Correlation of urethral physiology and skin collagen in postmenopausal women

Colposuspension after previous failed incontinence surgery: a prospective observational study

OBJECTIVE

To evaluate the outcome of colposuspension for genuine stress incontinence in women who had previously undergone bladder neck surgery.

DESIGN

Prospective observational study.

SETTING

Tertiary referral urogynaecology unit.

PARTICIPANTS

Fifty-two consecutive women with recurrent genuine stress incontinence operated on by one surgeon.

MAIN OUTCOME MEASURES

Subjective and objective cure of stress incontinence. Complications of surgery.

RESULTS

The mean age of the women was 51 years (range 28-72) and weight 72.7 kg (range 53-112). Sixty-five continence procedures had been performed previously, with 13 women (25%) having had more than one operation. Nine months post-operatively the subjective cure rate was 80% and objective cure rate 78%. Intraoperative complications were few but included two bladder injuries and one rectus muscle tear which required repair. Seven women (13%) developed voiding difficulties which required clean intermittent self-catheterisation, but only one needed to continue this for six months. None of the women developed detrusor instability.

CONCLUSIONS

In this setting colposuspension after previous bladder neck surgery offers a high rate of success. However, long term follow up is needed to see if this effect is maintained.

Urogenital symptoms in women aged 50-59 years. Women's Health in Lund Area (WHILSA) Study Group

Problems related to the urogenital tract are common in elderly women. Control of micturition is often impeded and questionnaire-based studies have reported a prevalence of poor control of micturition in about 30% of postmenopausal women. In an ongoing cohort comprising women born between 1935 and 1945, an interim analysis was performed in 1800 women based on an interview and questionnaire. The prevalence of urinary incontinence was found to be 33%, which is in accordance with previous reports. The main difference between the interview and the questionnaire was that the interview could take into account intensity as well as intermittence of symptoms. There were no differences between premenopausal women and postmenopausal women using or not using hormone replacement therapy. In agreement with earlier studies, we found poorer control of micturition in parous women. A higher percentage of incontinence was also found in women who had lost more than 5 kg in body weight during the preceding 5 years. In addition, women with a family history of diabetes were more prone to complaints of incontinence. Of the 155 women who had a family history of diabetes, 66 were incontinent (p < 0.01). It was also found that women who were incontinent were more often on regular surveillance for various diseases, using more medications regularly and had been hospitalized during the last 5 years more often than women who were continent. There were no differences in smoking habits. The present results imply that urinary incontinence in women is of a complicated origin and that the hormonal situation plays a minor role for this socially handicapping symptom.

Pathophysiology of pelvic organ prolapse

Pelvic organ prolapse is usually caused by weakness of the pelvic diaphragm. Descent of the pelvic diaphragm places stress on the endopelvic connective tissue support system. Subsequent increases in intra-abdominal pressure result in prolapse. In the majority of cases, labor and childbirth are thought to be the primary factors responsible for pelvic neuropathies and tissue damage that predispose to the development of POP. Certain connective tissue defects, congenital defects, and operative procedures also contribute to pelvic support defects.

Urogenital aging--a hidden problem

Urogenital problems in the elderly female population are experienced by one third of women from the age 50 years and onward. Symptoms from the lower urinary tract include incontinence, urethritis, and recurrent urinary tract infections. Atrophic changes within the bladder neck and urethra could be corrected by estrogen administration even at doses so low that endometrial proliferation is avoided. Hence such estrogens could be given without progestogen comedication. Control of micturition is a complex process of which estrogen deficiency is only one of several factors. The aging process with subsequent changes in membrane permeability, neuromuscular function, and collagen synthesis contributes to the local problems of control of micturition. In addition, the central control may also be affected by degenerative changes of the nervous system. Vaginal symptoms comprise dryness of vagina, dyspareunia, and recurrent vaginitis often followed by a foul odor and discharge. The microflora with lactobacilli and low pH as seen in fertile women is gradually replaced by a mixed germ flora including several of the pathogenic organisms common in urinary tract infections. Vaginal pH increases from around 4 to between 6 and 7. It is a puzzling fact that the urogenital tissues seem to be more "sensitive" to estrogens than other tissues. Conformational changes of the estrogen receptor(s) brought about by the local cytokine milieu is one possibility to explain the situation. The systemic absorption of low-dose estrogen preparations is dependent on the status of the vaginal mucosa. Absorption is high when the vaginal mucosa is atrophic and gradually decreases (but not to zero) as the vaginal mucosa matures under estrogen influence.

Analysis of collagen status in premenopausal nulliparous women with genuine stress incontinence

OBJECTIVE

To determine if differences exist in the collagen status of premenopausal nulliparous women with genuine stress incontinence compared with continent controls.

DESIGN

Thirty-six premenopausal nulliparous women with urodynamically-proven genuine stress incontinence were compared with 25 controls. All the women studied had a periurethral vaginal biopsy taken of approximately 30-50 mg in wet weight. This biopsy was then analysed to determine the collagen content, the type I:III collagen ratio and the collagen cross-link content.

SETTING

A tertiary referral urodynamic unit.

RESULTS

The nulliparous women with genuine stress incontinence had significantly less collagen in their tissues (P < 0.0001) compared with the continent controls. In addition, there was a decreased ratio of type I to type III collagen (P = 0.0008), and the cross-link content was also significantly reduced in the women with genuine stress incontinence (P < 0.0001).

CONCLUSION

Genuine stress incontinence is present in a significant number of women before childbirth. The aetiology of their incontinence appears to be due to a defect in their connective tissue, with both a quantitative and qualitative reduction in their collagen.

Changes in bone collagen markers and in bone density in hormone treated and untreated postmenopausal women

OBJECTIVE

This study aims to compare bone mineral density measurements (BMD), pyridinium crosslink levels and pyridinium crosslink levels in untreated and hormone treated postmenopausal women.

METHODS

A cross-sectional study comparing biophysical (BMD) and biochemical (pyridinium crosslink and PCICP) parameters in a group of untreated postmenopausal women (n = 145) to a group of postmenopausal women on hormone replacement therapy (HRT) (n = 92).

RESULTS

Untreated postmenopausal women compared to postmenopausal women on HRT had higher Osteoblastic and Osteoclastic activity. Procollagen I C-end terminal peptide (PCICP) was 11.3% lower in the women on HRT compared to controls whilst crosslinks were 27.2% lower than in controls. This seems to indicate that women on HRT had a bone balance that was higher compared to the control group (15.9%). The difference in bone density of L2-L4 between the two groups was (16.1%).

CONCLUSIONS

This study seems to indicate that postmenopausal women receiving HRT readjust their bone remodelling so that although osteoblastic function is reduced, there is a much greater deduction in osteoclastic function and this results in an overall higher bone mass observed in the BMD of women on HRT.

The role of estrogen replacement therapy in the management of urinary incontinence and urinary tract infection in postmenopausal women

The hormonal changes associated with normal aging and menopause may contribute to the development of urinary disorders including both urinary incontinence and urinary tract infections. Estrogen replacement therapy has been used successfully in the treatment of both of these disorders in postmenopausal women. Although the selection of specific treatment modalities should be tailored to the individual patient, hormonal replacement should be considered a viable conservative treatment option for many older women with urinary complaints. Future research will help to delineate the most effective route of administration and type of estrogen used in treating these complaints.

Changes in paraurethral connective tissue at menopause are counteracted by estrogen

OBJECTIVE

To study whether the transition to menopause is accompanied by changes in the paraurethral connective tissue and if these changes are modified by estrogen replacement therapy.

STUDY DESIGN

Biopsies were obtained from the paraurethral tissue from 34 women; 12 menstruating, 14 postmenopausal without estrogen treatment, and 8 with estrogen treatment. Collagen concentration and collagen extractability by pepsin digestion were measured. Proteoglycan composition and concentration were analysed using Alcian blue. The mRNA levels for collagen I and III, the small proteoglycans (PGS) decorin and biglycan, and the large proteoglycan versican, were estimated.

RESULTS

The paraurethral biopsies consisted of fibrous connective tissue, with collagen fibers as dominating structure. Several proteoglycans were identified; versican, heparansulphate proteoglycans, biglycan and decorin. The small proteoglycan decorin represented 85% of all proteoglycans. The collagen concentration was almost doubled in postmenopausal biopsies compared to premenopausal. The collagen fibril organization was also changed with higher cross-linking after menopause whereas the amount and the composition of the proteoglycans were unchanged. The proteoglycan/collagen ratio was significantly decreased. Estrogen replacement therapy resulted in decreased collagen concentration, decreased cross-linking of the collagen and reversal of the PGS/collagen ratio to almost premenopausal level. The therapy resulted in increased levels of mRNA for collagen I and III which suggests that the changes are due to an increased turnover.

CONCLUSION

The decrease in estrogen levels at menopause results in a connective tissue with different qualities after menopause. Estrogen replacement therapy tends to restore the metabolism of the genitourinary connective tissue to premenopausal conditions.

Clinical outcome and changes in connective tissue metabolism after intravaginal slingplasty in stress incontinent women

The intravaginal slingplasty procedure (IVS) was carried out on 75 patients with genuine stress urinary incontinence. The main aims of the operation are to create an artificial pubourethral ligament and to tighten the suburethral vaginal wall. An important ingredient in the supportive structures of the genitourinary region is fibrous connective tissue, consisting mainly of collagen. To analyse this component biopsies were obtained transvaginally, close to the position of the sling, both preoperatively and 2 years after surgery, from 6 patients. Collagen was analysed for concentration and extractability. Extractability by pepsin digestion was increased by 60% 2 years following surgery. Postoperative follow-up studies from 12 months to 3 years showed complete restoration of continence in 63 patients (84%) and considerable improvement in 4 others (5%). The 8 failures (9%) were all related to early rejection of the sling. The IVS procedure is an attractive surgical procedure as it necessitates minimum invasion and can be performed under local anesthesia, with a short hospital stay and sick-leave period. The enhanced collagen extractability indicates a changed metabolism, most likely induced by the implanted sling, resulting in a restoration of the elastic properties of the connective tissue.

Morphology and neuropathology of the pelvic floor in patients with stress incontinence

Urinary incontinence imposes a considerable workload on urological and gynecological practice. Many treatments exist, but recurrent stress incontinence remains a significant problem and the reasons remain unclear. Pathological and electrophysiological studies have shown that significant pelvic nerve damage and consequent denervation and reinnervation are associated with stress incontinence, and furthermore there are collagenous changes in the pelvic floor which are related to childbirth, endogenous hormone changes and the effects of increasing age. These changes include increased nerve fiber density and pudendal nerve terminal motor latency, hypertrophy of fiber types 1 and 2, type 1 fiber predominance and fiber type grouping. Connective tissue changes involve a reduction in hydroxyproline excretion, increased cross-linking and increased muscle collagen. It is only through a better understanding of the anatomy and pathophysiology of the pelvic floor that we will be able to improve outcome in women with stress incontinence and identify patients that may not be appropriate for surgical therapy. This paper reviews recent advances in the understanding of the etiology of stress incontinence.

A morphologist's approach to the vagina--age-related changes and estrogen sensitivity

This paper reviews basic facts on vagina histology and ultrastructure with respect to passage of different substances and drugs through the epithelium. Particular interest is devoted to the action mechanism of topically-applied vaginal estrogen, its binding to receptors in different vaginal cell types, and possible local metabolic routes. Differences in estrogen sensitivity between uterus and vagina are discussed as well as the background for the high vaginal sensitivity.

The prevalence of urogenital symptoms in postmenopausal women

Lower urogenital tract disorders, such as vaginal athropy, urethritis, dyspareunia, recurrent urinary tract infections and urinary incontinence symptoms, are more prevalent in postmenopausal women. While these disorders are attributed to the ageing process as well as estrogen deficiency, knowledge of the relationship between estrogen status and symptomatology is scarce and hard to investigate due to the complexity of the problem. Little is known about the epidemiology of urogenital symptoms and their relationship to estrogen status and treatment. Studies of the prevalence of urogenital symptoms in postmenopausal women have been rare and results divergent. Through reviewing existing literature and relating findings to our own prevalence studies of 61-, 71- and 81-year-old women, we can conclude that many of the symptoms accounted for in our study are those known to be due to the loss of estrogen and easily dealt with by estrogen therapy. However, there is a need for more adequate information about postmenopausal symptoms and the effect of estrogens, as only a minority of postmenopausal women are currently treated.

Cigarette smoking and urinary incontinence in women--a new calculative method of estimating the exposure to smoke

The aim of the study was to investigate the relation between cigarette smoking and urinary incontinence. A group of 80 women with incontinence (Group A) were tested urodynamically and compared with a group of 80 continent women (Group B). Patients were divided into smokers (S) and non-smokers (NS) with the incontinent ones classified as suffering from stress (SI) or motor in-continent (UI). The assessment of the smoking behavior of each individual focused upon the tar and nicotine content of each cigarette. The overall exposure to smoke was assessed as follows: tar/nicotine content in mg per cigarette x consumed cigarettes per day x duration of smoking intervals in years. According to the obtained data smokers were divided into current smokers (cs) and stop/start smokers (sss), whereas the current smokers were subdivided into heavy current smokers (hcs) and light current smokers (lcs). Significantly, more S were observed in Group A compared with Group B (48/80 vs. 11/32, P < 0.0005), whereas significantly more SI was found in NS compared with S (21/32 vs. 19/48, P < 0.0025). Particularly hcs developed more frequently UI than SI, although this difference had no statistical significance. According to our data smoking women are more likely to develop incontinence, especially motor incontinence, than non-smokers. Heavy smokers seem to tend more to UI.

Increase in bone mass of older postmenopausal women with low mineral bone density after one year of percutaneous oestradiol implants

OBJECTIVE

To evaluate the effect of 75 mg oestradiol implants on the bone mass of older postmenopausal women with osteoporosis.

DESIGN

One year prospective-controlled study.

SUBJECTS

Thirty-two postmenopausal women over 60 years of age and more than five years postmenopausal with low bone density were recruited. Thirty women completed treatment for one year with 75 mg oestradiol implants. The changes in bone density were compared with a control group of 14 women. The side effects with treatment were documented.

MAIN OUTCOME MEASURES

Dual energy X-ray absorptiometry of the lumbar spine and proximal femur using Hologic 1000 QDR before treatment and at one year. Plasma oestradiol assays were performed before and after one year.

RESULTS

The median percentage changes in the treated group after one year was 12.6% at the lumbar spine and 5.22% at the total hip. The increase in vertebral bone density was greatest in women with low initial bone density (r = -0.35, P < 0.05) and those with highest treatment plasma oestradiol levels (r = 0.47, P < 0.01). Side effects were common but most were transient and mild in nature.

CONCLUSION

75 mg oestradiol implants significantly increase the bone mineral density at the spine and hip of older postmenopausal women with established osteoporosis.

Pelvic fascia strength in women with stress urinary incontinence in comparison with those who are continent

Biophysical properties of the anterior vaginal wall as well as the rectus fascia were evaluated in vivo by penetrating the Stamey needle into these tissues of 26 female patients with stress incontinence in comparison with those of 21 continent subjects. The results demonstrated that shear strength of the anterior vaginal wall was lower in incontinent patients than in continent subjects (P < 0.01). Shear strength of the rectus fascia in the patients, which was not supposed to be related to urinary incontinence and should have had the same strength as the control subjects, was also found to be lower than the control (P < 0.01). Shear strength of the vaginal wall was not correlated with age irrespective of their continence status (P > 0.05). Based on our findings it is concluded that some women suffering from stress incontinence may have a hereditary disorder of biophysical properties of the tissues.

Oestriol in the treatment of postmenopausal urgency: a multicentre study

Oestrogen deficiency in postmenopausal women is thought to be important in the genesis of lower urinary tract symptoms, in particular the 'urge syndrome'. Evidence to support the use of oestrogen therapy in symptomatic postmenopausal women is, however, limited. Oestriol is a weak, naturally occurring oestrogen that may be beneficial to the urogenital tissues without stimulating the endometrium. We have investigated the use of oestriol in the treatment of postmenopausal sensory and motor urge incontinence.

MATERIALS AND METHODS

A double-blind, placebo-controlled, randomised, multicentre study of 3 mg oral oestriol/day for 3 months in the treatment of women with urge incontinence was undertaken.

RESULTS AND CONCLUSIONS

Sixty-four women were recruited into the study. Although oestriol produced both subjective and objective improvement in lower urinary tract function, it was not significantly better than placebo. Some of the difficulties of running a multicentre study were encountered.

HRT and osteoporosis

Hormone replacement therapy is well documented to reduce the increased bone turnover induced by oestrogen deficiency and, as a result, it prevents bone loss after the menopause. It has been shown that this effect leads to a significant reduction in osteoporotic fracture rates. There is a dose threshold effect, the duration of therapy influences the degree of benefit and, after the cessation of HRT, postmenopausal bone loss resumes. Women take HRT for many reasons, most for relief of menopausal symptoms, and 10-20% show poor compliance. The nature of HRT preparations is discussed and the current understanding of benefits and risks described.

Localization of steroid hormone receptors in the pelvic muscles

After the menopause the pelvic floor becomes progressively weaker, one consequence of which is the increasing incidence of prolapse and urinary incontinence. It is plausible that the reduction in estrogen levels postmenopausally is an etiological factor in these problems. For the pelvic floor muscles to be considered as target organs for estrogen, demonstration of the presence of estrogen receptors is required. The present study aims to confirm previous findings of estrogen and progesterone receptors in the levator ani muscle, and to further localize them histologically. In seven women biopsies from the levator ani muscle were taken and analyzed immunohistologically with monoclonal antibodies for estrogen and progesterone receptors. The receptors were detected in the nuclei of connective tissue cells and striated muscle cells. These findings provide a scientific basis for a possible beneficial effect of estrogen therapy, as a complement to other therapies, in prolapse and urinary incontinence.

Female urinary stress incontinence in terms of connective tissue biochemistry

The role of connective tissue in the aetiology of female stress incontinence has been investigated. Collagen content and extractability as well as estrogen receptor concentration in vesico-vaginal fascia were measured after small tissue biopsies had been obtained during vaginal repair surgery in cases of urinary incontinence. The mean concentration of estrogen receptor in vesico-vaginal fascia among incontinent women was 49.4 +/- 14.8 fmol/mg of protein as compared to 29.6 +/- 13.1 in continent control group (P < 0.03; t-test). The mean hydroxyproline concentration in vesico-vaginal fascia of incontinent women was 13.8 +/- 2.6 micrograms/mg wet weight, whereas in the control group it was significantly higher 20.6 +/- 2.4 (P < 0.001). The role of connective tissue components in the aetiology of female stress incontinence is discussed.

Cigarette smoking and urinary incontinence in women

OBJECTIVE

The goal of this case control study was to evaluate the relationship between smoking and female urinary incontinence.

STUDY DESIGN

The study included 606 women whose smoking histories were known; 322 were incontinent and 284 were continent. The condition(s) causing each subject's incontinence was determined by urodynamic testing; 40% of the continent subjects had the same testing.

RESULTS

There were highly significant overall differences (p = 0.000009) in the distribution of current, former, and never smokers between incontinent (35%, 16%, 49%) and continent (24%, 8%, 68%) groups. The odds ratio for genuine stress incontinence was 2.20 for former (95% confidence interval 1.18 to 4.11) and 2.48 for current smokers (95% confidence interval 1.60 to 3.84); for motor incontinence it was 2.92 for former (95% confidence interval 1.58 to 5.39) and 1.89 (95% confidence interval 1.19 to 3.02) for current smokers. Increasing daily and lifetime cigarette consumption was associated with an increasing odds ratio for genuine stress incontinence but not for motor incontinence. The increased risk for incontinence was not due to differences in age, parity, weight, or hypoestrogenic status.

CONCLUSION

The data establish a strong statistical relationship between current and former cigarette smoking and both stress and motor urinary incontinence in women.