Vaginal pessary in advanced pelvic organ prolapse: impact on quality of life.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) is a highly prevalent dysfunction of the pelvic floor affecting up to 40% of women. The symptoms of POP have a major impact on quality of life. Pessary treatment is a therapy option associated with high levels of satisfaction and few complications. OBJECTIVES: The objective was to assess the impact and efficacy of vaginal pessary use on the quality of life of women with advanced POP stages III and IV. MATERIALS AND METHODS: A multicenter, longitudinal, prospective observational study was conducted at the Urogynecology Sector of the Hospital Ipiranga and the Hospital Central of the Irmandade da Santa Casa de Misericórdia de São Paulo. A sociodemographic questionnaire was employed and two scales validated in Portuguese (ICIQVS and SF 12) were applied before and 6 months after pessary use. Student´s t test, Mann-Whitney test and Fisher´s exact test were applied, adopting a significance level of 0.05. RESULTS: The median age of participants was 71.5 (65-76) years and the median number of pregnancies was 4 (3-5). Deliveries were predominantly vaginal (82.5%). Women sexually active (16.49%) showed improvement in sexual function (78.6%). The participants showed improvement in vaginal symptoms (91.8%) and quality of life (92.8%) (p < 0.01) post-treatment. Of the total 97 women, the sample drop-out rate was 9.3% and 88 participants completed the two stages of the study. CONCLUSIONS: Vaginal pessary use had 90.7% efficacy, a high level of treatment satisfaction (75.3%), and a positive impact on the improvement of vaginal and sexual symptoms, quality of life, and mental health.

Is urodynamics necessary to identify occult stress urinary incontinence?

PURPOSE: To investigate Occult Stress Urinary Incontinence (OSUI) using physical exam (PE) and urodynamics (UDS) in women with advanced pelvic organ prolapse (POP), and compare the two methods. METHODS: This study comprised 105 women with POP stage-III and -IV, according to POP quantification (POP-Q) system, evaluated prospectively between January and December 2015. A standard history, an incontinence questionnaire and PE were completed before the investigation of the OSUI that was performed in the supine and standing positions, reducing the prolapse using gauze and Cheron dressing forceps. The stress test was performed with and without the prolapse reduction. RESULTS: The mean patient age was 65.7 years, mean parity 5.1 and mean body mass index 27.4. From a total of 105 patients, 70 (66.7%) presented with POP-Q stage III and 35 (33.3%) stage IV. Sixty-three (60%) women were identified as having OSUI, 27 (25.7%) as continent, and 15 (14.3%) having stress urinary incontinence. From the 63 OSUI subjects, 48 (76.2%) were identified in both evaluations, eight were identified only during PE, and seven only during UDS. The sensitivity to detect OSUI during PE and UDS was 88.9 and 87.3%, respectively (P = .783). The kappa value to measure the agreement between both tests was .648 (95% CI .441-.854). CONCLUSION: UDS and PE are equivalent and concordant to demonstrate OSUI, thus it is not necessary to perform UDS to exclusively identify OSUI. UDS utility in OSUI patients, to evaluate urethral and detrusor function, deserves further investigation.

Dados epidemiológicos, evidências e reflexões sobre a indicação de cesariana no Brasil / Epidemiological data, evidence and reflections on the indication of cesarean section in Brazil

A cesárea representa um notável progresso na assistência obstétrica,mas estamos longe de poder afirmar que possa substituir o parto varginal.O Brasil exibe uma das maiores taxas de cesáreas de mundo e tem sido citado como exemplo de possível abuso do procedimento.No Sistema Único de Saúde (SUS) ocorrem taxas médias de cesáreas de 28,6%,enquanto no setor de saúde complementar,os índices ultrapassam 80%.Não é possível afirmar que as mulheres preferem cesárea de antemão.Uma pesquisa identificou que,entre um grupo submetido a esse tipo de parto,mais de 81% tinham preferência pelo parto vaginal.A atual organização da atenção obstétrica exerce papel importante nesta questão,pois a assistência privada é personalizada e centrada no médico.Bebês com 37 a 38 semanas de gestação,quando comparados com nascidos entre 39 e 40 semanas,possuem 120 vezes mais chances de necessitarem de suporte ventilatório.A cesárea a pedido compõe um evento obstétrico comum.Cabe ao obstetra acolher e contornar as necessidades da paciente,além de informá-la sobre os riscos.O profissional tem liberdade ética para aceitar ou não essa demanda.A cada ano,dezenas de milhões de dólares são destinados para realização de cesáreas desnecessárias.