Abstract. FELDNER JR, Paulo Cezar et al. Reprodutibilidade interobservador da classificação da distopia genital proposta pela Sociedade Internacional de. Clase Distopia Genital-Incotinencia Urinaria. Uploaded by Ivette Collas Iparraguirre. Distopia genital. Copyright: © All Rights Reserved. Download as PPTX. Googleando veo gran cantidad de videos que mencionan la palabra distopía, distopía genital, para ser más exactos. Pero no sé si esos son ejemplos válidos.
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Pelvic organ prolapse is a highly prevalent condition in the female population, which impairs the health-related quality of life of affected individuals. Despite the lack of robust evidence, selective modification of obstetric events or other risk factors could play a central role in the prevention of prolapse. While the value of pelvic floor muscle training as a preventive treatment remains uncertain, it has an essential role in the conservative management of prolapse.
Surgical trends are currently changing due to the controversial issues surrounding the use of mesh and the increasing demand for uterine preservation.
The evolution of laparoscopic and robotic surgery has increased the use of these techniques in pelvic floor surgery. Pelvic organ prolapse refers to loss of support to the uterus, bladder and bowel leading to their descent from the normal anatomic position towards or through the vaginal opening.
Pelvic organ prolapse may seriously influence the physical, psychological and social wellbeing of affected individuals [ 5 ] and is associated with considerable resource implications for the health service. Modern health care systems are becoming gradually more community focused, with distopjas emphasis being on prevention rather than cure. While there are well established models in other fields of medicine, the attempts at prevention of pelvic floor dysfunction remain in geenitales very early stages.
The demand for conservative gfnitales increases in an ageing population, especially with women giving birth in older age. The rapid adoption of minimally invasive techniques laparoscopic and robotic surgery and the development of synthetic and biological grafts have dramatically transformed pelvic organ prolapse surgery.
We shall briefly discuss the evidence regarding prevention measures, and conservative and surgical management options for pelvic organ prolapse. Despite the high prevalence of pelvic organ prolapse, there is limited knowledge about its pathophysiology. A number of cross-sectional epidemiological studies have reported several risk factors for pelvic organ prolapse see Table 1.
As pelvic gebitales prolapse usually presents many years after childbirth, recent large longitudinal and national cohort studies with long-term follow-up have genitwles our current knowledge [ 678 ]. Without identifying the risk factors, efforts at prevention are fruitless, and therapy can only be empirical [ 9 ]. Over the last few years, there has been increasing interest disto;ias the role of levator ani muscle injuries in the development of pelvic organ prolapse.
Studies with magnetic resonance imaging MRI [ 10 ] and three-dimensional pelvic floor ultrasonography [ 11 ] have established the association between levator ani defects and pelvic organ prolapse. Women with levator ani defects are at least twice as likely to show clinically significant pelvic organ prolapse relative risk [RR] 1. Levator ani trauma could represent the missing link between childbirth and pelvic organ prolapse and could be used as a surrogate marker in future longitudinal studies, or as an essential co-variable in the selection of treatment options of women with pelvic organ gfnitales.
Despite the presence of modifiable risk factors for pelvic organ prolapse, little is known about the efficacy of relevant interventions for its prevention. Vaginal childbirth is probably the most important factor in the aetiology of pelvic organ prolapse. However, the concept of a planned caesarean section for the prevention of pelvic floor dysfunction is controversial, due to the risks associated with caesarean section [ 13 ] and the obvious resource implications for health care systems.
While caesarean section cannot be considered as preventative for developing pelvic organ prolapse, it could be offered antenatally to selected women with an increased risk of developing prolapse. Based on the recent epidemiological studies, a scoring system UR-CHOICE has been proposed to predict the risk of future pelvic floor dysfunction [ 14 ].
In the future, more variables, such as a diagnosis of benign joint hypermobility syndrome [ 15 ] or specific genotypes [ 16 ], could be included in more sophisticated models that could be used for the prediction of pelvic organ prolapse.
Certain surgical techniques have been linked to the development or recurrence of pelvic organ prolapse. While abdominal subtotal hysterectomy does not prevent the development of prolapse compared to total hysterectomy [ 17 ], a McCall culdoplasty at the time of a vaginal hysterectomy could prevent it [ 18 ]. Appropriate use of a vaginal apical support procedure at the time of prolapse surgery might reduce the long-term risk of recurrence [ 19 ].
Pelvic floor muscle training PFMT has been proposed as a measure to prevent pelvic organ prolapse. However, a recently published study [ 20 ], comparing a nurse-led intervention pelvic floor muscle training and bladder training at 5, 7, and 9 months after delivery to standard care, showed that the prevalence of prolapse symptoms or objectively measured pelvic organ prolapse did not differ between the groups at the year follow-up [ 20 ].
As pelvic organ prolapse has been associated with urogenital atrophy, it is possible that oestrogens, alone or in conjunction with other measures, may prevent its development by improving the strength of weakened supporting ligaments, muscles and vaginal mucosa [ 21 ]. However, there are no studies in the literature to assess this hypothesis. If we generalise findings from studies regarding lower urinary tract symptoms and hormone replacement therapy, local oestrogen treatments appear more promising compared to systemic administration [ 22 ].
There is a need for rigorous randomised controlled trials, with long-term follow-up, to assess oestrogen preparations for the prevention of pelvic organ prolapse. Modification of other risk factors could also reduce the risk of pelvic organ prolapse.
Reduction of straining and intra-abdominal pressure could help prevent the development of prolapse. Weight loss with diet or bariatric surgery has also been suggested as a preventive measure. The few published cohort studies with short-term follow-up have shown that weight reduction is associated with subjective improvement in prolapse symptoms [ 23 ] but no objective change was didtopias in examination using the pelvic organ genitalss quantification POP-Q system [ 24 dlstopias.
Conservative interventions include physical interventions to improve the function and support of the pelvic floor muscles via pelvic floor muscle training and mechanical interventions insertion of vaginal pessaries to support gentales prolapse. They are often offered for lower grades of prolapse and to women unwilling or unfit to undergo surgery.
From ancient times, a wide variety of items have been used to manage urogenital prolapse. Currently, a range of vaginal pessaries are available which can be broadly divided into two types: A recent Cochrane review has highlighted the lack of robust evidence regarding the effectiveness of vaginal pessaries [ 25 ]. As there is no evidence to support the use of a specific type, choice is based on experience and trial and error.
When the insertion of the pessary is successful, there is significant improvement in prolapse symptoms, and ditopias bladder, bowel and sexual function [ 27 ]. A robust evidence base has recently emerged regarding the role of PFMT in the treatment of pelvic organ prolapse.
Based on their findings, one-to-one PFMT for 16 weeks to 6 months is effective for the improvement of prolapse symptoms. The combination of PFMT with surgery or insertion of vaginal pessary has recently gained the attention of some researchers.
A pilot study has shown the benefit of perioperative PFMT in the post-surgery reduction dstopias symptoms and pelvic organ prolapse recurrence [ 32 ].
However, perioperative behavioural therapy with pelvic floor muscle training did not improve prolapse symptoms or anatomical distpias in a large multi-centre RCT OPTIMAL comparing transvaginal surgical procedures used to correct apical prolapse [ 33 ]. A recent systematic review and meta-analysis of RCTs showed that surgical interventions can improve the quality of life of women with pelvic organ prolapse [ 36 ].
Over genitaoes last few years, prolapse surgery has been changing constantly, with emerging trends gradually gaining or losing their popularity. Historically, surgeons have relied on patients’ native tissue for surgical correction of pelvic organ prolapse. Due to the reported high rates of recurrence [ 37 ] and the known weakness of the tissue associated with prolapse, a number of distopiqs and biological grafts have been introduced to improve surgical outcomes.
The success ditopias the synthetic midurethral slings [ 38 ], and data showing dramatic improvement of the outcomes with the use of mesh for repair of femoral and inguinal hernias [ 39 ], supported the introduction of grafts in vaginal surgery.
There distoplas a sudden increase in vaginal mesh use with cases performed in the US almost doubling between and These then plateaued between and [ 40 ]. However, in view of the reported high risk of complications e.
Following these, a dramatic decrease of mesh-augmented vaginal repairs has been reported [ 42 ] and many commercial transvaginal mesh kits have been withdrawn from the market. National and international professional bodies have published consensus documents on informed consent process and patient selection [ 434445 ]. However, gennitales outcomes do not translate into improved functional outcomes when validated questionnaires have been used.
Mesh repairs are also linked with higher rates of surgical complications and postoperative adverse events e. A decision-analytic Markov model, examining the cost-utility of anterior repair augmented with synthetic mesh, compared with non-mesh repair, suggests that the use of mesh is not cost-effective [ 47 ]. Absorbable meshes appear to be attractive options of surgical augmentation, offering strength during the early healing phase without the long-term problems of permanent mesh.
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Polyglactin mesh underlay improves the anatomical outcome, compared to native tissue repair of anterior pelvic organ prolapse [ 49 ]. A number of biological grafts have been evaluated in RCTs. Anterior repair with porcine dermis graft is superior to native tissue repair [ 50 ], but inferior to disotpias mesh augmentation [ 51 distoppias regarding anatomic outcomes.
The evidence on the use of porcine small intestine submucosa mesh is conflicting [ 5253 ]. Regarding the posterior compartment, vaginal wall repair may be better than transanal repair in the management of rectocele in terms of recurrence of prolapse. The evidence from a recent Cochrane review does not support mesh overlay or augmentation of a native tissue repair for posterior vaginal wall prolapse [ 54 ].
Traditionally, repair of uterovaginal prolapse includes concomitant hysterectomy. However, women increasingly desire uterine preservation and uterine-sparing procedures for apical prolapse are gaining in popularity. Education level and the belief that the uterus is important for a sense of self were predictors of preference dostopias uterine preservation, while the doctor’s opinion, risk of surgical complications, and risk of malignancy were the most important factors in surgical decision-making [ 56 ].
A number of uterine-preserving procedures have been described for apical prolapse, but there are a limited number of prospective RCTs comparing these techniques to vaginal hysterectomy. The benefit of the avoidance of hysterectomy-specific complications should be balanced against the risk of future uterine abnormalities and uncertainty about future pregnancies. Surgeons must provide adequate counselling and preoperative evaluation before proceeding with uterine preservation [ 57 ].
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The findings of this study were challenged by a more recent large RCT, which showed no difference in recurrence of apical prolapse after sacrospinous hysteropexy or vaginal hysterectomy [ 59 ]. Another uterine-sparing alternative is the laparoscopic sacrohysteropexy. A study comparing laparoscopic sacrohysteropexy with the use of polypropylene mesh to vaginal hysterectomy showed similar subjective and functional outcomes for the two groups with better apical anatomical outcomes after laparoscopic sacrohysteropexy [ 60 ].
Apical support procedures can be divided into those performed transvaginally and those performed abdominally. A recent RCT by Barber et al. Compared to SSLF and USLS, abdominal sacrocolpopexy with a polypropylene mesh has a higher success rate, with less post-operative dyspareunia but with longer operating and recovery times [ 54 ].
In an attempt to reduce mesh complications, some surgeons have considered the use of biological grafts. However, fascia lata had inferior anatomic outcomes, compared to polypropylene mesh [ 63 ]. Technological development has facilitated the adoption of minimally-invasive techniques laparoscopic and robotic for sacrocolpopexy. A US population-based study showed a dramatic increase 6 times in the number of minimally-invasive sacrocolpopexies from towhile the number of abdominal sacrocolpopexies remained stable [ 40 ].
An RCT comparing abdominal sacrocolpopexy to laparoscopic sacrocolpopexy revealed similar anatomic and subjective outcomes, but a shorter hospital stay and reduced blood loss in the laparoscopic group [ 64 ]. Comparison of porcine dermis and polypropylene mesh for laparoscopic sacrocolpopexy has shown no difference in subjective and objective results [ 65 ]. Robotic sacrocolpopexy is also a safe and effective option in the treatment of apical prolapse [ 66 ].
It is associated with similar anatomic and functional outcomes, but with a longer operating time, and increased pain and cost, compared with the conventional laparoscopic approach [ 6768 ]. Further controversy surrounds the role of prophylactic concomitant stress incontinence surgery for patients with symptomatic prolapse, not complaining of stress urinary incontinence SUI.
A number of well-designed RCTs have shown that concomitant continence surgery reduces the risk of postoperative de novo SUI in women previously without SUI who are undergoing pelvic organ prolapse surgery, through the abdominal [ 69 ] or vaginal route [ 70 ].
However, combination surgery is associated with an increased rate of adverse events such as major bleeding complications, bladder perforation, prolonged catheterisation, urinary tract infections [ 71 ]. As the benefits of combined surgery should outweigh its risks, careful patient selection is of paramount importance. The meta-analysis by van der Ploeg et al.
Therefore, pre-operative evaluation of occult SUI with reduction of prolapse, or the use of a clinical prediction model [ 72 ], could be used as a decision-making tool to determine the need for a concomitant continence operation.
Identifying women with an increased risk of developing pelvic organ prolapse could become easier with the implementation of clinical prediction models or the introduction of relevant genetic tests. The identification of a high-risk population could allow a focused modification of risk factors, such as obstetric events, by recommending delivery by caesarean section.