archives@tulane.edu / Pelvic organ prolapse (POP) is characterized by the descent of the pelvic organs due to the loss of pelvic support. The underlying mechanism leading to POP is unknown. However, age is a known risk factor for POP, and location and microstructural composition are both associated with prolapse. How the passive biaxial mechanical properties of the vagina change with age as well as between the anterior and posterior vaginal wall are not well-established. Additionally, the extent to which elastic fiber content disruption contributes to prolapse is unknown. The objective of this study was to elucidate the mechanical properties of the murine vagina as a function of age, location, and elastic fiber composition. A planar biaxial mechanical testing protocol evaluated mechanical properties of vaginal tissue from three age groups and the anterior and posterior vaginal walls. Additionally, histological analysis and opening angle measurements were performed on normal and elastase-treated tissues to determine the effect of elastic fiber disruption on mechanical function. Evaluation of mechanical changes within individual age groups showed that material stiffness was higher in the axial direction compared to the circumferential direction within the youngest age group but not in the older age groups. This may suggest that microstructural remodeling occurred that resulted in a comparable stiffness in both directions, thus, reducing the physiologic anisotropy of the tissue. As anisotropy is important for vaginal mechanohomeostasis, a disruption of this homeostasis may contribute to the increased prevalence of prolapse with age. Further, the posterior vaginal wall demonstrated a greater material stiffness compared to the anterior wall. However, prior worked suggests that increased stiffness is associated with prolapse and that anterior prolapse is more prevalent than posterior prolapse. Regional microstructural differences may be responsible for this disparity in material stiffness and may explain the increased susceptibility of the anterior vaginal wall to prolapse. Finally, elastin area fraction and mechanical function displayed a positive correlation suggesting that elastic fiber disruption directly affects mechanical properties. The data presented may improve clinical efficacy in POP treatment by elucidating relationships between POP risk factors and mechanical properties of the vagina. / 1 / Rachel Russell

Indiana University-Purdue University Indianapolis (IUPUI) / Women describe pelvic organ prolapse (POP) surgery as difficult to recover from. Expectancy is related to recovery in other surgeries but has not been examined in POP. There is no established measure of surgery expectancy or utility in women with POP. This research had four aims: 1) to establish the factor structure of a new measure of POP surgery expectancy; 2) to establish predictive validity of the expectancy measure by examining its ability to predict self-rated recovery over time; 3) to establish concurrent validity of the expectancy measure; and 4) to examine the ability of utility to predict additional variance in recovery. Exploratory factor analysis revealed a three-factor solution. Factors are conceptualized as: 1) Bladder/Bowel Function; 2) Sexual Function; and 3) Physical Function. Bladder/Bowel Function correlated with optimism and self-efficacy (r = .17, p = .03 and r = .27, p = .00, respectively). Physical Function was predictive of recovery at 42 days (standardized coefficient = .25; p < .05). However, these factors were generally poor and inconsistent predictors of recovery. Utility did not predict additional variance in recovery. Potential explanations for the poor predictive ability of the measure are discussed. The development of a measure that amends these limitations may still be beneficial. Further, exploring and establishing the relationship between surgery expectancy, utility, and recovery may guide physician-patient discussions and lead to improved surgical outcomes.

Women describe pelvic organ prolapse (POP) surgery as difficult to recover from. Expectancy is related to recovery in other surgeries but has not been examined in POP. There is no established measure of surgery expectancy or utility in women with POP. This research had four aims: 1) to establish the factor structure of a new measure of POP surgery expectancy; 2) to establish predictive validity of the expectancy measure by examining its ability to predict self-rated recovery over time; 3) to establish concurrent validity of the expectancy measure; and 4) to examine the ability of utility to predict additional variance in recovery. Exploratory factor analysis revealed a three-factor solution. Factors are conceptualized as: 1) Bladder/Bowel Function; 2) Sexual Function; and 3) Physical Function. Bladder/Bowel Function correlated with optimism and self-efficacy (<i>r</i> = .17, <i>p</i> = .03 and <i>r</i> = .27, <i>p</i> = .00, respectively). Physical Function was predictive of recovery at 42 days (standardized coefficient = .25; <i>p</i> < .05). However, these factors were generally poor and inconsistent predictors of recovery. Utility did not predict additional variance in recovery. Potential explanations for the poor predictive ability of the measure are discussed. The development of a measure that amends these limitations may still be beneficial. Further, exploring and establishing the relationship between surgery expectancy, utility, and recovery may guide physician-patient discussions and lead to improved surgical outcomes.

Orientadores: Viviane Herrmann Rodrigues, Cássio Luis Zanettini Riccetto / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-21T08:50:36Z (GMT). No. of bitstreams: 1 Barreiro_TiagoMonteiro_M.pdf: 3202790 bytes, checksum: 218f40f42f2aaad4c7a68ec4fc081044 (MD5) Previous issue date: 2012 / Resumo: Introdução e Objetivos O tratamento cirúrgico dos prolapsos vaginais de compartimento anterior apresenta índices de insucesso significativos. Próteses de polipropileno vêm sendo empregadas visando melhorar a eficácia do tratamento cirúrgico. Apesar dos bons resultados anatômicos, são descritas importantes complicações com o uso das mesmas e novas alternativas têm sido propostas. O objetivo deste estudo foi avaliar a segurança e a eficácia de uma nova técnica cirúrgica para correção de prolapso vaginal anterior. Pacientes e Métodos Foram incluídas no estudo 34 mulheres com prolapso de parede vaginal anterior estágio ? 2 da classificação de Pelvic Organ Prolapse Quantification (POP-Q) associado ao prolapso apical. No pré-operatório foi realizado exame ginecológico e avaliação do prolapso genital. A avaliação subjetiva constou de questionário de qualidade de vida International Consultation on Incontinence Questionnaire - Vaginal Symptoms (ICIQ-VS). Todas foram submetidas à correção cirúrgica com interposição de tela de polipropileno tipo 1, fixado em sua porção apical ao ligamento sacroespinhoso bilateralmente e em sua porção suburetral em região de membrana do músculo obliquo interno através de sistemas de ancoragem tecidual (Calistar A - Promedon). Após seis meses de seguimento, avaliou-se a cura objetiva, considerada estágio ? 1 de POP-Q e a cura subjetiva. Foi utilizado o método de Fisher, Razão das Chances e Wilcoxon para análise estatística. Resultados A média (±DP) dos pontos Aa, Ba e C antes da cirurgia foi de +1,8 (±0,9), +3.41 (± 1.55) e -0.33 (± 3.32). Aos seis meses o ponto Aa e Ba passou para-2.41 ± 0.67 e -2,64(± 0,58) e o ponto C para -7,55 (± 1,82) (p<0,01). O ICIQ-VS no préoperatório foi, para sintomas vaginais, 37,7 (±14,8), para problemas sexuais de 6,0 (±9,1) e a influência na qualidade de vida de 5,7 (±3,0). Seis meses após a cirurgia, foi observada redução significativa sobre sintomas vaginais para 11 (±8,5) (p<0,01) e qualidade de vida 1,0(± 2,0) (p<0,01). O score para problemas sexuais foi 2,1(± 2,5), não atingindo significância estatística (p=0,1675). Não houve sangramento ou necessidade de reintervenção cirúrgica por dor ou infecção. Exposição de tela foi observada em cinco pacientes (14,7%). Quatro (11,7%) pacientes apresentaram retenção urinária. Três (8,8%) das pacientes apresentaram infecção de trato urinário. Conclusões O Calistar A apresentou bons resultados no tratamento cirúrgico do prolapso vaginal de parede anterior e apical com melhora significativa na avaliação subjetiva e objetiva. Os resultados iniciais mostram que a técnica foi segura e eficaz, no seguimento de seis meses / Abstract: Introduction and Objectives Surgical treatment of anterior vaginal prolapse has significant failure rates. Polypropylene prostheses have been employed to improve the effectiveness of surgical treatment. Despite good anatomic results the use of these prostheses are still present complications and new methods are being proposed. This study evaluated the safety and efficacy of a new surgical technique for correction of anterior vaginal prolapse. Patients and Methods The study included 34 women with anterior vaginal wall prolapse stage ? 2 and apical prolapse according to the Pelvic Organ Prolapse Quantification (POP-Q). Before surgery all patients answered a Quality of life questionnaire (International Consultation on Incontinence Questionnaire - Vaginal Symptoms- ICIQ-VS). All patients underwent a single incision surgical repair through a type I polypropylene mesh fixed at the apical part of the sacrospinous ligament bilaterally and in the sub urethral portion in internal oblique muscle membrane (Calistar A - Promedon). Patients were followed for 6 months. Objective cure was considered when POP-Q was diagnosed as stage ? 1. Subjective cure was assessed by Quality of Life Questionnaire (ICIQ-VS). We used Fisher's method, Odds Ratio and Wilcoxon test for statistical analysis. Results The mean (± SD) of Aa, Ba and C points before surgery was, +1,8 (±0,9), +3.41 (± 1.55) and -0.33 (± 3.32). At 6 months point Aa and Ba was -2.41 ± 0.67 Ba and -2.64 (± 0.58) and point C was -7.55 (± 1.82) (p<0,01). ICIQ-VS was 37.7 (± 14.8) for vaginal symptoms, 6.0 (± 9.1) for sexual symptoms and the influence on quality of life 5.7 (± 3.0). Six months after surgery, significant reduction was observed on vaginal symptoms 11(± 8.5) (p<0,01) and quality of life 1.0 (± 2.0) (p<0,01). The score for sexual problems was 2.1(± 2.5) and did not reach statistical significance (p = 0.1675). There was no bleeding or surgical intervention for pain or infection. Mesh exposure was observed in five patients (14.7%). Four (11.7%) patients had urinary retention. Three (8.8%) patients had urinary tract infection. Conclusions The Calistar A showed good results in the surgical treatment of anterior vaginal prolapse and apex with a significant improvement in subjective and objective evaluation. Initial results show that the technique is safe and effective / Mestrado / Fisiopatologia Ginecológica / Mestre em Ciências da Saúde

Improving treatment and prevention of pelvic organ prolapse, a disorder affecting up to half of parous women, requires thorough mechanical analysis of the vagina and other endopelvic structures at the cellular level. In this study, we tested single vaginal smooth muscle cells (SMCs) to quantify their elastic moduli. Cells were enzymatically isolated from vaginal walls of freshly sacrificed, virgin Long Evans rats and cultured using well-established methods. A custom-built experimental setup was used to perform tensile tests. Micropipettes were fabricated to serve as cantilever-type load cells, which were coated in cellular adhesive. Two pipettes applied tension to SMCs until adhesion between the cell and a pipette failed. During mechanical testing, images of SMCs were collected and translated into strain and stress. Specifically, force/stress data were calculated using Euler-Bernoulli Beam Theory and by making simplifying geometric assumptions. The average initial and total elastic moduli (mean ± SEM) for single vaginal SMCs were 6.06 ± 0.26 kPa and 5.4 ± 0.24 kPa, respectively, which is within the range reported for other types of SMCs, mainly airway and vascular, of various species. This protocol can and will be applied to further investigate mechanics of single cells from the pelvic region with independent variables such as parity, age, body mass index, and various stages of POP. Results of these experiments will provide critical information for improving current treatments like drug therapies, surgical procedures, medical grafts and implants, and preventative practices like stretching and exercise techniques. / Master of Science / Pelvic organ prolapse, the descent of the pelvic organs into the vagina or rectum, affects up to half of women who have undergone childbirth. Improving treatment requires thorough analysis and quantification of the vagina and other endopelvic structures at the tissue and cellular levels. In this study, we tested single vaginal smooth muscle cells (SMCs) to quantify their elastic moduli. A custom-built experimental setup was used to pull single SMCs using two micropipettes. By measuring the deflection of a flexible pipette, we calculated force applied to each cell and the corresponding strain. The pipettes were coated in cellular adhesive and applied tension to SMCs until adhesion between the cell and a pipette failed. During mechanical testing, images of SMCs were collected and translated into strain and stress. Specifically, force/stress data were calculated using Euler-Bernoulli Beam Theory and by making simplifying geometric assumptions. The average initial and total elastic moduli (mean ± SEM) for single vaginal SMCs were 6.06 ± 0.26 kPa and 5.4 ± 0.24 kPa, respectively, which is within the range reported for other types of SMCs, mainly airway and vascular, of various species. This protocol can and will be applied to further investigate mechanics of single cells from the pelvic region with independent variables such as pregnancy, age, body mass index, and various stages of POP. Results of these experiments will provide critical information for improving current treatments like drug therapies, surgical procedures, medical grafts and implants, and preventative practices like stretching and exercise techniques.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24135号 / 医博第4875号 / 新制||医||1060(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 近藤 尚己, 教授 川上 浩司, 教授 阪上 優 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Background: Pelvic organ prolapse (POP) can be treated surgically or, more conservatively, with use of a pessary. Objective: To determine if the population of women treated for POP with the use of a pessary in one Nurse Practitioner's (NP) practice demonstrated health outcomes as better, same, or needing improvement through use of a data-based practice model from encounter data extracted from the electronic health record (EHR).Design: The project design was a quality improvement (QI) project, descriptive in nature. One Plan Do Study Act (PDSA) cycle was conducted for this QI project. Setting: NP managed specialty clinic in urban Southwestern Arizona that provides services to women with POP. Patients: Ten randomly selected women who had been treated conservatively for POP with use of a pessary were identified as two subpopulations and evaluated: women who received professional management of the pessary and women who were patient managed. Intervention: The intervention was the development of a data-based practice model, using patient profile data elements derived from the documented EHR encounters of the 10 women. Measurements: Twelve scales were developed to evaluate the patient profile data elements, generating numeric scores for each encounter. Two Decision Rules were then used to evaluate numeric scores by encounter, creating primary and secondary health outcomes. Limitations: Two limitations were identified. The QI project was limited by the small sample size of 10 patients. This is however, true to PDSA guidelines that recommend small scale cycles. The data were limited as only documented data were used. Conclusions: In general, the expected outcome was the outcome observed; the provider was unaware of any women in this QI Project who were not successfully treated with use of a pessary for treatment of POP. The value of this data-based practice model is that outcomes can be aggregated across populations rather than relying on recall of individual outcomes and therefore has potential to be used regularly and systematically as a quality feedback loop, as well as on a larger scale in future PDSA cycles to determine other outcomes beyond a single provider in this or other similar clinical populations.

abstract: The objective of this research is to develop a biocompatible scaffold based on dextran and poly acrylic acid (PAA) with the potential to be used for soft tissue repair. In this thesis, physical and chemical properties of the scaffold were investigated. The scaffolds were made using electrospinning and cross-linked under high temperature. After heat treatment, Scanning Electron Microscope (SEM) was used to observe the structures of these scaffolds. Fourier transform infrared spectroscopy (FTIR) was used to measure the cross-linking level of scaffold samples given different times of heat treatment by detecting and comparing the newly formed ester bonds. Single-walled carbon nanotubes (SWCNT) were added to enhance the mechanical properties of dextran-PAA scaffolds. Attachment of NIH-3T3 fibroblast cells to the scaffold and the response upon implantation into rabbit vaginal tissue were also evaluated to investigate the performance of SWCNT dextran-PAA scaffold. SEM was then used to characterize morphology of fibroblast cells and rabbit tissues. The results suggest that SWCNT could enhance cell attachment, distribution and spreading performance of dextran-PAA scaffold. / Dissertation/Thesis / Masters Thesis Bioengineering 2014

Orientador: Cassia Raquel Teatin Juliato / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-28T01:56:55Z (GMT). No. of bitstreams: 1 Mazzer_MairaFurtadoGreco_M.pdf: 1022810 bytes, checksum: a9f39810ef9b570472a358045117778c (MD5) Previous issue date: 2015 / Resumo: Introdução: O prolapso genital apical (uterino ou de cúpula vaginal) é uma condição que afeta a qualidade de vida das mulheres. Existem diversos tipos de tratamentos cirúrgicos para esses prolapsos, entre eles a colpopromontofixação e a colpofixação ao ligamento sacroespinhal. Esta última técnica tem menor morbidade, mas cursa com aumento nas taxas de prolapso em parede anterior após a cirurgia. O uso de telas sintéticas na parede vaginal poderia diminuir a ocorrência destes prolapsos de parede anterior, diminuindo o número de reintervenções necessárias. Objetivo: comparar a eficácia e a segurança da colpopromontofixação com a técnica de colpofixação ao ligamento sacroespinhal com uso de tela anterior para correção do prolapso genital apical. Sujeitos e métodos: Este foi um estudo corte transversal, com avaliação de 89 prontuários de mulheres submetidas à correção do prolapso apical pelas duas técnicas cirúrgicas, no Departamento de Tocoginecologia CAISM/UNICAMP, no período de 2005 a 2012. Os prolapsos uterinos foram avaliados no pré e pós-operatórios através da técnica de POP-Q. Foram comparadas as taxas de cura objetiva, complicações imediatas e tardias, índices de recidiva do prolapso. As taxas de cura, complicações e recidiva foram avaliadas pela prevalência simples e comparadas através do teste de qui-quadrado ou teste exato de Fisher. Para as variáveis não paramétricas foi utilizado teste de Mann-Whitney. Para as variáveis avaliadas nos momentos de seguimento, foi realizado teste de Wilcoxon pareado para medidas do POP-Q. O nível de significância foi de 5% e o software utilizado para análise foi o SAS. Resultados: Das 89 mulheres, 41 submeteram-se à colpofixação ao ligamento sacroespinhal e 48 à colpopromontofixação. Não houve diferença entre a média de idade, raça, IMC, tabagismo e presença de comorbidades entre os grupos. Das mulheres incluídas no estudo, 40,4% tinham prolapso de cúpula, também sem diferença entre os dois grupos estudados (p=0,9361). Ao analisar as complicações imediatas, observou-se que a grande maioria dos casos operados não apresentou complicações (93,2 %), sem diferença entre os dois grupos (p=0,9418). Não ocorreu nenhuma lesão vascular, intestinal ou de vias urinárias. Aproximadamente 30% das mulheres tiveram complicações tardias, sendo que a complicação mais frequente foi a dor local, presente apenas nas mulheres submetidas à técnica abdominal (25,6%) (p=0,001). Apenas as mulheres submetidas ao procedimento vaginal tiveram exposição de tela (18,4%). Um terço das mulheres submetidas à cirurgia para correção de prolapso apresentou sintomas miccionais após a cirurgia, sem diferença entre os grupos (p=0,5732), sendo que destas 22,1% apresentavam incontinência urinária de esforço e 9,1% apresentavam a urgência (tabela 3). A taxa de cura objetiva foi de 95,8%, sem diferença entre os grupos (p= 0,0955). Com relação ao prolapso de parede anterior após a cirurgia foi observado que não houve diferença entre as mulheres submetidas às duas técnicas cirúrgicas (p=0,2970), Conclusões: Ambas as cirurgias foram seguras e obtiveram resultados semelhantes na cura objetiva. O uso de tela em parede anterior na técnica vaginal mostrou-se eficaz na prevenção de prolapso genital anterior no pós-operatório / Abstract: Introduction and hypothesis: compare safety and efficacy of abdominal sacral colpopexy and sacrospinous ligament suspension with the use of vaginal mesh in apical prolapse. Methods: This retrospective study was conducted from 2005 to 2012, and included 89 women with apical prolapse who underwent surgery. Assessments included pre- and postoperative Pelvic Organ Prolapse Quantification (POP-Q) stage. Rates of objective cure and imediate/late complications were compared. Results: 41 of 89 women underwent sacrospinous ligament suspension and 48 women abdominal sacral colpopexy. 40, 4 % had apical prolapse (p=0, 9361).Most of them had no complications (93, 2 %) (p=0, 9418). Aproximately 30 % of women had late complications; local pain was the main symptom, only in women who underwent abdominal procedure (25, 6%) (p=0,001).Only women who were submitted to the vaginal procedure had mesh erosion (18,4%).Objective sucess rate and anterior vaginal prolapse (p= 0,2970) was similar in both techniques. Conclusion: Sacrospinous ligament suspension was as effective and had similar objective sucess rate as abdominal sacral colpopexy. Sacrospinous ligament suspension performed with vaginal mesh in the anterior compartment was effective to prevent anterior vaginal prolapse after surgery / Mestrado / Fisiopatologia Ginecológica / Mestra em Ciências da Saúde

Pelvic floor dysfunction in the form of pelvic organ prolapse (POP) is a common gynaecological condition, especially in the elderly. Although the aetiology is poorly understood, several risk factors such as vaginal childbirth, chronically raised intra-abdominal pressure (such as asthma and chronic constipation), ageing, previous hysterectomy and connective tissue disorders are thought to play a role in the pathophysiology of POP. Studies have shown that vaginal childbirth can result in both gross and micro-architectural distortion/alteration of the pelvic floor musculature and is thus considered to play a major role in the development of POP. Although ethnicity has been proposed as a risk factor, there are limited studies on this subject. Recently, transperineal ultrasound (TPUS) has been used to study the structural integrity and the dynamic interaction between the pelvic organs and pelvic floor musculature. Using a specified methodology we intended to determine and compare pelvic floor morphology, namely pelvic organ descent and levator hiatal distensibility in a multi-ethnic South African population (Asian, Caucasian and Black) in both asymptomatic nulliparous and symptomatic multiparous women. Secondly we also intended to study the association between prolapse symptoms and functional anatomy of the pelvic floor, and finally to determine the impact of vaginal childbirth on the pelvic floor morphology 3-6 month postpartum. For all the studies women were recruited from the local nursing school, general gynaecology and tertiary urogynaecology clinic. Pregnant women were recruited from the district antenatal clinic. This cohort included only Black pregnant women. After informed consent all ultrasound volumes were acquired at rest, maximal pelvic floor contraction and Valsalva maneuver. Volumes were deindentified and analysed 6-8 weeks later using GE Kretz 4D View (GE Kretztechnik Gmbh, Zipf, Austria). In the nulliparous cohort, we found that Black South African women had greater pelvic organ descent on ultrasound and clinically and greater distensibility compared to South Asian and Caucasian women. Multivariate modelling revealed that Black 2 ethnicity remained a significant factor for pelvic organ mobility on clinical examination, (P=0.024). In women with symptomatic POP, there was significant variation in clinical prolapse stage, levator distensibility and pelvic organ descent in this racially diverse population presenting with pelvic organ prolapse, with South Asians having a lower avulsion rate than the other two ethnic groups (P= 0.014). As regards the association between prolapse symptoms and functional anatomy of the pelvic floor we found a significant association between awareness, visualization and/or feeling of a vaginal lump and abnormal pelvic floor functional anatomy, that is, hiatal ballooning and levator avulsion (all P< 0.05). The fourth part of the study included eighty four women who returned at a mean of 4.8 months postpartum. We found significant alteration in pelvic organ support and levator hiatal distensibility after vaginal delivery i.e. a significant increase in mean values from ante to postpartum measurements, more so for the vaginal delivery group. 15% of Black primiparous women sustained levator trauma after their first vaginal delivery. In conclusion, to the author‘s knowledge this is the first study on pelvic floor morphology in South African women. Contrary to previous publications inferring that Black women rarely develop PFD, we have shown that this particular ethnic group had significantly different pelvic floor dynamics than Caucasian and South Asian women for both nulliparous and multiparous symptomatic women. Levator trauma occurs in 15% of Black women after vaginal childbirth. / Thesis (PhD)--University of Pretoria, 2017. / Obstetrics and Gynaecology / PhD / Unrestricted