Objectives Despite their growing prevalence, pelvic floor disorders (PFDs) remain undertreated and not well understood by patients, with treatment disparities noted in specific subgroups of women. The goal of the present study was to determine the basic understanding of PFDs of women in the southern Appalachian region of the United States, to determine factors that predict knowledge, and to explore the possible disparities in seeking access to care among women in this region who reported symptoms. Methods A survey of patient knowledge of PFDs, specifically urinary incontinence (UI) and pelvic organ prolapse (POP), was conducted in Johnson City, Tennessee, and involved 305 female patients from this city and the surrounding region. Results Almost half of the participants (43%) reported UI symptoms, with only 25% of these participants reporting treatment. A much smaller percentage (5%) reported POP symptoms, but 44% reported receiving treatment. Overall proficiency for UI knowledge was 54.4%, and 69.5% for POP knowledge. Higher UI knowledge was predicted (P < 0.05) by age younger than 60 years, annual income >$50,000, more than a high school education, and being married. UI knowledge was unrelated to the presence of UI symptoms, receipt of UI treatment, or having seen a urospecialist. Higher POP knowledge was predicted (P < 0.05) by annual income >$50,000, more than a high school education, and presence of POP symptoms. The only factor significantly predicting seeking treatment among women with UI symptoms was marital status. Conclusions Overall knowledge of both UI and POP was reasonably high in this population, suggesting appropriate self-education or education by providers in the region. The women most affected by UI, particularly those older than 60 years, were not well informed, and education by providers does not appear to specifically target women seeking treatment. We must continue to educate and further reduce the gap of knowledge and treatment regarding PFDs in southern Appalachia.

Os Prolapsos de Órgãos Pélvicos (POP) apresentam alta prevalência na população feminina causando grande impacto negativo, social, econômico e financeiro. Apesar de alguns estudos indicarem que mulheres com POP apresentam uma diminuição da função dos músculos do assoalho pélvico (MAP), a literatura é escassa em relação à função dos MAP antes e após cirurgia de POP e sua correlação com a severidade do problema, sintomatologia e impacto da qualidade de vida. O objetivo primário desta pesquisa foi avaliar a função dos MAP antes e após o tratamento cirúrgico para correção dos POP. Os objetivos secundários foram avaliar a severidade do POP antes e após a cirurgia; avaliar a sintomatologia e impacto do POP na qualidade de vida antes e após a cirurgia; verificar a correlação entre a função dos MAP com a severidade do POP antes e após a cirurgia; verificar a correlação entre a função dos MAP com a sintomatologia após a cirurgia; e avaliar a percepção de melhora das pacientes após a cirurgia. Trata-se de um estudo observacional prospectivo que recrutou 86 mulheres atendidas no setor de uroginecologia do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto com indicação cirúrgica para correção cirúrgica de POP estagio II, III e IV avaliado por meio do POP-Q, destas, 19 não atenderam os critérios de inclusão. Foram incluídas 67 mulheres, e finalizaram o estudo 65. As avaliações ocorreram 15 dias antes e 40 dias após a cirurgia. Para verificação do objetivo primário foram utilizados a escala de Oxford modificada e o perineômetro Peritron®. Para verificação dos objetivos secundários foram utilizados o POP-Q, o Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7) e Patient Global Impression of Improvement (PGI-I). O presente estudo encontrou melhora na função dos MAP após a cirurgia, na média da média do equipamento foi -2,356 cmH2O (±8,6797; p=0,0323). Passaram a contrair corretamente os MAP após a cirurgia 23,08% da amostra. Foi verificada diferença significativa na média do escore total do PFDI-20 de 36,901 pontos (±27,05; p=<0,0001), e do PFIQ-7 de 70,417 pontos (±72,285; p= <0,0001) antes e após a cirurgia. Verificou-se que quanto pior a função dos MAP maior é a sintomatologia do POP e seu impacto na qualidade de vida, e quanto maior a severidade do POP menor média da CVM (p= 0,042), após a cirurgia. Declararam-se \"muito melhor\" após a cirurgia 86,15% das participantes. / Pelvic Organ Prolapse (POP) has a high prevalence in the female population causing great negative social, economic and financial impact. Although some studies indicate that women with POP have a decreased function of the pelvic floor muscles (PFM), the literature is scarce in relation to PFM before and after POP surgery and its correlation with the severity of the problem, symptoms and impact on quality of life. The primary objective of this study was to evaluate the PFM function before and after POP surgery repair. Secondary objectives were to evaluate the severity of POP before and after surgery; assess the symptoms and impact of POP on quality of life before and after surgery; verify the correlation between the PFM function and severity of POP before and after surgery; verify the correlation between PFM function and symptoms after surgery; and to evaluate the patients global perception of improvement after surgery. This is a prospective observational study that recruited 86 women treated at the Urogynecology Unit of the Clinics Hospital of Ribeirão Preto Medical with medical indication for surgical correction of POP stage II, III and IV assessed using the POP-Q, of these, 19 did not meet the inclusion criteria. It was included 67 women, and 65 completed the study. Assessments occurred 15 days before and 40 days after surgery. For verification of the primary endpoint were used the modified Oxford grading scale and perineometer PeritronTM. To check the secondary endpoints were used the POP-Q, the Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7) and the Patient Global Impression of Improvement (PGI-I). This study found improvement in PFM function after surgery, the mean of the mean of the equipment was -2.356 cmH2O (± 8.6797; p = 0.0323). After surgery 23.08% of the sample was able to contract correctly the PFM. There was a significant difference in the mean total score of PFDI-20 of 36.901 points (± 27.05; p= <0.0001), and PFIQ-7 70,417 points (±72,285; p= <0.0001) after surgery. It was found that the worse the PFM function higher the symptomology of POP and it´s impact on quality of life, and the worse is the severity of the POP lowest are the values of the mean MVC (p= 0,042). After surgery 86.15% of the volunteers reported \"much better\".

Os Prolapsos de Órgãos Pélvicos (POP) apresentam alta prevalência na população feminina causando grande impacto negativo, social, econômico e financeiro. Apesar de alguns estudos indicarem que mulheres com POP apresentam uma diminuição da função dos músculos do assoalho pélvico (MAP), a literatura é escassa em relação à função dos MAP antes e após cirurgia de POP e sua correlação com a severidade do problema, sintomatologia e impacto da qualidade de vida. O objetivo primário desta pesquisa foi avaliar a função dos MAP antes e após o tratamento cirúrgico para correção dos POP. Os objetivos secundários foram avaliar a severidade do POP antes e após a cirurgia; avaliar a sintomatologia e impacto do POP na qualidade de vida antes e após a cirurgia; verificar a correlação entre a função dos MAP com a severidade do POP antes e após a cirurgia; verificar a correlação entre a função dos MAP com a sintomatologia após a cirurgia; e avaliar a percepção de melhora das pacientes após a cirurgia. Trata-se de um estudo observacional prospectivo que recrutou 86 mulheres atendidas no setor de uroginecologia do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto com indicação cirúrgica para correção cirúrgica de POP estagio II, III e IV avaliado por meio do POP-Q, destas, 19 não atenderam os critérios de inclusão. Foram incluídas 67 mulheres, e finalizaram o estudo 65. As avaliações ocorreram 15 dias antes e 40 dias após a cirurgia. Para verificação do objetivo primário foram utilizados a escala de Oxford modificada e o perineômetro Peritron®. Para verificação dos objetivos secundários foram utilizados o POP-Q, o Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7) e Patient Global Impression of Improvement (PGI-I). O presente estudo encontrou melhora na função dos MAP após a cirurgia, na média da média do equipamento foi -2,356 cmH2O (±8,6797; p=0,0323). Passaram a contrair corretamente os MAP após a cirurgia 23,08% da amostra. Foi verificada diferença significativa na média do escore total do PFDI-20 de 36,901 pontos (±27,05; p=<0,0001), e do PFIQ-7 de 70,417 pontos (±72,285; p= <0,0001) antes e após a cirurgia. Verificou-se que quanto pior a função dos MAP maior é a sintomatologia do POP e seu impacto na qualidade de vida, e quanto maior a severidade do POP menor média da CVM (p= 0,042), após a cirurgia. Declararam-se \"muito melhor\" após a cirurgia 86,15% das participantes. / Pelvic Organ Prolapse (POP) has a high prevalence in the female population causing great negative social, economic and financial impact. Although some studies indicate that women with POP have a decreased function of the pelvic floor muscles (PFM), the literature is scarce in relation to PFM before and after POP surgery and its correlation with the severity of the problem, symptoms and impact on quality of life. The primary objective of this study was to evaluate the PFM function before and after POP surgery repair. Secondary objectives were to evaluate the severity of POP before and after surgery; assess the symptoms and impact of POP on quality of life before and after surgery; verify the correlation between the PFM function and severity of POP before and after surgery; verify the correlation between PFM function and symptoms after surgery; and to evaluate the patients global perception of improvement after surgery. This is a prospective observational study that recruited 86 women treated at the Urogynecology Unit of the Clinics Hospital of Ribeirão Preto Medical with medical indication for surgical correction of POP stage II, III and IV assessed using the POP-Q, of these, 19 did not meet the inclusion criteria. It was included 67 women, and 65 completed the study. Assessments occurred 15 days before and 40 days after surgery. For verification of the primary endpoint were used the modified Oxford grading scale and perineometer PeritronTM. To check the secondary endpoints were used the POP-Q, the Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7) and the Patient Global Impression of Improvement (PGI-I). This study found improvement in PFM function after surgery, the mean of the mean of the equipment was -2.356 cmH2O (± 8.6797; p = 0.0323). After surgery 23.08% of the sample was able to contract correctly the PFM. There was a significant difference in the mean total score of PFDI-20 of 36.901 points (± 27.05; p= <0.0001), and PFIQ-7 70,417 points (±72,285; p= <0.0001) after surgery. It was found that the worse the PFM function higher the symptomology of POP and it´s impact on quality of life, and the worse is the severity of the POP lowest are the values of the mean MVC (p= 0,042). After surgery 86.15% of the volunteers reported \"much better\".

Orientador: Cássio Luís Zanettini Riccetto, Benedicto de Campos Vidal / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-18T18:21:20Z (GMT). No. of bitstreams: 1 Maciel_LuizCarlos_D.pdf: 8260525 bytes, checksum: 6e55aa9d959f06cd42ce61de61d4ac5e (MD5) Previous issue date: 2011 / Resumo: Introdução: O aumento da expectativa de vida elevou o risco da necessidade de cirurgia para o tratamento dos prolapsos de órgãos pélvicos (PO) em mulheres, principalmente no período pós-menopausa. Os distúrbios ocasionados pelos POP afetam a qualidade de vida, ao estabelecer alterações na sexualidade, função urinaria e intestinal. Neste cenário, o uso das telas ganhou popularidade. Embora as telas de polipropileno sejam consideradas um bom material para restaurar o assoalho pélvico, diminuindo o tempo cirúrgico e a dor pós-operatória, existem preocupações quanto à infecção e exposição da tela. Objetivos: Estudar as características da deposição colágena associada aos implantes subcutâneos de telas de polipropileno revestidas por biomembrana de colágeno de submucosa intestinal suína (BMSS) em ratas, e descrever as características da reação inflamatória local. Material e Métodos: 30 ratas fêmeas foram divididas em três grupos conforme a data de eutanásia (7º; 14º, e 28º pós-operatório). Foram implantadas no subcutâneo abdominal destes animais um segmento de tela de polipropileno revestida com colágeno à direita e outro segmento de tela não revestida no lado esquerdo. O material foi fixado em HE e analizado no microscópio de polarização Olympus BX51 e acoplado ao software image Pro plus 6.0 para estudar as propriedades anisotrópicas do colágeno e as características da reação inflamatória local. Resultados: 7ºPO: A biomembrana induziu intensa proliferação vascular, vasodilatação, infiltração de linfocitos e proliferação fibroblástica. No subgrupo da tela de polipropileno isolada notaram-se predomínio de células com aspecto histiocitário e células gigantes. 14ºPO: No subgrupo da biomembrana persistiu o infiltrado predominantemente linfocitário semelhante ao 7ºPO. Não ocorreram alterações expressivas na intensidade da deposição colágena, persistiu o aspecto de congestão vascular. No subgrupo do polipropileno isolado, observou-se alguma proliferação fibroblástica em torno dos filamentos de polipropileno, além de células gigantes achatadas pelo envoltório de colágeno e fibroblastos, mantendo pouco infiltrado linfocitário, em relação à tela recoberta pela biomembrana. 28º PO: No subgrupo da biomembrana de colágeno observou-se intensa deposição colágena com diminuição do infiltrado linfocitário e presença de mononucleares histiocitários. No subgrupo da tela de polipropileno isolada evidenciaram-se células gigantes as quais apresentavam tendência de envolver o polímero, além de menor infiltrado fibroblástico em comparação ao grupo recoberto com a biomembrana. Conclusão: A tela de polipropileno revestida pela BMSS evidenciou resolução precoce da inflamação, melhor neoangiogênese e deposição colágena melhor organizada do que a tela não revestida. Isto pode representar um vantagem em segmentos clínicos se estes resultados experimentais puderem ser reproduzidos em outros estudos / Abstract: Introduction: The raise of expectance of life has brought an increase of women which will underwent pelvic organ prolapse (POP) surgery, mainly in the post menopause period. The distress caused by POP affects women's quality of life, as it alters their sexuality, urinary and bowel functions. In this scenario, the use of meshes is gaining popularity worldwide. Although polypropylene mesh (PM) is considered a good material to restore the pelvic floor, decreasing operative time and post-operative pain, there are concerns about infection and vaginal mesh exposure. Objetives: To study the characteristics of collagen deposition related to covering subcutaneous implants of monofilament polypropylene mesh in rats with purified suine collagen biomembrane and to describe the characteristics of the local inflammatory reaction. Methods: Thirty female rats were shared in three groups according to the euthanasia's day (7º; 14º, 28º post-operative day). Polypropylene meshes were implanted at abdominal subcutaneous, on the right side the mesh covered by a collagen biomembrane and on the left side a non covered PM. The material were stained with HE and analyzed with Olympus BX51 polarized microscope and image Pro plus 6.0 software to study the collagen anisotropic properties and inflammatory reaction. Results: In the 7º PO the CM group showed vascular proliferation and intense infiltration of lymphocytes and fibroblasts. The PM without CM group presented a intense histiocytary infiltrate and a mild fibrosblastic reaction and angiogenesis. At the 14º PO, the group A maintained a similar lymphocytic infiltrate which was observed at the 7º PO, without expressive alterations in the degree of fibroblastic reaction and collagem deposition. In the group B, there was a intense fibroblastic reaction surrounding the PM. Also, there were multinucleated giant cells crushed by a wrap of collagen and fibroblasts. In the 28º PO, the group A revealed an intense fibroblastic reaction process and collagen deposition. In contrast, in the group B, it is observed that the multinucleated giant cells tried to wrap up the polypropylene, and there were a decrease of fibroblastic reaction in comparison to the PM with CM group. Conclusions: PM covered with a purified porcine collagen membrane showed earlier resolution of inflammatory reaction, better neoangiogenesis and more organized host collagen deposition than in pure PM. This can represent an advantage in clinical setting if these experimental results proved to be reproducible in other trials / Doutorado / Fisiopatologia Cirúrgica / Doutor em Ciências da Cirurgia

In many applications, the dataset for classification may be highly imbalanced where most of the instances in the training set may belong to some of the classes (majority classes), while only a few instances are from the other classes (minority classes). Conventional classifiers will strongly favor the majority class and ignore the minority instances. The imbalance problem can occur in both binary data classification and also in ordinal regression. Ordinal regression is a supervised approach for learning the ordinal relationship between classes. Extensive research has been performed for addressing imbalanced datasets for binary classification; however, current methods do not address within-class imbalance and between-class imbalance at the same time. Similarly, there has been very little research work on addressing imbalanced datasets for ordinal regression. Although current standard oversampling methods can be used to improve the dataset class distribution, they do not consider the ordinal relationship between the classes. The class imbalance problem is a big challenge in classification problems. Most of the clinical datasets are highly imbalanced, which can weaken the performance of classifiers significantly. In this research, the imbalanced dataset classification problem is also examined in the context of a clinical application, particularly pelvic organ prolapse diagnosis. Pelvic organ prolapse (POP) is a major health problem that affects between 30-50% of women in the U.S. Although clinical examination is currently used to diagnose POP, there is still little evidence on specific risk factors that are directly related to particular types of POP and their severity or stages (Stage 0-IV). Data from dynamic MRI related to the movement of pelvic organs has the potential to improve POP prediction but it is currently analyzed manually limiting its exploration and use to small datasets. Moreover, POP is a disorder with multiple stages that are ordinal and whose distribution is highly imbalanced. The main goal of this research is two-fold. The first goal is to design new oversampling methods for imbalanced datasets for both binary classification and ordinal regression. The second goal is to automatically track, segment, and classify the trajectory of multiple organs on dynamic MRI to quantitatively describe pelvic organ movement. The extracted image-based data along with the designed oversampling methods will be used to improve the diagnosis of POP. The proposed research consists of three major objectives: 1) to design a new oversampling technique for binary imbalanced dataset classification; 2) to design a novel oversampling technique for ordinal regression with imbalanced datasets; and 3) to design a two-stage method to automatically track and segment multiple pelvic organs on dynamic MRI for improving the prediction of multi-stage POP with imbalanced datasets. The proposed research aims to provide robust oversampling techniques and image processing models that can (1) effectively handle highly imbalanced datasets for both binary classification and ordinal regression, and (2) automatically track and segment multiple deformable structures for feature extraction from low contrast and nonhomogeneous images and classify them using the resulted trajectories. This research will set the foundation towards a computer-aided decision support system that can automatically extract and analyze image and clinical data to improve the prediction of disorders where the dataset is highly imbalanced through personalized and evidence-based assessment.

Introdução: A prevalência do prolapso de órgão pélvico (POP) aumenta com a idade, estimando-se que quase 30% das mulheres têm algum grau de POP. As pesquisas sobre qualidade de vida relacionada à saúde (QVRS) nesta patologia tornaram-se importantes. A QVRS das mulheres com POP é grandemente afetada; incluindo a alteração dos aspectos físicos e das áreas psicológica e social. Há pouca evidencia sobre os fatores que alteram a QVRS destas mulheres, e que poderiam predizer mudanças após do tratamento. O objetivo desta pesquisa é avaliar a QVRS das mulheres submetidas a cirurgia de correção de POP e conhecer os fatores preditores das mudanças. Método: Estudo longitudinal com desenho analítico, correlacional preditivo em 95 mulheres adultas Chilenas da Região Metropolitana, com diagnóstico de POP e com indicação de cirurgia. Realizou-se avaliação da QVRS em três momentos (basal pré-operatório, um e seis meses após a cirurgia para correção do POP), empregando-se o instrumento Prolapse Quality of Life (PQOL), em sua versão chilena, composto de nove dimensões: percepção geral de saúde (PGS), impacto do prolapso (IP), limitações de papel (LR), físicas (LF), sociais (LS) e relações pessoais (RP), emoções (E), sono/energia (SE) e medidas de gravidade (MS); Os fatores preditores da QVRS foram colhidos utilizando-se os seguintes instrumentos: dados demográficos e clínicos, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-12 versão Chilena (função sexual), Menopause Rating Scale versão Chilena (sintomas menopáusicos), Questionário Geral de Saúde de Golberg (sintomas depressivos) e Modified Body Image Scale (imagem corporal). Os dados foram submetidos às análises descritivas univariadas; análises de medidas repetidas com comparação de médias 2 a 2, usando-se o teste t-Student para comparação de grupos; e análise multivariada utilizando-se o Modelo Linear de Efeitos Mistos, para explicar as variáveis preditoras da QVRS. Além dessas, a Mínima Diferença Importante (MID) e o tamanho do efeito foram utilizados para determinar a magnitude das mudanças na QVRS após o tratamento cirúrgico, utilizando-se o Patient Global Impression of Improvement Index. Resultados: A idade média foi 60 anos (DP=10,3); 76% apresentaram nível educacional básico ou médio, com companheiro (61%), com atividade sexual (40%), com menopausa (74,5%); 2,5 procedimentos cirúrgicos para correção do POP em média. A QVRS melhorou após o tratamento cirúrgico, em ambos os seguimentos (p<0,001), e em todas as dimensões. A imagem corporal apresentou diferença significativa (p<0,05) em todos os momentos de avaliação: para cada ponto de piora da imagen corporal, menor mudança na QVRS após a cirurgia. Os sintomas menopáusicos impactaram em menores mudanças na QVRS nas dimensões PGS e E, em todos os tempos, embora a QVRS nas dimensões IP, LF, LS e SE tenha apresentado leve porém significativa melhora após a cirurgia (p<0,05). As mulheres com doença neurológica mostraram menores mudanças na QVRS no pós-operatório comparativamente àquelas sem essa doença nas dimensões LF, E e SE (p<0,05). Outras variáveis preditoras de QVRS foram a atividade sexual, nível educacional, idade e diabetes mellitus. Obteve-se um efeito de grande magnitude em todas as dimensões e estabeleceu-se MID entre -1,19 e -15 pontos para todas as dimensões de PQOL. Conclusão: A QVRS melhorou após o tratamento cirúrgico, em todas as dimensões, e as variáveis preditoras mais importantes foram a imagen corporal, os sintomas menopáusicos e as doenças neurológicas. O estudo contribui para corroborar a necessidade de avaliação integral das mulheres no pré-operatório visando a conhecer as tendências de sua QVRS posteriormente atuando nos fatores modificáveis que podem influir negativamente em sua recuperação pós-operatória. / Introduction: Prevalence of pelvic organ prolapse (POP) increase with age, estimating that almost 30% of women has some POP degree. Research about health related quality of life (HRQL) in this pathology it have gained relevance. HRQL of women with POP is highly affected; including physical impaired, and psychological and social spheres. There is little evidence about factors influence HRQL of these women. The aim of this research was to evaluate HRQL of women submitted to surgical correction of POP and predictors factors of changes. Methods: Llongitudinal study with analytical, correlational, predictive design in 95 Chilean women, of the Metropolitan Area, with POP diagnosis and surgical indication. An evaluation was performed of HRQL in three times (baseline before surgery, and follow up at first and six month after surgery) Instruments applied were Prolapse Quality of Life (PQOL) Chilean version which nine dimensions: General health perception (GHP), prolapse impact (PI), role (RL), physical (LF), socials (LS) and personal limitations, emotions (E), sleep/energy (SE) and, severity measurement (SM); predictors factors of HRQL were obtained using demographic and clinical data, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-12 Chilean version (sexual function), Menopause Rating Scale Chilean version (menopause symptoms), Goldbergs General Health Questionnaire (depressive symptoms) and Modified Body Image Scale (Body image). Data analysis included univariate descriptive analysis, repeated measures analysis with media comparison 2 to 2 for group and multivariate analysis with linear mixed effects models to explain predictors variables of HRQL. Also, the minimum important difference (MID) and effect size were used to determine magnitude of change in HRQL after surgical treatment, anchor used was Patient Global Impression of Improvement Index. Results: age average was 60 years (SD: 10.3), 76% primary or secondary educational level, 61% have couple, 40% was active sexually, most of women had menopause (74.5%), average of procedures of POP correction was 2.5. HRQL improved after surgical treatment, in both follow up (p<0.001) in every dimension. Body image had significant difference (p<0.05) without time interaction, every point for worse body image, HRQL get worse. Menopause symptoms had a positive impact on GHP and E, showed fewer score in every time, meanwhile PI, FL, SL and SE had a little but statistical significant improved after surgical treatment (p<0.05). Women with neurological disease showed less change in HRQL after surgery than without disease in FL, E and SE dimension (p<0.05). Other predictive variables after surgery (p<0.05) were sexual activity, educational level, age and diabetes. MID it determined among -1.19 y -15 points for all dimensions of HRQL, considering an large in all dimensions too. Conclusion: HRQL improved after surgery, most important predictive variables were body image, menopause symptoms and neurological disease, therefore integral assessment of women before surgery is important to know HRQL trend after treatment, to support them and improve or maintain modify factors that could have negative impact.

Introdução: O uso de telas de polipropileno para reforço em cirurgias para correção de prolapso vaginal apresenta taxas de complicação de até 25%. Trata-se de doença de alta prevalência, acometendo até 30% das mulheres, cujas opções atuais de tratamento foram reduzidas após a descontinuação da fabricação dos reforços tradicionais por diversos fabricantes. Uma alternativa é a utilização de matrizes sintéticas de outros materiais e com outras configurações, possibilitando inclusive cultura de células em seu leito. A eletrofiação possibilita a produção e reprodução em larga escala dessas matrizes a partir de polímeros solúveis expostos a um campo elétrico. Objetivos: Estabelecer parâmetros de produção de matrizes com fibras híbridas e randômicas através de eletrofiação, demonstrar sua reprodutibilidade e implantar tal tecnologia em solo brasileiro. Testar as seguintes características teóricas das matrizes híbridas produzidas com acido polilático (PLLA): maior força tênsil nos testes biomecânicos e biocompatibilidade mantida para cultura celular. Estudar a influência da cultura de células-tronco mesenquimais derivadas de adipócitos (CTDA) sobre as propriedades mecânicas das matrizes estudadas. Avaliar a influência da hidrólise na perda de força tênsil das matrizes em experimentos de até 90 dias. Métodos: Foram produzidas matrizes de PLLA dissolvidos em diclorometano (DCM) nas configurações de fibras randômicas, alinhadas e um novo método foi desenvolvido para produção de matrizes híbridas. Foram realizados microscopia eletrônica, testes biomecânicos, testes de atividade metabólica e biocompatibilidade com cultivo de células-tronco derivadas de adipócitos, além de testes de degradação em meio de cultura por 90 dias para comparar as matrizes. Análise de variância (ANOVA) com teste de Tukey foram utilizados para comparação dos resultados obtidos nos experimentos quando aplicáveis. Resultados: A produção de matrizes híbridas foi possível ajustando-se os parâmetros de eletrofiação. Imagens de microscopia comprovaram o alinhamento e hibridização das fibras. Testes uniaxiais mostraram que as matrizes híbridas foram 3 a 4 vezes mais resistentes a tração do que as matrizes randômicas (p < 0,0001) preservando sua biocompatibilidade e afinidade celular. A incorporação de células às matrizes híbridas e o experimento de degradação mostraram quedas nas propriedades mecânicas de força tênsil máxima das matrizes híbridas a partir de 14 dias em meio de cultura, mas sempre se mantendo acima das propriedades dos tecidos nativos pelo período estudado de até 90 dias. Conclusões: Foi possível o desenvolvimento de nova técnica de eletrofiação para produção de matrizes híbridas de fibras alinhadas e randômicas com maior força tênsil, ainda sim mantendo sua afinidade celular. Tais matrizes enfraqueceram no período de 90 dias estudado, sem contudo apresentar valores abaixo dos fisiológicos, mostrando-se como opção promissora para substituição de telas de polipropileno em clínica. Estudos com animais são necessários para confirmar essa hipótese / Introduction: Traditional reinforcement techniques for pelvic organ prolapse use mainly polypropylene meshes with complication rates up to 25%. It is a common disease with prevalence up to 30%, with reduced options of treatment after withdrawing of major companies from this market. An alternative is the use of synthetic matrices from other materials with other configurations, possibly with cell culture added. Electrospinning is a reproducible technique that uses solved polymers exposed to intense electric field to produce sheets like that. Objectives: Establish parameters to electrospin hybrid and random fibres and setup this technology in Brazil. Prove following theoretical characteristics of hybrid poly- L-lactide (PLLA) matrices: higher tensile strength in biomechanical tests with comparable biocompatibility. Study adipose derived stem cells (ADSC) culture impact over biomechanical properties of these matrices. Check hydrolysis influences on tensile strength up to 90 days. Methods: PLLA solved in dichloromethane (DCM) was electrospun in random fibres, align fibres and a novel method was developed to produce hybrid fibres. Electron microscopy (SEM), biomechanical tests, metabolic activity and biocompatibility with adipose-derived stem cells and additionally, degradation test up to 90 days in culture medium were performed to compare matrices. ANOVA with Tukey test of differences was used to compare experiment results. Results: The production of hybrid matrices was possible adjusting electrospinning parameters, SEM confirmed fibre\'s alignment and hybridization, uniaxial tests showed that hybrid matrices were 3 to 4 times stronger than random ones (p < 0,0001) maintaining its biocompatibility and cell affinity. Both cell incorporation to hybrid matrices and degradation experiment showed mechanical properties drop (ultimate tensile strength) after 14 days in culture medium but always keeping it above physiologic range up to 90 days studied. Conclusions: Development of new technique of electrospinning of hybrid matrices of align and random fibres was possible, with higher tensile strength and keeping the same cell affinity. These matrices showed drop in mechanical strength along 90 days of study but always above the natural tissues range being a promising option to polypropylene meshes in clinic. Further studies with animals are needed to confirm this hypothesis

Background: Pelvic organ prolapse (POP) is a relatively common condition. In Sweden, the overall estimated prevalence of POP in the female population is 31% and the prevalence of symptomatic prolapse is 8–15%. The prevalence of POP increases with age. The lifetime risk of undergoing pelvic floor surgery is estimated to 11%. The aim of this thesis was to investigate outcomes of vaginal hysterectomy for treatment of prolapse; to study outcomes of cystocele repair surgery and patient satisfaction related to different anaesthesia methods; to explore women’s experiences of vaginal prolapse; and to investigate what is known regarding POP prior to surgery and healthcare-seeking behaviour. Methods: In the Swedish National Quality Register for Gynaecological Surgery (Gynop-register), 941 women were identified who underwent vaginal hysterectomy for prolapse from 1997 to 2005 and 1,364 women were identified who underwent cystocele repair surgery from 2006 to 2009. In-depth interviews were performed with 14 women with vaginal prolapse. Interview data were analyzed with a qualitative content analysis. To investigate women’s knowledge about POP and healthcare-seeking behaviour, a questionnaire was developed, validated and distributed to women with planned surgery for POP. Women undergoing hysterectomy or incontinence surgery were used as reference groups. Results: Severe complications after vaginal hysterectomy occurred in 3% of cases. Sexual activity was improved after vaginal hysterectomy, the number of women reported to have intercourse increased by 20% (p = 0.006). Subjective symptoms of urinary incontinence and overactive bladder were resolved in 50% of the women. De novo stress incontinence was reported by 11% of the women. Use of local anaesthesia (LA) in reconstruction of cystocele showed advantage over other forms of anaesthesia. Length of hospital stay, duration of use of postoperative pain-killing drugs, and time to return to daily activity were shorter among women who underwent surgery with LA compared to other forms of anaesthesia. Patient satisfaction was not related to methods of anaesthesia. In an interview study, the process from recognition the symptoms to seeking healthcare was highlighted. Two categories, “obstacles” and “facilitators” to seeking health care, were identified. One of the obstacles was lack of information on POP in the public domain. The main facilitators were feeling sexually unattractive and impaired physical ability due to POP. Some findings from the interview study were further explored in the questionnaire study. One out of five women with vaginal prolapse did not know that the symptoms were related to prolapse before consulting their physician. Over 30% of the women in the incontinence group were embarrassed to talk about incontinence, and they were unaware that it could be treated. The most frequent description of vaginal prolapse was vaginal bulging. Women in the prolapse group had significantly less access to information through brochures and public media than women in the incontinence group (p &lt; 0.001). Conclusion: Short-term follow-up after vaginal hysterectomy showed that sexual activity and urinary symptoms had improved. Cystocele surgery using LA showed no disadvantage compared to surgery using other anaesthesia methods. POP surgery can therefore be performed safely with LA. Information on prolapse should be easily accessible to improve the possibility for women of gaining knowledge and thereby overcoming obstacles to seeking medical advice. Healthcare professionals have a significant role to play in informing women about symptoms and available treatment options.

Introduction: Pelvic organ prolapse is a major health problem affecting 50% of parous women over the age of 50. The lifetime risk for pelvic floor surgery for prolapse is likely to be between 10 and 20% and a large number of patients require repeat surgery for recurrence. Cochrane review showed that mesh use at the time of anterior repair reduce the risk of recurrence. In our first study we prospectively evaluate the impact of mesh insertion during anterior repair on sexual function and quality of life. Mesh insertion may be associated with significant and in some cases serious adverse events. To justify its use, it seems necessary to identify women at high risk of prolapse recurrence. There is evidence indicating that levator ani avulsion injury is closely associated with prolapse recurrence. The aim of our second and main study was to demonstrate in a prospective randomized way that levator avulsion may be used to identify patients at high risk for failed native tissue prolapse surgery. Methods: The first study prospectively evaluated with validated questionnaires the impact of mesh insertion on quality of life and sexual function. The second study is a single-center, prospective, randomized interventional trial of two standard surgical procedures for post-hysterectomy vaginal vault prolapse in...

Introdução: Devido à fatores hormonais e mecânicos, a gestação e o parto provocam alterações que podem gerar disfunções do assoalho pélvico (DAP). Os estudos sobre as DAP no puerpério a curto prazo são escassos e fazem uso assistemático de métodos avaliativos. Objetivo: Identificar e avaliar as DAP no pós-parto imediato, um mês e três meses após o parto, comparando parto vaginal (PV), cesárea eletiva (CE) e cesárea intraparto (CI). Métodos: Estudo observacional longitudinal que avaliou mulheres até 48 horas (fase 1); um mês (fase 2) e três meses após o parto (fase 3). Utilizou-se o International Consultation on Incontinence Questionnaire (ICIQ-SF); o Índice de Incontinência Anal (IA) de Jorge-Wexner; a Escala Análoga Visual (EVA) para dor pélvica; o Pelvic Organ Prolapse Quantification system (POP-Q) e a perineometria dos Músculos do Assoalho Pélvico (MAP), além de questionário estruturado. Resultados: Foram avaliadas 227 pacientes na fase 1 (141 realizaram PV; 28 realizaram CI e 58 realizaram CE); 79 na fase 2 e 41 na fase 3. O escore do ICIQ-SF, índice de IA, EVA e perineometria não apresentaram diferenças significativas em relação ao tipo de parto. O ponto distal do colo uterino apresentou-se mais prolapsado no grupo PV. Conclusão: O tipo de parto não foi um fator significante para o desenvolvimento das DAP no pós-parto a curto prazo. Foi identificado que ocorreu recuperação fisiológica na funcionalidade dos MAP e piora na sustentação da parede vaginal anterior e no impacto da incontinência urinária na qualidade de vida ao longo dos três meses. / Introduction: Due to mechanical and hormonal factors, pregnancy and childbirth triggers changes that can lead to pelvic floor dysfunction (PFD). PFD studies in the immediate postpartum period are scarce and do unsystematic use of evaluation methods. Objective: To identify and evaluate the immediate, one month and three months postpartum PFD, comparing vaginal delivery (VD), elective cesarean (ECS) and cesarean indicating (ICS) during labor. Methods: This was a longitudinal observational study that assessed postpartum women after up to 48 hours (phase 1); one month (phase 2) and three months (phase 3). The study used the International Consultation on Incontinence Questionnaire (ICIQ-SF); Jorge-Wexner's Anal Incontinence (AI) score; the Visual Analogue Scale (VAS) for pelvic pain; the Pelvic Organ Prolapse Quantification System (POP-Q); and a Pelvic Floor Muscles (PFM) perineometer, as well as a structured questionnaire. Results: A total of 227 patients were assessed in phase 1 (141 had VD, 28 ICS and 58 ECS); 79 in phase 2 and 41 in phase 3. The ICIQ-SF, AI, VAS and perineometer index did not present significant differences in relation to the type of delivery. The distal point of the cervix presented more prolapse in VD. Conclusion: The type of delivery was not a significant factor for the development of postpartum PFD in the short term. The study found that there was physiological recovery of the functionality of PFM and worsening prolapse of the anterior vaginal wall and urinary incontinence over the three months.