Ageing of the female pelvic floor: towards treatment a la carte of the “geripause”

Remodeling of murine vaginal smooth muscle function with reproductive age and elastic fiber disruption

Advanced maternal age during pregnancy is associated with increased risk of vaginal tearing during delivery and maladaptive postpartum healing. Although the underlying mechanisms of age-related vaginal injuries are not fully elucidated, changes in vaginal microstructure may contribute. Smooth muscle cells promote the contractile nature of the vagina and contribute to pelvic floor stability. While menopause is associated with decreased vaginal smooth muscle content, whether contractile changes occur before the onset of menopause remains unknown. Therefore, the first objective of this study was to quantify the active mechanical behavior of the murine vagina with age. Further, aging is associated with decreased vaginal elastin content. As such, the second objective was to determine if elastic fiber disruption alters vaginal contractility. Vaginal samples from mice aged 2-14 months were used in maximum contractility experiments and biaxial extension-inflation protocols. To evaluate the role of elastic fibers with age, half of the vaginal samples were randomly allocated to enzymatic elastic fiber disruption. Contractile potential decreased and vaginal material stiffness increased with age. These age-related changes in smooth muscle function may be due, in part, to changes in microstructural composition or contractile gene expression. Furthermore, elastic fiber disruption had a diminished effect on smooth muscle contractility in older mice. This suggests a decreased functional role of elastic fibers with age. Quantifying the age-dependent mechanical contribution of smooth muscle cells and elastic fibers to vaginal properties provides a first step towards better understanding how age-related changes in vaginal structure may contribute to tissue integrity and healing. STATEMENT OF SIGNIFICANCE: Advanced maternal age at the time of pregnancy is linked to increased risks of vaginal tearing during delivery, postpartum hemorrhaging, and the development of pelvic floor disorders. While the underlying causes of increased vaginal injuries with age and associated pathologies remain unclear, changes in vaginal microstructure, such as elastic fibers and smooth muscle cells, may contribute. Menopause is associated with fragmented elastic fibers and decreased smooth muscle content; however, how reproductive aging affects changes in the vaginal composition and the mechanical properties remains unknown. Quantifying the mechanical contribution of smooth muscle cells and elastic fibers to vaginal properties with age will advance understanding of the potential structural causes of age-related changes to tissue integrity and healing.

Keeping the pelvic floor healthy

Female pelvic floor muscles form a diaphragm that spans the entire pelvic cavity. They consist of the fibers of the coccygeus and the levator ani muscles, the latter of which is composed of five parts. Together with their fascia, the pelvic floor muscles provide support for the urethra, the vagina, and the rectum and constrict the urethral, vaginal, and anal orifices. Alterations in the composition of the pelvic floor muscles at menopause appear to affect their properties and, thereby, their ability to function adequately. This can lead to an increased prevalence in urinary incontinence and other lower urinary tract dysfunction, pelvic organ prolapse, and genitourinary syndrome of menopause. This article aims to define the pelvic floor muscles and functions and to summarize the direct and indirect changes to women's pelvic floor muscles during and after menopause and through aging. A particular focus is also given to the evidence-based literature on how to keep pelvic floor muscles healthy during menopause and in postmenopause using conservative management therapy.

The effect of non-surgical weight loss interventions on urinary incontinence in overweight women: a systematic review and meta-analysis

Although the aetiology of urinary incontinence can be multifactorial, in some cases weight loss could be considered as a part of the therapeutic approach for urinary incontinence in people who are overweight. The objective of this study was to review and meta-analyse the effect of non-surgical weight loss interventions on urinary incontinence in overweight women. Web of Science, PubMed, Pedro, SPORTDiscus and Cochrane were systematically searched for clinical trials that met the a priori set criteria. Data of women who participated in non-surgical weight loss interventions (diet, exercise, medication or a combination) were included in the meta-analysis. After removing duplicates, 62 articles remained for screening on title, abstract and full text. Six articles (totalling 2,352 subjects in the intervention groups) were included for meta-analysis. The mean change in urinary incontinence (reported as frequency or quantity, depending on the study) after a non-surgical weight loss intervention, expressed as standardized effect size and corrected for small sample sizes (Hedges' g), was -0.30 (95%CI = -0.47 to -0.12). This systematic review and meta-analysis shows evidence that a non-surgical weight loss intervention has the potential to improve urinary incontinence and should be considered part of standard practice in the management of urinary incontinence in overweight women.

Factors affecting reflex pelvic floor muscle contraction patterns in women with pelvic floor disorders

OBJECTIVE

To explore factors affecting the presence of two reflex pelvic floor muscle contraction (PFMC) patterns in women with pelvic floor disorders.

METHODS

This was a retrospective analysis of pelvic floor ultrasonography and urodynamic data for 667 consecutive symptomatic women with pelvic floor disorders. We identified on ultrasonography the presence or absence of two reflex PFMC patterns, anorectal lift (ARL) and inward clitoral motion (ICM), preceding or occurring during coughing, and evaluated their associations with possible factors affecting reflex PFMC reactivity, including patient demographics, pelvic organ prolapse stages, ultrasonography findings and urodynamic data.

RESULTS

Of the 667 women, 560 (84.0%) clearly demonstrated reflex ARL and 536 (80.4%) demonstrated ICM. There were significant differences in age (P < 0.001), parity (P = 0.033) and menopausal status (P = 0.005) between women with and those without reflex ICM before or during coughing. The multivariable logistic regression model showed that age was the only independent factor associated with presence of reflex ICM (odds ratio, 0.93 (95% CI, 0.88-0.99), P = 0.017). In contrast, no significant differences were noted between women with and without reflex ARL.

CONCLUSIONS

Increasing age is negatively associated with the presence of reflex ICM during coughing in symptomatic women with pelvic floor disorders.

Effect of weight loss on urinary incontinence in women

BACKGROUND

The purpose of this research was review the epidemiology of the association of obesity and urinary incontinence, and to summarize the published data on the effect of weight loss on urinary incontinence.

METHODS

A literature review of the association between urinary incontinence and overweight/obesity in women was performed. Case series and clinical trials reporting the effect of surgical, behavioral, and/or pharmacological weight loss on urinary incontinence are summarized.

RESULTS

Epidemiological studies demonstrate that obesity is a strong and independent risk factor for prevalent and incident urinary incontinence. There is a clear dose-response effect of weight on urinary incontinence, with each 5-unit increase in body mass index associated with a 20%-70% increase in risk of urinary incontinence. The maximum effect of weight on urinary incontinence has an odds ratio of 4-5. The odds of incident urinary incontinence over 5-10 years increase by approximately 30%-60% for each 5-unit increase in body mass index. There appears to be a stronger association between increasing weight and prevalent and incident stress incontinence (including mixed incontinence) than for urge incontinence. Weight loss studies indicate that both surgical and nonsurgical weight loss leads to significant improvements in prevalence, frequency, and/or symptoms of urinary incontinence.

CONCLUSION

Epidemiological studies document overweight and obesity as important risk factors for urinary incontinence. Weight loss by both surgical and more conservative approaches is effective in reducing urinary incontinence symptoms and should be strongly considered as a first line treatment for overweight and obese women with urinary incontinence.

Genetics of pelvic organ prolapse: crossing the bridge between bench and bedside in urogynecologic research

An increasing number of scientists have studied the molecular and biochemical basis of pelvic organ prolapse (POP). The extracellular matrix content of the pelvic floor is the major focus of those investigations and pointed for potential molecular markers of the dysfunction. The identification of women predisposed to develop POP would help in the patients' management and care. This article includes a critical analysis of the literature up to now; discusses implications for future research and the role of the genetics in POP.

Effects of age on levator function and morphometry of the levator hiatus in women with pelvic floor disorders

Introduction and hypothesis

Epidemiological data supports the hypothesis that ageing is a risk factor for pelvic organ prolapse. In this study, we intended to determine the effect of age on levator function and morphometry in women with pelvic floor disorders.

Methods

Three hundred seventy-five patients underwent an interview, physical examination and transperineal ultrasound. Clinical assessment included palpation using the Modified Oxford Scale. Ultrasonography was performed to diagnose levator defects and assess levator hiatal morphometry.

Results

Pelvic floor muscle strength was weakly associated with patient age (r = −0.25, p < 0.01). This remained true after accounting for the confounders parity and levator defects. Morphometry of the levator hiatus was weakly positively correlated with age.

Conclusions

Ageing seems to have a limited effect on contractility and distensibility of the pelvic floor muscle. The small effect of ageing results in reduced contraction strength and increased hiatal diameters. This effect is partly confounded by parity and levator defects.

Complications of transvaginal monofilament polypropylene mesh in pelvic organ prolapse repair

INTRODUCTION AND HYPOTHESIS

This study aimed to document intraoperative and postoperative complications associated with the use of transvaginal polypropylene mesh in the repair of pelvic organ prolapse (POP).

METHODS

This is a retrospective review of 127 cases of transvaginal repair of POP using synthetic mesh.

RESULTS

Mean postoperative value (+/-SD) for pelvic organ prolapse quantification (POPQ) measurements Aa, Ap, and C were: -2.4 +/- 1.1 (cm), -2.4 +/- 0.9 (cm), and -7.7 +/- 1.2 (cm), respectively. The difference between preoperative and postoperative values of these points was significant (p < 0.0001). Mesh erosion rate was 13/127 (10.2%) with significant correlation between mesh erosion and concurrent vaginal hysterectomy (p = 0.008). Combined anterior and posterior vaginal mesh surgery increased the risk of intraoperative bleeding and blood transfusion (p < 0.05).

CONCLUSIONS

Concurrent vaginal hysterectomy is associated with increased risk of vaginal mesh erosion. Combined anterior and posterior vaginal mesh repair is an increased risk factor for intraoperative bleeding and blood transfusion.