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May 18, 2013 - Romosan I: Rinichiul morfologie clinica. Ed. Helion , Timisoara, 1993. ...... 30. Barber MD. (). Pelvic organ prolapse. BMJ 354, pp. i3853. 31. ..... in perfect contact with the labia without exerting pressure. A midsagittal ...... A single cohort study was made between January 2014 and August 2016, on 11 women.
The 13th National Congress of Urogynecology UROGYN 2016

Editors Assoc. Prof. Dr Elvira Bratila

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INDEX Foreword 10 Incidence and influence of urinary incontinence on institutionalized women life quality ANASTASIU-POPOV Diana Maria, TOTH GA, HINOVEANU Denisa Adriana, ANASTASIU D., GLUHOVSCHI A.

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Variability of renal markers in preeclampsia TOTH GA., CRAINA M., ANASTASIU POPOV Diana Maria, ANASTASIU D., GLUHOESCHI A.

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Ultrasound landmarks in diagnosis of pelvic floor disorders. A comprehensive overview BERCEANU Costin, CÎRSTOIU Monica, MEHEDINŢU Claudia, BRĂTILĂ Petre, BERCEANU Sabina, BOHÎLŢEA Roxana, BRĂTILĂ Elvira

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Hormone deficiency and its impact on the lower urinary tract 29 BERCEANU Costin, CÎRSTOIU Monica, MEHEDINŢU Claudia, BRĂTILĂ Petre, BERCEANU Sabina, VLĂDĂREANU Simona, BOHÎLŢEA Roxana, BRĂTILĂ Elvira Intrapartum and postpartum bladder management BODEAN Oana, MUNTEANU Octavian, VOICU Diana, VASILESCU Sorin, BOHILTEA Roxana, CIRSTOIU Monica

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Pelvic floor ultrasound - review Bohîlțea Roxana Elena, Cîrstoiu Monica Mihaela, Turcan Natalia, Munteanu Octavian, Bodean Oana, Voicu Diana, Baroș Alexandru, Brătilă Elvira

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Mechanism and Risk Factors for Pelvic Organ Prolapse - Review 50 Bohîlțea Roxana Elena, Cîrstoiu Monica Mihaela, Turcan Natalia, Bohîlțea Laurențiu Camil, Munteanu Octavian, Bodean Oana, Voicu Diana, Baroș Alexandru, Brătilă Elvira Stress urinary incontinence (sui) due to causes other than parturition BOȚ Mihaela, VLĂDĂREANU Radu, VLĂDĂREANU Simona, ZVÂNCĂ Mona, PETCA Aida Delayed Recognition of a Sigmoid Colon Iatrogenic Lesion Following Total Abdominal Hysterectomy in a Patient with a Previous Episode of Acute Diverticulitis Socea Bogdan, Alexandru Carâp, Smaranda Alexandru, Moculescu Cezar, Bobic Simona, Dimitriu Mihai, Socea Laura, Vlad Denis Constantin

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Index Iatrogenic Ureteral Injuries During Gynecological Procedures Vlad Denis Constantin, Alexandru Carâp, Anca Nica, Moculescu Cezar, Bobic Simona, Socea Bogdan

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The benefits of laparoscopically assisted vaginal hysterectomy Cristurean V-C., Nour C., Cardon I.

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Assessing the severity of acute pelvic inflammatory disease CERNETCHI Olga, CAUS Catalin, CAUS Natalia, RAILEAN Ludmila, ILIADI TULBURE Corina

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Approach to complications caused by prosthetic materials used in pelvic reconstructive surgery 77 CIORTEA Răzvan, RADA Maria Patricia, BERCEANU Costin, MĂLUŢAN Andrei Mihai, MOCAN Radu, IUHAS Cristian, BUCURI Carmen Elena, CÂMPIAN Eugen Cristian, DICULESCU Doru, MIHU Dan Lower urinary tract symptomatology in deep infiltrating and bladder endometriosis 83 COROLEUCĂ Ciprian-Andrei, BRĂTILĂ Elvira, BRĂTILĂ Petre, HUDIȚĂ Decebal, STĂNCULESCU Ruxandra, COMANDAȘU Diana, COROLEUCĂ Cătălin-Bogdan Vaginal hysterectomy - an economic and less invasive type of approach Stuparu-Cretu Mariana, Caraman Liliana, Calin Alina Mihaela

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Laparoscopic cerclage in pregnant and non pregnant women DORU CIPRIAN Crisan

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Cure of stress urinary incontinence with canal transobturator tape DORU CIPRIAN Crisan, RATIU Adrian

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Comparative study of surgical care of stress incontinence using tension-free vaginale tape and transobturator tape DICULESCU Doru, MIHU Dan, CIORTEA Răzvan, CIUCHINĂ Septimiu, MĂLUȚAN Andrei, IUHAS Cristian, GROZA Daria, CAPOLNA Miorița, CĂLĂTAN C. The results of the treatment of stress urinary incontinence by “Bega-I Munteanu” procedure Gluhovschi Adrian, Anastasiu Doru Mihai, Anastasiu Popov Diana Mria Study on the level of knowledge about contraception of high school students HINOVEANU Adriana Denisa, ANASTASIU Popou Diana Maria, CARAIVAN Magdalena, ANASTASIU Entertainment, GLUHOVSCHI Adrian

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Index Uterine Fibroids and Urinary Symptoms HORHOIANU Irina-Adriana, HORHOIANU Vasile-Valerica, GRIGORIU Corina, CIRSTOIU Monica

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Lower Urinary Tract Disfunction and Oncologic Pelvic Surgery HORHOIANU Irina-Adriana, DUMITRACHE Mihai, DRAGOI Vlad, CIRSTOIU Monica

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Challenges of the surgical resection in pelvic masses involving uro-genital organs in women - our experience DAVITOIU Dragos, DIMA Ana Laura, BALEANU Vlad, MANDA Ana Laura

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Corrective Procedures for Apical Defects Associated with 2nd and 3rd Degree Anterior Vaginal Wall Prolapse 142 MANTA Anca, BRATILA Petre Corrnel, COMANDASU Diana, BERCEANU Costin, MEHEDINTU Claudia, CIRSTOIU Monica, BOHILTEA Roxana, CONSTANTIN Vlad Denis, BRATILA Elvira Bladder Evacuation Disorders Following Radical Surgery for Cervical Cancer MANTA Anca, BRATILA Petre Cornel, COMANDASU Diana, BERCEANU Costin, MEHEDINTU Claudia, CIRSTOIU Monica, BOHILTEA Roxana, STANCULESCU Ruxandra, CONSTANTIN Vlad Denis, BRATILA Elvira The Effect of Estrogen Deficiency Related to Aggressive Chemotherapy on Female Urogenital Tract PLOTOGEA Mihaela Nicoleta, TANASE Alina Daniela, SECUREANU Adrian Florin, IONESCU Sorin, BRATILA Elvira, BERCEANU Costin, CIRSTOIU Monica Mihaela, MEHEDINTU Claudia Laparoscopic Ureterolysis in the Management of Deep and Infiltrative Pelvic Endometriosis - Case report MEHEDINTU Claudia, DIACONU Victor, SECUREANU Adrian Florin, IONESCU Sorin, BRATILA Elvira, BERCEANU Costin, CIRSTOIU Monica Mihaela, ANTONOVICI Marina Rodica, PLOTOGEA Mihaela Nicoleta, IONESCU Oana Maria Modified Aburel Procedure for the Treatment of Uterine Prolapse with Stress Urinary Incontinence - Personal Experience MITRAN Mihai, PANA Doru, POPESCU Alina, VELICU Octavia, COMANDASU Diana-Elena, BRATILA Elvira Reconstructive options in managing the neurogenic bladder disfunction in children MUNTEANU Alexandra, FILIPOIU Florin, IONESCU Sebastian, CIRSTOIU Monica, RADULESCU Luiza, STAVARACHE Irina, MUNTEANU Octavian

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Index Reconstructive options after iatrogenic ureteral lesions MUNTEANU Octavian, MUNTEANU Alexandra, VOICU Diana, BODEAN Oana, BOHALTEA Roxana, BRATILA Elvira, CIRSTOIU Monica Treating genital prolaps revolutionary concept, 4 years from applying “Process Saba Nahedd” - 90 cases SABA Nahedd

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The Management of Grade II/III Hydronephrosis During Pregnancy NASTAS Ana, STANCULESCU Ruxandra, MEHEDINTU Claudia, BERCEANU Costin, COMANDASU Diana-Elena, CIRSTOIU Monica, BOHILTEA Roxana, VLADAREANU Simona, PATRASCOIU Sorin, NASTAS Alexandru, BRATILA Elvira

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Treatment of Interstitial Cystitis in Menopausal Women NASTAS Ana, MEHEDINTU Claudia, BERCEANU Costin, CIRSTOIU Monica, BOHILTEA Roxana, COMANDASU Diana-Elena, PATRASCOIU Sorin, NASTAS Alexandru, BRATILA Elvira

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Female sexual dysfunction and pelvic floor surgery NENCIU Cătălin George, AFLOAREA Adina Elena, ALBU Ruxandra Andreea, VOICU Diana, MUNTEANU Octavian, VASILESCU Sorin, ȘANDRU Florica, DUMITRAȘCU Mihai Cristian

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Modern Treatment In Pelvic Perineal Statics Dysfunctions SIMONA Niculescu, MIHAI Burniche, DAN Niculescu

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Assessing etiological prognostic factors associated with preterm birth by a questionnaire-based risk score OANCEA Alexandru, FRANDES Mirela, LUNGEANU Diana, ANASTASIU Doru, STANESCU Casiana, ANASTASIU-POPOV Diana Maria Associations between the risk of preterm birth, gestational age at which the birth occurred and birth weight of newborns OANCEA A, ANASTASIU D, TOTH AG, FRANDEȘ Mirela, STĂNESCU Casiana, GLUHOVSCHI A, ANASTASIU-OPOV Diana Maria Repairing the vesicovaginal fistula by transvesical (extraperitoneal) approach PATRASCOIU Sorin, BRATILA Elvira, BRATILA Petre, STROESCU Cezar, HANNA Adrian, ZAMFIR Radu, MISCHIE Oana Gabriela, POPA Laura, CONSTANTIN Carmen, GILCA Iulian, PUSCASU Ana, BIRCEANU Adelina, GURAU Claudia, COPCA Narcis

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Index Suburethral endometriosic cyst and stress urinary incontinence PATRASCOIU Sorin, GILCA Iulian, BRATILA Elvira, COPCA Narcis, PIVNICERU Catalin, STROESCU Cezar, CONSTANTINICA Victor, ZAMFIR Radu, ROSULESCU Corneliu, PRIE Ioan, MISCHIE Oana Gabriela, BIRCEANU Adelina, GURAU Claudia Management of vesicovaginal fistula by combined transperitoneal and tansvesical approach PATRASCOIU Sorin, BRATILA Elvira, BRATILA Petre, COPCA Narcis, ZAMFIR Radu, MISCHIE Oana Gabriela, PRIE Ioan, GURAU Claudia, ROSULESCU Corneliu, CONSTANTINICA Victor, GILCA Iulian Laparoscopic pectopexy: a new technique for the treatment of vaginal apical prolapse PIRTEA Laurentiu, SECOSAN Cristina, ILINA Razvan, SAS Ioan, PIRTEA Marilena, HORHAT Florin, JIANU Adelina, GRIGORAS Dorin Transperineal Ultrasound Role for Pelvic Floor Dysfunction Evaluation PLES Liana, SIMA Romina-Marina, STANESCU Anca Daniela, POENARU Mircea Octavian, MOGA Marius Comparison Between Classical and Protetic Surgical Intervention for Pelvic Floor Dysfunctions and Urinary Stress Incontinence POENARU Mircea Octavian, SIMA Romina-Marina, DAN Diana, STANESCU Anca Daniela, PLES Liana

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Pregnancy complications in women with Abruptio Placentae SAGAIDAC Irina, FRIPTU Valentin

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Up-date Concerning Medical Drugs Useful To Treat Urinary Incontinence STANCULESCU Ruxandra, COMANDASU Diana-Elena, BAUSIC Vasilica, BRATILA Elvira

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Robotic Assisted Sacrocolpopexy: operative technique and post-operative outcomes for a single center experience in a series of 158 patients STANIMIR Marius, BENIJTS Jan, TWAHIRWA Michael, CHIUȚU Luminița, NEMEȘ Răducu, MITROI George, ASSENMACHER Christophe Quality of life outcomes after Robotic Assisted Sacrocolpopexy: a single center experience in a series of 50 patients STANIMIR Marius, BENIJTS Jan, TWAHIRWA Michael, CHIUȚU Luminița, NEMEȘ Răducu, MITROI George, ASSENMACHER Christophe The Role of Urodynamics in Evaluation of Women with Urinary Incontinence TÎRNOVANU Mihaela Camelia, PASAT Sebastian, COZOREANU Ana Maria, CARA Andreea Raluca, TÎRNOVANU Ştefan Dragoş, HOLICOV Monica, ONOFRIESCU Mircea

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Index Pelvic organ prolapse in women: Our experience at Bucharest Emergency University Hospital VOICU Diana, Oana BODEAN, Octavian MUNTEANU, VASILESCU Sorin, Roxana BOHILTEA, Vlad BALEANU, Claudia MEHEDINTU, Costin BERCEANU, CIRSTOIU Monica

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Foreword

FOREWORD

We have the pleasure to present to you the proceedings volume of The XIIIth National Congress of Urogynecology held in Brasov between 29 September – 1 October 2016. The Romanian Society of Urogynecology is knowing a very large development and admiration by the other societies of urogynecology in Europe. This year the meeting was larger than ever, bringing together about 200 attendants. A main attraction was the pre-congress course “Hysterectomy minimally invasive by vaginal and laparoscopic approaches”. A selection of the papers accepted to the congress is now published in this proceedings volume with the commitment of the publisher. In this volume the readers will find beside updated information in most fields of urogynecology, a cross-sectional profile of our scientific research. Of course, the responsibility of the content belongs to the contributors. We are confident that the readers will find this book useful and welcome.

Conf. Dr. Elvira Bratila Editor President of the Congress

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Incidence and influence of urinary incontinence on institutionalized women life quality ANASTASIU-POPOV Diana Maria1, TOTH GA1,2, HINOVEANU Denisa Adriana2, ANASTASIU D.1,3, GLUHOVSCHI A.1 Department XII Obstetrics, Gynecology and Neonatology, “Victor Babes” University of Medicine and Pharmacy, Timisoara (ROMANIA) 2 Obstetrics and Gynecology, “Bega” Maternity Clinic, Timisoara (ROMANIA) 3 Department of Functional Sciences/Medical Informatics and biostatistics, “Victor Babes” University of Medicine and Pharmacy, Timisoara (ROMANIA) E-mail: [email protected] 1

Introduction Urinary incontinence is a hard to define clinical entity. There is no unanimous definition accepted, some authors considering it a symptom, others describing it as a disease [9, 10]. Urinary incontinence is still an actual problem due to the increase in life expectance of women witch leads to a higher incidence for these disease, this affection being a concern for women over 60 years. It’s still an actual problem due to the fact that it has an influence on the quality of life for women, being a personal problem as well as a problem for the family. In the same time it is an issue for prophylaxis as well for the choice of treatment being it surgical or therapeutic. Choosing an surgical treatment is another issue because there are 200 surgery’s available for urinary incontinence in this moment [1, 2]. There are problems as well with the differential diagnosis as well with the investigations that need to be made. Incidence for urinary incontinence is variable in the data found is the medical literature depending on: studied population, age and profession. In the same time we need to keep in mind that this pathology is underdiagnosed due to the fact that women don’t show up for medical examination for this disease because they are embarrassed by it. In the United States there are around 11 million women witch are affected by urinary incontinence from witch 1.5milion are institutionalized [4, 5, 25]. In Europe around 55% of the women population suffers from a form of urinary incontinence from witch 5-6% needs a surgical treatment. In Austria 250.000 women are diagnosed with urinary incontinence. Statistically speaking the incidence is between 5 – 25% a value witch is lower in reality due to the taboo character of this disease. Monthly statistics in UK show that 46% of the women witch come for clinical prime care assistance suffer for a type of urinary incontinence being it mixt or the urge to urinate. On a study population of 22.000 Thomas finds in England an incidence for urinary incontinence of 5% in the age group of 5 and 34 years, 19% in 35 – 74 years and 16% for the group over 74 years. Brocklehurst [6] finds on study population of 4000 people an incidence of 9% for urinary

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© Filodiritto Editore - Proceedings incontinent and 57% on the group with the age between 45 and 69 years. In England on a study population of women over 65 witch are institutionalized Harrison [7] found a incidence for urinary incontinence in 1/3 of the women and Stots et. all. Found that ¾ of women in a geriatric department suffer from urinary incontinence. There are few studies in Romania for the incidence of urinary incontinence. In Bucharest, Poiana, Nahed and Saba found an incidence of 20%, appreciating that 50% of the women that come for a gynecologic examination suffer form urinary incontinence in preclimax. The Center for urinary incontinence appreciates that 25% of the women over 65 have symptoms for urinary incontinence for witch 50% are stress urinary incontinence, 25% urge incontinence and 25% are mixed urinary incontinence. On a study population of 327 women Bumbu in Oradea found an incidence of 23% and Marta Arsoly in Targul Mures [5] through a screening found an incidence of 21,9% in women with the age of 70-75 years, every second women suffering from urinary incontinence. In Timisoara, Anastasiu found on a group of 1329 women an incidence of 17% for urinary incontinence of various degrees and on a group of 1100 of exanimated women through directed talks about the existence or not of a urinary incontinence an incidence of 10,75% [2, 11]. In this conditions we can appreciate that the prevalence of urinary incontinence in women in Romania is between 18-20%. A study made by Dioknot showed that 50% of institutionalized women suffer from urinary incontinence, 59% of these not telling they’re doctor of this problem. The social impact of urinary incontinence on women points out that regardless of the type of urinary incontinence in the first phase it leads to a state of discomfort along the way as shown by Joyles [14] and Brocklehurst (6.13) cause a feeling of embarrassment and anxiety that may progress to depression, going through this with progressing stages of shame and anger because of perceived an odor that may occur especially in the elderly with poor hygiene. At this stage they hide they’re affection for they’re husband and friends [6]. Evolution of urinary incontinence may lead to a restriction of social and sexual life (trips, theater, sports). Harris (7) showed that in this phase 2% of women lose they’re friends. The worse the symptoms become women stop their activity, 4% of the women staying in the comfort of their home close to a toilet. It is noteworthy that 40% of women report that urinary incontinence significantly affects their life and lifestyle. This is due to the fact that women are forced to have better care for their personal hygiene (special underwear for incontinence, medicated pad, toilet nearby). In severe forms of urinary incontinence, the condition does not allow women to leave their home thus considering themselves infirm, many using catheters and other devices, probes bladder, artificial sphincters that increase the risk of urinary infections. Unfortunately many of these women do not seek medical advice, although they are concerned about their affection, researching it on the internet, reading literature about their disease and practicing from their own initiatives exercises to strengthen the pelvic floor muscles or using self-medication.

Material and Methods We have a group of 92 institutionalized women with the age between 50 and 91 in 2 houses for elderly people in the county of Timis. One is in the urban area and one is the countryside. We did a complete medical history with a directed talk to point out the presents of urinary incontinence, a complete medical checkup with gynecologic examination to investigate the urinary incontinence, inclusive provocation test and driptest for the type of urinary incontinence.

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© Filodiritto Editore - Proceedings Table 1. Study group according to age

Age 51-60 61-65 66-70 71-75 76-80 81-85 >85 Total

Nr. Cases 6 9 15 24 12 16 10 92

Percent 6,52 9,78 16,30 26,08 13,04 17,39 10,86 99,97

The study highlighted several body changes in menopausal women insisting on those who might have influence on the occurrence of urinary incontinence. Thus it was found that 47.2% of cases of anorexia with muscle hypotrophy especially in women over 70 years as well as obesity in 52.17% of cases with a body mass index greater than 25, 18.75% of them were with 1st degree of obesity, 56.25% with 2nd degree and 25% with 3rd degree of obesity. We mention that 84,78% of them were under treatment for HTA with hypotensive medication and B-blocants and 13,04% with Diabetes Mellitus type II and 17.39% had various degrees of atherosclerosis. Of the women who strongly denied the existence of a urinary incontinent 16 (53.33%) did not accept the challenge test for urinary incontinence, we are convinced that at least half of them could be symptoms of urinary incontinence relying on the results of the driptest which showed that 9.78% of with bladder instability, 29.34% in a mixed-type incontinence and in 60.86% of cases are with stress urinary incontinence. In conclusion we can say that the incidence of urinary incontinence in the study group was 90.2%. These women are not disturbed by those symptoms due the fact that they are institutionalized and gave up on social life. No women in the study group acted any type treatment for urinary incontinence offered by the doctor this suggesting the pessimistic view on menopause and the consolation in the approach on the so called “old age” although the urinary incontinence has a negative effect on their life quality.

Conclusion 1. The morphofunctional changes in a women’s body at menopause are significant and obvious in institutionalized women due to the lack of estrogens. 2. The incidence of urinary incontinence in this category of women is 90,2% from witch 60,86% suffer from stress urinary incontinence. 3. Urinary incontinence has a negative effect on the quality of life in institutionalized women but it does not bother them due to the fact that they are in isolated and they refused any treatment type offered by they’re doctor.

REFERENCES 1. Anastasiu D, Munteanu I, Dorneanu F – SIU problema de actualtiate a ginecologicei

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© Filodiritto Editore - Proceedings contemporane; vol A IV Conf DKMT Timisoara, 2007 pag 19 – 20. 2. Anastasiu D – Metode moderne de investigatii si tratamentul chirurgical pe cale vaginala a afectiunilor ginecologice – Teza de doctorat, UMF Timisoara, 1999. 3. Anastasiu D – Stress urinary incontinance in women between dicomfort and infirmity – an epidemiological study; Rev. Rom. Journal of Urogynecology and Pelvic Floor disorders; 2004; vol. 1, Nr. 3; pag 33 – 40. 4. Fantl JA – Urinary incontinace duet o detresor instability; Clinic. ObstetGynecol, 1984,27 pag 414. 5. Bumbu G – Uroginecologie practica, Oradea, Ed. Imprimeriei de Vest,2007; pag 107-109. 6. Harris TA, Bent A, - Genital prolaps with or without urinary incontinance; J rep Med, 1990; pag 35 – 79. 7. Brocklehurst J – Urinary inconance in the community – annalisys of a MARI pol. Br. Med J; 1993, 306 pag 113 – 119. 8. Anastasiu D., Munteanu I – Tratamentul incontinetei de urina. Rev. Cer.Exp.Med.Chirug., 1997;4;1 pag 55 – 61. 9. Poiana M, Saba NO – Incontinance urinara de efort la femei, Ed universitara „Carol Davila” Buc. 2003. pag 7 – 8. 10. Managemantul incontinentei urinare la femei, rezumat al ghidurilor NICE actualizate. Rev BMJ, 2014, Nr 2 Traducere Rodica Chirculescu. 11. Anastasiu D., Munteanu I., Tudose M., Dorneanu F., Novac T – Modificari histologice ale vaginului in stress incontinenta urinara: vol Prima Conf. Nationala de Menopauza, Buc, 1997; pag 48. 12. Bratila P, Nicodin O, Niculescu M – Tratamentul incontinetei urinare de efort la femei in menopauza: Vol Prima Conf. Nat. De Menopauza, Bucuresti, 1997; pag 37. 13. Schaw C, Das Gupta R, Buschell DM, Assasda RP, Abrams P, Wagg A et al – The extent and severity of urinary incontinece amongst women in UK GP waiting rooms Fam Pract 2006, 23, pag 497-506. 14. Stanton Sl – Disfunction of the lower urinary tract. spesific diagnostic and therapeutic problems in the female disfunctions of the lower urinary tract. Ed Kerebroeck, Ed Debrungne FMJ, Netherlands, Medicon, 1989, pag 141 – 144. 15. Stanton SL – Stress urinary incontine, FBU – Simposion an Urology, Timisoara, 1994, pag 183 – 187. 16. Stanton SL – Surgery of urinary incontinance; Clinic in ObstetGynec, 1979;5; pag 83. 17. Jacquelen V. Jolleys – Urinary incontinance – Reviews in contemporary Pharmacotherpay, 1994, Tomz Nr.3 pag. 153 – 162. 18. Taylor L – Urinary incontinence in community dwelling eldery: prevlance and corelence Internationl continence society – 16th Annual Meeting Proceedings 1986; pag 76 – 78. 19. Peltecu G., Iancu G., – Intontinenca urinara in I.Popescu, C.Ciuce – Tratat de chirurgie: Ed. Academei Romana, Buc, 2014; pag 89 – 105. 20. MacLennon AH, Taylor AW, Willson DH – The prevalence of pelvic floor disorders and theyr relationship to gender, age, parity and mode of delivery; BJOG, 2000, 107 (12) pag 1460 – 1470. 21. Mygaard J., Barber MD., Burgio KL – Prevalence of symptomatic pelvic floor disorders in US women; Pelvic Floor Disorders Network JAMA , 2008, 300 , 11 pag 1311. 22. Komesee Ym, Rogers RG si altii – Incidence and revision of urinary incontience in a community based population of women over 50 years; Int urogynecol J Pelvic Floor dysfunction; 2009. 23. Mushkal Y., Bukovsky I., Langer R – Female urinary stress incontinence – does it have familial prevalence?; AmJunObstetGynecol, 1996 174(2); pag 617 – 619.

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© Filodiritto Editore - Proceedings 24. Tahtinen RM, Auvinen A, Cartwright R – Smoking and blader symptons in women. Obstet-Gynecol – 2011, 118(3) pag: 643 – 648.

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Variability of renal markers in preeclampsia TOTH GA.1,2, CRAINA M.1,3, ANASTASIU POPOV Diana Maria2, ANASTASIU D.1,3, GLUHOESCHI A.1 Department XII Obstetrics, Gynecology and Neonatology, “Victor Babes” University of Medicine and Pharmacy, Timisoara (ROMANIA) 2 Obstetrics and Gynecology, “Bega” Maternity Clinic, Timisoara (ROMANIA) 3 Department of Functional Sciences/Medical Informatics and biostatistics, “Victor Babes” University of Medicine and Pharmacy, Timisoara (ROMANIA) E-mail: [email protected] 1

Introduction Gestational hypertensions remains one of the main concerns of contemporary obstetrics due to complications that may appear to pregnant woman and the fetus, having paramount importance on fetal mortality, induction of premature birth and eclampsia being the third leading cause of maternal mortality. All these complications occur despite efforts in research directed towards this area in the last 100 years. Minor forms reveal a high incidence of gestational hypertension of 8-15% (16,30) at the same time representing an incidence of 5-10% of all pregnant women (1,2,6,22,40). During pregnancy the maternal body goes through a lot of adaptability changes to being pregnant, the most significant changes being for the urogenital and cardiovascular systems. Morphological and functional changes in the kidney during a state of gestation are very significant and important for the pregnancy. Proteinuria is common during preganancy and has it’s limits between 200-500mg/24h (41.42). The mechanisms for the development of proteinuria include increased glomerular filtration rate (GFR) inability to absorb filtered proteins and renal hemodynamics disorders induced by accentuated lordosis and compression of the uterus on the renal vein (40,41,46,47). Uric acid is an end product of purine metabolism filtered at the glomerulus. The bulk of filtered uric acid excretion is reabsorbed. It seems that the regulatory mechanism for uric acid secretion works due to a balanced active secretory reabsorption. During pregnancy there is an increase clearance for uric acid, its values normally exceeding 3-4mg%. A uremia 4mg% higher than in a pregnant pregnant can suggest a higher the risk of preeclampsia (25,45,47). In literature we find that hyperuricemia is a very serious maternal and fetal prognostic factor, especially when it’s associated with arterial hypertension and proteinuria. The Nephrology School from Timisoara showed that the renal secretion of uric acid is proportional with it’s plasmatic concentration and that the uric acid resorption is the first that gets affected, hyperuricema being an element for renal impairment in gestational hypertension, being an expression of hypovolemia. The serum creatinine in pregnant women with preeclampsia is sometimes lower then in nonpregnant women due to the glomerular filtration rate. In preeclampsia the kidney is so bad injured that the creatinine serum is 2 to 3 times lower then the normal values, especially in those cases that go with acute renal failure (28,29,32,39,40). All these elements indicated a major involvement in the etiopathology of gestational hypertension, theyre variability depending on gestation age and the presents of preeclampsia symtoms. The urea levels are

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© Filodiritto Editore - Proceedings usualy not modified during pregnancy, thou it can have a slightly lower values due to the high glomerular filtration rate.

Methodology We analyzed in our study a group of 300 pregnant women witch had all exams made when they came to the 1st prenatal examination and done again at 28 weeks of gestation. In this group for all pregnant women, blood pressure, weight, checked for edemas, urine examination for proteinuria and micro albuminuria. The presents and increase of those in the 2nd trimester of pregnancy is an indication of preeclampsia in 80% of cases. At 28 weeks of pregnancy for all women in the group we calculated the index Theodoru-Pascu and did the roll-over test (17,20,34). From all laboratory test that we did during the whole pregnancy we insisted on renal markers, the kidney being the most affected organ in gestational hypertension. We used and Architech CI 8220 and Disfunction to evaluated those markers. From a total of 300 pregnant women 267 (89%) had a normal out come, 33 (11%) had gestational hypertensions. From those 20 (60,6%) had mild symptoms with an gestosis index of 4 and the other 13 (39,4%) had preeclampsia and an gestosis index between 5 and 12 the maximal value being 16. The cases with an gestosis index under 5 had mild symptoms for gestational hypertension, edema or albuminuria, the sever form of gestational hypertension and preeclampsia had an gestosis index higher then 5 and needed hospitalization for observation and investigation. We analyzed the values of the laboratory examinations for the cases with gestational hypertension and we found that in 15 (45,45%) of the cases we found pathological values as follows: hyperuricemina in 4 cases (12,12%), presents of urea in 3 cases, and proteinuria >0.3mg% in 8 (29,26%) of cases. The serum creatinine wasn’t modified in pregnant women with gestational hypertension nor in the ones with preeclampsia. In all cases of gestational hypertension and preeclampsia there were renal injury’s present, indicated by the renal markers. From 33 pregnant women 22 (66,6%) underwent C-section and 11(33,3%) vaginal birth. In this group we had no fetal death and no maternal mortality.

Conclusions The incidence of preeclampsia in the study group was 11% of which 60.6% were mild or moderate form and in the remaining 39.4% being with preeclampsia. During the analyses of the renal makers we showed that proteinuria and uric acid had the highest variability, those rising to high values in sever cases. All cases with preeclampsia underwent C-section. Our conduct of choosing to terminate early a pregnancy is sustained by the absents of fetal and maternal mortality. The association of hyperuricemia and proteinuria are makers for a bad meterno-fetal outcome and indicated the presents of preeclampsia.

REFERENCES 1. Chesley LC – Disgnosis of preeclmapsia. Obstet-Gynecol, 1985, 65, pag 423. 2. Chesley LC – History and Epidemilogy of Preclampsai – Eclampsia Clinic ObsteticGynecol, 1984, 27, 4, pag 801 – 820. 3. Chiovschi S, Vasile C, Vasile M – Immunologic implication in preclampisa in:

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Munteanu I, rippman E, Hrubaru N. – Maternal-Fetal Risk in gestosis Roma, Cic Editioni Internationali, 1996 , pag 129 – 132. Crisan M, Constantiescu C, Nicolescu L, Ples N – Hipertensiunea arteriala indusa de sarcin, Info Medica, 1996, 6, 28 pag 30 – 34. Georgescu-Braila M, Berceanu S – Hypertensive disorder in pregnancy – major risk factor of extreme ages in: Maternal Fetal Risk in Gestos, CicEditini Internationali, 1996, pag 133 – 135. Gluhovschi Gh, Trandafirescu V, Schiller A., Petrica L. – Rinichiul si hipertensiunea arteriala, Timisoara , Ed. Helicon, 1995, pag 279 – 308. Gant MF, Worley RJ – Hypertension in pregnancy – Concepted managment, New York Appleton – County – Crofst, 1980, 4, 30, pag 94 – 95. Gluhoschi G, Romosn I, - Immunologia toxemiei gravidice, Viata medicala – 1985, 32, pag 5. Hutchesson ACJ, Macintosh MC, Danek SLK, Forrest ARW – Hypocalciemi and hypertension in pregnancy; a prospective study – Ciln. Exp. hypertens Bg, 1990, 2, pag 125 – 134. Jenkins DM – Immunology of gestots in: Perinata perspectives – Carring for the high risk fetus and mother – Alber Szent Gyorky Medical university szeged, 1990 pag 30 – 40. Jenkins DM – Immunological aspects of the pathogenisis of pregnancy hypertension. Clin.Obstet-Gynecol 1977, 4, pag 665 – 669. Kincoid – Smith P – The renal lesion of preeclapsia revisited – Am.J.Kidney Dis, 1991, 17 pag 144. McCartney JP – The acute hypertesive disorders of pregnancy, classified by renal histology. Gynecol, 1969, 167, pag 214 – 220. Moutguin J, Rainville C, Giroux L – A prospective study of blood pressure in pregnancy: prediction of preeclampsia. Am.J.Obstet-Gynecol, 1978, 136, pag 739 – 384. Munteanu I, Hrubaru N, Romosn I, Trandafirescu V – Hipertensiuena indusa de sarcina – patologie, diagnostic, tratament – Rev.Obstet.Ginec, 1993, 41, pag 1 – 4, 5 – 8. Munteanu I., Rippman FT., Hrubaru N. – Maternal-fetal risk in gestos, Roma Cic Editioni Internationali, 1996. Munteanu I, Hrubaru N, Hulpac E. – O granita modificata – terminarea nasterii la fatul ameninta de disgravidia tardiva in Bolile cardiovasculare la femeia gravia, Bucurest – 1980. Need JA – preeclampsia in pregnancy by different fathers – immunological studies, Br.Med.J, 1975, 1, pag 548 – 549. Nalan TE, Smith RP, Devoe LD – Maternal plasma D-meri levels in ormal and complicated pregnancies. ObstetGynecol, 1993, 81, 2, pag 235 - 238. Odendaal H – Managment of patiens with sever early preeclampsia in: Maternal Fetal Risk in Gestos, Roma, CIC Editoni Internationli, 1996 pag 444 – 448. Pascu H, Teodoru G – Scorul disgravidiei in: Asistenta mamei si copilului, Ed. Med. Buc, 1974 pag 25 – 52. Parapakkham S – An epidemiologic study o eclampsia, ObstetGynecol, 1979, 54 pag 26 – 31. Raca N., Ispas G., Buzua M., Cornitescu F. – argumente in favoarea unei nasteri inainte de termen in hipertensiune arterila severa in timpul graviditatii, Rev.Obst.Ginec, 1985, 3, pag 233 – 240. Raca N – Hipertensiune arterila in sarcina in Patologia generala asociata sarcinii, Ed.

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© Filodiritto Editore - Proceedings Litech Craiova, 1996, pag 65 – 71. 25. Manescu, Georgesc U, Romosan I – Nefropatiile tubulo-interstitiale, Ed. St. si Enciclopedica, Bucuresti; 1989. 26. Redman CW – Immunology of the placenta – Clinic. Obsteric –Ginec; 1986, 13, 3, pag 469-499. 27. Redman CWG – Immunological aspects of preeclampsia, Baillies Clinic Obst-Ginec, 1992, 6, pag 601 – 615. 28. Redman CWG – HLA antigens in sever reeclampsia, Lacent 1978, 2, pp 397. 29. Redman CWG - Current topic: Preeclampsia and the placenta. 1991 , 12, pag 301 – 308. 30. Hrubaru N., Munteau I – Hipertensiunea arterial indusa de sarcina, Timisoara, Ed. Mirton, 1999, pag 41 – 45. 31. Sibai BM – Immunologic aspects of preeclampsia. Clinic Obstetic-Gynec, 1991, 34, pag 27 – 30. 32. Sibai BM – Prevention of preelcmpsai: Is it possible?; J. Maternal Fetal invest.; 1992, 2, pag 75 – 79. 33. Sibai BM, Anderson GB, McCullin JH – Eclampsai. Clinical significance of lbaortatory findings. Obstet-Ginecol, 1982, 52,2, pag 153 – 157. 34. Teodom G., Constantinescu A: Patologia gestozei hypertensive tardive. Rev de obstet si Ginec, 1978, 25, 4, pag 345 – 355. 35. Trandafirescu U., Munteanu I., Hrubaru N., Schiller A., Gluhovschi Gh – Erori de diagnostic in hipertensiue arterial ainusa de sarcina in: vol Al Xi-lea Conf.Nat. de ObstetGinecol, Timisoara, 1993, pag 299 – 300. 36. Virtej P, Bodea C, Dorobantu M, albu A – Evaluarea efectelor hipertensiunii arterial materne asupra fatului prin velocimetria Doppler, Obstet-Ginecol, Ed All, 1996, pag 521 – 534. 37. Vinatier D., Mannier JC – Preeclampsai: physiology and immunological aspects. Eur.J.Obstet.Gynecol, Ed. Al, 1995, 61, 2, pag 85 – 97. 38. Yabes, De Suane M: Increasingly safe and successful pregnancies. Ed. Elsevier, 1996. 39. Wallenbug HCS, Visser W – Maternal hemodynamics in sever hypertensive disorders in pregnancy in “Perinatal perspective” proceeding of the 22nd international congress of pathopusiology of pregnancies, Budapest 1990, pag 15 – 25. 40. Rippman ET – On EPH gestosi vol al Xi-lea Conf.Nat.Obstetic-Ginecol Timisoara; 1993; pag 111 – 118. 41. Romosan I, Coraba A, Tuculeanu D – Aportul renourinar si arcina in: Imunteau – Tratat de obstetrica ed a II-a, Buc. Ed. Academiei Romane vol II; pag 260 – 282. 42. Romosan I – Rinichiul – Ghid diagnostic si terapeutic , Ed. Medicala , 1999. 43. Romosan I: Rinichiul morfologie clinica. Ed. Helion , Timisoara, 1993. 44. Pritchard J., Cunningham O., Pritchard S. - The Parkland Memorial Hospital protocol for treatment of eclampsia: evaluation of 245 cases.1984, 148; pag 951-983. 45. Lind T., Godfrey KA, Otnn H – Changes in serum uric acid concetrations during normal pregnancy, Br. J. Obstet, 1984 pag 91 – 128. 46. Zosin C, Chiovschi ST, Dragan P, Golea O, Romosan I, Zosin Ioana – Rinichiul si sarcina, Ed. Facla, Timisoara; 1985. 47. Munteanu I, Rippman ET, Hrubaru N – Hipertensiunea arteriala indusa de sarcina in Munteanu I – Tratat de obstetrica Ed. II Buc. Editura Academia Romana, 2006, pag 928 - 959.

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Ultrasound landmarks in diagnosis of pelvic floor disorders. A comprehensive overview BERCEANU Costin1, CÎRSTOIU Monica2, MEHEDINŢU Claudia2, BRĂTILĂ Petre2, BERCEANU Sabina1, BOHÎLŢEA Roxana2, BRĂTILĂ Elvira2 1 Department of Obstetrics and Gynecology, University of Medicine and Pharmacy Craiova (ROMANIA) 2 Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, Bucharest (ROMANIA) E-mails: [email protected], [email protected], [email protected], [email protected], [email protected], [email protected], [email protected]

Abstract Ultrasonography (US) can provide useful information in diagnosing the stress urinary incontinence (SUI) by morphologically assessing the bladder, as well as the status and mobility of the urethral-bladder mobility. Morphologically, the prolapsed uterus and vaginal walls are the messengers of anatomical defects. The clinical examination assesses the hernia defect and the prolapsing degree. The content of the hernial sac and the mechanism of prolapse occurrence are important for an accurate treatment. US can provide data on the content of the hernial sac, can explain the symptoms – difficulties of bladder, rectal evacuation, SUI – and directs on the anatomical defects. The US diagnosis solutions in uterovaginal prolapse are represented by the transperineal (translabial) ultrasound – TPUS, transvaginal ultrasound – TVUS or endoanal ultrasound – EAUS. The US assessment of the anterior pelvic compartment aims to: measure the residual urine volume, thickness of the detrusor, dynamics of the bladder neck, the presence of the cystocele, the integrity of the urethra, tumours or diverticula. The introital US (5MHz probe) can diagnose the elongation of the cervix or the colpocele – the retroverted uterus occupying the posterior hernial sac. EAUS and 2D/3D TPUS are complementary in assessing the posterior compartment. The US landmarks of the posterior compartment are: the central tendon of perineum – triangular shape, slightly hyperechoic, located anteriorly the anal sphincter; the rectovaginal septum – hyperechoic appearance between the (hypoechogenic) vaginal wall and rectal muscles and anorectal angle – between the longitudinal axis of the anal canal and the posterior rectal wall. Conclusions: US is non-invasive versus the cystourethrogram/defecography, cost-efficient compared to the dynamic MRI, enables the real-time evaluation of the pelvic floor, providing functional anatomy data or the assessment of the position and dynamics of the polypropylene meshes. US is useful in the preoperative assessment by the possibility to evaluate the contents of the hernia sac and correlation of anatomic defect – symptoms. US contributes to assessing the post-therapeutic results, the position of the synthetic meshes and to checking their functional effect. Keywords: morphologic evaluation, anatomic defect, dynamic assessment

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© Filodiritto Editore - Proceedings General Aspects The topographic and morphological changes in urogenital organs that generate stress urinary incontinence can be assessed by ultrasound techniques. [1] The ultrasound examination (US) of urogenital organs provides the following techniques: transperineal/translabial ultrasound (TPUS), transvaginal ultrasound (TVUS) or endoanal ultrasound (EAUS). [1, 2] The surgical management of the pelvic floor disorders depends on the overall understanding of its structural and functional integrity. [3] Pregnancy and childbirth are unanimously acknowledged risk factors for the development of anatomic and functional disorders of the pelvic floor – prolapse of the pelvic organs and urinary incontinence. [3, 4] Falkert A et al. Suggest that the changes of the hormonal status characteristic to the pregnancy condition and anatomic and functional particularities of the pregnant uterus lead to connective tissue remodelling and subsequent occurrence of morphological and functional disturbances in the pelvic floor. [5] Currently, the diagnostic assessment involves the clinical, ultrasound examination, urodynamic and anorectal tests, video-cystourethrogram or dynamic cystourethrogram. [2-5] The usefulness of dynamic magnetic resonance imaging is controversial in terms of high costs and limited access. [3, 6-9] The prevalence of urinary incontinence among women in Western countries has been estimated to range between 12 and 38% and increases with age. [5, 10] US has many advantages compared to other imaging techniques, through the minimum discomfort, relative easiness of use, a reasonable learning curve, absence of ionizing radiations, relatively low examination, favourable cost-effectiveness ratio, as well as the wide availability. [3, 11] The genital prolapse is a relatively common problem, and Falkert A et al. Estimate that in general, women have 12% lifetime risk to be undergo a surgical treatment for this pathology that also constantly includes urinary inconsistence. [5, 10-13] Morphologically, the prolapsed uterus and vaginal walls are the messengers of anatomical defects. The clinical examination assesses the hernia defect and the prolapsing degree. The content of the hernial sac and the mechanism of prolapse occurrence are important for an accurate treatment. [14]

Transperineal Ultrasound US can provide data on the content of the hernial sac, can explain the symptoms – difficulties of bladder, rectal evacuation, stress urinary incontinence and directs on the anatomical defects. The transducer is placed in the vulvar area and is slightly rotated 5-10 degrees until an image of the urethra and bladder is obtained. The next step is to slowly and progressively rotate until the flat rectum and perineal plate appear in the image, continuing to keep the urethra and bladder in the image. The descent of pelvic organs is assessed. [3, 10, 11, 14] Santoro GA et al. recommend that the TPUS for the assessment of stress urinary incontinence to be done with a patient placed in the dorsal lithotomy position, with the hips flexed and abducted, and a convex transducer positioned on the perineum between the mons pubis and the anal margin. [3] The TPUS of the pelvic floor uses conventional convex transducers (with frequencies of 3-6MHz and field of view of at least 70 degrees). [3, 7, 14] The TPUS assessment of the anterior compartment aims at the following parameters: the residual urine volume (Fig. 1 A), thickness of the detrusor, dynamics of the bladder neck, the

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© Filodiritto Editore - Proceedings presence of the cystocele, the integrity of the urethra, diagnosis of tumours or diverticula. (Table 1) Table 1. Ultrasound assessment of urogenital organs in diagnosis of the stress urinary incontinence Compartment

Ultrasound landmarks

Anterior

Residual urine volume Thickness of the detrusor Dynamics of the bladder neck Presence of the cystocele Integrity of the urethra Diagnosis of tumours and diverticula

Middle

Translabial ultrasound - no diagnosis data Introital ultrasound (5MHz probe) – can diagnose the elongation of the cervix. Colpocele – the retroverted uterus occupying the posterior hernial sac Central tendon of perineum Rectovaginal septum Anorectal angle Investigation of the anal sphincter

Posterior

The dynamics of the bladder neck can be assessed by using this technique; under normal conditions, it remains closed under stress. The opening of the bladder neck – the normal posterior urethtral-bladder between 900-1100 changes from 900 to over 1800 during the Valsalva manoeuvre (Fig. 1 B). The descent of the bladder neck on the lower edge of the symphysis implies a difference of rest –Valsalva > 25mm. [3-5, 15, 16] Cystocele diagnosis (Fig. 2) by assessing the lowering degree of the bladder base below the bladder neck, by more than 4 cm under the lower edge of the pubic symphysis. [14, 17, 18]

Fig. 1 A. Measurement of bladder residue (A x B x 5.6 mm). B. 3D TPUS Measurement of the posterior urethral-bladder angle

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Fig. 2 Cystocele diagnosis The two-dimensional transperineal US also assesses the medium compartment (Fig. 3). In the mid-sagittal secion, the cervix placed unusually low is isoechoic and frequently generates acoustic shadowing. [3-5] The body of the uterus can be assessed in the same section. The introital ultrasound using the 5MHz transducer can diagnose the elongation of the cervix. [1, 3-5, 7, 14] The assessment of the posterior compartment involves the 2D/3D translabial/ transperineal US, endoanal ultrasound after the clinical examination. The video-defecography and magnetic resonance imaging can be used.

Fig. 3. Introital ultrasound – can diagnose the elongation of the cervix. Colpocele – the retroverted uterus occupying the posterior hernial sac The evaluable structures in the posterior compartment are the central tendon of the perineum of triangular shape, slightly hyperechoic, located anteriorly the anal sphincter, the rectovaginal septum having a hyperechoic appearance between the (hypoechogenic) vaginal wall and rectal muscles and anorectal angle arranged between the longitudinal axis of the anal canal and the posterior rectal wall. [3-5, 17, 18] (Table 1) The dynamic evaluation of the anterior compartment is done in the mid-sagittal plane, having the advantage of the landmark exactly on the lower edge of pubic symphysis. [3-5] The ultrasound investigation may reveal anatomical defects hiding behind the posterior vaginal wall prolapse: rectocele, perineal (rectal) hypermobility – change in the central tendon of the perineum, enterocele, rectal intussusceptions and investigation of the anal sphincter. [3,

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© Filodiritto Editore - Proceedings 4, 19] The measurable landmarks in the posterior compartment for evaluating the retrocele are represented by the maximum depth of the protrusion of the rectal wall in the posterior vaginal wall, the rectal descent related to the line intersecting the lower edge of the pubis, the maximum protrusion being measured on the line perpendicular to the contour of the anterior rectal wall. The rectocele may be diagnosed when the protrusion exceeds 10mm (Fig. 4). [3, 17-19]

Fig. 4 Rectocele – defect of the retrovaginal septum (R - rectocele) Perineal hypermobility when the rectovaginal septum is intact, although there is rectal descent, the protrusion of the rectal wall in the posterior vaginal wall is not observed – a protrusion that sets the rectocele diagnosis. [3-5, 17-21] Rectal intussusception or rectal invagination – this term practically defines an enterocele containing the ptosis sigmoid, omentum or thin intestinal loops protruding in the rectal walls, not in the vaginal wall. Under stress, the rectal wall pushed by the enterocele protrudes in the lumen of the anal canal (Fig. 5). It is associated with biometric abnormalities of the urogenital hiatus and pubic-rectal muscle avulsion. [3-5, 17-21]

Fig. 5 Rectal intussusception. A. Gel applied intravaginally (arrow). B. Protrusion of the rectal wall. The plication appearance of the intraluminal rectal wall (Ac - anal canal, R - rectum, S - sigmoid) The internal anal sphincter can also be located by ultrasound, most preferably with a 5 MHz transducer, from the perineum. The transducer is placed on the central tendon of the perineum and is turned towards the rear. Thus, the thickness of the anterior and posterior portions of the internal anal sphincter can be measured. This procedure is less unpleasant

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© Filodiritto Editore - Proceedings compared to endoanal ultrasound. [3-5, 21]

Transvaginal Ultrasound The TVUS is performed with the patient placed in the same position as that used for the TPUS. [3]It is important to maintain the transducer inserted into the vagina in neutral position and avoid exercising an excessive pressure on the neighbouring structures, not to distort the anatomy. The TVUS is usually carried out having the patient at rest, during the maximum Valsalva manoeuvre. [3, 22]

Endoanal Ultrasound Santoro GA et al. describe this technique with a high multifrequency, 360 degrees rotational mechanical probe or a radial electronic probe, as described above for TVS. [3] The patient may be placed in a dorsal lithotomy, left lateral or prone position. [3, 22] The anatomic evaluation of the anal canal involves assessing the upper portion (the analrectal junction) – the pubic-rectal muscle anchoring the sphincter complex to the pubic ramus, internal anal sphincter – hypoechogenic circular fibres, it does not have a constant thickness over the entire length of the anal canal, the external anal sphincter with hyperechoic appearance – the longitudinal muscle of the anus – located in the intersphincteric groove and the junction with the levator ani muscle. [3, 4, 10] The US assessment of the synthetic meshes is of significant importance, because synthetic implants cannot be investigated by X-ray or computed tomography exploration. In terms of ultrasound, they are intensely hyperechoic, and the US can be assess either the incorrect location of them, or the failure in achieving the support for the compartment wherein they have been placed (Fig. 6). [2, 10, 24]

Fig. 6 Volumetric assessment of synthetic meshes. Multi slice view - MSV

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© Filodiritto Editore - Proceedings The assessment of suburethral bandelets is done with a full bladder, at rest and stress. The proper placement of the bandelet involves 3-5 mm of the urethral wall and more than 1 cm of the pubic symphysis. The bandelet is properly placed on the limit between the distal urethra and medium urethra, and under stress, the bandelet is placed in the medium urethra. [3, 24-29]

Conclusions The US is non-invasive versus the cystourethrography/defecography, cost-efficient compared to the dynamic MRI, enables the real-time evaluation of the pelvic floor, providing functional anatomy data or the assessment of the position and dynamics of the polypropylene meshes. US is useful in the preoperative assessment by the possibility to evaluate the contents of the hernia sac and correlation of anatomic defect – symptoms. US contributes to assessing the post-therapeutic results, the position of the synthetic meshes and to checking their functional effect. US becomes an important element both in the SUI, enabling the morphological and dynamic assessment of the lower urinary tract, as well as in the preoperative assessment for establishing the surgical conduct.

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© Filodiritto Editore - Proceedings 10. Brătilă E, Vlădăreanu S, Berceanu C, Cîrstoiu M, Mehedințu C, Comandașu D. (2015). The anatomy of urinary continence in women. Revista Ginecologia.ro 10, (4/2015), pp. 45-51. 11. Dietz H. (2007). Quantification of major morphological abnormalities of the levator ani. Ultrasound Obstet Gynecol 29, pp. 329–334. 12. Rortveit G, Brown JS, Thom DH, Van Den Eeden SK, Creasman JM, Subak LL. (2007). Symptomatic pelvic organ prolapse: prevalence and risk factors in a population-based, racially diverse cohort. Obstet Gynecol 109, pp. 1396–1403. 13. Fialkow MF, Newton KM, Lentz GM, Weiss NS. (2008). Lifetime risk of surgical management for pelvic organ prolapse or urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 19, pp. 437–440. 14. Brătilă E, Vlădăreanu S, Berceanu C, Cîrstoiu M, Mehedințu C, Comandașu D, Mitran M. (2015). Rolul sarcinii și al nașterii în apariţia tulburărilor de statică pelvică. Revista Ginecologia.ro 10, (4/2015), pp. 28-33. 15. Khullar V, Cardozo LD, Salvatore S, Hill S. (1996). Ultrasound: a noninvasive screening test for detrusor instability. Br J Obstet Gynaecol 103, pp. 904–908. 16. Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J,Monga A, Petri E, Rizk DE, Sand PK, Schaer GN. (2010). An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J 21, pp. 5–26. 17. Lee SJ, Park JW. (2000). Follow-up evaluation of the effect of vaginal delivery on the pelvic floor. Dis Colon Rectum 43, pp. 1550–1555. 18. Bratila E, Bratila CP, Comandasu DE. (2015). Recurrent rectovaginal fistula treated by acellular interposition graft. A case report. Paripex – Indian Journal of Research 4(3/2015), pp. 28-30. 19. Valsky DV, Messing B, Petkova R, Savchev S, Rosenak D, Hochner-Celnikier D, Yagel S. (2007). Postpartum evaluation of the anal sphincter by transperineal three-dimensional ultrasound inprimiparous women after vaginal delivery and following surgical repair of third-degree tears by the overlapping technique.Ultrasound Obstet Gynecol 29, pp. 195– 204. 20. Dietz H, Shek K. (2008). Levator avulsion and grading of pelvic floor muscle strength. Int Urogynecol J 19, pp. 633–636. 21. Thyer I, Shek C, Dietz HP. (2008). New imaging method for assessing pelvic floor biomechanics. Ultrasound Obstet Gynecol 31, pp. 201–205. 22. Santoro GA, Wieczorek AP, Stankiewicz A, Wozniak MM, Bogusiewicz M, Rechbereger T. (2009). High-resolution threedimensional endovaginal ultrasonography in the assessment of pelvic floor anatomy: a preliminary study. Int Urogynecol J 20, pp. 1213– 1222. 23. Santoro GA, Fortling B. (2007). The advantages of volume rendering in three-dimensional endosonography of the anorectum. Dis Colon Rectum 50, pp. 359–368. 24. Bratila E, Bratila CP, Coroleuca CB, Cirstoiu MM, Berceanu C. (2015). The impact of biomaterials in the reconstructive gynecologic surgery. Gineco.eu 42 (4/2015), pp. 172175. 25. Svabik K, Martan A, Masata J, El Haddad R. (2009). Vaginal mesh shrinking – ultrasound assessment and quantification. Int Urogynecol J 20, pp. S166. 26. Meyer SM, Salchli F, Achtari C, Hohlfeld P, De Grandi P. (2005). Monitoring the pelvic floor: is it possible? Preliminary results with a new microsystem device. Int Urogynecol J Pelvic Floor Dysfunct 16, pp. S77. 27. Tunn R, Picot A, Marschke J, Gauruder-Burmester A. ( 2007). Sonomorphological evaluation of polypropylene mesh implants after vaginal mesh repair in women with cystocele or rectocele. Ultrasound Obstet Gynecol 29, pp 449–452.

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© Filodiritto Editore - Proceedings 28. Devreese A, Staes F, De Weerdt W, Feys H, Van Assche A, Penninckx F, Vereecken R. (2004). Clinical evaluation of pelvic floor muscle function in continent and incontinentwomen. Neurourol Urodyn 23, pp. 190–197. 29. Shek KL, Rane A, Goh J, Dietz HP. (2009). Stress urinary incontinence after transobturator mesh for cystocele repair. Int Urogynecol J 20, pp. 421–425.

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Hormone deficiency and its impact on the lower urinary tract BERCEANU Costin1, CÎRSTOIU Monica2, MEHEDINŢU Claudia2, BRĂTILĂ Petre2, BERCEANU Sabina1, VLĂDĂREANU Simona2, BOHÎLŢEA Roxana2, BRĂTILĂ Elvira2 Department of Obstetrics and Gynaecology, University of Medicine and Pharmacy Craiova (ROMANIA) 2 Department of Obstetrics - Gynaecology and Neonatology, “Carol Davila” University of Medicine and Pharmacy, Bucharest (ROMANIA) E-mails: [email protected], [email protected], [email protected], [email protected], [email protected], [email protected], [email protected], [email protected] 1

Abstract The horomonal receptors are present in supporting structures of pelvic organs, especially in pubocervical muscle and pubocervical fascia involved in the continence mechanisms. Due to the low production of estrogens in late menopause, genitourinary atrophy can lead to a variety of symptoms with significant impacts on the quality of life. The development of any incontinence was associated with a higher baseline BMI, weight gain, and an increase in anxiety symptoms. Estrogen levels can be normal, low or even high depending on the stage of the transition to menopause. Only in menopause the estrogen levels are extremely low or undetectable. The main postmenopausal changes are hormonal deficiency and ageing and these are overlapping effects. The effects of ageing and the postmenopausal bladder changes include capacity decreasement, compliance decreasement, post void residual increasement, glycosaminoglycan layer thinning and the ability to initiate or suppress detrusor contractility is impaired. Age-related postmenopausal urethral changes include epithelium thinning, blood flow and vascular pulsations decreasement and total collagen reduction. Alpha adrenergic receptors are also decreasing, as well as a slowing of nerve conduction time is noticed. The central element of the aging process in the lower urinary tract is the urethral support impaired by degenerative changes in elastic connective tissue. The vaginal route for administration of estrogens has some advantages as avoiding enterohepatic circulation, the lowest possible dose, no endometrial stimulation, cyclical progestogens unnecessary, no systemic side effects, exerts mainly local effect and acceptable following breast cancer. The role of oestrogens remains important in the management of women with urogenital symptoms. Traditional knowledge has been challenged by large epidemiological studies and may not be representative of our patient populations. Current evidence would favour the use of vaginal oestrogens. Keywords: hormonal receptors, lower urinary tract, incontinence, estrogens

Overview of the menopause transition The menopause is a physiologically state in which a woman spend 30% of her entire life.

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© Filodiritto Editore - Proceedings [1, 2] The future will reserve us a spectacular demographic phenomenon: the ageing of world population from 530 mil. in 2010 to 1.3 billion in 2040. 8% of world population have urogenital symptoms. [1-3] Since the ‘80 years the studies have shown that the estrogen deficiency is the leading factor in the aetiology of lower urinary tract symptoms and 70% of women relate the onset of the stress urinary incontinence to their final menstrual period. [3, 4] In the lower urinary tract we can find estrogen, progesterone and androgen receptors. [5] Vagina and bladder base have the same pattern including all type of hormone receptors. [3, 5] The hormonal receptors are present in supporting structures of pelvic organs, especially in pubocervical muscle and pubocervical fascia involved in the continence mechanisms. [5, 6] Due to the low production of estrogens in late menopause, genitourinary atrophy can lead to a variety of symptoms with significant impacts on the quality of life. [3] The urethral mucosa and urinary bladder thinning leads to the occurrence of the urinary symptoms including dysuria, frequent urination, sensation of impending urination, urinary incontinence or recurring infections of the urinary tract. [3, 7, 8] On the one hand, the urethral shortening and atrophic changes on the other hand may lead to stress or strain urinary incontinence. [3,7-9] In a recent study, Waetjen et al. have evaluated the women in transition to menopause and observed a slight increase in the incidence of stress urinary incontinence and strong sensation of needing to urinate [10] The development of any incontinence was associated with a higher baseline BMI, weight gain, and an increase in anxiety symptoms. [10] A biological basis may explain the association between menopausal stage and the reporting of new onset incontinence. Some women report that their incontinence is affected by menstrual cycle phase, with most women reporting increases in incontinence in the luteal phase when both estradiol and progesterone levels are elevated. [11] Also, It is possible that for women in the peri-menopause, the increased frequency of anovulatory cycles and the associated relatively prolonged elevated levels or peaks of estrogen in a subset of women increases the likelihood of developing infrequent incontinence, while the lower or declining estrogen levels of postmenopause decreases that risk. [10-12] Estrogen levels can be normal, low or even high depending on the stage of the transition to menopause. Only in menopause the estrogen levels are extremely low or undetectable. [3]

Postmenopausal lower urinary tract changes The main postmenopausal changes are hormonal deficiency and ageing and these are overlapping effects. The prevalence of one or another factor may show individual variances related to several factors such as genetic, geoethinic or behavioural particularities. [13, 14]

The effect of hypoestrogenism It has been demonstrated that collagen metabolism does not change in menopause and the effect of hypoestrogenism consists in a decrease in sensory treshold wich could generate overactive bladder and decrease of urethral venous plexus creating a favourable conditions for stress urinary incontinence. [3, 15-18] The effects of ageing and the postmenopausal bladder changes include capacity decreasement, compliance decreasement, post void residual increasement, glycosaminoglycan layer thinning and the ability to initiate or suppress detrusor contractility is impaired. [15-18] The symptoms of lower the urinary tract are frequent causes for which patients seek

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© Filodiritto Editore - Proceedings specialised check-up. [15, 16] The change in the urinary system functions is systematised in Table 1, adapted from Wall L.L., 1999. [16] Table 1. Classification of urinary symptoms in women (Wall LL, 1999, adapted) [16] Abnormal accumulation

- Incontinence - Strain incontinence - Stimulation incontinence - Mixed incontinence - Unconscious incontinence - Urinations at short time intervals - Nocturia - Nocturnal enuresis

Abnormal evacuation - Delay in starting the urine flow - Effort to urinate - Low urine flow - Intermittent urine flow - Full evacuation - Post-micturition dribble - Acute urinary retention

Abnormal sensation

- Urgent sensation of micturition - Dysuria - Bladder pain - Pain in the flank - Pressure - Loss of bladder sensation

Abnormal bladder content - Abnormal colour - Abnormal odour - Haematuria - Pneumaturia - Gallstones - Foreign bodies

Urinary incontinence involves the involuntary loss of urine, representing both a social issue and one related to hygiene, being a symptom, and not a diagnosis. [3, 8, 15, 16, 19] The estrogenic deficit related to menopause determines the occurrence of urogenital manifestations by epithelial atrophy, reduction of the connective tissue and alteration of tissue perfusion. [20] Estrogens increase the sensitivity of alpha-adrenergic receptors in the urethral smooth muscle and in the bladder neck, increasing the muscle tone and contractility and maintaining the urinary continence. Estrogen hormones also improve the urethral tissue perfusion, being demonstrated that the vascular bed has a critical role in maintaining the intraurethral pressure. [20-23] The genital tract and the urinary one are intimately associated anatomically and embryologically, the common embryonic origin in the urogenital sinus, lower genital tract, vulva and lower third of the vagina, as well as the urethra and bladder trigon explain the density of estrogen receptors at this level and the tissue suffering under the conditions of estrogen deficiency (Table 2). [16, 20-23] Table. 2 Hormonal receptors in LUT and in the pelvic support [5, 23] Anatomic ER PR AR structures Hormonal Pubocervical + receptors in muscle pelvic support Levator ani muscle ?(+/_) Cardinal ligament Sacrouterine ligament Pubocervical fascia

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+

+

-

+(a,b)

+

-

+ (a,b)

-

-

© Filodiritto Editore - Proceedings Hormonal receptors in LUT

Urethra Urethral

+

+

+

Sphyncter Periurethral veins

+

Vagina

+

+

+

Bladder base

+

+

+

LUT - lower urinary tract, ER - estrogen receptors, PR - progesterone receptors, AR androgen receptor

For this table, data from the following sources have been used: Fu X, Rezapour M, Wu X, Li L, Sjögren C, Ulmsten U. (2003). Expression of estrogen receptor - alpha and - beta in anterior vaginal walls of genuine stress incontinent women. Int Urogynecol J Pelvic Floor Dysfunct 14(4), pp. 276-81. Goeshen K, Petros P, Funogea A, Brătilă E, Brătilă P, Cîrstoiu M. (2016). Planşeul pelvic la femeie. Anatomia funcţională, diagnostic şi tratament-în acord cu teoria integrative, Editura Universitara Carol Davila Bucharest, Bucharest.

The striated muscles and pelvic floor fascia act on the entire pelvis in order to prevent the displacement of pelvic organs, to maintain the continence and control the activities of excretion. [16, 23] The prolapsed of pelvic organs, vaginal relaxation with cystocele, rectocele or uterine prolapsed are not a direct consequence of the lack of estrogens, the etiology being multifactorial and progressive over time. Old age is obviously an important factor. [3, 24-26]

The effect of ageing Age-related postmenopausal urethral changes include epithelium thinning, blood flow and vascular pulsations decreasement and total collagen reduction. Alpha adrenergic receptors are also decreasing, as well as a slowing of nerve conduction time is noticed. [3, 7, 16, 27-29] The central element of the aging process in the lower urinary tract is the urethral support impaired by degenerative changes in elastic connective tissue. [3, 7, 27] The main ageing effect for stress urinary incontinence is the degenerative changes in elastic connective tissue of urethral support. Plenty of other anatomical and functional modifications are to be found. [3,7,27-29] The mucosa of the urethra is thining and loses the ability of coaptation. The atrophy of vaginal mucosa induces major changes in vaginal ecosystem. In the absence of lactobacilar flora the vagina is colonized by mixed germs inducing pH modification (Table 3). [3, 16, 20, 23]

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© Filodiritto Editore - Proceedings Table 3. The effects of urogenital ageing [3,20] - Stress/ strain urinary incontinence Lower urinary tract - Recurring urinary infections - Dysuria - Nocturia - Frequent urination - Urgent sensation of urination - Vaginal stenosis Genital - Genital prolapse - ↓ of libido - Dyspareunia - Vaginal dryness - Itchiness - Postcoital bleeding - Genital infections This table is designed as a synopsis of the effects of urogenital ageing and data from the following sources have been used: Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG. (2008). Menopausal Transition. In: Williams Gynecology, McGraw Hill, New York, pp. 468-491. Vârtej P, Vârtej I, Poiană C. (2014). Ginecologie endocrinologică, Ediţia a IV-a, Editura All, Bucharest, pp. 156-222.

The support of pelvic organs is maintained by complex interactions between the muscles of the pelvic floor, its connective tissues and vaginal wall. This morpho-functional complex provides the support and physiological functioning of the vagina, urinary bladder urethra and rectum. [3, 30-33] Arcus tendineus fascia pelvis is a complex of parietal fascia covering the median area of the internal obturator and levator ani muscles. Recent studies prove that a major factor for the occurrence of genital prolapsed is the loss of the connective tissue support on the vaginal apex, leading to the rupture or elongation of the arcus tendineus fascia pelvis. [3, 16, 23] The complex of fascia and connective tissues of the pelvic floor can lose their bearing capacity through the aging process, which also contributes to the reduction of the neuroendocrine signals in the pelvic structures. [3, 23, 34, 35]

Controversies and certitudes in using oestrogens for incontinence Oestrogen treatment for urinary incontinence has been tested using oral, transdermal and vaginal routes of administration. Available evidence suggests on one hand that vaginal oestrogen treatment with oestradiol and oestriol is not associated with the increased risk of thromboembolism, endometrial hypertrophy, and breast cancer as observed with systemic administration, and on the other hand the fat that vaginal (local) treatment is primarily used to treat symptoms of vaginal atrophy in postmenopausal women. [36-39] The main problem related to estrogen effect on stress urinary incontinence is the route of administration. As a matter of this fact there are two main questions arising: In women with

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© Filodiritto Editore - Proceedings urinary incontinence, does oral (systemic) oestrogen cure or improve urinary incontinence compared to no treatment? and In women with urinary incontinence, does vaginal (local) oestrogen cure or improve urinary incontinence compared to no treatment or other active treatment? A study on 28 randomised trials shows a statistically significant improvement of stress urinary incontinence and urinary incontinence after estrogen treatment over placebo, but we have too few data to asses dose and route of administration. Another meta-analysis shows that local estrogens may improve incontinence but no date regarding types of estrogen and mode of delivery. (Table 4) Table 4. Cochrane Incontinence Group Meta-analysis Maher C et al., 2004 [40]

Cochrane Incontinence Group Metaanalysis

28 randomised trials 2926 women Overall, a statistically higher cure and improvement rate for oestrogen over placebo (RR: 1.61; CI: 1.042.49) Stress Incontinence (43% Vs 27%) Urge Incontinence (57% Vs 28%) No serious adverse events Too few data to assess type, dose and route of administration

Cody JD et al., 2012 [41]

Cochrane Incontinence Group Metaanalysis

33 randomised trials 19313 women 1262 women involved in trials of local oestrogens Systemic oral oestrogens worsen incontinence Oestrogen alone (RR: 1.32; 95%; CI: 1.17-1.48) Oestrogen and Progestogen (RR 1.11; 95%; CI: 1.041.18) Local oestrogens may improve incontinence (RR 1.11; 95%; CI: 1.04-1.18) Not enough data regarding types of oestrogen and mode of delivery

The focused study on hormone replacement therapy included a large cohort of women but their goal was not to prove the results on urinary incontinence. These studies were designed for prevention of ischemic heart disease, osteoporosis and evaluation of thromboembolism risk. The incontinence data simply represent a sub-group post hoc analysis. Two of the studies used conjugated equine oestrogens rather than synthetic oestradiol, which is more commonly used in Europe. Many of the patients had significant co-morbidities and were older than 60. In women with stress urinary incontinence the use of oral conjugated equine estrogens, estradiol, or estrone showed no improvement. [42-44] Two placebo-controlled trials using sub-cutaneous estradiol or oral estriol showed no benefit for improvement of urinary incontinence. [45] The oral and subcutaneous use of conjugated equine estrogens, estradiol and or estrone showed no benefit for improvement of stress urinary incontinence. The vaginal route for administration of estrogens has some advantages as avoiding enterohepatic circulation, the lowest possible dose, no endometrial stimulation, cyclical progestogens unnecessary, no systemic side effects, exerts mainly local effect and acceptable following breast cancer. [15, 23, 29, 45]

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© Filodiritto Editore - Proceedings Vaginal oestrogens have also direct action to the urogenital cells. Hormone therapy reduces autonomic and sensory vaginal innervation density, which may, in part, contribute to relief from vaginal discomfort. Topical therapy causes more dramatic reductions in innervation than systemic HRT, which explains the greater improvement reported with local oestrogens. [46] Cardozo et al., in 11 randomized placebo controlled trials including 430 women, shows that estrogens are superior to placebo in terms of urge incontinence, frequency, nocturia, first sensation, bladder capacity and urgency. [47] Tseng et al showed significantly improvement of quality of life when Tolterodine treatment was associated with Premarin cream twice weekly. [48] On the contrary the study of Serrati et al shoved no difference in terms of efficacy between adding vaginal estriol and treatment with Tolterodine alone. [49] The recent study of Nappi and Davis in 2012 demonstrate the role of use of vaginal estrogens only for UUI and OAB without evidence for stress urinary incontinence. [50]

Conclusions Vaginal oestrogen therapy can be given as conjugated equine oestrogen, oestriol or oestradiol in vaginal pessaries, vaginal rings or creams. Current data do not allow differentiation among the various types of oestrogens or delivery methods. The ideal treatment duration and the long-term effects are uncertain. The role of oestrogens remains important in the management of women with urogenital symptoms. Traditional knowledge has been challenged by large epidemiological studies and may not be representative of our patient populations. Current evidence would favour the use of vaginal oestrogens. More evidence is needed in order to rationalise type, dose and route of administration. Precise role of exogenous oestrogen therapy remains unclear.

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© Filodiritto Editore - Proceedings estrogens for symptoms suggestive of overactive bladder. Acta Obstet Gynecol Scand 83(10), pp. 892-7. 48. Tseng LH, Wang AC, Chang YL, Soong YK, Lloyd LK, Ko YJ. (2009). Randomized comparison of tolterodine with vaginal estrogen cream versus tolterodine alone for the treatment of postmenopausal women with overactive bladder syndrome. Neurourol Urodyn 28(1), pp. 47-51. 49. Serati M, Salvatore S, Uccella S, Cardozo L, Bolis P. (2009). Is there a synergistic effect of topical oestrogens when administered with antimuscarinics in the treatment of symptomatic detrusor overactivity? Eur Urol 55(3), pp 713-9. 50. Nappi RE, Davis SR. (2012). The use of hormone therapy for the maintenance of urogynecological and sexual health post WHI. Climacteric 15(3), pp. 267-74.

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Intrapartum and postpartum bladder management BODEAN Oana1, MUNTEANU Octavian1, VOICU Diana2, VASILESCU Sorin2, BOHILTEA Roxana1, CIRSTOIU MONICA1 “Carol Davila” University of Medicine and Pharmacy, Bucharest (ROMANIA) Emergency University Hospital Bucharest (ROMANIA) Corresponding author: Munteanu Octavian, e-mail: [email protected]

1 2

Abstract During labour and in the postpartum period the urinary bladder is usually at risk for possible injuries and dysfunction. In the postpartum, the bladder has a tendency of being underactive, therefore is vulnerable to retention. Also, the bladder sensation may be affected and most women are not aware of a fully distended bladder and the voiding necessity. A prolonged over distension can permanently affect the detrusor muscle causing severe or permanent dysfunction such as: acute urinary retention, incontinence, recurrent urinary tract infections. Any woman can develop postpartum voiding dysfunction regardless of mode of delivery and some patients may have permanent complications later in life. We present our experience with a number of cases who developed bladder dysfunction in the postpartum. Keywords: urinary incontinence, bladder dysfunction, postpartum

Background Bladder care is a very important aspect of management in the postpartum period. Voiding dysfunction can occur in any patient and if left undetected, it can produce permanent damage to the detrusor muscle. There is no universal protocol for postpartum bladder care and many cases can be easily missed. [1] Definitions Urinary retention is defined as the inability to urinate despite sustained effort. [2] Acute urinary retention is defined by the International Continence Society as a painful or palpable bladder with the patient unable to pass any urine when the bladder is full. [3] Some patients pass a small amount of urine due to bladder over distention (overflow incontinence). Pain may also not be present in the postpartum following epidural analgesia. Most frequently, postpartum urinary retention is described as the absence of spontaneous micturition within 6 hours of delivery. There are two types of urinary retention described in the literature: acute (overt) and chronic (covert). [4] Acute retention is the sudden onset of the inability to void, leaving a significant residual urine in the bladder. Chronic retention refers to a non-painful bladder with a post-void residual volume of over 150 ml. [5] Incidence The reported incidence of postpartum bladder dysfunction varies due to inconsistencies

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© Filodiritto Editore - Proceedings in the definitions and methods of diagnosis. It is estimated that 10-15% of women have some degree of voiding dysfunction after delivery. [6] Part of these patients may have significant and long term dysfunction leading to urinary incontinence. [7] There is a series of possible risk factors which need to be recognised by the patient and the medical team involved in patient care in order to prevent complications. It cannot be predicted which patient will develop postpartum urinary retention [8] or other voiding dysfunction, therefore every case has its own peculiarity. Aim of this study is to highlight the necessity of proper recognition of postpartum voiding problems.

Cases

Case 1 - 27 years old, G1P1 - Spontaneous vaginal delivery at 39 weeks - epidural analgesia - Delivered 3700g new born baby - At 8 hours post-partum patient describes: mild abdominal pain and impossible spontaneous micturition - Palpable bladder - Abdominal ultrasound: distended bladder - Foley catheter inserted: voids 3200 ml urine - Foley is maintained for 12 hours - The patient is encouraged to drink more fluids and to urinate by herself after the catheter is removed - Abdominal ultrasound at 2 hrs after catheter removal (Fig. 1) - Resumption of spontaneous urination Case 2 - 34 years old, G3P2 - Caesarean section (CS) at 37 weeks for fetal distress - Spinal anaesthesia - 2900 g new born baby - Foley catheter inserted prior to intervention - At 6 hrs post CS: diuresis=2500 ml normochromic urine, then mild haematuria. - Removal of Foley catheter: patient is unable to pass any urine. No visible urethral injury at inspection - Replace Foley: catheter is inserted with difficulty (urethral obstacle) - Urology specialist is consulted. Cystoscopy. - Conclusion: urethral oedema, possibly due to malposition or traction of catheter. - Foley is maintained for 48 hours - Resumption of spontaneous urination with normochromic urine Case 3 - 32 years old G2P1 - spontaneous vaginal delivery at 40 weeks - 3650g new born baby - epidural anaesthesia - long labour - Foley in for 2nd stage of labour - 2nd stage>3 hours

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perineal injury At 2 hours post-partum: urinary incontinence No visible urethral injury at inspection Incontinence persists 6 weeks postpartum Conclusion: Foley catheter in maintained during expulsion of fetal head. Urethral distension Case 4 - 36 years old G7P5 - heavy smoker - spontaneous vaginal delivery at 39 weeks of a 3800 g baby - other large babies (3750 g, 3900 g, 4200 g) delivered vaginally - reported cystocele and urinary incontinence after 3rd baby - recurrent urinary tract infections prior to current pregnancy - recurrent urinary tract infections and long term urinary incontinence - patient returned for surgical cure of urinary incontinence (Fig. 2, Fig.3, Fig. 4)

Figure 1. Ultrasound image of bladder after remission of urinary retention in patient with vaginal delivery

Figure 2. Ultrasound image of vaginal prolapse in multiparous woman

Figure 3. Cystocele, urinary incontinence on a multiparous woman

Figure 4. Surgical treatment of urinary incontinence with TOT mesh. Cure of cystocele and rectocele

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© Filodiritto Editore - Proceedings Discussion Risk factors Although one cannot predict which patient will develop postpartum voiding dysfunction, there are a few suggested risk factors [9] (Table 1): Table 1: Suggested risk factors for post-partum voiding dysfunction Risk factor: Nulliparous women Prolonged labour or long 2nd stage of labour Instrumental delivery (forceps) Perineal injury Caesarean section Regional analgesia Immobility History of previous voiding problems

Pathophysiology The pathophysiology of post-partum urinary retention is multifactorial and it can be explained by: - hormonal changes during pregnancy (the post-partum bladder is hypotonic due to elevated progesterone levels) [10] - local trauma during delivery (trauma to the pelvic floor muscles and nerves, trauma to the bladder) - pudendal nerve damage by pelvic floor tissue stretching or injury (instrumental delivery, prolonged labour) [11] - tissue oedema of the urogenital area (large baby, compression of the presenting part onto the birth canal, instrumental delivery, perineal lacerations) - physiological factors (fear of pain, lack of privacy) [12]

Diagnosis Symptoms of acute urinary retention are the most obvious: inability to urinate and painful palpable bladder. However, pain may be absent in women who had an epidural or it can be mistaken by caesarean wound pain. Some patients have overflow incontinence due to overdistended bladder and some patients are asymptomatic. [13] Chronic urinary retention with incomplete voiding of bladder in the postpartum present with [14]: - difficult initiation of voiding after birth - the sensation of bladder fullness after voiding - frequent urination with small volumes - dribbling urine after voiding

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© Filodiritto Editore - Proceedings - nocturia Bladder distention can be felt by abdominal palpation, but volumes smaller than 300 ml are difficult to detect. Catheterisation is the best method to measure residual volumes in the postpartum, but it can be uncomfortable for the patient and it increases the risk of urinary tract infection. Bladder ultrasound is useful and non-invasive, but once a significant residual volume is detected, it should be confirmed by catheterisation. [15]

Bladder care management for vaginal delivery Intrapartum bladder care is very important, as it is the first step to prevent urinary dysfunction. There are no universally accepted standard protocols described in the literature, but most practitioners encourage bladder emptying every 4 hours in the first stage of labour. At the beginning of the active phase of the second stage, the bladder must be emptied. If a Foley catheter is used, the balloon must be deflated when the woman starts pushing. [16] Otherwise, urethral trauma may occur, as it did in case 3. Urethral tear may occur, with a visible balloon at inspection and urinary incontinence in the first hour post-delivery. Prior to any instrumental delivery, the bladder must be emptied either by an in and out catheter or with a Foley catheter. All catheters must be removed prior to operative delivery. Each void should be measured and recorded, as well as volume intake. Postpartum bladder care includes a key moment: timing of first void after delivery. This moment should be documented by the medical practitioner (nurse and doctor). After spontaneous vaginal delivery, the first void should occur in the first 4-6 hours after delivery. [17] The patient is encouraged to drink at least 1500 ml of fluids in 24 hours and to mobilise as soon as possible. For women who had an epidural or an operative delivery an indwelling catheter is recommended for at least 6 hours postpartum. In case of severe genital trauma some authors recommend an indwelling catheter for 24 hours following delivery. [18, 19]

Bladder care management for caesarean section In our hospital the Foley catheter is usually removed at 12 hours after caesarean section, unless the nurse is instructed by the surgeon to leave it in for a longer time. After catheter removal, the patient is encouraged to increase fluid intake, to move and urinate in the next 2-4 hours.

Management of suspected/confirmed postpartum urinary retention According to the WHO Technical Consultation on Postpartum and Postnatal Care, “every post-delivery woman should void within 6 hours; if not, catheterisation should be performed”. [20-22] Therefore, in our hospital, if the patient did not urinate within 6 hours she is asked to drink more fluids and she is provided more privacy and proper analgesia in order to obtain spontaneous micturition. Vulvar oedema must also be excluded. If voiding is not possible within 6 hours, despite proper hydration, an abdominal ultrasound scan followed by catheterisation is performed. A Foley catheter can be inserted for at least 24 hours if there is a residual volume >

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© Filodiritto Editore - Proceedings 150ml. If acute urinary retention is detected, a Foley catheter is immediately inserted in order to empty the bladder and it can be kept in place for 5 days. The patient is also checked for urinary tract infection. [23]

Postpartum urinary incontinence Urinary incontinence that occurs in the first hours or days after birth may be a sign of fistula or pelvic floor muscle or nerve injury. A Foley catheter should be inserted and fistula should be ruled out. [24] A urology specialist should be consulted. Incontinence can be present for a long time and it can impair the woman’s life. Multiparous women or those who had operative vaginal deliveries, or large babies are especially prone to developing pelvic floor muscle rupture, anal and vaginal fistulae cystocele, rectocele, vaginal prolapse, anal incontinence. [25] Therefore, we recommend surgical treatment of such pathology.

Conclusion Urinary dysfunction in the postpartum period can occur in any patient despite suggested risk factors. Intrapartum bladder care and prevention of postpartum urinary retention are very important in order to prevent acute bladder distention and to avoid permanent bladder and urinary tract damage. The lack of protocols can lead to a poor management of cases. Therefore, we consider useful a better standardization of procedures in order to being able to recognise the problems and to provide proper treatment.

REFERENCES 1. Carley, M. E., Carley, J. M., Vasdev, G., Lesnick, T. G., Webb, M. J., Ramin, K. D., & Lee, R. A. (2002). Factors that are associated with clinically overt postpartum urinary retention after vaginal delivery. American journal of obstetrics and gynecology, 187(2), 430-433. 2. Yip, S. K., Sahota, D., Pang, M. W., & Chang, A. (2004). Postpartum urinary retention. Acta obstetricia et gynecologica Scandinavica, 83(10), 881-891. 3. Rizvi, R. M., Z. S. Khan, and Z. Khan. «Diagnosis and management of postpartum urinary retention.» International Journal of Gynecology & Obstetrics 91.1 (2005): 71-72. 4. Haylen, Bernard T., et al. «An International Urogynecological Association (IUGA)/ International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction». International urogynecology journal 21.1 (2010): 5-26. 5. Lim, Jeanette L. «Post partum voiding dysfunction and urinary retention”. Australian and New Zealand Journal of Obstetrics and Gynaecology 50.6 (2010): 502-505. 6. WHO - Postpartum care of the mother and newborn: a practical guide. Maternal and newborn health. 7. Brătilă E., Vlădăreanu S, Berceanu C, Cîrstoiu M. et al., “Rolul sarcinii și al nașterii în apariţia tulburărilor de statică pelvică”. Revista Ginecologia.ro Anul III, Nr.10, (4/2015), pg. 28-33, ISSN 2344 – 2301, ISSN – L 2344 – 2301. 8. Brătilă E., Vlădăreanu S, Berceanu C, Cîrstoiu M.-The anatomy of urinary continence in women Revista Ginecologia.ro Anul III, Nr. 10, (4/2015), pg. 45-51, ISSN 2344 – 2301, ISSN – L 2344 – 2301.

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© Filodiritto Editore - Proceedings 9. Saultz, John W., William L. Toffler, and Janette Y. Shackles. “Postpartum urinary retention”. The Journal of the American Board of Family Practice 4.5 (1991): 341-344. 10. Teo, Roderick, et al. “Clinically overt postpartum urinary retention after vaginal delivery: a retrospective case-control study”. International Urogynecology Journal 18.5 (2007): 521-524. 11. Bollard, Ruth C., et al. “Anal Sphincter Injury, Fecal and Urinary Incontinence”. Diseases of the colon & rectum 46.8 (2003): 1083-1088. 12. Tan, Jo-Lynn, Tracy Ruane, and Margaret Sherburn. “The role of physiotherapy after obstetric anal sphincter injury: An overview of current clinical practice”. Australian and New Zealand Continence Journal, The 19.1 (2013): 6. 13. Liang, C. C., et al. “Postpartum urinary retention after cesarean delivery”. International Journal of Gynecology & Obstetrics 99.3 (2007): 229-232. 14. Kekre, Aruna N., et al. “Postpartum urinary retention after vaginal delivery”. International Journal of Gynecology & Obstetrics 112.2 (2011): 112-115. 15. Persson, Jan, Pål Wølner-Hanssen, and Hakan Rydhstroem. “Obstetric Risk Factors for Stress Urinary Incontinence: A Population Based Study”. Obstetrics & Gynecology 96.3 (2000): 440-445. 16. Mulder, F. E. M., et al. “Postpartum urinary retention: a systematic review of adverse effects and management”. International urogynecology journal 25.12 (2014): 1605-1612. 17. Rortveit, Guri, et al. “Urinary incontinence after vaginal delivery or cesarean section”. New England Journal of Medicine 348.10 (2003): 900-907. 18. Østergaard, Jeanett, Jens Langhoff-Roos, and L. M. Møller. «[Postpartum urinary retention]». Ugeskrift for laeger 172.7 (2010): 528-533. 19. Basson, Jennifer, C. L. E. Van der Walt, and Chris F. Heyns. «Urinary retention in women». Continuing Medical Education 31.5 (2012): 182-184. 20. MacLean, Allan B., Linda Cardozo, and Allan B. MacLean, eds. Incontinence in women. RCOG Press, 2002. 21. National Collaborating Centre for Primary Care (UK. «Postnatal care: routine postnatal care of women and their babies». (2006). 22. World Health Organization. «WHO technical consultation on postpartum and postnatal care». (2010). 23. Groutz, Asnat, et al. «Persistent postpartum urinary retention in contemporary obstetric practice. Definition, prevalence and clinical implications». The Journal of reproductive medicine 46.1 (2001): 44-48. 24. Ching Chung, Liang, et al. “Postpartum urinary retention: assessment of contributing factors and long term clinical impact”. Australian and New Zealand journal of obstetrics and gynaecology 42.4 (2002): 367-370. 25. Bratila, E., et al. “Recurrent Obstetric Rectovaginal Fistula Treated By Surgisis GraftCase Report”. Dan L. Dumitrascu, Piero Portincasa (2015): 59.

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Pelvic floor ultrasound – review Bohîlțea Roxana Elena1,2, Cîrstoiu Monica Mihaela1,2, Turcan Natalia2, Munteanu Octavian1,2, Bodean Oana2, Voicu Diana2, Baroș Alexandru1,2, Brătilă Elvira1,3 “Carol Davila” University of Medicine and Pharmacy, Bucharest Bucharest University Emergency Hospital 3 “St. Pantelimon” Clinic Emergency Hospital, Bucharest Correspondent author: Roxana Bohîlțea E-mail: [email protected] 1 2

Abstract It is possible that for the physician, clinical evaluation alone of women with pelvic organ prolapse complicated with urinary and fecal incontinence or defecation disorders to be insufficient for an appropriate assessment. The role of ultrasonography is currently limited around the investigation of pelvic floor disorders. Besides that, the sonography presents the advantage of a low cost, non-invasively, accessible and very much represents a part of general practice in obstetrics and gynecology spread universally. Insensible urine loss, persistent dysuria, symptoms of prolapse, obstructed defecation or fecal incontinence are just a few of indications for pelvic floor incontinence. Trough transrectal, transvaginal, transperineal/ translabial ultrasonography, functional and structural abnormalities like residual urine, detrusor wall thickness, bladder neck mobility, urethral integrity anterior, central and posterior compartment prolapse can be evaluated. By means of 2-dimensional pelvic floor ultrasound or, if its possible 3-/4-dimensional, the delivery related levator trauma can be easily diagnosed, this being the most important known etiologic factor for pelvic organ prolapse. Definitely, diagnosis by imaging is more reproducible that a clinical based one. Keywords: ultrasound, transperineal, pelvic prolapse

Introduction Ultrasound imaging represents one of the greatest revolution in medicine; it is used for medical purposes for several decades, having the advantage of safety when properly performed (1). One of the disadvantages is the operator-dependent status technology, a correct examination requiring an experience of a large variety of normal and abnormal examination. In gynecology, ultrasonography is used by routine, some of the main indication being evaluation of the menstrual cycle and abnormal uterine bleeding (endometrium, follicles), examination of the position of intrauterine device, assessment of a pelvic mass, confirmation if a suspected hydrosalpinx or adnexal abscess, evaluation of congenital uterine anomalies and screening for malignancy (2). Transvaginal sonography is preferential in gynecology being safe with no radiation, simple, cheap, easily accessible and provides high spatial and temporal resolutions. Translabial or transperineal ultrasound have and increasing tendency of use for the evaluation

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© Filodiritto Editore - Proceedings of the pelvic floor in course of diagnosis and for deciding an appropriate management of women with pelvic organ prolapse and urinary or fecal incontinence (3). Despite is mentioned clinical purposes, ultrasound is valuable also in research purposes. The role of ultrasonography is currently limited around the investigation of pelvic floor disorders of patients with previously surgical procedures who can be completed examined by ultrasound that help to see and understand pelvic modifications. Additional maneuvers (Valsalva, squeezing) performed during ultrasound examination helps to see the organs of the pelvis that are changing their normal position and also the grade of this abnormal condition (4). As respects the sonographic pelvic floor examination after a reconstructive surgery, the use is the correlation of various methods of reconstruction with the prevalence of reintervention. The etiology of pelvic flor disorders is not completely understood, however, deliveryrelated levator ani injury remains to be the main etiological factor for pelvic organ prolapse and recurrence after pelvic reconstructive surgery; an appropriate evaluation of levator ani anatomy and function can be provided only by pelvic ultrasonography (5). Recalling other uses of pelvic floor ultrasound, we mention the possibility of determining residual urine (pre and post-operatory); detrusor wall thickness; bladder neck mobility; urethral integrity, Also, diverse abnormal condition can be visualized and evaluated such as urethral diverticula, rectal intussusception, mesh dislodgment, and avulsion of the puborectalis muscle (5) (Fig 1, 2).

Fig. 1, 2 Recurrent central compartment pelvic organ prolapse, transperineal ultrasound

Indication for pelvic ultrasound In multiple cases, diagnosis by imaging is more reproducible than diagnosis by palpation; for example palpation of levator ani trauma requires considerable skills and teaching (6), ultrasound on the other part being simpler and easier to teach. Dietz HP, in his published review on pelvic floor ultrasound (4) suggests a series of 12 indication for performing pelvic floor imaging (4): 1. Recurrent urinary tract infections 2. Urgency, frequency, nocturia, and orurge urinary incontinence 3. Stress urinary incontinence 4. Insensible urine loss 5. Bladder-related pain 6. Persistent dysuria 7. Symptoms of voiding dysfunction

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© Filodiritto Editore - Proceedings 8. Symptoms of prolapse, ie, sensation oflump or dragging sensation 9. Symptoms of obstructed defecation, eg,straining at stool, chronic constipation,vaginal or perineal digitation, andsensation of incomplete bowel emptying 10. Fecal incontinence 11. Pelvic or vaginal pain afterantiincontinence or prolapse surgery 12. Vaginal discharge or bleeding afterantiincontinence or prolapse surgery

Examination technique Basic 2-dimensional translabial pelvic floor ultrasound requires a 3.5- to 6-MHz curved array transducer and a monochrome video printer. The position should be dorsal, with hips flexed and slightly abducted, imaging in standing position is also possible. Prior voiding is preferred, as an empty rectum. Visibility can be reduced by the poor hydration of tissues and by vaginal scars; obesity does not represent an inconvenient. The transducer should be placed in perfect contact with the labia without exerting pressure. A midsagittal view will include anteriorly the symphysis, the urethra and bladder neck, the vagina, cervix, rectum, and anal canal (4). Anterior compartment prolapse includes usually a cystocele. In this cases ultrasound is helpful in determining the bladder neck mobility and funneling of the internal urethral meatus, the impact of both this situation being urinary incontinence. Valsalva maneuver is used to evaluate the patients with urinary stress incontinence and also asymptomatic women; during the maneuver funneling of the internal urethral meatus may be observed (7). In other line, translabial ultrasound can detect foreign bodies or bladder tumors (8). Central compartment includes uterine prolapse, and usually is obvious clinical diagnosis; ultrasound for this compartment is used to assess the impact of an enlarged retroverse uterus with an implicit anteriorized cervix, explaining this way the symptoms of voiding dysfunctions. Pelvic floor ultrasound is beneficial in the assessment of the posterior compartment prolapse, respectively rectocele. Colorectal surgeons use this technique as an initial investigation of women with defecatory symptoms; studies show that ultrasound is much better tolerated than defecation proctography (9, 10). A defect of the rectovaginal septum can be observed on ultrasound exam; these patients are the candidates for a defect-specific rectocele repair as first introduced by Cullen Richardson (11).

Clinical impact With the help of pelvic floor ultrasound, clinical data and studies results were objectified, confirming that vaginal delivery is reflected in major morphologic abnormalities of levator structure and function (12). Levator defects are associated with cystocele recurrence after anterior repair, hysterectomy and anti-incontinence and prolapse surgery according to Dietz HP et al (13) and Model A. et al (14). Palpation of these defects is possible but difficult, hard interpretable and requires an intense special training, ultrasound being more reproducible, accessible and easily learned in these areas (15). Hiatal distention on Valsalva > 25 cm2 is defined as “ballooning” associated with prolapse recurrence after rectocele repair (16); it can be measured in axial plane, the degree of distention being strongly associated with prolapse and symptoms of prolapse (17). Another important fact resulted from the use of ultrasonography in pelvic floor disorders diagnosis is the possibility of comparing pre and post-operative data in patients with recurrent prolapse, helping to understand the impact of certain surgical procedures, influencing the future management strategies (4).

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© Filodiritto Editore - Proceedings REFERENCES 1. Phillips RA, Stratmeyer ME, Harris GR. Safety and U.S. Regulatory considerations in the nonclinical use of medical ultrasound devices. Ultrasound Med Biol 2010; 36:1224. 2. AIUM Practice Guideline for the Performance of Pelvic Ultrasound Examinations. American Institute of Ultrasound in Medicine. Laurel, MD 2009. 3. Densor L, Shobeiri SA. Three-dimensional endovaginal sonography of synthetic implanted materials in the female pelvic floor. J Ultrasound Med 2014 Mar; 33: 221-229. 4. Dietz HP. Pelvic floor ultrasound: a review. Am J Obstet Gynecol 2010 Apr; 202: 321334. 5. Shek KL, Dietz HP. Pelvic floor ultrasonography: an update. Minerva Ginecol. 2013 Feb;65(1):1-20. 6. Dietz HP, Shek KL. Validity and reproducibil-ity of the digital detection of levator trauma. IntUrogynecol J Pelvic Floor Dysfunct 2008; 19: 1097-101. 7. Schaer GN, Perucchini D, Munz E,Peschers U, Koechli OR, DeLancey JO. Sono-graphic evaluation of the bladder neck in conti-nent and stress-incontinent women. Obstet Gynecol 1999; 93: 412-6. 8. Oerno A, Dietz H. Levator co-activation is asignificant confounder of pelvic organ descenton Valsalva maneuver. Ultrasound Obstet Gy-necol 2007; 30: 346-50. 9. Beer-Gabel M, Teshler M, Schechtman E,Zbar AP. Dynamic transperineal ultrasound vsdefecography in patients with evacuatory diffi-culty: a pilot study. Int J Colorectal Dis 2004; 19: 60-7. 10. Perniola G, Shek K, Chong C, Chew S,Cartmill J, Dietz H. Defecation proctographyand translabial ultrasound in the investigation ofdefecatory disorders. Ultrasound Obstet Gynecol 2008; 31: 567-71. 11. Richardson AC. The rectovaginal septumrevisited: its relationship to rectocele and its importance in rectocele repair. Clinical Ob Gyn 1993; 36:976-83. 12. Gainey HL. Post-partum observation of pel-vic tissue damage. Am J Obstet Gynecol 1943; 46: 457-66. 13. Dietz HP, Chantarasorn V, Shek KL. Avul-sion of the puborectalis muscle is a risk factorfor recurrence after anterior repair. Int Urogy-necol J Pelvic Floor Dysfunct 2009;20(suppl 2): S172-3. 14. Model A, Shek KL, Dietz HP. Do levator de-fects increase the risk of prolapse recurrenceafter pelvic floor surgery? Neurourol Urodyn2009;28(suppl 1): 888-9. 15. Weinstein MM, Pretorius D, Nager CW, Mit-tal R. Inter-rater reliability of pelvic floor muscleimaging abnormalities with 3D ultrasound. Ul-trasound Obstet Gynecol 2007; 30: 538. 16. Barry C, Dietz H, Lim Y, Rane A. A short-term independent audit of mesh repair for thetreatment of rectocele in women, using 3-di-mensional volume ultrasound: a pilot study.Aust N Z Continence J 2006;12:94-9. 17. De Leon J, Steensma AB, Shek C, DietzHP. Ballooning: how to define abnormal distensibility of the levator hiatus. Ultrasound ObstetGynecol 2007; 30: 447.

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Mechanism and Risk Factors for Pelvic Organ Prolapse - Review Bohîlțea Roxana Elena1,2, Cîrstoiu Monica Mihaela1,2, Turcan Natalia2, Bohîlțea Laurențiu Camil1, Munteanu Octavian1,2, Bodean Oana2, Voicu Diana2, Baroș Alexandru1,2, Brătilă Elvira1,3 “Carol Davila” University of Medicine and Pharmacy, Bucharest Bucharest University Emergency Hospital 3 “St. Pantelimon” Clinic Emergency Hospital, Bucharest Correspondent author: Roxana Bohîlțea E-mail: [email protected] 1 2

Abstract Female pelvic organ prolapse refers to a loss of fibromuscular support of the pelvic viscera resulting the protrusion of the pelvic organs into the vaginal canal. These are worldwide problems that affect the quality of life of millions of women. The mortality due to this condition is rare, but symptomatic form is common, 11% of all women requiring at least one corrective surgical procedure. Thanks to standardized evaluation method, pelvic organ prolapse quantification system, the distribution of the severity of this condition among general population is highly studied. Through this article we intend to review the latest specialized literature discussing the clinical presentation, pathophysiology, evaluation and management of pelvic organ prolapse. Also, we proposed to summarize the risk factors leading to pelvic organ prolapse such as age, vaginal childbirth and obesity, diabetes, connective tissue disorders, neurological diseases and genetic predisposition to the development of pelvic organ prolapse. Keywords: pelvic prolapse, risk factors, connective tissue disorder

Introduction Pelvic organ prolapse refers to the herniation of the pelvic organs into the vaginal canal and represents a global health problem (1). As the proportion of elderly women in the population increases, the prevalence of pelvic organ prolapses increases exponentially, and this injury continues to be commonly encountered by the gynecologist. Usually this pathology presents together with urinary incontinence and/or fecal incontinence, the association of these three conditions being summarized as pelvic floor disorders. Being a common condition, affecting millions of women, the patients experience various symptoms that impact significantly the life quality (2). Pelvic Floor Lifespan Model elaborated by DeLancey et al. (3) comprises the description of the functionality of the female pelvic floor across a woman’s lifespan. During life time, three functionality phases of a woman’s pelvic floor are described; phase 1 characterized by the period predisposing factors and the maximum potential of the pelvic floor muscle; phase 2, characterized by the “inciting factors” added secondary to vaginal birth related injuries and also the ability of the woman’s recovery; phase 3 or “intervening factors”, refers to the natural

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© Filodiritto Editore - Proceedings course of the pelvic floor muscle atrophy that accompanies physiological aging. Reported data affirm that about 50% of parous women develop symptoms related to pelvic organ prolapse (4) and the risk of the necessity of surgical correction is 11% (5). The reflection of the high prevalence of the pelvic organ prolapse is represented by the important annual costs used in this direction. The surgical repair of prolapse was the most common surgical procedure performed in women older than 70 years over several years (6). In course of time reconstructive surgery of pelvic organ prolapse was improved, but the basic principle remains the re-suspension of the vaginal apex and anterior and posterior vaginal wall. Despite important health technology evolution, the failure rate of the reconstructive surgery is high, estimated incidence of women that require re-intervention is estimated to be about 30%, according to Olsen AL et al. (7).

Prevalence Due to the fact that pelvic organ prolapse may present symptomatic and in equal proportion asymptomatic and also it is impossible to determine how many women with pelvic organ prolapse do not presents himself to a gynecologist, the real prevalence of this condition remains difficult to specify. National Health and Nutrition Examination Survey (NHANES) of the United States conducted a cross-sectional study including 1961 women aged 20 to 80. The used method was just subjective, with the purpose to determine the prevalence of symptomatic pelvic organ prolapse by an interview, without using clinical examination. Reported prevalence was 2.9% (8), afterwards, this incidence was underreported, with the notice that the study was able to identify only women with advanced prolapse. An incidence of 50% for symptomatic pelvic organ prolapse, among parous women was worldwide approved (9). An indirect value for the prevalence of the pelvic organ prolapse is suggested by the number of women who undergo surgical prolapse repair, noticing here that annually approximatively 200.000 reconstructive surgical procedures are performed only in the USA (10). Citing data of other studies, we mention a number of 200.000 of correction procedures performed annually for this pathology (11), with the maximum incidence at the age 80 to 85. The percentage of re-intervention for this injury is reported to be 30% (12).

Risk factors Risk factors leading to pelvic organ prolapse comply with the same factors that lead to the development of anterior and posterior vaginal wall prolapse. The etiology is multifactorial; forwards the main risk factors are enumerated considering their incidence. 1. Number of vaginal deliveries (13) and related pelvic floor trauma. The causal role of parity is sustained by the fact that the incidence of pelvic floor disorders increase directly proportional with the number of vaginal delivery, it has been estimated that 75% of pelvic organ prolapses can have the main risk factor the pregnancy and childbirth (14). Table 1 comprise the most representative studies for illustrate de impact of parity and age among nulliparous and parous women. Study Nulliparous women Parous women National survey of United Pelvic organ prolapse 0.6% Pelvic organ prolapse: one States nonpregnant women birth (2.5%); two births (3.7%; and three or more births (3.8%). Norwegian Study on urinary incontinence 14% urinary incontinence 22 to premenopausal women 34%

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© Filodiritto Editore - Proceedings Oxford Family Planning study

the risk of hospital admission for pelvic organ prolapse surgery increased markedly for the first (fourfold) and second (eightfold) birth, and then increased less rapidly for subsequent births (third: ninefold; fourth: 10-fold) Table 1. Studies regarding the impact of parity on pelvic floor diseases (15, 16, 17)

2. Previous hysterectomy, objectified by a case control-stud, which included 160.000 women with a previous hysterectomy that were more predisposed to require a subsequent pelvic floor repair intervention comparing to the control cases (14). 3. Obesity was correlated with the pelvic floor injuries, based on the increased abdominal pressure that leads to structural damage and neurological dysfunctions predisposing to pelvic organ prolapse (18). According to Prolapse Quantification system (POP-Q) BMI is not correlated with pelvic organ prolapse severity (19), data regarding this hypothesis show no significant difference in the stage of pelvic organ prolapse between obese and women with a normal BMI (20). 4. Ageing. The impact of advancing age on the prevalence of pelvic organ prolapse was objectified by the study of Swift S et al on 1000 women presenting for an annual gynecological exam, the results showed that every 10 years of age conferred an increased risk of prolapse of 40% (21). 5. Levator ani avulsion. The levator ani complex has an incontestable important role as pelvic support and also as keeping proper orientation of the female pelvic organs. This function requires an intact qualitative and functional nervous innervation. Parturition may include the injury of the described complex and implicitly an inappropriate functionality of it.

Anatomy and mechanism of the pelvic organ prolapse The anatomy of the female pelvic floor favors the downward of the pelvic organs if the presented risk factors are present. The etiology is most commonly related to connective tissue, neural, and/or neural defects in the normal structural support (21). Normal anterior wall support includes levator ani muscles (pubococcygeus, puborectalis, and iliococcygeus) and also a layer of dense fibrous musculoconnective tissue (22). Uterosacral and cardinal ligaments are formed by the condensation of the endopelvic fascia, and have an important role in the stabilization of the pelvic organ in the correct position (23). On the other side, the bladder does not have an original support; the only anatomic resistance structure is the vagina, on which the bladder overlies. There are three levels of vaginal support that are connected by the endopelvic fascia. The first level is represented by the uterosacral/cardinal ligament complex and is the first line support of the uterus and upper vagina, the loss of this level is reflected trough the prolapse of the uterus and/or the vagina. Second level, represented by paravaginal attachments, the length of the vagina to the superior fascia of the levator ani muscle and the arcus tendineus fascia pelvis; the injury of this levels contributes to anterior vaginal wall prolapse. Level three is constitute by perineal body, perineal membrane, and superficial and deep perineal muscles, which injury can result in a posterior prolapse (rectocele) (24).

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© Filodiritto Editore - Proceedings Clinical manifestations Usually the symptoms are related specifically to the prolapsed structures, main affected functions are urinary, defecatory or sexual (25). Symptoms are related to the position and, interesting not correlated to the stage of the prolapse (26). An important percentage of women with pelvic organ prolapse present asymptomatic, and no treatment in these cases is required. The symptoms that often accompany this condition are vaginal or pelvic pressure, the sensation of a vaginal bulge or a structure that falls out of the vagina (Fig 1, 2). There are cases when the patient describes the structure that is seen beyond the introitus; ulceration and bleeding may result in this situation. Stage I or II prolapse includes frequently the affection of the bladder with the incontestable appearance of the urinary incontinence (27). In the case of advanced anterior prolapse, an increased difficulty voiding may be developed; the patient could relate the necessity of changing the position or manually reduce the prolapse to urinate. Other urinary symptoms related to pelvic organ prolapse are enuresis, incontinence with sexual intercourse, dysuria (28).

Fig. 1, 2 Pelvic organs prolapse grade 4 Defecatory symptoms appear if any posterior compartment is affected: rectocele, enterocele, sigmoidocele, perineocele, internal rectal prolapse (intussusception), or full mucosal rectal prolapse. On sexual function, prolapse of pelvic organ associates adverse effects on orgasm or sexual satisfaction (29). The diagnosis of pelvic organ prolapse is clinically next to a detailed anamnesis. The staging is accorded to the Society of Gynecologic Surgeons, American Urogynecologic Society, and International Continence Society, the Pelvic Organ Prolapse Quantitation (POPQ) system.

Management The treatment is indicated for patient with urinary, defecation and sexual dysfunction, or symptoms of prolapse. Expectant management is preferred in asymptomatic cases or the patient tolerates their symptoms and chose to avoid the treatment (30). Conservative management has the advantage of avoiding the surgical complication that may appear and the disadvantage of the necessity of ongoing maintenance. Vaginal pessary is a silicone device which supports the pelvic organs; they must be removed and cleaned regularly. Randomized trials reported improved pelvic organ prolapse symptoms after pelvic floor muscle training and lifestyle

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© Filodiritto Editore - Proceedings advice program (31). Estrogen therapy was evaluated by only three trails whit the unanimous result that the estrogenic therapy focuses mostly on vaginal atrophy and less on the prolapse itself (32). For all symptomatic women with pelvic organ prolapse, surgical treatment is recommended. The approach may be abdominal or vaginal and could or not include graft materials. As mentioned above, the reoperation rate is high, evaluated on up to 30%; the prognosis depending on the severity of symptoms, extent of the prolapse, physician experience, and patient expectations (33).

REFERENCES 1. Bump RC, Norton PA. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am. 1998; 25: 723–746. 2. Lowder JL, Ghetti C, Nikolajski C, et al. Body image perceptions in women with pelvic organ prolapse: a qualitative study. Am J Obstet Gynecol 2011; 204:441.e1. 3. DeLancey JOL, Kane Low L, Miller JM, et al. Graphic integration of causal factors of pelvic floor disorders: an integrated life span model. Am J Obstet Gynecol. 2008; 199: 610.e1–5. 4. Subak LL, Waetjen LE, van den Eeden S, Thom DH, Vittinghoff E, Brown JS (2001) Cost of pelvic organ prolapse surgery in the United States. Obstet Gynecol 98(4):646–651. 5. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL (1997) Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 89(4):501–506. 6. Oliphant SS, Jones KA, Wang L, et al. Trends over time with commonly performed obstetric and gynecologic inpatient procedures. Obstet Gynecol 2010; 116:926. 7. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL (1997) Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 89:501–506. 8. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008; 300:1311. 9. LL Subak, LE Waetjen, S van den Eeden, DH Thom, E Vittinghoff, JS Brown. Cost of pelvic organ prolapse surgery in the United States. Obstet Gynecol 2001; 98: 646–65. 10. Jones KA, Shepherd JP, Oliphant SS, et al. Trends in inpatient prolapse procedures in the United States, 1979-2006. Am J Obstet Gynecol 2010; 202: 501.e1. 11. Boyles SH, Weber AM, Meyn L. Procedures for pelvic organ prolapse in the United States, 1979-1997. Am J Obstet Gynecol 2003; 188:108. 12. Olsen AL, Smith VJ, Bergstrom JO, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997; 89:501. 13. Blandon RE, Bharucha AE, Melton LJ 3rd, et al. Incidence of pelvic floor repair after hysterectomy: A population-based cohort study. Am J Obstet Gynecol 2007; 197: 664.e1. 14. Elvira Brătilă, Simona Vlădăreanu, Costin Berceanu, Monica Cîrstoiu, Claudia Mehedințu, Diana Comandașu, Mihai Mitran. Rolul sarcinii și al nașterii în apariţia tulburărilor de statică pelvică. Revista Ginecologia.ro; 2015 10(4): 28-33 15. Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol 1997; 104:579. 16. Rortveit G, Hannestad YS, Daltveit AK, Hunskaar S. Age- and type-dependent effects of parity on urinary incontinence: the Norwegian EPINCONT study. Obstet Gynecol 2001;

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© Filodiritto Editore - Proceedings 98:1004. 17. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008; 300:1311. 18. Altman D, Falconer C, Cnattingius S, Granath F. Pelvic organ prolapse surgery following hysterectomy on benign indications. Am J Obstet Gynecol 2008; 198: 572. e1. 19. Kesharvarz H, Hillis SD, Kieke BA, Marchbanks PA. Hysterectomy surveillance—United States 1994–1999. MMWR Surveill Summ 2002, 51 (SS05): 1–8. 20. RC Bump, PA Norton. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am 1998, 25: 723–746. 21. Klauss Goeshen, Peter Petros, Andrei Funogea, Elvira Brătilă, Petre Brătilă, Monica Cîrstoiu. Planșeul pelvic la femeie. Anatomia funcțională, diagnostic și tratament - în acord cu teoria integrativa. Editura Universitara «Carol Davila Bucuresti», Bucuresti, 2016, ISBN 978-973- 708-894-9. 22. Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford family planning association study, BJOG 1997, 104: 579–585. 23. Swift S, Woodman P, O’Boyle A, et al. Pelvic Organ Support Study (POSST): the distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. Am J Obstet Gynecol 2005; 192:795. 24. Boyles SH, Edwards SR. Repair of the anterior vaginal compartment. Clin Obstet Gynecol 2005; 48:682. 25. Stepp KJ, Walters MD. Anatomy of the lower urinary tract, rectum and pelvic floor. In: Urogynecology and Reconstructive Surgery, 3, Walters M, Karram M (Eds), Mosby, Philadelphia 2007: 24. 26. Percy JP, Neill ME, Swash M, Parks AG. Electrophysiological study of motor nerve supply of pelvic floor. Lancet 1981; 1:16. 27. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet 2007; 369:1027. 28. Kahn MA, Breitkopf CR, Valley MT, et al. Pelvic Organ Support Study (POSST) and bowel symptoms: straining at stool is associated with perineal and anterior vaginal descent in a general gynecologic population. Am J Obstet Gynecol 2005; 192:1516. 29. Elvira Brătilă. Complicații uroginecologice în chirurgia vaginală. Editura Universitara «Carol Davila Bucuresti», Bucuresti, 2016, ISBN 978-973- 708-902-1. 30. Tok EC, Yasa O, Ertunc D, et al. The effect of pelvic organ prolapse on sexual function in a general cohort of women. J Sex Med 2010; 7:3957. 31. Braekken IH, Majida M, Engh ME, Bø K. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. Am J Obstet Gynecol 2010; 203:170.e1. 32. Weber MA, Kleijn MH, Langendam M, et al. Local Oestrogen for Pelvic Floor Disorders: A Systematic Review. PLoS One 2015; 10:e0136265. 33. Lavelle RS, Christie AL, Alhalabi F, Zimmern PE. Risk of Prolapse Recurrence after Native Tissue Anterior Vaginal Suspension Procedure with Intermediate to Long-Term Followup. J Urol 2016; 195:1014.

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Stress urinary incontinence (sui) due to causes other than parturition BOȚ Mihaela1, VLĂDĂREANU Radu1, VLĂDĂREANU Simona1, ZVÂNCĂ Mona1, PETCA Aida1 ROMANIA, Obstetrics - Gynaecology and Neonatology Department, Elias University Emergency Hospital, Bucharest, University of Medicine and Pharmacy Carol Davila E-mails: [email protected], [email protected], [email protected], [email protected] gmail.com

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Abstract Stress urinary incontinence represents involuntary loss or leakage of urine from the urethra during the increase in intra-abdominal pressure, thus significantly affecting the patient’s wellbeing on a social, psychological and physical level. With population ageing, the incidence of this condition will grow and will have a bigger and bigger impact on the deterioration of quality of life. The prevalence of this condition is largely different depending on the study, ranging from 20% to 50%. The prevalence of the condition increases with age, starting from 6,5% in 20/25 year-old women, until 35-50% in 80 year-old women, thus menopausal women, even nulliparous ones, manifest SUI. Although nulliparous patients or the ones who had a C section are not included in the SUI risk group, a series of women show this condition as a result of the alteration of the pelvic floor statics during pregnancy. An excessive body weight, with a high body mass index (BMI), is one of the important risk factors in urinary incontinence. The bigger BMI is, the more frequent urinary incontinence symptoms are. Female patients with professions which involve intense physical effort or athletes may be affected by this pathology, too. The most frequent activities which can cause involuntary loss of urine have been reported in women who are involved in high impact sports such as jumps and running (athletic sports).

Introduction In women, urinary incontinence represents involuntary loss or leakage of urine from the urethra during the increase in the intra-abdominal pressure, after coughing, sneezing, laughing or heavy lifting and which is not accompanied by the sensation of urinary urge [1]. Usually, involuntary loss of urine is not accompanied by any other symptoms, such as a painful urge, pain, a burning sensation in the urethra or polyuria [1, 2]. Stress urinary incontinence largely affects the patient’s well-being on a social, psychological and physical level and has a negative impact on family life and health care services [3]. We see female patients with a low self-esteem, depression and sexual dysfunctions [4]. With population ageing, the incidence of this condition will grow to have a bigger and bigger effect on the deterioration of quality of life [1].

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© Filodiritto Editore - Proceedings Menopause The 20th century brought about a longer life span and, as a consequence, a decrease of the quality of life of the elderly. The age of menopause is, without any change, assessed to be approximately 50, therefore, considering the fact that women live more nowadays, they spend one third of their life during postmenopausal period [5]. Ageing symptoms of urogenital system occur in approximately 50% of women. The prevalence of the condition increases with age, starting from 6,5% in 20-25 year-old women [5] to 35-50% [5, 7] in women older than 80. A higher incidence in white women and the fact that nulliparous females show this condition too are elements which plead in favour of involving the constitutional factor, along with the well-known theories trying to explain stress urinary incontinence as a multi-parity, estrogenic deficiency through its atrophying effect upon venous plexuses. The exact prevalence of urinary incontinence in women is difficult to assess, considering that a vast part of the affected population does not report the condition out of socio-cultural reasons. Thus, it largely fluctuates depending on each study, ranging from 20% to 50%. The incidence of urinary incontinence in these female patients is double in the 50 - 54 age group as opposed to the one of females younger than 40 years old because the urogenital atrophy caused by estrogenic deficiency is an established component of urinary incontinence pathogeny, although randomised studies failed to prove any association. Stress urinary incontinence can worsen during the week before the menstrual period. In that moment, the reduced level of estrogen may cause a decreased pressure of the periurethral muscular layer, increasing the chances of involuntary loss of urine. Similarly, due to the decreased level of estrogen, the same mechanism is involved in the post-menopausal period [8] too. The relationship between the urinary continence/incontinence and level of hormones is confirmed by the fact that cyclical hormonal changes happening during menstrual cycle determine changes in the parameters of the urodynamic test [2]. Estrogens affect the mechanism of urinary continence by increasing the urethral resistance, increasing the sensory threshold of the urinary bladder, as well as increasing the sensitivity of alpha receptors in the urethral smooth muscle [2, 5]. Probably, estrogen receptors are to some extent responsible even for the central control of micturition [2]. The decrease of the serum estrogen level produces changes on all these levels. It is presumed that the functioning of the structures involved in the control of micturition in SUI may become less efficient with advancing age and might become the groundwork for estrogen therapy [1, 5, 9] whenever there are no clear contraindications. The integrity of levator ani muscle is unanimously accepted as being very important in the urinary continence [10, 11] and, as it is basically a striated muscle is subject to change with ageing and time, e.g. the loss of its mass, known as sarcopenia [12].

Nulliparous women and patients after Caesarean sections Although nulliparous patients or the ones who underwent a C-section are not included in the risk group, a series of women are affected by this condition. SUI incidence is by 5,7% higher after giving birth by C-section compared to nulliparous women and by 8,4% higher after vaginal deliveries compared to deliveries by C-section [13]. According to EPINCONT Study [13], there is no significant difference in the incontinence prevalence rate in women who

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© Filodiritto Editore - Proceedings underwent an elective C-section and the ones who had an emergency C-section. Vaginal delivery is an established risk factor for urinary incontinence among young and middle-aged women. It has been suggested that vaginal delivery is the main contributing factor because of the deterioration of the muscle tissue or the nervous endings in the pelvic floor. Nevertheless, pregnancy itself may cause mechanic or/and hormonal changes, which determine urinary incontinence [14, 15]. Therefore, stress urinary incontinence in women who gave birth by C-section is a result of the alteration of the pelvic floor statics during pregnancy. Even if these results are relevant for advising patients to choose C-sections, the results should not be used as an argument for the increased use of Caesarean delivery. Stress urinary incontinence in nulliparous patients can also be seen in patients with an increased intra-abdominal pressure as a result of obesity, chronic obstructive pulmonary diseases or asthma, which involve repeated and long coughing episodes or chronic constipation [6].

Overweight An excessive body weight, with a high body mass index (BMI), is one of the important risk factors of urinary incontinence. The higher the BMI, the more frequent urinary incontinence symptoms are. Asymmetric obesity (BMI > 30 kg/m2) with an excess of adipose tissue on the abdominal level determines involuntary urine loss 4-5 times more frequently than in women with a normal body weight [16]. The increase in the intra-abdominal pressure, which coincides with a high BMI, leads to a proportionally higher intravesical pressure, which overcomes the urethral closure pressure and determines urinary incontinence. Obesity, which is an important etiologic factor in SUI, nevertheless does not influence the urodynamic parameters [17]. Although the role of obesity in the complex etiopathogenesis of urinary incontinence has not been fully acknowledged or studied, there is no doubt that weight loss often leads to alleviation of symptoms, an improvement of micturition control, and an improvement of quality of life, too [18]. This fact is best evidenced during weight loss obtained through a diet programme or bariatric surgery, when stress urinary symptoms are alleviated [19].

Intense physical activity Patients with professions which involve intense physical effort or athletes may be affected too by this pathology, but incontinence is many times underreported [20]. In high performance athletes, stress incontinence can occur during playing any sport which involves effort, sudden and repeated increase and decrease of intraabdominal pressure, straining the resistance of perineal floor [8]. Urinary incontinence prevalence ranges from 28% to 80% among sportswomen. The most frequent activities susceptible of provoking involuntary loss of urine are being reported in women involved in high impact sports 20 such as jumps and running (athletic sports). In these women, involuntary urine loss can occur outside the training or the competing programme too, during daily or recreational activities [20]. 92,5% of the female athletes who admit having SUI state that the involuntary urine loss occurs rather during training opposed to 51, 2 during competition (probably due to increased catecholamine levels, which determine the urethral alpha-receptors to maintain its closure) [21].

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© Filodiritto Editore - Proceedings The thickness of the ani levator and ouborectalis muscles was measured by means of nuclear magnetic resonance imaging [22], while pubovesical muscle was measured by means of translabial ultrasound in female athletes and the bladder neck descent was observed, along with the hypertrophy of the ani levator muscle, with a larger hiatus [23]. Intensive trainings led to the mentioned morphological changes, but also to compensatory hyper-distensibility functional changes in female athletes. These changes corroborated with a decrease of collagen production in their skin and periurethral tissue and a decreased ratio of type I/type III collagen 24, 25 in some women explain the stress urinary incontinence. Outside high performance sports activities, 8,5% young women between 16 and 20 years old have reported involuntary urine loss during physical education classes [26]. Also, female smokers or the ones that use caffeine-based preparations or medicines show an increased incidence of this condition [3].

Treatment Urinary incontinence treatment should start with treating determinant or contributing factors such as: eating disorders, genital atrophy, smoking, obesity and a decreasing intake of caffeine. Athletes should avoid excessive fluid intake before trainings and competitions, but at the same time they should avoid dehydration [27]. Physical training for strengthening the pelvic floor muscle is an important component in preventing and treating urinary incontinence, having no known side effects. Therefore, it should be chosen as the first therapeutic approach, especially in nulliparous women [28]. Cochrane established after a review of 17 studies that for the women unable to do physical exercises, the use of vaginal cones or local electrostimulation is equally efficient [29]. Along with anticholinergic medication30, which is used in treating SUI, other substances such as imipramine can improve quality of life of women who suffer from urinary incontinence, but they have not been tested for athletes [31]. Adrenergic agonists such as Pseudoephedrine hydrochloride are efficient, but they may have usually rare and minor side effects, but also serious ones, such as arterial hypertension and cardiac arrhythmia. Moreover, they are forbidden to elite athletes [32]. Duloxetine, a serotonin-norepinephrine reuptake inhibitor, can significantly improve the quality of life for stress urinary incontinence patients. Duloxetine is frequently associated with nausea, which may cause non-compliance with this treatment [33]. Indication for surgical treatment is considered when the involuntary urine loss is very upsetting for patients, the incontinence has been under a gynaecologist observation during clinical examination, its causes have been properly assessed and the conservative therapy failed [31]. Surgical treatments include pubovaginal or transobturator midurethral sling procedures, retropubic suspension or periurethral injection therapy. Surgical treatment is not indicated for young women, including elite athletes who are continent during regular, daily activities and have incontinence only during physical trainings [34]. Stem-cell therapy could be the next step in treating urinary incontinence. In years to come, it will enable a broadening of indications for SUI women with associated comorbidities, who cannot undergo surgical treatment. Being administered in the periurethral region, stem cells contribute to increasing the urethral occlusion pressure, thus restoring normal urinary continence [35].

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© Filodiritto Editore - Proceedings Conclusions Stothers and colab [36] show that age has the most important effect in the occurrence of urinary incontinence. Obesity significantly contributes to an increased prevalence of this condition, while weight loss is highly important in alleviating SUI symptoms. The objective of this article was to present this difficult clinical problem and to assess the occurrence frequency of stress urinary incontinence, with consideration of the most frequent risk factor of this condition in the group of nulliparous, perimenopausal women with SUI after C-section delivery, or athletes without morphological pelvi-genital statics disorders.

REFERENCES 1. Kwias Z. Wysiłkowe nietrzymanie moczu u kobiet jako problem kliniczny, leczniczy i społeczny. (Stress urinary incontinence as a clinical therapeutic and social problem) Przew Lek. 2000; 10: 32-37 (in Polish). 2. Ahn KH, Kim T, Hur JY, Kim SH, Lee KW, Kim YT. Relationship between serum estradiol and follicle-stimulating hormone levels and urodynamic results in women with stress urinary incontinence. Int Urogynecol J. 2011; 22(6): 731-7. 3. Nicolae Crisan, Dimitrie Nanu - Ginecologie – Ed. Știința și Tehnică 1995, ISBN 9739236-23-5 4. Coyne KS, Sexton CC, Irwin DE, et al. The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study. BJU Int 2008; 101:1388–95. 5. Contreras Ortiz O. Stress urinary incontinence in the gynecological practice. Int J Gynaecol Obstet. 2004; 86 Suppl 1: S6-16. 6. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008; 300:1311-6. 7. Sub redacția Irinel Popescu, Constantin Ciuce - Tratat de chirurgie, ediția a 2-a, 2014, ISBN 978-973-27-2185-8 8. Crepin G, Biserte J, Cosson M, Duchene F (October 2006). “[The female urogenital system and high level sports]”. Bull. Acad. Natl. Med. (in French). 190 (7): 1479–91; discussion 1491–3. 17450681. 9. Rechberger T. Nowości w diagnostyce i leczeniu zabiegowym nietrzymania moczu u kobiet. (Developments in diagnostics and treatment of urinary incontinence in women) Przew Lek. 2007; 2: 94-100 (in Polish). 10. Norton P, Brubaker L. Urinary incontinence in women. Lancet 2006; 367:57-67. 442 11. DeLancey JOL, Kearney R, Chou Q, Speights S, Binno S. The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol 2003; 101:46-53. 12. Mitchell WK, Williams J, Atherton P, Larvin M, Lund J, Narici M. Sarcopenia, dynapenia, and the impact of advancing age on human skeletal muscle size and strength; a quantitative review. Front Physiol 2012; 3, nr260,1-18. 13. Guri Rortveit, M.D., Anne Kjersti Daltveit, Ph.D., Yngvild S. Hannestad, M.D., and Steinar Hunskaar, M.D., Ph.D., for the Norwegian EPINCONT Study - Urinary Incontinence after Vaginal Delivery or Cesarean Section- N Engl J Med 2003; 348:900-907March 6,

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© Filodiritto Editore - Proceedings 2003DOI: 10.1056/NEJMoa021788 14. Rortveit G, Hannestad YS, Daltveit AK, Hunskaar S. Age- and type-dependent effects of parity on urinary incontinence: the Norwegian EPINCONT study. Obstet Gynecol 2001; 98:1004-1010 CrossRef|Web of Science|Medline 15. Thom DH, Brown JS. Reproductive and hormonal risk factors for urinary incontinence in later life: a review of the clinical and epidemiologic literature. J Am Geriatr Soc 1998; 46:1411-1417 Web of Science|Medline 16. Hannestad YS, Rortveit G, Daltveit AK, Hunskaar S. Are smoking and other lifestyle factors associated with female urinary incontinence? The Norwegian EPINCONT Study. BJOG. 2003; 110(3): 247-54. 17. Bai SW, Kang JY, Rha KH, Lee MS, Kim JY, Park KH. Relationship of urodynamic parameters and obesity in women with stress urinary incontinence. J Reprod Med. 2002; 47(7): 559-63. 18. Whitcomb EL, Horgan S, Donohue MC, Lukacz ES. Impact of surgically induced weight loss on pelvic floor disorders. Int Urogynecol J. 2012 Apr 12. [Epub ahead of print]. 19. Bart S, Ciangura C, Thibault F, Cardot V, Richard F, Basdevant A, Chartier-Kastler E. Stress urinary incontinence and obesity. Prog Urol. 2008; 18(8): 493-8. 20. Orly Goldstick and Naama Constantini - Urinary incontinence in physically active women and female athletes - Br J Sports Med 2014 48: 296-298 originally published online May 18, 2013 doi: 10.1136/bjsports-2012-091880. 21. Thyssen HH, Clevin L, Olesen S, et al. Urinary incontinence in elite female athletes and dancers. Int Urogynecol J 2002; 13:15–17. 22. Kruger JA, Murphy BA, Heap SW. Alterations in levator ani morphology in elite nulliparous athletes: a pilot study. Aust NZ J Obstet Gynecol 2005; 45:42–7. 23. Kruger JA, Dietz HP, Murphy BA. Pelvic floor function in elite nulliparous athletes. Ultrasound Obstet Gynecol 2007; 30:81–5. 24. Keane DP, Sims TJ, Abrams P, et al. Analysis of collagen status in premenopausal nulliparous women with genuine stress incontinence. Br J Obstet Gynecol 1997; 104:994– 8. 25. Ulmsten U, Ekman G, Giertz G, et al. Different biochemical composition of connective tissue in continent and stress incontinent women. Acta Obstet Gynecol Scand 1987; 66:455–7. 26. Nygaard IE1, Thompson FL, Svengalis SL, Albright JP.- Urinary incontinence in elite nulliparous athletes- Obstet Gynecol. 1994 Aug;84(2):183-7. 27. Greydanus DE, Patel DR. The female athlete before and beyond puberty. Pediatr Clin N Am 2002;49:553–80. 28. Hay-Smith J, Mørkved S, Fairbrother KA, et al. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev 2008;(4):CD007471. 29. Herbison GP, Dean N. Weighted vaginal cones for urinary incontinence. Cochrane Database Syst Rev 2002;(1):CD002114. 30. Greydanus DE, Patel DR. The female athlete before and beyond puberty. Pediatr Clin N Am 2002; 49:553–80. 31. Corcos J, Gajewski J, Heritz D, et al. Canadian Urological Association guidelines on urinary incontinence. Can J Urol 2006; 13:3127–38.

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© Filodiritto Editore - Proceedings 32. Alhasso A, Glazener CMA, Pickard R, et al. Adrenergic drugs for urinary incontinence in adults. Cochrane Database Syst Rev 2005;(3): CD001842. 33. Mariappan P, Alhasso AA, Grant A, et al. Serotonin and noradrenaline reuptake inhibitors (SNRI) for stress urinary incontinence in adults. Cochrane Database Syst Rev 2005;(3):CD004742. 34. ø K. Pelvic floor physical therapy in elite athletes. In: Bø K, Berghmans B, Mørkved S, et al, eds. Evidence-based physical therapy for the pelvic floor. Oxford, UK: ButterworthHeinmann Elsevier, 2007:369–78. 35. Stangel-Wójcikiewicz K, Majka M, Basta A, Stec M, Pabian W, Piwowar M, Chancellor M. Adult stem cells therapy for urine incontinence in women. Ginekol Pol. 2010; 81: 378-381. 36. Stothers L, Friedman B. Risk factors for the development of stress urinary incontinence in women. Curr Urol Rep. 2011; 12(5): 363-9.

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Delayed Recognition of a Sigmoid Colon Iatrogenic Lesion Following Total Abdominal Hysterectomy in a Patient with a Previous Episode of Acute Diverticulitis Socea Bogdan1,2, Alexandru Carâp1,2, Smaranda Alexandru1, Moculescu Cezar1, Bobic Simona1,2, Dimitriu Mihai2,3, Socea Laura4, Vlad Denis Constantin1,2 General Surgery Department, “St. Pantelimon” Emergency Clinical Hospital, Bucharest (Romania) 2 Surgery Department, “Carol Davila” University of Medicine and Pharmacy, Bucharest (Romania) 3 Obstetrics and Gynecology Department, “St. Pantelimon” Emergency Clinical Hospital, Bucharest (Romania) 4 Organic Chemistry Department, “Carol Davila” University of Medicine and Pharmacy, Bucharest (Romania) E-mail: [email protected] 1

Abstract Gastrointestinal injuries can occur during gynaecological procedures. The range of gastrointestinal lesions is very wide and encompasses the small and large intestines, the rectum and less frequently the gastric region. We present the case of a 47 year old woman that had a medical history significant for acute diverticulitis and that sustained an iatrogenic colon lesion during an abdominal hysterectomy for leiomyoma. The lesion was not diagnosed at the time of surgery and required reoperation and Hartmann’s procedure. Iatrogenic gastrointestinal lesions during gynaecological procedures are an overlooked entity in the medical literature. While their incidence is not extremely high, their potential complications can lead to serious disability, as evidenced by the case we present, and even mortality. All gynaecologists should be trained in simple enteral and colorectal resections and when doubtful situations appear a digestive surgeon should be a part of the management team. We recommend that in cases with previous diverticular disease a digestive surgeon should assist during surgery in order to help with difficult dissections and to evaluate the health of the sigmoid colon and decide its eventual resection. Keywords: gynaecology, iatrogenic large bowel lesion, acute diverticulitis

Introduction Gastrointestinal injuries can occur during gynaecological procedures. The range of gastrointestinal lesions is very wide and encompasses the small and large intestines, the rectum and less frequently the gastric region. Small intestine injuries and large bowel injuries can take place during dilatation and curettage, total abdominal hysterectomy and hysteroscopic and laparoscopic procedures [1]. Mild injuries of the intestines are amenable to simple suture

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© Filodiritto Editore - Proceedings repair but extensive lesions may require resections [2]. Lesion can occur during opening of the abdomen and adhesiolysis in the previously operated patients and during the surgical steps required to perform the specific gynaecological procedure. Colon injuries can appear in patients that have surgery for left adnexal masses and patients with a history of pelvic inflammatory disease and diverticulitis [3]. The aim of this case report is to emphasize the importance of a high index of suspicion for colonic lesions during gynaecological procedures in women who have a history of diverticulitis. We would also like to state that the presence of a general surgeon or of a colorectal surgeon during procedures for these patients is advisable.

Case report We present the case of a 47 year old woman that was scheduled for a total abdominal hysterectomy for a voluminous, bleeding, uterine fibroma. Her medical history is significant for arterial hypertension and an episode of acute diverticulitis one year prior to the current presentation. She was diagnosed and treated for Hynchey class III acute diverticulitis with laparoscopic lavage and drainage. The episode resolved successfully following surgical treatment and the patient presented no new symptoms pertaining to diverticulitis. Repeated episodes of bleeding have resulted in a gynaecological consult, ultrasound and bioptic curettage one month prior to presentation that resulted in the previously mentioned diagnosis, an 8/8 cm uterine leiomyoma. The patient was scheduled for total abdominal hysterectomy. During the procedure extensive adhesions were found and lysed in the pelvis. After adhesiolysis, the operation continued uneventfully. Hysterectomy was performed and a drainage tube was placed in the pelvis through a separate stab wound. In the postoperative period the patient’s condition progressively worsened, she was febrile and had no bowel movements and on the third postoperative day the abdomen was distended, painful and presented guarding especially in the lower abdomen. Drainage was minimal and serous. Plain abdominal x-rays identified distended bowel loops with multiple air-fluid levels suggesting an intestinal obstruction. Abdominal ultrasound identified free fluid in the abdomen and an exploratory laparotomy was performed. Intraoperative exploration revealed distended bowel loops and free feculent fluid in the peritoneal cavity. After the aspiration and lavage of the peritoneal cavity a partial section of the sigmoid colon was identified and a Hartmann’s procedure was performed. The patient recovered well and she was discharged on the 6th postoperative day. She is scheduled for Hartmann reversal at six months.

Discussion Iatrogenic gastrointestinal lesions during gynaecological procedures are an overlooked entity in the medical literature. While their incidence is not extremely high, their potential complications can lead to serious disability, as evidenced by the case we present, and even mortality. Classification of these lesions by the procedure performed shows a correlation between procedures and the site of the injury at the level of the bowel. Total abdominal hysterectomy has a correlation with cecal lesions, dilatation and curettage associates with small bowel injuries while gastric lesions associate seldom with laparoscopic surgery and trocar placement [4, 5]. Other studies find a high rate of small bowel lesion that occur during adhesiolysis, 61-75% [6, 7]. Although these rates may differ between case series one aspect is very clear, and that is that a high rate of intestinal iatrogenic lesions appear in patients that had

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© Filodiritto Editore - Proceedings previous abdominal surgery and extensive adhesions, with rates as high as 44-64% [6]. Early and intraoperative diagnosis is the rule for gastrointestinal iatrogenic lesions, the exteriorization of feculent biliary fluid leading, most commonly, to a straightforward diagnosis. Missed bowel lesions due to thermal injury are more frequently associated with laparoscopic procedures [8]. Adhesions are a common complication of acute diverticulitis whatever the treatment modality is. It is not yet clear whether treatment with lavage and drainage without resection for Hinchey class III disease will lead to more adherences compared to other treatment strategies [9]. Reports are scarce about diverticulitis and gynaecological procedures and their risk for iatrogenic gastrointestinal injuries. However we believe that in our case the adhesions were the reason for the sigmoid injury. Early recognition of the lesion is of paramount importance. Intraoperative diagnosis can most often be resolved by primary suture repair (approximately 50% of cases). However if the lesion occurs on a diseased sigmoid colon with a previous episode of acute diverticulitis, resection is probably the safer option. The extensiveness of the injury can be the difference between simple suture repair and resections followed by anastomosis or stoma formation. Unrecognised lesions can lead to sepsis and septic shock and their delayed repair is most commonly done by resection of the affected segment and anastomosis and/or stoma formation. All gynaecologists should be trained in simple enteral and colorectal resections and when doubtful situations appear a digestive surgeon should be a part of the management team. We recommend that in cases with previous diverticular disease a digestive surgeon should assist during surgery in order to help with difficult dissections and to evaluate the health of the sigmoid colon and decide its eventual resection. As laparoscopic techniques become ever more prevalent, special attention should be paid in the training of basic digestive techniques in order to avoid occult lesions of bowel.

REFERENCES 1. Richter R. Prophylaxis and therapy of intestinal complications in surgical gynecology. Ther Umsch. 1981;38(6):516-23. 2. Davis JD. Management of injuries to the urinary and gastrointes- tinal tract during cesarean section. Obstet Gynecol Clin North Am. 1999;26(3):469-80. 3. Paloyan D, Tommaso F, William W. Clinical Reproductive: Medicine and Surgery. In: Paloyan D, Tommaso F, William W, editors. Intestinal Problems in Gynecologic Surgery. GLOWM; 2008. 4. Mesdaghinia, E., Abedzadeh-kalahroudi, M., & Hedayati, M. (2013). Iatrogenic Gastrointestinal Injuries During Obstetrical and Gynecological Operation MoussaviBioki, 2(2), 81–84. 5. Rock JA, Jones HW. TeLinde’s Operative Gynecology. 2011. 6. Bhattee GA, Rahman J, Rahman MS. Bowel injury in gynecologic operations: analysis of 110 cases. Int Surg. 2006;91(6):336-40. 7. Krebs HB. Intestinal injury in gynecologic surgery: a ten-year ex- perience. Am J Obstet Gynecol. 1986;155(3):509-14. 8. Baggish MS. Lessons in timely recognition of laparoscopy-relat- ed bowel injury. JFPonlinecom. 2008;20(7):55-60. 9. Fingerhut A, Veyrie N. Complicated diverticular disease: the changing paradigm for treatment. (2012), 39(4), 322–327.

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Iatrogenic Ureteral Injuries During Gynecological Procedures Vlad Denis Constantin1,2, Alexandru Carâp1,2, Anca Nica1, Moculescu Cezar1, Bobic Simona1,2, Socea Bogdan1,2 General Surgery Department, “St. Pantelimon” Emergency Clinical Hospital, Bucharest (Romania) Surgery Department, “Carol Davila” University of Medicine and Pharmacy, Bucharest (Romania) E-mail: [email protected]

1 2

Abstract Traumatic injuries to the ureter are rare occurrences whether from external trauma or iatrogenic trauma. They make up about 1-2% of all urinary tract injuries. The most common causes of iatrogenic ureteral injuries are complications of pelvic procedures most often gynecological, endourological, urological, vascular and colorectal. The aim of this paper is to present our experience with ureteral iatrogenic injuries that occurred during gynecological procedures and their diagnosis and management. For this we used data recorded in the patient’s chart, operative descriptions and imaging studies. We analyzed these variables retrospectively. We analyzed six cases of ureteral injury following gynecological procedures that occurred in our department in the period January 2014 – April 2016. Four cases had an intraoperative diagnosis and primary repair while the remaining two were diagnosed postoperatively. All six cases had a favorable outcome after reconstructive surgery. Gynecological procedures have the highest rate of ureteral injuries among surgical specialties. Rapid diagnosis is the cornerstone of management and allows for a timely reconstruction and minimal morbidity. Delayed diagnosis can have serious consequences including nephrectomy. It is therefore essential that a high index of suspicion should be maintained during procedures that present a risk of ureteral injuries. Keywords: iatrogenic ureteral injury, gynecology

Introduction Traumatic injuries to the ureter are rare occurrences whether from external trauma or iatrogenic trauma. They make up about 1-2% of all urinary tract injuries [1]. Reasons for this low number of injuries include their retroperitoneal anatomical position, and their mobility and flexibility. Blunt trauma that results in ureteral injury is very rare and most traumatic lesions of the ureter are a consequence of penetrating injuries, most often gunshot wounds [2]. The most common causes of iatrogenic ureteral injuries are complications of pelvic procedures most often gynaecological, endourological, urological, vascular and colorectal. These types of lesions can appear in open or laparoscopic approaches [3]. The mechanisms by which injuries occur are partial or complete clamping, incomplete or complete transection, suture ligation, angulations with secondary obstruction and ischemic lesions resulting from

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© Filodiritto Editore - Proceedings denudation. Conditions that are frequently associated with ureteral injuries are reoperations, inflammation, extensive tumors, ureteral duplications and renal ectopia, and external irradiation [4].

Methods The aim of this paper is to present our experience with ureteral iatrogenic injuries that occurred during gynaecological procedures and their diagnosis and management. For this we used data recorded in the patient’s chart, operative descriptions and imaging studies. We analysed these variables retrospectively. The lesions were characterized by the affected ureteral segment, the mechanism of iatrogenic injury and the procedure that led to the injury. In the period January 2014 – April 2016 six cases of iatrogenic ureteral injury were identified, all female patients subjected to gynaecological procedures.

Results All six injuries were located in the pelvic portion of the ureter. The procedures that led to the injuries were total hysterectomy for bleeding voluminous uterine fibromas in four cases and two Wertheim procedures for cervical cancer. The mechanism of injury was: incomplete transection in three cases, complete transection, suture ligation and ischemic injury in one case respectively. Surgical procedures were used for repair in all cases. Depending on the time of diagnosis the repair was performed during the same surgical procedure in four cases, or in a delayed fashion in two cases. The four cases that were diagnosed intraoperatively with complete and incomplete transections underwent primary repair. The three cases with compete transection required uretero-ureteral anastomosis. In the case with incomplete transection simple suture was possible. Postoperative recovery was uneventful in these four cases showcasing the importance of intraoperative recognition of iatrogenic ureteral lesions. In the remaining two cases, one suture-ligation and one ischemic injury to the ureter the diagnosis was delayed and occurred after the development of pain and the use of abdominal ultrasound and iv urography that showed hydronephrosis and the obstruction in the pelvic ureter. Direct ureterovesical anastomosis was performed in these cases and the postoperative course was generally good but the cases required a longer hospital stay (mean 17 days compared to mean 5 days in the intraoperative diagnosis group) and required a second surgical procedure.

Discussions It is estimated that, while uncommon, the greatest number of iatrogenic ureteral injuries occur after gynaecological procedures, 52 to 82% of iatrogenic ureteral injuries in reports by Lee et al., Dowling et al and Stoller [5, 6, 7]. The rate is higher for abdominal hysterectomy compared with vaginal hysterectomy although a selection bias is suspected as large tumors, infected pathologies that pose more technical difficulties are often approached abdominally. Clinical factors that predispose to ureteral injuries are a large uterus, endometriosis, pelvic organ prolapse and prior pelvic surgery [8]. Prevention of ureteral injuries is of great interest as iatrogenic lesions can sometimes lead to catastrophic events. A proposition for prevention is the routine catheterization of the ureter preoperatively. A recent randomized study however

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© Filodiritto Editore - Proceedings found no statistical difference when comparing a group with and a group without preoperative catheterization [9]. The diagnosis of ureteral injuries depends on many factors like the extent and the type of injury. While ischemic lesions can only be assumed intraoperatively complete, partial transections and suture-ligations should be diagnosed intraoperatively. Early diagnosis is preferable and can avoid serious complications including nephrectomy in the setting of delayed recognition and therapeutic intervention. Unfortunately only 10-15% of all lesions are recognized intraoperatively [10]. Urinary extravasation is the most obvious sign that can lead to recognition. If the exact site cannot be determined intravenous indigo carmine can be useful together with intraoperative excretory urography. In the case of ligation, after liberating the ureter from the ligature its viability should be assessed. Partial transections are amenable by simple suture. Uretero-ureteral anastomosis over a double J stent is the procedure of choice for early repair considering that it retains the physiologic antireflux mechanism and keeps an intact bladder. Ureterocystoneostomy procedures are safe and applicable especially in the case of delayed diagnosis for the distal ureter. Gynaecological procedures have the highest rate of ureteral injuries among surgical specialties. Rapid diagnosis is the cornerstone of management and allows for a timely reconstruction and minimal morbidity. Delayed diagnosis can have serious consequences including nephrectomy. It is therefore essential that a high index of suspicion should be maintained during procedures that present a risk of ureteral injuries.

REFERENCES 1. Summerton DJ, Djakovic N, Kitrey ND, Kuehhas FE, Lumen N, Serafetinidis E, et al. Guidelines on urological trauma. In: EAU Guidelines. Arnhem (The Netherlands): European Association of Urology (EAU); 2014. p.30-33. 2. Elliot SP, Mc Anninch JW. Ureteral injuries from external violence: the 25-year experience at San Francisco General Hospital. J Urol. 2003; 170(4 Pt 1):1213-6. 3. Selzman AA, Spirnak JP. Iatrogenic ureteral injuries: a 20-year experience in treating 165 injuries. J Urol. 1996; 155(3):878-81. 4. Pfitzenmaier J, Gilfrich C, Haferkamp A, Hohenfellner M. Trauma of the ureter. In: Hohenfellner RAS, editor. Emergencies in Urology. New York, NY: Springer; 2007. p.233-45. 5. Dowling, R., Corriere, J., Jr and Sandler, C. (1986) Iatrogenic ureteral injury. J Urol 135: 912–915. 6. Lee, R., Symmonds, R. and Williams, T. (1988) Current status of genitourinary fistula. Obstet Gynecol 72: 313–319. 7. Stoller, M. and Wolf, J. (1996) Endoscopic ureteral injuries. In: McAninch, J. (ed.), Traumatic and Reconstructive Urology. Philadelphia, PA: Saunders. 8. Vakili, B., Chesson, R., Kyle, B., Shobeiri, S., Echols, K., Gist, R. et al. (2005) The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy. Am J Obstet Gynecol 192: 1599–1604. 9. Chou, M., Wang, C. and Lien, R. (2009) Prophylactic ureteral catheterization in gynecologic surgery: a 12-year randomized trial in a community hospital. Int Urogynecol J 20: 689–693. 10. Dobrowolski Z, Kusionowicz J, Drewniak T, Habrat W, Lipczyñski W, Jakubik P, et al. Renal and ureteric trauma: diagnosis and management in Poland. BJU Int. 2002; 89(7):748-51.

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The benefits of laparoscopically assisted vaginal hysterectomy Cristurean V-C.1, Nour C.2, Cardon I.2 Department of Obstetrics and Gynecology, Ovidius University of Medicine, Constanta(Romania) Department of Obstetrics and Gynecology, “Sfântul Apostol Andrei” Emergency Clinical County Hospital, Constanta (Romania) E-mails: [email protected] [email protected]

1 2

Abstract The aim of our study was to compare in terms of uterine volume and surgical proceedures associated with 30 cases of uterine pathology but with unprolapsed uterus or a minimal degree of prolapse such as 1st or 2nd degree of prolapse. Laparoscopically assisted vaginal hysterectomy offers a technique to overcoming clasic contraindications of vaginal hysterectomy approach meaning uterine wheight and adhesions prior surgycal proceedures, increasing complexity of the proceedures being a pathway to allow adnexectomies, ovarian cystectomies, McCall culdoplasty (by approach of uterosacral ligament in posterior and medium third also better interception of the ureter). It appears particularly useful for increased safety and convenience for operators by better approaching on difficult vaginal hysterectomy also we think about it to be favoring operators with a lower level of surgical performance and surgical experience, increase operator confidence and optimism in addressing vaginal hysterectomy with a high degree of difficulty all these for the most important conclusion about this approach which is inceasing the safety of the patients. Keywords: Difficult vaginal hysterectomy, Laparoscopically assisted vaginal hysterectomy, safety of patients, uterine prolapse, uterine wheight

Background Hysterectomy can be performed vaginally, abdominally, laparoscopically, or with robotic assistance, the route depending on physician choice however patient option should be taken into account. Choosing route for hysterectomy should be on closely related factors like safety of patient, cost-effectiveness, and medical needs of the patient, indications and contraindications well known by physicians. A laparoscopic-assisted vaginal hysterectomy (LAVH), a precursor to the TLH (total laparoscopic hysterectomy) is a technique to secure the ovarian via laparoscopy, the remainder of procedure is completed vaginally mentioning the laparoscope is often reinserted after closure of the vaginal cuff with the purpose to inspect the abdominal cavity and vaginal cuff for proper haemostasis at the end of the procedure [1]. Kovac et al has been conducted an algoritm, which comes to help the clinicians in choosing the route by which hysterectomy will be performed [2].

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© Filodiritto Editore - Proceedings Objective The aim of our study was to compare in terms of uterine volume and surgical proceedures associated with 30 cases of uterine pathology but with unprolapsed uterus or a minimal degree of prolapse such as 1st or 2nd degree of prolapse (Graph 1).

Results The 30 cases of hysterectomies were divided into two groups by approach of hysterectomy namely group of VH (vaginal hysterectomy) with 13 cases and group of LAVH (laparoscopically assisted vaginal hysterectomy) with 17 cases, according to main indications on both approach vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy such as cervix pathology, endometrial pathology and severe uterine bleedings unresponsive to treatment, uterine leiomyomas, ovarian pathology associated to uterine pathology (Table 1). Approach by laparoscopically assisted vaginal hysterectomies allowed us to addressing to heavier uterine weights such as 500g (n=1) and 600g (n=1) also average uterine weight in group of LAVH was 207g, compared to average uterine weight in group of VH with 172g (Table 2). The incidence of hysterectomy performed for uterine leiomyomas had close percentages in both groups (group of VH- 61,33% and group of LAVH- 70,58%) also had close percentages for severe uterine bleedings unresponsive to treatment (group of VH- 15,40% and group of LAVH- 11,77%). In approaching of ovarian pathology associated to uterine pathology of the 30 cases of hysterectomies all of them were performed by laparoscopically assisted vaginal hysterectomy (11,77% in group of LAVH and 0% in group of HV) whereas cervix pathology like cervical dysplasia had higher incidence in group of VH (23,07%) than in group of LAVH (5,88%). Approach through laparoscopically assisted vaginal hysterectomies allowed us to increasing complexity of surgery due to the possibility that it offers, namely to make the optimum adnexectomies (64,70% in group of LAVH compared to 7,69% in group of VH), ovarian cystectomy (11,76% in group of LAVH and 0% in group of VH), salpingectomies (17,64% in group of LAVH and 0% in group of VH), adheziolysis (52,945 in group of LAVH and 0% in group of VH) and McCall culdoplasty (by approach of uterosacral ligament in posterior and medium third, 53,84% in group of LAVH and 23,52% in group of VH) (Table 3).

Discussion The aim of the study wasn’t being in contradictions with the expert studies carried out today furthermore we were guided by it knowing that for the gynecologic surgeons, the laparoscope has been considered a tool to evaluate possible contraindications to vaginal hysterectomy with the primary goal being to assist in oophorectomy [4, 5] and leading us to conclusions mentioned below.

Conclusions Laparoscopically assisted vaginal hysterectomy offers a technique to overcoming clasic contraindications of vaginal hysterectomy approach meaning uterine wheight and adhesions prior surgycal proceedures, increasing complexity of the proceedures being a pathway to allow adnexectomies, ovarian cystectomies, McCall culdoplasty (by approach of uterosacral

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© Filodiritto Editore - Proceedings ligament in posterior and medium third also better interception of the ureter). It appears particularly useful for increased safety and convenience for operators by learning the difficult vaginal hysterectomy also we think about it to be favoring operators with a lower level of surgical performance and surgical experience, increase operator confidence and optimism in addressing vaginal hysterectomy with a high degree of difficulty all these for the most important conclusion about this approach which is inceasing the safety of the patients.

Graph 1. Uterine prolapse degrees repatition on study Indication of the approach Cervix pathology Endometrial pathology and severe uterine bleedings unresponsive to treatment Uterin leiomyoma Ovarian pathology associated to uterine pathology

3

Laparoscopic assisted vaginal hysterectomies (number of cases) 1

2

2

8

11

0

2

Vaginal Hysterectomies (number of cases)

Table 1. Repartition on number of cases by indication of approach on study Uterine weights

Vaginal hysterectomies

Laparoscopic assisted vaginal hysterectomies

Under 280g*

12 (cases)

13 (cases)

Above 280g*

1 (case)

4 (cases)

Greutate medie

172g

207g

Benchmark acording to Petre Brătilă. Histerectomia vaginală. Editura Dobrogea, Constanța, 2006[3]

*

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© Filodiritto Editore - Proceedings Table 2. Uterine weights in both approach on study, vaginal hysterctomies and laparoscopically assisted vaginal hystrectomies Surgycal proceedures associated to approach of vaginal hysterectomies Unilateral and bilateral adnexectomies Ovarian cystectomy

Vaginal hysterectomies (13 cases)

Laparoscopically assisted vaginal hysterectomies (17 cases)

1

11

0

2

Bilateral salpingectomies

0

3

Adhesiolysis (adhesions prior surgycal proceedures)

0

9

McCall culdoplasty

7

4

Table 3. Surgycal proceedures associated to approach of vaginal hysterectomies on study

REFERENCES 1. ACOG Committee Opinion No. 444: choosing the route of hysterectomy for benign disease. Obstet Gynecol. 2009 Nov. 114(5):1156-8. 2. Kovac SR. Clinical opinion: guidelines for hysterectomy. Am J Obstet Gynecol. 2004 Aug. 191(2):635-40. 3. Petre Brătilă. Histerectomia vaginală. Editura Dobrogea, Constanța, 2006 SR, Guidelines to determine the role of laparoscopically assisted vaginal hysterectomy. Am J Obstet Gynecol. 1998; 178(6):1257-63. 4. Kovac SR, the Divisions of Pelvic Reconstructive Surgery and Urogynecology and General Obstetrics and Gynecologic Surgery, Am J Obstet Gynecol. 1998; 178:12571263.

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Assessing the severity of acute pelvic inflammatory disease CERNETCHI Olga1, CAUS Catalin1, CAUS Natalia1, RAILEAN Ludmila1, ILIADI TULBURE Corina1 Republic of Moldova, State University of Medicine and Pharmacy “Nicolae Testemitanu” E-mails: [email protected], [email protected], [email protected], [email protected], [email protected]

1

Abstract Assessing the severity of acute pelvic inflammatory disease (APID) represents a dilemma for the contemporary researchers that is still to be solved. Evaluating the patients using the MIL score (clinical manifestations + imaging data + laboratory data) is aimed at determining the severity of the acute pelvic inflammatory disease (APID) and at optimizing the medical and surgical conduct as well. This mathematical score sums up three parameters: clinical manifestations, imaging data and laboratory data, which then establishes the degree of severity (mild, moderate and severe). Keywords: APID, PID, MIL score, disease severity

Introduction Acute pelvic inflammatory disease (APID) is a medical and social problem of an increasing resonance, being the most common gynecologic condition observed in women of reproductive age. The latest study regarding the gynecologic morbidity in the Republic of Moldova has established that out of 106142 surveyed female patients, 88.71% had suffered previously of APID. This disease represents the third reason of hospitalization in the gynecologic inpatient unit in the Republic of Moldova. The main etiological factor for the development of an ectopic pregnancy is a flare of APID, which precedes the ectopic pregnancy [1]. Women’s health remains a priority of the state, which is responsible of maintaining the welfare and the reproductive health of the nation. The quality of care is influenced by the correctness rate of the early diagnosis of APID and by the prescribing of an effective and safe treatment. The presence of difficulties in establishing the early and complete diagnosis can lead to severe forms of APID. One of the most pressing issues in the early diagnosis of APID and therefore related to the issue of reducing the amount of time before the surgical treatment are: establishing the duration of the conservative treatment, determining the optimal period for surgery and evaluating the effects after employing the chosen medical conduct. Currently, in the scientific literature, there is a lack of special instruments (scores) developed for assessing the severity degree of the inflammatory processes in APID that are to be used during patient

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© Filodiritto Editore - Proceedings hospitalization at the in-patient unit.

Materials and methods The present work (focused on the issue of APID), is a simple randomized blinded study focused on diagnostics. The sample of 234 female patients that were hospitalized with acute pelvic inflammatory disease was selected according to the CDC criteria [2]. There has been developed a mathematical score, with values ranging from 0 to 3 that corresponds to the data from clinical, paraclinic and laboratory examinations. The usefulness of the MIL score (table 1) is based on the possibility of evaluating the female patient and guiding the medical conduct, namely in the initiation of either an exclusively pharmacological treatment or by facilitating the process of preparing the female patient for surgery during the early hours after hospitalization.

Results Table 1. MIL score for assessment of the severity degree of acute pelvic inflammatory disease (APID) Score 0

General status Fever Leukorrhoea Abdominal pain Vaginal exam

Uterus (endometrium) Fallopian tubes

1 2 Clinical Manifestations satisfactory altered +nausea 37 38 39 absent slight abundant non-significant unilateral bilateral tenderness at pain at the the projected painless mobilization of areas of uterine the cervix appendages Imagistic data ordinary inhomogeneous thickened appearance non-visible

Presence of liquid

ordinary appearance non-significant fluid amount

Leukocytes

51

Laboratory data >10,000 >6

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© Filodiritto Editore - Proceedings Vaginal pH

(3,8-4,5)

(5,0-5,5)

(6,0-7,2)

(>7,2)

Semiquantitative Procalcitonin

0,5

>2

>10

Urine test strip

negative

leukocytes

+erythrocytes

+nitrates etc.

negative

positive

-

-

negative

positive

-

-

negative

positive

-

-

Syphilis (rapid test) Gonorrhea (rapid test) Chlamydia (rapid test)

A MIL score (table1) value of up to 15 indicates a mild form of APID; values between 16 to 28 point to moderate clinical form of APID and a score greater than 29 indicates the presence of a serious form of APID. According to our research, after evaluating the MIL score of the female patients included in the study, we have observed that 41.88% of the patients have a mild form of APID, 32.47% - moderate severity of APID and 25.64% have the severe form of APID. Laparoscopy is considered the gold standard for assessing the severity and the anatomic and clinical form of APID. In this study, there has been given a priority to perform laparoscopy. In the first 48 hours, laparoscopy has been performed for 73.01% of patients, where it was observed that the moderate form was present in 30.76% of cases, the generalized form was observed in 23.07% of cases; and the remaining 46.15% patients had mild forms of APID. After analyzing the data, we can conclude that the MIL score has shown a high diagnostic value and can be used to assess the severity of APID.

Discussion There should be conducted an evaluation of long-term usage of the MIL score and there should be performed an assessment of its diagnostic value concerning using it in order to determine the severity degree of APID. The first steps have been made in this research, but we encourage and hope that subsequently there will be developed other scores that will aid physicians in the process of determining the clinical form and the evolution of acute pelvic inflammatory disease.

Conclusions 1. The MIL score was of a great value to this study, allowing the initiation of early surgical treatment and was found out to be useful in assessing the degree of severity of acute pelvic inflammatory disease and in preventing complications. 2. There should be conducted comparative studies regarding the severity score assessment for acute pelvic inflammatory disease. 3. The concept of summing up clinical data with imaging and laboratory data can be used also for other pathological conditions and by other medical specialties with the aim of assessing the severity of the process.

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© Filodiritto Editore - Proceedings REFERENCES 1. Tihon-Pascal L. (2015). Aspectele clinice şi medico-sociale ale stărilor de urgenţă ginecologică în Republica Moldova. Autoreferatul tezei de doctor în ştiinţe medicale. Chişinău. 30p. 2. Center for Disease Control and Prevention. (2002). Sexually transmitted diseases treatment guidelines 2002, MMWR, Recommendation, vol. 51, pp. 01-78.

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Approach to complications caused by prosthetic materials used in pelvic reconstructive surgery CIORTEA Răzvan¹, RADA Maria Patricia¹, BERCEANU Costin², MĂLUŢAN Andrei Mihai¹, MOCAN Radu¹, IUHAS Cristian¹, BUCURI Carmen Elena¹, CÂMPIAN Eugen Cristian³, DICULESCU Doru1, MIHU Dan¹ ¹ Universitatea de Medicină și Farmacie “Iuliu Hațieganu” Cluj-Napoca, Disciplina Obstetrică – Ginecologie II (Romania) 2 Universitatea de Medicină și Farmacie Craiova, Departamentul Obstetrică-Ginecologie (Romania) ³ Saint Louis University, Division of Urogynecology, Female Pelvic Medicine & Reconstructive Surgery (USA) E-mails: [email protected], [email protected], [email protected], [email protected], [email protected], [email protected], [email protected], [email protected], [email protected]

Abstract Increased recurrence of pelvic organ prolapse (POP) following reconstructive pelvic surgery entails a careful surgical technique, corroborated with the possibility of using biological or synthetic prostheses to ensure adequate support. Simultaneous correction of pelvic floor disorders and urinary incontinence can be performed using prosthetic material that facilitates the consolidation of local tissue and have supportive role. Attention should be paid to potential complications arising from the use of these materials: erosions, pain, infections, dyspareunia, perforation of adjacent organs, urinary and/or neuromuscular disorders and relapses. Selecting suitable patients in whom prosthetic materials might be used for pelvic floor diseases is a key element that contributes to the success of an intervention. Risk factors such as diabetes, advanced age, smoking predict unfavorable prognostic. Use of prosthetic materials should be adapted to the anatomo-clinical particularities and differentiated for primary, secondary or relapses corrections and the benefits of surgical prosthesis usage should exceed the risk of complications as well. One of the current concerns is represented by mesh erosions, the most common complication following vaginal surgery involving prosthetic materials. The frequency of this complication varies depending on surgical approach and the used materials. In order to minimize the occurrence of complications caused by surgical pelvic reconstruction techniques and predict a favorable outcome, extensive experience of the operator, high quality of prosthetic materials and patient selection should be all present. Keywords: pelvic organ prolapse, vaginal mesh, complications

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© Filodiritto Editore - Proceedings Introduction POP is a disorder in which one or more of the pelvic organs drop from their normal position. In patients with severe symptomatic POP that disrupts life and in whom nonsurgical treatment options have not helped, surgery may be considered. Reconstructive surgery has the goal of restoring the organs to their original position. Even though different terms like exposure, extrusion or perforation were proposed by the International Urogynecological Association (IUGA) and International Continence Society (ICS), the generic term erosion appears to best describe the protruding prosthetic material into the vaginal wall [1]. The incidence of mesh erosions is dependent on the type and size of the mesh but no mesh material is nonsusceptible to erosions. Monofilament, macroporous polypropylene mesh with large pore size seems to entail a reduced infection risk, but a significantly more intense aggregation of macrophages in the area may indicate a stronger inflammatory response of the vaginal wall. This fact may be the trigger for the erosion. Dyspareunia, another complication that may appear after vaginal reconstructive surgery is caused by mesh erosion, mesh infection or extensive fibrosis [2]. Vaginal surgery alone, without the use of prosthetic materials, may also cause dyspareunia, but there is one subjective element that can suggest mesh generated dyspareunia, namely male dyspareunia (hispareunia) [3]. Chronic pelvic pain is a challenging aspect after pelvic floor reconstruction. Transobturator approach for placing slings is susceptible for generating pelvic pain due to anatomical reasons. Symptoms of the complications vary depending on the organ involved. Vaginal erosion may present with vaginal bleeding, abnormal discharge, dyspareunia or vaginal pain. Mesh erosion into the bladder/urethra include painful voiding, urinary frequency, urgency, hematuria, recurrent urinary tract infection, urinary calculi and urinary fistula [4]. Mesh infection may or may not be associated with vaginal mesh exposure. Non-specific pelvic pain, persistent vaginal discharge or bleeding, dyspareunia, and urinary or fecal incontinence are the most common manifestations of vaginal mesh-related infection. Clinical examination may reveal induration of the vaginal incision, vaginal granulation tissue, draining sinus tracts and prosthesis erosion or rejection [5].

Methodology This article was written based on the authors’ clinical experience in pelvic reconstructive surgery and taking into account current concepts regarding this subject. Scientific support was found in PubMed, ScienceDirect and Cochrane resources; studies regarding complications arising from synthetic mesh use in POP and urinary incontinence were mainly of interest. Different surgical procedures are used nowdays for the repair of POP. Concerning vaginal procedures, an increased interest has been shown in the use of synthetic meshes. Especially in patients with tissues of poor quality, prostetic repair seems to be a reliable therapeutic option. Materials should be inert, nonresorbable and resistant to infection. Based on published experimental and clinical experience, polypropylene is assumed to be the most appropriate material for POP vaginal repair procedures. The following characteristics of polypropylene meshes should be present: resistance to degradation by tissue enzymes, indefinite strength in clinical use, elastic property that allows adaptation to various stresses, possibility to be trimmed without unraveling. Prosthetic materials that are necessary in pelvic organ reconstruction were categorized two decades ago [6]. Type I monofilament, macroporous polypropylene mesh with large pore size (> 75 μm) is currently preffered. Type II monofilament microporous (< 10 μm) mesh use may result in a higher risk of infection. T ype III multifilament mesh have interstices that are 5 mm [2]. In descending order of frequency, deep endometriosis locations are utero-sacral ligaments (USL), the pouch of Douglas, rectum, sigmoid, vagina and urinary bladder [3, 4]. Urinary tract endometriosis (UTE) is an uncommon condition. The incidence of urinary tract endometriosis ranges from 0.3 up to 12% of all women affected by endometriosis [5, 6]. Bladder endometriosis (BE) is the most common location of UTE, representing 85% of these cases [7]. BE usually affects women in the reproductive age with a mean age of 35 years [8]. Although possible, postmenopausal BE is extremely rare because endometriotic tissue is estrogen dependent and generally undergoes remission after menopause [8]. Depending on the time of onset, BE is classified as “primary BE” – spontaneously occurring disease (11% of all patients with DIE) and “secondary BE” – iatrogenic lesion occurring after pelvic surgery (cesarean, hysterectomy) [9]. Similarly with endometriosis, the pathogenesis of BE is still unclear and four etiologic hypotheses are widely supported: the embryonal theory, the migratory theory, the transplantation theory and the iatrogenic theory. Around 50% of all patients with BE have a history of pelvic surgery [8]. BE lesions usually evolves from the bladder serosa toward mucosa and is often multifocal; the most frequent BE sites are the trigone and the dome [10]. Patients with BE often reports nonspecific symptoms and the diagnosis is incidental during a check-up procedure for a known DIE or for infertility. The aim of our study was to assess urinary symptoms in patients with deep infiltrating and bladder endometriosis.

Material and methods We conducted a retrospective study between January 2011 until January 2016, in the Obstetrics and Gynecology Clinic of “St. Pantelimon” Clinical Emergency Hospital, Bucharest. The analysis included 21 patients with BE out of 196 patients with endometriosis (prevalence 10.71%). All endometriosis cases were confirmed histologically after laparoscopic surgery or cystoscopic biopsy. All patients had a complete evaluation, including history, physical examination (bimanual vaginal examination), urine examination (general urine analysis and urine culture), transvaginal ultrasound (TVUS) with a 7.5 MHz transvaginal probe and cystoscopy.

Results The patient mean age was 34.2 years. Five patients (23.81%) were nulliparous; of the remaining 16 patients, 10 women had a cesarean section (47.61% of the series) – “secondary BE”. 42.85% of the patients (9/21) had a history of endometriosis in some other location, while in 12 cases (57.14%) the urinary tract was the first diagnosis of endometriosis. In 5 cases (23.81%) a palpable nodule was identified by clinical examination on the posterior wall of the urinary bladder.

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© Filodiritto Editore - Proceedings Urine examination showed macroscopic hematuria in 7 cases (33.33%) and microscopic hematuria in 9 cases (42.85%). Urine cultures were positive for E. Coli in 4 cases (19.1%). In 15 cases (71.42%) TVUS identified the presence of hypoechoic nodular structures with regular or irregular contour or linear hypoechoic thickenings in the walls of bladder or in vesicouterine space, which were confirmed histologically as endometriosis. Cystoscopy was performed in all cases and in 7 patients (33.33%) were identified 7 lesions (1 lesion per patient) that involved the full thickness of the bladder wall including the mucosal lining; in the other 14 patients (66.66%) cystoscopy showed bluish irregular submucosal lesions. Regarding the location of the lesions, 10 lesions (47.61%) were located on the bladder fundus, 5 lesions (23.81%) on the posterior wall and 6 lesions (28.57%) in the retrotrigone area. Six patients (28.57%) were asymptomatic. In the remaining 15 symptomatic patients (71.42%), symptomatology consisted in: dysuria in 12 cases (57.14%), pollakiuria in 8 patients (38.1%), urinary tract infection in 4 cases (19.1%), hematuria in 7 cases (33.33%) and menouria (hematuria coinciding with menstruation) in 7 cases (33.33%). Regarding the relation with the menstrual period, 10 patients (47.61%) reported symptoms that occur in a cyclic pattern, usually during the premenstrual period.

Discussion Bladder endometriosis symptomatology vary considerably depending on the location and site of the lesion [7]. Although can be asymptomatic, 70% of women with BE have lower urinary tract symptoms [7]. Specific symptoms are present infrequently and BE is frequently underdiagnosed. Usually patients report nonspecific symptoms such as dysmenorrhea, dyspareunia, infertility and chronic pelvic pain. Patients with BE complain also about dysuria, hematuria, pollakiuria, urinary tract infections, burning sensation and suprapubic discomfort and pain, as part of an acute urethral syndrome [6, 7, 11]. Hematuria is described only in 20-35% of patients, due to the fact that endometrial lesion infiltrates the bladder from the pericystium toward the mucosa (from outside to inside) and for this reason BE rarely infiltrates the mucosal layer of the hollow viscera [7, 12]; our study showed similar results. Menouria appears in 20-25% of cases, only when mucosa is affected [13]; our results (33.33%) are higher, but in accordance with the lesions that infiltrated the mucosal layer of the bladder.

Conclusions Bladder endometriosis is the most common localization of urinary tract endometriosis. Diagnosis is often delayed because patients are asymptomatic or have nonspecific symptoms. The most frequently reported symptoms are dysuria, pollakiuria, hematuria, menouria and urinary tract infections. Patients thorough medical history combined with imagistic and endoscopic examination are essential for early diagnosis of bladder endometriosis.

REFERENCES 1. Vigano P, Parazzini F, Somigliana E, Vercellini P. Endometriosis: epidemiology and

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© Filodiritto Editore - Proceedings aetiological factors. Best Pract Res Clin Obstet Gynaecol 2004; 18:177–200. 2. Koninckx PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie FJ. Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril 1991; 55:759–765. 3. Jenkins S, Olive DL, Haney AF. Endometriosis: pathogenetic implications of the anatomic distribution. Obstet Gynecol 1986; 67: 335–338. 4. Cornillie FJ, Oosterlynck D, Lauweryns JM, Koninckx PR. Deeply infiltrating pelvic endometriosis: histology and clinical significance. Fertil Steril 1990; 53: 978–983. 5. Chapron C, Fauconnier A, Vieira M, Barakat H, Dousset B, Pansini V, Vacher-Lavenu MC, Dubuisson JB: Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification. Hum Reprod 2003; 18: 157–161. 6. Collinet P, Marcelli F, Villers A, Regis C, Lucot JP, Cosson M, Vinatier D: Management of endometriosis of the urinary tract. Gynecol Obstet Fertil 2006; 34: 347–352. 7. Donnez J, Spada F, Squifflet J, Nisolle M: Bladder endometriosis must be considered as bladder adenomyosis. Fertil Steril 2000; 74: 1175–1181. 8. Comiter CV: Endometriosis of the urinary tract. Urol Clin North Am 2002; 29: 625– 635. 9. Vercellini P, Frontino G, Pisacreta A, De Giorgi O, Cattaneo M, Crosignani PG: The pathogenesis of bladder detrusor endometriosis. Am J Obstet Gynecol 2002; 187: 538– 542. 10. Somigliana E, Vercellini P, Gattei U, Chopin N, Chiodo I, Chapron C: Bladder endometriosis: getting closer and closer to the unifying metastatic hypothesis. Fertil Steril 2007; 87: 1287–1290. 11. Villa G, Mabrouk M, Guerrini M, Mignemi G, Montanari G, Fabbri E, Venturoli S, Seracchioli R: Relationship between site and size of bladder endometriotic nodules and severity of dysuria. J Minim Invasive Gynecol 2007; 14: 628–632. 12. Abrao MS, Dias JA Jr, Bellelis P, Podgaec S, Bautzer CR, Gromatsky C: Endometriosis of the ureter and bladder are not associated diseases. Fertil Steril 2009; 91: 1662–1667. 13. Westney OL, Amundsen CL, McGuire EJ: Bladder endometriosis: conservative management. J Urol 2000; 163: 1814–1817.

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Vaginal hysterectomy - an economic and less invasive type of approach Stuparu-Cretu Mariana¹,², Caraman Liliana¹,², Calin Alina Mihaela¹,³ Faculty of Medicine and Pharmacy, University “Dunarea de Jos” Galati (ROMANIA) Obstetrics and Gynecology Hospital “Bunavestire” Galați (ROMANIA) 3 Clinical Hospital “Sf. Apostol Andrei” Galați (ROMANIA) E-mails: [email protected], [email protected] 1 2

Abstract Introduction

As caesarean section in the obstetrics, the hysterectomy kept its place on the podium of the most common surgeries in gynecology. The way still oscillates between the transabdominal approach and vaginal approach and/or laparoscopic. Although the frequency of vaginal hysterectomy has increased, the indications regarding the type of approach covers both the pathology and age and parity, leaving the orientation to the surgeon’s sole discretion, depending on his professional experience.

Materials and methods

The therapeutic indication, route of approach, complications and costs regarding the non-gynecological cases hysterectomised in the Gynecology Departments of Galati Clinical Hospitals “Bunavestire” and “Sf. Andrei” in the last eight years were analyzed in retrospect.

Results

The main indications for which abdominal hysterectomy has been carried out were the excessive bleeding (24.7%) and uterine fibroids (59.1%), while the vaginal approach has been practiced for uterine prolapse in 60.8% of cases, for women aged over 60 years or general pathologies associated. Recovery of patients was faster in cases with vaginal approach, and the average length of hospital stay, the costs of investigations, and the medication were lower in the same cases.

Conclusion

Although the vaginal way of approach represented a percentage below 20% of the casuistry, the study demonstrated the benefits for the patients regarding the range of ages, development of complications, and recovery and the benefits of efficiency and unit costs.

Keywords: hysterectomy, surgical approach, vaginal hysterectomy

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© Filodiritto Editore - Proceedings Introduction After cesarean section, the gynecological practice kept hysterectomy on the podium of the most common surgeries performed around the globe, indicated for benign causes in over 90% of cases. As the etymology suggests (hystera-uterus + ektomé –cutting out), hysterectomy refers mainly to the removal of the uterus. The decision to keep or not the cervix and annexes described the types of hysterectomy (subtotal, total or radical). Originally mentioned in ancient Greece, the medical history notes the first vaginal hysterectomy (VH) in Italy at the beginning of the XVI century, followed by impaired sexual life. Later, in the XVIII century, most doctors forecast a low probability of survival after hysterectomy due to a mortality rate of ~90% due to massive bleeding or infections [1], [2]. The XIX century brought the benefits of antisepsis and anesthesia and thus the success of hysterectomy, the first successful VH being mentioned in Germany in 1813. The laparoscopic procedure has been used since 1940, and the first laparoscopic-assisted VH was practiced in 1989 [1], [2]. Studies in recent years estimate that over one third of women in the United States have had a hysterectomy by age 60, and yearly costs amount to ~$ 50 million [3], [4]. Hysterectomy has been the subject of many studies and today is considered a routine surgery. The medical aspect of the indications and possible complications as well as the efficiency of medical acts in terms of costs and postoperative recovery of patients have been analyzed. Dilemmas which have arisen over the years referred to the need for intervention, psychological impact, complications, and limitations versus conservative alternative therapies. [5]. Most often, the collation between the pathology of patient, other personal data, and the preferences of the surgeon based on personal experience, decided both the indication for surgery and the approach way (abdominal, vaginal or laparoscopic).

Methodology The retrospective study comprises data concerning the age and environment of patients, therapeutic indication and the approach route of hysterectomies performed during the period 2008-2015 in the Obstetrics and Gynecology Hospital “Bunavestire” and the Obstetrics and Gynecology Department of Clinical Hospital “Sf. Apostol Andrei” Galati, Romania. For the same type of pathology, the existence of complications, recovery and hospitalization costs were compared between the types of interventions. Data were obtained from the statistics of the county, identified by codes comprised in the International Classification of Diseases, WHO’s 10th Revision and the medical records of health facilities. The main diagnoses for which a hysterectomy was carried out have been identified by age group. The cases were grouped by type of abdominal and vaginal approach and those with the same diagnosis code have been compared. Hospitalization costs relating to the average number of hospitalization days, investigations, medication and medical supplies, the occurrence of complications have been noted. Data were processed for statistical purposes with Microsoft Excel 2010 program, Data Analysis ToolPak.

Results The 90 beds of the gynecology departments are serving the female population of Galati

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© Filodiritto Editore - Proceedings County, represented by 246,275 people aged over 19 years, from the total of 632,452 inhabitants at the end of 2015 [6]. A rate of 5.6% of patients are from neighboring counties. The study identified 1182 women hysterectomised during the period 2008-2015, so the intervention was practiced on 24.2/100,000 inhabitants in 2008 and 30.8/100,000 inhabitants in 2015, far below the country average reported [6]. Basically, 187 from 1,000 women in Galati County aged over 19 years have had a hysterectomy in the past eight years. If in the USA 217 hysterectomies have been performed per 100,000 inhabitants, when referring to Europe, the Eurostat statistics show that in 2015, the highest number of hysterectomies was estimated in Germany (153.4/100,000 inhabitants) and Switzerland, and the fewest in Denmark (20/100,000 inhabitants). Laparoscopic surgical approach to hysterectomy prevails in Switzerland, Poland, Finland (over half of cases), while Romania is the penultimate country on the Eurostat list (2.3 of a total of 106.6/100,000 inhabitants), followed by Macedonia [7]. The studied cases were divided into two groups, depending on the type of approach: 232 women have undergone an intervention by vaginal route (19.6%) and the remaining 944 cases were solved by abdominal route (80.4%) - Table1. We note that the number of VH declined progressively due to the change of surgical teams, young professionals who replaced the retired doctors, preferred the abdominal approach - however, the percentage is similar to other previous studies [8]. In case of VH, most doctors comply to excise the uterus (80%), compared to 37.6% for abdominal hysterectomy (AH). In more than half of AH, a bilateral anexectomy was practiced, compared to 17.4% for VH and a small percentage of unilateral anexectomy. The results are comparable with data from the French College of Obstetrics and Gynecology, which recommends the preservation of the ovaries for premenopausal women. [9]. The age of patients was comprised between 27 and 84 years, with a higher percentage of AH for the groups of 25-59 years, compared to VH which prevailed at ages over 60 yearsTable 1. From the point of view of surgical indication, AH was preferentially practiced in case of excessive bleeding (1/4 of cases) and symptomatic uterine fibroids (over 1/2 of cases), the vaginal hysterectomy in case of uterine prolapse being preferred to ~ 2/3 of cases, for women aged 60 years or associated general pathologies - Table 1. Table 1: The correlation for the main frequency features in cases with VH and AH Frequency % Type of approach

VH 19,6

AH 80,4

p-value* -

25-39 years 40-59 years 60-79 years 80 years and more

2,1 26,3 67,7 3,9

14,9 72 12,1 0,3

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