Zsuzsanna Ilona Katalin de Jármy Di Bella

Efficacy of pelvic floor muscle training and hypopressive exercises for treating pelvic organ prolapse in women: randomized controlled trial

CONTEXT AND OBJECTIVE Previous studies have shown that women with pelvic floor dysfunctions present decreased cross-sectional area (CSA) of the levator ani muscle. One way to assess the effects of training programs is to measure the CSA of the muscle, using ultrasonography. The aim here was to evaluate the efficacy of pelvic floor muscle training and hypopressive exercises for increasing the CSA of the levator ani muscle in women with pelvic organ prolapse. DESIGN AND SETTING Prospective randomized controlled trial at the Urogynecology outpatient clinic of Universidade Federal de São Paulo. METHODS Fifty-eight women with stage II pelvic organ prolapse were divided into three groups for physiotherapy: a pelvic floor muscle training group (GI); a hypopressive exercise group (GII); and a control group (GIII). The patients underwent transperineal ultrasonographic evaluation using a transducer of frequency 4-9 MHz. The (CSA) of the levator ani muscle was measured before physiotherapy and after 12 weeks of treatment. RESULTS The groups were homogeneous regarding age, number of pregnancies, number of vaginal deliveries, body mass index and hormonal status. Statistically significant differences in CSA were found in GI and GII from before to after the treatment (P < 0.001), but not in relation to GIII (P = 0.816). CONCLUSIONS The CSA of the levator ani muscle increased significantly with physiotherapy among the women with pelvic organ prolapse. Pelvic floor muscle training and hypopressive exercises produced similar improvements in the CSA of the levator ani muscle.

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.

Vaginoplasty with oxidized cellulose: anatomical, functional and histological evaluation

OBJECTIVE To present and evaluate the histological, anatomical and functional results of the McIndoe procedure, as modified by the application of oxidized cellulose (Surgicel™) in women with vaginal agenesis. STUDY DESIGN Eleven patients with vaginal agenesis underwent vaginoplasty using a mould that had been wrapped with oxidized cellulose. The surgeries were performed between January 2009 and January 2010. Eight of the patients had been diagnosed with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, and the remaining three had been diagnosed with cervicovaginal agenesis (CVA). The mean follow-up time was 14 months (range, 6-24 months), and it included clinical examinations and evaluation of the Female Sexual Function Index (FSFI). Neovaginal biopsies were taken at the time of surgery and 1-12 months after surgery. The histology of the samples was evaluated to determine squamous epithelialization of the neovaginal tissue over time, and the total collagen content of the neovaginas were compared with normal control subjects. For statistical analysis we employed the ANOVA test and the t-test. RESULTS At 6 months, anatomical success was achieved in 100% of the MRKH syndrome patients (neovaginal length ≥ 6 cm), and functional success was achieved in 100% of the patients who started their sexual life (FSFI score ≥ 30). Biopsy results showed complete epithelialization of the neovagina after 5 months in all samples, and the collagen content was comparable to that of a normal vagina. One major postoperative complication occurred in a patient with CVA, which culminated in death. The uterovaginal canalization procedure was unsuccessful at creating an outflow tract for regular menses in all cases. CONCLUSIONS The procedure described here offers patients a functional vagina by means of a simple and low-cost procedure that elicits squamous epithelialization of the neovaginal vault, with total collagen content similar to that of normal vaginal tissue. It is a potential alternative therapeutic approach for MRKH syndrome but not applicable to cases of CVA.

Portuguese validation of the Urinary Incontinence-Specific Quality-of-Life Instrument: I-QOL

Introduction and hypothesisOur objective was to translate and validate a Portuguese version of the Urinary Incontinence-Specific Quality-of-Life Instrument (I-QOL), a questionnaire that is widely used in clinical trials.MethodsFifty patients completed the same questionnaire twice at a 2-week interval. During the first visit, we conducted a face-to-face interview and collected demographic data. The Kings Health Questionnaire was completed during the same visit for comparisons.ResultsThe results showed that the Portuguese version of the I-QOL has very good psychometrics properties. Reliability was assessed by Cronbachs alpha (0.93), reproducibility was calculated through the intraclass correlation coefficient (0.88), construct validity was determined by comparing the I-QOL scores and Kings Health scores, and discriminant validity was calculated by comparing the total I-QOL scores with measures of gravity.ConclusionsWe conclude that the Portuguese version of the I-QOL is a very good tool for the evaluation quality-of-life in women with urinary incontinence in Portuguese-speaking countries.

Ultrasonographic and doppler velocimetric evaluation of the levator ani muscle according to the hormonal status.

OBJECTIVE We aimed to study the cross-sectional area of levator ani muscle and the doppler velocimetric parameters of vessels its in premenopausal and postmenopausal women. STUDY DESIGN Sixty-four patients, divided into 3 groups, were assessed: group I (20 women-average age 28 years) premenopausal and nulliparous (control); group II (24 women-average age 38 years, vaginal delivery 1-4) premenopausal with vaginal deliveries; group III (20 women-average age 55 years, parity 0-4) postmenopausal without hormonal therapy. Doppler velocimetry of levator ani muscle vessels through resistance and pulsatility indices was used and the means of the groups compared by adjusting the weighed variance model with multiple comparisons, according to Tukeys method. Similarly, we measured the cross-sectional area of the muscle using ultrasonography. RESULTS There was a significant increase in resistance and pulsatility indices in postmenopausal patients as compared to the other two groups. We also observed a significant decrease in the cross-sectional area of the muscle of postmenopausal patients when compared to those in premenopausal. CONCLUSION The obtained results allow us to conclude that levator ani muscle vascularization significantly decreases after menopause (age and/or hipoestrogenism) and that it can be assumed that vaginal delivery does not promote long-term alterations in levator ani muscle vascularization. We also observed a significant decrease in the cross-sectional area of the muscle in postmenopausal women when compared to those in premenopausal.

Assessment of pelvic floor by three-dimensional-ultrasound in primiparous women according to delivery mode: initial experience from a single reference service in Brazil

PURPOSE To evaluate changes to the pelvic floor of primiparous women with different delivery modes, using three-dimensional ultrasound. METHODS A prospective cross-sectional study on 35 primiparae divided into groups according to the delivery mode: elective cesarean delivery (n=10), vaginal delivery (n=16), and forceps delivery (n=9). Three-dimensional ultrasound on the pelvic floor was performed on the second postpartum day with the patient in a resting position. A convex volumetric transducer (RAB4-8L) was used, in contact with the large labia, with the patient in the gynecological position. Biometric measurements of the urogenital hiatus were taken in the axial plane on images in the rendering mode, in order to assess the area, anteroposterior and transverse diameters, average thickness, and avulsion of the levator ani muscle. Differences between groups were evaluated by determining the mean differences and their respective 95% confidence intervals. The proportions of levator ani muscle avulsion were compared between elective cesarean section and vaginal birth using Fishers exact test. RESULTS The mean areas of the urogenital hiatus in the cases of vaginal and forceps deliveries were 17.0 and 20.1 cm(2), respectively, versus 12.4 cm(2) in the Control Group (elective cesarean). Avulsion of the levator ani muscle was observed in women who underwent vaginal delivery (3/25), however there was no statistically significant difference between cesarean section and vaginal delivery groups (p=0.5). CONCLUSION Transperineal three-dimensional ultrasound was useful for assessing the pelvic floor of primiparous women, by allowing pelvic morphological changes to be differentiated according to the delivery mode.

Effectiveness of adding voluntary pelvic floor muscle contraction to a Pilates exercise program: an assessor-masked randomized controlled trial

Introduction and hypothesisThe purpose of this study was to evaluate the effectiveness of adding voluntary pelvic floor muscle contraction (PFMC) to a Pilates exercise program in sedentary nulliparous women.MethodsFifty-seven healthy nulliparous and physically inactive women were randomized to a Pilates exercise program (PEP) with or without PFMC. Forty-eight women concluded this study (24 participants for each group). Each woman was evaluated before and after the PEP, by a physiotherapist and an urogynecologist (UG). Neither of the professionals was revealed to them. This physiotherapist measured their pelvic floor muscle strength by using both a perineometer (Peritron) and vaginal palpation (Oxford Scale). The UG, who performed 3D perineal ultrasound examinations, collected their data and evaluated the results for pubovisceral muscle thickness and the levator hiatus area (LA). Both professionals were blinded to the group allocation. The protocol for both groups consisted of 24 bi-weekly 1-h individual sessions of Pilates exercises, developed by another physiotherapist who specializes in PFM rehabilitation and the Pilates technique.ResultsThe PEP+ PFMC group showed significantly greater strength improvements than the PEP group when comparing the Oxford scale, vaginal pressure and pubovisceral muscle thickness during contraction measurements at baseline and post-treatment.ConclusionsOur findings suggest that adding a voluntary PFMC to a Pilates exercise program is more effective than Pilates alone in improving PFM strength in sedentary nulliparous women.

Ultrasound Thickness of Bladder Wall in Continent and Incontinent Women and Its Correlation with Cystometry

Objective. To compare bladder wall thickness in two kinds of urinary incontinent women—stress urinary incontinence (SUI) and overactive bladder (OAB) with urodynamic detrusor overactivity (DO), and to compare them with continent patients by ultrasound, also, correlate with cystometric results in incontinent women. Methods. 91 women were divided into the following groups: continent (n = 31), SUI (n = 30), and DO (n = 30) groups after clinical evaluation and urodynamic test (only in incontinent women). Transvaginal ultrasound was performed to the bladder wall thickness (BWT) measurement. The mean of BWT was calculated and data were analyzed with ANOVA and Turkeys multiple comparison tests. Pearsons correlation coefficient (r) was used to compare two variables. Receiver operating characteristic (ROC) curve was performed to study BWT as a diagnostic parameter. Results. BWT in DO group was significantly higher than that in the other groups (P < 0.005). A moderate positive correlation was found between BWT and maximum bladder pressure during involuntary bladder contraction. There was no difference in BWT between SUI and continent groups. DO group had lower first desire to void and cystometric capacity. Maximum bladder pressure at detrusor contraction had a moderate positive correlation with BWT. The ROC revealed an area under the curve of 0.962 (95% CI, 0.90–1.01). Conclusions. DO patients have increased bladder wall thickness, lower first desire to void, and lower cystometric capacity. There was a moderate correlation between BWT and maximum bladder pressure during involuntary bladder contraction.

Assessing the Impact of Twin Pregnancies on the Pelvic Floor Using 3-Dimensional Sonography A Pilot Study

The purpose of this study was to compare the morphologic characteristics of the pelvic floor musculature between women with twin and singleton pregnancies.

Influence of estrogen replacement and aging on the expression of nerve growth factor in the urethra of female rats.

To evaluate the expression of nerve growth factor (NGF) in the urethra of adult female rats in different hormonal status using immunohistochemical assay.