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American Family Physician Aug 2017Pelvic organ prolapse is the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of the vagina (vaginal vault... (Review)
Review
Pelvic organ prolapse is the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy). Prevalence increases with age. The cause of prolapse is multifactorial but is primarily associated with pregnancy and vaginal delivery, which lead to direct pelvic floor muscle and connective tissue injury. Hysterectomy, pelvic surgery, and conditions associated with sustained episodes of increased intra-abdominal pressure, including obesity, chronic cough, constipation, and repeated heavy lifting, also contribute to prolapse. Most patients with pelvic organ prolapse are asymptomatic. Symptoms become more bothersome as the bulge protrudes past the vaginal opening. Initial evaluation includes a history and systematic pelvic examination including assessment for urinary incontinence, bladder outlet obstruction, and fecal incontinence. Treatment options include observation, vaginal pessaries, and surgery. Most women can be successfully fit with a vaginal pessary. Available surgical options are reconstructive pelvic surgery with or without mesh augmentation and obliterative surgery.
Topics: Female; Humans; Pelvic Organ Prolapse
PubMed: 28762694
DOI: No ID Found -
International Braz J Urol : Official... 2020The exact prevalence of pelvic organ prolapse is difficult to establish. The anatomical changes do not always consist with the severity or the symptoms associated with... (Review)
Review
The exact prevalence of pelvic organ prolapse is difficult to establish. The anatomical changes do not always consist with the severity or the symptoms associated with prolapse. There are many risk factors associated with pelvic organ prolapse and this review aims to identify the epidemiology and pathophysiology while looking at the known risk factors for pelvic organ prolapse. PubMed search involved a number of terms including: epidemiology, risk factors, reoccurrence indicators, management and evaluation. Several risk factors have been associated with pelvic organ prolapse, all contribute to weakening of the pelvic floor connective tissue/collagen, allowing the pelvic organs to prolapse through the vaginal walls. Among the risk factors are genetic background, childbirth and mode of delivery, previous hysterectomy, menopausal state and the ratio between Estrogen receptors. The "Integral theory" of Petros and the "Levels of Support" model of Delancey enable us to locate the defect, diagnose and treat pelvic organ prolapse. The currently available demographic data is not reliable enough to properly estimate the true extent of pelvic organ prolapse in the population. However, standardization of the diagnosis and treatment may significantly improve our ability to estimate the true incidence and prevalence of this condition in the coming years.
Topics: Collagen; Female; Humans; Menopause; Obesity; Parity; Pelvic Floor; Pelvic Organ Prolapse; Risk Factors
PubMed: 31851453
DOI: 10.1590/S1677-5538.IBJU.2018.0581 -
Journal of Cosmetic Dermatology Oct 2021Botulinum toxin A (BoNT-A) has grown tremendously in aesthetic dermatology since 2002 when the United States Food and Drug Administration (FDA) first approved its use... (Review)
Review
BACKGROUND
Botulinum toxin A (BoNT-A) has grown tremendously in aesthetic dermatology since 2002 when the United States Food and Drug Administration (FDA) first approved its use for treating moderate-to-severe glabellar lines. Blepharoptosis, due to local spread of toxin, is a reported side effect of BoNT-A which, although rare, more frequently occurs among inexperienced practitioners.
OBJECTIVES
The purpose of this review is to highlight the causes and management of eyelid ptosis secondary to BoNT-A administration including new anatomic pathways for BoNT-A spread from the brow area to the levator palpebrae superioris muscle.
METHODS
A literature search was conducted using electronic databases (PubMed, Science Direct, MEDLINE, Embase, CINAHL, EBSCO) regarding eyelid anatomy and the underlying pathogenesis, presentation, prevention, and treatment of eyelid ptosis secondary to BoNT-A. Anatomic dissection has been performed to assess the role of neurovascular pedicles and supraorbital foramen anatomic variations.
RESULTS
Blepharoptosis occurs due to weakness of the levator palpebrae superioris muscle. Mean onset is 3-14 days after injection and eventually self-resolves after the paralytic effect of BoNT-A wanes. Administration of medications, such as oxymetazoline hydrochloride or apraclonidine hydrochloride eye drops, anticholinesterase agents, or transdermal BoNT-A injections to the pre-tarsal orbicularis, can at least partially reverse eyelid ptosis. Anatomic study shows that a supraorbital foramen may be present in some patients and constitutes a shortcut from the brow area directly into the orbital roof, following the supraorbital neurovascular pedicle.
CONCLUSION
Providers should understand the anatomy and be aware of the causes and treatment for blepharoptosis when injecting BoNT-A for the reduction of facial wrinkles. Thorough anatomic knowledge of the supraorbital area and orbital roof is paramount to preventing incorrect injection into "danger zones," which increase the risk of eyelid ptosis.
Topics: Blepharoptosis; Botulinum Toxins, Type A; Humans; Neuromuscular Agents; Oculomotor Muscles; Skin Aging
PubMed: 34378298
DOI: 10.1111/jocd.14361 -
Eye (London, England) Sep 2021Blepharoptosis (ptosis) is among the most common disorders of the upper eyelid encountered in both optometric and ophthalmic practice. The unilateral or bilateral... (Review)
Review
Blepharoptosis (ptosis) is among the most common disorders of the upper eyelid encountered in both optometric and ophthalmic practice. The unilateral or bilateral drooping of the upper eyelid that characterises ptosis can affect appearance and impair visual function, both of which can negatively impact quality of life. While there are several known forms of congenital ptosis, acquired ptosis (appearing later in life, due to a variety of causes) is the predominant form of the condition. This review summarises the prevalence, causes, identification, differential diagnosis, and treatment of acquired ptosis. Particular attention is paid to the differential diagnosis of acquired ptosis and emerging treatment options, including surgical and pharmacologic approaches.
Topics: Blepharoplasty; Blepharoptosis; Eyelids; Humans; Prevalence; Quality of Life
PubMed: 33927356
DOI: 10.1038/s41433-021-01547-5 -
American Journal of Obstetrics and... Aug 2022To update a previously published systematic review and perform a meta-analysis on the risk factors for primary pelvic organ prolapse and prolapse recurrence. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To update a previously published systematic review and perform a meta-analysis on the risk factors for primary pelvic organ prolapse and prolapse recurrence.
DATA SOURCES
PubMed and Embase were systematically searched. We searched from July 1, 2014 until July 5, 2021. The previous search was from inception until August 4, 2014.
STUDY ELIGIBILITY CRITERIA
Randomized controlled trials and cross-sectional and cohort studies conducted in the Western developed countries that reported on multivariable analysis of risk factors for primary prolapse or prolapse recurrence were included. The definition of prolapse was based on anatomic references, and prolapse recurrence was defined as anatomic recurrence after native tissue repair. Studies on prolapse recurrence with a median follow-up of ≥1 year after surgery were included.
METHODS
Quality assessment was performed with the Newcastle-Ottawa Scale. Data from the previous review and this review were combined into forest plots, and meta-analyses were performed where possible. If the data could not be pooled, "confirmed risk factors" were identified if ≥2 studies reported a significant association in multivariable analysis.
RESULTS
After screening, 14 additional studies were selected-8 on the risk factors for primary prolapse and 6 on prolapse recurrence. Combined with the results from the previous review, 27 studies met the inclusion criteria, representing the data of 47,429 women. Not all studies could be pooled because of heterogeneity. Meta-analyses showed that birthweight (n=3, odds ratio, 1.04; 95% confidence interval, 1.02-1.06), age (n=3, odds ratio, 1.34; 95% confidence interval, 1.23-1.47), body mass index (n=2, odds ratio, 1.75; 95% confidence interval, 1.17-2.62), and levator defect (n=2, odds ratio, 3.99; 95% confidence interval, 2.57-6.18) are statistically significant risk factors, and cesarean delivery (n=2, pooled odds ratio, 0.08; 95% confidence interval, 0.03-0.20) and smoking (n=3, odds ratio, 0.59; 95% confidence interval, 0.46-0.75) are protective factors for primary prolapse. Parity, vaginal delivery, and levator hiatal area are identified as "confirmed risk factors." For prolapse recurrence, preoperative prolapse stage (n=5, odds ratio, 2.68; 95% confidence interval, 1.93-3.73) and age (n=2, odds ratio, 3.48; 95% confidence interval, 1.99-6.08) are statistically significant risk factors.
CONCLUSION
Vaginal delivery, parity, birthweight, age, body mass index, levator defect, and levator hiatal area are risk factors, and cesarean delivery and smoking are protective factors for primary prolapse. Preoperative prolapse stage and younger age are risk factors for prolapse recurrence after native tissue surgery.
Topics: Birth Weight; Cross-Sectional Studies; Delivery, Obstetric; Female; Humans; Pelvic Organ Prolapse; Pregnancy; Risk Factors
PubMed: 35500611
DOI: 10.1016/j.ajog.2022.04.046 -
Revista de Neurologia Sep 2022Myasthenia gravis is characterized by skeletal muscle weakness, the most common initial presentation includes ocular weakness with asymmetric ptosis and binocular... (Review)
Review
INTRODUCTION
Myasthenia gravis is characterized by skeletal muscle weakness, the most common initial presentation includes ocular weakness with asymmetric ptosis and binocular diplopia. Around 19-50% of pregnant women with myasthenia gravis will experience a worsening of the disease. The objective of this article was to review the current information regarding the interrelation between MG and pregnancy; as well as its approach.
DEVELOPMENT
Bibliographic search in databases such as PubMed, ScienceDirect, SciELO, Google Scholar and medRxiv. Original articles, reviews, series and case reports between 2013 and 2022 are included.
CONCLUSIONS
Myasthenia gravis would not significantly effects on pregnancy; however, pregnancy can exacerbate the disease, especially during the first trimester or after delivery. The approach to pregnant women with myasthenia gravis must be multidisciplinary and involves the adjustment of pharmacological treatment and constant monitoring.
Topics: Blepharoptosis; Diplopia; Eye; Female; Humans; Muscle Weakness; Myasthenia Gravis; Pregnancy
PubMed: 35880965
DOI: 10.33588/rn.7505.2022207 -
International Urogynecology Journal Nov 2015Pelvic organ prolapse (POP) is a common condition with multifactorial etiology. The purpose of this systematic review was to provide an overview of literature on risk... (Review)
Review
INTRODUCTION AND HYPOTHESIS
Pelvic organ prolapse (POP) is a common condition with multifactorial etiology. The purpose of this systematic review was to provide an overview of literature on risk factors for POP and POP recurrence.
METHODS
PubMed and Embase were searched with "pelvic organ prolapse" combined with "recurrence" and combined with "risk factors," with Medical Subject Headings and Thesaurus terms and text words variations until 4 August 2014, without language or publication date restrictions. Only cohort or cross-sectional studies carried out in western developed countries containing multivariate analyses and with a definition of POP based on anatomical references were included. POP recurrence had to be defined as anatomical recurrence after native tissue repair without mesh. Follow-up after surgery should have been at least 1 year. Articles were excluded if POP was not a separate entity or if it was unclear whether the outcome was primary POP or recurrence.
RESULTS
PubMed and Embase revealed 2,988 and 4,449 articles respectively. After preselection, 534 articles were independently evaluated by two researchers, of which 15 met the selection criteria. In 10 articles on primary POP, 30 risk factors were investigated. Parity, vaginal delivery, age, and body mass index (BMI) were significantly associated in at least two articles. In 5 articles on POP recurrence, 29 risk factors were investigated. Only preoperative stage was significantly associated in at least two articles.
CONCLUSION
Parity, vaginal delivery, age, and BMI are risk factors for POP and preoperative stage is a risk factor for POP recurrence.
Topics: Female; Humans; Pelvic Organ Prolapse; Recurrence; Risk Factors
PubMed: 25966804
DOI: 10.1007/s00192-015-2695-8 -
Nature Communications Jan 2021Anterior vaginal prolapse (AVP) is the most common form of pelvic organ prolapse (POP) and has deleterious effects on women's health. Despite recent advances in AVP...
Anterior vaginal prolapse (AVP) is the most common form of pelvic organ prolapse (POP) and has deleterious effects on women's health. Despite recent advances in AVP diagnosis and treatment, a cell atlas of the vaginal wall in AVP has not been constructed. Here, we employ single-cell RNA-seq to construct a transcriptomic atlas of 81,026 individual cells in the vaginal wall from AVP and control samples and identify 11 cell types. We reveal aberrant gene expression in diverse cell types in AVP. Extracellular matrix (ECM) dysregulation and immune reactions involvement are identified in both non-immune and immune cell types. In addition, we find that several transcription factors associated with ECM and immune regulation are activated in AVP. Furthermore, we reveal dysregulated cell-cell communication patterns in AVP. Taken together, this work provides a valuable resource for deciphering the cellular heterogeneity and the molecular mechanisms underlying severe AVP.
Topics: Aged; Cell Communication; Female; Gene Expression Profiling; Gene Expression Regulation; Humans; Ligands; Middle Aged; Pelvic Organ Prolapse; Receptors, Cell Surface; Severity of Illness Index; Single-Cell Analysis; Transcription Factors; Uterine Prolapse; Vagina
PubMed: 33397933
DOI: 10.1038/s41467-020-20358-y -
JAMA Dec 2022Pelvic organ prolapse is a prevalent condition among women that negatively affects their quality of life. With increasing life expectancy, the global need for... (Comparative Study)
Comparative Study Randomized Controlled Trial
IMPORTANCE
Pelvic organ prolapse is a prevalent condition among women that negatively affects their quality of life. With increasing life expectancy, the global need for cost-effective care for women with pelvic organ prolapse will continue to increase.
OBJECTIVE
To investigate whether treatment with a pessary is noninferior to surgery among patients with symptomatic pelvic organ prolapse.
DESIGN, SETTING, AND PARTICIPANTS
The PEOPLE project was a noninferiority randomized clinical trial conducted in 21 participating hospitals in the Netherlands. A total of 1605 women with symptomatic stage 2 or greater pelvic organ prolapse were requested to participate between March 2015 through November 2019; 440 gave informed consent. Final 24-month follow-up ended at June 30, 2022.
INTERVENTIONS
Two hundred eighteen participants were randomized to receive pessary treatment and 222 to surgery.
MAIN OUTCOMES AND MEASURES
The primary outcome was subjective patient-reported improvement at 24 months, measured with the Patient Global Impression of Improvement scale, a 7-point Likert scale ranging from very much better to very much worse. This scale was dichotomized as successful, defined as much better or very much better, vs nonsuccessful treatment. The noninferiority margin was set at 10 percentage points risk difference. Data of crossover between therapies and adverse events were captured.
RESULTS
Among 440 patients who were randomized (mean [SD] age, 64.7 [9.29] years), 173 (79.3%) in the pessary group and 162 (73.3%) in the surgery group completed the trial at 24 months. In the population, analyzed as randomized, subjective improvement was reported by 132 of 173 (76.3%) in the pessary group vs 132 of 162 (81.5%) in the surgery group (risk difference, -6.1% [1-sided 95% CI, -12.7 to ∞]; P value for noninferiority, .16). The per-protocol analysis showed a similar result for subjective improvement with 52 of 74 (70.3%) in the pessary group vs 125 of 150 (83.3%) in the surgery group (risk difference, -13.1% [1-sided 95% CI, -23.0 to ∞]; P value for noninferiority, .69). Crossover from pessary to surgery occurred among 118 of 218 (54.1%) participants. The most common adverse event among pessary users was discomfort (42.7%) vs urinary tract infection (9%) following surgery.
CONCLUSIONS AND RELEVANCE
Among patients with symptomatic pelvic organ prolapse, an initial strategy of pessary therapy, compared with surgery, did not meet criteria for noninferiority with regard to patient-reported improvement at 24 months. Interpretation is limited by loss to follow-up and the large amount of participant crossover from pessary therapy to surgery.
TRIAL REGISTRATION
Netherlands Trial Register Identifier: NTR4883.
Topics: Female; Humans; Middle Aged; Netherlands; Patient Reported Outcome Measures; Pelvic Organ Prolapse; Pessaries; Quality of Life; Treatment Outcome; Aged; Gynecologic Surgical Procedures
PubMed: 36538310
DOI: 10.1001/jama.2022.22385 -
JAMA Aug 2023Surgical repairs of apical/uterovaginal prolapse are commonly performed using native tissue pelvic ligaments as the point of attachment for the vaginal cuff after a... (Comparative Study)
Comparative Study Randomized Controlled Trial
IMPORTANCE
Surgical repairs of apical/uterovaginal prolapse are commonly performed using native tissue pelvic ligaments as the point of attachment for the vaginal cuff after a hysterectomy. Clinicians may recommend vaginal estrogen in an effort to reduce prolapse recurrence, but the effects of intravaginal estrogen on surgical prolapse management are uncertain.
OBJECTIVE
To compare the efficacy of perioperative vaginal estrogen vs placebo cream on prolapse recurrence following native tissue surgical prolapse repair.
DESIGN, SETTING, AND PARTICIPANTS
This randomized superiority clinical trial was conducted at 3 tertiary US clinical sites (Texas, Alabama, Rhode Island). Postmenopausal women (N = 206) with bothersome anterior and apical vaginal prolapse interested in surgical repair were enrolled in urogynecology clinics between December 2016 and February 2020.
INTERVENTIONS
The intervention was 1 g of conjugated estrogen cream (0.625 mg/g) or placebo, inserted vaginally nightly for 2 weeks and then twice weekly to complete at least 5 weeks of application preoperatively; this continued twice weekly for 12 months postoperatively. Participants underwent a vaginal hysterectomy (if uterus present) and standardized apical fixation (either uterosacral or sacrospinous ligament fixation).
MAIN OUTCOMES AND MEASURES
The primary outcome was time to failure of prolapse repair by 12 months after surgery defined by at least 1 of the following 3 outcomes: anatomical/objective prolapse of the anterior or posterior walls beyond the hymen or the apex descending more than one-third of the vaginal length, subjective vaginal bulge symptoms, or repeated prolapse treatment. Secondary outcomes included measures of urinary and sexual function, symptoms and signs of urogenital atrophy, and adverse events.
RESULTS
Of 206 postmenopausal women, 199 were randomized and 186 underwent surgery. The mean (SD) age of participants was 65 (6.7) years. The primary outcome was not significantly different for women receiving vaginal estrogen vs placebo through 12 months: 12-month failure incidence of 19% (n = 20) for vaginal estrogen vs 9% (n = 10) for placebo (adjusted hazard ratio, 1.97 [95% CI, 0.92-4.22]), with the anatomic recurrence component being most common, rather than vaginal bulge symptoms or prolapse repeated treatment. Masked surgeon assessment of vaginal tissue quality and estrogenization was significantly better in the vaginal estrogen group at the time of the operation. In the subset of participants with at least moderately bothersome vaginal atrophy symptoms at baseline (n = 109), the vaginal atrophy score for most bothersome symptom was significantly better at 12 months with vaginal estrogen.
CONCLUSIONS AND RELEVANCE
Adjunctive perioperative vaginal estrogen application did not improve surgical success rates after native tissue transvaginal prolapse repair.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT02431897.
Topics: Aged; Female; Humans; Middle Aged; Administration, Intravaginal; Estrogens, Conjugated (USP); Gynecologic Surgical Procedures; Hysterectomy; Hysterectomy, Vaginal; Pelvic Organ Prolapse; Secondary Prevention; Treatment Outcome; Uterine Prolapse; Vagina; Vaginal Creams, Foams, and Jellies
PubMed: 37581673
DOI: 10.1001/jama.2023.12317