Diagnóstico ecográfico de la endometriosis y los miomas / Sonographic diagnosis of endometriosis and fibroids

La ecografía transvaginal se considera la prueba diagnóstica de elección en el estudio de la mujer con miomas, adenomiosis y endometriosis ovárica y profunda. Se recomienda realizar dicha ecografía siguiendo la sistemática exploratoria propuesta tras el consenso Morphological Uterus Sonographic Assessment (MUSA) para la patología miometrial, y el consenso IDEA para la endometriosis.Para realizar el diagnóstico de la adenomiosis, es necesario identificar como mínimo un criterio «directo» (islotes, yemas hiperecogénicas o quistes intramiometriales), así como uno o varios criterios indirectos (aspecto globuloso del útero, sombras «en abanico», asimetría de paredes miometriales o zona de transición endometrio-miometrio irregular). También definir si afecta a la capa externa uterina, o bien a la interna (zona de transición). La vascularización translesional de la adenomiosis es distinta a la circunferencial que presentan los miomas, de los que también debemos medir sus tres diámetros, describir su ecogenicidad y definir el número y la localización según la clasificación de la International Federation of Gynecology and Obstetrics (FIGO).La ecografía de la endometriosis se realiza mediante la exploración sistemática del útero y los ovarios (identificar y describir endometriomas), los marcadores menores o soft markers (pseudoquistes adherenciales perianexiales, líquido libre tabicado en Douglas, ovarios fijos, zonas sensibles a la presión y útero en forma de coma), el signo del deslizamiento (anterior, retrouterino y retrocervical) y la detección y descripción de los nódulos de endometriosis profunda en compartimento anterior (vejiga, uréteres) o posterior (ligamentos uterosacros, parametrios, fórnix vaginal, tabique rectovaginal y cara anterior de rectosigma).(AU)

Transvaginal ultrasound is considered the first-line imaging diagnostic test in the study of women with fibroids, adenomyosis, and ovarian and deep endometriosis. It is recommended that the ultrasound should follow the MUSA consensus for myometrial pathology, and the IDEA consensus for endometriosis.To diagnose adenomyosis, it is necessary to identify at least one «direct» criterion (hyperechogenic buds or island or intramyometrial cysts), as well as one or several «indirect» criteria (globulous uterine morphology, «fan-shaped» shadowing, asymmetry, or non-defined junctional zone). It is recommended to specify if the adenomyosis is internal or external. Translesional vascularization of adenomyosis is different from circumferential vascularization of fibroids, of which the measurement of the 3 diameters should be reported, the echogenicity should be described, and the number and location defined according to the FIGO classification.Ultrasound for endometriosis is performed by systematic examination of the uterus and ovaries (endometriomas), soft markers (periadnexal pseudocysts, tabicated fluid in the pouch of Douglas, fixed ovaries, tenderness-guide areas, and comma-shaped uterus), sliding sign (anterior, retrouterine, and retrocervical) and the detection and description of deep endometriotic nodules in the anterior (bladder, ureters) or posterior compartment (uterosacral ligaments, parametria, vaginal fornix, rectovaginal septum, and rectosigma).(AU)

Cambio del modelo asistencial en una unidad de uroginecología de un hospital de tercer nivel: impacto de la pandemia por COVID-19 en la presencialidad / Update of the care model in a urogynaecology unit of a tertiary hospital: impact of the COVID-19 pandemic on face-to-face care

La pandemia por la COVID-19 generó un cambio de forma brusca en la práctica asistencial habitual de nuestra unidad de uroginecología, y a raíz de esta situación se ideó un nuevo modelo asistencial para adaptarnos a la nueva etapa epidemiológica. Se acordó, como eje central del nuevo modelo, la disminución de la presencialidad hospitalaria, ofreciendo la misma calidad asistencial mediante la introducción de la telemedicina.Para conseguir tal fin, se elaboró un modelo con tres tipos de visitas nuevas: primera visita médica telemática, visitas de seguimiento de tratamientos conservadores y farmacológicos telemáticas, y creación de visita pack (pack STUI, el pack posparto y el pack postalta) que incluye visitas y pruebas diagnósticas uroginecológicas que se realizan todas el mismo día.El pack STUI va dirigido a todas las pacientes con síntomas del tracto urinario inferior, asociados o no a prolapso de órganos pélvicos. Consta de dos visitas (enfermería y médica), y dos pruebas diagnósticas avanzadas (urodinamia y ecografía de suelo pélvico).El pack posparto va dirigido a mujeres con síntomas de incontinencia urinaria, incontinencia anal, prolapso y/o alteraciones de la sexualidad tras el parto. También incluye mujeres asintomáticas con antecedente de trauma perineal obstétrico. Consta de una visita médica, una ecografía de suelo pélvico y una visita por la fisioterapeuta.El pack postalta se realiza al mes de la cirugía e incluye dos pruebas (ecografía de suelo pélvico y flujometría) y una visita médica.Los tratamientos de fisioterapia y otras visitas que por motivos médicos lo requirieran, han mantenido su presencialidad.(AU)

The COVID-19 pandemic caused a sudden change in the usual care practice of our urogynaecology unit. Therefore, we designed a new healthcare model to adapt our practice to the epidemiological situation. The central axis of the new model was reduced hospital attendance, offering the same healthcare quality through the introduction of telemedicine.To achieve this aim, we made the following changes: a first telematic medical visit was the first step, telematic monitoring visits for conservative and pharmacological treatments and pack visit. We created the following packs: LUTS, postpartum and post-discharge pack. All packs included visits and diagnostic tests performed on the same day.The LUTS pack is indicated in patients with lower urinary tract symptoms, associated or not with pelvic organ prolapse. It includes two visits (nursing and medical) and two tests (urodynamics and pelvic floor ultrasound).The postpartum pack is indicated in women with symptoms of urinary incontinence, anal incontinence, pelvic organ prolapse and sexual disfunctions after delivery, as well as asymptomatic patients with a history of obstetric perineal trauma. It includes a medical visit, a pelvic floor ultrasound and a visit with the physiotherapist.The post-discharge pack is scheduled a month after the surgery and includes two tests (pelvic floor ultrasound and uroflowmetry) and a medical visit.Some face-to-face visits were maintained, as were physiotherapy treatments and other visits following medical criteria.(AU)

Aplicabilidad clínica de la ecografía de suelo pélvico en las mujeres con disfunciones miccionales / Clinical applicability of pelvic floor ultrasound in women with urinary dysfunction

Las disfunciones miccionales más frecuentes son la incontinencia urinaria de esfuerzo (IUE), la incontinencia urinaria de urgencia y la dificultad miccional. Son un problema de salud que afecta a la calidad de vida y, a pesar de su alta prevalencia, su etiopatología y fisiopatología sigue sin estar bien establecida. La ecografía de suelo pélvico (ESP) tiene un papel importante para ayudarnos a comprender conceptos de la fisiopatología de estas disfunciones y el manejo clínico de la paciente.La ESP nos permite evaluar la movilidad uretral, la longitud de la uretra y la presencia de embudización del cuello vesical, todos ellos parámetros importantes a considerar, especialmente en aquellas pacientes que se someterán a una cirugía correctora de la IUE. Mediante la ESP evaluamos de forma rutinaria las paredes vesicales y la morfología uretral con el fin de descartar una enfermedad orgánica asociada. La ESP también nos permite evaluar el residuo posmiccional, importante en todas las pacientes con disfunciones miccionales. Finalmente, la ESP es de gran utilidad en la evaluación de las pacientes con antecedente de cirugía antiinconinencia con una banda suburetral libre de tensión (BSLT), permitiendo valorar los parámetros estáticos y dinámicos de la BSLT (en Valsalva), que se correlacionan con la sintomatología descrita por las pacientes.La ESP es una prueba subespecializada que se debe realizar por personal entrenado, y que cada vez va adquiriendo más protagonismo en las unidades de uroginecología. Se espera en un futuro disponer de una terminología estandarizada y de una aplicabilidad más extendida.

Stress urinary incontinence (SUI), urge urinary incontinence, and voiding dysfunction are the most frequent urinary dysfunctions. These dysfunctions affect the patient's quality of life and despite their high prevalence, their aetiopathology and pathophysiology are still not well established. Pelvic floor ultrasound (PFUS) helps us to understand the pathophysiology of these dysfunctions and the clinical evaluation and treatment of patients.PFUS allows us to assess urethral mobility, urethral length, and bladder neck funnelling, all of which are important parameters to be considered in patients undergoing SUI surgery. The evaluation of bladder walls and urethral morphology could be routinely performed by PFUS to assess other pathologies. PFUS also allows us to evaluate the post void residual volume which is especially important in patients with voiding dysfunction. Finally, PFUS is useful in the assessment of the mid urethral slings used for the surgical treatment of SUI. We can evaluate the static and dynamic (with Valsalva) parameters which correlate with the patient's symptoms.PFUS should be performed by trained professionals, and it is expected that in the near future its use will be more extended.

[Update of the care model in a urogynaecology unit of a tertiary hospital: impact of the COVID-19 pandemic on face-to-face care]. / Cambio del modelo asistencial en una unidad de uroginecología de un hospital de tercer nivel: impacto de la pandemia por COVID-19 en la presencialidad.

The COVID-19 pandemic caused a sudden change in the usual care practice of our urogynaecology unit. Therefore, we designed a new healthcare model to adapt our practice to the epidemiological situation. The central axis of the new model was reduced hospital attendance, offering the same healthcare quality through the introduction of telemedicine.To achieve this aim, we made the following changes: a first telematic medical visit was the first step, telematic monitoring visits for conservative and pharmacological treatments and pack visit. We created the following packs: LUTS, postpartum and post-discharge pack. All packs included visits and diagnostic tests performed on the same day.The LUTS pack is indicated in patients with lower urinary tract symptoms, associated or not with pelvic organ prolapse. It includes two visits (nursing and medical) and two tests (urodynamics and pelvic floor ultrasound).The postpartum pack is indicated in women with symptoms of urinary incontinence, anal incontinence, pelvic organ prolapse and sexual disfunctions after delivery, as well as asymptomatic patients with a history of obstetric perineal trauma. It includes a medical visit, a pelvic floor ultrasound and a visit with the physiotherapist.The post-discharge pack is scheduled a month after the surgery and includes two tests (pelvic floor ultrasound and uroflowmetry) and a medical visit.Some face-to-face visits were maintained, as were physiotherapy treatments and other visits following medical criteria.

Cómo la pandemia por COVID-19 ha cambiado la forma de atender a las pacientes en una unidad de uroginecología / How did COVID-19 pandemic change the way we attend the patients in an urogynaecological unit

La actual pandemia ocasionada por el SARS-coronavirus tipo 2 ha generado, en pocas semanas, cambios importantes en el funcionamiento del sistema sanitario y la forma en cómo se realiza la atención a las pacientes. La patología uroginecológica afecta a la calidad de vida, pero sin riesgo vital en la mayoría de casos, por lo que suele ser demorable. Además, afecta a un alto porcentaje de mujeres > 65 años (población de riesgo ante la infección por COVID-19). En este manuscrito se resume la evidencia que existe sobre la efectividad de la telemedicina aplicada en las disfunciones de suelo pélvico, así como recomendaciones de las sociedades científicas uroginecológicas durante el estado de alarma. Describimos el abordaje de las disfunciones de suelo pélvico durante la pandemia por COVID-19 y una propuesta de cómo organizar las agendas para el diagnóstico (visitas y pruebas diagnósticas) y tratamiento (conservador, farmacológico y la cirugía) en el período interpandemia y en el futuro

The current SARS-coronavirus type 2 pandemic caused, in few weeks, important changes in the health system organization and in the way we attend the patients. Urogynaecological diseases affect quality of life, but without life risk in most cases, so it is possible to delay. Moreover, urogynaecological diseases affect mostly women over 65 years old (a high risk population for contracting COVID-19). In this manuscript we summarise the current evidence about telemedicine efectivity to manage to pelvic floor dysfunctions and, in addition, the recommendations of Urogynaecological scientific societies during state of alarm. We describe the management of the different pelvic floor dysfunctions during COVID-19 pandemic and a proposal to organize the urogynaecological services to diagnose (visits and diagnostic investigations) and to treat (conservative, pharmacological or surgery) in the interpandemic period and in the future

[How did COVID-19 pandemic change the way we attend the patients in an urogynaecological unit]. / Cómo la pandemia por COVID-19 ha cambiado la forma de atender a las pacientes en una unidad de uroginecología.

The current SARS-coronavirus type 2 pandemic caused, in few weeks, important changes in the health system organization and in the way we attend the patients. Urogynaecological diseases affect quality of life, but without life risk in most cases, so it is possible to delay. Moreover, urogynaecological diseases affect mostly women over 65 years old (a high risk population for contracting COVID-19). In this manuscript we summarise the current evidence about telemedicine efectivity to manage to pelvic floor dysfunctions and, in addition, the recommendations of Urogynaecological scientific societies during state of alarm. We describe the management of the different pelvic floor dysfunctions during COVID-19 pandemic and a proposal to organize the urogynaecological services to diagnose (visits and diagnostic investigations) and to treat (conservative, pharmacological or surgery) in the interpandemic period and in the future.

Actividad y función sexual en mujeres con prolapso de órganos pélvicos avanzado sometidas a cirugía vaginal clásica. Estudio multicéntrico / Sexual activity and function of women with severe pelvic organ prolapse subjected to a classical vaginal surgery. A multicentre study

Introducción y objetivo: El prolapso de órganos pélvicos (POP) puede asociarse a la disfunción sexual femenina. El presente estudio pretendía determinar el impacto de la cirugía correctora del POP sobre la vida sexual de mujeres con POP avanzado. Materiales y métodos: Se diseñó un estudio de cohortes prospectivo, multicéntrico, incluyendo pacientes con POP sintomático, de grado ≥ ii, sometidas a cirugía vía vaginal con tejidos propios. Se evaluó la actividad y función sexual mediante el PISQ-IR antes y 12 meses tras la cirugía. Resultados: Se incluyeron 355 mujeres, 322 con datos de la visita de seguimiento. La media (DE) de edad fue de 64,8 (9,9) años. Basalmente, 170 mujeres eran sexualmente activas y 185 no. Veintinueve mujeres (16,8%) pasaron a ser sexualmente activas y 20 (12,8%) dejaron de serlo tras la cirugía. Un 42,3% reportaron no tener relaciones sexuales debido a problemas de vejiga, intestino o POP, antes de la cirugía y solo un 11,4% después de la cirugía. El 25,3% de las mujeres refería no tener actividad sexual por dolor en la visita basal, mientras que tras la cirugía este porcentaje era del 8,5%. Se observó una mejora estadísticamente significativa en 5 de 6 escalas del PISQ-IR en mujeres sexualmente activas. Conclusiones: El POP sintomático se asocia a la disfunción sexual femenina. El tratamiento quirúrgico del POP parece tener un impacto positivo sobre la vida sexual de mujeres tanto inactivas como activas

Introduction and objective: Pelvic organ prolapse (POP) is related with female sexual dysfunction. The present study aimed to determine the impact of POP corrective surgery on the sexual life of women with advanced POP. Materials and methods: A prospective, multicentre cohort study was designed, including patients with grade ≥ II, symptomatic POP, who underwent vaginal surgery with traditional procedures. Sexual activity and function were assessed by PISQ-IR before surgery and 12 months after. Results: We included 355 women; 322 had data from the follow-up visit. The mean (SD) age was 64.8 (9.9) years. At baseline, 170 women were sexually active and 185 were not. After surgery, 29 women (16.8%) became sexually active and 20 (12.8%) ceased sexual activity. Before surgery, 42.3% reported not having sexual intercourse due to bladder, bowel or POP problems; and 11.4% after surgery. At baseline visit, 25.3% had no sexual activity due to pain, however, at follow-up visits, this percentage was 8.5%. A statistically significant improvement was observed in 5 out of 6 scales of the PISQ-IR in sexually active women. Conclusions: Symptomatic POP is associated with female sexual dysfunction. Surgical intervention seems to have a positive impact on sexual life among sexually inactive and active women

Sexual activity and function of women with severe pelvic organ prolapse subjected to a classical vaginal surgery. A Multicentre study. / Actividad y función sexual en mujeres con prolapso de órganos pélvicos avanzado sometidas a cirugía vaginal clásica. Estudio multicéntrico.

INTRODUCTION AND OBJECTIVE: Pelvic organ prolapse (POP) is related with female sexual dysfunction. The present study aimed to determine the impact of POP corrective surgery on the sexual life of women with advanced POP. MATERIALS AND METHODS: A prospective, multicentre cohort study was designed, including patients with grade≥II, symptomatic POP, who underwent vaginal surgery with traditional procedures. Sexual activity and function were assessed by PISQ-IR before surgery and 12 months after. RESULTS: We included 355 women; 322 had data from the follow-up visit. The mean (SD) age was 64.8 (9.9) years. At baseline, 170 women were sexually active and 185 were not. After surgery, 29 women (16.8%) became sexually active and 20 (12.8%) ceased sexual activity. Before surgery, 42.3% reported not having sexual intercourse due to bladder, bowel or POP problems; and 11.4% after surgery. At baseline visit, 25.3% had no sexual activity due to pain, however, at follow-up visits, this percentage was 8.5%. A statistically significant improvement was observed in 5 out of 6 scales of the PISQ-IR in sexually active women. CONCLUSIONS: Symptomatic POP is associated with female sexual dysfunction. Surgical intervention seems to have a positive impact on sexual life among sexually inactive and active women.