Prolapso uterino neonatal: relato de dois casos clínicos em hospital universitário e uma breve revisão da literatura / Neonatal uterine prolapse: two cases reports in an university hospital and a brief review of the literature

O prolapso genital neonatal é uma condição clínica rara e na maioria das vezes associada a anomalias neurológicas. Nos últimos 50 anos, foram relatados menos de 10 casos na literatura de prolapso genital em recém-nascido sem espinha bífida ou meningomielocele (nenhum deles no Brasil), tornando tal entidade ainda mais rara em neonatos neurologicamente normais. Neste artigo relatamos dois casos clínicos de prolapso genital em neonatos prematuros neurologicamente normais. Em ambos os casos foi optado por manejo conservador com redução digital do prolapso. Foi realizada também uma breve revisão da literatura para melhor discussão sobre o tema (etiologia, diagnóstico e manejo).(AU)

Neonatal genital prolapse is a rare clinical condition and most often associated with neurological abnormalities. In the last 50 years, less than 10 cases of genital prolapse have been reported in literature in neonates without spina bifida or meningomyelocele (none of them in Brazil), making this entity even rarer in neurologically normal neonates. In this article we report two clinical cases of genital prolapse in neurologically normal preterm neonates. In both cases, conservative management with digital reduction was chosen. A brief review of the literature was also carried out to better discuss the topic (etiology, diagnosis and management).(AU)

Impact of Sacrospinous Colpopexy Associated with Anterior Colporrhaphy for the Treatment of Dome Prolapse on all Three Vaginal Compartments / Resultados da colpofixação sacroespinal associada a colporrafia anterior para o tratamento do prolapso de cúpula vaginal

Objective To evaluate the results of sacrospinous colpopexy surgery associated with anterior colporrhaphy for the treatment of women with post-hysterectomy vaginal vault prolapse. Methods This prospective study included 20women with vault prolapse, PelvicOrgan Prolapse Quantification System (POP-Q) stage≥2, treated between January 2003 and February 2006, and evaluated in a follow-up review (more than one year later). Genital prolapse was evaluated qualitatively in stages and quantitatively in centimeters. Prolapse stage < 2 was considered to be the cure criterion. Statistical analysis was performed using the Wilcoxon test (paired samples) to compare the points and stages of prolapse before and after surgery. Results Evaluation of the vaginal vault after one year revealed that 95% of subjects were in stage zero and that 5% were in stage 1. For cystocele, 50% were in stage 1, 10% were in stage 0 (cured) and 40% were in stage 2. For rectocele, three women were in stage 1 (15%), one was in stage 2 (5%) and 16 had no further prolapse. The most frequent complication was pain in the right buttock, with remission of symptoms in all three cases three months after surgery. Conclusions In this retrospective study, the surgical correction of vault prolapse using a sacrospinous ligament fixation technique associatedwith anterior colporrhaphy proved effective in resolving genital prolapse. Despite the low complication rates, there was a high rate of cystocele, which may be caused by posterior vaginal shifting due to either the technique or an overvaluation by the POP-Q system.

Objetivo Avaliar os resultados da cirurgia de colpofixação sacroespinal associada a colporrafia anterior, para o tratamento de mulheres com prolapso de cúpula vaginal pós-histerectomia. Métodos Estudo prospectivo que incluiu 20 mulheres com prolapso de cúpula em estágio≥2 de acordo com o Sistema de Quantificação do Prolapso Genital (POP-Q) tratadas no período de janeiro de 2003 a fevereiro de 2006 e avaliadas emrevisão tardia (maior que um ano). O prolapso genital foi avaliado qualitativamente em estágios e, quantitativamente, emcentímetros. Como critério de cura, consideramos prolapso em estágio < 2. Para análise estatística, foi utilizado teste de Wilcoxon (amostras pareadas) para comparar os pontos e estágios dos prolapsos antes e depois da cirurgia. Resultados Na cúpula vaginal a avaliação após um ano mostrou 95% em estágio zero e 5% em estágio 1. Cistocele: 50% em estágio 1, 10% em estágio zero (curadas) e 40% emestágio 2. Retocele: trêsmulheres apresentavamestágio 1 (15%), uma emestágio 2 (5%) e dezesseis não apresentavam prolapso posterior. As complicações mais frequentes foramdor no glúteo direito com remissão do sintoma emtodos os três casos após três meses da cirurgia. Conclusões Neste estudo retrospectivo, a cirurgia de correção do prolapso de cúpula pela técnica de fixação no ligamento sacroespinal, associada à colporrafia anterior, se mostrou efetiva na resolução do prolapso genital com baixa taxa de complicações; porém com alta taxa de cistocele - o que pode ter sido decorrente do desvio vaginal posterior pela técnica, ou ainda uma supervalorização pelo sistema POP-Q.

Dehiscencia y evisceración vaginal recidivante: a propósito de un caso / Recurrent vaginal dehiscence and evisceration: a case report

La dehiscencia de la cúpula vaginal, con o sin evisceración, es una complicación rara de la cirugía ginecológica. El principal factor de riesgo es el antecedente de una histerectomía, a lo que se añaden otros factores desencadenantes, entre los que destaca la atrofia vaginal. El diagnóstico de evisceración es fácil, al comprobar salida de material intestinal a través de la vagina, siendo más dificultoso el diagnóstico de dehiscencia, ya que puede acontecer con síntomas banales. El tratamiento supone una urgencia quirúrgica al existir riesgo de lesión intestinal y peritonitis, pudiéndose realizar diferentes vías de abordaje teniendo en cuenta sobre todo la clínica de la paciente y tras comprobar el estado del contenido eviscerado. Presentamos el caso de una paciente con varios factores de riesgo, que presentó dehiscencia de la cúpula vaginal con evisceración de intestino de manera reiterada, y a la que se le practicó tratamiento quirúrgico por diferentes vías de abordaje así como tratamiento médico.

Dehiscence of the vaginal vault with or without evisceration is a rare complication after gynaecological surgery. The main risk factor is a previous hysterectomy, with the addition of other trigger conditions, the most important is vaginal atrophy. The diagnosis of evisceration is easy by confirmation the loosing of intestinal contents through the vagina. Diagnosis of dehiscence is more difficult because its symptoms could be more generic. The treatment is an emergency surgery as there is a risk of intestinal injury and peritonitis. There could be different surgical approaches taking into consideration the patient's clinic symptoms and after checking the state of eviscerated tissues. We expose the case of a patient with several risk factors, who presented dehiscence of the vaginal vault with recurrent bowel evisceration, and who we performed surgical treatment by different approaches and medical treatment.

Bladder exstrophy: reconstructed female patients achieving normal pregnancy and delivering normal babies

PURPOSE: Bladder exstrophy (BE) is an anterior midline defect that causes a series of genitourinary and muscular malformations, which demands surgical intervention for correction. Women with BE are fertile and able to have children without this disease. The purpose of this study is to assess the sexual function and quality of life of women treated for BE. MATERIALS AND METHODS: All patients in our institution treated for BE from 1987 to 2007 were recruited to answer a questionnaire about their quality of life and pregnancies. RESULTS: Fourteen women were submitted to surgical treatment for BE and had 22 pregnancies during the studied period. From those, 17 pregnancies (77.2 percent) resulted in healthy babies, while four patients (18.1 percent) had a spontaneous abortion due to genital prolapse, and there was one case (4.7 percent) of death due to a pneumopathy one week after delivery. There was also one case (5.8 percent) of premature birth without greater repercussions. During pregnancy, three patients (21.4 percent) had urinary tract infections and one patient (7.14 percent) presented urinary retention. After delivery, three patients (21.4 percent) presented temporary urinary incontinence; one patient (7.14 percent) had a vesicocutaneous fistula and seven patients (50 percent) had genital prolapsed. All patients confirmed to have achieved urinary continence, a regular sexual life and normal pregnancies. All patients got married and pregnant older than the general population. CONCLUSIONS: BE is a severe condition that demands medical and family assistance. Nevertheless, it is possible for the bearers of this condition to have a satisfactory and productive lifestyle.

Prolapso genital: etiopatogenia, diagnóstico y tratamiento / Genital prolapse: etiopathogenesis, diagnosis and treatment

Vaginal prolapse is a very common disorder in the general female population. Because it is so common and often asymptomatically, there is no exact definition of this condition. Additionally its exact prevalence is not known. There are multiple risk factors that cause vaginal prolapse, for example age and vaginal deliveries are the most common, and nevertheless it is considered a multifactorial process. From the surgical point of view the most accepted theory for its production is site-specific tears that would generate the prolapse as they occur. Its diagnosis is clinical and is currently classified into four stages according to the degree of descent that exists with respect to the hymen. There are many different types of treatment, and the most used are pessaries, physiotherapy and surgery. The following is a review that covers various relevant aspects of the vaginal prolapse, his confrontation and treatment.

Prolapso genital: alteraciones del colágeno como factor etiológico / Genital prolapse: alterations of collagen as an etiological factor

The etiological search of pelvic organ prolapse has led to the study of connective tissue that surrounds it directly, called endopelvic fascia. So there have been several studies looking for changes in the main types of collagen existing in this area, trying to describe the changes that they would experience in order to facilitate the prolapse. It has been postulated mainly a decrease in collagen content, thereby reducing the tensile strength of the suspension elements of the pelvic organs and thus descent occurring. However, the literature has been discordant, and published numerous studies that show an increase of collagen in this area, which could be due to a state of pelvic floor repair in patients with various recognized risk factors. Most publications have different biases that preclude a completely valid conclusion. Because of this, still is not clear what changes would experience at the histological level the endopelvic fascia and there is no consensus among different centers. Here is a review of existing literature on this subject with emphasis on different molecular and histological findings of each study and their biases.

Disfunción del piso pélvico: epidemiología / Pelvic floor dysfunction: epidemiology

Evaluar la prevalencia de la disfunción del piso pélvico, factores relacionados, tratamientos y evolución en pacientes gineco-obstétricas de un hospital privado. Estudio descriptivo, retrospectivo, epidemiológico. Se revisaron 4555 historias desde 1998 a 2008 y se seleccionaron 430 con alteraciones del piso pélvico. Se evaluaron los factores asociados: edad, embarazos, partos, distocias, episiotomías, peso máximo fetal, masa corporal, incontinencia urinaria de esfuerzo, infecciones urinarias bajas recurrentes, alteraciones tiroideas, diabetes, fibromatosis uterina, menopausia, intervenciones ginecológicas previas, estreñimiento, trabajos forzados, tos crónica y uso de fajas. Se clasificaron los tipos y grados de prolapsos, tratamientos y complicaciones. Instituto Médico Quirúrgico Ribas. Los Teques, Estado Miranda, Venezuela. Promedio de edad 47,72 ± 11,88 años. Incidencia de disfunción 9,4 por ciento; en 72 por ciento fue un hallazgo del médico, 73,2 por ciento referían incontinencia urinaria de esfuerzo, 18 por ciento infecciones urinarias bajas recurrentes, paridad promedio 3,86 ± 2,59; 21,4 por ciento distocias y 48,8 por ciento episiotomías. Diagnóstico de prolapso 97,4 por ciento, grado II más frecuente 73,3 por ciento. Entre los factores relacionados se encontró: masa corporal elevada, fibromatosis uterina, estreñimiento e intervenciones anteriores. Se indicó tratamiento conservador en 67,3 por ciento, cirugía vaginal 8 por ciento y abdominal 11 por ciento. La incidencia de disfunciones es baja, el cistocele grado II es el más frecuente y está relacionados con incontinencia urinaria de esfuerzo, infecciones urinarias bajas recurrentes, grupo etario entre 40 y 50 años, multiparidad, mayor índice de masa corporal, estreñimiento, fibromatosis uterinas e intervenciones pélvicas previas. El tratamiento más aceptado es la rehabilitación muscular

To evaluate the prevalence of pelvic floor dysfunction, related factors, treatment and evolution in gyneco-obstetric patients in a private hospital. A descriptive, retrospective, epidemiologic study. 4555 records were reviewed from 1998 to 2008 and 430 with pelvic floor disorders were selected. Associated factors such as age, pregnancy, dystocia, episiotomy, fetal weight, body mass, stress urinary incontinence, recurrent lower urinary tract infections, thyroid disorders, diabetes, uterine fibromatosis, menopause, previous gynecologic interventions, constipation, hard work, chronic cough and use of belts were evaluated. Types and degrees of prolapse, treatments and complications were classified. Instituto Médico Quirúrgico Ribas. Los Teques, Estado Miranda, Venezuela. Average age 47.72 ± 11.88 years. 9.4 percent dysfunction incidence; in 72 percent was medical finding, 73.2 percent referred stress urinary incontinence, 18 percent urinary tract infections, average parity 3.86 ± 2.59, 21.4 percent dystocia and 48.8 percent episiotomy. Prolapse diagnosis 97.4 percent, grade II 73.3 percent more frequent. Among the factors were: high body mass, uterine fibromatosis, constipation, and previous interventions. Non surgical treatment was indicated in 67.3 percent, 8 percent vaginal surgery and abdominal 11 percent. The incidence of dysfunction is low, the grade II cystocele is the more common and is associated with stress urinary incontinence, urinary tract infections, age group between 40 and 50 years, multiparity, higher body mass index, constipation, uterine fibromatosis and previous pelvic interventions. The most accepted treatment is the muscular rehabilitation

Fatores de risco para o prolapso genital em uma população brasileira / Risk factors for genital prolapse in a Brazilian population

OBJETIVO: avaliar os fatores de risco para o desenvolvimento de prolapso genital na população brasileira. MÉTODOS: estudo caso-controle envolvendo 316 pacientes que foram submetidas a estadiamento de prolapso, utilizando-se o sistema de quantificação de prolapso dos órgãos pélvicos. As pacientes foram divididas em dois grupos. No Grupo Caso, foram incluídas 107 pacientes com prolapso nos estádios III ou IV, e no Controle, 209 mulheres com estádios 0 ou I. As mulheres selecionadas respondiam à anamnese na qual eram questionadas sobre a presença de possíveis fatores de risco para prolapso genital, tais como: idade, idade da menopausa, paridade, tipos de parto (vaginal, cesariana ou fórcipe), ocorrência de macrossomia fetal, história familiar em parentes de primeiro grau de distopia genital, tosse crônica e constipação intestinal. RESULTADOS: as variáveis que se mostraram diferentes entre os grupos foram: idade, índice de massa corpórea, paridade, número de partos vaginais, de cesarianas, de partos fórcipe, peso do recém-nascido e história familiar positiva para prolapso. Raça, idade da menopausa, tosse crônica e constipação intestinal não se mostraram diferentes entre os grupos. Após a regressão logística, somente três variáveis se apresentaram como fatores de risco independentes: presença de pelo menos um parto vaginal, macrossomia fetal e história familiar positiva. A cesariana se mostrou como fator protetor. CONCLUSÕES: na população brasileira, os fatores de risco independentes para prolapso foram a presença de pelo menos um parto normal, macrossomia fetal e história familiar positiva para distopia.

PURPOSE: to evaluate risk factors for the development of genital prolapse in the Brazilian population. METHODS: case-control study involving 316 patients submitted to prolapse staging, according to the pelvic organ prolapse quantification system. The patients were divided into two groups: in the Case Group there were 107 patients with prolapse at stage III or IV, and in the Control Group, 209 women at stage 0 or I. In the anamnesis, the selected women have been questioned about the presence of possible risk factors for genital prolapse, such as: age, menopause age, parturition, delivery type (vaginal, caesarean section or forceps), occurrence of fetal macrosomia, family history of genital dystopia in first degree relatives, chronic cough and intestinal constipation. RESULTS: The variables that were different between the groups were: age, body mass index, parturition, number of vaginal, caesarean section or forceps deliveries, newborn weight and positive family history for prolapse. Race, menopause age, chronic cough and intestinal constipation did not present differences between the groups. After logistic regression, only three variables have been shown to be independent risk factors: presence of at least one vaginal delivery, fetal macrosomia and positive family history for dystopia. Cesarean section was shown to be a protective factor. CONCLUSION: in the Brazilian population, the independent risk factor for genital prolapse were: personal antecedent of at least one vaginal delivery, fetal macrosomia and family history of dystopia.

Prolapsed uterus with huge rectocele and omentocele following cervical amputation: a rare and unusual case presentation.

Pelvic organ prolapse is a common condition whose incidence is increasing. Many cases of prolapse of the posterior vaginal wall occur along with other pelvic support defects. Pelvic surgeons who treat rectocele must have an excellent understanding of the normal anatomy, interactions of the connective tissue and muscular supports of the pelvis, and the relationship between anatomy and function. Pelvic pressure, the need to splint the perineum to defecate, impaired sexual relations, difficult defecation, and faecal incontinence are some of the symptoms that have been described in patients with rectocele.

Prolapso genital severo: consideraciones clínicas, fisiopatológicas y de técnica quirurgica al momento de su corrección

El tratamiento quirúrgico actual del prolapso genital severo es el resultado de un mejor conocimiento y comprensión del piso pelviano. Se revisan los fundamentos anatómicos y fisiopatológicos implicados en el desarrollo del prolapso genital severo y de la cirugía reconstructiva del piso pélvico.

Surgery for post-hysterectomy vaginal prolapse

Nine cases treated by surgery for post-hysterctomy vaginal prolapse are reviewed. The mean time between presentation and the antecedent hysterectomy was 12.8 years. Two patients who had abdominal sacral colpopexy alone developed recurrence of prolapse. Additional culdoplasty and colposuspension improved the cure rate but prolonged the mean operating time. Restoration of vaginal anatomy and function is best achieved with the combination operation.

Tratamento do prolapso de cúpula vaginal pós-histerectomia pela técnica transvaginal de fixaçäo no ligamento sacroespinhal / Treatment of the vaginal vault prolapse after hysterectomy by the sacrospinal ligament fixation transvaginal technique

Os autores utilizaram a técnica transvaginal de fixaçäo no ligamento sacroespinhal para correçäo do prolapso de cúpula vaginal pós-histerectomia. Foram selecionadas sete pacientes do Ambulatório de Ginecologia do Hospital das Clínicas da UFMG.

Histerectomia vaginal: análise de 73 casos / Vaginal histerectomy: analysis of 73 cases

Foram analisadas 73 histerectomias vaginais realizadas no Serviço de Ginecologia do Hospital Universitário de Santa Maria, no período de junho de 1975 a fevereiro de 1988, onde o prolapso uterino, nos seus mais variados graus, foi a principal indicaçäo cirúgica (98,6 por cento dos casos). A idade média das pacientes foi de 62,7 anos e a maior causa de prolapso foi a paridade múltipla, estando relacionado somente um caso em nulíparas. Ocorreram 58,9 por cento de complicaçöes no pós-operatório, sendo que dentre as imediatas destacou-se a retençao urinária. O granuloma de cúpula e o fluxo persistente foram as complicaçoes tardias mais encontradas. Houve um caso de óbito, ocorrido no transoperatório.

Incontinencia urinaria de esforco: conceito, diagnostico e tratamento / Urinary incontinence stress: concept, diagnosis and treatment

Os autores revisaram os aspectos etiologicos, fisiologicos, diagnostico e tratamento da incontinencia urinaria de esforco discutindo os recursos diagnosticos e inovacoes do tratamento.

Prolapso de cúpala / Uterine prolapse

1. Las pacientes del estudio en su mayoría fueron mayores de 50 años, con posible relajación pélvica secundaria a su edad, que predispondría a un mayor riesgo de prolapso postoperatorio. 2. El número de hijos fue grande en el grupo de pacientes, factor también predisponente al prolapso de cúpula por relajamiento del piso pélvico. 3. El prolapso de cúpula se produce casi con la misma frecuencia, en pacientes con cirugía previa abdominal o vaginal, especialmente el diagnóstico preoperatorio de la cirugía abdominal sea por alteración de la estática pélvica. 4. El tiempo operatorio no parece influir en la frecuencia del prolapso de cúpula. . El tiempo de aparición del prolapso de cúpula, fue más precoz posterior a histerctomía vaginal que abdominal. 6. La vía de elección para la reparación del prolapso de cúpula, parece ser la vía vaginal, por baja frecuencia de recidibvas. 7. Las técncias abdominales de reparación del prolapso de cúpula, mostraron alta frecuencia de recidivas. 8. Hay frecuencia importante de enterocele en los prolapsos de cúpula, lo que podría estar representando enteroceles no vistos durante la primera intervención quirúrgica y cuya detección temprana, podría disminuir el número de prolapsos postoperatorios. 9. Hay poco interés en el estudio de esta patología dadas las pocas referencias encontradas. 10 Debe crearse protocolos de estudio prospectivos para evaluar, adecuadamente, cada técnica quirúrgica a realizar

Estudio prospectivo sobre la relación existente entre prolapso genital e infecciones urinaria / A prospective study relation about existent between genitalprolapsus and urinary infection

Se realiza un estudio prospectivo en 52 pacientes con prolapso genital de grado variable para observar la incidencia de infección urinaria.Se analizan antecedentes importante que están en relación con el prolapso genitalasí como la presencia o no de incontinencia urinaria de esfuerzo;igualmente se hacen estudios comparativos en cuanto la forma de toma de la muestra de orina (chorro y cateterismo). Hacemos incapié sobre la relación existente entre la edad, pariedad, grado de prolapso, presencia o no de incontinencia urinaria de esfuerzoe infección urinaria; esta ultima determinada por urocultivo