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Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
Epidemiologia della disfunzione perineale vignoli
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Epidemiologia della disfunzione perineale vignoli

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GLUP_Gardone_Epidemiologia della disfunzione perineale – G. Vignoli

GLUP_Gardone_Epidemiologia della disfunzione perineale – G. Vignoli

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  • 1. The Prevalence of Pelvic Floor Dysfunctions Descriptive and Analitical analysis in relation to obstetric event Giancarlo Vignoli ,MD Functional Urology Unit , Casa Madre Fortunata Toniolo , Bologna
  • 2. Foreword <ul><li>Existing data about potentially causal factors of obstetric event on pelvic floor dysfunction, limit our ability to evaluate critically any recommendations for a primary prevention of PDF at delivery.  </li></ul>
  • 3. Reference list of relevant articles <ul><li>Prevalence of pelvic floor disorders in the female population and the impact of age, mode of delivery, and parity. </li></ul><ul><li>Kepenekci I ,  Keskinkilic B ,  Akinsu F ,  Cakir P ,  Elhan AH ,  Erkek AB ,  Kuzu MA . Dis Colon Rectum. 2011 </li></ul><ul><li>Vaginal delivery and pelvic floor dysfunction: current evidence and implications for future research. </li></ul><ul><li>Bortolini MA ,  Drutz HP ,  Lovatsis D ,  Alarab M . Int Urogynecol J Pelvic Floor Dysfunct. 2010  </li></ul><ul><li>Incidence and etiology of pelvic floor dysfunction and mode of delivery: an overview.   </li></ul><ul><li>Turner CE ,  Young JM ,  Solomon MJ ,  Ludlow J ,  Benness C . Int Urogynecol J Pelvic Floor Dysfunct. 2010 </li></ul><ul><li>The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery.   </li></ul><ul><li>MacLennan AH ,  Taylor AW ,  Wilson DH ,  Wilson D . Dis Colon Rectum. 2009 </li></ul><ul><li>Epidemiology of female pelvic floor dysfunction </li></ul><ul><li>Sung VW ,  Hampton BS . Obstet Gynecol Clin North Am. 2009 </li></ul><ul><li>Epidemiology and natural history of pelvic floor dysfunction. </li></ul><ul><li>Bump RC ,  Norton PA . Obstet Gynecol Clin North Am. 1998  </li></ul><ul><li>The epidemiology of female pelvic floor dysfunction. </li></ul><ul><li>Mallett VT ,  Bump RC . Curr Opin Obstet Gynecol. 1994  </li></ul>
  • 4. Pelvic Floor Dysfunctions <ul><li>HYPO- </li></ul><ul><li>Urinary Incontinence </li></ul><ul><li>Fecal Incontinence </li></ul><ul><li>Pelvic Organ Prolapse </li></ul><ul><ul><li>HYPER- </li></ul></ul><ul><ul><li>Voiding Dysfunction </li></ul></ul><ul><li>Defecatory Dysfunction </li></ul><ul><li>Sexual Dysfunction &amp; Chronic Pain Disorders </li></ul>
  • 5. <ul><li>Most epidemiological studies correlate obstetric event to hypo - pelvic floor dysfunctions </li></ul>
  • 6. Prevalence of Hypo - Pelvic Floor Disorders <ul><li>Urinary (urge or stress) incontinence 17% - 45% </li></ul><ul><li>Anal (faecal or flatus) incontinence 0.4% - 17% </li></ul><ul><li>Urogenital prolapse 20% </li></ul>
  • 7. Basic Methodological Considerations <ul><li>Virtually all epidemiologic studies rely on participant self-report </li></ul><ul><li>Symptom-based diagnosis ( QUESTIONNAIRES , PHONE CALLS ,WEB INTERVIEWS ) underestimates the true prevalence of pelvic floor dysfunctions . </li></ul>
  • 8. FEMALE INCONTINENCE Validated diagnostic questions vs diagnosis after urodynamics <ul><li>SUI 51% 77% </li></ul><ul><li>Mixed 39% 11% </li></ul><ul><li>UI 10% 12% </li></ul><ul><li>“ bladder unreliable witness “ </li></ul><ul><li>Sandvik H et al,J Clin Epidemiol , 1995 </li></ul>
  • 9. POP in asymptomatic women <ul><li>Swift SE ,AJOG ,2000 </li></ul>
  • 10. Basic Methodological Considerations <ul><li>Descriptive Epidemiology : </li></ul><ul><li>- description of disease prevalence </li></ul><ul><li>Analitical Epidemiology: </li></ul><ul><li>- search for determinants of disease risks </li></ul>
  • 11. PF D risk factors model by BUMP &amp; NORTON ,1998
  • 12. Graphic Integration of PDF by DeLancey et al , 2008
  • 13. <ul><li>DeLancey J , Am J Obstet Gynecol , 2008 </li></ul>
  • 14. “ Poor Quality Pelvic Floor “ <ul><li>What really means ? </li></ul>
  • 15. Badlani G, AUA Lecture at EAU Congress 2011
  • 16. Allen-Brady K, Norton P et al Am J Hum Gen , 2009 <ul><li>Several genes linked to elastin synthesis and collagen degradation </li></ul>
  • 17. Badlani G, AUA Lecture at EAU Congress 2011
  • 18. Connective tissue is a living structure that undergoes remodeling in response to various factors.  <ul><li>COLLAGEN : </li></ul><ul><li>Reduced collagen production </li></ul><ul><li>- Ulmsten U, 1987 </li></ul><ul><li>- Bergman A ,1994 ( less hydroxyproline ) </li></ul><ul><li>- Falconer C ,1994 ( fibroblasts less active ) </li></ul><ul><li>Changes in type 1 to type 3 ratio </li></ul><ul><li>- Falconer C , 1998 ( higher ratio in incontinence) (Menopause – Estrogens) </li></ul><ul><li>- Norton P, 1992 ( lower ratio in POP ) </li></ul><ul><li>- Keane D ,1997 ( lower ratio in POP ) (wound repair principles) </li></ul><ul><li>- Liapis A, 2000–1 ( lower ratio in incontinence and POP) </li></ul><ul><li>Increased collagen breakdown </li></ul><ul><li>- Chen B , 2002 ( increased metalloproteinases activity) </li></ul><ul><li>ELASTIN </li></ul><ul><li>Elastin may impart extensibility and elastic recoil to particular collagenous tissues.  </li></ul><ul><li>Alteration of elastin metabolism in women with pelvic organ prolapse . </li></ul><ul><li>Moon YJ, Choi JR, Jeon MJ, Kim SK, Bai SW. </li></ul><ul><li>J Urol. 2011 May;185(5):1786-92. </li></ul><ul><li>Alteration of vaginal elastin metabolism in women with pelvic organ prolapse . </li></ul><ul><li>Zong W, Stein SE, Starcher B, Meyn LA, Moalli PA. </li></ul><ul><li>Obstet Gynecol. 2010 May;115(5):953-61. </li></ul><ul><li>MATRIX </li></ul><ul><li>Include linker glycoproteins (ie, fibronectin, vitronectin, and laminin), which provide a direct linkage role to cell surfaces of collagens  </li></ul><ul><li>LOX family enzymes expression in vaginal tissue of premenopausal women with severe pelvic organ prolapse . </li></ul><ul><li>Alarab M, Bortolini MA, Drutz H, Lye S, Shynlova O. </li></ul><ul><li>Int Urogynecol J Pelvic Floor Dysfunct. 2010 Nov;21(11):1397-404. </li></ul>
  • 19. 1° Birth Damage &amp; Repair <ul><li>DeLancey J , Am J Obstet Gynecol , 2008 </li></ul>
  • 20. <ul><li>There is no agreement whether it is pregnancy per se  * or parturition that predisposes to pelvic floor dysfunction . </li></ul><ul><li>*Mid-trimester serum relaxin concentrations and post-partum pelvic floor dysfunction. </li></ul><ul><li>Harvey MA, Johnston SL, Davies GA.Acta Obstet Gynecol Scand. 2008;87(12):1315-21. </li></ul>
  • 21. PELVIC FLOOR STRUCTURES INVOLVED IN VAGINAL DELIVERY <ul><li>Levator Ani </li></ul><ul><li>Apical Support </li></ul><ul><li>Urethral Support </li></ul><ul><li>Descriptive Epidemiology: </li></ul><ul><li>Overall risk PFD 10.8% </li></ul><ul><li>SUI 4-25% </li></ul><ul><li>FI 26% </li></ul><ul><li>Vaginal wall prolapse 52% </li></ul><ul><li>Bortolini M.A.T. et al , Int Urogynecol J,2010 </li></ul><ul><li>Analitical Epidemiology : </li></ul><ul><li>What are determinants of disease risk? </li></ul>
  • 22. Levator Ani
  • 23. &nbsp;
  • 24. TRANSLATION of BIOMECHANICS to UROGYNECOLOGY <ul><li>Ashton-Miller &amp; DeLancey,2009 </li></ul>
  • 25. 3D- COMPUTER RECONSTRUCTION <ul><li>Pubo-coccygeal m. stretch ratio in 2° stage : 3.25 </li></ul><ul><li>Striated muscle maximun tolerated stretch ratio : 1.5 </li></ul>
  • 26. Partial avulsion of the pubo-coccygeal muscle off its insertion
  • 27. Clinical correlates
  • 28. Apical Support
  • 29. 3D COMPUTER SIMULATION OF VAGINAL PROLAPSE CHEN L et al , 2008 <ul><li>Simulation of vaginal prolapse utilizing ABAQUS technology </li></ul><ul><li>John DeLancey </li></ul>
  • 30. Urethral Support
  • 31. &nbsp;
  • 32. &nbsp;
  • 33. Summary Points <ul><li>Levator damage POP </li></ul><ul><li>Apical support damage Vag. wall prolapse </li></ul><ul><li>Poor urethral function SUI </li></ul>
  • 34. FECAL INCONTINENCE ( 26%) <ul><li>Anal sphincter damage </li></ul><ul><li>Pudendal nerve damage </li></ul><ul><li>What are determinants of disease risk? </li></ul>
  • 35. Anal Spincter Damage ( 5% ) <ul><li>Over 35% of primiparous women suffer some degree of damage to the external anal sphincter, persisting until six months post vaginal delivery </li></ul><ul><li>Lesions of the external anal sphincter are significantly related to lacerations and/or episiotomy, while internal anal sphincter lesions may occur with an intact perineum </li></ul><ul><li>Permanent sphincter damage account for 5% of fecal incontinence ( Eason E et al ,J Canad Med Ass.2002 ) </li></ul>
  • 36. Pudendal Nerve Damage ( 32%) <ul><li>The nerves innervating the anal sphincter are stretched beyond the 15% strain threshold known to cause permanent damage in the peripheral nerve ( Ashton-Miller et al ,AJOG,2005 ) </li></ul><ul><li>Permanent pudendal nerve damage account for 32% of fecal incontinence ( Fitzpatrick et al,AJOG,2003 ) </li></ul>
  • 37. 2° Birth Damage <ul><li>DeLancey J , Am J Obstet Gynecol , 2008 </li></ul>
  • 38. <ul><li>DeLancey J , Am J Obstet Gynecol , 2008 </li></ul>
  • 39. AGE-RELATED PELVIC FLOOR MODIFICATIONS <ul><li>Connective tissue is a living structure that undergoes remodeling in response to various factors.  </li></ul><ul><li>COLLAGEN : </li></ul><ul><li>Reduced collagen production </li></ul><ul><li>- Ulmsten U, 1987 </li></ul><ul><li>- Bergman A ,1994 ( less hydroxyproline ) </li></ul><ul><li>- Falconer C ,1994 ( fibroblasts less active ) </li></ul><ul><li>Changes in type 1 to type 3 ratio </li></ul><ul><li>- Falconer C , 1998 ( higher ratio in incontinence) (Menopause – Estrogens) </li></ul><ul><li>- Norton P, 1992 ( lower ratio in POP ) </li></ul><ul><li>- Keane D ,1997 ( lower ratio in POP ) (wound repair principles) </li></ul><ul><li>- Liapis A, 2000–1 ( lower ratio in incontinence and POP) </li></ul><ul><li>Increased collagen breakdown </li></ul><ul><li>- Chen B , 2002 ( increased metalloproteinases activity) </li></ul><ul><li>ELASTIN </li></ul><ul><li>Elastin may impart extensibility and elastic recoil to particular collagenous tissues.  </li></ul><ul><li>MATRIX </li></ul><ul><li>Include linker glycoproteins (ie, fibronectin, vitronectin, and laminin), which provide a direct linkage role to cell surfaces of collagens  </li></ul><ul><li>Tinelli A . et al , Menopause 2010 </li></ul>
  • 40. Accelerated deterioration may influence surgical repair
  • 41. DNA microarrays analysis <ul><li>In a DNA sequence , some genes are working , many others no </li></ul><ul><li>How much they work ? </li></ul><ul><li>Technique : </li></ul><ul><li>mRNA extraction </li></ul><ul><li>Fluorescent labeling of cDNA’s </li></ul><ul><li>Hybridization to DNA chips (sequence of thousand genes ) </li></ul><ul><li>Scanning the hybridized array </li></ul><ul><li>Human Genome U95A </li></ul>
  • 42. POP &amp; DNA microarray analysis 12626 TOTAL GENES ( muscles , ECM, others) <ul><li>Underexpressed </li></ul><ul><li>2-fold 257 </li></ul><ul><li>5-fold 20 </li></ul><ul><li>10-fold 3 </li></ul><ul><li>Overexpressed </li></ul><ul><li>2-fold 479 </li></ul><ul><li>5-fold 18 </li></ul><ul><li>10-fold 2 </li></ul><ul><li>Visco A,Yuan L : </li></ul><ul><li>Differential gene expression in pubococcygeus muscle from pts. with POP. Amer J Obstet Gynecol , 2003 </li></ul>
  • 43. <ul><li>DeLancey J , Am J Obstet Gynecol , 2008 </li></ul>
  • 44. Lifestyle Impact <ul><li>OBESITY </li></ul><ul><li>Data from numerous cross-sectional studies indicate that PDF in women is associated with higher body mass index and greater weight </li></ul><ul><li>Obesity may also act via pathways other ( metabolism ? ) than increased intraabdominal pressure. </li></ul><ul><li>ESTROGENS </li></ul><ul><li>HERS 2001 : postmenopausal women randomized to conjugated oral estrogen plus medroxyprogesterone were more likely then women taking the placebo to experience worsening of their incontinence over 4 years (39%vs 27%, p&lt;.001) </li></ul><ul><li>“ Estrogens increase elastolytic activity in fibroblasts” </li></ul><ul><li>SMOKING </li></ul><ul><li>Conflicting data </li></ul><ul><li>PHYSICAL ACTIVITY </li></ul><ul><li>Risk factor in the short term , but protective in the long term </li></ul>
  • 45. CONCLUSIONS <ul><li>Epidemiological studies reaffirms vaginal delivery as the main etiological agent of pelvic floor dysfunction. </li></ul><ul><li>Obstetrical event must be put in context of predisposing factors such as predisposing and other phenotypic risk factors that occur during the 40 to 50 years of life after delivery. </li></ul><ul><li>Future goal will be toward the quantification of the degree to which each of these factors contributes to development of pelvic floor disorders in order to improve both prevention </li></ul><ul><li>( primary &amp; secondary ) and consequent treatment strategies. </li></ul>

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