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L’endométriose est définie comme la présence de tissu endométrial et de stroma en dehors de la cavité utérine. Ses localisations les plus fréquentes sont le péritoine pelvien et les ovaires. L’endométriose infiltrante est classiquement décrite comme la présence de tissu endométriotique plus de cinq millimètres sous le péritoine pelvien ou la séreuse d’un organe. Histologiquement il s’agit d’une lésion endométriotique mais qui contrairement aux lésions ovariennes ou péritonéales contient significativement plus de muscle lisse et de fibrose et est davantage associée à la douleur. Les lésions infiltrantes peuvent être responsables de dysménorrhée, dyspareunie profonde et douleurs pelviennes chroniques sévères ayant un charactère hyperalgique tel qu’on peut le retrouver dans les douleurs neuropathiques. Ces douleurs nécessitent souvent la prise de quantités importantes d’antalgiques et ont des répercussions importantes sur la vie professionnelle, quotidienne et sexuelle des femmes atteintes. L’endométriose infiltrante présente un rapport histologique étroit avec les structures nerveuses du rétropéritoine ou les nerfs des organes atteints. Dans sa localisation rectovaginale il existe une relation histologique étroite entre les lésions d’endométriose et les nerfs ainsi qu’une correlation entre l’intensité de la douleur et le nombre de structures nerveuses envahies par l’endometriose ou engaînées dans la fibrose. Ces lésions infiltrantes expriment le «nerve growth factor» (NGF), une neurotrophine qui joue un rôle clé dans la genèse de l’hyperalgie et de la douleur. Les structures nerveuses du rétropéritoine pelvien expriment quant à elles le récepteur spécifique pour la neurotrophine NGF. Le système «NGF-récepteur spécifique» peut être responsable d’un chimiotactisme tissulaire entre les tissus sécrétant du NGF et les nerfs qui expriment le récepteur pour le NGF. Le système «NGF- récepteur spécifique» au sein de la relation endométriose-nerfs pourrait rendre compte du caractère hyperalgique des lésions endométriotiques infiltrantes ainsi, qu’expliquer pourquoi les lésions nodulaires n’apparaissent que dans les sites anatomiques richement innervés (ligaments utérosacrés, lame rectovaginale, paroi du rectum ou du côlon…) et pas ailleurs. Le traitement de première intention est chirurgical. Il convient d’être suffisamment agressif sur les lésions tout en engendrant le moins de séquelles postopératoires possibles sachant que nombre de ces femmes sont stériles. En cas d’atteinte digestive basse, les modalités de l’intervention sont dictées par l’extension et le degré d’infiltration de la paroi digestive. Dans le but de réaliser dans la majorité des cas une chirurgie minimalement invasive (laparoscopique) avec des cicatrices de petites tailles, nous avons développé une stratégie de traitement basée sur le degré d’infiltration de la paroi digestive. Dans ce cadre nous avons développé une technique laparo-assistée de résection colique segmentaire et de résection antérieure du rectum. / Doctorat en sciences médicales / info:eu-repo/semantics/nonPublished

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, 2014. / Flexion distraction chiropractic technique (FDCT) is a commonly used manual therapy technique which is purported to address various clinical pain syndromes. However, it lacks the credibility of appropriate evidence-based guidelines. An analysis of the literature would be able to inform the development of guidelines. Objectives: The aim of this systematic review was to determine the evidence to support the use of FDCT in clinical practice. Data sources: A systematic review of PubMed and Summons was conducted, using the following search terms: chiropractic, flexion distraction, protocol and / or technique. Study selection: All electronic or paper, English articles, which possessed the required key indexing terms and represented randomised and non-randomised controlled study designs were included. Data extraction: Blinded review of the articles was conducted by three independent reviewers utilising the PEDro (for randomised controlled trials) and NOS for (non-randomised controlled trials). This allowed the methodological rigour of the article to be ranked. This ranking was compared to a critical appraisal of the article in order to achieve an overall decision with regards to the contribution of the article to the level of evidence for FDCT. Data synthesis: 18 review outcomes were aggregated around four clinical categories; two articles each on neck pain, chronic pelvic pain, and physiological outcomes and the remaining twelve on low back pain. There was agreement that the evidence for pelvic pain and physiological function was limited to no evidence and limited respectively. Conflicting evidence existed for neck and low back pain (single and multimodal treatment) with limited and moderate evidence respectively. Conclusion: FDCT is clinically advocated for many conditions. The evidence provided in this review indicates that practitioners should be guarded in their use of FDCT, as the evidence to its widespread use is limited to only those conditions noted in this review. Therefore, further high quality and rigorous studies are required to develop appropriate treatment guidelines for use by practitioners to adequately provide evidence based care in clinical practice.

Thesis (MScPhysio (Interdisciplinary Health Sciences. Physiotherapy))--University of Stellenbosch, 2010. / ENGLISH ABSTRACT: The pelvic floor muscles (PFM) contribute to urinary continence and overactive PFM seem to be associated with pelvic pain syndrome (PPS). The literature indicates that ethnic differences regarding symptoms of urinary incontinence may exist. Research is needed to establish relationships between PFM function and symptoms reported by women of different ethnic groups. Objectives: To compare the PFM strength and endurance in black, white and coloured women. To investigate relationships between PFM strength, vaginal resting pressures, risk factors and symptoms associated with PFM dysfunction and PPS. Method: A cross-sectional study assessed the PFM strength and vaginal resting pressures of 122 nulliparous black (n=44), white (n=44) and coloured (n=34) university students. A self-developed questionnaire determined inclusion, demographic variables, factors affecting/factors associated with PFM strength and symptoms related to PPS. Maximum voluntary contraction pressure (cmH2O) and vaginal resting pressure (cmH2O) were measured with the Peritron TM 9300 (Cardio Design, Australia) used with the Camtech AS vaginal balloon sensor (Sandvika, Norway). Two sets of 3 maximum voluntary contractions of the PFM were recorded. Results: The mean age of the group was 22 ± 3.54 years and mean BMI of 23± 4.16 kg/m2. Black women (25 cmH2O ± 13.5) had significantly stronger PFM than white (p=0.02) or coloured (p<0.01) women, but no significant difference (p=0.78) in PFM strength existed between white (18.4 cmH2O ± 9.8) and coloured (15.6 cmH2O ± 8) women. In black women, PFM strength decreased significantly (p=0.02) between the sets, whereas no significant difference between sets was noted in the other ethnic groups. Increased PFM strength was associated with SUI (p=0.03) and amenorrhoea (p=0.01) and decreased PFM strength was associated with decreased frequency of bowel motion (p=0.01). In this sample, increased vaginal resting pressure was associated with menorrhagia (p=0.04). Conclusion: Black nulliparous women had stronger PFM than white and coloured women. There was no difference in PFM strength between white and coloured women. Endurance, as measured in this study, indicates that black women have decreased endurance of the PFM compared to white and coloured women. These findings inform the current research on ethnic differences in the prevalence of urinary incontinence. Preliminary data suggest that there was no relationship between vaginal resting pressures and symptoms of PPS and risk factors for PFM dysfunction, except for menorrhagia. / AFRIKAANSE OPSOMMING: Die bekkenvloer spiere (BVS) dra by tot urinêre kontinensie en ooraktiewe BVS kan moontlik geassosieer wees met pelviese pyn sindroom (PPS). Uit die literatuur blyk dit of daar etniese verskille bestaan in die simptome van urinere inkontinensie gerapporteer deur vroue. Navorsing is nodig om die verwantskap tussen BVS funksie en simptome wat deur pasiënte van verskillende etniese groepe gerapporteer word vas te stel. Doel: Om „n vergelyking te tref tussen BVS sterkte in swart, wit en kleurling vroue. Om vas te stel of daar assosiasies bestaan tussen BVS sterkte, rustende vaginale druklesings en risiko faktore en simptome geassosieer met bekkenvloer disfunksie en PPS. Metodologie: „n Dwarssnit studie het die BVS sterkte en rustende vaginale drukke van 122 nullipareuse swart (n=44), wit (n=44) en kleurling (n=34) universiteit studente geëvalueer. Insluiting, uitsluiting, demografiese veranderlikes, faktore wat kan affekteer/faktore geassosieer met BVS sterkte en simptome geassosier met PPS is deur „n self ontwikkelde vraelys geëvalueer. Maksimale willekeurige spiersametrekking drukke (cmH2O) en rustende vaginale drukke (cmH2O) was gemeet met „n Peritron™9300 perineometer (Cardio Design, Australië) wat saam „n vaginale ballon sensor (Camtech AS, Sandvika, Noorweë) gebruik is. Twee stelle van 3 maksimale willekeurige sametrekkings van die BVS was gemeet. Resultate: Die groep se gemiddelde ouderdom was 22±3.54 jaar en die gemiddelde liggaamsgewig indeks was 23±4.16kg/m2. Swart vroue (25 cmH2O ±13.5) het beduidend sterker BVS gehad as wit (p=0.02) en kleurling (p<0.01) vroue, maar daar was geen beduidende verskil (p=0.78) in BVS sterkte tussen wit (18.4 cmH2O ± 9.8) en kleurling (15.6 cmH2O ± 8) vroue nie. Die BVS sterkte in swart vroue het beduidend (p=0.02) verminder tussen die stelle, maar geen beduidende verskille was waargeneem in die ander etniese groepe tussen stelle. Verhoogde BVS sterkte was geassosieer met druklek (p=0.03), amenorrhoea (p=0.01) en verminderde BVS sterkte was geassosieer met verminderde frekwensie van opelyf (p=0.01). Verhoogde rustende vaginale drukke was geassosieer met menoragie in hierdie steekproef. Gevolgtrekking: Swart nullipareuse vroue het sterker BVS gehad as wit en kleurling vroue, Daar was geen verskil in BVS sterkte tussen wit en kleurling vroue nie. Uithouvermoë soos in hierdie studie getoets toon dat swart vroue verminderde uithouvermoë het i.v.m. wit en kleurling vroue. Hierdie bevindings dra by tot die huidige navorsing oor etniese verskille in die prevalensie van urinêre inkontinensie. Daar was geen verwantskap tussen vaginale rustende drukke en simptome van PPS en risiko faktore vir die ontwikkeling van bekkenvloer disfunksie, behalwe vir menoragie.

Introdução- A dor pélvica crônica é patologia debilitante em mulheres em idade reprodutiva, considerada problema de saúde pública, responsável por gasto anual nos EUA acima de 5 bilhões de dólares com diagnóstico desconhecido em cerca de 60% dos casos e se associa a dispareunia em 50% dos casos. E fundamental a obtenção de métodos diagnósticos dessa patologia. A ultrassonografia tridimensional vem se mostrando método de confiabilidade para avaliação do assoalho pélvico. ObjetivoAvaliar as lesões do músculo levantador do ânus (MLA) e a confiabilidade inter e intraobservador da biometria do assoalho pélvico pela ultrassonografia 3D em mulheres com dor pélvica crônica e dispareunia. Métodos- O estudo incluiu 49 pacientes com dor pélvica crônica e dispareunia no HCFMRP-USP. A aquisição dos blocos de ultrassonografia 3D foi realizada por dois examinadores de forma independente e \"cegados\", via transperineal utilizando a sonda RIC5-9D. Foram coletados três blocos por paciente (total 147) que foram analisados pelo examinador A (estudo intraobservador) e pelos examinadores A e B (estudo interobservador). A análise das medidas intraobservador foi realizada em dois tempos com intervalo de 90 dias. Os seguintes parâmetros foram avaliados: diâmetro transverso do hiato, diâmetro ânteroposterior do hiato, área hiatal, espessura do MLA às 3 e 9 h, as distâncias entre o músculo levantador do ânus e a uretra (DMLU) direita (D) e esquerda (E) e calculados os coeficientes de correlação intraclasse (CCI) e o coeficiente de correlação de concordância (CCC). Os gráficos correlação e de Bland e Altmann com seus limites de concordância (LC) foram elaborados. Adicionalmente os examinadores avaliaram as lesões do MLA através de sistema de score. Resultados - Na análise intraobservador os melhores parâmetros foram o diâmetro ântero-posterior (CCC 0,98; CCI 0,99 e LC 4,5%), a área hiatal Omni-VCI (CCC 0,99; CCI 0,98 e LC 3,8%) e área hiatal render (CCC 0,99; CCI 0,99 e LC 5,4%). Os parâmetros menos reprodutíveis foram a espessura do MLA às 3 h (CCC 0,58, CCI 0,90 e LC 28,2%) e 9 h (CCC 0,53, CCI 0,93 e LC 29,7%). Na análise interobservador os melhores parâmetros foram o diâmetro ântero-posterior (CCC 0,96; CCI 0,97 e LC 5,4) e a área hiatal Omni-VCI (CCC 0,97; CCI 0,97 e LC 8,9%). Os piores parâmetros foram espessura do MLA às 3 h (CCC 0,30; CCI 0,34 e LC de 38,2%) e às 9 h (CCC 0,32; CCI 0,32 e LC 35,1%). Tais achados foram reforçados pelos gráficos de Bland and Altman e de correlação. As lesões do levantador do ânus foram observadas em 10,2% (5/49) com excelente concordância. Conclusão - A avaliação do assoalho pélvico pela ultrassonografia transperineal em pacientes com dor pélvica crônica e dispareunia foi reproduzível através das análises morfológicas das lesões, do estudo biométrico intra ou interobservador para o diâmetro ântero-posterior, área hiatal render e Omni-VCI. Entretanto as medidas do diâmetro transverso do hiato, a espessura do MLA, o DMLU e a distância uretra ânus não são recomendadas para uso clínico devendo estar restritos à pesquisa / Introduction: Chronic pelvic pain is a debilitating condition in women of childbearing age, considered a public health problem, responsible for annual US spending of over US $ 5 billion, with an unknown diagnosis in about 60% of the cases and is associated with dyspareunia in 50% of cases. It is fundamental to obtain diagnostic methods for this pathology. Three-dimensional ultrasonography has shown to be a reliable method for evaluation of the pelvic floor. Objective: to assess levator ani muscle (LAM) injury and intra/interobserver reliability of pelvic floor biometry by 3D ultrasound in women with chronic pelvic pain and dyspareunia. Methods: The study included 49 women with pelvic pain and dyspareunia of the HCFMRP-USP. Two examiners performed the acquisition of 3D ultrasound via transperineal using the probe RIC5-9D independently and blindly. There were collected three blocks per patient (total 147) that were analyzed by the observer A (intraobserver study) and A and B (interobserver study). The analysis of the intraobserver measurements was performed in two times with 90 days apart. The following parameters were evaluated: the hiatal transverse diameter, hiatal anteroposterior diameter, hiatal area, thickness of the LAM at the 3 h and 9 h positions and right and left levator-urethra gap (LUG) measurements and calculated the intra-class correlation coefficient (ICC) and concordance correlation coefficient (CCC). Plots of correlation and Bland and Altmann with the limits of agreement (LoA) were constructed. Additionally, the observers evaluated the LAM injury using a score system. Results: In the intraobserver analisys the best parameters were the anteroposterior diameter (CCC 0.98; ICC 0.99 and LoA 4.5%), the hiatal area Omni-VCI (CCC 0.99; ICC 0.98 and LoA 3,8%) and hiatal area render (CCC 0.99; ICC 0.99 and LC 5.4%). The least reproducible parameters were the LAM thickness at 3 h (CCC 0.58, ICC 0.90 and LC 28.2%) and 9 h (CCC 0.53, ICC 0.93 and LC 29.7%). In relation to the interobserver analysis the best parameters were the anteroposterior diameter (CCC 0.96; ICC 0.97 and LoA 5.4) and the hiatal area Omni-VCI (CCC 0.97; ICC 0.97 and LC 8.9%). The worst results were LAM thickness at 3 h (CCC 0.30; ICC 0.34 and LC de 38.2%) and at 9 h (CCC 0.32; ICC 0.32 and LC 35.1%). Such findings were enforced by Bland and Altman and correlation plots. The LAM injuries were observed in 10.2% (5/49) with excellent concordance. Conclusions: The assessment of pelvic floor by transperineal ultrasound in patients with chronic pelvic pain and dyspareunia was reproducible either by morphology of LAM injuries or by biometric study, using intra or interobserver analysis for the anteroposterior diameter, hiatal area render and Omni-VCI. However, the measurements for the hiatal transverse diameter, levator ani thickness, right and left LUG and urethra-anus distance are not recommended for clinical use and it should be restricted for research purpose

Bakgrund: Bukväggens muskulatur spelar en viktig roll gällande hållning, bål- och bäckenstabilitet, andning, bålrörelser och som stöd för de inre organen i buken. Rektusdiastas, en delning av bukmusklerna, är vanligt förekommande framför allt hos kvinnor under och efter graviditet och kan eventuellt påverka dessa funktioner och göra ländryggen och bäckenet mer sårbara. Syfte: Att undersöka om det finns ett samband mellan vidden på rektusdiastasen och ländryggs- och bäckensmärta samt vidden på rektusdiastasen och rörelserädsla, hos kvinnor efter graviditet. Metod: Kvantitativ tvärsnittsstudie. Antalet deltagare var 141. Populationen var kvinnor 20-50 år som fött barn där yngsta barnet var mellan 1-8 år och som förstod och kunde uttrycka svenska i tal och skrift. Deltagarna skulle ha en rektusdiastas på minst 2 fingerbredd mellan rektusbukarna mätt 4 cm ovanför naveln. Datainsamlingen bestod av ultraljudsmätning samt frågeformulären Numeric Rating Scale (NRS) och Tampa Scale of Kinesiophobia (TSK-SV). Korrelation analyserades med Spearmans korrelationskoefficient. Deltagarna delades in i två grupper utifrån att de hade en rektusdiastas på mer eller mindre än 2,4 cm och skillnaderna mellan grupperna analyserades med Mann-Whitney U-test. Resultat: Ingen statistisk signifikant korrelation över p = 0,05 förelåg mellan vidden på rektusdiastasen och någon av smärtskattningarna. Däremot förelåg en statistiskt signifikant svagt positiv korrelation mellan vidden på rektusdiastasen och rörelserädsla. Vidare sågs ingen statistisk signifikant skillnad mellan de två grupperna, ≤ 2,4 cm eller &gt;2,4 cm rektusdiastas, och smärtskattningarna. Resultatet visade dock på statistisk signifikant skillnad mellan grupperna och skattningen av rörelserädsla. Slutsats: Studien visade att vidden av rektusdiastas som enskild faktor inte hade något samband med ländryggs- och bäckensmärtor hos kvinnor efter graviditet. Kvinnor med kvarstående rektusdiastas &gt; 2,4 cm, tenderade i denna studien att skatta högre på TSKSV, än de som hade ≤ 2,4 cm. Gällande skattningen av smärtan sågs ingen statistisk signifikans mellan grupperna. I mötet med dessa kvinnor bör fysioterapeuter inte endast fokusera på smärtan utan beakta fler faktorer såsom rörelserädsla, och fokusera på att guida dessa personer till att våga röra sig för att minska och undvika utveckling av rörelserädsla. / Background: The abdominal muscles play an important part in posture, inner unit stability, breathing, upper body movement, to generate power of the abdominal muscles and in supporting inner organs. Diastasis of the rectus abdominis muscles is common during and after pregnancy and might affect these important functions and thereby increase the vulnerability of the lower back and pelvic areas. Aim: To determine the correlation between the width of the diastasis recti abdominis and low back- and pelvic pain and the width of diastasis recti abdominis and fear of movement, in women after pregnancy. Method: Quantitative cross-sectional study. The amount of participants was 141. The population was women, 20-50 years old, who had given birth, the youngest child between the ages of 1-8 years old and were able to understand Swedish both verbally and in writing. The research participants had a diastasis recti abdominis more than 2 finger-widths, measured 4 cm above the umbilicus. The data collection was made with ultrasound and the questionnaires used were Numeric Rating Scale (NRS) and the swedish version of Tampa Scale of Kinesiophobia (TSK-SV). Correlation was analyzed with Spearman’s correlation coefficient. The participants were also divided into two groups based on a cut-off value of the diastasis of 2,4 cm and differences between groups were analyzed with Mann-Whitney U-test. Results: No statistical significance in correlation over p = 0,05 was found between the width of the diastasis recti abdominis and any of the pain ratings. However, there was a statistical significant weak positive correlation between the width of the diastasis recti abdominis and fear of movement. Furthermore there was no statistical significance between the groups ≤ 2,4 cm or &gt; 2,4 cm of diastasis recti abdominis and the pain ratings, but a significant difference between the groups and the estimation on fear of movement. Conclusion: The study showed that the width of diastasis recti abdominis as alone factor doesn’t have any correlation with low back- and pelvic pain in women after pregnancy. Women with remaining diastasis recti abdominis &gt; 2,4 cm, tended to estimate higher in this study in TSK-SV than those who had ≤ 2,4 cm. Regarding the ratings of the pain, no statistically significant difference between the groups were shown. When meeting these women physiotherapists should not only focus on the pain but also consider factors such as fear of movement and focus their efforts on guiding the women so that the risk of developing fear of movement is reduced.

ROCHA, MG. Mediadores inflamatórios na dor pélvica crônica Identificação de possíveis marcadores séricos da doença. Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, 2010. Introdução: Dor pélvica crônica é uma doença de elevada prevalência e fisiopatologia complexa. Os métodos diagnósticos muitas vezes são insuficientes e, em decorrência, o tratamento e seguimento das mulheres é difícil. Inúmeras doenças que se apresentam com dor crônica tem um perfil inflamatório, que ainda não foi investigado para o tema em questão. Objetivos: Quantificar os níveis de óxido nítrico (NO) e das metaloproteinases 2 (MMP-2) e 9 (MMP-9) no plasma de mulheres com dor pélvica crônica. Pacientes e métodos: Foram incluídas 64 mulheres, subdivididas em 02 grupos: dor pélvica crônica e grupo controle, com 37 pacientes no primeiro grupo e 27 pacientes no segundo grupo. As pacientes do grupo de estudo eram seguidas no Ambulatório de Dor Pélvica e Endoscopia e as pacientes do grupo controle eram seguidas no Ambulatório de Anticoncepção do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto USP. Foi realizada a mensuração clínica da dor através de uma escala unidimensional (VAS) e uma escala multidimensional (McGill). Também foram preenchidas as escalas de ansiedade e depressão (HAD). Indivíduos com qualquer evidência de processos inflamatórios, hipertensão, tabagismo ou uso de contraceptivos hormonais foram excluídos. Indivíduos tomando medicação para a dor, como analgésicos ou antiinflamatórios foram solicitados a pará-los 72 horas antes de participar do estudo. Foi coletada uma amostra sanguínea de 10 ml, no ato da consulta. Esse material foi armazenado em frasco próprio com anti-coagulante, processado imediatamente no local para separação do plasma e armazenado em freezer, a -70C para mensuração subseqüente. As concentrações de espécies relacionadas ao NO (nitrato) em líquidos foram medidas, sempre em triplicata, pelo método da quimioluminescência, que é um dos métodos mais simples, sensíveis e precisos disponíveis para medir NO. Foi utilizado um analisador de NO (Sievers Model 280 NO Analyzer - Boulder, CO, EUA), o qual permite medir NO em quantidades tão pequenas quanto 1 pmol. A atividade das MMP-2 e MMP-9 no plasma serão determinadas pelo método da zimografia, que consiste em uma eletroforese das amostras em um sistema SDS/PAGE que inclui o substrato da enzima (gelatina) no gel de separação, de modo a permitir a evidenciação e quantificação da atividade da enzima. Resultados: Os níveis plasmáticos de NO foram maiores nas pacientes com DPC quando comparadas às pacientes do grupo controle (16.8 ± 7.9 versus 12.2 ± 2.4, respectivamente (P = 0.0016). Especificamente, os níveis plasmáticos de NO foram maiores nas pacientes com DPC de origem visceral quando comparadas às pacientes com dor exclusivamente somática ou aos controles saudáveis (19.2 ± 8.9 versus 12.4 ± 1.8 versus 12.2 ± 2.4, respectivamente) (P=0.0001). Não observamos uma correlação entre os níveis plasmáticos de NO e a duração dos sintomas (em meses) (Spearman r = 0.04, 95%CI:-0.34 to 0.40, P = 0.84) ou com a intensidade dos sintomas dolorosos: EAV (Spearman r =:-0.18, 95%CI:-0.52 to 0.20, P=0.34), ou McGill (Spearman r = -0.06, 95%CI:-0.41 to 0.30, P =0.72). Com relação às MMP´s, não houve diferença estatística entre os dois grupos. Conclusões: Os níveis plasmáticos de NO encontram-se elevados em mulheres com DPC, especialmente naquelas com dor de origem visceral. Este fato pode ser considerado uma possibilidade no seguimento de pacientes com DPC, visto que pode ser usado como um marcador sérico para a doença. Já a dosagem das MMP-s não se mostrou útil como marcador plasmático para mulheres com DPC. / Background: Chronic pelvic pain is a disease of high prevalence and a complex pathophysiology. The diagnostic methods are often inadequate and, consequently, treatment and follow-up of women is quite difficult. Several diseases that present with chronic pain has an inflammatory profile, which has not yet been investigated for the topic. Aim: to quantify levels of nitric oxide (NO) and metalloproteinases 2 (MMP-2) and 9 (MMP-9) in plasma of women with chronic pelvic pain. Methods: 64 women were included in the sudy and divided into 02 groups: chronic pelvic pain and control group with 37 patients in the first group and 27 patients in the second group. Patients in the study group were followed at the Endoscopy and Pelvic Pain Unit and the control group patients were followed in the Contraception Unit of the Hospital of the Medical School of Ribeirão Preto University of São Paulo. We performed the measurement of clinical pain by a unidimensional scale (VAS) and a multidimensional scale (McGill). Anxiety and depression scales were also filled. Individuals with any evidence of inflammation, hypertension, smoking or use of hormonal contraceptives were excluded. Individuals taking medication for pain, such as painkillers or antiinflammatory drugs were asked to stop them 72 hours before entering the study. A blood sample was collected from 10 ml during the appointment. This material was stored in bottle itself with anti-coagulant (EDTA and / or heparin), processed immediately on site for plasma separation and stored in a -70 ºC freezer. The concentrations of species related to NO were measured in liquid, always in triplicate by the method of chemiluminescence, which is one of the most simple, sensitive and accurate available to measure NO. We used a NO analyzer (Sievers Model 280 NO Analyzer - Boulder, CO, USA), which allows the measurement of NO in quantities as small as 1 pmol. The activity of MMP-2 and MMP-9 in plasma was determined by the zymography method, which consists of an electrophoresis of the samples in an SDS / PAGE system, which includes the enzyme substrate (gelatin) in the gel separation, allowing the disclosure and quantification of enzyme activity. Results: Plasma NO levels were higher in CPP women than in controls (16.8 ± 7.9 versus 12.2 ± 2.4, respectively) (P=0.0016). Furthermore, plasma nitrate levels were higher in CPP women with evidence of pain of visceral origin than in CPP women with evidence of an exclusive somatic component or controls (19.2 ± 8.9 versus 12.4 ± 1.8 versus 12.2 ± 2.4, respectively) (P=0.0001). No correlation was detected between NO levels and duration of symptoms or intensity of pain. Regarding the MMP\'s, there was no statistical difference between the two groups. Conclusion: Plasma levels of NO are elevated in women with CPP, especially those with visceral pain. This fact can be considered an option in treating patients with CPP as it can be used as a serum marker for the disease. On the other hand, MMP´s did not turn out to be a good serum marker for women with CPP.

Made available in DSpace on 2016-08-10T10:54:00Z (GMT). No. of bitstreams: 1 ROSA AZEVEDO DA LUZ.pdf: 2733181 bytes, checksum: 33f5625707dda92fee0de48ecb07a255 (MD5) Previous issue date: 2011-06-02 / Chronic pelvic pain (CPP) has been acknowledged as a frequent chronic condition affecting the lives of women. This study evaluates the impact of CPP in the Quality of Life (QofL) of women cared for in the gynecological outpatient service of Hospital das Clinicas at the Federal University of Goiás. This cross-sectional descriptive study was conducted with 50 women with CPP and 50 women without CPP. Data were collected through structured interviews addressing socio-demographic and economic information in addition to clinical and surgical aspects. QofL was evaluated through the generic questionnaire Medical Outcomes Study 36®-Item Short-Form Health Survey (SF-36), and depression through the Beck Depression Inventory (BDI). Intensity of pain was inferred by a visual analogue scale. Descriptive statistical analyzes, mean comparison test, correlation and multiple linear regression analyzes were carried out. The level of significance was set at 0.05. The average age of women with CPP was 41.65 years old (±9.42) and those without CPP were 28.97 years old (±6.68). Both groups, with and without CPP, included women with secondary school of mixed race, with stable partners, who performed domestic chores, were economically active and the primary income earners, with two children in average. Significant differences were found between the groups concerning: age, income, housing, and dysuria; 52% of the women with CPP reported intense pain. The left iliac fossa was the most frequent site of pain. Physical effort and sexual intercourse prevailed as factors that worsen pain. Analgesic and rest were among factors improving pain. From the women s perspective, emotional state, trauma due to physical and/or sexual abuse as well as childbirth were factors that contributed to the development of CPP. A total of 57% women reported that surgical treatment did not change pain intensity. When QofL of the two groups were compared, women with CPP presented worse scores in all the dimensions evaluated through the SF-36 with exception of mental health. A significant negative correlation between pain intensity and pain dimension from the SF-36 was observed, as well as among depression and the dimensions emotional aspects and mental health . A high prevalence of depression was identified in both groups: 72% in those with CPP and 58% without CPP. The group with CPP presented the worse score in depression. The Cronbach s alpha varied between 0.76 and 0.79 for the BDI, indicating good reliability of the instruments. The conclusion is that CPP has a significant negative impact on these women s QofL and depression was important in the QofL. / A dor pélvica crônica (DPC) tem sido reconhecida como uma condição crônica frequente que afeta a vida das mulheres. O objetivo do estudo foi avaliar o impacto da DPC na qualidade de vida (QV) das mulheres atendidas no ambulatório de ginecologia do Hospital das Clínicas da Universidade Federal de Goiás. Optou-se por um estudo descritivo de corte transversal, em 50 mulheres com DPC e 50 sem DPC. Os dados foram coletados por meio de uma entrevista estruturada com informações para avaliação das características sociodemográficas, econômicas, aspectos clínicos e cirúrgicos. A QV foi avaliada por um questionário genérico The Medical Outcomes Study 36®-Item Short- Form Health Survey (SF-36), e depressão investigada, pelo Inventário de Depressão de Beck (BDI). A intensidade da dor foi aferida pela escala visual analógica (EVA). Foram realizadas análises estatísticas descritivas, testes de comparação de médias, correlações e regressão linear múltipla. O nível de significância foi 0,05. A média de idade das mulheres com DPC foi de 41,65 (±9,42) anos e aquelas sem DPC 28,97 (±6,68) anos. Os grupos com e sem DPC caracterizaram-se por incluírem mulheres com nível médio de escolaridade, cor parda, companheiros fixos, que exerciam serviços domésticos e estavam economicamente ativas, responsáveis pela renda familiar e em média com dois filhos. Houve diferença significativa entre ambos os grupos nas variáveis: idade, renda, moradia e disúria. Evidenciou-se que 52% das mulheres com DPC referiram dor intensa. A fossa ilíaca esquerda foi o local de maior ocorrência da dor. O esforço físico e relação sexual prevaleceram como fatores de piora. Entre os fatores de melhora da dor identificou-se, o uso de analgésico e o repouso. Na percepção das mulheres, o estado emocional, estresse, trauma por abuso físico e/ou sexual, bem como, o parto foram citados como fatores que contribuíram para o desenvolvimento da DPC. 57% das mulheres relataram que a intensidade da dor não mudou com o tratamento cirúrgico. Ao comparar, a avaliação da QV dos dois grupos identificou-se que as mulheres com DPC apresentaram piores escores em todas as dimensões avaliadas pelo SF-36, exceto na dimensão saúde mental. Houve correlação negativa, significativa, entre intensidade da dor e a dimensão dor do SF-36, e da depressão com as dimensões, aspectos emocionais e saúde mental. Identificou-se, alta prevalência de depressão, em ambos os grupos, 72% com DPC e 58% sem DPC. O grupo com DPC apresentou pior escore de depressão. O alfa de Cronbach variou entre 0,76 e 0,79 para as dimensões do SF-36 e entre 0,85 e 0,86 para o BDI, caracterizando boa confiabilidade dos instrumentos. Conclui-se que a dor pélvica crônica causa impacto negativo significativo na QV dessas mulheres, e a depressão foi um fator impactante na avaliação da QV.

Introdução: A dor crônica pélvica É uma das doenças mais frequentes entre mulheres na idade reprodutiva, e como a maioria delas, tem impacto direto na vida conjugal, social e profissional da mulher. O impacto da dor no desempenho ocupacional das mulheres afeta diretamente a atividade econômica domiciliar, visto que, atualmente, a mulher representa uma parte considerável da renda familiar. A terapia ocupacional pelo Modelo Canadense de Desempenho Ocupacional as dimensões holísticas do individuo nas 3 áreas de desempenho ocupacional: autocuidado, produtividade e lazer; e do ponto de vista do estudo da dor, os procedimentos da terapia ocupacional incluem a avaliação da multiplicidade de fatores físicos, psicossociais e ambientais agravados pela dor, nos diversos contextos de desempenho do indivíduo. Objetivo: Caracterizar o desempenho ocupacional de mulheres portadoras de DPC atendidas em um serviço terciário e verificar a associação entre as limitações ocupacionais com a presença de dor pélvica crônica, o grau de cinesiofobia e os sintomas psicológicos. Casuística e Métodos: Estudo transversal qualitativo descritivo. Foram coletadas 150 mulheres, sendo 75 mulheres com DPC (grupo: dor) e 75 mulheres saudáveis (grupo: saudáveis), todas as participantes receberam o termo de consentimento livre e esclarecido. O cálculo do tamanho da amostra foi realizado sobre proporções com margem de erro relativo em populações infinitas através da seguinte expressão: n=(z2 · q)/(2 p). As avaliações e escalas utilizadas foram: Visual analogue scale VAS (Escala visual analógica),Escala de faces, Questionários de saúde do paciente: PHQ-4 (Patient Health Questionnaire), SRQ (Self-reportQuestionnaire), Escala Tampa de Cinesiofobia, Medida Canadense de Desempenho Ocupacional (COPM). Os dados obtidos foram registrados em formulário próprio. Foi avaliada a distribuição normal das variáveis através do teste de DAgostino e Pearson. Para verificar a associação entre grupos e variáveis qualitativas nós utilizamos o teste exato de Fisher, ou o Qui-quadrado quando mais pertinente. Resultado: Mulheres com DPC estão inseridas em menor número no mercado de trabalho em relação a mulheres saudáveis, e apresentam mais alterações no sono e histórico de cirurgia abdominal, além de terem pontuações acima da média nos testes PHQ-4, SRQ e Tampa, o tempo de dor (M) foi de 108 meses e o VAS (M) 74. As mulheres com DPC se preocupam menos com o autocuidado, nas 3 subcategorias de autocuidado as mulheres com DPC ressaltam menos importância. Na categoria produtividade o nível de 8 importância é homogêneo, mas apesar de mulheres com DPC estarem em menor número no mercado de trabalho, na subcategoria trabalho ambos os grupos apresentam preocupações em suas atividades de trabalho, em relação à tarefas domésticas mulheres com DPC se preocupam mais do que mulheres com saudáveis, e o inverso ocorre em deveres. Na ultima categoria analisada ambos os grupos revelam o lazer e suas 3 subcategorias importantes de forma homogenia. O desempenho e satisfação de mulheres com DPC é menos do que a média do grupo de mulheres Saudáveis. Conclusão: O desempenho e a satisfação de mulheres com DPC são prejudicados devido, principalmente, a DPC. Alterações no sono e cirurgia abdominais anteriores, podem estar relacionadas diretamente com DPC. Essas mulheres apresentam um comportamento como a perda de identidade, isolamento social, coping e dor social. O questionário TAMPA sugere que mulheres com DPC apresentam medo ao realizar suas atividades. Nosso trabalho tenta preencher uma lacuna na literatura sobre o desempenho ocupacional em mulheres portadoras de dor pélvica crônica, pois pouco se sabe sobre a doença e o quanto interfere no desempenho ocupacional dessas mulheres. / Introduction: Pelvic chronic pain is one of the most common disease among women of reproductive age, and like most of them, have a direct impact on marital life, social and professional woman. The impact of pain on work performance of women directly affects household economic activity, since, currently, the woman is a substantial part of household income. Occupational therapy by the Canadian Model of Occupational Performance holistic dimensions of the individual in the three areas of occupational performance: self-care, productivity and leisure; and from the viewpoint of the pain study, occupational therapy procedures include the evaluation of the multitude of physical, environmental and psychosocial factors aggravated by pain in many contexts individual\'s performance. Objective: To characterize the occupational performance of women with DPC met in a tertiary center and the association between occupational limitations with the presence of chronic pelvic pain, the degree of kinesiophobia and psychological symptoms. Methods: Qualitative descriptive cross-sectional study. 150 women were collected, of which 75 women with CPP (group: pain) and 75 healthy women (group: healthy), all participants were given free and informed consent form. The calculation of sample size was performed on proportions with margin of error relative in infinite populations by the following expression: n = (z 2 q) / (2 · p). Reviews and scales used were: Visual analogue scale VAS (visual analogue scale), Face Scale, Health Questionnaires patient: PHQ-4 (Patient Health Questionnaire), SRQ (Self-report Questionnaire), Scale Tampa kinesiophobia, Measurement Canada Occupational Performance (COPM). Data were recorded on a specific form. The normal distribution was evaluated variables by D\'Agostino and Pearson test. To investigate the association between groups and qualitative variables we used Fisher\'s exact test or chi-square when more relevant. Result: Women with DPC are inserted into fewer in the labor market compared to healthy women, and have more sleep disturbances and history of abdominal surgery, and have above average scores on the PHQ-4 tests, SRQ and Tampa, time of pain (M) was 108 months and the VAS (M) 74. Women with DPC care less about the \"self-care\" in the three subcategories of \"self-care\" women with DPC emphasize less important. In the category \"productivity\" the level of importance is homogeneous, but despite women with CPP are outnumbered in the labor market, in the subcategory \"work\" both groups have concerns about their work activities, regarding the \"housekeeping\" women with CPP are more concerned than women with healthy and the opposite occurs in \"duties\". In the last category analyzed both groups reveal the \"leisure\" and its 10 three major subcategories of homogeneous manner. The performance and satisfaction of women with CPP is less than the average of the group Healthy women. Conclusion: The performance and satisfaction of women with CPP are harmed due mainly to DPC. Changes in previous abdominal surgery and sleep, can be directly related to DPC. These women exhibit behavior such as loss of identity, social isolation, coping and social pain. The CAP survey suggests that women with CPP have fear when performing their activities. Our work tries to fill a gap in the literature on occupational performance in women with chronic pelvic pain, because little is known about the disease and how much interferes with the work performance of those women.

Introdução: a dor pélvica crônica é um problema que afeta uma significativa parcela de pacientes que buscam atendimento ginecológico. Dentre suas etiologias, destaca-se a síndrome de congestão pélvica, causada por insuficiência venosa pélvica. A justificativa deste estudo foi verificar se a técnica endovascular pode ser considerada estratégia terapêutica efetiva e válida para a população brasileira. Objetivo: avaliar a resposta clínica e a taxa de sucesso após embolização de varizes periuterinas em pacientes com dor pélvica crônica secundária à síndrome de congestão pélvica, e relatar a segurança do tratamento endovascular e o índice de complicações. Materiais e métodos: coorte retrospectiva de pacientes submetidas a tratamento endovascular da síndrome de congestão pélvica em nosso serviço, no período de janeiro de 2012 até novembro de 2015. Foram analisados dados relativos aos antecedentes das pacientes, achados de exames de imagem, veias embolizadas, taxa de complicações e resposta clínica baseada na escala visual analógica de dor. Resultados: Foi realizada embolização de varizes periuterinas em 22 pacientes no período estudado, sendo que quatro delas realizaram uma segunda embolização. Foi observada redução da dor em 17 pacientes considerando-se a primeira embolização (77.3%) e em 3 pacientes na segunda embolização (75%). Foram observadas complicações menores em 5 pacientes, como hipotensão postural, dor no pós-operatório e perfuração venosa sem repercussão clínica durante o procedimento. Conclusão: O presente estudo apresentou resultados satisfatórios da embolização de varizes periuterinas na redução dos sintomas de pacientes com dor pélvica crônica secundária à síndrome de congestão pélvica, mostrando-se como método seguro. / Introduction: Chronic pelvic pain accounts a significant number of gynecologic referrals. Among its etiologies, there is the pelvic congestion syndrome, caused by pelvic venous insufficiency. The rationale of this study was to determine whether endovascular technique can be considered effective and valid therapeutic strategy for the Brazilian population. Objective: To evaluate the clinical response and the success rate after periuterine varices embolization in patients with chronic pelvic pain secondary to pelvic congestion syndrome, and report the safety of endovascular treatment and the rate of complications. Materials and methods: Retrospective cohort of patients undergoing endovascular treatment of pelvic congestion syndrome in our department from January 2012 to November 2015. Data were analyzed on the background of patients, imaging findings, embolized veins, rate complications and clinical response based on visual analog pain scale. Results: We performed peiruterine varices embolization in 22 patients during the study period, four of which held a second embolization. 17 patients reported a reduction in pelvic pain considering the first embolization (77.3%) and 3 patients in the second embolization (75%). Minor complications were observed in 5 patients, such as postural hypotension, postoperative pain and venous perforation during the procedure, without clinical repercussion. Conclusion: The present study showed satisfactory improvement of clinical symptons after periuterine varices embolization in patients with chronic pelvic pain secondary to pelvic congestion syndrome, showing up as a safe method.