Three-Dimensional Volume Rendering of Pelvic Floor Anatomy with Focus on Fibroids in Relation to the Lower Urogenital Tract Based on Cross-Sectional MRI Images.

We aimed to assess the feasibility of developing three-dimensional (3D) models of pelvic organs using cross-sectional MRI images of patients with uterine fibroids and urinary symptoms and of obtaining anatomical information unavailable in 2D imaging modalities. We also aimed to compare two image processing applications. We performed a feasibility study analysing MRI scans from three women, aged 30 to 58 years old, with fibroids and urinary symptoms. Cross-sectional images were used to render 3D models of pelvic anatomy, including bladder, uterus and fibroids, using 3D Slicer and OsiriX. Dimensions, volumes and anatomical relationships of the pelvic organs were evaluated. Comparisons between anatomical landmarks and measurements obtained from the two image processing applications were undertaken. Rendered 3D pelvic models yielded detailed anatomical information and data on spatial relationships that were unobtainable from cross-sectional images. Models were rendered in sufficient resolution to aid understanding of spatial relationships between urinary bladder, uterus and fibroid(s). Measurements of fibroid volumes ranged from 5,336 to 418,012 mm3 and distances between the fibroid and urinary bladder ranged from 0.10 to 83.60 mm. Statistical analysis of measurements showed no significant differences in measurements between the two image processing applications. To date, limited data exist on the use of 3D volume reconstructions of routine MRI scans, to investigate pelvic pathologies such as fibroids in women with urinary symptoms. This study suggests that post-MRI image processing can provide additional information over standard MRI. Further studies are required to assess the role of these data in clinical practice, surgical planning and training. Three-dimensional reconstruction of routine two-dimensional magnetic resonance imaging provides additional anatomical information and may improve our understanding of anatomical relationships, their role in clinical presentations and possibly guide clinical and surgical management.

Systematic review and appraisal of clinical practice guidelines on pelvic organ prolapse using the AGREE II tool.

AIMS: To systematically evaluate the content and quality of national and international clinical guidelines on pelvic organ prolapse (POP). METHODS: We searched medical databases and organizations websites, to identify national and international guidelines on diagnosis and management of POP. Five authors independently assessed guidelines using the validated AGREE II tool. Its six domains include (1) scope and purpose, (2) stakeholder involvement, (3) rigor of development, (4) clarity of presentation, (5) applicability, and (6) editorial independence. RESULTS: Eight guidelines met the inclusion criteria. Three hundred and thirteen different recommendations were identified. One hundred and ninety-nine recommendations were comparable across guidelines. Thirty-one recommendations were not supported by research evidence. Assessment by history and physical examination using the POP quantification system and consideration of imaging were recommendations featuring in all guidelines. Conservative treatment recommendations namely pelvic floor muscle training and vaginal pessaries were also found in all guidelines. Regarding surgical management, patient counseling, treating only symptomatic POP, consideration of apical fixation during surgical treatment, and use of biological or synthetic implants in recurrent cases were recommendations in all guidelines. Overall, the highest median scores were in the domains "scope and purpose" and "rigor of development". The lowest median score was for applicability (28.3%). Although the median score of "editorial independence" was high (85.4%), variability was also substantial (interquartile range: 12.5-100). CONCLUSION: We identified variations in quality and deficiencies in certain areas, especially "applicability" and "editorial independence." Improvements in these key domains may enhance the quality and clinical impact of clinical practice guidelines.

Quality assessment of outcome reporting, publication characteristics and overall methodological quality in trials on synthetic mesh procedures for the treatment of pelvic organ prolapse for development of core outcome sets.

INTRODUCTION AND HYPOTHESIS: Variations in outcome measures and reporting of outcomes in trials on surgery for pelvic organ prolapse (POP) using synthetic mesh have been evaluated and reported. However, the quality of outcome reporting, methodology of trials and their publication parameters are important considerations in the process of development of Core Outcome Sets. We aimed to evaluate these characteristics in randomized controlled trials on surgery for POP using mesh. METHODS: Secondary analysis of randomized controlled trials on surgical treatments using synthetic mesh for POP previously included in a systematic review developing an inventory of reported outcomes and outcome measures. The methodological quality was investigated with the modified Jadad criteria. Outcome reporting quality was evaluated with the MOMENT criteria. Publication parameters included publishing journal, impact factor and year of publication. RESULTS: Of the 71 previously reviewed studies published from 2000 to 2017, the mean JADAD score was 3.59 and the mean MOMENT score was 4.63. Quality of outcomes (MOMENT) was related to methodological quality (JADAD) (rho = 0.662; p = 0.000) and to year of publication (rho = 0.262; p = 0.028). CONCLUSIONS: Methodological quality and outcome reporting quality appear correlated. However, publication characteristics do not have strong associations with the methodological quality of the studies. Evaluation of the quality of outcomes, methodology and publication characteristics are all an indispensable part of a staged process for the development of Core Outcome and Outcome Measure Sets.

Transcutaneous tibial nerve stimulation to treat urgency urinary incontinence in older women: 12-month follow-up of a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: Urgency urinary incontinence (UUI) is highly prevalent in elderly individuals and has a great impact on quality of life. Transcutaneous tibial nerve stimulation (TTNS) can be an effective treatment option for UUI in older women. METHODS: This is a single-center randomized clinical trial with a 12-month follow-up involving 106 women > 60 years of age. Kegel exercises and bladder retraining were performed alone or in combination with TTNS, which consisted of using a transcutaneous electrical nerve stimulator for 30 min once a week for 12 weeks with the following settings: continuous mode, 10 Hz, 200 ms, and 10 to 50 mA (according to hallux mobilization). Responders to therapy who experienced failure during follow-up were invited for a 3-week protocol with the same parameters as those used for the initial therapy. Patients were evaluated at baseline, 4 weeks after the 12-week protocol, and every 3 months for 12 months, through subjective satisfaction questionnaires, a 3-day bladder diary and the International Consultation on Incontinence Questionnaire-Short Form. King's Health Questionnaire was applied pretreatment and 4 weeks after the last session of the 12-week protocol. RESULTS: A total of 101 women completed the initial 12-week protocol. TTNS patients reported 66.7% subjective global satisfaction vs. 32.0% in the control group (p < 0.001). The TTNS group showed statistically significant improvement in quality of life (QoL) and UUI parameters compared with the control group. Forty-eight patients were satisfied after the 12-week protocol and completed the 12-month follow-up (32 in the TTNS group and 16 in the control group). A total of 80.5% of responders to TTNS were still satisfied at the end of the 12-month follow-up vs. 30.8% in the control group (p = 0.009). CONCLUSION: TTNS is effective at the 12-month follow-up for the treatment of UUI in elderly women.

Urinary Incontinence and Surgery for Obesity and Weight-Related Diseases: Are There Predictors of Improvement?

PURPOSE: The aim of this study was to evaluate changes in urinary incontinence (UI) before and after surgery for obesity in female patients and to identify factors related to the remission of symptoms. MATERIALS AND METHODS: This was a prospective cohort study with female patients over 18 years old who underwent surgery for obesity and weight-related diseases between June 2016 and September 2017. Urinary symptoms and quality of life related to UI were assessed based on a structured interview and the results of the validated questionnaires. RESULTS: Two hundred twenty-one patients were assessed pre-operatively, and 118 (53.3%) reported UI. Eighty-eight patients (74.6%) completed the pre- and postoperative questionnaires. After 6 to 12 months, patients were revaluated, and 50 (56.8%) were considered to be in remission of urinary symptoms. Women who had only a cesarean birth had a 117% increase in the probability of achieving remission of UI compared with women who had both vaginal and cesarean deliveries, and patients with an additional point in the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score at the beginning had a 4% lower probability of having remission of symptoms. CONCLUSIONS: Improvement in UI may be an important outcome of surgery for obesity and weight-related diseases. In this study, previous cesarean section was only associated with the highest rate of remission of symptoms, and patients with higher scores in the ICIQ-UI-SF had a lower probability of remission.

Urinary Incontinence and Quality of Life in Female Patients with Obesity.

OBJECTIVE: To analyze the prevalence of urinary incontinence (UI) in female patients with an indication for bariatric surgery, to investigate the potential risk factors and the impact on quality of life. METHODS: A cross-sectional study with female patients with obesity. The evaluation consisted of a structured interview, a specific study form and quality of life questionnaires. The Poisson regression was performed to identify independent risk factors related to UI. RESULTS: A total of 221 patients were enrolled; 118 of the study participants (53.4%) reported UI episodes. Mixed UI (MUI), stress UI (SUI) only, and urgency UI (UUI) only were reported by 52.5% (62), 33.9% (40) , and 13.5% (16) of these patients respectively. The prevalence of UI was increased by 47% among the women who had given birth vaginally and by 34% of the women who had entered menopause. Vaginal delivery and menopause were identified as independent risk factors related to UI. The mean International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) score was 9.36 ± 4.9. The severity of symptoms was considered moderate in 53.3% (63) of the patients with UI. CONCLUSION: Urinary incontinence impacts quality of life negatively, and the prevalence of UI is high among obese patients. In the present study, vaginal delivery and menopause were independently associated with UI.

OBJETIVO: Analisar a prevalência de incontinência urinária (IU), os fatores de risco e o impacto na qualidade de vida em pacientes femininas com indicação para realização de cirurgia bariátrica. MéTODOS: Estudo transversal com pacientes femininas obesas. A avaliação consistiu em entrevista estruturada, com questionários de estudo específico e de qualidade de vida. A regressão de Poisson foi utilizada para identificar os fatores de risco independentes para IU. RESULTADOS: Um total de 221 pacientes foram incluídos; 118 participantes (53.4%) relataram episódios de IU. Incontinência urinária mista, IU de esforço e IU de urgência foram relatadas por 52.5% (62), 33.9% (40) e 13.5%(16) das pacientes, respectivamente. A prevalência de IU foi 47% maior em mulheres que tiveram parto vaginal, e 34% maior em mulheres que já entraram no período da menopausa. Parto vaginal e menopausa foram identificados como fatores de risco independentes para IU. A média da pontuação do International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) foi de 9.36 ± 4.9. A severidade dos sintomas foi considerada moderada em 53.3% (63) das pacientes com IU. CONCLUSãO: A IU impacta negativamente a qualidade de vida, e a prevalência de IU é maior em pacientes obesas. Neste estudo, parto vaginal e menopausa foram fatores de risco independentes para a ocorrência de IU.

Urinary incontinence and quality of life in female patients with obesity / Incontinência urinária e qualidade de vida em pacientes femininas com obesidade

Abstract Objective To analyze the prevalence of urinary incontinence (UI) in female patients with an indication for bariatric surgery, to investigate the potential risk factors and the impact on quality of life. Methods A cross-sectional study with female patients with obesity. The evaluation consisted of a structured interview, a specific study form and quality of life questionnaires. The Poisson regression was performed to identify independent risk factors related to UI. Results A total of 221 patients were enrolled; 118 of the study participants (53.4%) reported UI episodes. Mixed UI (MUI), stress UI (SUI) only, and urgency UI (UUI) only were reported by 52.5% (62), 33.9% (40) , and 13.5% (16) of these patients respectively. The prevalence of UI was increased by 47% among the women who had given birth vaginally and by 34% of the women who had entered menopause. Vaginal delivery and menopause were identified as independent risk factors related to UI. The mean International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) score was 9.36 ± 4.9. The severity of symptoms was considered moderate in 53.3% (63) of the patients with UI. Conclusion Urinary incontinence impacts quality of life negatively, and the prevalence of UI is high among obese patients. In the present study, vaginal delivery and menopause were independently associated with UI.

Resumo Objetivo Analisar a prevalência de incontinência urinária (IU), os fatores de risco e o impacto na qualidade de vida em pacientes femininas comindicação para realização de cirurgia bariátrica. Métodos Estudo transversal com pacientes femininas obesas. A avaliação consistiu em entrevista estruturada, com questionários de estudo específico e de qualidade de vida. A regressão de Poisson foi utilizada para identificar os fatores de risco independentes para IU. Resultados Um total de 221 pacientes foram incluídos; 118 participantes (53.4%) relataram episódios de IU. Incontinência urinária mista, IU de esforço e IU de urgência foram relatadas por 52.5% (62), 33.9% (40) e 13.5%(16) das pacientes, respectivamente. A prevalência de IU foi 47%maior emmulheres que tiveramparto vaginal, e 34% maior em mulheres que já entraram no período da menopausa. Parto vaginal e menopausa foram identificados como fatores de risco independentes para IU. A média da pontuação do International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) foi de 9.36 ± 4.9. A severidade dos sintomas foi considerada moderada em 53.3% (63) das pacientes com IU. Conclusão A IU impacta negativamente a qualidade de vida, e a prevalência de IU é maior empacientes obesas. Neste estudo, parto vaginal e menopausa foram fatores de risco independentes para a ocorrência de IU.

Systematic Review of Oral Therapy for the Treatment of Symptoms of Bladder Pain Syndrome: The Brazilian Guidelines.

Interstitial cystitis (IC), including bladder pain syndrome (BPS), is a chronic and debilitating disease that mainly affects women. It is characterized by pelvic pain associated with urinary urgency, frequency, nocturia and negative urine culture, with normal cytology. In 2009, the Society for Urodynamics and Female Urology (SUFU) defined the term IC/BPS as "an unpleasant sensation (pain, pressure, and discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms for more than 6 weeks duration, in the absence of infection or other identifiable causes." This is the definition used by the American Urological Association (AUA) in the most recent guidelines on IC/BPS. Interstitial cystitis may be sufficiently severe to have a devastating effect on the quality of life, but it may also be associated with moderate symptoms whose effects are less debilitating. Although there are several clinical trials to assess oral and intravesical therapies, the treatment for IC remains far from ideal. This systematic assessment evaluates published randomized clinical trials on oral medications used to treat symptoms of BPS. This study was performed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) method. Two independent reviewers screened the studies to determine their inclusion or exclusion and to perform the methodological analysis. The inclusion criteria included randomized studies published between April of 1988 and April of 2016 that used oral medications to treat symptoms of BPS or IC. According to the systematic review performed, we should consider pentosan polysulfate as one of the best options of oral drugs for the treatment of BPS symptoms. However, this drug is not an available option in Brazil. Orally administered amitriptyline is an efficacious medical treatment for BPS, and it should be the first treatment offered.

Cistite intersticial (IC), incluindo a síndrome da bexiga dolorosa (SBD), é uma doença crônica e debilitante que afeta principalmente mulheres. É caracterizada por dor pélvica associada à urgência miccional, frequência urinária, noctúria e exame cultural de urina negativo, com citologia normal. A cistite intersticial pode ser suficientemente severa para ter um efeito devastador na qualidade de vida, mas também pode estar associada a sintomas moderados e menos debilitantes. Embora existam vários ensaios clínicos para avaliar terapias orais e intravesicais, o tratamento para IC permanece longe do ideal. Esta revisão sistemática avaliou ensaios clínicos randomizados publicados sobre medicamentos orais usados para tratar sintomas de SBD. Este estudo foi realizado de acordo com o método preferred reporting items for systematic reviews and meta-analyses (PRISMA). Dois revisores independentes examinaram os estudos para determinar sua inclusão ou exclusão e para realizar a análise metodológica. Os critérios de inclusão foram: ensaios clínicos randomizados publicados entre abril de 1988 e abril de 2016 que usaram medicações orais no tratamento dos sintomas da SBD ou CI. De acordo com a revisão sistemática realizada, a melhor opção de medicação oral para o tratamento dos SBD é o pentosano polissulfato sódico. No entanto, esta droga não está disponível no Brasil. A amitriptilina administrada por via oral é um tratamento eficaz para SBD e deve ser oferecida como primeira escolha.

Vaginal evisceration related to genital prolapse in premenopausal woman

ABSTRACT Background Vaginal evisceration is a rare problem, usually related to a previous hysterectomy. We report a case of spontaneous rupture of the cul-de-sac in a premenopausal woman under treatment with glucocorticoids to treat Systemic Lupus Erythematosus (SLE), with uterine prolapse that occurred during evacuation. Case Report A 40-year-old woman with SLE, using glucocorticoids, with uterine prolapse grade 4 (POP-Q), awaiting surgery presented at the emergency room with vaginal bleeding after Valsalva during defaction. Uterine prolapse associated with vaginal evisceration was identified. Under vaginal examination, we confirmed the bowel viability and performed a vaginal hysterectomy and sacrospinous fixation. Case hypothesis This case draws attention to the extreme risk of untreated uterine prolapse, as well as the importance of multidisciplinary care of patients with vaginal prolapse and chronic diseases.

Vaginal evisceration related to genital prolapse in premenopausal woman.

BACKGROUND: Vaginal evisceration is a rare problem, usually related to a previous hysterectomy. We report a case of spontaneous rupture of the cul-de-sac in a premenopausal woman under treatment with glucocorticoids to treat Systemic Lupus Erythematosus (SLE), with uterine prolapse that occurred during evacuation. Main findings-Case Report: A 40-year-old woman with SLE, using glucocorticoids, with uterine prolapse grade 4 (POP-Q), awaiting surgery presented at the emergency room with vaginal bleeding after Valsalva during defection. Uterine prolapse associated with vaginal evisceration was identified. Under vaginal examination, we confirmed the bowel viability and performed a vaginal hysterectomy and sacrospinous fixation. Case hypothesis: This case draws attention to the extreme risk of untreated uterine prolapse, as well as the importance of multidisciplinary care of patients with vaginal prolapse and chronic diseases.

Electrical stimulation for urinary incontinence in women: a systematic review.

BACKGROUND: Electrical stimulation is commonly recommended to treat urinary incontinence in women. It includes several techniques that can be used to improve stress, urge, and mixed symptoms. However, the magnitude of the alleged benefits is not completely established. OBJECTIVES: To determine the effects of electrical stimulation in women with symptoms or urodynamic diagnoses of stress, urge, and mixed incontinence. SEARCH STRATEGY: Our review included articles published between January 1980 and January 2012. We used the search terms ″urinary incontinence″, ″electrical stimulation ″, ″ intravaginal ″, ″ tibial nerve ″ and ″ neuromodulation ″ for studies including female patients. SELECTION CRITERIA: We evaluated randomized trials that included electrical stimulation in at least one arm of the trial, to treat women with urinary incontinence. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the data from the trials, for inclusion or exclusion, and methodological analysis. MAIN RESULTS: A total of 30 randomized clinical trials were included. Most of the trials involved intravaginal electrical stimulation. Intravaginal electrical stimulation showed effectiveness in treating urge urinary incontinence, but reported contradictory data regarding stress and mixed incontinence. Tibial-nerve stimulation showed promising results in randomized trials with a short follow-up period. Sacral-nerve stimulation yielded interesting results in refractory patients. CONCLUSIONS: Tibial-nerve and intravaginal stimulation have shown effectiveness in treating urge urinary incontinence. Sacral-nerve stimulation provided benefits in refractory cases. Presently available data provide no support for the use of intravaginal electrical stimulation to treat stress urinary incontinence in women. Further randomized trials are necessary to determine the magnitude of benefits, with long-term follow-up, and the effectiveness of other electrical-stimulation therapies.

Impact of menopausal status on the outcome of pelvic floor physiotherapy in women with urinary incontinence.

INTRODUCTION AND HYPOTHESIS: The purpose of this study was to evaluate the effectiveness of pelvic floor muscle training in pre- and postmenopausal women using a quality-of-life questionnaire. METHODS: We retrospectively reviewed the medical records of 96 patients with urinary incontinence who participated in a pelvic floor muscle-training (PFMT) program at the Physiotherapy Department in a London University Hospital between January 2010 and August 2011. RESULTS: A period of supervised PFMT resulted in significant improvement in symptoms of stress urinary incontinence, urge urinary incontinence, urgency, frequency, and nocturia, irrespective of menopausal status. CONCLUSIONS: Pre- and postmenopausal women experience similar outcomes in relation to urinary symptoms following a short-term supervised PFMT.

Electrical Stimulation for Urinary Incontinence in Women: A Systematic Review

Background Electrical stimulation is commonly recommended to treat urinary incontinence in women. It includes several techniques that can be used to improve stress, urge, and mixed symptoms. However, the magnitude of the alleged benefits is not completely established. Objectives To determine the effects of electrical stimulation in women with symptoms or urodynamic diagnoses of stress, urge, and mixed incontinence. Search Strategy: Our review included articles published between January 1980 and January 2012. We used the search terms “urinary incontinence”, “electrical stimulation”, “intravaginal”, “tibial nerve” and “neuromodulation” for studies including female patients. Selection Criteria We evaluated randomized trials that included electrical stimulation in at least one arm of the trial, to treat women with urinary incontinence. Data Collection and Analysis Two reviewers independently assessed the data from the trials, for inclusion or exclusion, and methodological analysis. Main Results A total of 30 randomized clinical trials were included. Most of the trials involved intravaginal electrical stimulation. Intravaginal electrical stimulation showed effectiveness in treating urge urinary incontinence, but reported contradictory data regarding stress and mixed incontinence. Tibial-nerve stimulation showed promising results in randomized trials with a short follow-up period. Sacral-nerve stimulation yielded interesting results in refractory patients. Conclusions Tibial-nerve and intravaginal stimulation have shown effectiveness in treating urge urinary incontinence. Sacral-nerve stimulation provided benefits in refractory cases. Presently available data provide no support for the use of intravaginal electrical stimulation to treat stress urinary incontinence in ...

Urethral prolapse in premenopausal, healthy adult woman.

Urethral prolapse is an uncommon clinical condition that is reported predominantly in children and postmenopausal women. We describe a case of a 39-year-old woman who presented at the emergency room with vaginal bleeding and pain related to Valsalva maneuver (lifting weight). She described several similar previous episodes, which started during her second pregnancy at 32 years of age. The episodes initially occurred every 6 months, but she did not seek medical assistance for 7 years, during which time symptoms became more frequent. She had no previous history of irradiation, pelvic infection, or urogenital surgery. During physical examination, a urethral prolapse was identified. Pelvic and urinary ultrasound (US) showed no other abnormality. The patient underwent cystourethroscopy and surgical excision of the urethral prolapse, with complete resolution of symptoms. Histopathology confirmed benign inflammatory urethral mucosa tissue with edema and vascular congestion.

Endometriose e infertilidade / Endometriosis and infertility

Os autores fazem uma revisão bibliográfica sobre endometriose associada à infertilidade com enfoque aos aspectos terapêuticos da doença.