease in total GAGs, CS, DS and HS in postmenopausal women with prolapse stage 2 and 3 compared to the premenopausal group, independent of the stage. In stage 2 and 3 postmenopausal patients there was a significant decrease of DS and HS compared to the stage 1 postmenopausal group. In perineal skin there was no significant difference between total GAG amount, DS and HS. However, the amount of CS in premenopausal stage 1 patients was significantly than that in postmenopausal patients stage 1 and stages 2 and 3. In conclusions, there are quantitative and qualitative differences in GAGs of the ECM in vaginal wall and perineal skin between women in menacme and the postmenopause, according to genital prolapse stage.

Sulfated glycosaminoglycans of periurethral tissue in pre- and postmenopausal women

OBJECTIVE The objective was to determine the sulfated glycosaminoglycans (GAGs) of the extracellular matrix (ECM) in pre- and postmenopausal women. STUDY DESIGN Periurethral tissue was obtained from 44 consecutive women who underwent surgery for urinary incontinence, for pelvic organ prolapse, or for other gynecologic benign conditions. Biopsy specimens were assessed by biochemical methods to characterize and quantify sulfated GAG. Measurements were made of total GAG, chondroitin sulfate, dermatan sulfate and of heparan sulfate. Data were compared using the t-test. RESULTS Patients were divided into two groups (pre- and postmenopausal groups) and dermatan sulfate was the most predominant glycosaminoglycan. Postmenopausal women had significantly less total sulfated glycosaminoglycans (p<0.01), dermatan sulfate (p<0.01) and chondroitin sulfate (p<0.05) than premenopausal women. We did not observe any differences in heparan sulfate. CONCLUSIONS Postmenopausal women showed quantitative differences in the biochemical characteristics of the ECM in periurethral tissue by analysis of sulfated GAG.

Sexual function after anterior vaginal wall prolapse surgery

OBJECTIVE: The aim of this study was to compare female sexual function after surgical treatment of anterior vaginal prolapse with either small intestine submucosa grafting or traditional colporrhaphy. METHODS: Subjects were randomly assigned, preoperatively, to the small intestine submucosa graft (n = 29) or traditional colporrhaphy (n = 27) treatment group. Postoperative outcomes were analyzed at 12 months. The Female Sexual Function Index questionnaire was used to assess sexual function. Data were compared with independent samples or a paired Students t-test. ClinicalTrials.gov: NCT00827528. RESULTS: In the small intestine submucosa group, the total mean Female Sexual Function Index score increased from 15.5±7.2 to 24.4±7.5 (p<0.001). In the traditional colporrhaphy group, the total mean Female Sexual Function Index score increased from 15.3±6.8 to 24.2±7.0 (p<0.001). Improvements were noted in the domains of desire, arousal, lubrication, orgasm, satisfaction, and pain. There were no differences between the two groups at the 12-month follow-up. CONCLUSIONS: Small intestine submucosa repair and traditional colporrhaphy both improved sexual function postoperatively. However, no differences were observed between the two techniques.