As dimensões ósseas da pelve podem estar relacionadas à gênese dos prolapsos de órgãos pélvicos? Uma revisão sistemática de estudos observacionais para avaliação de risco e prognóstico / Can the bone dimensions of the pelvis be related to the genesis of pelvic organ prolapses? A systematic review of observational studies for risk assessment and prognosis

Objetivo: Averiguar qual o papel desempenhado pelas dimensões ósseas da pelve em relação à gênese do prolapso de órgãos pélvicos por meio de publicações dos últimos quinze anos. Métodos: Trata-se de uma revisão sistemática de estudos ob- servacionais para avaliação de risco e prognóstico por meio de um levantamento bibliográfico virtual de artigos científicos publicados em revistas digitais entre os anos 2007 e 2022, nas bases de dados PubMed, BVS e ScienceDirect. Resultados: Uma área pélvica anterior mais ampla e um maior diâmetro interespinhoso foram caracterizados como possíveis causas para prolapso de órgãos pélvicos. A maior parte dos estudos contou com mensurações ósseas diversificadas, nas quais as demais dimensões não apresentaram significância estatística. Conclusão: Os estu- dos avaliados nesta revisão sugerem uma nova medida do assoalho pélvico rela- cionada a mulheres com prolapso, com apresentação de uma maior área anterior, em grande parte influenciada pelo diâmetro interespinhoso, o qual leva a um au- mento da carga sobre o assoalho pélvico. Porém, ainda assim, urge a necessidade de mais estudos para corroborar nossos achados.

Objective: To investigate the role played by the bone dimensions of the pelvis in relation to the genesis of pelvic organ prolapses through publications from the last fifteen years. Methods: This is a systematic review of obser- vational studies for risk assessment and prognosis through a virtual bibliographic survey of scientific articles published in digital journals between 2007 and 2022, in PubMed, BVS and ScienceDirect databases. Results: A wider anterior pelvic area and a larger interspinous diameter were characterized as possible causes for pelvic organ prolapses. Most of the studies have diversified bone measurements, in which the other dimensions weren't statistically significant. Conclusion: The studies evaluated in this review suggest a new measure- ment of the pelvic floor related to women with prolapse, with a larger anterior area, largely influenced by the interspinous diameter, which leads to an increased load on the pelvic floor. However, even so, there is an urgent need for further studies to corroborate our findings.

Does vaginal delivery cause more damage to the pelvic floor than cesarean section as determined by 3D ultrasound evaluation? A systematic review.

INTRODUCTION AND HYPOTHESIS: Pregnancy and delivery are well-established risk factors for pelvic floor dysfunction (PFD), but the physiopathology, such as the delivery route, is not well understood. This study evaluated the impact of delivery route on the pelvic floor muscles via 3D ultrasound. METHODS: This review is registered in the PROSPERO database. The criteria for inclusion were prospective studies with 3D translabial ultrasound assessment in primigravida women during pregnancy and postpartum published in English, Spanish or Portuguese between 1980 and 2016. We excluded studies that did not include the topic of urogenital hiatus measurement and literature reviews. The MeSH terms were obstetric delivery, postpartum period, labor, parturition, three-dimensional images, ultrasonography, pelvic floor, and pelvic floor disorders. RESULTS: The search retrieved 155 articles. After analysis, 6 articles were included. Four studies showed that vaginal delivery (VD) was associated with a larger hiatal area. One study associated the hiatal area with levator ani muscle (LAM) defects in VD. Four articles evaluated the bladder neck, 3 of which showed a significant increase in bladder neck mobility associated with VD and 1 showed decreased bladder neck elevation, not associated with the delivery mode; the first 3 articles all evaluated LAM injuries and showed an association between VD and LAM injury. Women who underwent VD presented defects of the puborectalis muscle. CONCLUSIONS: Vaginal delivery was associated with a higher number of LAM injuries, puborectalis defects, increased bladder neck mobility, and enlargement of the hiatal area.

Reproducibility in pelvic floor biometric parameters of nulliparous women assessed by translabial three-dimensional ultrasound using Omniview reformatting technique.

AIM: To assess the reproducibility of pelvic floor biometric parameters by translabial three-dimensional ultrasound compared with the OmniView® reformatting technique. MATERIAL AND METHODS: We performed a cross-sectional study involving 47 nulliparous women without symptoms of pelvic floor dysfunction. The hiatal area and right pubovisceral muscle width measurements were performed in the axial plane using both 3D ultrasound in the rendering mode and OmniView® techniques. To determine the occurrence of standardized error between examiners and the two sonographic methods, the paired t-test was used. The intra- and inter-observer reliability and agreement were estimated by concordance correlation coefficient (CCC) and limits of agreement, respectively. RESULTS: We did not observe significant statistical differences among both measurements performed by the first examiner, both examiners and both methods in the assessment of the hiatal area; however, the measurements of the right pubovisceral muscle were significantly lower using OmniView®. The intra-observer reliability was good in the evaluation of all pelvic floor parameters; however, the inter-observer reliability was good only to the 3D rendering mode (CCC=0.87). The intra-observer agreement was good in the assessment of all pelvic floor parameters; however, the inter-observer agreement was found to be good only when 3DUS in the rendering mode was used (<+/-15%). CONCLUSION: Both 3D ultrasound in the rendering mode and OmniView® reformatting techniques were concordant in the assessment of pelvic floor parameters; however, the 3D ultrasound rendering in the mode demonstrated better inter-observer reliability and agreement.

Can Abdominal Hypopressive Technique Change Levator Hiatus Area?: A 3-Dimensional Ultrasound Study.

This study aimed to evaluate the levator hiatus area (LHA) at rest and during the performance of maximal pelvic floor muscle (PFM) contractions, during the abdominal hypopressive technique (AHT), and during the combination of PFM contractions (PFMCs) and the AHT. The study included 17 healthy nulliparous women who had no history of pelvic floor disorders. The LHA was evaluated with the patients in the lithotomy position. After a physiotherapist instructed the patients on the proper performance of the PFM and AHT exercises, 1 gynecologist performed the 3-dimensional translabial ultrasound examinations. The LHA was measured with the patients at rest. The PFMC alone, the AHT alone or the AHT in combination with a PFMC with 30 seconds of rest between the evaluations were performed. Each measurement was performed 2 times, and the mean value was used for statistical analysis. The Wilcoxon test was used to test the differences between the 2 maneuvers. Similar values were observed when comparing the LHA of the PFM at rest (12.2 ± 2.4) cm and during the AHT (11.7 ± 2.6) cm (P = 0.227). The AHT+ PFMC (10.2 ± 1.9) cm demonstrated lower values compared with AHT alone (11.7 ± 2.6) cm (P = 0.002). When comparing the PFMC (10.4 ± 2.1) cm with the AHT + PFMC (10.2 ± 1.9) cm, no significant difference (P = 0.551) was observed. During PFMC, the constriction was 1.8 cm; during the AHT, the constriction was 0.5 cm; and during the AHT + PFMC, it was 2 cm. The LHA assessed by 3-dimensional ultrasound did not significantly change with AHT. These results support the theory that AHT does not strengthen PFM.

Pre-operative training induces changes in the histomorphometry and muscle function of the pelvic floor in patients with indication of radical prostatectomy.

OBJECTIVE: To evaluate the efficacy of preoperative pelvic floor muscle training (PFMT) on histomorphometry, muscle function, urinary continence and quality of life of patients undergoing radical prostatectomy (RP). MATERIAL AND METHODS: A prospective intervention clinical study was designed in 16 patients with indication of RP who were randomized into two groups. The Control Group received routine pre-surgical education (hygienic-dietary measures). The intervention group received a training session with supervised PFMT, three times a day, for four weeks, 30 days before the PR. Muscle function of the external urethral sphincter, contraction pressure of the levator ani, urinary continence and quality of life related to health (HRQoL) were evaluated before and after the intervention. At the end of the intervention and day of the surgery, samples of residual muscle tissue were obtained from the external sphincter muscle of the urethra for histomorphometric analysis. RESULTS: After the intervention, those participants who carried out PFMT showed an increase in the cross-sectional area of the muscle fibers of the external urethral sphincter (1,313 ± 1,075 µm(2)vs. 1,056 ± 844 µm(2), P=.03) and higher pressure contraction of the levator ani (F=9.188; P=.010). After catheter removal, 62% of patients in the experimental group and 37% in the control group showed no incontinence. After removal of the catheter, 75% of the experimental group did not require any pad compared to 25% in the control group (p=NS). There were no significant differences between the two groups in any of the HRQoL domains studied. CONCLUSIONS: Pre-surgical PFMT in patients with RP indication induces changes in the histology and function of the pelvic floor muscles, without changes in urogenital function and HRQoL. These results provide new evidence regarding the benefit of PFMT in preventing RP associated complications.

Denervation and castration effects on the cross-sectional area of pubococcygeus muscle fibers in male rats.

The number of fibers in skeletal muscles changes little through life; however, the cross-sectional area of its fibers is modified as result of denervation and in some muscles by castration. The pubococcygeus muscle (Pcm) participates in micturition and ejaculatory processes and its fibers cross-sectional area is reduced in castrated rats, but denervation effects remained unknown. Here, we used a model in which unilateral denervation of this muscle in gonadally intact and castrated male rats, allowed us to explore the neural and gonadal hormone effects on the cross-sectional area of its fibers. Denervation significantly reduced the mean cross-sectional area values; likewise, the percentage distribution of its fibers. We found that castration had a greater effect than denervation. Castration resulted in a lack of fibers from 2,000 to 3,999 µm(2) , while in denervation it was from 2,500 to 3,999 µm(2) . It was interpreted that the castration effect was due to a lack of the direct gonadal hormone effect on muscle fibers, and to a reduction of the indirect hormonal action in its neuromuscular complex. In denervated Pcm of gonadally intact animals these effects were present; however, in denervated but castrated animals these were absent. Thus, combined surgeries resulted in the lowest mean cross-sectional area values with a restricted fiber distribution from 500 to 1,499 µm(2) . In conclusion, the study in this important muscle showed that cross-sectional area of its fibers depends on neural and direct/indirect gonadal hormone effects.

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 Fisher's 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.

Anatomical and functional characteristics of the pelvic floor in nulliparous women submitted to three-dimensional endovaginal ultrasonography: case control study and evaluation of interobserver agreement.

PURPOSE: To determine anatomical and functional pelvic floor measurements performed with three-dimensional (3-D) endovaginal ultrasonography in asymptomatic nulliparous women without dysfunctions detected in previous dynamic 3-D anorectal ultrasonography (echo defecography) and to demonstrate the interobserver reliability of these measurements. METHODS: Asymptomatic nulliparous volunteers were submitted to echo defecography to identify dynamic dysfunctions, including anatomical (rectocele, intussusceptions, entero/sigmoidocele and perineal descent) and functional changes (non-relaxation or paradoxical contraction of the puborectalis muscle) in the posterior compartment and assessed with regard to the biometric index of levator hiatus, pubovisceral muscle thickness, urethral length, anorectal angle, anorectal junction position and bladder neck position with the 3-D endovaginal ultrasonography. All measurements were compared at rest and during the Valsalva maneuver, and perineal and bladder neck descent was determined. The level of interobserver agreement was evaluated for all measurements. RESULTS: A total of 34 volunteers were assessed by echo defecography and by 3-D endovaginal ultrasonography. Out of these, 20 subjects met the inclusion criteria. The 14 excluded subjects were found to have posterior dynamic dysfunctions. During the Valsalva maneuver, the hiatal area was significantly larger, the urethra was significantly shorter and the anorectal angle was greater. Measurements at rest and during the Valsalva maneuver differed significantly with regard to anorectal junction and bladder neck position. The mean values for normal perineal descent and bladder neck descent were 0.6 cm and 0.5 cm above the symphysis pubis, respectively. The intraclass correlation coefficient ranged from 0.62-0.93. CONCLUSIONS: Functional biometric indexes, normal perineal descent and bladder neck descent values were determined for young asymptomatic nulliparous women with the 3-D endovaginal ultrasonography. The method was found to be reliable to measure pelvic floor structures at rest and during Valsalva, and might therefore be suitable for identifying dysfunctions in symptomatic patients.

Assessment of pelvic floor by three-dimensional-ultrasound in primiparous women according to delivery mode: initial experience from a single reference service in Brazil / Avaliação do assoalho pélvico por meio da ultrassonografia tridimensional de mulheres primíparas de acordo com o tipo de parto: experiência inicial de um centro de referência do Brasil

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 Fisher's exact test. RESULTS: The mean areas of the urogenital hiatus in the cases of vaginal and forceps deliveries were 17.0 and 20.1 cm², respectively, versus 12.4 cm² 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.

OBJETIVO: Avaliar as mudanças no assoalho pélvico de mulheres primíparas em diversos tipos de partos por meio da ultrassonografia tridimensional. MÉTODOS: Estudo de corte transversal prospectivo com 35 primigestas, divididas em grupos com relação ao tipo de parto: cesariana eletiva (n=10), parto vaginal (n=16) e fórceps (n=9). A ultrassonografia tridimensional do assoalho pélvico foi realizada no segundo dia pós-parto com a paciente em repouso. Utilizou-se transdutor convexo volumétrico (RAB4-8L) em contato com os grandes lábios vaginais, estando a paciente em posição ginecológica. Medidas biométricas do hiato urogenital foram tomadas no plano axial da imagem renderizada para avaliar a área, os diâmetros anteroposterior e transverso, a espessura média e a avulsão do músculo elevador do ânus. Diferenças entre os grupos foram avaliadas pela determinação da média das diferenças com seus respectivos intervalos de confiança de 95%. As proporções de avulsão do músculo elevador do ânus foram comparadas entre a cesárea eletiva e o parto vaginal pelo teste exato de Fisher. RESULTADOS: As áreas médias do hiato urogenital dos partos vaginais e fórceps foram 17,0 e 20,1 cm², respectivamente, contra 12,4 cm² do Grupo Controle (cesárea eletiva). Avulsão do músculo elevador do ânus foi observado em mulheres submetidas ao parto vaginal (3/25); no entanto, não houve diferença significativa entre os grupos cesárea e parto vaginal (p=0,5). CONCLUSÃO: A ultrassonografia tridimensional por via perineal foi útil na avaliação do assoalho pélvico de mulheres primíparas, diferenciando alterações pélvicas de acordo com o tipo de parto.

Anatomical and functional characteristics of the pelvic floor in nulliparous women submitted to three-dimensional endovaginal ultrasonography: case control study and evaluation of interobserver agreement / Características anatômicas e funcionais do assoalho pélvico em nulíparas avaliadas por ultrassonografia tridimensional endovaginal: estudo caso-controle e avaliação da confiabilidade interobservador

PURPOSE: To determine anatomical and functional pelvic floor measurements performed with three-dimensional (3-D) endovaginal ultrasonography in asymptomatic nulliparous women without dysfunctions detected in previous dynamic 3-D anorectal ultrasonography (echo defecography) and to demonstrate the interobserver reliability of these measurements. METHODS: Asymptomatic nulliparous volunteers were submitted to echo defecography to identify dynamic dysfunctions, including anatomical (rectocele, intussusceptions, entero/sigmoidocele and perineal descent) and functional changes (non-relaxation or paradoxical contraction of the puborectalis muscle) in the posterior compartment and assessed with regard to the biometric index of levator hiatus, pubovisceral muscle thickness, urethral length, anorectal angle, anorectal junction position and bladder neck position with the 3-D endovaginal ultrasonography. All measurements were compared at rest and during the Valsalva maneuver, and perineal and bladder neck descent was determined. The level of interobserver agreement was evaluated for all measurements. RESULTS: A total of 34 volunteers were assessed by echo defecography and by 3-D endovaginal ultrasonography. Out of these, 20 subjects met the inclusion criteria. The 14 excluded subjects were found to have posterior dynamic dysfunctions. During the Valsalva maneuver, the hiatal area was significantly larger, the urethra was significantly shorter and the anorectal angle was greater. Measurements at rest and during the Valsalva maneuver differed significantly with regard to anorectal junction and bladder neck position. The mean values for normal perineal descent and bladder neck descent were 0.6 cm and 0.5 cm above the symphysis pubis, respectively. The intraclass correlation coefficient ranged from 0.62-0.93. CONCLUSIONS: Functional biometric indexes, normal perineal descent and bladder neck descent values were determined for young asymptomatic nulliparous women with the 3-D endovaginal ultrasonography. The method was found to be reliable to measure pelvic floor structures at rest and during Valsalva, and might therefore be suitable for identifying dysfunctions in symptomatic patients.

OBJETIVO: Avaliar as medidas anatômicas e funcionais do assoalho pélvico utilizando a ultrassonografia tridimensional transvaginal em nulíparas assintomáticas sem disfunções do compartimento posterior evidenciado pela ecodefecografia. Demonstrar o grau de concordância entre observadores do método utilizado para medir as estruturas anatômicas. MÉTODOS: Voluntárias nulíparas assintomáticas foram submetidas à ecodefecografia para identificar alterações dinâmicas no compartimento posterior, incluindo aquelas anatômicas (retocele, intussuscepção, entero/sigmoidocele e descenso perineal) e funcionais (ausência de relaxamento ou contração paradoxal do puborretal) e avaliadas com ultrassonografia tridimensional transvaginal para determinar índices biométricos do hiato dos elevadores do ânus, espessura do músculo pubovisceral, comprimento da uretra, ângulo anorretal, posição da junção anorretal e posição do colo vesical. Todas as medidas foram comparadas em repouso e durante Valsalva; e determinado descenso perineal e do colo da bexiga. A variabilidade interobservador foi avaliada utilizando o coeficiente de correlação intraclasse. RESULTADOS: Foram avaliadas 34 voluntárias com a ecodefecografia e a ultrassonografia tridimensional transvaginal. Dessas, 20 foram incluídas no estudo. As 14 excluídas apresentavam alterações dinâmicas no compartimento posterior. Durante a manobra de Valsalva, a área hiatal foi significativamente maior. A uretra foi significantemente mais curta e o ângulo anorretal foi maior. Medidas em repouso e durante a Valsalva diferiram significativamente em relação à posição da junção anorretal e do colo vesical. A média de valor do descenso perineal e do descenso da bexiga foram de 0,6 cm e 0,5 cm acima da sínfise púbica, respectivamente. O coeficiente de correlação intraclasse variou entre 0,62-0,93. CONCLUSÕES: Foram determinados valores normais para os índices biométricos funcionais, descida perineal e colo vesical em nulíparas assintomáticas utilizando-se a ultrassonografia transvaginal tridimensional. É um método seguro para mensurar a anatomia do assoalho pélvico durante o repouso e a manobra de Valsalva, e pode ser adequado para a identificação de disfunções em pacientes sintomáticos.

El impacto de la resonancia magnética dinámica en el diagnostico de las disfunciones del piso pélvico / Impact of dynamic magnetic resonance in the diagnosis of pelvic floor dysfunctions

Introducción: La Resonancia Magnética Dinámica del Piso Pelviano (RMDPP) es un estudio diagnóstico que permite la evaluación dinámica y/o estática de todos los compartimentos de la pelvis (anterior, medio y posterior) en un solo estudio. Material y Método: Se presenta una serie prospectiva y consecutiva de 223 pacientes evaluados en el periodo comprendido entre abril de 2005 y Junio de 2011. Resultados: Del total de 223 pacientes 5 (2.3%) fueron del sexo masculino y 218 (97.7%) del sexo femenino. Cuatro casos normales (para estandarizar el procedimiento), 20 controles post operatorios y un paciente con una fistula colo - vesical, fueron excluidos de la serie a analizar. La coexistencia de patología en los distintos sectores del piso pelviano, mas frecuente en el sexo femenino, hace necesario su confirmación diagnóstica a fin implementar terapéuticas adecuadas en un solo tiempo quirúrgico. Ciento noventa y seis pacientes padecían un síndrome de obstrucción de tracto de salida (SOTS) y dos dolores perineales crónicos. Ciento veintiocho (64,6%) presentaron rectocele anterior de los cuales en 25 (12.6%) fue el único hallazgo. En 152 pacientes se constataron alteraciones de otras estructuras anatómicas abdomino-pelvianas que no habían sido sospechadas o comprobadas durante el examen fisico. Discusión: Es un estudio que no expone al paciente a radiaciones ionizante y brinda datos anatómicos y funcionales. Mediante la obtención de imágenes multiplanares se visualizan con detalle los órganos contenidos en la pelvis y la musculatura del piso pelviano, no siempre accesibles al examen físico. La RMDPP es hoy en día, el estudio más indicado para evaluar las disfunciones del piso pelviano...(AU)

Background: Dynamic magnetic resonance imaging of the pelvic floor (DMRPP) is a complementary diagnostic tool that allows dynamic and/or static assessment of all compartments of the pelvis (anterior, middle and posterior) in a single study. Method: We present a prospective and consecutive series of 223 patients evaluated between the period April 2005 and June 2011. Results: Of the total of 223 patients 5 (2.3%) were male and 218 (97.7%) females. Four normal cases (to standardize the procedure), 20 post-operative evaluation and one patient with a sigmoid- bladder fistula, were excluded from the analyzed series. The coexistence of pathology in different parts of the pelvic floor, more often in women, diagnostic confirmation is necessary to implement appropriate treatment in a single surgical session. One hundred ninety six patients had symptoms from an obstructive outlet syndrome (ODS) and two complained of chronic perineal pain. In 128 (64.6%) patients an anterior rectocele was confirmed. Only in 25 (12.6%) was the single finding. In 152 patients, other abdomino-pelvic anatomical dislocations were found that had not been suspected or found during physical examination. Discussion: DMRPP is a study that does not exposes patients to ionizing radiation and provides anatomical and functional data. Using multiplanar imaging, the organs in the pelvis and pelvic floor muscles are displayed in detail not always accessible to physical examination. The DMRPP is today an appropriate study to evaluate pelvic floor dysfunction, confirms presumptive diagnosis and quantify the incidence of dislocation of organs such as bladder, bowel and/or colon, uterus and vagina, influencing on intestinal voiding dynamics, as well as inadequate muscle relaxation such as: the puborectalis and/or anal sphincter. Conclusion: With DMRPP we have gained a comprehensive view of the pelvic floor enabling more rational treatments of pelvic floor dysfunctions...(AU)

El impacto de la resonancia magnética dinámica en el diagnostico de las disfunciones del piso pélvico / Impact of dynamic magnetic resonance in the diagnosis of pelvic floor dysfunctions

Introducción: La Resonancia Magnética Dinámica del Piso Pelviano (RMDPP) es un estudio diagnóstico que permite la evaluación dinámica y/o estática de todos los compartimentos de la pelvis (anterior, medio y posterior) en un solo estudio. Material y Método: Se presenta una serie prospectiva y consecutiva de 223 pacientes evaluados en el periodo comprendido entre abril de 2005 y Junio de 2011. Resultados: Del total de 223 pacientes 5 (2.3%) fueron del sexo masculino y 218 (97.7%) del sexo femenino. Cuatro casos normales (para estandarizar el procedimiento), 20 controles post operatorios y un paciente con una fistula colo - vesical, fueron excluidos de la serie a analizar. La coexistencia de patología en los distintos sectores del piso pelviano, mas frecuente en el sexo femenino, hace necesario su confirmación diagnóstica a fin implementar terapéuticas adecuadas en un solo tiempo quirúrgico. Ciento noventa y seis pacientes padecían un síndrome de obstrucción de tracto de salida (SOTS) y dos dolores perineales crónicos. Ciento veintiocho (64,6%) presentaron rectocele anterior de los cuales en 25 (12.6%) fue el único hallazgo. En 152 pacientes se constataron alteraciones de otras estructuras anatómicas abdomino-pelvianas que no habían sido sospechadas o comprobadas durante el examen fisico. Discusión: Es un estudio que no expone al paciente a radiaciones ionizante y brinda datos anatómicos y funcionales. Mediante la obtención de imágenes multiplanares se visualizan con detalle los órganos contenidos en la pelvis y la musculatura del piso pelviano, no siempre accesibles al examen físico. La RMDPP es hoy en día, el estudio más indicado para evaluar las disfunciones del piso pelviano...

Background: Dynamic magnetic resonance imaging of the pelvic floor (DMRPP) is a complementary diagnostic tool that allows dynamic and/or static assessment of all compartments of the pelvis (anterior, middle and posterior) in a single study. Method: We present a prospective and consecutive series of 223 patients evaluated between the period April 2005 and June 2011. Results: Of the total of 223 patients 5 (2.3%) were male and 218 (97.7%) females. Four normal cases (to standardize the procedure), 20 post-operative evaluation and one patient with a sigmoid- bladder fistula, were excluded from the analyzed series. The coexistence of pathology in different parts of the pelvic floor, more often in women, diagnostic confirmation is necessary to implement appropriate treatment in a single surgical session. One hundred ninety six patients had symptoms from an obstructive outlet syndrome (ODS) and two complained of chronic perineal pain. In 128 (64.6%) patients an anterior rectocele was confirmed. Only in 25 (12.6%) was the single finding. In 152 patients, other abdomino-pelvic anatomical dislocations were found that had not been suspected or found during physical examination. Discussion: DMRPP is a study that does not exposes patients to ionizing radiation and provides anatomical and functional data. Using multiplanar imaging, the organs in the pelvis and pelvic floor muscles are displayed in detail not always accessible to physical examination. The DMRPP is today an appropriate study to evaluate pelvic floor dysfunction, confirms presumptive diagnosis and quantify the incidence of dislocation of organs such as bladder, bowel and/or colon, uterus and vagina, influencing on intestinal voiding dynamics, as well as inadequate muscle relaxation such as: the puborectalis and/or anal sphincter. Conclusion: With DMRPP we have gained a comprehensive view of the pelvic floor enabling more rational treatments of pelvic floor dysfunctions...

Forma e função dos músculos perineais da viscacha (Lagostomus maximus) / Shape and function of the perineal muscles of viscacha (Lagostomus maximus)

Entre as espécies de roedores já estudadas podemos destacar a grande variação na morfologia do aparelho reprodutor masculino. Assim, considerando a importância ecológica dos roedores, e a grande representatividade numérica quanto geográfica destes animais, bem como a escassez que aborda a anatomia reprodutiva, desenvolvemos este trabalho com um roedor histricomorfo da América do Sul, a viscacha. Este animal apresenta algumas características reprodutivas bem peculiares, desta forma descreveremos a anatomia macroscópica da musculatura perineal, e o papel dos músculos no comportamento copulatório desta espécie. A região perineal da viscacha é composta por cinco músculos, sendo que três músculos encontram-se dispostos no diafragama urogenital superficial, Musculus ischiocavernosus, M. bulbocavernosus e M. bulbospongiosus, e pelos músculos que se encontram no diafragma pélvico, M. levator ani e M. retractor penis. Sendo assim, destacamos que o estudo do assoalho pélvico em animais silvestres é de grande valia, uma vez que contribuem com o melhor entendimento dos mecanismos relacionados â ereção e ejaculação; ou seja colaboram com os estudos sobre a reprodução dos animais.(AU)

Among the rodent species studied we can highlight the wide variation in the morphology of the male reproductive system. Thus, considering the ecological importance of rodents, and the large number and geographical representation of this animal, as well as shortages regarding the reproductive anatomy, we developed this study with viscacha, a South American histricomorph rodent. As this species has some very peculiar reproductive features, we described the gross anatomy of the perineal muscles and the role of copulatory behavior. The perineal region of viscacha is composed of five muscles, three of which are arranged in the superficial genitourinary diaphragm, as Musculus ischiocavernosus, M. bulbocavernosus and M. bulbospongiosus, and the muscles that lie at the pelvic diaphragm, M. levator ani and M. retractor penis. Therefore, we emphasize that the study of the pelvic floor in wild animals is of great value, then contribute to a better understanding of the mechanisms related to erection and ejaculation or collaborate with studies on the reproduction of animals.(AU)

Forma e função dos músculos perineais da viscacha (Lagostomus maximus) / Shape and function of the perineal muscles of viscacha (Lagostomus maximus)

Entre as espécies de roedores já estudadas podemos destacar a grande variação na morfologia do aparelho reprodutor masculino. Assim, considerando a importância ecológica dos roedores, e a grande representatividade numérica quanto geográfica destes animais, bem como a escassez que aborda a anatomia reprodutiva, desenvolvemos este trabalho com um roedor histricomorfo da América do Sul, a viscacha. Este animal apresenta algumas características reprodutivas bem peculiares, desta forma descreveremos a anatomia macroscópica da musculatura perineal, e o papel dos músculos no comportamento copulatório desta espécie. A região perineal da viscacha é composta por cinco músculos, sendo que três músculos encontram-se dispostos no diafragama urogenital superficial, Musculus ischiocavernosus, M. bulbocavernosus e M. bulbospongiosus, e pelos músculos que se encontram no diafragma pélvico, M. levator ani e M. retractor penis. Sendo assim, destacamos que o estudo do assoalho pélvico em animais silvestres é de grande valia, uma vez que contribuem com o melhor entendimento dos mecanismos relacionados â ereção e ejaculação; ou seja colaboram com os estudos sobre a reprodução dos animais.

Among the rodent species studied we can highlight the wide variation in the morphology of the male reproductive system. Thus, considering the ecological importance of rodents, and the large number and geographical representation of this animal, as well as shortages regarding the reproductive anatomy, we developed this study with viscacha, a South American histricomorph rodent. As this species has some very peculiar reproductive features, we described the gross anatomy of the perineal muscles and the role of copulatory behavior. The perineal region of viscacha is composed of five muscles, three of which are arranged in the superficial genitourinary diaphragm, as Musculus ischiocavernosus, M. bulbocavernosus and M. bulbospongiosus, and the muscles that lie at the pelvic diaphragm, M. levator ani and M. retractor penis. Therefore, we emphasize that the study of the pelvic floor in wild animals is of great value, then contribute to a better understanding of the mechanisms related to erection and ejaculation or collaborate with studies on the reproduction of animals.

Avaliação de um modelo anatômico sintético tridimensional de assoalho pélvico no ensino de anatomia comparado com a pélve cadavérica / A synthetic three-dimensional pelvic model as na effective didactic tool compared to cadaveric pelvis

Introdução e objetivos: O estudo da Anatomia humana se faz imprescindível para o conhecimento e compreensão do corpo humano como um todo, na importância e interação de todas as suas estruturas e características de cada um de seus órgãos ou partes, como meio essencial para promover a vida e cura dos males, intenção primária no ato de cuidar, enquanto técnica, arte e ciência, no seu mais expressivo compromisso (1). Além disto, a aula prática com o uso de componentes anatômicos manipuláveis é essencial para um bom processo de ensino e aprendizagem. Portanto, o componente pedagógico do material utilizado é essencial, de forma que as ferramentas escolhidas possam agregar valor na construção de uma aprendizagem significativa dos alunos. Os objetivos deste estudo foram avaliar: 1- o Modelo Anatômico Sintético de Assoalho Pélvico (MASAP) como uma ferramenta didática, comparando o mesmo com a pelve cadavérica (PC) durante a aula prática de Anatomia, e 2- a satisfação dos estudantes com ambos os métodos. Materiais e métodos: Foram utilizadas pelves cadavéricas e modelos anatômicos sintéticos de pelve. A pesquisa foi do tipo experimental, desenvolvida através de estudo prospectivo longitudinal. Sessenta e sete estudantes de Medicina, voluntários para este estudo, foram submetidos a um teste teórico preliminar (TTP) e a uma aula teórica de anatomia do assoalho pélvico. Após esta aula os estudantes foram randomizados em três grupos: G1, G2 e G3. G1 submeteu-se a aula prática tradicional de anatomia (APT) com o uso de PC, e G2 submeteu-se à aula prática proposta com uso do MASAP (APM). G3, denominado grupo controle, não foi submetido à aula prática. Um teste teórico final (TTF) foi aplicado para todos os grupos G1, G2 e G3. G1 e G2 foram submetidos a uma avaliação de satisfação relativa ao método utilizado para realização da aula prática (Avaliação do método - AM).

The study of human anatomy is indispensable for knowledge and understanding of the human body as a whole, that is to say, the importance and interaction of all its structures and characteristics of each of its organs or parts, as an essential means to promote life and healing ills, primary intention in the act of caring, while technical, art and science, in its most significant commitment (1). Furthermore, the practice class using a comprehensive and manageable anatomic component is fundamental for a good teaching and learning process. The goals of this study were to evaluate: 1- the synthetic anatomic model of pelvic floor (SAMPF) as a didactic tool comparing it to the traditional anatomic class using cadaveric pelvis (CP) and 2- the satisfaction of the students with both didactic methods. Sixty seven medicine students, volunteers for this study, received a conventional theoretic anatomy class. Following this class, all students were randomized in 3 groups (G1, G2 and G3). G1 and G2 attended anatomical classes with different didactic methods, respectively: traditional practice anatomy class (TPC), practice anatomy class with SAMPF (SPC).

Histochemical and morphological characteristics of the levator ani muscle in rats / Características morfológicas e histoquímicas del músculo elevador del ano en ratas

The current study aimed to analyze the histochemical and morphological characteristics of the levator ani muscle in rats. For this, we used 10 Wistar rats (5 males and 5 females), weighing between 200 and 765g. The animals were dissected fresh and in formalin for the levator ani muscle anatomical observation. Muscle fragments were collected and frozen in n-Hexane previously cooled in liquid nitrogen. Then, the muscles were transferred to a microtome cryostat (HM 505 E Microm), being fixed in metal mounts with the adhesive Tissue Freezing Medium. Histological sections of 6.0um were removed and subjected to HE staining. Other sections were subjected to NADH-TR and SDH reactions. After being dissected and fixed, the architecture of the female pelvic floor revealed the presence of two muscles: iliocaudalis and pubocaudalis. The anatomical inspection in male rats revealed, pronouncedly, the presence of the levator ani muscle: ischiocavernosus and bulbocavernous. We therefore observed a marked anatomical difference between animals of the same species, which does not occur with humans. The HE staining revealed muscular fibers with preserved morphology, contours ranging from polygonal to rounded, acidophilic cytoplasm, one or more peripheral nuclei with rounded shape and dense chromatin aspect. The fibers were organized in fascicles arranged by a dense connective tissue, the perimysium, and each fiber surrounded by the endomysium, composed of loose connective tissue. The sections subjected to NADH-TH and SDH, whose reactions show the activity of oxidative or glycolytic muscle fibers, allowed the identification of the two types of fiber. The fast-twitch fiber shows weaker reactivity, whereas the slow-twitch fiber has small diameter and intense reactivity, especially in the subsarcolemmal, presenting a highly oxidative metabolism. It was found that the pelvic floor muscles in rats are composed primarily by fast-twitch fibers, while in humans they are...

El estudio tuvo como objetivo analizar las características histoquímicas y morfológicas del músculo elevador del ano en ratas. Para esto, se utilizaron 10 ratas Wistar (5 machos y 5 hembras), con un peso entre 200 y 765g. Los animales fueron disecados frescos y en formol para la observación anatómica del músculo elevador del ano. Fragmentos de músculo fueron recogidos y congelados en n-Hexano, previamente enfriado en nitrógeno líquido. Luego, los músculos fueron trasladados a un micrótomo criostato (Microm HM 505 E), fijados en soportes metálicos con adhesivo Tissue Freezing Medium. Cortes histológicos de 6,0 um fueron retirados y sometidos a tinción de H-E. Otras secciones fueron sometidas a las reacciones de NADH-TR y SDH. Después de haber sido disecado y fijado, la arquitectura del suelo de la pelvis de las ratas hembra, reveló la presencia de dos músculos: m. iliocaudalis y m. pubocaudalis. La inspección anatómica de las ratas macho mostró, marcadamente, la presencia del músculo elevador del ano: isquiocavernoso y bulbocavernoso. Por lo tanto, observamos una marcada diferencia anatómica entre los animales de la misma especie, lo que no ocurre con los seres humanos. La tinción HE reveló fibras musculares con morfología conservada, contornos que van desde el esquema poligonal al redondeado, citoplasma acidófilo, uno o más núcleos periféricos con forma redondeada y un aspecto denso de la cromatina. Las fibras se organizaban en fascículos compuestos por un tejido conectivo denso, perimisio, y cada fibra rodeada por el endomisio compuesto por tejido conectivo laxo. En las secciones sometidas a NADH-TH y SDH, cuyas reacciones muestran la actividad oxidativa o glicolítica de las fibras musculares, permitió la identificación de los dos tipos de fibras. Las fibras de contracción rápida muestran más débil reactividad y, las de contracción lenta tienen un diámetro pequeño y reactividad intensa, especialmente en las regiones subsarcolemales, presentando un...

Modelo pélvico sintético como uma ferramenta didática efetiva comparada à pelve cadavérica / A synthetic three-dimensional pelvic model as an effective didactic tool compared to cadaveric pelvis

A anatomia é considerada matéria essencial à educação médica. Aulas práticas com uso de componentes anatômicos manipuláveis são fundamentais ao ensino e à aprendizagem. O objetivo deste estudo foi avaliar o Modelo Sintético de Pelve (Masp) como ferramenta didática, comparada à pelve cadavérica (PC) tradicionalmente utilizada, bem como a satisfação dos estudantes em relação a ambos os métodos. Sessenta e sete estudantes receberam aula teórica após teste teórico preliminar (TTP). Foram randomizados em três grupos: G1 teve aula prática tradicional (APT); G2, aula prática com Masp (APM); e G3 não teve aula prática. Um teste final (TTF) foi aplicado a todos os grupos. G1 e G2 submeteram-se à avaliação do método (AM). A análise estatística foi realizada utilizando-se Anova (Análise de Variância) e teste não paramétrico Mann-Whitney. No TTF, G3 apresentou escores mais baixos do que G1 (p = 0,041) e G2 (p = 0,000). Não foi encontrada diferença estatisticamente significante entre G1 e G2 (p >0,05). G2 apresentou maior satisfação com o método (p = 0,001). Concluiu-se que PC e Masp provaram ser ferramentas didáticas efetivas e que G2 mostrou maior satisfação.

Anatomy is considered a fundamental subject of medical education. Practical classes which involve the use of manipulable anatomic components are essential to teaching and learning. The aim of this study was to evaluate the synthetic pelvic model (SPM) as a didactic tool, compared to the traditionally- -used cadaveric pelvis (CP), as well as student satisfaction in relation to both methods. Sixty-seven students were given a theory class following the preliminary theoretical test (PTT). The study sample was randomized in three groups: G1 had a traditional practical class (TPC); G2 had a practical class with SPM (PCS); and G3 had no practical class. A final test (FTT) was applied to all the groups. G1 and G2 were subjected to method evaluation (ME). Statistical analysis was conducted using analysis of variance (ANOVA) and the Mann-Whitney U test. In the FTT, G3 presented scores lower than G1 (p = 0.041) and G2 (p = 0.000). No statistically significant difference was found between G1 and G2 (p >0.05). G2 presented greater satisfaction with the method (p = 0.001). In conclusion, both CP and SPM proved to be effective didactic tools and student satisfaction was greater with G2.

An approach on determining the displacements of the pelvic floor during voluntary contraction using numerical simulation and MRI.

The present study was conducted in order to establish a methodology based on the finite element method to simulate the contraction of the pelvic floor (PF) muscles. In the generated finite element model, a downward pressure of 90 cm H(2)O was applied, while actively contracting the PF muscles with different degrees of muscular activation (10, 50 and 100%). The finite element methodology of the active contraction behaviour proposed in this study is adequate to simulate PF muscle contraction with different degrees of muscular activation. In this case, in particular, for an activation of 100%, the numerical model was able to displace the pubovisceral muscle in a range of values very similar to the displacement found in the magnetic resonance imaging data. In the analysed case study, it would be possible to conclude that an intensity contraction of 50% would be necessary to produce enough stiffness to avoid possible urine loss.

[The anatomical-functional characteristics of the pelvic floor and quality of life of women with stress urinary incontinence subjected to perineal exercises]. / Las características anatomofuncionales del suelo pélvico y la calidad de vida de mujeres con incontinencia urinaria de esfuerzo sometidas a ejercicios perineales.

OBJECTIVE: To determine the effects of exercise in anatomic abnormalities of the pelvic floor (SP) and the quality of life (QOL) of women with stress urinary incontinence (SUI). METHOD: An experimental study with 50 women with SUI, distributed randomly into two groups, experimental (GE, 49.24±7.37 years) and control group (CG; 45.25±5.60 years). The groups performed ultrasound evaluation of the SP, evidence of pelvic floor muscle strength by palpation bidigital, surface EMG motor activity and replied to the CV before and after treatment. The GE had 16 sessions of pelvic floor exercises twice a week for 30min. RESULTS: Comparison between the GE and GC revealed significant differences in favor of GE, namely: mobility of the bladder neck (Δ=-0.79mm, p=0.00), thickness of pelvic floor muscle (Δ=-0.04mm, p=0.00), EMG (Δ=0.05.V, p=0.00), muscle strength by the AFA (Δ=0.05 level, p=0.00), DOMI1 (Δ%=5.67%, p=0.00), DOMI2 (Δ%=18.00%, p=0.00), DOMI3 (Δ%=18.22%, p=0.00), DOMI4 (Δ%=4.45%, p=0.00), DOMI5 (Δ%=0.22%, p=0.00), DOMI6 (Δ%=2.00%, p=0.00), DOMI7 (Δ%=3.78%, p=0, 00), DOMI8 (Δ%=6.33%, p=0.00), DOMI9 (Δ%=4.03%, p=0.00). CONCLUSION: It was modified and improved anatomic features of the pelvic floor of women from GE through perineal exercises, which will positively influence the CV of these women.