RESUMO
La patología de piso pélvico es una entidad multifactorial con un conjunto de síntomas ginecológicos, urinarios, fecales y de sensibilidad pelviperineal. La Teoría Integral de la Continencia propone un tratamiento holístico con la reconstrucción de los ligamentos del piso pélvico. La presente técnica propuesta constituye una alternativa quirúrgica que permite dar respuesta de forma global a los síntomas que refieren las pacientes. Método: Reconstrucción de los ligamentos pubouretrales, cardinales y úterosacros con acortamiento de su longitud y colocación de cinta de malla de polipropileno que permita la formación de colágeno y mejore los resultados a largo plazo. Resultados: Se incluyeron 15 pacientes con prolapso de órganos pélvicos, incontinencia urinaria, vulvodinia, nocturia, alteración del vaciamiento vesical y nocturia. Se realizó seguimiento al 1, 3 y 6 años. Se obtuvo diferencia estadísticamente significativa al año en la incontinencia urinaria de esfuerzo, dolor pélvico, alteración del vaciamiento y nocturia y prolapso ( p = 0,33, 0,033, 0,002 y 0,001 respectivamente). En el seguimiento a 6 años se evaluó el 20 % de la muestra inicial, 2 pacientes con recidiva de la alteración del vaciamiento y la incontinencia urinaria, ninguna con recidiva de prolapso. Vulvodinia: Se incluyeron 2 pacientes las cuales no tuvieron el síntoma a los 3 años de seguimiento. Conclusiones: La técnica propuesta es una alternativa para el tratamiento de la patología del piso pélvico y requiere aumentar el tamaño de la muestra para aumentar el aprendizaje de la técnica y tener mayor evidencia estadística de sus resultados a corto y largo plazo(AU)
Pelvic floor pathology is a multifactorial entity with a set of gynecological, urinary, fecal and pelviperineal sensitivity symptoms. The Integral Theory of Continence proposes a holistic treatment with the reconstruction of the ligaments of the pelvic floor. This proposed technique constitutes a surgical alternative that allows a global response to the symptoms reported by the patients. Method: Reconstruction of the pubourethral, cardinal and uterosacral ligaments with shortening of their length and placement of polypropylene mesh tape that allows collagen formation and improves long-term results. Results: 15 patients with pelvic organ prolapse, urinary incontinence, vulvodynia, nocturia, impaired bladder emptying and nocturia were included. Follow-up was performed at 1, 3 and 6 years. A statistically significant difference was obtained at one year in stress urinary incontinence, pelvic pain, impaired voiding, and nocturia and prolapse (p = 0.33, 0.033, 0.002, and 0.001, respectively). At 6-year follow-up, 20% of the initial sample was evaluated, 2 patients with recurrence of impaired voiding and urinary incontinence, none with recurrence of prolapse. Vulvodynia: 2 patients were included who did not have the symptom at 3 years of follow-up. Conclusions: The proposed technique is an alternative for the treatment of pelvic floor pathology. A larger sample is necessary to improve the learning curve of this technique and achieve greater statistical evidence of its outcomes at short and long term(AU)
Assuntos
Diafragma da Pelve/patologia , Procedimentos Cirúrgicos Operatórios , ColpotomiaRESUMO
ABSTRACT Purpose Pelvic floor dysfunction has a high prevalence in the adult population. The Dynamic and Multiplanar Evaluation of the Pelvic Floor (DMRIPF) represents an ideal tool for multidisciplinary management. The purpose of this analysis is to evaluate the added value of the Dynamic and Multiplanar Evaluation of the Pelvic Floor in patients with suspected pelvic floor disorders. Methods Retrospective analysis of a consecutive series of patients who underwent a DMRIPF due to suspected pelvic floor disorders between April 2005 and July 2019. Results 359 patients were included. The average number of diagnoses achieved by physical examination was 1.2 vs. 2.5 by the Dynamic and Multiplanar Evaluation of the Pelvic Floor (p < 0.001). Physical examination found a single pathology in 80.8 % of cases. Anterior rectocele (AR) was the most frequent isolated diagnosis on physical examination (68 %). On the Dynamic and Multiplanar Evaluation of the Pelvic Floor, anterior rectocele was diagnosed as an isolated condition in 10.9 %. In 231 cases, anterior rectocele was associated with up to 5 other pelvic floor disorders. The number of individuals with associated pathologies of the posterior and anterior compartments tripled. It modified physical examination findings in 17 % of individuals and, in 63.5 %, allowed the identification of additional pelvic floor pathologies that were missed by physical examination. The Dynamic and Multiplanar Evaluation of the Pelvic Floor had greater added value in patients with anterior rectocele (59.6 % vs. 20.9 %; p < 0.001). Female gender was also associated with a greater diagnostic yield (p < 0.001). Conclusion The Dynamic and Multiplanar Evaluation of the Pelvic Floor allows the detection of multi-compartment defects that could otherwise go undetected, or even alter the initial clinical diagnosis, representing an ideal tool for multidisciplinary approach of pelvic floor dislocations, allowing a comprehensive therapeutic planning.
RESUMO Objetivo A disfunção do assoalho pélvico tem alta prevalência na população adulta. A avaliação dinâmica e multiplanar do assoalho pélvico (DMRIPF) representa uma ferramenta ideal para o gerenciamento multidisciplinar. O objetivo desta análise é avaliar o valor agregado da avaliação dinâmica e multiplanar do assoalho pélvico em pacientes com suspeita de distúrbios do assoalho pélvico. Métodos Análise retrospectiva de uma série consecutiva de pacientes submetidos à avaliação dinâmica e multiplanar do assoalho pélvico por suspeita de distúrbios do assoalho pélvico entre Abril de 2005 e Julho de 2019. Resultados 359 pacientes foram incluídos. O número médio de diagnósticos alcançados pelo exame físico foi de 1,2vs. 2,5 pela avaliação dinâmica e multiplanar do assoalho pélvico p < 0,001. O exame físico encontrou uma única patologia em 80.8 % dos casos. A retocele anterior (RA) foi o diagnóstico isolado mais frequente no exame físico (68 %). Na avaliação dinâmica e multiplanar do assoalho pélvico, a retocele anterior foi diagnosticada como uma condição isolada em 10.9 %. Em 231 casos, a retocele anterior foi associada a até 5 outros distúrbios do assoalho pélvico. O número de indivíduos com patologias associadas dos compartimentos posterior e anterior triplicou. Modificou os achados do exame físico em 17 % dos indivíduos e em 63.5 %; permitiu a identificação de outras patologias do assoalho pélvico que foram esquecidas pelo exame físico. A avaliação dinâmica e multiplanar do assoalho pélvico teve maior valor agregado em pacientes com retocele anterior (59.6 % vs.20.9 %; p < 0,001. O sexo feminino também foi associado a um maior rendimento diagnóstico p < 0,001. Conclusão A avaliação dinâmica e multiplanar do assoalho pélvico permite a detecção de defeitos multicompartimentários que, de outra forma, poderiam não ser detectados, ou mesmo alterar o diagnóstico clínico inicial, representando uma ferramenta ideal para a abordagem multidisciplinar das luxações do assoalho pélvico, permitindo um planejamento terapêutico abrangente.
Assuntos
Humanos , Masculino , Feminino , Imageamento por Ressonância Magnética/métodos , Distúrbios do Assoalho Pélvico/diagnóstico , Exame Físico/métodos , Diafragma da Pelve/patologia , Retocele/diagnósticoRESUMO
OBJECTIVE: To provide an overview of the hormone actions and receptors expressed in the female pelvic floor muscles, relevant for understanding the pelvic floor disorders. METHODS: We performed a literature review focused on the expression of hormone receptors mainly in the pelvic floor muscles of women and female rats and rabbits. RESULTS: The impairment of the pelvic floor muscles can lead to the onset of pelvic floor dysfunctions, including stress urinary incontinence in women. Hormone milieu is associated with the structure and function alterations of pelvic floor muscles, a notion supported by the fact that these muscles express different hormone receptors. Nuclear receptors, such as steroid receptors, are up till now the most investigated. The present review accounts for the limited studies conducted to elucidate the expression of hormone receptors in pelvic floor muscles in females. CONCLUSION: Hormone receptor expression is the cornerstone in some hormone-based therapies, which require further detailed studies on the distribution of receptors in particular pelvic floor muscles, as well as their association with muscle effectors, involved in the alterations relevant for understanding pelvic floor disorders.
Assuntos
Hormônios Esteroides Gonadais/biossíntese , Células Neuroendócrinas/metabolismo , Diafragma da Pelve/fisiologia , Receptores de Peptídeos/biossíntese , Animais , Feminino , Expressão Gênica , Hormônios Esteroides Gonadais/genética , Humanos , Células Neuroendócrinas/patologia , Diafragma da Pelve/patologia , Receptores de Peptídeos/genética , Incontinência Urinária por Estresse/genética , Incontinência Urinária por Estresse/metabolismo , Incontinência Urinária por Estresse/patologiaRESUMO
We report the case of a 29-year-old woman with deep infiltrating endometriosis who underwent robotic nerve-sparing surgery for resection of all visible lesions infiltrating pelvic and extrapelvic sites. Painful symptoms included severe dysmenorrhea, menstrual dyschezia and stranguria, with no improvement in response to hormonal treatment. The location on physical examination of a painful retrocervical nodule was identified by magnetic resonance imaging to be infiltrating the right parametrium/paracervix. During surgery, this nodule was recognized as an important retrocervical/rectovaginal lesion infiltrating the pelvic floor (i.e. levator ani and coccygeus), and was histopathologically confirmed as endometriosis infiltrating the skeletal pelvic floor muscles. A Pubmed search of the MEDLINE database in March (2019) found no publication reporting histopathologic confirmation of endometriosis infiltrating the pelvic floor muscles.
Assuntos
Endometriose/patologia , Diafragma da Pelve/patologia , Adulto , Endometriose/diagnóstico por imagem , Endometriose/cirurgia , Feminino , Procedimentos Cirúrgicos em Ginecologia , Humanos , Imageamento por Ressonância Magnética , Diafragma da Pelve/diagnóstico por imagem , Diafragma da Pelve/cirurgiaRESUMO
INTRODUCTION AND HYPOTHESIS: Temporary effects to pelvic floor muscles are linked to impairments in micturition, particularly stress urinary incontinence (SUI), during pregnancy. We hypothesize that bulbospongiosus (Bsm) and pubococcygeus (Pcm) are differently damaged in primigravid and primiparous rabbits. METHODS: Twenty-four rabbits allocated evenly (n = 6) into nulliparous, pregnant, and primiparous groups on postpartum days 3 (P3) and 20 (P20) were used to evaluate the myofiber cross-sectional area (CSA), ß-glucuronidase activity, and anti-3-nitrotyrosine (anti-3-NTyr) immunoreactivity in Bsm and Pcm muscles. Appropriate statistical tests were done to determine significant differences among groups (P ≤ 0.05). RESULTS: The average CSA of Bsm was not significantly different, albeit a high percentage of myofibers was enlarged in late-pregnant and primiparous rabbits on P3; ß-glucuronidase activity and indirect parameter of muscle damage was also higher. These variables did not change in the Pcm muscle during the different reproductive stages. In contrast, the 3-NTyr immunoreactivity, an indicator of oxidative damage, was increased on P3 for Pcm myofibers and P20 for myofibers of both muscles. CONCLUSIONS: Our findings demonstrate reliable signs of damage to Bsm and Pcm muscles in young female rabbits passing different reproductive stages. Damage to the Bsm muscles as detected at the end of pregnancy persisted after delivery. This was not the case for Pcm muscles, in which damage seems to appear after delivery.
Assuntos
Glucuronidase/metabolismo , Fibras Musculares Esqueléticas/metabolismo , Fibras Musculares Esqueléticas/patologia , Diafragma da Pelve/patologia , Tirosina/análogos & derivados , Animais , Biomarcadores/metabolismo , Feminino , Paridade , Diafragma da Pelve/fisiopatologia , Período Pós-Parto , Gravidez , Coelhos , Tirosina/metabolismoRESUMO
OBJECTIVE: To identify and assess postpartum pelvic floor dysfunction (PFD) between vaginal delivery, elective cesarean delivery (ECD), and intrapartum cesarean delivery (ICD). METHODS: The present prospective observational study included women aged at least 18 years with no history of pelvic surgery or lower urinary tract malformation, and who had not undergone pelvic floor muscle (PFM) training in the preceding 12 months, who underwent delivery at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil between August 1, 2016, and May 31, 2017. Participants were assessed at 48 hours (phase 1), 1 month (phase 2), and 3 months (phase 3) after delivery. Assessments included the International Consultation on Incontinence Questionnaire, Short Form (ICIQ-SF); the Jorge-Wexner anal incontinence scale; a self-rated visual analog scale for pelvic pain; the pelvic organ prolapse quantification (POP-Q) system; and a PFM perineometer. RESULTS: A total of 227 women were assessed in phase 1 (141 vaginal deliveries; 28 ICDs; and 58 ECDs), 79 in phase 2, and 41 in phase 3. The ICIQ-SF, Jorge-Wexner scale, visual analog scale, and perineometer measurements did not identify significant differences in relation to the type of delivery (P>0.05). CONCLUSION: The type of delivery was not associated with differences in the short-term development of postpartum PFD.
Assuntos
Cesárea , Distúrbios do Assoalho Pélvico/epidemiologia , Diafragma da Pelve/patologia , Prolapso de Órgão Pélvico/epidemiologia , Adulto , Brasil/epidemiologia , Parto Obstétrico/métodos , Incontinência Fecal/epidemiologia , Feminino , Humanos , Estudos Longitudinais , Dor Pélvica/epidemiologia , Período Pós-Parto , Gravidez , Estudos Prospectivos , Inquéritos e Questionários , Escala Visual Analógica , Adulto JovemRESUMO
El desarrollo de la cirugía vaginal y de las diferentes técnicas terapéuticas de las patologías del piso pélvico femenino en la realidad de la ginecotocología de Uruguay ha presentado un importante desarrollo en los últimos 20 años. El objetivo es presentar la forma de abordaje diagnóstico y los fundamentos y arsenal quirúrgico de la Unidad de Patología de Piso Pélvico de la Clínica Ginecotocológica A, en base a la teoría integral. Se realiza una descripción evolutiva de las diferentes técnicas quirúrgicas implementadas y desarrolladas en nuestro medio, así como la fundamentación anátomo-funcional de las mismas. Como conclusión del análisis evolutivo es fundamental conceptualizar que las alteraciones funcionales y anatómicas de los órganos pélvicos femeninos forman parte de una unidad y no de la suma de compartimentos estancos, celdas o sectores. En este sentido, desarrollar estrategias terapéuticas quirúrgicas cada vez menos invasivas, con correcciones sitio específico, aparece como la perspectiva estratégica por sobre las correcciones estereotipadas.(AU)
Vaginal surgery and the different therapeutic techniques to treat pelvic floor disorders in the context of Gynecotocology in Uruguay have dramatically developed in the last 20 years. The study aims to present the different diagnostic approaches, the principles and the surgical possibilities at the Pelvic Floor Pathology Department of Gynecotocology Clinic "A", based on the comprehensive theory. It comprises a description of the evolution of the different surgical techniques implemented and developed in our country, as well as the anatomic and functional grounds that support them. In order to come up with a conclusion on the analysis of this evolution it is of the essence to conceptualize that the functional and anatomic alterations of the female pelvic organs are all part of a whole, rather than the addition of different domains, cells or sectors. In that sense, developing surgical strategies that are gradually less invasive and include specific-site correction seems to be the best the strategic perspective over stereotype corrections.(AU)
O desenvolvimento da cirurgia vaginal e das diferentes técnicas terapêuticas das patologias do assoalho pélvico feminino mostrou um avanço importante nos últimos 20 anos na tocoginecologia do Uruguai. O objetivo é apresentar a forma de abordagem diagnóstica e os fundamentos e o arsenal cirúrgico da Unidad de Patología de Piso Pélvico da Clínica Ginecotocológica A, baseado na teoria integral. Faz-se uma descrição evolutiva das diferentes técnicas cirúrgicas desenvolvidas e implementadas no nosso meio, assim como a fundamentação anatomofuncional das mesmas. Como conclusão da análise evolutiva é fundamental incorporar o conceito de que as alterações funcionais e anatómicas dos órgãos pélvicos femininos formam parte de uma unidade e não da soma de compartimentos estanques. Nesse sentido, o desenvolvimento de estratégias terapêuticas cirúrgicas cada vez menos invasivas, com correções específicas para um ponto específico, aparece como a perspectiva estratégica sobre as correções estereotipadas.(AU)
Assuntos
Procedimentos Cirúrgicos Operatórios , Vagina/cirurgia , Diafragma da Pelve/patologiaRESUMO
INTRODUCTION AND HYPOTHESIS: The aim of this study was to evaluate the correlations between the POP-Q Bp point and the perineal body (Pb) and genital hiatus (Gh) measurements and constipation, anal incontinence, severity of symptoms and quality of life. METHODS: The patients were distributed into two groups according to the posterior vaginal wall Bp point: one group with Bp ≤-1 (without posterior vaginal wall prolapse, control group) and the other group with Bp ≥0 (with posterior vaginal wall prolapse, case group). Demographic data, defecatory dysfunction and SF-36 scores were compared between the groups. Correlations between severity of posterior prolapse (Bp, Gh, Pb and Gh + Pb) and severity of bowel symptoms were also calculated. RESULTS: A total of 613 women were evaluated, of whom 174 were included, 69 (39.7%) in the control group and 105 (60.3%) in the case group. The groups were similar in terms of anal incontinence, fecal urgency and/or constipation. There was no correlation between the severity of constipation and anal incontinence according to the Wexner score, and the severity of posterior vaginal wall prolapse measured in terms of point Bp. There were, however, statistically significant differences in Pb, Gh and Gh + Pb between the groups. The Pb and Gh + Pb measurements were positively correlated with symptoms of constipation, as well as with the scores of some SF-36 domains, but were not correlated with anal incontinence. CONCLUSIONS: These results suggest that the severity of posterior vaginal wall prolapse is not correlated with constipation or anal incontinence, but Pb and Gh + Pb measurements are correlated with constipation and SF-36 scores.
Assuntos
Constipação Intestinal/fisiopatologia , Incontinência Fecal/fisiopatologia , Distúrbios do Assoalho Pélvico/fisiopatologia , Índice de Gravidade de Doença , Adulto , Constipação Intestinal/etiologia , Constipação Intestinal/patologia , Incontinência Fecal/etiologia , Incontinência Fecal/patologia , Feminino , Humanos , Pessoa de Meia-Idade , Diafragma da Pelve/patologia , Diafragma da Pelve/fisiopatologia , Distúrbios do Assoalho Pélvico/complicações , Distúrbios do Assoalho Pélvico/patologia , Períneo/patologia , Qualidade de Vida , Prolapso Uterino/complicações , Prolapso Uterino/patologia , Prolapso Uterino/fisiopatologia , Vagina/patologia , Vagina/fisiopatologiaRESUMO
Recurrence of perineal hernias is frequent, and is associated to poor identification of anatomical structures during surgery, inadequate suture placement, and failure of physical support of the pelvic diaphragm after surgical reconstruction. The objective of this work is to describe a novel surgical technique for reinforcement of the pelvic diaphragm after performing the internal obturator transposition technique in dogs with perineal hernia.(AU)
As recidivas das hérnias perineais são frequentes e associadas à falha no isolamento das estruturas anatômicas, inadequada colocação de suturas e falência na sustentação do diafragma pélvico reconstruído cirurgicamente. Objetiva-se descrever uma nova técnica cirúrgica para reforço do diafragma pélvico após a realização da técnica de elevação do músculo obturador interno em cães com hérnia perineal.(AU)