Stress urinary incontinence in the gynecological practice.

This review discusses the prevalence, risk factors, the impact on the quality of life and healthcare-seeking behavior of women suffering from urinary incontinence (UI) and stress urinary incontinence (SUI) in particular. UI is a common problem, affecting women in all age groups, and has devastating effects on their social, professional and family life. UI may be manifest as stress urinary continence (SUI), i.e. 'the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing'. SUI is the most common form of UI, reported by approximately 50% of the incontinent women. Alternatively, patients may suffer from urge urinary incontinence (UUI), characterized by the 'complaint of involuntary leakage accompanied or immediately preceded by urgency'. This is reported by 10-20% of incontinent women. Patients having symptoms of both disorders may be afflicted by mixed urine incontinence (MUI), being reported by 30-40% of incontinent women. This complaint was recently included in the definitions as: 'Involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing'. Urodynamic studies show that the prevalence of SUI is underestimated when based on symptoms alone, as many patients with mixed symptoms have pure SUI during urodynamics. Although the etiology of SUI is still poorly understood, among the main risk factors are age, pregnancy, childbirth and obesity. Unfortunately, the majority of the patients suffering UI postpones looking for medical help for years, or may even never consult a physician regarding their problem, despite the considerable negative impact on their quality of life. Feelings of shame and embarrassment play an important role in this, in combination with the common belief that UI is a normal and inevitable consequence of the aging process. Clearly, there is still a long way to go in making patients and society aware of the fact that UI is a disorder, which can and should be treated. Consequently, patients must be encouraged to report their problem, while health care providers should raise the issue on routine exams in risk groups.

Colpocleisis parcial en el tratamiento quirúrgico del prolapso genital / Partial colpocleisis in the genital prolapse treatment

El incremento de las consultas por disfunciones del piso pelviano en pacientes mayores de 70 años en la proyección al año 2030 justifica el análisis de métodos específicos preventivos, diagnósticos y terapéuticos para este grupo etario. Consideramos que la Colpocleisis Parcial Neubaguer/LeFort es una técnica adecuada para el tratamiento del prolapso genital en pacientes de edad avanzada y alteraciones clínicas que no lo permitan o hagan preferible esta variable

Pelvic floor dysfunction management practice patterns: a survey of members of the International Urogynecological Association.

The authors report results of a survey of the practice patterns of International Urogynecological Association (IUGA) members in the management of urinary incontinence and pelvic organ prolapse. A questionnaire regarding current urogynecological clinical practice was developed by the Research and Development Committee of IUGA and mailed to all members of IUGA. Age, specialty, and geographic location factors were used for response comparisons. One hundred and fifty-two surveys (30%) were returned, 35% from North America, 51% from Europe/Australia/New Zealand, and 14% from elsewhere. The average age of respondents was 47.2 years (SD = 9.5), 89% were gynecologists and 11% were urologists. Overall, the procedures of choice for stress incontinence (SUI) were tension-free vaginal tape (TVT; 48.8%) and Burch colposuspension (44%). There were significant geographic variations noted. For SUI with low-pressure urethra/intrinsic sphincteric deficiency, TVT was used by 44.6% and suburethral sling by 32.3%. Various materials are used for suburethral slings, including autologous fascia (46.5%), Marlex mesh (27.8%) and cadaveric fascia lata (11.6%). Bulking agent injection therapy is used for ISD by 75% of respondents. Traditional reconstructive procedures are performed by the majority of respondents, including sacrospinous fixation (78%), abdominal sacrocolpopexy (77%), paravaginal repair (65%) and vaginal enterocele repair (93%); 6.5% use defecography in evaluating rectoceles and 44% use the POP-Q. Seventy-two per cent use urodynamic evaluation routinely in prolapse cases with no manifest SUI. Most IUGA members perform commonly accepted procedures for surgical therapy of urinary incontinence and genital prolapse. IUGA members do not frequently use anorectal physiology and fluoroscopic investigations to evaluate rectoceles prior to repair.

Use of GnRH analogs for functional protection of the ovary and preservation of fertility during cancer treatment in adolescents: a preliminary report.

OBJECTIVE: Recent success in polychemotherapy (PCT) in adolescent female cancer patients has become a source of concern for specialists who also strive to preserve fertility. We studied whether gonadotropin-releasing hormone (GnRH) analogs could prevent the early onset of ovarian insufficiency postchemotherapy and protect fertility. METHODS: The patients were divided into three groups: Control group 1 (Group A), premenarchal patients aged 3 to 7.5 years (n = 5), were not given GnRH analogs administered prior to PCT. Postmenarchal patients (Group B), aged 14.7 to 20 years (n = 12) with normal menstrual rhythm and ovulatory cycles, received treatment with GnRH analogs prior to PCT. Control group 2 (Group C), postmenarchal patients aged 15.9 to 20 years (n = 4), received PCT but no GnRH analog protection. All groups received the PCT regimens CAVPE, CVPP, ABVD, TAMO, ARA-C, and MTT. In group B, leuprolide acetate inhibition was obtained with a depot injection administered each month before and during treatment with PCT. To accelerate the timing of ovarian regression, a subcutaneous injection (0.2 mg) was administered simultaneously. RESULTS: In Group A, patients had spontaneous menarche between the ages of 12 and 17.9 years, followed by normal menstruation and ovulatory cycles. Three patients became pregnant. After GnRH analog withdrawal, Group B patients continued with normal ovulatory cycles. Two patients became pregnant. Group C patients presented hypergonadotrophic hypoestrogenic amenorrhea. CONCLUSION: GnRH analog treatment before and during PCT enhances ovarian function and preserves adolescent fertility. The results must be confirmed in a larger study.

Apoptosis and expression of Bcl-2 and Bax in eutopic endometrium from women with endometriosis.

OBJECTIVE: To evaluate and compare spontaneous apoptosis and Bcl-2 and Bax expression in eutopic endometrium from women with and without endometriosis. DESIGN: Apoptosis and Bcl-2 and Bax expression were examined in eutopic endometrium from women with and without endometriosis. SETTING: Instituto de Biología y Medicina Experimental-CONICET, Department of Gynecology and Department of Gynecological Pathology, Clínicas University Hospital, Buenos Aires, Argentina. PATIENT(S): Women with untreated endometriosis (n = 14) and controls (n = 16). INTERVENTION(S): Collection of endometrial samples during diagnostic or therapeutic laparoscopy. MAIN OUTCOME MEASURE(S): Apoptotic cells were detected with use of the dUTP nick-end labeling (TUNEL) assay; Bcl-2 and Bax expressions were assessed with use of immunohistochemical techniques. RESULT(S): Spontaneous apoptosis was significantly lower in eutopic endometrium from patients with endometriosis, compared with healthy controls (2.26 +/- 0.53 and 9.37 +/- 1.69 apoptotic cells/field, respectively) and was independent of cycle phase. An increased expression of Bcl-2 protein was found in proliferative eutopic endometrium from patients with endometriosis. Bax expression was absent in proliferative endometrium, whereas there was an increase in its expression in secretory endometrium from both patients and controls. CONCLUSION(S): Women with endometriosis show decreased number of apoptotic cells in eutopic endometrium. The abnormal survival of endometrial cells may result in their continuing growth into ectopic locations.

Apoptosis y expresión de Bcl-2 y Bax en el endometrio eutópico de pacientes con endometriosis / Apoptosis and Bcl-2 and Bax in normal endometrium of patients with endometriosis

El objetivo de este trabajo es investigar una posible predisposición de las células endometriales de pacientes con endometriosis (EDT), a ser resistentes a la muerte celular programada. Se evaluó apoptosis y expresión de las proteínas Bcl-2 y Bax en 30 cortes de tejido de endometrio eutópico, 14 de mujeres con EDT y 16 de controles (C). Para la determinación de apoptosis, se utilizó el kit Apoptag-Plus basado en la localización y tinción de los extremos 3'-OH de los fragmentos de ADN. Los resultados se expresan como nº de células apoptóticas (CA)/campo a 630x de aumento. Se detectaron CA sólo en el epitelio glandular. Se observó menor cantidad de CA en tejido endometrial proveniente de pacientes con EDT: 2,26 ñ 0,53 vs 9,37 ñ 1,69 en los C (p<0,001). Esta disminución se conservó a lo largo del ciclo menstrual. En la fase proliferativa tardía, los resultados fueron de: 7,08 ñ 0,92 vs 1,9 ñ 0,73 (p<0,05), para las muestras provenientes de mujeres C y pacientes con EDT respectivamente; mientras que en el endometrio secretorio los niveles de apoptosis detectados fueron de 11,6 ñ 1,74 en los C vs 2,7 ñ 0,82 en EDT (p<0,001). No se observaron diferencias significativas de apoptosis en endometrio de acuerdo al grado de la enfermedad. La evolución de los productos de protooncógenes, bcl-2 y bax se realizó utilizando metodologías de inmunohistoquímica. Se halló incrementada la expresión de la proteína antiapoptótica Bcl-2 en el endometrio proliferativo proveniente de pacientes con EDT comparado con el C. La expresión del antagonista de Bcl-2, Bax, aumentó durante la fase secretoria tanto en muestras provenientes de pacientes como de C, y se halló ausente durante la fase proliferativa. De los resultados se desprende que las células endometriales de pacientes con EDT poseen características apoptóticas alteradas que las harían más susceptibles a crecer en un sitio ectópico. Estas no se ven modificadas a lo largo del ciclo menstrual. La proteína Bcl-2 estaría implicada en la protección de la apoptosis de las células endometriales eutópicas de pacientes con EDT durante la fase proliferativa del ciclo menstrual. La proteína Bax estaría involucrada en la regulación de la muerte celular programada que se produce en el endometrio eutópico previo a la menstruación. La resistencia a la muerte celular programada que posee el endometrio eutópico de pacientes con EDT, estaría relacionada con la etiología y/o fisiopatología de la enfermedad

Protección funcional ovárica con análogos de GnRH y preservación de la fertilidad en adolescentes durante la terapéutica oncológica / Protection of the ovarian function with GnRH analogs and preservation of fertility during cancer therapy

Objetivos: Investigar si los análogos de GnRH pueden evitar la falla ovárica precoz post-quimioterapia antineoplásica y tener así un efecto protector de la fertilidad. Diseño del Estudio: Veintiún pacientes oncológicas fueron divididas en dos grupos y seguidas a lo largo de 18 años. A: premenarca, 3-7,5 años (n:5) recibió poliquimioterapia (PCT). B: post-menarca, 14,7 - 20 años (N:12), ciclos menstruales ovulatorios normales, recibieron análogos de GnRH antes de la PCT.B1 (n:5) trasplante de médula ósea previo (BMT) a la PCY.B2 (n:7) recibió PCT y cobaltoterapia supradiafragmática. C: post-menarca, 15,9 - 20 años (n:4) recibió PCT y fue sometida a BMT. La inhibición se obtuvo mediante la administración de acetato de Leuprolide de depósito en dosis mensuales antes y durante la poliquimioterapia. Resultados: A: menarca espontánea (12.17.8 años), ciclos menstruales ovulatorios normales, cinco embarazos normales. B: ciclos ovulatorios normales desde la supresión del análogo de GnRH, tres embarazos. C: amenorrea hipergonadotrófica hipoestrogénica. Conclusiones: El seguimiento de estas pacientes demostró que la administración de análogos de GnRH antes y durante la poliquimioterapia protege la función ovárica y preserva la fertilidad futura de las adolescentes

Dynamic assessment of pelvic floor function in women using the intravaginal device test.

The aim of the study was to assess pelvic floor function and dysfunction using intravaginal devices (IVD test). One hundred and eighty-five patients were evaluated, 65 (35.1%) in the control group without genital prolapse and 120 (64.9%) in the study group, with prolapse. Anatomic changes were evaluated on a scale described by Halban, and functional classification based on palpation of the muscles of the pelvic floor during contraction. Additionally, weighted vaginal devices were used to assess pelvic floor function. Statistic analysis was performed with the Spearman-Pearson correlation coefficient, the chi2 test and the response/operator characteristic curve. There was an acceptable correlation between the IVD test and the functional classification of 0.75. Using this classification, the IVD test showed 86.58% sensitivity, 75.72% specificity, and had a positive predictive value of 73.95% and a negative predictive value of 87.64%. Significant differences between pelvic floor muscle activity in those patients with and without genital prolapse were observed (chi2 = 58.28, P=<0.005). It was concluded that pelvic floor assessment can be done through the evaluation of active muscle strength or pelvic floor integrity using the functional classification and the IVD test.

Reflejo pudendo profundo / Deep pudendal reflex

Se estudiaron 32 mujeres voluntarias normales, con edades que oscilaron entre los 20 y 68 años. Se les provocó el Reflejo Pudendo Profundo (RPP) mediante un electrodo de superfície especial que tiene la ventaja de servir para el registro del esfínter anal y también para el estímulo del nervio pudendo. Se describe la técnica para la obtención del reflejo tras la estimulación de dicho nervio a nivel de la espina isquiática. Se obtuvo una latencia media de 36,18 mseg ñ 4,29 con una amplitud media de 306,11 uv ñ DS 227,15. Al efectuar el RPP se realiza un reflejo pudendo-anal que difere del clássico reflejo bulbocavernoso en cuanto a la localización del estímulo, de las latencias, y también en su vía aferente aunque comparten un trayecto común en parte del mismo

Pudendal reflexes in women with pelvic floor disorders.

The objective of this work was to study two pudendal anal reflexes: Deep Pudendal Reflex (DPR) and classical Bulbocavernosus Reflex (BCR) in women with primary and recurrent genital prolapse to obtain support to the hypothesis of pelvic nerve damage in patients with pelvic floor disorders. 124 women were studied: 68 were normal; 38 with genital prolapse (GP); and 18 with recurrent GP. Clinical and electrophysiological studies were carried out. Delayed reflex responses were found in 44/56 of patients (79%). [27/38 in genital prolapse group (71%); 17/18 in recurrent GP group (94%)]. The evaluation of pelvic floor reflex responses are tests to be taken into account in the diagnosis and management of pelvic floor disorders.

[Deep pudendal reflex]. / Reflejo pudendo profundo.

32 healthy women ranging from 20 to 68 years (51.84 +/- 10.36) were tested for Deep Pudendal Reflex (DPR). Dantec 13L40 (St. Mark's) superficial electrodes were used to pick up the responses of the external anal sphincter. These devices consist of a bipolar stimulating electrode mounted on the tip of the gloved index finger which is inserted into the rectum; 3 cm proximally at the base of the finger are recording electrodes which pick up the contraction response of the anal sphincter. To obtain the DPR the ischial spine is localized on transrectal examination and electrical stimuli given at that side, applying square stimulus of 0.2 ms duration and 0.5 Hz frequency. This stimulates the pudendal nerve as it leaves the pelvis through the greater sciatic notch, before it branches into the inferior rectal (to the anal sphincter) and perineal nerve (to the periurethral striated muscle). The conduction time was measured as the latency from the time of stimulation of the starting point of the reflex response curves. The shortest latency of various responses was accepted and measured in milliseconds (ms). The amplitudes of the responses were measured in microvolts (uv). We obtained reproducible DPR in all subjects. Mean latency was 36.18 +/- 4.29 ms; mean amplitude was 337.50 +/- 218.49 uv (Fig. 1, Table 2). DPR is a pudendal-anal reflex like the bulbo-cavernous reflex, but differs in latency, stimulation localization and afferent limb although both follow a common final afferent pathway.

Non-invasive diagnosis of bladder instability using the Bladder Instability Discriminant Index (BIDI).

The purpose of this study was to validate prospectively the BIDI index in the non-invasive diagnosis of bladder instability, as a procedure for clinical evaluation in primary health care of women. 217 patients were studied; 82 with stress incontinence, 39 with urge incontinence and 96 with both symptoms. All patients were studied by specialist physicians, who conducted a clinical evaluation, questionnaire, gynecological and urological examination, stress test, urodynamic assessment and a 7 day frequency/volume study, recording each intake and micturition; data that were used to calculate the BIDI index. The results obtained through the application of the BIDI were compared with the corresponding urodynamic diagnoses, achieving 88% sensitivity and 83% specificity. The use of the BIDI index is suggested as a non-invasive clinical diagnostic method, of low cost and simple performance. It is recommended for treatment control and for taking diagnostic and therapeutic decisions in medical centres lacking proper urodynamic equipment.

Immunological changes in human breast cancer.

In 38 breast cancer patients were examined the following immune system parameters: total and active T lymphocytes; killer cells; bastogenic response to Phytohaemaglutinin; leucocyte migration inhibition test with autologous tumor extract; serum immunoglobulins and phagocytosis and intracellular killing of Candida albicans. The immunological evaluations were made in pre-surgery and after each 3 months, during 18 months. In stage I practically there was no difference with controls. The active T lymphocytes were significant decreased until 15 months post surgery in stage II and in all samples stages III and IV. The response to Phytohaemaglutinin was diminished in all samples of stages II, III and IV. A recognition and sensitiveness to tumoral antigen were observed until 6 months post surgery in stage I and during checking time in the others stages. Respect to the phagocytic function only the intracellular killing mechanism failed at 3 months post surgery.

Hormonal receptors in endometrial neoplasias.

The Authors studied the concentration of cytosolic and nuclear receptor for Estradiol and Progesterone in endometrial hyperplasia and carcinoma, compared with a control group. Comparative study of hormone receptor concentrations in different populations shows: 1) A significant increase in Estradiol receptors in endometrial hyperplasia (p less than 0.01); 2) A decreasing concentration of estradiol receptors with the decreasing of cellular differentiation in endometrial carcinoma (p less than 0.01); 3) A similar tendency and significance for Progesterone receptors; 4) For both receptors the tendency in the nuclear compartment is similar to that in cytosol but the significance is smaller (p less than 0.05).