US and MR imaging findings to detect placental adhesion spectrum (PAS) in patients with placenta previa: a comparative systematic study

PURPOSE

To compare the performance US and MR in identifying placental adhesion spectrum (PAS) in placenta previa (PP) and to establish a potential method of image interpretation.

METHODS

US and MR examinations of 51 patients with PP were selected. The presence of imaging signs commonly used to detect PAS was assessed. Penalized logistic regression was performed considering histology as standard of reference; only signs statistically significant (p < 0.05) were considered for ROC and multivariate analysis. The probability of PAS according to the presence of US and/or MR signs was then assessed.

RESULTS

At univariate analysis, loss of retroplacental clear space, myometrial thinning (MT) and placenta lacunar spaces on US, intraplacental dark bands (IDBs), focal interruption of myometrial border (FIMB) and abnormal vascularity (AV) on MR were statistically significant (p < 0.01). Three diagnostic methods for PAS were then developed for both US and MR when at least one (Method 1), two (Method 2) or three (Method 3) imaging signs occurred, respectively. Method 2 for MR showed a significantly (p < 0.05) higher accuracy (91%) compared to the other methods. When MR IDBs and AV as well as IDBs and FIMB were present in combination with US MT the probability of PAS increased from 75 to 90% and from 80 to 91%, respectively.

CONCLUSION

MR demonstrated a higher diagnostic accuracy than US to detect PAS. However, since the combination of MR and US signs could improve the probability to detect PAS, a complementary diagnostic role of these techniques could be considered.

Investigational Drug Therapies for Overactive Bladder Syndrome: The Potential Alternatives to Anticolinergics

Background

Overactive bladder is a high prevalent and quality of life affecting disease. The mainstay of the medical therapy is represented by antimuscarinic drugs, but their side effects markedly affect patient compliance and prompt studies on novel investigational drugs.

Methods

A systematic literature search of peer-reviewed papers and meeting abstracts published by December 2008 was performed. PubMed databank was searched for original English articles, by using the following search terms: “overactive bladder” or “detrusor overactivity” or “urinary incontinence” and “treatment”, alone and linked to any potential molecular target or novel drug cited in the literature.

Results

Effective alternative pharmacological treatments are currently scarce, but many new promising compounds are emerging which target key molecular pathways involved in micturition control. The most promising potential therapeutic targets include central nervous system GABAergic inhibitory pathway, dopaminergic and serotoninergic systems, b-adrenoceptors and cAMP metabolism, nonadrenergic-noncholinergic mechanisms such as purinergic and neuropeptidergic systems, vanilloid receptor, bladder sensory nervous terminals, nonneuronal bladder signalling systems including urothelium and interstitial cells, prostanoids, Rho-kinase and different subtypes of potassium and calcium channels.

Conclusions

Despite the enormous amount of new biologic insight, very few novel pharmacological therapies seems to have passed the proof-of-concept clinical stage. The ultimate clinical utility of new drugs will depend on the ability to exploit tissue-specific differences and disease-related changes in molecular expression/function and to improve storage phase dysfunctions without interfering with the emptying phase. Further preclinical investigations and controlled clinical trials are urgently needed in this challenging field.

Sports and Genitourinary Traumas

Introduction

Statistical data referring to sports-related traumas of the urinary tract are quite scarce; nevertheless, it is possible to draw general data on the relationship between sports and urological traumas.

Methods

Literature review of peer-reviewed articles published by May 2009.

Results

Urological traumas account for about 10% of all traumas, and about 13% of them is sports-related. Genitourinary traumas are among the most common cause of abdominal injuries in sports. Blunt injuries are more common than penetrating ones and renal injuries are by far the most common, followed by testicular injuries; ureters, bladder and penis injuries are much more infrequent. Considering chronic microtraumas, injuries of bulbar urethra are also common in sports that involve riding. Overall, the incidence of genitourinary trauma due to sports is low. Renal traumas in sports injuries usually consist of grade 1–11 lesions and usually do not require surgical treatment. Cycling is the sporting activity most commonly associated with genitourinary injuries, followed by winter sports, horse riding and contact/collision sports. Literature data suggest that significant injuries are rare also in athletes with only one testicle or kidney. General preventive measures against sport-related injuries, along with the use of protective cups for male external genitalia, are generally sufficient to reduce the incidence of urogenital trauma.

Conclusions

Overall, studies show that urogenital injuries are uncommon in team and individual sports, and that most of them are low-grade injuries. Participation in sports that involve the potential for contact or collision needs to be carefully assessed in the athletes with only one testicle or kidney, even though urogenital injuries should not preclude sports participation to an appropriately informed and counseled patient. Further research is needed to acquire more knowledge on genitourinary injuries according to age, sports type and technical skill.

Botulinum toxin in the treatment of overactive bladder

Clinical effectiveness of botulinum toxin (BTX) in the treatment of both neurogenic and idiopathic detrusor overactivity has been demonstrated in several studies. However, different protocols and techniques have been used by authors.

Methods.

Literature review on intradetrusor injection of BTX for detrusor overactivity.

Results.

The greatest clinical experience reports the use of 200 and 300 U Botox®. Available data suggest that clinical efficacy, duration, and the side effect profile is similar at these doses. Very few data, on the other hand, are available regarding the clinical outcomes using the Dysport® preparation; isolated reports support that efficacy is similar when using a dosing range of 500 to 1000 SU with increased risk of systemic side effects using 1000 SU. A variety of injection volumes was used, demonstrating similar efficacy and tolerability profile. Clinical effect duration extends six to ten months in the majority of studies. Data suggest that a repeated injection scheme proves successful in the vast majority of initial responders.

Conclusions.

Safety, effectiveness, specificity and reversibility make BTX a new attractive treatment modality for overactive bladder syndrome. However, more experience is needed to standardize the injection protocol with respect to therapeutic outcomes and adverse effects.

Prostatitis Syndromes and Sporting Activities

Introduction

Prostatitis-like syndromes are high prevalent health problems and frequently considered by patients and physicians as strictly correlated to sports causing perineal compression. These syndromes and their relationships with sporting activities have been discussed in this report.

Methods

We reviewed peer-reviewed scientific articles published by May 2009 and searched according to the following term selection: prostatitis, pudendal nerve, sport, cycling.

Results

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a major healthcare burden heavily affecting patients’ Quality of Life. No clear evidence of any direct etiologic relationship has been found in literature between prostatitis, either bacterial or non-bacterial, and sports activities. On the other hand, some types of sport causing perineal compression, such as cycling, can exacerbate symptoms of acute and chronic prostatitis; a temporary sport discontinuation is justified in these patients. CP/CPPS may be often caused by pudendal nerve entrapment (PNE). Prostatitis-like urogenital neuropathic pain together with voiding and sexual dysfunctions are the hallmark of PNE. A common feature is that flexion activities of the hip, such as climbing, squatting, cycling provoke or worsen urogenital pain or pelvic pain. Many of the patients with PNE are cyclists, played American football, lifted weights, or wrestled as teenagers and young adults. PNE represents the most common bicycling associated urogenital problems.

Conclusions

Overall, studies show that no causal relationship has been demonstrated between prostatitis and sporting activities. Conversely, urologists should be aware that sports involving vigorous hip flexion activities or prolonged perineal compression are a potential and not an infrequent cause of uroand rological symptoms caused by pudendal nerve entrapment.

Bladder Tumor Markers: A Review of the Literature

Bladder cancer is among the top eight most frequent cancers. Its natural history is related to a combination of factors that impact on its aggressiveness. Cystoscopy and urine cytology are the currently used techniques for the diagnosis and surveillance of non-invasive bladder tumors. The sensitivity of urine cytology for diagnosis is not high, particularly in low-grade tumors. The combination of voided urine cytology and new diagnostic urine tests would be ideal for the diagnosis and follow-up of bladder cancer. However, in order to have some clinical utility, new diagnostic and/or prognostic markers should achieve better predictive capacity that the currently used diagnostic tools. None of the markers evaluated over the last years showed remarkable sensitivity or specificity for the identification of any of the diverse types of bladder cancer in clinical practice. The limitations of the known prognostic markers have led to the research of new molecular markers for early detection of bladder cancer. This research focused in particular on the discovery of biomarkers capable of reducing the need for periodic cystoscopies or, ideally, offering a non-invasive examination instead. In this review, we will examine various new markers of bladder cancer and their value in the diagnosis and follow-up of non-muscle-invasive bladder cancer. When compared with urine cytology, which showed the highest specificity, most of these markers demonstrated an increased sensitivity.

Menopause and hormone replacement therapy: the 2017 Recommendations of the Italian Menopause Society

Over the last decade, the risk benefits ratio of hormone replacement therapy (HRT) has been reevaluated mainly in tens of cardiovascular risk. Present Consensus Statement is largely inspired by the Global Consensus on Menopausal Hormone Therapy in 2013 and 2016 by leading global menopause societies (The American Society for Reproductive Medicine, The Asia Pacific Menopause Federation, The Endocrine Society, The European Menopause and Andropause Society, The International Menopause Society, The International Osteoporosis Foundation and The North American Menopause Society). The aim of these recommendations is to provide a simple and updated reference on postmenopausal HRT. The term HRT typically includes estrogen replacement therapy (ERT) and estrogen-progestogen therapy (EPT). EPT can be sequential, when progestogen is added to ERT for 10-14 days a month, or continuous combined when progestogen is administered continuously every day along with a fixed amount of estrogen, In the everyday language, HRT includes also tibolone and the tissue-selective estrogen complex.

[18F]tetrafluoroborate-PET/CT enables sensitive tumor and metastasis in vivo imaging in a sodium iodide symporter-expressing tumor model

Cancer cell metastasis is responsible for most cancer deaths. Non-invasive in vivo cancer cell tracking in spontaneously metastasizing tumor models still poses a challenge requiring highest sensitivity and excellent contrast. The goal of this study was to evaluate if the recently introduced PET radiotracer [18F]tetrafluoroborate ([18F]BF4-) is useful for sensitive and specific metastasis detection in an orthotopic xenograft breast cancer model expressing the human sodium iodide symporter (NIS) as a reporter. In vivo imaging was complemented by ex vivo fluorescence microscopy and γ-counting of harvested tissues. Radionuclide imaging with [18F]BF4- (PET/CT) was compared to the conventional tracer [123I]iodide (sequential SPECT/CT). We found that [18F]BF4- was superior due to better pharmacokinetics, i.e. faster tumor uptake and faster and more complete clearance from circulation. [18F]BF4--PET was also highly specific as in all detected tissues cancer cell presence was confirmed microscopically. Undetected comparable tissues were similarly found to be free of metastasis. Metastasis detection by routine metabolic imaging with [18F]FDG-PET failed due to low standard uptake values and low contrast caused by adjacent metabolically active organs in this model. [18F]BF4--PET combined with NIS expressing disease models is particularly useful whenever preclinical in vivo cell tracking is of interest.

Estrogen Changes as a Critical Factor in Modulation of Central Opioid Tonus: Possible Correlations with Post-Menopausal Migraine

The effects exerted by ovarian steroids on the modulation of opioid activity were investigated in post-menopausal migraine sufferers and in healthy controls. In order to evaluate central opioid tonus, plasma LH rise after naloxone injection was measured, bearing in mind the tonic inhibition of endogenous opioid on hypothalamic LH-RH. There was no response of plasma LH to naloxone in post-menopausal women or in patients submitted to ovariectomy in fertile life. When the subjects underwent a sequencial estrogens + progestagens therapy, such a response was noted from the first month of treatment; progestagens alone were ineffective. The same phenomena were also evident in post-menopausal migraine sufferers. These data indicate that ovarian steroids modulate the activity of opiate receptors in both healthy women and migraine sufferers. Interestingly, replacement therapies through ovarian steroids restored the activity of central opioid tonus in patients affected by migraine.

Hypothalamus pituitary-ovarian axis in menstrual migraine: effect of dihydroergotamine retard prophylactic treatment

LH, FSH, Prolactin (PRL), Estradiol (E) and Progesterone (P) plasma levels were measured in different periods of the menstrual cycle in 15 control subjects and in 9 women suffering from perimenstrual migraine before and after prophylactic treatment with 10 mg/day dihydroergotamine (DHE) retard. LH, FSH and PRL plasma levels were similar between patients and controls and were unaffected by DHE therapy. Migraineurs showed markedly reduced P levels in the entire luteal phase, concomitantly with higher E levels, leading to a P/E ratio significantly interfering with ovarian steroids secretion. These data indicate the presence of ovarian impairment in women suffering from perimenstrual migraine, whose symptoms could be successfully treated with DHE retard without interfering with the endocrine state.

Les variations cicliques de LH, FSH, Prolactine (PRL) de la Estradiol (E) et de la Progesterone (P) ont ete evaluèes chez 15 subjets temoins et chez 9 femmes souffrant de la maladie migraineuse, en conditions de base et au cours d'un traitment prophilactique avec 10 mg par jour de Dihydroergotamine (DHE) rètard. LH, FSH et PRL etaient au meme niveau chez les temoins et les patients et n'ont pas ètè modifiès par le traitment avec DHE rètard; tandis que les taux plasmatiques de la P etaient rèduites et, au contraire, ceux de la E eatient elevèes pendant toute la phase luteale des migraineuses. Par consequence le rapport P/E les patientes etait significativement inferieur que chez les temoins. Le traitment avec la DHE rètard a presque totalement prevenue les accès migraineux, sans modifier le status normonal. Les femmes souffrant de maladie migraineuse au cours du cicle menstruel, notament dans la periode premenstruelle, montrent des affections de la secretion ovarienne qui doivent etre ancore expliquées. En tous cas las symptomatologie peut etre convenablement rèlevèe par le traitment prophilactique avec DHE rètard qui d'ailleur n'a aucune influence sur les secretions hypophisaires et ovariennes.

I tassi plasmatici di LH, FSH, Prolattina (PRL), Estradiolo (E) e Progesterone (P) sono stati studiati nel corso del ciclo mestruale in 15 soggetti di controllo e in 9 pazienti affette da emicrania premestruale prima e dopo un trattamento profilattico con Diidroergotamina (DHE) ritardo (10 mg/die). LH, FSH e PRL sono risultati simili nei due gruppi e non ha mostrato variazioni in seguito al trattamento. Durante l'intera fase luteale, i tassi di P delle pazienti sono risultati significativamente ridotti, mentre quelli di E al contrario, erano più elevati, rispetto a quelli dei soggetti di controllo. La terapia con DHE ha pressoché abolito l'insorgenza degli attacchi emicranici, senza interferire con le concentrazioni di E e P. In conclusione, questi dati indicano che le pazienti affette da emicrania perimestruale presentano un'alterazione della funzione ovarica che resta da definire. Il trattamento profilattico conDHE ritardo però, è risultato efficacie nella abolizione delle crisi, senza interferire con le secrezioni ormonali.

Cardiovascular response to cognitive stress in subjects with menstrually related disorders

We measured reactivity to a stress paradigm during the premenstrual period in 19 women affected by Menstrually Related Disorders (MRD) and in 11 normal controls. Eight had premenstrual syndrome diagnosed by the Menstrual Distress Questionnaire and 11 suffered menstrual migraine, diagnosed according to International Headache Society criteria. Subjects were observed during two menstrual cycles and submitted to a psychocognitive test (Stroop Color Word) during the luteal phase. In both groups the stimulation by Stroop C-W was present for systolic blood pressure (SBP) (F = 18.14, p = 0.000), diastolic blood pressure (DBP) (F = 9.56, p = 0.000), and heart rate (F = 12.80, p = 0.000). Moreover, an interaction of response by group was present for DBP (2.58, p = 0.04); DBP values were higher in MRD subjects. Also baseline DBP values were higher in MRD with respect to controls. Area under the curve (AUC) subtracted from baseline for the SBP, DBP and heart rate did not differ between groups. In conclusion, MRD subjects facing a cognitive stress had normal cardiovascular response. However, patients had increased arousal of cardiovascular measures before and after testing. The significant differences during stress of testing were dissociated from those of experimental stress stimulation. MRD subjects may have less ability to cope with novelty than healthy volunteers.

Anti-Mullerian Hormone in Premenopausal Women and After Spontaneous or Surgically Induced Menopause

OBJECTIVE

The objectives of this study were: (1) to determine anti-Mullerian hormone (AMH) levels in menopausal women, and (2) to confirm the source of AMH in cycling women and its disappearance after the removal of the source.

METHODS

An observational and prospective study was conducted.

RESULTS

A total of 47 women were recruited for the study. The study population consisted of the following groups of patients: (A) women of late reproductive age (n = 24; mean age +/- SD, 44 +/- 2.8 years); (B) menopausal women (n =14; mean age, 56 +/- 4 years); and (C) regularly cycling women undergoing surgical menopause (n = 9; mean age, 43 +/- 4 years). Blood samples were obtained from all patients. In patients undergoing surgery, blood samples were obtained before and after surgery. AMH was undetectable in 13 of 14 postmenopausal women, whereas it was undetectable in only two of 24 women of late reproductive age. A significant negative correlation has been found between AMH and age or follicle-stimulating hormone (FSH) in women of late reproductive age. In women who were candidates for oophorectomy, samples were obtained 3-5 days after surgery. AMH was undetectable after the surgery in all women.

CONCLUSIONS

We found that AMH levels decreased in women in the late reproductive period and that menopause and ovariectomy in regularly cycling women are associated to undetectable AMH in serum. These observations confirm that the ovary could be the only source of AMH in women and that it is a novel marker for ovarian aging.

Does dienogest influence the inflammatory response of endometriotic cells? A systematic review

OBJECTIVE AND DESIGN

A systematic review of all literature was done to assess the ability of the progestin dienogest (DNG) to influence the inflammatory response of endometriotic cells.

MAIN OUTCOME MEASURES

In vitro and in vivo studies report an influence of DNG on the inflammatory response in eutopic or ectopic endometrial tissue (animal or human).

RESULTS

After strict inclusion criteria were satisfied, 15 studies were identified that reported a DNG influence on the inflammatory response in endometrial tissue. These studies identified a modulation of prostaglandin (PG) production and metabolism (PGE2, PGE2 synthase, cyclo-oxygenase-2 and microsomal PGE synthase-1), pro-inflammatory cytokine and chemokine production [interleukin (IL)-1β, IL-6, IL-8, tumor necrosis factor-α, monocyte chemoattractant protein-1 and stromal cell-derived factor-1], growth factor biosynthesis (vascular endothelial growth factor and nerve growth factor) and signaling kinases, responsible for the control of inflammation. Evidence supports a progesterone receptor-mediated inhibition of the inflammatory response in PR-expressing epithelial cells. It also indicated that DNG inhibited the inflammatory response in stromal cells, however, whether this was via a PR-mediated mechanism is not clear.

CONCLUSIONS

DNG has a significant effect on the inflammatory microenvironment of endometriotic lesions that may contribute to its clinical efficacy. A better understanding of the specific anti-inflammatory activity of DNG and whether this contributes to its clinical efficacy can help develop treatments that focus on the inhibition of inflammation while minimizing hormonal modulation.