Dissertations / Theses on the topic 'Incontinenza'

L'incontinenza anale (IA), è definita come l'incapacità a controllare volontariamente l'emissione di gas e/o feci. L' IA si definisce totale se comporta la perdita di feci solide, parziale se solo di gas e feci liquide; potrà essere passiva (fecal soiling), oppure manifestarsi durante urgenza defecatoria. La gravità dell' IA si valuta con degli score. I più affidabili sono CCF score (Jorge & Wexner) da 0-20, il quale valuta anche l'impatto della IA sulla qualità di vita, il Pescatori score (1-6), AMS, Vaizey ( St. Mark's Hospital), Williams. I pazienti con IA che presentano sintomi da lievi a moderati, rispondono bene al trattamento conservativo, il trattamento chirurgico invece è riservato a quelli pazienti con IA grave. L'associazione tra prolasso rettale e IA rappresenta un entità clinica di non semplice risoluzione. Matteriali e Metodi. L'esame obiettivo ano perineale, intergrato dall'esame anoscopico sarà mirato a cercare di identificare quale struttura anatomico-funzionale è principalmente coinvolta nella patogenesi del disturbo. L'ispezione potrà evidenziare: ano beante, cicatrici, ectropion mucoso, fistole, ascessi, emorroidi, patologie uro-ginecologiche (es. cistocele, prolasso utero-genitale), l'entità del prolasso del retto, perineo discendente. L'esplorazione rettale valuterà il tono sfinteriale (in condizioni basali, durante contrazione volontaria e sotto i colpi di tosse). L'esame endoscopico valuta la presenza di malattie infiammatorie,tumori, ulcera solitaria e prolasso mucoso del retto. Le indagini morfologiche quali la manometria anale, la colpocisto-defecografia, l'eletromiografia dei muscoli del pavimento pelvico,l'endosonografia anale,vaginale e perineale dinamica, potranno rivelarsi utili nello studio di lesioni organiche colo-rettali e dell'integrità anatomica della componente sfinteriale. Trattamento chirurgico: sfinterolpastica, levatorplastica anteriore, plicatura posteriore del pavimento pelvico sec. Park's, total pelvic floor repair, iniezioni di biomateriali, procedure di "encirclement". Nelle unità di coloproctologia della Società Italiana di Chirurgia Colo-Rettale (1983-2000), sono stati osservati 738 pazienti. Quarantasette (30 donne) pazienti, (6.4%), presentavano IA associata a prolasso rettale, di questo gruppo, venticinque pazienti (53%), sono stati sottoposti a trattamento chirurgico Prolasso rettale (PR), il prolasso rettale è caratterizzato dalla fuoriuscita di vari strati della parete attraverso il canale anale. Può essere a tutto spessore (completo) o esterno, oppure occulto (interno). I sintomi più frequenti sono dolore anale, perdite ematiche, perdite mucose, urgenza defecatoria. L' incontinenza anale associata è stata dimostrata nel 50-70% dei casi, il 25-50% dei paziente invece potrebbe presentare stipsi, valutata secondo il CCF score (0-30), per la stipsi. Anamnesi accurata, esame obiettivo,valutazione di patologie genito-urinarie associate, abitudini intestinali. I pazienti vengono sottoposti ad anoscopia, colonscopia, cine-defecografia, misurazione dei tempi di latenza del nervo pudendo e tempi di transito intestinale. La manometria ano-rettale spesso risulta essere alterata. La terapia chirurgica del prolasso del retto è la cosiddetta terapia su misura (tailored surgery), tenendo in considerazione i disordini funzionali associati, in particolare se vi sia o no IA associata. Gli approcci perineali comprendono più frequentemente l'intervento secondo Delorme e Altemeier. Risultati. Nella nostra casistica Ospedale S. Eugenio (1987-2003), sedici pazienti (10 donne ) sono stati sottoposti ad intervento sec. Delorme. Il tasso di recidiva era 9% a 5 anni (range del follow-up 6-60 mesi). L'indice di soddisfazione nel postoperatorio era 73%, il 46-75% dei pazienti hanno avuto miglioramento della loro continenza. Dodici pazienti (8 donne) sono stati sottoposti ad intervento chirurgico sec. Altemeier, il tasso di recidiva era 1% (range del follow-up 6-60 mesi), sono stati raggiunti con questo tipo di tecnica ottimi risultati funzionali per incontinenza e stipsi. Nelle procedure addominali, la rettopessi secondo Orr-Loyge è stata effettuata in 25 pazienti (9 donne), il tasso di recidiva era 2,5%, (range del follow-up 8-80 mesi). La continenza è stata migliorata nel 58% dei casi, la stipsi invece nel 61% dei pazienti. Trentasei pazienti (16 donne), sono stati sottoposti a rettopessi secondo Wells, 12 pazienti hanno avuto recidiva di malattia (range del follow-up 8-80 mesi). La continenza è migliorata nel 35% dei casi, la stipsi invece è peggiorata nel 20% dei pazienti. L'approccio addominale ha dimostrato minor rischio di recidiva e migliori risultati funzionali, in termini di incontinenza anale e stipsi in confronto alle tecniche perineali. La chirurgia laparoscopica anche, dimostra essere una scelta affidabile, con ottimi risultati in termini di recidiva ed outcomes funzionali. Conclusioni La chirurgia del prolasso rettale è la tipica chirurgia su misura. Lo specialista deve considerare varie tecniche in base al tipo di paziente,( se maschio o femmina, se giovane o anziano, se sano o fragile), del rischio operatorio, delle caratteristiche del prolasso (se interno o esterno, se mucoso o totale, se piccolo oppure di grandi dimensioni), i sintomi associati, in particolare la stipsi cronica o incontinenza anale. Questa risulta essere complessa e di eziologia multifattoriale, e potrebbe essere dovuta sia a difetti anatomici, sia funzionali. In alcuni casi il trattamento chirurgico esclusivo del prolasso rettale, potrebbe non essere sufficiente, a risolvere tutti i sintomi, per qui potrebbe essere indicato associare alla prolassectomia o rettopessi una sfinteroplastica, tenendo presente che dopo rettopessi, o Altemeier, o Delorme, ci si può attendere un miglioramento della continenza. Parole chiave Incontinenza anale, stipsi, prolasso rettale, recidiva, rettopessi, laparoscopia, risultati funzionali
Background. Anal Incontinence (AI) is the ability to defer the call to stool to a socially acceptable time and place. Loss of control of solid feces is complete anal incontinence, whereas loss of control over flatus or liquid is partial anal incontinence, incomplete and more associated with diarrheal syndromes and fecal impaction. The most frequently used score are the CCF (0-20) score (Jorge and Wexner), which takes in account also the quality of life, and the Pescatori score (0-6), which is simple an easily understandable by the patients, AMS, Vaizey (St.Mark’s Hospital), Williams. Severe incontinence is likely to require surgery, whereas mild and moderate AI are better managed conservatively. The association between rectal prolapse and AI represent a clinical entity difficult to manage. Methods History, the most important factor is determination of the etiology, by physical examination, inspection of perineus for soiling, scars, mucosal ectropion , size of the rectal prolapse muscular deficit, fistulae, prolapsing hemorrhoids. digital exploration will allow to assess anal sphincter’s function: such as resting tone and squeeze contraction endoscopic evaluation to esclude the existence of inflammatory bowel disease, tumors, solitary rectal ulcer syndrome, mucosal prolapse. Special Investigations: anal manometry, cine defecography, electromyography of the pelvic floor, rectal compliance, anal, vaginal and dynamic parineal endosonography. Surgical treatment: Park’s post anal repair, overlapping sphincteroplasty, total pelvic floor repair, encirclement procedures, injection of bulking agents. At the coloproctology units of the Italian society of Colorectal surgery, from 1983 to 2000, 738 patients were observed . Fortyseven (30 women) pts (6.4%), presented AI associated with rectal prolapse, twentyfive of those patients (53%), underwent surgical treatment. Rectal prolapse ( RP) may be full thickness, i.e. procidentia of the rectum through the sphincters, causes a variety of symptoms including pain, bleeding, mucous discharge, and urge to defecate. Associated AI, is experienced by 50% to 70% of the patients, and 25% to 50% of them have significant constipation according to CCF scoring system (0-30) for constipation. The specific causation has yet to be fully elucidated. The patients generally undergo baseline functional tests, following a detailed history and physical examination, as well as an evaluation of a comorbid history of genitourinary dysfunction and bowel habits. In addition anoscopy and full colonoscopy should be performed to exclude other sources of rectal bleeding or the presence of masses that may initiate an intussusception. Cinedefecography, pudendal nerve terminal motor latency assessment and colonic transit studies are generally performed to better evaluate the concomitant presence of enterocele, paradoxical puborectalis contraction, pudendal nerve injury and denervation of the pelvic floor muscles and sphincter. Anorectal manometry is usually abnormal in the incontinent rectal prolapse patients. Surgical therapy of rectal prolapse is often non standard, but rather, tailored after careful consideration of the patient’s operative risk, life expectancy, associated functional disorders, and previous operative history.The goals of the surgical treatment are to eradicate the external prolapse of the rectum and to reduce the risk of recurrence, without causing an adverse impact on bowel function and continence. Perineal approaches, including Delorme’s procedure and perineal rectosigmoidectomy according to Altemeier, with or without levatorplasty (in case of incontinence) are usually carried out and may be tailored according to the presence and the degree of AI. Results Sixteen patients (10 women), at St. Eugenio Hospital (Rome) from 1987 to 2003, underwent Delorme’s procedure. Recurrence rate was 9% at 5 years (range of follow-up 6-60 months). Postoperative overall satisfaction was 73%, 46-75% of the patients experienced an improvement in continence. Twelve patients (8 women) underwent Altemeier procedure, recurrence rate was 1% with excellent results in terms of functional outcome regarding constipation and incontinence rates. Twenty five patients (9 women), underwent abdominal rectopexy according Orr-Loygue, recurrence rate at 5 years, was 2.5%, (range of follow-up 8-80 months).Continence was improved in 58% and constipation was improved in 61% of the patients. Satisfaction rate was 72%. Thirty six patients (16 women),underwent rectopexy according to Wells technique, 12 patients developed recurrence (range of follow-up 8-80 months). Continence was improved in 35%, constipation was worsened in 20% of the cases. Transabdominal open repair, has gained acceptance by most clinicians as the standard surgical procedure for patients with acceptable surgical risks, and is considered to have lower recurrence rates and better functional results than perineal approaches. In addition low recurrence rates, better functional outcome can be safely achieved using laparoscopic surgical techniques to repair full thickness rectal prolapse. Conclusion Selecting an operative approach based on clinical criteria provides satisfactory functional outcomes with regard to symptoms of constipation and incontinence. Anal incontinence is a complex dysfunction with multiple causes, and in rectal prolapse, it may be difficult to understand if it is due anatomical defect (full rectal eversion, internal and external anal sphincter and anal canal integrity in their anatomy and nerve supply) or to a functional lesion (abnormal anal and rectal sensitivity, loss of rectal reservoir function and rectal compliance). This may explain why in some cases treating just the prolapse may not be sufficient to cure all symptoms. A combination of both rectal excision or rectopexy and sphincteroplasty may be required to cure some patients with rectal prolapse and severe anal incontinence due to sphincters weakness, taking in account that rectopexy and other rectal prolapse procedure may improve anal continence. Keywords Anal incontinence, constipation, rectal prolapse, recurrence, rectopexy, laparoscopy, treatment outcomes.

OBIETTIVI DELLO STUDIO. Questo è uno studio prospettico, doppio cieco, controllato con placebo, basato su una tecnica placebo originale, con lo scopo di valutare l’efficacia della stimolazione percutanea del nervo tibiale (PTNS) in pazienti di sesso femminile con incontinenza da iperattività detrusoriale. PAZIENTI E METODI. 35 pazienti di sesso femminile, con incontinenza da iperattività detrusoriale , non rispondenti alla terapia con antimuscarinici, sono state assegnate a caso al gruppo PTNS o al gruppo controllo. Il gruppo PTNS (18 pazienti) è stato trattato con 12 sessioni di PTNS. Il gruppo controllo (17 pazienti) è stato sottoposto ad un trattamento placebo originale, utilizzando un ago 34 G posizionato nella parte mediale del muscolo gastrocnemio. Le sessioni sono durate 30 minuti e sono state eseguite tre volte a settimana così come per le sessioni PTNS. Tutte le pazienti sono state valutate con diario minzionale e questionario sulla qualità di vita (I-QoL) prima e dopo il trattamento. Le pazienti che hanno mostrato una riduzione >50% degli episodi di urge incontinence sono state considerate "responders." RISULTATI. 3 pazienti (1 nel gruppo PTNS e 2 nel gruppo placebo) non hanno completato lo studio per ragioni non riferite alla tecnica. 12/17 pazienti (71%) nel gruppo PTNS e 0/15 nel gruppo placebo (p <0.001) sono state considerate "responders" secondo la definizione prima riportata. Il miglioramento del numero degli episodi di incontinenza, del numero di minzioni, del volume vuotato e del punteggio I-QoL è stato statisticamente significativo nel gruppo PTNS ma non nel gruppo placebo. CONCLUSIONI. PTNS può essere considerato un trattamento efficace dell'incontinenza da iperattività detrusoriale, con il 71% delle pazienti considerate “responders”, mentre nessuno dei pazienti trattati con placebo è stato considerato "responder". La rilevanza di un effetto placebo sembra essere trascurabile in questo gruppo di pazienti.
PURPOSE. This is a prospective double blind, placebo controlled study, based on an original placebo technique, aimed to evaluate the efficacy of percutaneous tibial nerve stimulation (PTNS) in female patients with detrusor overactivity incontinence. PATIENTS AND METHODS. 35 female patients presenting with detrusor overactivity incontinence non responding to antimuscarinic therapy, were randomly assigned either to PTNS or to control group. PTNS group (18 patients) was treated with 12 PTNS sessions. Control group (17 patients) underwent an original placebo treatment, using a 34 G needle placed in the medial part of the gastrocnemius muscle. The sessions lasted for 30 minutes and were performed 3-times per week as PTNS sessions. All patients were evaluated with bladder diaries and quality of life scores (I-QoL) before and after treatment. Patients showing a reduction >50% of urge incontinence episodes were considered responders. RESULTS. 3 patients (1 in PTNS group and 2 in placebo group) did not complete the study for reasons not related to the technique. 12/17 patients (71%) in PTNS group and 0/15 in placebo group (p<0.001) were considered �responders� according to the previously reported definition. Improvement in number of incontinence episodes, number of voids, voided volume and I-QoL score were statistically significant in PTNS group but not in placebo group. CONCLUSIONS. PTNS can be considered an effective treatment of detrusor overactivity incontinence with 71% of patients considered responders, whilst none of the patients treated with placebo was considered responders. The relevance of a placebo effect seems to be negligible in this patient population.

L’incontinenza urinaria viene considerata come uno dei disturbi urologici che hanno maggior impatto sulla qualità della vita dei pazienti, sia uomini sia donne, anche a causa del variegato e complesso quadro patologico da cui deriva. I soggetti più colpiti sono gli anziani, i bambini autistici e i diabetici, ma anche pazienti paraplegici e tetraplegici: secondo l’Organizzazione Mondiale della Sanità, il totale degli individui affetti da tale patologia risulta essere di oltre 300 milioni nel mondo. Nel caso in cui le terapie farmacologiche si rivelino inefficaci, è possibile ricorrere all’impianto di uno sfintere urinario artificiale (AUS), scegliendo tra quelli localizzati internamente all’uretra (intrauretrali), in prossimità dello sfintere vescico-uretrale naturale, e quelli che occludono l’uretra esternamente a essa (extrauretrali), nel tratto in cui scorre adiacente al pavimento pelvico. A oggi, tra le soluzioni extrauretrali, lo sfintere artificiale AMS800 rappresenta il gold standard, pur non essendo esso stesso esente da difetti. Tra le complicanze più frequenti correlate alla sua applicazione si annoverano infatti infezioni ed erosioni uretrali dovute alla compressione dell’uretra. Nell’ultimo decennio sono state quindi proposte alcune apparecchiature che permettono di avere gli stessi vantaggi del AMS800, riducendo al contempo le problematiche da esso associate, grazie all’introduzione di miglioramenti quali il controllo wireless real-time e l’azionamento magnetico. Questo lavoro si propone di presentare il progetto sviluppato presso l’Area Ricerca del Centro Protesi INAIL, in collaborazione con la Scuola Superiore Sant’Anna di Pisa, nell’ambito del progetto RELIEF relativo alla progettazione di un sistema AUS ad azionamento magnetico, che coniughi facilità di utilizzo per l’utente finale senza essere eccessivamente invasivo e con costi di fabbricazione tali da renderlo accessibile.

Introduzione: L’incontinenza urinaria (IU) è ad oggi un problema riconosciuto e riportato in letteratura da vari studi, anche se la sua prevalenza risulta variabile (27-74%). La sua causa principale, nelle pazienti con fibrosi cistica, è la tosse cronica, che porta ad una progressiva debolezza dei muscoli del pavimento pelvico. L’obiettivo della tesi è di valutare la prevalenza dell’IU nelle pazienti con fibrosi cistica seguite al Centro Regionale di Cesena, determinare la presenza o meno di correlazione tra incontinenza ed età, indice di massa corporea e funzionalità polmonare e confrontare i risultati ottenuti con quelli presenti in letteratura, con lo scopo di pianificare la presa in carico riabilitativa. Materiali e metodi: Il questionario ICIQ-UI SF è stato somministrato durante le visite di routine alle pazienti di età maggiore o uguale a 10 anni. Sono inoltre stati raccolti i dati clinici di ciascun paziente: altezza, peso, FVC, FEV1 e MEF 75/25. Risultati: 49 pazienti hanno partecipato allo studio. 20 di queste sono risultate incontinenti e sono significativamente più grandi di età rispetto alle continenti (p=0,01). Esiste inoltre una correlazione tra incontinenza e FEV1 o MEF 75/25, sebbene non sia statisticamente significativa (p=0,06). Non è stata trovata alcuna correlazione tra IU e BMI o FVC. Tutte le donne incontinenti hanno riportato IU da stress; le situazioni che più comunemente causano le perdite di urina sono tosse/starnuti, attività fisica e risate. Conclusioni: L'incontinenza urinaria è una condizione frequente e sottovalutata che colpisce comunemente le donne con fibrosi cistica, sebbene questo problema non sia spesso riportato dalle pazienti al medico o al fisioterapista, forse a causa dell’imbarazzo. È però importante identificare le pazienti con incontinenza perché semplici esercizi per rinforzare i muscoli del pavimento pelvico possono migliorare la situazione. Indagare la presenza dell’IU dovrebbe diventare parte delle visite di routine.

La disfunzione vescico-uretrale rappresenta un importante problema nella pratica medica quotidiana a causa dei disturbi psicologici, i costi sociali e l’elevato impatto sulla qualità di vita. Recentemente, la neuromodulazione sacrale, cioè la stimolazione elettrica dei nervi sacrali, sembra rappresentare un’alternativa nei casi di iperattività vescicale idiomatica resistente alla terapia medica. Il meccanismo di azione è soltanto parzialmente noto, ma sembra coinvolgere la modulazione nel midollo spinale per via della stimolazione degli interneuroni inibitori. La prima tappa è rappresentata da un test di prova (PNE test). Comprende l’applicazione di un elettrodo monopolare temporaneo quale test diagnostico per determinare la sede migliore per l’impianto e per verificare, dopo un periodo di applicazione della neuromodulazione di 7-14 giorni la risposta clinica. Se il test di simulazione è efficace, viene impiantato un elettrodo quadripolare connesso ad un neuromodulatore definitivo. L’iperattività vescicale idiopatica rappresenta la principale indicazione per questa tecnica. I pazienti che hanno le minori probabilità di beneficiare da questa procedura sono coloro con lesioni spinali complete o quasi complete, mentre le lesioni spinali incomplete sembrano rappresentare una potenziale indicazione. Questa tecnica è attualmente indicata anche nei casi di ritenzione cronica non ostruttiva e nella sindrome del dolore pelvico cronico. Quando si effettua la selezione, oltre tre quarti dei pazienti hanno mostrato una risposta clinicamente significativa con una riduzione di almeno 50% nella frequenza di episodi di incontinenza, ma i risultati variano in base alla metodica di valutazione di ciascun Autore. Dal punto di vista economico, l’investimento iniziale per l’apparecchiatura è ammortizzato nel medio termine dalla riduzione dei costi legati alla disfunzione delle basse vie urinarie. Infine, questa tecnica richiede un attento follow-up ed adattamenti dei parametri elettrici per ottimizzare l’equilibrio tra i sistemi neurologici
Vesico-urethral dysfunction is a major problem in daily medical practice due to its psychological disturbances, its social costs and its high impact on quality of life. Recently, sacral neuromodulation, namely the electrical stimulation of the sacral nerves, appears to have become an alternative for radical bladder surgery particularly in cases of idiopathic bladder over¬activity. The mechanism of action is only partially understood but it seems to involve a modulation in the spinal cord due to stimulation of inhibitory interneurons. Temporary sacral nerve stimulation is the first step. It comprises the temporary application of neuromodulation as a diagnostic test to deter¬mine the best location for the implant and to control the integrity of the sacral root. If test stimulation is successful, a permanent device is implanted. This procedure is safe in experienced hands. So-called idiopathic bladder overactivity still the major indication for this technique. Patients not likely to benefit from the procedure were those with complete or almost complete spinal lesions, but incomplete spinal lesions seemed to be a potential indication. This technique is now also indicated in the case of idiopathic chronic retention and chronic pelvic pain syndrome. When selection is performed, more than three-quarters of the patients showed a clinically significant response with 50% or more reduction in the frequency of incontinent episodes, but the results vary according to the author’s mode of evaluation. From the economic point of view, the initial investment in the device is amortized in the mid-term by savings related to lower urinary tract dysfunction. Finally, this technique requires an attentive follow-up and adjustments to the electric parameters so as to optimize the equilibrium between the neurological systems

Introduzione L’incontinenza urinaria è una patologia che affligge circa 36 milioni di persone in Europa di cui, circa il 60%, è costituita da donne. I fattori di rischio per lo sviluppo di questa patologia sono molteplici e tra di essi viene inserita la gravidanza ed, in particolare, il parto vaginale. Nelle donne in gravidanza che presentano tale patologia si evidenzia una riduzione della qualità della vita (QoL) in termini di attività fisica, viaggi, relazioni sociali, salute mentale ed emotiva. Obiettivo Valutare, secondo i più recenti studi scientifici, l’efficacia dell’esercizio terapeutico della muscolatura del pavimento pelvico per la prevenzione dell’incontinenza urinaria femminile durante la gravidanza e dopo il parto. Materiali e metodi La ricerca è stata svolta sulle banche dati PubMed e Cochrane Library, servendosi del metodo P.I.C.O. . Sono state incluse nella ricerca revisioni sistematiche pubblicate negli ultimi 5 anni, in lingua inglese e che prevedessero programmi di prevenzione comprendenti esercizi di rinforzo della muscolatura del pavimento pelvico. Risultati Sono state selezionate tre revisioni sistematiche; ciascuna di esse indaga l’efficacia preventiva dell’esercizio terapeutico della muscolatura del pavimento pelvico applicato in momenti diversi della gravidanza; tutti e tre gli studi valutano positivamente l’applicazione di tale metodica per la prevenzione dell’incontinenza urinaria femminile durante la gravidanza e nel periodo successivo al parto. Conclusioni Dall’analisi dei risultati ottenuti dalle tre revisioni prese in esame, è possibile affermare l’efficacia dell’esercizio terapeutico della muscolatura del pavimento pelvico nella prevenzione dell’incontinenza urinaria femminile sia durante che dopo il parto. I limiti evidenziati negli studi analizzati, tuttavia, suggeriscono la necessità di ulteriori ricerche per valutare il reale impatto di questa metodica.

Orientadores: Cassio Luis Zanettini Riccetto, Paulo Cesar Rodrigues Palma
Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas
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Resumo: OBJETIVOS: Analisar quantitativamente, com método estereológico, a densidade de fibras colágenas formadas após implante de quatro diferentes tipos de sling;verificar por análise histopatológica a reação inflamatória. MATERIAS E MÉTODOS: Realizou-se o estudo em 70 ratas da raça Wistar, divididas em 3 grupos (A,B,C): No grupo A (30 ratas) implantou-se uma faixa de silicone e outra de submucosa intestinal suína, de 8x 4 mm, no tecido subcutâneo da parede abdominal. No grupo B (30 ratas), implantou-se, da mesma maneira, uma faixa de copolímeros de poligalactina com ácido poliglicólico e outra de polipropileno monofilamentar, de 8x 4 mm. Sutura com fio de nylon 5/0, fixou as faixas e, no grupo C (10 ratas), denominado controle, realizou-se dissecção do subcutâneo e aplicação do mesmo fio, sem implante de material. A coloração de Picro-Sirius, empregada apenas no 90° dia de pós-operatório, permitiu análise das fibras colágenas e a de Hematoxilia-eosina, o estudo histopatológico da reação inflamatória. Nos dias 7, 30 e 90 de pós-operatório, sacrificaram-se 10 ratas de cada grupo. RESULTADOS: No 7° dia, todos os materiais induziram moderada reação inflamatória, sem diferença com o controle. No 30° dia, os copolímeros de poligalactina com ácido poliglicólico apresentaram a menor reação inflamatória, sem diferença com o controle. Neste período, polipropileno monofilamentar e silicone produziram inflamação moderada, enquanto que na submucosa intestinal suína, a intensidade foi severa. No 90° dia, a reação inflamatória, nos copolímeros de poligalactina com ácido poliglicólico, foi maior que antes, porém menor do que a do polipropileno monofilamentar e silicone, que permaneceram semelhantes entre si. Novamente, o grau de inflamação na submucosa intestinal suína continuou o maior de todos. Na análise estereológica, a densidade. de fibras colágenas dos copolímeros de poligalactina com ácido poliglicólico e polipropileno monofilamentar foi significativamente menor (61 % e 65% respectivamente) do que o silicone (85%) e submucosa intestinal suína (86%). CONCLUSÕES: Polipropileno monofilamentar foi o melhor material inabsorvível, pois induziu menos reação inflamatória que os outros materiais testados. Como a submucosa intestinal suína foi completamente removida, a intensa reação fibrótica que produz, toma-se útil, e responsável pelo suporte suburetral após a cirurgia
Abstract: OBJECTIVES: To analyse quantitatively, using stereological methods, the density of the collagen fibres induced by four types of sling materials, and verify by a histopathological analysis the corresponding inflammatory reaction, as fibrosis secondary to sling implantation is considered responsible for restoring urethral support and re-establishing continence in women with stress urinary incontinence, and new synthetic materials that promote adequate fibrosis with the least intensity and duration have been proposed to substitute the aponeurotic sling. MATERIALS AND METHODS: The study comprised 70 isogenic white Wistar rats divided into three groups: group A (30 rats) had 8 x 4 mm strips of silicone and porcine small intestine submucosa (SIS) implanted in the abdominal subcutaneous tissues; group B (30 rats) had 8 x 4 mm strips of polycaprolactone and polylactic acid copolymers and monofilament polypropylene (PLP) implanted the abdominal subcutaneous layer; while a control group of 10 rats had dissection and suturing with 5/0 Nylon in the abdominal subcutaneous layer, as used to fix the strips in the other rats. Picro-Sirius staining was used to assess collagen fibres, and haematoxylin-eosin for the histopathological study. At 7, 30 and 90 days after surgery, 10 rats from each group were killed and assessed. RESULTS: Afier 7 days all the materials induced a moderate inflammatory reaction that did not differ from that in the control group. At 30 days there was no difference between the control and polycaprolactone and polylactic acid copolymers, having the least inflammatory reaction. PLP and silicone produced a moderate inflammatory reaction, while the porcine SIS induced a more intense reaction. At 90 days there was a more intense inflammatory reaction in polycaprolactone and polylactic acid copolymers than before but it was less than with PLP and silicone, which again were no different. During this period the inflammatory reaction induced by SIS was greater. The stereological analysis indicated that collagen fibres induced by polycaprolactone and polylactic acid copolymers and PLP were less dense (61% and 65%, respectively), and significant1y less than with silicone (85%) and SIS (86%). CONCLUSION: PLP was the best nonabsorbable material as it induced a less intense inflammatory reaction than the other tested materials. As porcine SIS was completely absorbed the intense fibrosis induced is useful, as it is exclusively responsible for the urethral support later after surgery
Doutorado
Cirurgia
Mestre em Cirurgia

Urinary incontinence has been described as a devastating symptom, an embarrassing condition, and a major geriatric problem, creating substantial personal, medical, and social difficulties. Urinary incontinence is a problem which affects men and women of all ages, but is predominantly a concern for elderly women! It is estimated that 50% to 75% of cases of incontinence are hidden or unreported. A review of the literature on urinary incontinence reveals numerous studies describing prevalence rates and types of incontinence. Characteristics of incontinent individuals and experimental studies comparing different treatments are also available. However, qualitative studies of urinary incontinence as it is experienced by elderly women are nonexistent. The purpose of this study is to explore and describe the impact of living with untreated urinary incontinence upon the daily lives of elderly women living in the community. The phenomenological approach to qualitative methodology was used for this study. This approach seeks to discover and describe the human experience as it is lived, and for this study, that experience was living with untreated urinary incontinence. Incontinent women, 60 years of age and over, were contacted through seniors' community centres, seniors' newspapers, and community service agencies. Nine women served as informants and participated in intensive interviews guided by open-ended questions. Verbatim transcriptions of these interviews and field notes from contact with seniors provided the data for analyses. Four major themes comprise the research findings: the recognition of incontinence, the avoidance of exposure, the need for information, and the redefinition of normal. The first theme describes the women's struggle to recognize the incontinence for what it was, acknowledging to themselves that it was an ongoing problem. Even after incontinence was recognized, the women emphasized the importance of keeping their symptoms hidden. This avoidance of exposure necessitated reorganization of their lives and limited opportunities to talk about problems with incontinence. Despite their hesitation in talking about incontinence, the women identified a compelling need for information. Finally, over and above these three management strategies, living with incontinence led to an attitudinal strategy of redefining what would constitute normal. For these women, this new definition of normal included incontinence. In light of these findings, implications for nursing education and practice are identified. Suggestions for future research stemming from this study conclude the discussion.
Applied Science, Faculty of
Nursing, School of
Graduate

Orientadores: Paulo Cesar Rodrigues Palma, Miriam Dambros
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
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Resumo: A Incontinência urinária de esforço (IUE) feminina, condição com alta prevalência, é definida como um sinal e sintoma ligado a distúrbios funcionais da uretra (esfíncteres) e/ou bexiga e não caracteriza uma doença. Trata-se então de uma disfunção mecânica em que alterações na biomecânica da bacia pélvica podem estar associadas à modificação deste mecanismo. Atualmente tem-se valorizado e vem-se aplicando o tratamento fisioterapêutico nesta afecção, como o treinamento dos músculos do assoalho pélvico, obtendo-se bons resultados a curto e médio prazos. Além disso, técnicas baseadas na abordagem global da paciente, que consideram aspectos da estrutura postural, estão ainda em fase de investigação. O trabalho aqui descrito constou da aplicação do tratamento da Reeducação Postural Global (RPG), trabalhando-se a reestruturação postural por meio do reequilíbrio do Sistema músculo esquelético (SME), alongamento das cadeias musculares e reequilíbrio dos eixos ósseos, num enfoque global. Objetivo: Avaliar os efeitos da RPG nas queixas de IUE e qualidade de vida em um grupo de mulheres incontinentes. Casuística e Método: Para o estudo, foram selecionadas 26 mulheres portadoras de queixa clínica de IUE, que foram submetidas ao tratamento da RPG. O tratamento constou de sessões semanais de 50 minutos num período de três meses e posteriormente de sessões quinzenais por mais três meses. O grupo foi acompanhado por seis meses após final do tratamento, sendo reavaliado no término do tratamento, no terceiro e sexto meses. A avaliação foi feita usando Questionário de Qualidade de Vida, diário miccional de três dias, Pad Use e Avaliação funcional do assoalho pélvico (AFA). No término do tratamento e no seguimento de seis meses, as pacientes também foram avaliadas por meio de escala analógica de satisfação. Resultados: Das 26 pacientes que iniciaram o programa, 25 concluíram o tratamento. No final deste quatro pacientes (16%) estavam curadas, 18 (72%) apresentaram melhora significativa e três (12%) não apresentaram melhora. No seguimento de seis meses, seis (24%) pacientes estavam curadas, 16 (64%) apresentaram melhora e três (12%) não apresentaram melhora. Diferenças significativas foram notadas no número de perdas (p<0.001), Pad Use (p<0.001) e AFA (p<0.001). Além disso, foi percebida melhora em todos os domínios do Questionário de Qualidade de Vida, especialmente em Percepção geral da saúde (p<0.005) e Impacto da incontinência (p<0.001) em todos os seguimentos da avaliação. Conclusão: A RPG induziu à melhora significativa dos sintomas de IUE e qualidade de vida no grupo de mulheres incontinentes estudado
Abstract: Stress Urinary Incontinence (SUI), is defined as a signal and/or a symptom connected to functional disorders of the urethra (sphincter) and/or blader and do not characterize a disease. It is, indeed a dysfunction where alterations in the pelvis biomechanics can be associated to a modification of this mechanism. Lately, physiotherapeutic treatments, as the training of the pelvic floor muscles, have been used and good results have been obtained in short and medium terms. Besides, techniques based on a global approach of the patient, which consider also aspects of the postural structure, are still under investigation. The work hereby described consisted of the application of the Global Postural Reeducation (GPR) treatment, in which the postural restructuring is worked through the reestablishment of the balance of the skeletal muscle system, stretching of the muscle chains and rebalance of the bone axis, in a global approach. Objective: Evaluate the effects of the GPR on Stress Urinary Incontinence and Life Quality in a group of incontinent women. Material and Methods: For this study, 26 women with SUI were selected, who underwent a GPR treatment. All patients were treated for six months using GPR, 50 minutes weekly sessions during three months and three more months of sessions every other week. The patients were evaluated before and after the treatment, and also at three and six months follow-up. Outcome measures were made using King's Health Questionnaire, three days voiding diary, Pad Use and Functional Evaluation of Pelvic Floor (FEPF). In the end of the treatment and after six months, the patient satisfaction was evaluated trough a standardized analogical visual scale. Results: Twenty-five patients were available for follow-up. At the end of the treatment there were four (16%) patients completely dry, 18 (72%) pesented significant improvement and three (12%) did not presented improvement. At six months follow-up there were six (24%) patients completely dry, 16 (64%) improved and three (12%) failures. Significant differences were noted in the number of leak episodes (p<0.001), Pad Use (p<0.001) and FEPF (p<0.001). Regarding the King's Health Questionnaire, improvement in all domains were observed, especially in General Perception of Health (p<0.005), leakage impact (p<0.001) in all the moments of evaluation. Conclusion: GPR significantly improved the symptoms and Quality of Life in women with SUI
Mestrado
Pesquisa Experimental
Mestre em Cirurgia

Orientadores: Cassio Luis Zanettini Riccetto, Paulo Cesar Rodrigues Palma
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias
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Resumo: Objetivos: Com o objetivo de avaliar os resultados cirúrgicos e de modificação na qualidade de vida de mulheres submetidas ao tratamento de incontinência urinária de esforço com sling sintético de polipropileno com abordagem pré-púbica. Métodos: Foi desenvolvido estudo prospectivo, de intervenção, com seguimento por seis meses, envolvendo 20 pacientes, com idade mínima de 21 anos e com diagnóstico de incontinência urinária de esforço realizado no Serviço de Uroginecologia do Hospital das Clínicas da Universidade Estadual de Campinas, Campinas, São Paulo, com base em dados clínicos, urodinâmicos e de Pad-test compatíveis, as quais expressaram a vontade de se submeter à implantação de sling para correção cirúrgica; não gestantes; sem doença ou qualquer condição que pudesse comprometer o resultado da cirurgia, tal como: distúrbio de coagulação sanguínea, obstrução do trato urinário superior, insuficiência renal, comprometimento do sistema imune, infecção urinária ou vaginal; não submetidas a procedimento de sling sintético prévio; que concordaram em participar do estudo, por meio da assinatura do Termo de Consentimento Livre Esclarecido e em responder os questionários King's Health Questionnaire (KHQ) e International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) antes da cirurgia e decorridos seis meses do procedimento. Para o tratamento de incontinência urinária de esforço, empregou-se tela manufaturada em fibras de polipropileno, classe I, monofilamentar com 42 µm de diâmetro e macroporos maiores que 75 mm, por abordagem pré-púbica. As variáveis estudadas incluíram: idade, avaliação urodinâmica, Pad-test e resultados dos questionários King's Health Questionnaire (KHQ) e International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) . Os dados foram organizados por meio do programa Epi-INfo versão 6.04d e analisados com o programa Statistical Package for Social Sciences (SPSS), versão 13.0. As variáveis nominais e ordinais foram expressas em distribuição de freqüências absolutas e relativas e as quantitativas, pelos parâmetros da Estatística Descritiva. Para comparação dos parâmetros objetivos uroginecológicos e de qualidade de vida aferida pelos questionários International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) e King's Health Questionnaire (KHQ), do período pré-operatório e decorridos seis meses do procedimento cirúrgico, empregou-se teste de diferença de médias, em nível de significância de 0,05, determinando-se o intervalo de confiança em nível de confiança de 95%. Resultados: Comparando a avaliação pré-operatória àquela decorridos seis meses do procedimento cirúrgico, verificou-se redução significante da perda de urina mensurada através do Pad-test (p<0,001). A pressão de perda sob esforço foi negativa em 90% das pacientes decorridos seis meses da cirurgia. Os demais parâmetros urodinâmicos da cistometria não foram alterados significativamente comparando antes e depois da cirurgia. O fluxo máximo miccional despida de significância estatística (p = 0,034). Houve melhora de todos os parâmetros subjetivos avaliados pelo International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), com significância estatística da freqüência de perda de urina (0,009) e menor interferência na vida da pacientes (p= 0,001), assim como de todos os domínios do King's Health Questionnaire (KHQ). Houve 6 (30%) casos de complicações, que consistiram em extrusão vaginal do sling, instituindo-se tratamento cirúrgico por retirada do segmento da tela exposta e síntese da mucosa vaginal. Conclusão: Embora tenha havido a necessidade de interromper este estudo devido ao alto índice de complicações, confirmou-se o fato de ser a incontinência urinária um evento que compromete a qualidade de vida das pacientes exercendo tal impacto que, mesmo diante do insucesso do procedimento terapêutico, a avaliação subjetiva foi favorável, decorridos seis meses da cirurgia
Abstract: Objectives: A prospective study of intervention was developed aiming to evaluate the surgical results and impact in the quality of life of women submitted to stress urinary incontinence treatment with polypropylene synthetic sling with prepubic approach. Methods: Twenty patients were included in this study. Diagnosis of stress urinary incontinence were based on clinical data, urodynamics and Pad-test. Inclusion criteria included: minimum age of 21 years; non pregnant; without illness or any condition that could compromise surgery's result (sanguineous coagulation disorders, superior urinary tract obstruction, renal insufficiency, immune system disorder, urinary or vaginal infection); abcense of previous synthetic sling procedure; agreement to participate of the study, by means of Free Consent Term signature and to answer to the questionnaires King's Health Questionnaire (KHQ) e International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) before the surgery and after six months of the procedure. Its was used a sling made of staple fibres of polypropylene, type I, monofilamentar (42 µm diameter) and macropores. All the procedures were performed under spinal anesthesia. The sling was placed and adjusted in midurethral area with minimal periurethral dissection. The proper tension and fixation was achieved by passing the sling arms through the prepubic subcutaneous fat tissue. The variables studied included: age; urodynamic evaluation; Pad-test; King's Health Questionnaire; and International Consultation on Incontinence Questionnaire. Data were recorded using Epi-INfo version 6.04d software and analyzed with Statistical Package for Social Sciences (SPSS), version 13.0. The nominal and ordinal variables were express in absolute and relative frequency distribution and the quantitative ones by parameters of descriptive statistics. Difference of means test was used (significance level of 0,05, 95% confidence interval) for comparison of the urogynecologic objective parameters and quality of life surveyed by ICIQ and KHQ questionnaires, of pre-operative and six months post-operative evaluation. Results: Comparing pre-surgical evaluations with those after six months of the surgical procedure, there were significant reduction of urine loss assessed by the pad-test (p<0,001). Comparing urodynamics evaluations before and after surgical procedure 90% patients no there were of urine loss. Other urodynamics parameters no there were significant alterations. The max flow there was significant reduction (p=0,034). There was an improvement of all subjective parameters evaluated by ICIQ-SF, with significance for frequency of urine loss (0,009) and minor interference in life (p= 0.001), as well as of all KHQ domains. Six patients (20%) presented complications which consisted of vaginal exposition of the sling. All of them were corrected surgically by excision of the mesh and suture of the vaginal wall. The study was interrupted after six months of follow up due to the high frequency of adverse effects. Conclusion: Although the decision of interrupting the study due to the high index of complication, it allowed to confirm that stress urinary incontinence compromises the quality of life of the patients significantly, and the treatmet could promote an improvement in the quality of life, even when objective results were unfavourable
Mestrado
Cirurgia
Mestre em Cirurgia

Introduction: Faecal incontinence is more common in parous women who have had a difficult vaginal delivery. However, the pathophysiology of the injury resulting in faecal incontinence in such women is incompletely understood. This study therefore aimed to compare anal canal and pelvic floor parameters between continent and incontinent women and measure these during pregnancy and after delivery in order to more fully understand the initial insult to the pelvic floor. Methods: Anal manometry and fatigue (using a water-filled microballoon) and pelvic floor strength and fatigue (using an air-filled vaginal probe connected to a Peritron) were measured in 30 primiparous women at booking, end of pregnancy and 6 months post partum. Ten of these women also underwent measurement of pelvis size using ultrasound. A further 61 women, 39 incontinent and 22 continent, also underwent these measurements in order to compare pelvic floor parameters between continent and incontinent women. Results: Voluntary contraction of the external anal sphincter (EAS) was significantly lower 11 weeks post partum than antenatal values (106.5 ± 43.6 cmH2O antenatally vs 75.5 ± 45.6 cmH2O post partum, p < 0.001) but there was no significant difference between antenatal values and those measured 6 months post partum (p = 0.24). Anal fatigue rate was significantly slower 11 weeks post partum (p = 0.001), but by six months post partum the difference is no longer significant (p = 0.053). Pelvic floor muscle (PFM) strength fell with age and was significantly lower in incontinent women (8.97 ± 12.88 cmH2O) than incontinent women (27.17 ± 18.16 cmH2O; p < 0.001). PFM fatigue rate was also significantly slower in incontinent women (p = 0.01). The PFM strength was significantly higher in nulliparous than parous women (p = 0.002) and fatigue rate was faster (p = 0.022). PFM strength (p = 0.006) and fatigue rate (p =0.004) were significantly lower six months post partum when compared with antenatal values. It was shown that pelvis size can be measured using ultrasound and was found to be repeatable, but inaccurate when compared with magnetic resonance imaging. Insufficient numbers were studied to show an effect on pelvic floor function. Conclusion: Vaginal delivery causes impairment of EAS voluntary contraction which appears to have recovered by six months post partum. It also causes impairment of PFM contraction which is persistent at six months post partum. The reduced PFM function seen post partum also occurs in incontinent women, adding to the evidence that childbirth causes the initial insult to the pelvic floor which results in faecal incontinence, either immediately or some years later.

Orientadores: Viviane Herrmann, Paulo César Rodrigues Palma
Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
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Resumo: A incontinência urinária de esforço é uma das queixas clínicas mais comuns de mulheres em consultório médico e o desequilíbrio postural tem sido considerado como possível causa deste sintoma. Estudos demonstram que disfunções posturais como a hiperlordose, a anteversão da bacia pélvica, dores lombares e fraqueza dos músculos abdominais estão associados às disfunções dos músculos do assoalho pélvico. Objetivo: Comparar o efeito da Reeducação Postural Global com o treinamento dos músculos do assoalho pélvico no tratamento da incontinência urinária de esforço feminina a curto e a longo prazo. Metodologia: Cinquenta e duas mulheres com queixa clínica de incontinência urinária de esforço foram divididas em dois grupos: o Grupo 1 (G1) recebeu tratamento pela Reeducação Postural Global em 1 sessão semanal de 50 minutos por três meses e o Grupo 2 (G2) recebeu treinamento dos músculos do assoalho pélvico quatro vezes por semana, uma vez supervisionada em sessão individual de 50 minutos e três não supervisionadas, por três meses. Ao final do tratamento, após 6 meses, e em dois anos, foi realizada avaliação subjetiva (cura, melhora, inalterada e piora), diário miccional, avaliação funcional do assoalho pélvico (AFA) e questionário de qualidade de vida. Resultados: Concluíram o tratamento 25 pacientes do G1 e 17 do G2. A avaliação subjetiva do G1 ao final do tratamento apresentou 16% cura e após seis meses, 24%. No G2, no final do tratamento, nenhuma paciente considerava-se curada, 69% referiram melhora e 31% encontravam-se inalteradas. Após seis meses, 19% referiram cura, 37,5% melhoram, 31% inalteradas e 12,5% que haviam referido melhora ao final do tratamento, apresentaram piora dos sintomas. O número de episódios de perda e o número de troca de absorventes diminuiram significativamente nos dois grupos (p<0,001), sendo significativamente menor no G1. A Avaliação Funcional do Assoalho Pélvico (AFA) melhorou significativamente nos dois grupos (p<0,001), sem diferença entre eles. A avaliação da Qualidade de Vida demonstrou melhora significativa nos dois grupos, em todos os domínios. Após dois anos foram reavaliadas 21 pacientes no G1 e 12 no G2. O G1 apresentou 47,6% de cura e o G2, 16,7%, sendo que neste grupo, 33,3% das pacientes referiram piora com relação ao final do tratamento. O número de perdas e o número de absorventes diminuíram significativamente nos dois grupos (p=0,0001), sem diferença significativa entre eles (p=0,0787 e p=0,0579, respectivamente). A AFA melhorou significativamente no G1, porém no G2, apresentou melhora significativa ao final do tratamento e mante-se inalterada no seguimento de dois anos (p=0,045). Conclusão: A RPG mostrou-se uma alternativa eficaz no tratamento da Incontinência Urinária de Esforço Feminina, com resultados comparáveis ao treinamento dos músculos do assoalho pélvico, a curto e a longo prazo
Abstract: Stress urinary incontinence (SUI) is one of the most common complains of women and postural unbalances have been considered as a possible cause. Studies have shown that postural disequilibrium such as hiperlordose, pelvis anteversion, lumbar pain and weakness of the abdominal muscles are associated to pelvic floor muscles dysfunctions. Objective: To compare the effect of Global Postural Re-education (GPR) and Pelvic Floor Muscle Training (PFMP) for the treatment of female stress urinary incontinence at short and long term. Methodology: Fifty-two women with SUI complain were distributed into two groups: Group 1 (G1) was submitted to 50 minutes weekly sessions of GPR for three months and Group 2 (G2) performed PFMT four times a week for three months, being one time in individual session under professional supervision and the other three times at home, for three months. Patients were evaluated at the end of the treatment and after six months and two years on subjective evaluation (cure, improvement, no change and recurrence), voiding diary, functional evaluation of pelvic floor (FEPF) and through a questionnaire of quality of life. Results: The number of patients completing the treatments was 25 in G1 and 17 in G2. The subjective evaluation of G1 showed cure in 16% women at the end of the treatment and 24% after six months. In G2 no women reported cure at the end of the treatment, 69% indicated improvement and 31% reported no change. After six months, the reports of cure, improvement and no change in G2 were, respectively, 19%, 37.5% and 31%. Additionally, 12.5% of the women in this group, who had referred to improvement at the end of the treatment, reported symptom recurrence after six months. The urine leakage episodes reduced significantly in both groups (p<0.001), being significantly lower in G1. PAD use reduced significantly in both groups (p<0.001) and was significantly lower in G1. FEPF improved significantly in both groups (p<0.001), with no difference between them. The evaluation of Quality of Life had shown significantly improvement in both groups, in all domains. Two years after the end of the treatment, 21 patients of G1and 12 of G2 were reevaluated. The amount of women reporting cure in G1 and G2 were, respectively, 47.6% and 16.7%. In G2, 33.3% of the patients referred to symptoms recurrence in comparison with the end of the treatment. Episodes of urine leakage and PAD use reduced significantly in both groups (p=0.0001), without significant difference between groups (p=0.0787 and p=0.0579, respectively). FEPF had shown improvement in G1 in the evaluation at six months and two years; however, in G2 it had shown improvement at the end of the treatment but it did not change in the evaluation at two years. This shows that the behavior of the groups was different throughout the time (p=0.045). Conclusion: GPR has proven to be an efficient alternative to treat SUI in women when compared to PFMT, either on short term or long term follow-up
Doutorado
Fisiopatologia Cirúrgica
Doutor em Ciências

Orientador: Viviane Herrmann Rodrigues
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
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Resumo: Introdução: A Incontinência Urinária (IU) tem impacto na qualidade de vida da mulher, física, psicológica e socialmente. A Avaliação Urodinâmica (AU) pode ser considerada o padrão ouro no diagnóstico da etiologia da IU. Entretanto, trata-se de exame invasivo, que provoca desconforto e constrangimento à paciente e cujo resultado nem sempre reproduz a sintomatologia clínica. Objetivo: Avaliar a associação entre o "International Consultation on Incontinence Questionnaire - Urinary Incontinence/Short Form" (ICIQ-UI/SF) e a Avaliação Urodinâmica, em mulheres com incontinência urinária. Métodos: Foi realizada análise retrospectiva dos dados clínicos e AU de 358 mulheres com IU atendidas em clínica privada. Utilizou-se a curva ROC com os valores de sensibilidade e especificidade dos escores do ICIQ-UI/SF apresentados pelas pacientes, a fim de estabelecer o escore capaz de discriminar o diagnóstico urodinâmico nos grupos estudados. Para o cálculo do p valor foi utilizado o teste de qui-quadrado ou exato de Fisher. O teste de Spearman avaliou a correlação entre o ICIQ-UI/SF e os parâmetros urodinâmicos. O nível de significância foi de 5% e o software utilizado para a análise foi o SAS versão 9.2. Resultados: A média de idade entre as pacientes foi de 51,1 anos, a raça predominante foi branca e 86,5% das pacientes tiveram ao menos duas gestações. As pacientes com Incontinência Urinária de Esforço segundo a AU (grupo 1) representaram 67.3% das pacientes estudadas. As pacientes com IUE na AU e Hiperatividade Detrusora (HD) - grupo 2 - representaram 16,2% da amostra e as pacientes com HD isolada (grupo 3) representaram 7,3% do total. Em 9.2% a Avaliação Urodinâmica foi considerada normal. Pacientes dos grupos 1 e 2 apresentaram escore ? 14 no ICIQ-UI/SF, sendo esta associação significativa (p=0,01 e p=0,001, respectivamente). Foi observada significativa associação entre a PPE ? 90 cmH2O e escore ICIQ-UI/SF ? 15 (p=0,0037). O teste de Spearman mostrou significativa correlação inversa entre o escore do ICIQ-UI/SF e a PPE, porém não mostrou correlação entre este escore e a Capacidade Cistométrica Máxima (CCM) ou com o volume vesical no primeiro desejo miccional (PDM). Conclusão: Mulheres com PPE ? 90 cmH2O apresentaram escores mais altos ao ICIQ-UI/SF, porém não há correlação com a CCM ou o PDM. Foi observada associação significativa entre a IUE e a PPE ? 90 cmH2O e escores mais altos no ICIQ-UI/SF
Abstract: Introduction: Urinary incontinence (UI) compromises women's quality of life, either in physical, psychological or sexual aspects. Urodynamics is considered the gold standard in the diagnosis of urinary symptoms. However it is invasive, expensive, provokes constraints to patients and is not always related to clinical complains. Objective: To evaluate the association between the "International Consultation on Incontinence Questionnaire - Urinary Incontinence/Short Form" (ICIQ-UI/SF) and urodynamics in women with urinary incontinence. Methods: It was a retrospective analysis of the data of 358 women with urinary incontinence attending a private clinic. A ROC curve was applied for sensitivity and specificity of ICIQ-UI/SF, to identify the score that would discriminate urodynamic diagnosis for the groups considered. P-value was obtained by Q-square and Fishers Exact Test. Spearman's test was used to correlate the ICIQ-UI/SF score to urodinamic parameters. Significance was 5% and the software SAS version 9.2. Results: Mean age was 51.1 years-old, the majority was white and 86.5% has been pregnant at least twice. Two hundred forty one patients (67.3%) presented stress urinary incontinence (SUI) on urodynamics (group 1), 16.2% presented SUI and Detrusor Overactivity (DO) (group 2) and 7.3% only DO. In 9.2% of the cases, urodynamics was considered normal. Women in groups 1 and 2 presented a significant association with ICIQ-UI/SF scores ? 14 (p=0.01 and p=0.001, respectively). A significant association was observed between Leak-point Pressure (LPP) ? 90 cmH2O and an ICIQ-UI/SF ? 15 (p=0.0037). Spearman's test showed a significant inverse correlation between ICIQ-UI/SF and LPP, but not to Maximum Cistometric Capacity (MCC) or First Desire to Void (FDV). Conclusions: Women with LPP ? 90cmH2O presented higher ICIQ-UI/SF scores, but no correlation was observed with MCC or FDV. Higher scores of the ICIQ-UI/SF were significantly associated with SUI and LPP ? 90cmH2O
Mestrado
Fisiopatologia Ginecológica
Mestra em Ciências da Saúde

Introducció: La incontinència pot donar complicacions com Dermatitis Associada a la Incontinència (DAI). L'etiologia de la DAI és complexa i multifactorial i sovint es confon amb úlceres per pressió (UPP). La Perineal Assessment Tool (PAT) és una escala que valora el risc de DAI però no està validada en l'àmbit espanyol. Objectius: Fase I: Traduir i adaptar a l'espanyol l'escala PAT. Fase II: Determinar la fiabilitat Intra i Interobservador, Viabilitat i Validesa de contingut. Fase III: Determinar la Consistència Interna, la Validesa de Constructe i la Validesa de Criteri. Determinar estadísticament la puntuació de tall. Determinar la prevalença de DAI en la mostra estudiada. Material i mètode: Fase I: Es va realitzar la traducció-retrotraducció per dos traductors professionals. Fase II: va correspondre a la prova pilot. La mostra va ser de 15 pacients majors de 65 anys, institucionalitzats i diagnosticats amb algun tipus d'incontinència. Fase III: estudi transversal amb una mostra d'estudi de 171 pacients diagnosticats amb algun tipus d'incontinència.
Introducción: La incontinencia puede dar complicaciones como Dermatitis Asociada a la Incontinencia (DAI). La etiología de la DAI es compleja y multifactorial y a menudo se confunde con úlceras por presión (UPP). La Perineal Assessment Tool (PAT) es una escala que valora el riesgo de DAI pero no está validada en el ámbito español. Objetivos: Fase I: Traducir y adaptar al español la escala PAT. Fase II: Determinar la Fiabilidad Intraobservador e Interobservador, Viabilidad y Validez de Contenido. Fase III: Determinar la Consistencia Interna, la Validez de Constructo y la Validez de Criterio. Determinar estadísticamente la puntuación de corte. Determinar la prevalencia de DAI en la muestra estudiada. Material y métodos: Fase I: Se realizó la traducción-retrotraducción por dos traductores profesionales. Fase II: correspondió a la prueba piloto. La muestra fue de 15 pacientes mayores de 65 años, institucionalizados y diagnosticados con algún tipo de incontinencia. Fase III: estudio transversal con una muestra de estudio de 171 pacientes diagnosticados con algún tipo de incontinencia.
Incontinence can lead to complications such as Incontinence Associated Dermatitis (IAD). The etiology of IAD is complex and multifactorial and is often confused with pressure ulcers (PU). The Perineal Assessment Tool (PAT) is a scale that assesses the risk of IAD but is not validated in the Spanish context. Goals: Phase I: Translate and adapt the PAT scale to Spanish. Phase II: Determining Intraobserver and Interobserver, Reliability and Content Validity. Phase III: Determine Internal Consistency, Construct Validity and Criterion Validity. Determine the cutoff score statistically. To determine the prevalence of IAD in the sample studied. Material and methods: Phase I: Translation-back translation was performed by two professional translators. Phase II: corresponded to the pilot test. The sample consisted of 15 patients older than 65 years, institutionalized and diagnosed with some type of incontinence. Phase III: cross-sectional study with a study sample of 171 patients diagnosed with some type of incontinence.

Background: Urinary incontinence affects people of different ages, gender and ethnic backgrounds. Current review of literature shows very that very little work has been done with regards to urinary incontinence in ethnic minority groups. At Leicester there is a high ethnic minority population comprising of different ethnic groups, the largest in inner city Leicester being the Indians that migrated from the state of Gujarat in India. Observations of clinic attendees, and unpublished data from the Medical Research Council Leicester Incontinence Study, lead us to believe that significant numbers of Indian women have continence problems but do not make use of currently available services. Aims: To explore inequality in health, barriers towards accessing continence care and to further understand how best to provide continence services to this group the research program was formulated comprising of: Prevalence study, Cultural context study, Patients‘ journey through primary care study. These will address the various aspects of the influence and interaction of ethnic origin with incontinence care. Methods: This project uses a mixed method approach combining both quantitative and qualitative research methods. The quantitative arm of the study uses validated self administered questionnaires to determine the prevalence and quality of life scores in women suffering with urinary incontinence in the community. The qualitative arm of the study uses focus groups and interviews to further explore women‘s coping strategies, the effect of migration in their symptoms and help seeking behaviour, the impact incontinence has on their lives and their attitudes towards available continence care, including suggestions for improving services. Results: The South Asian named women in our research reported higher rates and severity of urinary symptoms, with a corresponding greater impact on their quality of life when compared to White British named women and Indian women in Gujarat. It highlights some of the barriers in effective continence care. None of these women were referred to secondary care immediately, unlike their White British counterparts within the same primary care setup. Management of incontinence in primary care is inadequate and doesn‘t comply with the recommendations made in the NICE guidelines. Conclusions: This research project is a unique opportunity to study the impact of ethnic origin upon urinary incontinence. The inequalities in healthcare that have been highlighted together with the suggestions of service improvement that have come from the service users has resulted in the development of a strategic framework of continence care for ethnic minority women. This will aim to ensure accessible and acceptable care for these patients.

Faecal incontinence is an embarrassing and socially debilitating condition which is primarily acquired and increases in prevalence with age. Current conservative measures are aimed at dietary modification and changing the consistency of stool with no targeted treatments available to address the underlying cause of incontinence. Surgical treatments are either unsatisfactory or carry significant morbidity. There is currently increasing interest in the use of α adrenoceptor agonists to increase the tone of the anus and thereby improve continence. One of the potential drugs, L-erythro-methoxamine, has been shown to increase mean anal resting tone in healthy volunteers and is well tolerated as suppositories. Extensive data exists on the neuromyogenic properties of the human internal anal sphincter (IAS) and its response to various drugs, particularly α adrenoceptor agonists. Little data exists on the response of the rectum to α agonists. The ideal drug treatment for incontinence would cause a contraction in the IAS and a relaxation in the rectum – increasing the reservoir of stool while augmenting the sphincter to aid continence. We performed in vitro experiments on sheep internal anal sphincter (IAS) using an organ bath method and subjected the tissues to electrical field stimulation to mimic nerve stimulation. Our results were comparable to results of previous authors who also examined the sheep IAS. Using this validated protocol, we investigated the sheep rectum to identify the neuronal mediators of the EFS response and to investigate the effect of α1 adrenoceptor agonists. Our results showed that sheep rectum relaxes in response to nerve stimulation and this relaxation is the result of the release of nitric oxide. Contraction in response to nerve stimulation is primarily mediated by acetylcholine acting on muscarinic receptors. Methoxamine caused a contraction in the sheep rectum. We also examined the pig IAS and rectum in vitro. An identical organ bath technique was used with Electrical Field Stimulation to mimic nerve stimulation. For both IAS and rectum in the pig, nerve stimulation caused a relaxation via nitric oxide and a contraction mediated primarily by noradrenaline acting on α1 adrenoceptors with a small component mediated by acetylcholine acting via muscarinic receptors. Methoxamine caused a contraction in both IAS and rectal tissue with similar potency in each. We were part of an industry-sponsored multi-centre randomised placebo-controlled clinical trial investigating the safety and efficacy of L-erythro-methoxamine on patients with faecal incontinence. The nine patients recruited from our centre showed no significant improvement in the number of episodes of incontinence or in the questionnaire scores measuring the impact of incontinence on quality of life after eight weeks of daily suppositories. The drug was well tolerated with few adverse events. There were no significant safety concerns although there was a prolongation of the PR interval in post-treatment ECGs and a positive correlation between the QT intervals on ECGs with serum concentrations of the drug. Our results were typical of those obtained in the other centres. The overall result of the trial was that there was no improvement in episodes of faecal incontinence following treatment with L-erythro-methoxamine at the chosen doses. The results from our in vitro experiments suggest that α adrenoceptor agonists may not be the best methods of treating faecal incontinence. The results from the clinical study support this finding. We believe that more in vitro studies need to be performed on human rectal tissue to confirm our findings that α adrenoceptor agonists cause a contraction in the rectum.

Orientadores: Paulo César Rodrigues Palma, Cássio Luís Zanettini Riccetto
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
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Resumo: Introdução e hipótese: O implante de slings corresponde ao padrão atual de tratamento da incontinência urinária de esforço. Para sua eficácia, exigem um mecanismo de ancoragem adequado. O objetivo deste estudo foi comparar as características biomecânicas de sistemas de fixação de dois modelos de mini slings atualmente disponíveis no mercado (Ophira® e Mini Arc®) por meio de teste de tração uniaxial em modelo murino ex vivo. Materiais e Métodos: Os dispositivos de ancoragem dos mini sling foram implantados cirurgicamente na parede abdominal de 15 ratos divididos em três grupos de cinco animais. Estes grupos foram sacrificados de acordo com a data pós implante em 7, 14 e 30 dias. Na sequência, extraia-se em bloco a parede abdominal de cada animal contendo os dispositivos de fixação. Este material era submetido a teste de tração até o despreendimento do sistema de ancoragem a partir do tecido leito de implante. Foram determinadas a medida da carga máxima (N) e deformação total (mm) até a avulsão. Os resultados foram comparados por meio do teste t de Student e o valor de p 5% foi considerado significativo. Resultados: O sistema de fixação do mini sling Ophira® em comparação ao Mini Arc® exigiu maior carga máxima para avulsão do tecido abdominal nos 3 períodos avaliados com significância estatística: 7º dia, 5,14 ± 0,69 N versus 4,11 ± 0,81 N (p 0,037), 14º dia 10,64 ± 0,81 N contra 9,02 ± 0,54 N (p 0,001) e no 30º dia 18,76 ± 1,48 N versus 14,85 ± 1,28 N (p < 0,001), respectivamente. Quanto ao deslocamento ocorrido durante a tração, o Ophira® desenvolveu maior deflexão significante em todos os momentos avaliados: no dia 7, 11,14 ± 0,53 mm enquanto o Mini Arc® 7,89 ± 1,01 mm (p 0,001), no dia 14 15,80 ± 0,95 mm versus 12,49 ± 1,43 mm (p < 0,001) e no trigésimo dia os valores foram 23,95 ± 1,38 mm contra 18,24 ± 0,50 mm (p < 0,001), respectivamente. Conclusão: O dispositivo de ancoragem do mini sling Ophira® proporcionou melhor fixação à parede abdominal murina em relação ao do Mini Arc®. Este resultado foi mantido mesmo no período pós-operatório tardio
Abstract: Introduction and hypothesis: Slings are currently the standard treatment for stress urinary incontinence. To be effective, they require an adequate anchoring system. The aim of this study is compare the biomechanical features of fixation systems of two mini slings models currently available on the market (Ophira¿ and Mini Arc¿). Materials and Methods: Anchoring devices of each sling were surgically implanted in the abdominal wall of 15 rats divided into three groups of five animals. These groups are formed according to the date of post implant euthanasia on 7, 14 and 30 days. Each abdominal wall was extracted in block containing the mini sling fixation device and was submitted to a tensile strength test for measure the maximum load and total deflection until device avulsion from the tissue. The results were compared using Student test t and a 5% cut off was considered significant. Results: The Ophira¿ mini sling fixation system demanded a greater maximum load compared to the Mini Arc¿ for avulsion of abdominal tissue in 3 evaluation periods with statistical significance: 7th day, 5.14 ± 0.69 versus 4.11 ± N 0,81 N (p 0.037), on day 14 10.64 ± 0.81 N versus 9.02 ± 0.54 N (p 0.001) and on day 30 18.76 ± 1.48 N versus 14.85 ± 1.28 N (p <0.001), respectively. Regarding the displacement occurred during traction, the Ophira¿ has developed significant higher deflection at all times evaluated: on day 7, 11.14 ± 0.53 mm while the Mini Arc¿ 7.89 ± 1.01 mm (p 0.001), on day 14 15.80 ± 0.95 versus 12.49 mm ± 1.43 mm (p <0.001) and on day 30 the values were 23.95 ± 1.38 mm vs. 18.24 ± 0.50 mm (p <0.001), respectively. Conclusion: The Ophira¿ mini sling anchoring device provided better fixation to the host tissue site compared to the Mini Arc¿ device in rats. This outcome were maintained even in the late post operative period
Mestrado
Fisiopatologia Cirúrgica
Mestre em Ciências

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.

Background There is a delay between obstetric injury and the onset of faecal incontinence (FI) for most females, yet traditional surgical management has focussed on the obstetric injury when treating FI. Recently, electrical stimulation has been used in a number of treatments however the modes of action and efficacies are unknown. This study aimed to assess the aetiology of FI, while exploring the efficacy of the three main modalities of electrical stimulation for FI, namely sacral nerve stimulation (SNS), percutaneous tibial nerve stimulation (PTNS) and electrically stimulated gracilis neosphincter (ESGN). Methods Data was analysed for 999 females, who had undergone anorectal physiology testing (ARP) excluding confounding factors other than aging and childbirth. Patients treated for FI with PTNS or SNS were investigated with ARP to assess their efficacy and any potential indicators of success. Patients with ESGN were evaluated to assess efficacy in the short, mid and long term. Results The function of the external anal sphincter is affected by childbirth, while the internal anal sphincter deteriorates with age. SNS can be effective in the treatment of FI, but only 26% of patients experience a resolution of symptoms with 74% remaining incontinent. PTNS performs slightly better with 32% of patients experiencing apparent continence; however this is significantly cheaper and less invasive than SNS. Outcome for ESGN also revealed a high failure rate, yet in the long term, this outperforms SNS and PTNS with 43% of patients being successfully treated. Discussion Both aging and childbirth contribute via different mechanisms to produce decreased anal sphincteric function. Symptomatic patients can be treated with electrical stimulation therapies however, a high failure rate is noted for all modalities. A treatment “ladder” is emerging, starting with minimally invasive PTNS, through SNS and finally the costly and demanding ESGN for highly motivated patients.

Background: Both urgency and stress urinary incontinence are heritable, with genetic factors contributing approximately half of total susceptibility. Aims: The overall aim of this project is to identify known and novel genetic polymorphisms associated with urgency and stress incontinence in women. Design: We systematically reviewed prior genetic association studies of incontinence, and other pelvic floor disorders. We then conducted a two stage GWAS, using women enrolled in NFBC1966, UK Twins, and ALSPAC for discovery, and women in six separate cohorts for replication. To prioritise likely susceptibility genes we measured gene expression in bladder biopsies, using whole genome microarrays, and PCR using custom microfluidic plates. Results: From prior studies of incontinence, and the related condition of prolapse among women, we conducted 13 meta-analyses for different polymorphisms, finding a single moderately credible association for a common variant in the ADRB3 gene associated with overactive bladder. From prior studies of lower urinary tract symptoms in men, we conducted 35 meta-analyses for different polymorphisms, finding a single moderately credible association for a common variant in the VDR gene associated with a composite of symptoms. For the GWAS discovery phase 8,997 women provided both incontinence phenotypes and genome wide genotypes. In meta-analysis, five loci included at least one genome-wide significant variant (p < 5x10⁻⁸). Twelve loci were taken forward for replication, with two demonstrating robust replication. In bladder biopsies we identified 1,115 significantly differentially expressed genes between stress and urgency incontinence. In the context of the previous literature, these results suggested EN1 and EDN1 as the most likely causal genes within the two replicated GWAS significant loci. Conclusions: This work highlights many of the challenges of identification of risk variants for complex conditions such as incontinence. The discovery of two novel risk loci for incontinence represents a significant advance in understanding the pathophysiology of these conditions.

Orientador: Maria Helena Baena de Moraes Lopes
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
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Resumo: Pesquisas realizadas relatam que a Incontinência Urinária (lU) causa nas mulheres conseqüências físicas, econômicas e psicossociais que interferem na qualidade de vida e estudos recentes têm mostrado que a lU interfere também nas atividades ocupacionais. O objetivo do presente estudo foi avaliar a prevalência da lU, suas associação com alguns fatores, sua interferência no desenvolvimento das atividades diárias ocupacionais e seu manejo entre mulheres profissionais de enfermagem de um hospital-escola na cidade de Campinas - SP, Brasil. O estudo foi tipo corte transversal. A população de estudo foi composta por todas as profissionais de enfermagem que se encontravam em atividade no mês de fevereiro de 2003. A coleta de dados foi realizada em duas fases. Na primeira fase foi distribuído um questionário que identificou as funcionárias que apresentavam queixa de perda involuntária de urina pelo menos uma vez por mês, durante o último ano, além de questões sobre algumas variáveis de interesse. Na segunda fase foi realizada entrevista com as profissionais que apresentavam queixa de lU, identificando-se sua interferência nas atividades ocupacionais, as estratégias para manejo da lU e outros aspectos. Para verificar associações, os grupos com ou sem lU foram comparados utilizando-se os testes t de Student, qui-quadrado, exato de Fisher ou Mann-Whitney. Através da análise de regressão logística univariada e multivariada, pelo processo de seleção das variáveis "Stepwise", foram selecionadas as variáveis mais significativas. Dentre os 378 formulários distribuídos, 291 (77%) foram respondidos de maneira adequada e completa. A queixa de lU foi relatada por 80 funcionárias (27,5%). A análise multivariada indicou que as mulheres que engordaram e emagreceram tinham 26 vezes mais chance de queixa de lU, sendo esta possibilidade de 4,2 vezes entre mulheres que emagreceram; 3,8 vezes entre as mulheres com hipertensão arterial; 3,1 vezes entre as que tinham constipação intestinal e 3,0 vezes após os 41 anos de idade. A lU causou restrições nas atividades ocupacionais, sexuais e sociais. As atividades que demandavam maiores esforços físicos como carregar peso, empurrar maca e cadeira de rodas, tomaram a lU mais freqüente. A incontinência durante a jornada de trabalho foi responsável por problemas como: estresse, vergonha, constrangimento, raiva e falta de concentração no trabalho. As estratégias mais utilizadas foram: usar forro ou absorvente higiênico e reduzir a ingestão hídrica. O manejo inadequado causou prejuízos à saúde como: irritação, assadura, alergia na pele e infecção urinária. Foram identificadas facilidades para o manejo, como poder utilizar o toalete sempre que necessário e trocar de roupa, forro ou absorvente higiênico durante a jornada de trabalho. As dificuldades mais citadas foram: distância do toalete maior que 12 metros, quantidade insuficiente de toalete nas unidades e não poder interromper a atividade para o uso do toalete. Concluiu-se que o aumento da freqüência da perda urinária devido às atividades que demandavam maiores esforços físicos, dificuldades para manejo adequado e a interferência no desempenho profissional caracterizaram o impacto da lU nestas trabalhadoras. Medidas educativas de prevenção e tratamento se fazem necessárias para melhorar o desempenho profissional e a qualidade de vida destas mulheres
Abstract: The urinary incontinence (UI) causes physical, economic and psychosocial effects to the women. The aim of this present study was to assess the UI prevalence, its association to some factors, its interference at the performance of the occupational daily activities and its management among nurse female staff of a school hospital at Campinas, São Paulo State, Brazil. It was a cross-sectional cohort study. The population studied was composed by ali the nursing staff that working during the month of February of 2003. The data collecting was performed into two phases. At the first phase, it was delivered a questionnaire that had identified the employers who complaint of UI at least once a month during the past year, a part from the issues about some variables of interesting. At the second phase, it was performed an interview to the employers who had presented complaints of U I, its interference at the occupational activities, the management strategies of the UI and other aspects. In order to verify the association, the groups with or without UI were compared using the following tests t Student, Qui-square, Fisher Exact or Mann Whitney. The univariate and multivariate analysis of logistic regression by the selection process of -"stepwise" variables had selected the most significant variables. Of the 378 questionnaires delivered, 291 (77%) were completely answered. The UI complaint was reported by 80 employers (27.5%). The multivariate analysis had shown that the women that having gained and lost weight has had 26 times more chance to complaints of UI; this possibility was 4,2 time more among women that having lost weigth; 3,8 time more among women that having arterial hypertension; 3,1 times more among those that having intestinal constipation and 3,0 time more after 41 years of age was. The UI was reported as being responsible by restrictions at the occupational, sexual and social activities. The activities which require more effort, like to lifI: heavy things and to push stretchers and wheelchairs became the UI more frequento The UI during the working was responsible by stress, shame, restraint, angry, lack of concentration at work among other complaints. The most used strategies were: wearing pads, diapers and decreasing oral fluid intake. The inadequate management caused damages to health, such as: irritation, skin rash, skin allergy and urinary tract infection. It was identified facilities for the management, as uses the toilette as much as necessary changes the dothes and the diapers or pads. The most important difficulties were: a distance of more than 12 meters of the toilette trom the workplace, not enough amounts of toilettes available at the workplace unit, and impossibility of not interrupting the activity that they were performing to go the toilette. It was concluded that the trequency increased of the UI due to developrnent effort activities at work, difficulties for the adequate managernent of the UI and professional performance interference characterized the impact of urinary incontinence in these working women. Preventable educational rneasures and treatment are necessary in order to irnprove the professional developrnent and quality of Ufe of these wornen
Mestrado
Enfermagem e Trabalho
Mestre em Enfermagem

The purpose of this study was to examine factors that influence the experience of urinary incontinence (UI) as it relates to sexual intimacy for older women. Additionally, I wanted to identify perceived areas of intervention that might positively influence the experience of UI as it relates to sexual intimacy for participants. The sample consisted of 10 women who ranged in age from 65 to 81. The theoretical framework guiding this study was a systemic perspective in which how participants make meaning is given prominence. Symbolic interactionism, social constructionism, and systems perspective are interwoven to provide the foundation for this study. Data were collected utilizing in-depth interviews. Self-portraits were introduced to enrich conversation during the second interview. Three conclusions were drawn from this study. First, feelings of secrecy that permeated this project were manifested in the lack of willing participants as well as brevity of responses during interactions with participants. Second, participants indicated a tendency to minimize their incontinence and to manage their symptoms without formal medical intervention. Third, participants offered perceived potential interventions that might positively influence the experience of UI. These included the provision information related to UI in a way that does not require individuals to request the information, such as brochures at physicians' offices, post-surgical follow-up, and individuals from whom participants would be most comfortable receiving such information.
Ph. D.

Introducción: Según la International Continence Society, la incontinencia urinaria es la pérdida involuntaria de orina objetivamente demostrable, lo cual origina un problema social que perjudica la calidad de vida del paciente. Además, este problema llega a provocar aislamiento social y síntomas depresivos. De la misma forma que el proceso de continencia depende de múltiples factores. Es por ello que en esta tesis se descrive la asociación los diferentes factores de riesgo que provocan la incontinencia urinaria en mujeres entre 25 y 35 años de edad. Material y Metodos: Con una muestra de 257 mujeres. Con un reclutamiento de la muestra con mujeres voluntarias que habían recibido información a través de redes sociales y en instituciones sanitarias. Las variables de estudio fueron la continencia o la incontinencia de orina, el tipo de incontinencia, el impacto en la calidad de vida, el nivel de actividad física, el consumo de cafeína, de alcohol y de bebidas diuréticas, los hábitos intestinales (estreñimiento), el peso (obesidad), el estrés, así como el número y el tipo de partos. Todos estos datos han sido recogidos mediante cuestionarios validados. Resultados: El análisis estadístico descriptivo, de la muestra seleccionada (257), teniendo como referencia el cuestionario UDI-6 (presencia o no de incontinencia urinaria) nos indica que el 34.63% de la muestra no presenta incontinencia urinaria frente al 65.37% que si la presenta. Donde destacan los datos obtenidos en referencia a la variable “fuerza defecatoria”. Observando una diferencia estadísticamente significativa (p=0.0014) estando esta variable presente en el 76.92% de las mujeres que presentan incontinencia urinaria. Conclusiones: En nuestro estudio, realizado en mujeres de entre 25 y 35 años, se ha observado una prevalencia de incontinencia urinaria del 65.37%. Si se considera que la incontinencia urinaria produce deterioro de la calidad de vida, como propone la definición de la International Continence Society, se justifica que en la práctica clínica sea más frecuente atender pacientes en este rango de edad, ya que mujeres mayores consideran este problema como “normal o natural”, relacionado con la edad. Hemos optado por utilizar cuestionarios de fácil comprensión y realización, así como de bajo coste económico. Los cuestionarios utilizados han sido: Para la detección de la sintomatología de la incontinencia urinaria: el Urogenital Distress Index-6 ya que lo consideramos corto y fácil respecto a otros cuestionarios. Además, incluye diversos aspectos que nos guían hacia la presencia, frecuencia y tipología de la incontinencia urinaria. Para valorar el impacto en la calidad de vida: el Incontinence Impact Quetsionanaire-7, ya que presenta propiedades similares al Urogenital Distress Index-6, siendo de fácil realización. Para valorar la actividad física: el International Physical Activity Questionnaire, ya que fue realizado dentro de un programa internacional conjunto para establecer parámetros regulares. El otro cuestionario validado para la población española, el Global Physical Activity, creado por la OMS, no lo hemos utilizado ya que tiene una mayor extensión. Para valorar el consumo de ingesta de líquidos: hemos validado el Beverage Intake Questionnaire-15, el cuál reúne los ítems necesarios para este objetivo. No hemos utilizado el Cuestionario de frecuencia de consumo alimentario por ser demasiado global y no específico para este fin. Para la valoración de la variable estrés: el cuestionario Perceived Stress Scale-10, validado al español, al considerarlo fácil y de rápida comprensión. La variable obesidad fue valorada mediante el cálculo del Índice de Masa Corporal (IMC), mientras que otras variables, como el nivel de estudios, el estreñimiento, la fuerza al defecar, la historia obstétrica o el hábito tabáquico, se realizaron mediante preguntas directas. En el estudio no se encuentra una relación estadísticamente significativa entre el nivel de estudios, el estrés, así como la ingesta de líquidos, en referencia a la presencia de incontinencia urinaria.Las variables peso y altura de forma separada, así como el Índice de Masa Corporal no muestran una relación estadísticamente significativa con la incontinencia urinaria. Sin embargo, la incontinencia urinaria y el aumento del índice de masa corporal tienen una cierta tendencia de relación. El número de embarazos, el tipo de parto (por cesárea o por vía vaginal), instrumentado y/o con lesiones no muestran una relación estadísticamente significativa con respecto a la incontinencia urinaria. El hábito tabáquico no se ha demostrado estadísticamente significativo respecto a la incontinencia urinaria. Sin embargo se aprecia una cierta tendencia entre el mayor consumo de tabaco y la incontinencia urinaria. El estreñimiento, y especialmente el sobreesfuerzo para defecar, es un factor de riesgo con significación estadística en nuestros resultados para la incontinencia urinaria. La actividad física no se relaciona estadísticamente con la incontinencia urinaria, pero se observa un indicio como factor protector de la misma. Referente al impacto en la calidad de vida de las mujeres que presentan incontinencia, se observa un porcentaje bajo, en las limitaciones de la vida diaria.
Introduction: According to the International Continence Society, urinary incontinence is the involuntary loss of objectively demonstrable urine, which causes a social problem that harms the quality of life of the patient. In addition, this problem causes social isolation and depressive symptoms. In the same way that the process of continence depends on multiple factors. That is why this thesis describes the association of the different risk factors that cause urinary incontinence in women between 25 and 35 years of age. Material and Methods: With a sample of 257 women. With a recruitment of the sample with women volunteers who had received information through social networks and in health institutions. The study variables were continence or urinary incontinence, the type of incontinence, the impact on quality of life, the level of physical activity, the consumption of caffeine, alcohol and diuretic drinks, bowel habits (constipation) , weight (obesity), stress, as well as the number and type of births. All these data have been collected through validated questionnaires. Results: The descriptive statistical analysis of the selected sample (257), taking as reference the UDI-6 questionnaire (presence or absence of urinary incontinence), indicates that 34.63% of the sample does not present urinary incontinence compared to 65.37% if presents it. Where the data obtained in reference to the variable "defecatory force" stand out. Observing a statistically significant difference (p = 0.0014), this variable is present in 76.92% of women with urinary incontinence. Conclusions: In our study, performed in women between 25 and 35 years old, a prevalence of urinary incontinence of 65.37% was observed. If it is considered that urinary incontinence causes deterioration of the quality of life, as proposed by the International Continence Society definition, it is justified that in clinical practice it is more frequent to treat patients in this age range, since older women consider this problem as "normal or natural", related to age. We have chosen to use questionnaires of easy comprehension and realization, as well as of low economic cost. The questionnaires used were: For the detection of the symptoms of urinary incontinence: the Urogenital Distress Index-6 since we consider it short and easy with respect to other questionnaires. In addition, it includes various aspects that guide us towards the presence, frequency and typology of urinary incontinence. To assess the impact on quality of life: the Incontinence Impact Quetsionanaire-7, since it has properties similar to the Urogenital Distress Index-6, being easy to perform. To assess physical activity: the International Physical Activity Questionnaire, since it was carried out within a joint international program to establish regular parameters. The other questionnaire validated for the Spanish population, the Global Physical Activity, created by the WHO, we have not used it since it has a greater extension. To assess the consumption of fluid intake: we have validated the Beverage Intake Questionnaire-15, which brings together the items necessary for this purpose. We have not used the Food Consumption Frequency Questionnaire because it is too global and not specific for this purpose. For the assessment of the stress variable: the Perceived Stress Scale-10 questionnaire, validated to Spanish, considering it easy and quick to understand. The variable obesity was valued by calculating the Body Mass Index (BMI), while other variables, such as educational level, constipation, defecation strength, obstetric history or smoking habit, were made by direct questions. The study does not find a statistically significant relationship between the level of studies, stress, as well as fluid intake, in reference to the presence of urinary incontinence. The variables weight and height separately, as well as the Mass Index Corporal do not show a statistically significant relationship with urinary incontinence. However, urinary incontinence and increased body mass index have a certain relationship tendency. The number of pregnancies, the type of delivery (by cesarean or vaginal delivery), instrumented and / or with injuries do not show a statistically significant relationship with respect to urinary incontinence. The smoking habit has not been shown to be statistically significant with respect to urinary incontinence. However, there is a certain tendency between increased tobacco consumption and urinary incontinence. Constipation, and especially overexertion to defecate, is a risk factor with statistical significance in our results for urinary incontinence. Physical activity is not statistically related to urinary incontinence, but an indication is observed as a protective factor. Regarding the impact on the quality of life of women with incontinence, a low percentage is observed in the limitations of daily life.

Esta investigación, se centra en la promoción de la salud, pretende contribuir a la misma aportando conocimiento documentado sobre la incontinencia urinaria (IU) de la mujer a partir de las propias protagonistas que la padecen. Para explicar sus comportamientos de salud desde la perspectiva de género en relación a las pérdidas de orina, el estudio ha optado como referente teórico, el Modelo de Promoción de la Salud de Pender. Objetivo: Describir, en mujeres con incontinencia urinaria, sus conductas o comportamientos de salud en relación con la pérdida de orina. Metodología: La investigación se plantea a través del paradigma cualitativo a partir de la perspectiva filosófica de la fenomenología descriptiva. El ámbito de estudio ha sido la provincia de Barcelona. Resultados: Las informantes no dimensionan la IU como una enfermedad ni perciben la gravedad de su problema por ser pérdidas esporádicas y poco abundantes, las viven con resignación y no se plantean buscar ayuda profesional. Otorgan un significado peyorativo a las pérdidas de orina por vincularlas al proceso de envejecimiento. Se aprecian influencias interpersonales y situacionales que las predispone a normalizar la IU como algo propio por ser mujer y por la edad. Conclusiones: El comportamiento de salud en relación con la pérdida de orina de las mujeres participantes, viene marcado por la interiorización de los estereotipos negativos de género vinculados a la vejez.
This research, based on health promotion, aims to improve documented knowledge on women with urinary incontinence (UI) by focusing on their own perspective. The theoretical framework of this study is based on the model of Health Promotion by Pender. Objective: To describe, in women with urinary incontinence, their health behaviors in relation with the leaks of urine. Methodology: A descriptive phenomenological approach was adopted for the study. The area of study was the province of Barcelona. Results: The informants did not recognize UI as a disease and did not perceive the severity of the problem because of the sporadic and scanty urine losses. Moreover, they resigned and gave a negative meaning to the urine leakage by relating it to the aging process. Also, they did not look for professional help. Interpersonal and situational influences were evidenced, predisposing them to normalize UI because of gender and age. Conclusions: Health behavior in relation to UI from female participants is influenced by the internalization of negative gender stereotypes associated with aging.

Abstract Faecal incontinence disables the patients physically, emotionally and socially. The subjects affected are heterogenous and the tests and treatments offered vary widely. Knowledge of methods of assessments and treatments available is important in optimising the management. As General Practitioners are the first point of contact, we carried out a postal survey to assess this among 1100 General Practitioners and this showed that their knowledge is limited in this regard. Lack of standardisation of tests and the definition of variables used along with the heterogenous nature of the aetiology of this condition; make it difficult to compare the treatment outcomes from various centres. Hence we proposed a new classification based on anorectal investigation which helped comparison between patients from various centres easier. Faecal incontinence is more likely to happen in the erect posture but most of the tests are carried out in the left lateral position. We assessed the manometric variables in both positions which showed a significant difference in two positions. Studies have explained the role of anal cushions in normal continence. We devised a method to quantify the anal cushions with the help of yielding a cushion-canal (C: C) ratio based on the measurements made by transvaginal ultrasound scans. Initially we carried out this study in 106 continent subjects and -, ----------- 5 defined the normal range. This has shown that the method is simple and repeatable with good correlation coefficients. In a subset of patients (n=15) we assessed the ratio in both supine and semi erect postures which confirmed a significant rise in the semi erect posture. Subsequently, we measured the anal cushions in patients with idiopathic faecal incontinence (n=21) which has shown a significant decrease in the cushion canal ratio in these patients suggesting a possibility that the atrophy of these cushions might well be a cause for their incontinence

The present study group consists of 45 women with genuine stress incontinence who were selected for surgical treatment and randomized either to retropubic urethrocystopexy (n=30) or pubococcygeal repair (n=15). The preoperative assessment included medical history, gynecological examination, urine analysis and culture, residual urine, pad test, frequency-continence charts, water urethrocystoscopy, continence test and cystometry with analysis of micturition. Moreover, five semistructured interviews were performed with the women and two with their partner. The following questionnaires were used measuring a) personality characteristics: Karolinska Scales of Personality (KSP), Eysenck Personality Inventory (EPI), b) depression: Beck Depression Inventory (BDI) and c) social support: Interview Schedule for Social Interaction (ISSI). The results have shown that there was no difference in the subjective cure rate between the two surgical methods (73% vs. 80 % respectively). The bladder volume had increased in both groups and the intravesical pressure of the bladder filled to maximum had increased in the pubococcygeal repair group. Other urodynamic variables were unchanged by the operation. Pad tests have demonstrated that 67 % of the women in the urethrocystopexy group and 47 % in the pubococcygeal repair group ceased to leak urine. Postoperatively, 63 % of the women in the urethrocystopexy group needed high doses of analgesics compared with only 33 % in the pubococcygeal repair group. Among the women experiencing severe to very severe pain dysphoric subjects were overrepresented. Postoperative residual urine was a minor nursing problem in both groups. Women with SUI of long duration scored significantly higher than controls on the KSP scales of somatic anxiety, psychic anxiety, psychasthenia, suspicion and on the EPI lie-scale. There was no significant difference in sexual activity before and after surgery. One or two sexual dysfunctions within the desire, excitement, orgasmic and resolution phase were reported by the majority of women both before and after surgical intervention. The cured women reported a higher level of overall activities before surgery than the improved (i.e. not cured) women, whereas post surgery both the cured and the improved women obtained about the same level of activities. Regarding social support, no differences between the cured or improved women occured as concerns attachment. The cured women showed a higher degree of adequacy of social integration compared with the improved women. In order to delineate predictive factors for the surgical outcome the following variables were investigated: age of patient, duration of urine leakage, parity, personality, psychological and social factors. The following predictors of the outcome of surgical treatment emerged: duration of stress incontinence, neuroticism and age of patient. The results of the present study indicate the ecessity of a multidisciplinary approach to the treatment and nursing of women with SUI.

Diss. (sammanfattning) Umeå : Umeå universitet, 1995

digitalisering@umu

Urinary incontinence is a common health problem with not only physical, but also far-reaching psychological and social implications for the sufferer, her family and carers. Assisting patients with meeting their eliminatory needs is a fundamental part of nursing care. Incontinence is encountered in almost every sphere of clinical practice and is a problem with which nurses are often directly concerned. Nurses, in association with other members of the health care team, have considerable potential to help patients regain continence, or when this is not possible, to ensure that the individuals concerned, and their relatives or carers, can cope effectively with the problem, both physically and psychologically. This is an area of nursing care, however, which to date has attracted little research. The studies undertaken in this thesis sought to examine the nursing assessment and management of the care of patients with urinary incontinence in acute medical and care of the elderly wards. The research comprises of a sequence of studies which examined the problem from a number of perspectives. Methods of data collection included nurse and patient self-, reports, the examination of nursing and medical documentation, direct observation and self-completed questionnaires. Findings indicated that urinary incontinence was common in acute medical and care of the elderly wards, and that a considerable proportion of patients had indwelling catheters to manage the problem. Nurses were not always aware of patients' incontinence problems and their assessments concerning important aspects of the symptom were frequently unreliable. Further inadequacies in nurses' assessments, as well as in the management of the care of patients with incontinence, were identified from an examination of the nursing and medical records, and observations of verbal hand-over reports. Qualified nurses and learners appeared ill-informed about the causes of incontinence, and the majority had little knowledge of the range of factors which need to be considered to ensure that a systematic assessment of the problem is carried out. Despite considerable scope for the provision of rehabilitative care for incontinence sufferers, many nurses appeared to have a limited appreciation of their potential for initiating such care. Evidence collected from the nursing and medical records, the verbal hand-over reports and nurses' questionnaires, suggested that the management of patients with incontinence still focuses predominantly on measures which aim to contain the problem with little attention being given to rehabilitative interventions. A considerable proportion of the charge nurses, and the majority of the other qualified nursing staff, stated they had not received any continuing in-service education relevant to the promotion of continence or management of incontinence since their basic training. Nurses exhibited positive attitudes, overall, towards the management of incontinence but their responses indicated that a number of common misconceptions surrounding the problem persist. The enrolled nurses demonstrated significantly less positive attitudes towards the management of patients with incontinence than other grades of nurses. Similarly, the nursing staff who worked in the slow-stream rehabilitation care of the elderly wards showed significantly less positive attitudes towards incontinence than the nurses working in other types of wards. The implications of the findings of these studies for nursing practice, education and further research are discussed.

Orientador: Maria da Consolação Gomes Cunha Fernandes Tavares
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Educação Fisica
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Resumo: A incontinência urinária é definida como ¿queixa de qualquer perda involuntária de urina¿. Apesar da incontinência urinária não ameaçar a vida das mulheres que apresentem os sintomas, ela causa danos de ordem social, econômica e emocional podendo assim influenciar de forma negativa na qualidade de vida de mulheres com incontinência urinária. O objetivo desta pesquisa foi realizar uma revisão bibliográfica sobre a incontinência urinária entre mulheres que praticam atividades físicas e esportivas e suas implicações acerca dessa prática. Essa dissertação foi redigida sob a forma de três artigos que já foram submetidos à publicação. O primeiro artigo intitulado ¿Incontinência urinária e a prática de atividades físicas¿, corresponde à revisão bibliográfica relacionada com a prevalência da incontinência urinária entre mulheres atletas e não atletas durante atividades físicas e esportivas. O segundo artigo intitulado ¿Atividade sexual, exercícios perineais e incontinência urinária¿, refere-se à sexualidade da mulher com incontinência urinária. O terceiro artigo, ¿Incontinência urinária entre estudantes de Educação Física¿ corresponde a um trabalho no qual foi verificada a freqüência de perda de urina entre estudantes de Educação Física. Os dados da literatura mostraram que a prática de atividades físicas e esportivas constituídas de exercícios que exijam muito esforço e alto impacto pode contribuir para o desenvolvimento da incontinência urinária. Muitas mulheres com incontinência urinária abandonam a prática de atividades físicas e esportivas para evitarem perder urina durante essa prática, pois essa perda causa vergonha, constrangimento além de interferir no desempenho durante o exercício físico. Contudo, inexistem pesquisas na área da educação física que discutam esse tema. Algumas estratégias para prevenir a incontinência urinária entre mulheres que praticam atividades físicas devem ser consideradas pelo profissional de Educação Física buscando proporcionar a essas mulheres maior conforto, segurança, confiança e evitar que ocorra o abandono dessa prática. Mulheres de todas as idades devem ser estimuladas a contraírem o assoalho pélvico, e essa estimulação pode ser feita durante a prática de atividades físicas simultaneamente aos exercícios físicos e treinamentos esportivos ou de forma isolada. Através de orientações adequadas o profissional de Educação Física pode transformar a prática de atividades físicas e esportivas numa intervenção preventiva da incontinência urinária. Estabelecendo uma relação de confiança com sua aluna e com sua atleta, esse profissional pode contribuir com a diminuição do abandono por essas mulheres da prática de atividades físicas e esportivas e garantir que possam usufruir dos benefícios inerentes à prática de atividades físicas orientada na prevenção da incontinência urinária
Abstract: The urinary incontinence is defined as ¿complaining of any involuntary loss of urine¿. Despite the urinary incontinence does not threaten the life of women that shows these symptoms, it may cause social, economic and emotional damages to their life. The purpose of this research is to perform a bibliography review about urinary incontinence among women that usually practice physical and sports activities and their implications about this practice. This dissertation was written in a way of three articles that have already been published. The first article entitled ¿Urinary incontinence and practice of physical activities¿ corresponds to bibliographic review concerning to the predominance of urinary incontinence among athletes and non-athletes women during their physical and sports activities. The second article entitled ¿Sexual activities, perineum exercises and urinary incontinence¿ corresponds the sexuality of a woman with urinary incontinence. The last article ¿Urinary incontinence among Physical Education students¿ corresponds a study by which was evaluated the frequency of urine loss among Physical Education students. The literature data shows that the physical and sports activities composed of high strain and impact may cause the developing of urinary incontinence. Many women with urinary incontinence give up to practice physical activities to avoid lose urine during this activity. Some strategies in order to prevent the urinary incontinence among women that practice physical activities should be considered by the Physical Education professional, with the objective of providing to these women more comfort, security, trusting and avoid they give up to practice physical activities. Women of all ages should be encouraged to get their pelvic floor compressed, and this stimulation can be performed during the practice of physical activities simultaneously to physical exercises, sports training or on a isolated way. Through suitable orientation, the professional of Physical Education may turn the practice of physical and sports activities into a preventive intervention of urinary incontinence. Establishing a trusting relationship to its woman student or athlete, this professional may contribute to decrease of withdrawing from these woman to practice physical and sports activities and assure that they may enjoy the benefits regarded physical activities oriented to preventing of urinary incontinence
Mestrado
Atividade Fisica, Adaptação e Saude
Mestre em Educação Física

The thesis discusses disorders of anorectal and pelvic floor function, i.e. faecal incontinence and intractable constipation. Relevant anatomy, physiology and methodology are first described. Newer forms of apparatus were applied such as a surface anal plug electrode for non-invasive integrated electromyography, a pudendo-anal reflex electrical stimulator for activating the external anal sphincter and a form of EMG biofeedback for relaxation of the pelvic floor musculature. An essential part of the study is anorectal manometry. Various systems for the measurement of pressure are contrasted using both analogue and digital recorders. The digital system was the more sensitive, but the analogue system using a microballoon was free of orientational changes. Over 200 patients with idiopathic faecal incontinence were examined by manometric and somatosensory testing, the majority of whom had pudendal neuropathy. Four subgroups were characterised, two with impairment of either the external or internal anal sphincters, another with both sphincters affected and a fourth with no apparent sphincter deficit but presenting an abnormal rectal compliance. The effect of stimulating the sacral outflow from the spinal cord, via the pudendal nerve to the sphincter mechanism, was therefore assessed and revealed significant improvement in tests of anorectal function.

Aim: To determine the reliability of scoring real-time ultrasound (RTUS) record during an exercise protocol aimed at developing pelvic floor motor control in men with prostate cancer, and to determine predictors of acquiring control. Methods: 91 men diagnosed with prostate cancer attending physiotherapy for pelvic floor exercises. Detailed pelvic floor motor control exercises were taught by a physiotherapist to participants using trans-abdominal RTUS for biofeedback. A new protocol to measure skill attainment was developed. Three independent physiotherapists assessed skill attainment by viewing RTUS videos of the exercise. Reliability was evaluated using intraclass correlation coefficients. Logistic regression analysis was conducted to identify predictors of successful skill attainment. Acquisition of the skill was compared between pre and post-operative participants using an independent-groups t-test. Results: There was good reliability for scoring the outcome method (ICC 0.73 (95%CI 0.59 - 0.82)) for experienced therapists. Having low BMI and being seen pre- operatively predicted motor skill attainment, accounting for 46.3% of the variance. Significantly more patients trained pre-operatively acquired the skill of pelvic floor control compared with patients initially seen post-operatively (OR 11.87 95%CI 1.4 to 99.5 p = 0.02). Conclusions: A new protocol to evaluate attainment of pelvic floor control in men with prostate cancer can be scored reliably from RTUS record, and is most effective delivered pre-operatively. Future Studies: Based on the above research a proposed RCT has been
developed comparing current standard pelvic floor training protocols with a motor control led training protocol. This protocol is followed by development into a progressive resistance program that utilises progressively incremental intra- abdominal pressures as a resistance tool. Further discussion is made to evaluate optimal pelvic floor rehabilitative strategies.

Urinary incontinence (UI) is a common public health concern among women worldwide, with adverse effects on their quality of life (QoL). This study aims to explore the prevalence of UI among Omani women aged 18-49 years old, and to explore the impact of UI on women's daily prayers, physical activities, social life, mental health, and general QoL. The study is of quantitative comparative design, and the researcher used the World Health Organization’s (WHOs) International Classification of Functioning, Disability and Health (ICF), as a conceptual framework. The researcher randomly chose four-hundred and one participants from ten primary health care centres in Muscat. The researcher assessed their UI status and impact on different domains of their life using UDI-6 and IIQ-7 respectively, which are validated self-reported questionnaires. From the results, the researcher highlighted the high prevalence (85%) of UI among young Omani women. Additionally, UI did have a statistically significant impact on Omani women’s ability to perform their daily prayers, physical activities, social life, mental health, as well as, their general QoL. The use of ICF framework allows policymakers and public health officials to see the big picture of UI as public health concern in Oman. It forms the basis for implementing cost-effective health education programs at the Primary Health Care (PHC) institutions in Oman, for the goal of improving women’s health and community health.

This thesis describes an investigation of the prevalence of urinary incontinence (UI) among Omani women. First, a culturally specific questionnaire for interviews in English or Arabic was developed and tested. Next, feasibility of sampling and data collection methods were field-tested in 120 urban women. Finally, a national population-based sample of 800 women was interviewed. The prevalence of UI was 42.9%. Although UI was bothersome to 65%, care seeking was low (23.3%).

Orientador: Carlos Arturo Levi D'Ancona
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
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Resumo: Objetivos: Comparar parâmetros ultrassonográficos através de ultrassonografia perineal em homens sem cirurgia prostática, com homens no pós-operatório de prostatectomia radical, continentes e incontinentes. Métodos: Trata-se de um estudo transversal, multicêntrico (2 centros), envolvendo 92 colaboradores, dos quais 70% foram submetidos à prostatectomia radical retropúbica há mais de um ano. Estes pacientes foram provenientes do ambulatório do Serviço de Urologia do Hospital Universitário Pedro Ernesto e do ambulatório do Serviço de Urologia do Hospital de Clínicas - UNICAMP, com indicação adequada para o exame. Estes pacientes foram escolhidos aleatoriamente, de acordo com os critérios de inclusão e exclusão, e foram divididos em três diferentes grupos: 27 pacientes sem cirurgia prostática, 34 pacientes em pós-operatório de prostatectomia radical continentes e 31 pacientes em pós-operatório de prostatectomia radical incontinentes. Todos apresentaram urocultura negativa. O grupo incontinente realizou, ainda, pad test de 24h e avaliação urodinâmica. O exame foi realizado com o paciente em posição supina, com as pernas levemente abduzidas, semelhante à litotomia. O transdutor foi posicionado na região perineal (entre o escroto e o ânus), em orientação sagital, para obter imagens da sínfise púbica, bexiga, colo vesical e uretra. No exame foram avaliadas a hipermobilidade da uretra proximal, ângulo uretral, funelização do colo vesical e contração voluntária do assoalho pélvico, sendo estes avaliados durante manobra de Valsalva, contração perineal e repouso. Após coleta de dados, foram comparados padrões ultrassonográficos em homens sem cirurgia prostática e em homens no pós-operatório de prostatectomia radical, continentes e incontinentes. Resultados: Neste trabalho, observamos que o grupo continente apresentou o ângulo uretral em repouso significativamente menor que o grupo sem cirurgia (p = 0,0002). Observamos ainda que o grupo incontinente apresentou deslocamento da porção anterior da junção uretrovesical durante a contração significativamente menor que o grupo continente. (p = 0,008) Esta condição foi mais evidente quando comparamos o grupo com incontinência grave ao grupo continente.(p = 0,022). Conclusão: Observamos diferença significativa entre o grupo continente e o grupo sem cirurgia prostática em relação ao ângulo uretral. Observamos ainda diferença significativa no deslocamento da porção anterior da junção uretrovesical durante a contração quando comparamos os grupos continente e incontinente
Abstract: Purpose: To compare sonographic patterns through perineal ultrasonography in men without prostate surgery, with continent and incontinent men after radical prostatectomy. Methods: This cross-sectional clinical study investigated the differences of a dynamic evaluation of the urethra and pelvic floor contraction using perineal ultrasound in men without prostate surgery and in men submitted to radical prostatectomy with and without stress urinary incontinence. Ninety two male patients were included, which 70% of them underwent radical prostatectomy (RP) for more than one year. Thirty one men with clinically post prostatectomy incontinence were compared by two-dimensional (2D) perineal ultrasound to 34 patients without post prostatectomy incontinence and to 27 men without surgery in two centers in Brazil. All patients had negative urine culture. The incontinent group also presented 24h pad test and urodynamic evaluation. The examination was performed with the patient in supine position, with legs slightly abducted, similar to lithotomy. The transducer was placed in the perineal area (between the scrotum and anus), with sagittal orientation, to obtain images of the pubic symphysis, bladder, bladder neck and urethra. During examination, hypermobility of the proximal urethra, urethral angle, bladder neck funnelling and voluntary contraction of the pelvic floor were assessed. These parameters were evaluated during Valsalva maneuver, perineal contraction and rest. Results: Our results showed that the continent group presented the urethral angle at rest significantly lower than the prostate group (p = 0.0002). We also observed that the incontinent group showed the displacement of the anterior bladder neck during contraction significantly lower than the continent group (p = 0.008). This condition was more evident when compared the severe incontinent group with the continent group. (p=0,022) Conclusion: We observed a significant difference between the continent group and the group without prostate surgery when urethral angle was compared. We also observed a significant difference in anterior displacement of the bladder neck during contraction when comparing continent and incontinent groups
Mestrado
Fisiopatologia Cirúrgica
Mestre em Ciências

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This study proposes to evaluate the results post stress urinary incontinence surgery (SUI) using the Sling technique and utilizing a range of polypropylene sub urethral manually manufactured (Marlex®), and laboratory made (Advantage®), comparing the results in both groups and prostheses costs. The sample used was of 39 women carriers of SUI resulting from hyper mobility of the bladder neck and/or sphincteric incompetence determined by clinical evaluation and urodynamic studies. The criterion considered was the exclusion of diabetes mellitus, previous extended pelvic surgeries and previous radiotherapy. The patients were split in 2 groups. Group 1 Patients from the department of Urology at the University Hospital of the Federal University of Maranhao (19 patients) and Group 2 Patients from private clinics (20 patients). Group 1 used the manually manufactured polypropylene sub urethral while group 2 used the laboratory made. Patients were evaluated in between thirty, sixty and ninety days post surgery comparing the following variables: Average surgery time, hospitalization time, difficulty to urinate, length of time using the post surgery probe, normalization of urinary jet, involuntary urine loss, level of satisfaction regarding the surgery, urodynamic alterations and probe costs. The average surgery time was of 43 25 in Group 1 and 51 42 Group 2. As to difficulty to urinate post surgery, in Group I, one hundred percent (100%) of the patients presented no difficulties while in Group 2; ninety four point seven percent (94.7%) were able to urinate properly. Regarding the probe use one hundred percent (100%) of the patients from both groups were free from it by the end of this study. All patients from both groups presented normal urinary jet during the last evaluation. In Group 1 one hundred percent (100%) of the patients did not accuse urine loss, while in Group 2 it was ninety four point seven percent (94.7%) at the ninetieth day. The level of satisfaction was of one hundred percent (100%) of the patients from Group 1 while one patient in Group 2 considered the surgery unsuccessful. The evaluation urodynamic presented non inhibit contraction of low vesical pressure in eleven point one percent (11.1%) in Group 1 and ten point five percent (10.5%) in Group 2. There were no complications in both groups. Occurrences observed: burning micturition and urinary urgency spontaneously disappeared by the end of this study and did not have any relations with sub urethral meshes. We can conclude the use of polypropylene mesh (Marlex ®) manually manufactured can also be used in Sling surgeries, saving on resources and having similar results to the use of the laboratory made version.
Este trabalho se propõe avaliar os resultados pós-operatórios da cirurgia de incontinência urinária de esforço (IUE), pela técnica de Sling, utilizando-se faixa de polipropileno suburetral de fabricação artesanal (Marlex®) e industrializada (Advantage®). comparando os resultados em ambos os grupos e o custo das próteses. A amostra foi de 39 mulheres portadoras de IUE resultante de hipermobilidade do colo vesical e/ou incompetência esfincteriana feita pela avaliação clinica e estudo urodinamico. Foram considerados critério de não inclusão diabetes mellitus, passado de cirurgias pélvicas ampliadas e radioterapia prévia. As pacientes foram dividas em grupos: Grupo I oriundas do Serviço de Urologia do Hospital Universitário da Universidade Federal do Maranhão (19 pacientes) e Grupo II pacientes provenientes da Clinica Privada (20 pacientes). No Grupo I, utilizou-se tela artesanal e no Grupo II, tela industrializada. As pacientes foram avaliadas com trinta, sessenta e noventa dias de pós-operatório comparando-se as seguintes variáveis: tempo médio de cirurgia,tempo de internação, dificuldade para urinar, tempo de permanência de sonda no pós-operatório, normalização do jato urinário, perda urinária involuntária, grau de satisfação em relação à cirurgia, alteração urodinâmica e custo das próteses. O tempo médio de cirurgia foi de 43 25 no Grupo I e 51 42 no Grupo II. O tempo médio de internação foi de 52hs8min horas no Grupo I e de 49hs14min no grupo II. Quanto à dificuldade de urinar no pós-operatório, no Grupo I, 100% das pacientes nada referiam no final da observação e no Grupo II, 94,7% urinavam bem. No que concerne ao uso de sonda, em ambos os grupos, 100% das pacientes estavam livre desta ao fim da observação. Todas as pacientes de ambos os grupos apresentavam jato urinário normal na ultima avaliação. No Grupo I, 100% das pacientes não referiam perda urinária e no Grupo II 94,7% no 90º dia pós-operatório. O grau de satisfação foi de 100% nas pacientes do Grupo I, enquanto no Grupo II uma paciente referiu insucesso. A avaliação urodinâmica demonstrou Contração Não Inibida (CNI) de baixa pressão em 11,1% no Grupo I e em 10,5% no Grupo II. Não houve complicação importante em ambos os grupos. As intercorrências observadas: ardência miccional e urgência urinária desapareceram espontaneamente ao final da observação não tinham relação com o material das faixa suburetrais.Conclui-se que a utilização de alça de polipropileno (Marlex ®) de fabricação artesanal pode de ser utilizada nas cirurgias de Sling, com economia de recursos e com resultados semelhantes àqueles observados com a utilização das alças industrializadas.

The purpose of this descriptive study was to determine the existence of a relationship between perceptions of global self-esteem and stress incontinence episodes in a group of older women participating in a bladder retraining protocol. A convenience sample of fifteen older women was obtained. The participants constituted a group of well older women who ranged in age from 63 years to 82 years. All participants were living in the community and experiencing urinary incontinence. The University of British Columbia Model for Nursing was the conceptual framework which guided the focus of the study. The model views the individual as a behavioural system composed of nine interrelated and interdependent subsystems. This study focused on the interrelationship of the excretory and ego-valuative subsystems. The theory of self-efficacy, as outlined by Bandura provided the method by which this study was operationalized. Self-efficacy is the product of personal efficacy—an individual's judgement of the effectiveness of an executed course of action in achieving a desired outcome. The enactive, persuasive, and emotive modes of influence were utilized to provide efficacy information. Data were collected on three occasions using four instruments. The first instrument involved collection of selected demographic variables and was completed during the initial interview. A continence assessment and the Rosenberg self-esteem scale were completed during the initial and final interviews. An interview guide was used during a telephone contact. The telephone contact occurred four days following the first interview; the final interview occurred fourteen days after the first. The data were summarized, compared and described using measures of central tendency and frequency distributions. Paired t-tests were performed on selected variables to determine if there was a difference between pre and post intervention interview score. These tests demonstrated no significant differences in scores. Study findings indicated that at the end of the two week trial 53% of the women were able to identify a change in their voiding habits. Four of the participants (26.7%) stated that they were completely continent at the completion of the two week trial and four other participants (26.7%) indicated that $ some type of positive change had occurred. Three women (20%) identified a negative change in their continence status. Global self-esteem scores, as measured by the Rosenberg self-esteem scale, remained relatively stable during the two week trial period. Scores appeared to be unaffected by a change in continence status. This may be due to the many successful normalizing strategies subjects had developed to hide the evidence of the symptom of urinary incontinence.
Applied Science, Faculty of
Nursing, School of
Graduate