Role of multidisciplinary cooperation in the diagnosis and treatment of pelvic floor disorder disease / 中华胃肠外科杂志

The pelvic floor disorder disease (PFDD) typically originates from supportive tissue defects or injuries in the pelvic floor with a wide spectrum of symptoms such as urinary incontinence, pelvic organ prolapse, sexual dysfunction, fecal incontinence and chronic pelvic pain. But its etiology is complex, involving multiple systems and organs. So the best management of PFDD requires the implementation of multidisciplinary team (MDT). Pelvic floor centers have been developed abroad to provide pelvic floor services. In the setting of PFDD, the concept of MDT starts lately and develops slowly in China. The MDT approach was demonstrated to improve general rehabilitation, psychological state and quality of life. However, there is no unified standardization for MDT diagnosis and treatment of PFDD at home and abroad. Meanwhile, the personnel composition, responsibilities, training, and operation mode of the MDT need to be further developed. Perfecting the management mode of MDT team members, establishing standardized training programs and assessment criteria play crucial role in the future development of MDT in PFDD.

Uso de pesario para prolapso de órganos pélvicos durante el embarazo: serie de casos y revisión de la literatura / Pessary use in pelvic organ prolapse during pregnancy: case series and literature review

INTRODUCCIÓN: El prolapso de órganos pélvicos es infrecuente durante el embarazo y se asocia principalmente a mujeres multíparas. Dado que la población gestante no es la ideal para manejo quirúrgico, los pesarios son útiles para controlar los síntomas con pocos efectos adversos y contraindicaciones. Por su baja incidencia, la información reportada en la literatura se deriva de reportes de caso y las recomendaciones se extrapolan de pacientes no embarazadas. METODOLOGÍA: Revisión de la literatura y exposición de casos. Resultados: Se exponen cuatro casos de gestantes con prolapso de órganos pélvicos manejadas exitosamente con pesarios hasta el final de la gestación sin presentar complicaciones serias. CONCLUSIONES: Los pesarios son un método seguro y eficaz para el manejo de síntomas de prolapsos de órganos pélvicos durante el embarazo.

INTRODUCTION: Pelvic organ prolapse is rare during pregnancy and is associated to women with multiple vaginal child births. Pregnant women are not ideal candidates for surgical management of prolapse, making pessaries useful for symptom control with few adverse effects. Due to its low incidence, information reported in literature is derived from case reports and recommendations are extrapolated from non-pregnant patients. METHODOLOGY: Literature review and presentation of cases. RESULTS: Four cases of pregnant women with pelvic organ prolapse successfully managed with pessaries until the end of pregnancy without presenting serious complications are described. Conclusions: Pessaries are a safe and effective way to treat symptoms of pelvic organ prolapse during pregnancy.

Narrative review of the epidemiology, diagnosis and pathophysiology of pelvic organ prolapse

ABSTRACT The exact prevalence of pelvic organ prolapse is difficult to establish. The anatomical changes do not always consist with the severity or the symptoms associated with prolapse. There are many risk factors associated with pelvic organ prolapse and this review aims to identify the epidemiology and pathophysiology while looking at the known risk factors for pelvic organ prolapse. PubMed search involved a number of terms including: epidemiology, risk factors, reoccurrence indicators, management and evaluation. Several risk factors have been associated with pelvic organ prolapse, all contribute to weakening of the pelvic floor connective tissue/collagen, allowing the pelvic organs to prolapse through the vaginal walls. Among the risk factors are genetic background, childbirth and mode of delivery, previous hysterectomy, menopausal state and the ratio between Estrogen receptors. The "Integral theory" of Petros and the "Levels of Support" model of Delancey enable us to locate the defect, diagnose and treat pelvic organ prolapse. The currently available demographic data is not reliable enough to properly estimate the true extent of pelvic organ prolapse in the population. However, standardization of the diagnosis and treatment may significantly improve our ability to estimate the true incidence and prevalence of this condition in the coming years.

Factors associated with the prescription of vaginal pessaries for pelvic organ prolapse

OBJECTIVE: To identify the factors associated with the prescription of vaginal pessaries (VPs) as a conservative treatment for pelvic organ prolapse (POP). METHODS: A cross-sectional study was performed during two annual urogynecology and general obstetrics and gynecology meetings in 2017 (São Paulo, SP, Brazil). A 19-item deidentified questionnaire regarding experiences and practices in prescribing VPs for POP patients was distributed among gynecologists. Our primary outcome was the frequency of prescribing VPs as a conservative treatment for POP. The reasons for prescribing or not prescribing VPs were also investigated. Univariate and multivariate analyses with crude and adjusted odds ratios (ORs) were performed for variables associated with the prescription of pessaries. RESULTS: Three hundred forty completed surveys were analyzed. Half of the respondents (53.53%) were between 30-49 years old; most of them were female (73.53%), were from the Southeast Region (64.12%), were trained in obstetrics and gynecology (80.24%) or urogynecology (61.18%) and worked in private offices (63.42%). More than one-third (36.48%) attended four or more POP cases/week, and 97.65% (n=332) had heard or knew about VPs for POP; however, only 47.06% (n=160) prescribed or offered this treatment to patients. According to the multivariate analysis, physicians aged 18-35 years (OR=1.97[1.00-3.91]; p=0.04), those who participated in a previous urogynecology fellowship (OR=2.34[1.34-4.09]; p<0.01), those with relatively high volumes of POP cases (4 or +) (OR=2.23[1.21-4.47]; p=0.01) and those with PhD degrees (OR=2.75[1.01-7.54]; p=0.05) prescribed more pessaries. CONCLUSIONS: Most gynecologists did not prescribe VPs. Younger physician age, participation in a previous urogynecology fellowship, a PhD degree, and a relatively high volume of POP cases were associated with increased VP prescription rates.

Quality of life and vaginal symptoms of postmenopausal women using pessary for pelvic organ prolapse: a prospective study

SUMMARY OBJECTIVE: The use of pessary is an option for the conservative treatment of pelvic organ prolapse (POP). However, here are few studies assess the quality of life (QoL) after inserting the pessary for POP. We have hypothesized that the use of pessary would modify QoL in women with POP. METHODS: A prospective, observational study was performed that included 19 women with advanced POP. Pessary was introduced, and the SF-36 (general quality of life) and ICIQ-VS (vaginal symptoms and quality of life subdomain) questionnaires were applied before the introduction and after six months. A single question about the satisfaction regarding the use of the device was presented (subjective impression). RESULTS: The mean age of the women included was 76 years. Most of them were non-caucasian (52.6%), with no prior pelvic surgery (57.5%), with urinary symptoms (78.9%). A third of the patients reported sexual activity. After treatment, 22.2% of them presented vaginal infection, and 27.7% increased vaginal discharge. Urinary symptoms remained unaltered. Women reported 100% satisfaction after using the pessary (77.7% partial improvement; 22.3% total improvement). SF-36 had significant improvement in three specific domains: general state of health (p=0.090), vitality (p=0.0497) and social aspects (p=0.007). ICIQ-VS presented a reduction in the vaginal symptoms (p < 0.0001) and an improvement in QoL (P < 0.0001). CONCLUSION: The use of pessary for six months improved the QoL and reduced vaginal symptoms for women with advanced POP.

RESUMO OBJETIVO: O pessário é uma opção para o tratamento conservador do prolapso genital. MÉTODOS: Um estudo prospectivo e observacional foi realizado com 19 mulheres com prolapso genital avançado. A avaliação da qualidade de vida e dos sintomas vaginais foi mensurada pelos questionários SF-36 e ICIQ-VS antes e seis meses depois da colocação do pessário. Uma pergunta simples sobre satisfação do uso do dispositivo foi também feita (impressão subjetiva). RESULTADOS: A idade média das mulheres foi de 76 anos. A maioria era parda/negra (52,6%), sem cirurgias pélvicas (57,5%), com sintomas urinários (78,9%). Um terço das pacientes relatou atividade sexual. Depois do tratamento, 22,2% apresentaram infecção vaginal e 27,7% fluxo vaginal aumentado. Não houve alteração da prevalência dos sintomas urinários. As mulheres relataram 100% de satisfação (77,7% melhora parcial e 22,3% melhora completa) depois do uso do pessário. Houve melhora em três domínios do SF-36: saúde em geral (p=0,090), vitalidade (p=0,0497) e aspectos sociais (p=0,007). O ICIQ-VS apresentou redução nos sintomas vaginais (p<0,0001) e melhora da qualidade de vida (p<0,0001). CONCLUSÕES: O uso do pessário por seis meses em mulheres com prolapso genital melhorou a qualidade de vida e reduziu os sintomas vaginais.

Uso de pesarios en mujeres menores de 65 años con diagnóstico de prolapso de órganos pelvianos: estudio de factibilidad / Pessaries for pelvic organ prolapse: feasibility study

Antecedentes: El prolapso de los órganos pelvianos (POP) es una enfermedad prevalente. Los pesarios vaginales son una opción de tratamiento. Algunos especialistas prefieren la cirugía como el tratamiento de elección. Objetivo: Describir la respuesta subjetiva y complicaciones asociadas al uso de pesarios en pacientes <65 años con POP en el Hospital Dr. Sotero del Río. Métodos: Estudio retrospectivo de pacientes con POP sintomático <65 años con indicación de pesario, entre julio de 2009 y noviembre de 2012. Para la evaluación de los resultados subjetivos del uso de pesarios, se utilizó la escala PGI-I. Resultados: Cuarenta y nueve pacientes cumplieron los criterios de inclusión. En 39 pacientes el fitting fue exitoso. Veinticinco de las 39 pacientes, fueron capaces de acceder y usar el pesario, de las cuales 6 abandonaron el tratamiento. La mediana de la edad fue 62,5 años. Un 48 por ciento eran sexualmente activas. La mediana de seguimiento fue 9 semanas. Según POP-Q un 60 por ciento se encontraba en etapa III. El tipo de pesario más utilizado fue el Gellhorn. Trece pacientes presentaron efectos adversos, siendo lo más frecuente el flujo vaginal (40 por ciento). La respuesta subjetiva de mejoría estuvo disponible en 15 (64 por ciento) de 25 pacientes. Un 88 por ciento notaron mejoría subjetiva importante. Conclusión: El uso de pesarios vaginales en pacientes menores de 65 años con POP es factible, asociado a mejoría subjetiva de los síntomas, con baja tasa de complicaciones. Son necesarios estudios prospectivos de mayor tamaño muestral para evaluar este subgrupo.

Background: Pelvic organ prolapse (POP) is a common disease. Vaginal pessaries are a treatment option. Some specialists prefer surgery as the treatment of choice. Objective: To describe the subjective response and complications associated with the use of pessaries in patients <65 years old with POP in Dr. Sotero del Rio Hospital. Methods: Retrospective study of patients with symptomatic POP <65 and use pessary between July 2009 and November 2012. And assessment of the subjective results of using the PGI-I pessaries scale was used. Results: 49 patients met the inclusion criteria. In 39 patients the fitting was successful. 25 of 39 patients were able to access and use the pessary. 6 patients discontinued treatment. The median age was 62.5 years. 48 percent were sexually active. Median follow-up was 9 weeks. According POP-Q 60 percent were in stage III. The type of pessary was the most used Gellhorn. 13 patients had adverse effects. The subjective response improvement was available in 15 (64 percent) of 25 patients. 88 percent noted significant subjective improvement. Conclusion: The use of vaginal pessaries in patients under 65 with POP is feasible, associated with subjective improvement in symptoms, with low complication rate. Prospective studies are needed with larger sample sizes to evaluate this subgroup.

Análise dos recursos para reabilitação da musculatura do assoalho pélvico em mulheres com prolapso e incontinência urinária / Analysis of the resources for rehabilitation of pelvic floor muscles in women with prolapse and urinary incontinence / Análisis de los recursos para rehabilitación de la musculatura del suelo pélvico en mujeres con prolapso e incontinencia urinaria

Esta revisão teve como objetivo analisar os recursos e sua eficácia na reabilitação do assoalho pélvico no tratamento dos prolapsos genitais e incontinência urinária. As buscas foram realizadas nas bases de dados MEDLINE/PubMed, LILACS/SciELO e Biblioteca Cochrane. Foram encontrados 886 artigos, dos quais foram utilizados 34 estudos clínicos relevantes que respondiam às perguntas construídas pelos autores. Os estudos analisados mostraram que o treinamento do assoalho pélvico pode ser usado no tratamento dos prolapsos, porém são necessários mais estudos randomizados para sustentar essa evidência. Para a incontinência urinária a reabilitação do assoalho pélvico é eficiente e deve ser o tratamento de primeira escolha.

This review aimed to assess the capabilities and effectiveness of pelvic floor rehabilitation in the treatment of genital prolapse and urinary incontinence. The research was conducted in MEDLINE/PubMed, LILACS/SciELO and Cochrane Library. There were found 886 articles, of which were used 34 relevant clinical trials that answered the questions constructed by the authors. The studies analyzed showed that pelvic floor training can be used in prolapse treatment, but further randomized studies are necessary to support this evidence. For urinary incontinence pelvic floor, rehabilitation is effective and should be the treatment of first choice.

Esta revisión tiene como objetivo analizar los recursos y su eficacia en la rehabilitación del suelo pélvico en el tratamiento de los prolapsos genitales y la incontinencia urinaria. Las búsquedas fueron realizadas en las bases de datos Medline/Pubmed, LILACS/SciELO y Cochrane. Fueron encontrados 886 artículos, de los cuales fueron utilizados 34 estudios clínicos relevantes y que respondían las preguntas construidas por los autores. Los estudios analizados mostraron que el entrenamiento del suelo pélvico puede ser usado en el tratamiento de los prolapsos, sin embargo, son necesarios más estudios randomizados para sustentar esta evidencia. Para la incontinencia urinaria la rehabilitación del suelo pélvico es eficiente y debe ser el tratamiento de primera opción.

Conduta nos prolapsos genitais / Management of genital prolapse

O prolapso genital constitui afecção de grande importância social e econômica dada sua prevalência estimada em até 40% das mulheres, cujo aumento gradual coincide com o envelhecimento populacional. Estima-se que 30% das pacientes submetidas ao tratamento cirúrgico já foram operadas previamente pelo mesmo motivo. Fatos como esses e outras situações conflitantes, como a escolha entre tratamento conservador ou cirúrgico, a melhor técnica operatória para tratar as alterações anatômicas e funcionais do assoalho pélvico e o uso ou não de uma grande complexidade de materiais sintéticos e biológicos, têm sido objeto de constante investigação. O presente estudo teve por objetivo realizar uma revisão sistemática da literatura em relação ao manejo das pacientes portadoras de prolapso genital, considerando as evidências atuais referentes à utilização dos pessários vaginais, ao papel da fisioterapia, à melhor abordagem cirúrgica, às indicações do uso de telas e a concomitância, na vigência do prolapso, do tratamento cirúrgico da incontinência urinária

The pelvic organ prolapse is an important social and economic problem with the estimated prevalence at up to 40% of women, increasing with the aging population. It is estimated that 30% of patients undergoing surgical treatment, have been operated previously for the same reason. Facts such as these and other situations of conflict as the choice between conservative or surgical treatment, the best surgical technique to treat the anatomical and functional changes of the pelvic floor and use or not of a great complexity of biological and synthetic materials, have been under constant investigation. This study aims to realize a systematical review regarding the management of patients with genital prolapse, considering the current evidence regarding the use of vaginal pessaries, the role of physiotherapy, the best surgical approach, the indications for the meshes use and the concomitant surgical treatment of urinary incontinence, in the presence of prolapse

Efficacy of pelvic floor muscle training and hypopressive exercises for treating pelvic organ prolapse in women: randomized controlled trial / Eficácia do treinamento da musculatura do assoalho pélvico e de exercícios hipopressivos para o tratamento do prolapso de órgãos pélvicos em mulheres: ensaio clínico randomizado

CONTEXT AND OBJECTIVE: Previous studies have shown that women with pelvic floor dysfunctions present decreased cross-sectional area (CSA) of the levator ani muscle. One way to assess the effects of training programs is to measure the CSA of the muscle, using ultrasonography. The aim here was to evaluate the efficacy of pelvic floor muscle training and hypopressive exercises for increasing the CSA of the levator ani muscle in women with pelvic organ prolapse. DESIGN AND SETTING: Prospective randomized controlled trial at the Urogynecology outpatient clinic of Universidade Federal de São Paulo. METHODS: Fifty-eight women with stage II pelvic organ prolapse were divided into three groups for physiotherapy: a pelvic floor muscle training group (GI); a hypopressive exercise group (GII); and a control group (GIII). The patients underwent transperineal ultrasonographic evaluation using a transducer of frequency 4-9 MHz. The (CSA) of the levator ani muscle was measured before physiotherapy and after 12 weeks of treatment. RESULTS: The groups were homogeneous regarding age, number of pregnancies, number of vaginal deliveries, body mass index and hormonal status. Statistically significant differences in CSA were found in GI and GII from before to after the treatment (P < 0.001), but not in relation to GIII (P = 0.816). CONCLUSIONS: The CSA of the levator ani muscle increased significantly with physiotherapy among the women with pelvic organ prolapse. Pelvic floor muscle training and hypopressive exercises produced similar improvements in the CSA of the levator ani muscle.

CONTEXTO E OBJETIVO: Estudos anteriores mostraram que mulheres com disfunção do assoalho pélvico possuem diminuição da área de secção transversal (AST) do músculo levantador do ânus. Uma forma de avaliar os efeitos de um programa de treinamento é mensurar a AST do músculo por ultrassonografia. O objetivo foi avaliar a eficácia do treinamento da musculatura do assoalho pélvico e de exercícios hipopressivos no aumento da AST do músculo levantador do ânus em mulheres com prolapso de órgãos pélvicos. TIPO DE ESTUDO E LOCAL: Estudo prospectivo, randomizado e controlado realizado no Ambulatório de Uroginecologia da Universidade Federal de São Paulo. MÉTODOS: Cinquenta e oito mulheres com prolapso de órgãos pélvicos estádio II foram divididas em três grupos para tratamento fisioterapêutico: (GI) grupo de treinamento dos músculos do assoalho pélvico, (GII) grupo de exercícios hipopressivos e (GIII) grupo controle. As pacientes se submeteram a avaliação ultrassonográfica transperineal com transdutor de frequência 4-9 MHz. Foi mensurada a AST do músculo levantador do ânus antes e após 12 semanas de tratamento fisioterapêutico. RESULTADOS: Os grupos foram homogêneos no que se refere a idade, número de gestações, número de partos vaginais, índice de massa corpórea e estado hormonal. Diferença significante foi observada na AST de GI e GII antes e após o tratamento (P < 0,001) e isso não ocorreu com o GIII (P = 0,816). CONCLUSÕES: A AST do músculo levantador do ânus aumentou significativamente com tratamento fisioterapêutico em mulheres com prolapso de órgãos pélvicos. Treinamento dos músculos do assoalho pélvico e exercícios hipopressivos são semelhantes no que se refere ao aumento da AST do músculo levantador do ânus.

Evaluation of vaginal pessary use by South African gynaecologists

Introduction:The use of vaginal pessaries for conservative management of pelvic organ prolapse (POP) is well established. However; there is limited data on current clinical practice among gynaecologists; and thus the aim of this survey was to evaluate vaginal pessary use among South African gynaecologists. Methods: An anonymous self administered one page questionnaire was designed by the author and administered to South African gynaecologists at an Obstetrics and Gynaecology Update meeting in 2009. Results: The response rate was 32(133 out of 420). 24(29 out of 123) offered vaginal pessaries as first line treatment for pelvic organ prolapse in their clinical practice. The ring pessary was the commonest pessary for all compartmental defects. The two most favored reasons for pessary use was surgical or anaesthetic risk (64) (85 out of 133) and patient declining surgery (50) (66 out of 133). Recurrent involuntary expulsion (52) (69 out of 133); discomfort (41) (55 out of 133); opting for surgery (39) (52 out of 133) were the three top reasons for pessary discontinuation. 88(92 out of 105) responded that they would have reviewed patients within 6 weeks after initial pessary insertion; and thereafter 46(44 out of 96) reviewed patients on 3-6 monthly interval. Conclusion: When compared to other surveys fewer South African gynaecologists offer vaginal pessaries as first line treatment to patients with symptomatic pelvic organ prolapse. Similar practice trends included the choice of pessary; follow up interval and reasons for pessary discontinuation