Visual function in menopause: the role of hormone replacement therapy.

OBJECTIVE: To assess the effects of hormone replacement therapy (HRT) on visual function after menopause. DESIGN: This study was conducted on 80 postmenopausal women aged 52 to 70 years. Women were randomly divided into two groups: 40 women were treated by oral HRT (equine conjugated estrogens 0.625 mg/day + dydrogesterone 5 mg/day in a continuous combined regimen), and 40 women were not treated with hormones (control group). Each woman underwent a contrast sensitivity test, a Schirmer test, and an evaluation of intraocular pressure before starting the study and 1 year after the beginning of the study. Statistical analysis was performed by Student's test and Fisher's exact test. RESULTS: Contrast sensitivity function was significantly improved in all spatial frequencies (1.5, 3, 6, and 12 cycles per degree) with the exception of 18 cycles per degree in the HRT group 1 year after the beginning of treatment, whereas the control group demonstrated significant impairment at the lowest spatial frequencies (1.5, 3, and 6 cycles per degree). Tear production was significantly improved in the HRT group 1 year after the beginning of treatment, and intraocular pressure was similar in the two groups before and after the beginning of the study. CONCLUSIONS: HRT improves visual function, promoting a better contrast sensitivity and a higher tear production, but does not modify intraocular pressure.

Immediate postpartum perineal examination as a predictor of puerperal pelvic floor dysfunction.

OBJECTIVE: To determine the relation between postpartum perineal trauma and the development of puerperal pelvic floor dysfunctions. METHODS: A prospective study was conducted on 218 primiparae immediately after vaginal delivery. Women were divided in three groups according to perineal trauma: group A (n = 171) intact perineum or superficial tear, group B (n = 39) perineal muscle tears, group C (n = 8) anal sphincter tears with or without disruption of the rectal mucosa. Two months later, each woman was questioned about urogynecologic symptoms and examined by digital test, vaginal perineometry, and uroflowmetric stop test score. RESULTS: No significant difference was found among the groups with regard to the incidence of stress incontinence, frequency/urgency, and urge incontinence, whereas anal incontinence was found more commonly in group C (group C versus group A: P =.003, odds ratio 18.78). No significant difference was found for digital test, perineometry, and uroflowmetric stop test. CONCLUSION: Immediate postpartum perineal examination is not a good predictor of stress incontinence and pelvic floor weakness but could identify women at risk for anal dysfunctions: intact perineum does not exclude the appearance of symptoms related to perineal trauma after vaginal delivery.

Postpartum urinary symptoms: prevalence and risk factors.

OBJECTIVES: To assess the prevalence of urinary symptoms, the relationship between urinary symptoms and vaginal descent, and the association between urinary symptoms and obstetric factors. STUDY DESIGN: Five hundred and thirty-seven women were interviewed and underwent a urogynaecological evaluation 3 months after vaginal delivery. Quantitative-type variables were subjected to Student's t test. Simple logistic regression analyses were carried out on the symptoms studied as a function of risk factors. RESULTS: 8.2% of primiparae showed stress urinary incontinence and multiparae in 20% (P=0.0001); urge incontinence was present in 5.5% of primiparae and in 13% of multiparae (P=0.004). Significant correlations were found among operative vaginal delivery, dysuria (P=0.048) and frequency (P=0.036). Urinary incontinence appeared associated with induced labour with prostaglandins (P=0.018) and with general maternal factors, such as parity (P=0.001) and elevated weight at the beginning of pregnancy (P=0.019). CONCLUSIONS: It is likely that the pathogenesis of postpartum urinary incontinence includes not only the effects of pelvic floor trauma on urethrovesical mobility under stress, but also a deficiency in urethral resistance caused by drugs, such as prostaglandins.

Assessment of pelvic floor muscle function after vaginal delivery. Clinical value of different tests.

OBJECTIVE: To evaluate the efficacy of different tests in identifying pelvic floor dysfunction after vaginal delivery. STUDY DESIGN: One hundred ninety-seven primiparae were investigated 2 months after vaginal delivery. They underwent pelvic floor muscle assessment by digital test, vaginal manometry and uroflowmetric stop test. Puerperae were divided into continent and incontinent subpopulations. Variables were subjected to Student's t test and Fisher's exact test to verify the difference between the subpopulations. Kappa values were used to correlate the tests. RESULTS: Perineal performance in incontinent primiparae was weaker in all the tests; only the urine stream interruption test score showed significantly different values (P = .0026), but it did not correlate with the other two tests. CONCLUSION: A simple, objective, noninvasive and low-cost technique, such as the urine stream interruption test, is useful in assessing pelvic floor performance after vaginal delivery but reflects urethrovesical support function rather than pelvic muscle function in toto.

Perineal evaluation in the puerperium. Role of testing with a cotton-tipped swab.

OBJECTIVE: To verify the applicability and significance of testing with a cotton-tipped swab in postpartum evaluation. STUDY DESIGN: One hundred seventy-eight puerperas were examined two months after vaginal delivery and underwent testing with a cotton-tipped swab, digital test, vaginal manometry and uroflowmetric urine stream interruption test. Statistical analysis was performed using Student's t test to evaluate the difference between mean values of continent and incontinent puerperas and the Bravais-Pearson coefficient to test the correlation between all the tests used in the study. RESULTS: Incontinent puerperas and multiparas had significantly higher swab test values than did continent and primiparas, who demonstrated a swab test mean value of 39.5 degrees during the Valsalva maneuver. The sensitivity of the swab test for stress urinary incontinence was 82.5%, while its specificity and positive predictive value were, respectively, 31.1% and 25.8%. CONCLUSION: Perineal damage occurs not only in symptomatic puerperas but most women. The swab test was unable to assess stress urinary incontinence in postpartum women, also, and demonstrated only urethral hypermobility. The swab test in the puerperium does not add significant information about pelvic floor performance and should not be used routinely postpartum.

Effects of epidural analgesia during labor on pelvic floor function after vaginal delivery.

BACKGROUND: Aims of this study were to determine the rate of symptoms related to perineal trauma (anal and stress urinary incontinence) and to assess pelvic floor muscle function in women who underwent epidural analgesia. METHODS: Comparative design comprising 70 matched pairs of primiparous mothers. Each woman was questioned about urogynecologic symptoms and examined by digital test, vaginal perineometry and uroflowmetric stop test score 3 months after vaginal delivery. Urogenital prolapse was defined in accordance with the Baden and Walker's 'Halfway System Classification'. Statistical analysis was performed using Fisher's exact test to compare the two groups and simple logistic regression models to estimate the odds ratios of every variable considered in respect of the control population. RESULTS: No significant difference was found in the incidence of stress urinary incontinence, anal incontinence and vaginal prolapse in the two study groups. No significant differences were found between the study groups with regard to the digital test, vaginal manometry and urine stream interruption test. CONCLUSIONS: Use of epidural analgesia is not associated with symptoms related to perineal trauma and pelvic floor muscle weakness.

Perineal ultrasound evaluation of urethral angle and bladder neck mobility in women with stress urinary incontinence.

OBJECTIVES: 1. To assess the reproducibility of an electronic ultrasonographic technique for the measurement of urethral angulation; 2. to test the ability of measurement of the urethral angle and bladder neck mobility to predict genuine stress incontinence; 3. to compare ultrasound variables in stress incontinent women and in controls. DESIGN: Case-control study. POPULATION: Twenty-three incontinent women and 50 controls. METHODS: Electronic measurements of the distance between the bladder neck and the symphysis pubis, the bladder neck and the symphysis pubis line and the midline of the symphysis (alpha angle) and the angle between the proximal and distal urethra (beta angle) by means of perineal ultrasonography with a comfortably full bladder at rest, during the Valsalva manoeuvre and during maximal pelvic floor contraction. The same procedure was performed by a second investigator. Repeatability was evaluated by the technique described by Bland and Altman. Statistical analysis was performed using Student's t test and the two-tailed paired t test. MAIN OUTCOME MEASURES: To test the possible role of the urethral angle in maintaining female continence. RESULTS: Ultrasound analysis showed good repeatability between the two observers and is not influenced by vesical volume. Beta angle and urethrovesical mobility are inversely proportional, both in continent and in incontinent women. Urethral angle identifies genuine stress incontinence better than urethrovesical mobility (sensitivity 96% vs 87%; specificity 92% vs 68%; positive predictive value 85% vs 55%). There are significant differences in all ultrasound variables between incontinent women and continent controls. CONCLUSIONS: This study suggests a significant role of the urethral angle in maintaining female continence (in incontinent women it is lower at rest and lowers with straining). Measurement of the urethral angle can provide useful additional information to that provided by ultrasound evaluation of bladder neck mobility.