Pelvic organ prolapse and collagen-associated disorders

The difference in extracellular matrix metabolism in women with and without pelvic organ prolapse: A systematic review and meta-analysis

BACKGROUND

Studies on the changes of extracellular matrix (ECM) in pelvic organ prolapse (POP) are still controversial.

OBJECTIVE

To identify the changes in the ECM in POP patients.

SEARCH STRATEGY

Comprehensive searching in Embase, PubMed, Web of Science and the Cochrane Library was carried out until 23 February 2023.

SELECTION CRITERIA

Studies comparing the protein levels of ECM-related components between women with and without POP.

DATA COLLECTION AND ANALYSIS

Quality and risk of bias were assessed using the Agency for Healthcare Research and Quality assessment. Indicators were pooled with random or fixed effect meta-analysis based on heterogeneity and sub-grouped analysed by the biopsy site.

MAIN RESULTS

Thirty cross-sectional studies were included, comprising 840 POP cases and 755 controls. Overall results showed that the expression of type III collagen (COLIII) and several matrix metalloproteinases (MMP-1, -2 and -9) were increased, whereas those of type I collagen (COLI), and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) were decreased in patients with POP. Subgroup analysis showed that the expression of COLIII in the anterior vaginal wall (AVW) and COLIII, MMP-2 and -9 in the uterosacral ligament (USL) were consistent with the overall results. However, the expression of COLI and MMP-1 in the AVW showed no difference and the expression of COLI and MMP-1 in the USL is still controversial based on current studies.

CONCLUSIONS

Patients with POP have lower expression of COLI and TIMP-1 and higher expression of COLIII and MMPs compared with non-POP cases, but further studies are required to investigate in specified anatomical sites.

Management of childbearing with hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders: A scoping review and expert co-creation of evidence-based clinical guidelines

OBJECTIVE

To co-create expert guidelines for the management of pregnancy, birth, and postpartum recovery in the context of hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSD).

DESIGN

Scoping Review and Expert Co-creation.

SETTING

United Kingdom, United States of America, Canada, France, Sweden, Luxembourg, Germany, Italy, and the Netherlands.

SAMPLE

Co-creators (n = 15) included expertise from patients and clinicians from the International Consortium on the Ehlers-Danlos syndromes and Hypermobility Spectrum Disorders, facilitated by the Ehlers-Danlos Society.

METHODS

A scoping review using Embase, Medline, the Cochrane Central Register of Controlled Trials and CINHAL was conducted from May 2022 to September 2023. Articles were included if they reported primary research findings in relation to childbearing with hEDS/HSD, including case reports. No language limitations were placed on our search, and our team had the ability to translate and screen articles retrieved in English, French, Spanish, Italian, Russian, Swedish, Norwegian, Dutch, Danish, German, and Portuguese. The Mixed Methods Appraisal Tool was used to assess bias and quality appraise articles selected. The co-creation of guidelines was based on descriptive evidence synthesis along with practical and clinical experience supported by patient and public involvement activities.

RESULTS

Primary research studies (n = 14) and case studies (n = 21) including a total of 1,260,317 participants informed the co-creation of guidelines in four overarching categories: 1) Preconceptual: conception and screening, 2) Antenatal: risk assessment, management of miscarriage and termination of pregnancy, gastrointestinal issues and mobility, 3) Intrapartum: risk assessment, birth choices (mode of birth and intended place of birth), mobility in labor and anesthesia, and 4) Postpartum: wound healing, pelvic health, care of the newborn and infant feeding. Guidelines were also included in relation to pain management, mental health, nutrition and the common co-morbidities of postural orthostatic tachycardia syndrome, other forms of dysautonomia, and mast cell diseases.

CONCLUSIONS

There is limited high quality evidence available. Individualized strategies are proposed for the management of childbearing people with hEDS/HSD throughout pregnancy, birth, and the postpartum period. A multidisciplinary approach is advised to address frequently seen issues in this population such as tissue fragility, joint hypermobility, and pain, as well as common comorbidities, including dysautonomia and mast cell diseases.

Pelvic Floor Dysfunction Among Persons With Marfan and Loeys-Dietz Syndrome

IMPORTANCE

Connective tissue disorders are proposed in the literature to be predisposing risk factors for pelvic floor disorders. Prior data characterizing the prevalence of and symptom burden related to pelvic floor disorders are limited for individuals with Marfan syndrome and are nonexistent for those with Loeys-Dietz syndrome.

OBJECTIVE

The objective of this study was to determine the prevalence and severity of symptoms related to pelvic floor disorders among individuals with Marfan syndrome and Loeys-Dietz syndrome using the Pelvic Floor Distress Inventory-20 (PFDI-20).

STUDY DESIGN

In this cross-sectional study, a survey including the PFDI-20 was administered to biologically female individuals older than 18 years with a confirmed diagnosis of Marfan syndrome or Loeys-Dietz Syndrome. Respondents were solicited through the websites, email lists, and social media forums of The Marfan Foundation and The Loeys-Dietz syndrome Foundation.

RESULTS

A total of 286 respondents were included in the final analysis, 213 with Marfan syndrome and 73 with Loeys-Dietz syndrome. The median PFDI-20 score of the cohort was 43.8. Individuals with Loeys-Dietz syndrome had higher PFDI-20 scores and were more likely to have established risk factors for pelvic floor disorders that correlated with their PFDI-20 scores compared with those with Marfan syndrome.

CONCLUSIONS

Respondents with Marfan syndrome and Loeys-Dietz syndrome experience a high burden of symptoms related to pelvic floor disorders. Despite the similar pathophysiology and clinical manifestations of these disorders, there were differences in PFDI-20 responses that may suggest that these diseases differ in the ways they affect the pelvic floor.

Clinical characteristics of patients with hypermobile type Ehlers-Danlos syndrome (hEDS) and generalized hypermobility spectrum disorders (G-HSD): an online survey

To examine the perspective of individuals with Hypermobile Ehlers-Danlos Syndrome (hEDS) and Generalized Hypermobility Spectrum Disorder (G-HSD), needed to help identify priorities and improve the lives of people living with these conditions. We conducted an online survey between November 2021 and January 2023. Participants were recruited through the Ehlers-Danlos Society's Research Surveys website. We obtained 483 responses and 396 were analyzed. 80% of the survey's respondents were individuals with hEDS, 90% were females, 30% were between 21 and 30, and 76% lived in North America, with 85% of the participants living in North America indicated being White or European American. Participants reported exercising from none to less than three times per week, with no physical therapy treatment. Ninety-eight percent of participants reported pain mainly at the neck (76%), lower (76%) and upper back (66%), knees (64%), shoulders (60%), and hips (60%). Approximately 80% of participants reported fatigue, joint hypermobility, joint instability, interference with daily activities, gastrointestinal problems, orthostatic hypotension, muscle weakness, and emotional distress. About 60% of respondents indicated walking issues, balance issues, and reduced joint proprioception. Nearly 40% of participants reported pelvic floor dysfunction and cardiovascular problems. Participants with hEDS and G-HSD reported pain on an average (SD) of 6.4 (± 1.3) and 5.9 (± 1.5) days in a typical week, respectively. People with hEDS and G-HSD desperately need more effective treatment options, a better diagnostic process, and education among health care providers.

PEOPLE: Lifestyle and comorbidities as risk factors for pelvic organ prolapse-a systematic review and meta-analysis PEOPLE: PElvic Organ Prolapse Lifestyle comorbiditiEs

INTRODUCTION AND HYPOTHESIS

The literature is scarce regarding the effects of comorbidities, clinical parameters, and lifestyle as risk factors for pelvic organ prolapse (POP). This study was performed to systematically review the literature related to body mass index (BMI), waist circumference, diabetes mellitus (DM), hypertension (HT), dyslipidemia, chronic constipation, smoking, chronic cough, occupation, and striae and varicose veins as determinants for POP.

METHODS

Search terms in accordance with Medical Subject Headings were used in PubMed, Embase, LILACS, and the Cochrane Library. Clinical comparative studies between women with and without POP and containing demographic and/or clinical raw data related to lifestyle and/or comorbidities were included. The ROBINS-I (risk of bias in non-randomized studies of interventions) instrument was used. Fixed-effects and random-effects models were used for homogeneous and heterogeneous studies, respectively.

RESULTS

Forty-three studies were included in the meta-analysis. BMI < 25 kg/m2 was found to be a protective factor for POP [OR 0.71 (0.51, 0.99); p = 0.04], and BMI > 30 kg/m2 was a risk factor for POP [OR 1.44 (1.37, 1.52); p < 0.00001]. Waist circumference (≥ 88 cm) was reported as a risk factor for POP [OR 1.80 (1.37, 2.38); p < 0.00001], along with HT [OR 1.18 (1.09, 1.27); p = 0.04], constipation [OR 1.77 (1.23, 2.54); p < 0.00001], occupation [OR 1.86 (1.21, 2.86); p < 0.00001], persistent cough [OR 1.52 (1.18, 1.94); p < 0.0001]), and varicose veins [OR 2.01 (1.50, 2.70); p = 0.12].

CONCLUSIONS

BMI < 25 kg/m2 is protective while BMI > 30 kg/m2 is a risk factor for POP. Large waist circumference, dyslipidemia, HT, constipation, occupation, persistent cough, and varicose veins are also determinants for POP.

RECTAL PROLAPSE IN THE SULAWESI CRESTED BLACK MACAQUE (MACACA NIGRA): MORBIDITY, MORTALITY, AND RISK FACTORS

Empirical data suggest that rectal prolapse (RP) is common in captive Sulawesi crested black macaques (Macaca nigra) in Europe, resulting in the euthanasia of animals that experience repeat occurrences. However, the prevalence, etiology, and risk factors of RP remain unidentified. The aims of this retrospective study were to assess the morbidity and mortality of RP, to provide an overview of management practices, and to identify risk factors for RP in this species. A questionnaire was sent to all European Ex situ Programme institutions that housed M. nigra between 01 January 2014 and 31 December 2020. Zoological Information Management System medical records and the studbook were used to obtain additional information. The questionnaire had a response rate of 65%, accounting for 204 animals. Of these animals, 25 (12.3%) suffered from at least one RP event during the study period and recurrence was noted in 72%. The majority of prolapses reverted naturally, but 28% of afflicted animals were euthanized for this ailment. Institutions with M. nigra with high frequencies of diarrhea (P= 0.035), those that provided diets of ≥90% vegetables and high-fiber pellet (P < 0.001), and those with more male than female M. nigra (P < 0.001) had increased odds of RP. Institutions that provided fruits daily (P < 0.002) had reduced odds of having RP cases. Although correlation of RP with diet was identified, confounding cannot be excluded, and a detailed dietary analysis needs to take place before altering feeding practices. Acute stressors and detection of protozoa in fecal samples were common findings before an RP event. Demographic analysis indicated that aged females, young males, and subordinate individuals were most affected by this condition. Where tested during an RP intervention, animals had low serum levels of vitamin D. Pedigree analysis hinted at genetic predisposition in this species and requires further investigation.

Anorectal manometry for the diagnosis of pelvic floor disorders in patients with hypermobility spectrum disorders and hypermobile Ehlers-Danlos syndrome

INTRODUCTION

Functional gastrointestinal disorders (FGID) including impaired rectal evacuation are common in patients with Hypermobility Spectrum Disorder (HSD) or Hypermobile Ehlers-Danlos Syndrome (hEDS). The effect of connective tissue pathologies on pelvic floor function in HSD/hEDS remains unclear. We aimed to compare clinical characteristics and anorectal pressure profile in patients with HSD/hEDS to those of age and sex matched controls.

METHODS

We conducted a retrospective review of all FGID patients who underwent high resolution anorectal manometry (HR-ARM) and balloon expulsion test (BET) for evaluation of impaired rectal evacuation. Patients with HSD/hEDS were age and sex matched to a randomly selected cohort of control patients without HSD/hEDS. An abnormal BET was defined as the inability to expel a rectal balloon within 2 minutes. Wilcoxon rank sum test and Fisher's exact test were used to make comparisons and logistic regression model for predictive factors for abnormal evacuation.

RESULTS

A total of 144 patients (72 with HSD/hEDS and 72 controls) were analyzed. HSD/hEDS patients were more likely to be Caucasian (p < 0.001) and nulliparous. Concurrent psychiatric disorders; depression, and anxiety (p < 0.05), and somatic syndromes; fibromyalgia, migraine and sleep disorders (p < 0.001) were more common in these patients. Rate of abnormal BET were comparable among the groups. HDS/hEDS patients had significantly less anal relaxation and higher residual anal pressures during simulated defecation, resulting in significantly more negative rectoanal pressure gradient. The remaining anorectal pressure profile and sensory levels were comparable between the groups. While diminished rectoanal pressure gradient was the determinant of abnormal balloon evacuation in non HSD/hEDS patients, increased anal resting tone and maximum volume tolerated were independent factors associated with an abnormal BET in HSD/hEDS patients. Review of defecography data from a subset of patients showed no significant differences in structural pathologies between HSD/hEDS and non HSD/hEDS patients.

CONCLUSIONS

These results suggest anorectal pressure profile is not compromised by connective tissue pathologies in HSD patients. Whether concurrent psychosomatic disorders or musculoskeletal involvement impact the pelvic floor function in these patients needs further investigation.

Transanal rectopexy for external rectal prolapse

PURPOSE

The surgical management of patients with full-thickness rectal prolapse (FTRP) continues to remain a challenge in the laparoscopic era. This study retrospectively assesses a cohort of patients undergoing a transanal suture sacro rectopexy supported by sclerosant injection into the presacral space under ultrasound guidance.

METHODS

Patients with FTRP underwent a sutured transrectal presacral fixation of 2/3 of the circumference of the rectum from the third sacral vertebra to the sacrococcygeal junction through a side-viewing operating proctoscope. The procedure was supplemented by ultrasound-guided injection into the retrorectal space of a 2 mL solution of sodium tetradecyl sulfate/polidocanol mixed with air. Patients were functionally assessed before and 6 months after surgery with the Agachan constipation score and the Pescatori incontinence score.

RESULTS

There were 36 adult patients (26 males; the range of age, 23-92 years). The mean operative time was 27 minutes (range, 23-50 minutes) with no recorded perioperative morbidity. The median follow-up was 66 months (range, 48-84 months) with 1 (2.8%) recurrence presenting 18 months after surgery. There were 19 patients (52.8%) who presented with incontinence before surgery with 17 out of 19 (89.5%) reporting improvement in their Pescatori score (P<0.001). No patient had worsening incontinence and there were no de novo incontinence cases. Constipation scores improved in 23 out of 36 patients (63.9%) with a mean score reduction difference of 7.91 (P=0.001).

CONCLUSION

Transanal sutured sacral rectopexy with supplemental presacral sclerosant injection is safe and effective in the management of FTRP with sustained improvement in bowel function.

Ehlers-Danlos: A Literature Review and Case Report in a Colombian Woman with Multiple Comorbidities

Ehlers-Danlos syndromes (EDS) are a heterogeneous group of genetically transmitted connective tissue disorders that directly affect collagen synthesis, with a broad range of symptoms. Case presentation: This study presents a clinical case of a Colombian woman with myopathic EDS and multiple comorbidities taking 40 years of medical history to make the right diagnosis. This article also presents a review of the current literature on EDS, not only to remind the syndrome but also to help the clinician correctly identify symptoms of this diverse syndrome. Conclusion: A multidisciplinary approach to the diagnosis of the patient, including clinical and molecular analysis, and neuropsychological and psychological assessment, is important to improve the treatment choice and the outcome prediction of the patients.

Distinctive structure, composition and biomechanics of collagen fibrils in vaginal wall connective tissues associated with pelvic organ prolapse

Collagen is the predominant structural protein within connective tissues. Pelvic organ prolapse (POP) is characterized by weakening of the pelvic floor connective tissues and loss of support for pelvic organs. In this study, we examined the multiscale structure, molecular composition and biomechanics of native collagen fibrils in connective tissues of the posterior vaginal fornix collected from healthy women and POP patients, and established the correlation of these properties with clinical POP quantification (POP-Q) scores. The collagen characteristics, including collagen amount, ratio of Collagen I and Collagen III, collagen fibril d-period, alignment and stiffness, were found to change progressively with the increase of the clinical measurement of Point C, a measure of uterine descent and apical prolapse. The results imply that a severe prolapse is associated with stiffer collagen fibrils, reduced collagen d-period, increased fibril alignment and imbalanced collagen synthesis, degradation and deposition. Additionally, prolapse progression appears to be synchronized with deterioration of the collagen matrix, suggesting that a POP-Q score obtained via a non-invasive clinical test can be potentially used to quantitatively assess collagen abnormality of a patient's local tissue. STATEMENT OF SIGNIFICANCE: Abnormal collagen metabolism and deposition are known to associate with connective tissue disorders, such as pelvic organ prolapse. Quantitative correlation of the biochemical and biophysical characteristics of collagen in a prolapse patient's tissue with the clinical diagnostic measurements is unexplored and unestablished. This study fills the knowledge gap between clinical prolapse quantification and the individual's cellular and molecular disorders leading to connective tissue failure, thus, provides the basis for clinicians to employ personalized treatment that can best manage the patient's condition and to alert pre-symptomatic patients for early management to avoid unwanted surgery.

The difference in collagen type-1 expression in women with and without pelvic organ prolapse: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

This study was aimed at identifying the difference in collagen type-1 expression in women with and without pelvic organ prolapse (POP).

METHODS

A systematic review and meta-analysis was carried out women with and without pelvic organ prolapse. This meta-analysis was conducted on research articles describing the evaluation of collagen type-1 expression between patients with and without POP. The articles were obtained from PubMed, EBSCO, and ProQuest, and were published between January 2000 and June 2021. Pooled mean difference (MD) and pooled odds ratio (OR) were calculated using fixed effect models. Review Manager (RevMan 5.4) was used to analyze the data. The main outcome measures were pooled MD and pooled OR of collagen type-1 expression in patients with and without POP.

RESULTS

A total of seven case-control studies were included in the meta-analysis using the effect size of the MD and two case-control studies were included in the meta-analysis using the effect size of the OR. A total of 247 POP cases and 132 non-POP cases were identified from the studies. Our study indicated that patients with POP had a lower level of collagen type-1 expression than non-POP patients (MD = -6.77; 95% CI: -8.37, -5.17, p < 0.00001). Patients with low expression of collagen type-1 in pelvic support tissue are at a more than 3 times higher risk of suffering from pelvic organ prolapse (OR = 3.23, 95% CI: 1.52 to 6.87, p = 0.002).

CONCLUSION

The results of this study showed that patients with pelvic organ prolapse have lower expression of collagen type-1 than nonpelvic organ prolapse patients.

Childbirth resulting in traumatic stretching and prolapsing of the anterior lip of the cervix outside the vagina: A case report

Background

We report on childbirth trauma resulting in a rare stretching and prolapsing of the anterior lip of the cervix beyond the vaginal introitus, and describe the management.

Case Presentation

A 17-year-old primigravida who had normal antenatal care delivered a live normal male baby weighing 3600 g at 39 weeks of gestation. The patient sustained a birth trauma resulting in the anterior lip of the cervix becoming stretched and prolapsing outside the vagina. There was an associated uterovaginal prolapse (Pelvic Organ Prolapse Quantification System grade 2). The prolapse of the cervix recurred after the initial repositioning of the cervix into the vagina. Subsequently, a vaginal ring pessary was applied to reduce the uterus and cervix. The most distal part of the prolapsed cervix was necrotic, remained outside the vagina despite the application of the ring pessary, and was excised. The use of the ring pessary was discontinued at 6 weeks postpartum, the cervix healed without obvious defect, and there was no prolapse at 3-month follow-up.

Conclusion

A stretched cervix that prolapses beyond the vaginal introitus and uterovaginal prolapse are rare complications of childbirth that may be amenable to treatment with a ring pessary and to surgical excision of non-viable cervical tissue.

•

Trauma to the cervix may occur due to incomplete dilatation of the anterior lip of the cervix before childbirth.

•

Stretching and prolapsing of the anterior lip of the cervix outside the vagina are rare forms of birth trauma.

•

Both stretched cervix which prolapses outside the vagina and uterovaginal prolapse are treatable with a ring pessary.

•

Excision of the cervix following birth trauma is rarely appropriate.

•

Excision of the necrotic distal part of a prolapsed cervix may be undertaken, as in the index case.

Mesenchymal stem cell transplantation for vaginal repair in an ovariectomized rhesus macaque model

BACKGROUND

Current surgical therapies for pelvic organ prolapse (POP) do not repair weak vaginal tissue and just provide support; these therapies may trigger severe complications. Stem cell-based regenerative therapy, due to its ability to reconstruct damaged tissue, may be a promising therapeutic strategy for POP. The objective of this study is to evaluate whether mesenchymal stem cell (MSC) therapy can repair weak vaginal tissue in an ovariectomized rhesus macaque model.

METHODS

A bilateral ovariectomy model was established in rhesus macaques to induce menopause-related vaginal injury. Ten bilaterally ovariectomized rhesus macaques were divided into two groups (n=5/group): the saline group and the MSC group. Three months after ovariectomy, saline or MSCs were injected in situ into the injured vaginal wall. The vaginal tissue was harvested 12 weeks after injection for histological and biochemical analyses to evaluate changes of extracellular matrix, microvascular density, and smooth muscle in the vaginal tissue. Biomechanical properties of the vaginal tissue were assessed by uniaxial tensile testing. Data analysis was performed with unpaired Student's t test or Mann-Whitney.

RESULTS

Twelve weeks after MSC transplantation, histological and biochemical analyses revealed that the content of collagen I, elastin, and microvascular density in the lamina propria of the vagina increased significantly in the MSC group compared with the saline group. And the fraction of smooth muscle in the muscularis of vagina increased significantly in the MSC group. In addition, MSC transplantation improved the biomechanical properties of the vagina by enhancing the elastic modulus.

CONCLUSION

Vaginal MSC transplantation could repair the weak vaginal tissue by promoting extracellular matrix ingrowth, neovascularization, and smooth muscle formation and improve the biomechanical properties of the vagina, providing a new prospective treatment for POP.

Oxidative Stress and Musculoskeletal Pain in University Students with Generalized Joint Hypermobility: A Case-Control Study

Objective

The current case–control study aimed to evaluate generalized joint hypermobility (GJH) and its association with pain intensity, cellular oxidative stress, and collagen-associated disorders in university students aged 18–25 years old.

Background

Joint hypermobility has been recognized in healthy subjects and people who are carriers of cellular disorders in connective tissues. Cellular tissue oxidative stress and collagen-associated disorders were shown to be associated with joint hypermobility (JH).

Materials and Methods

A total of 300 university students aged 18–25 years were randomly invited from different medical and science faculties in Mansoura university, Mansoura, Egypt to participate in this case–control study. Only 280 university students who had no exclusion criteria like chronic health problems, physical disability, musculoskeletal disorders, and body mass index (BMI) of ≥25 underwent an initial clinical interview and Beighton scoring as measures of GJH. Pain intensity, physical activity, oxidative stress parameters; TAC, TOC, OSI, and collagen-associated parameters; cellular prolidase activity and hydroxyproline were evaluated by using a prevalidated questionnaire, colorimetric, and immunoassay techniques.

Results

GJH was significantly reported in 57.1% of the study population, and most of them are females. Compared to men, females with GJH showed poor physical activity, lower TAC, and significantly higher levels of TOC, OSI, cellular prolidase activity, and hydroxyproline. Based on our findings, a high Beighton score is closely related to the tissue levels of prolidase, hydroxyproline, antioxidant activity, pain intensity, and poor physical activity in the female with GJH compared to men.

Conclusion

GJH was significantly reported in 57.1% of the study population, and most of them are females. The incidence of GJH showed to be associated with poor physical activity, abnormal cellular oxidative stress, and collagen abnormalities measured by significant increase in change in cellular prolidase activity and hydroxyproline.

Perioperative outcomes following pelvic floor reconstruction in women with hereditary disorders of connective tissue: a retrospective cohort study

INTRODUCTION AND HYPOTHESIS

Women with hereditary disorders of connective tissue (HDCT) are at increased risk of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). We hypothesized that patients would have increased incidence and severity of perioperative complications up to 6 weeks after surgeries for POP/SUI. Secondary objectives were to compare pre- and post-operative pelvic floor symptoms and anatomical support as well as pelvic floor disorder recurrence.

METHODS

In this multi-center retrospective cohort study, we identified patients with HDCTs by patient history and ICD-9 codes over an 11-year period. Controls without HDCTs were matched 2:1 to the primary POP or SUI procedure and surgeon. Demographic characteristics, perioperative pelvic floor information and complications were collected. A sample size of 65 HDCT patients and 130 controls was calculated to detect a 20% difference in complications with 80% power and alpha of 0.05.

RESULTS

We identified 59 HDCT patients and 118 controls. Of the women with HDCTs, 49% had Ehlers-Danlos, 22% joint hypermobility syndrome, 15% Marfan syndrome, and 14% had others. Compared with controls, HDCT patients had more total perioperative complications (46% vs 22%, p = 0.002); an age-adjusted relative risk of complications was 1.4 (CI 0.7-2.6). HDCT patients had more Clavien-Dindo grades I and II complications (p = 0.02, 0.03) and more hospital readmissions (14% vs 3%, p = 0.01) than controls. There was no difference in the incidence of specific complications nor was there a difference in recurrence of POP (10%) or SUI (11%) between groups.

CONCLUSIONS

Patients with HDCTs had more Clavien-Dindo grade I and II complications following pelvic floor reconstructive surgery and more readmissions.

The Role of Cell Adhesion and Cytoskeleton Dynamics in the Pathogenesis of the Ehlers-Danlos Syndromes and Hypermobility Spectrum Disorders

The Ehlers-Danlos syndromes (EDS) are a group of 13 disorders, clinically defined through features of joint hypermobility, skin hyperextensibility, and tissue fragility. Most subtypes are caused by mutations in genes affecting the structure or processing of the extracellular matrix (ECM) protein collagen. The Hypermobility Spectrum Disorders (HSDs) are clinically indistinguishable disorders, but are considered to lack a genetic basis. The pathogenesis of all these disorders, however, remains poorly understood. Genotype-phenotype correlations are limited, and findings of aberrant collagen fibrils are inconsistent and associate poorly with the subtype and severity of the disorder. The defective ECM, however, also has consequences for cellular processes. EDS/HSD fibroblasts exhibit a dysfunctional phenotype including impairments in cell adhesion and cytoskeleton organization, though the pathological significance of this has remained unclear. Recent advances in our understanding of fibroblast mechanobiology suggest these changes may actually reflect features of a pathomechanism we herein define. This review departs from the traditional view of EDS/HSD, where pathogenesis is mediated by the structurally defective ECM. Instead, we propose EDS/HSD may be a disorder of membrane-bound collagen, and consider how aberrations in cell adhesion and cytoskeleton dynamics could drive the abnormal properties of the connective tissue, and be responsible for the pathogenesis of EDS/HSD.

Association between pelvic floor disorders and hernias

INTRODUCTION AND HYPOTHESIS

Connective tissue disorders may contribute to pelvic floor disorders (PFDs). Like PFDs, abdominal wall hernias are more common in patients with systemic connective tissue disorders. We conducted this study to explore the possible association between PFDs and hernias in adult women.

METHODS

We obtained the data for this study from a study of PFDs among parous women. At enrollment, stress urinary incontinence (SUI), overactive bladder (OAB), and anal incontinence (AI) were assessed using the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ) and pelvic organ prolapse (POP) was assessed through the Pelvic Organ Prolapse Quantification (POP-Q) examination. Participants were asked to report hernia surgery and list their hernia types. We compared the prevalence of PFDs in those with and without hernias using chi-square test. We used multiple regression analysis to adjust for obstetric and sociodemographic variables.

RESULTS

Among 1529 women, 79 (5.2%) reported history of hernia surgery. The prevalence of POP was 7.6% (6 cases) vs. 7.4% (107 cases), the prevalence of SUI was 7.6% (6 cases) vs. 9.9% (144 cases), the prevalence of OAB was 7.6% (6 cases) vs. 5.7% (83 cases), and the prevalence of AI was 7.6% (6 cases) vs. 10.8% (156 cases) in those with hernias compared to those without hernias, respectively. None of these differences were statistically significant. There was no association between hernias and PFDs after adjustment for type of delivery, number of deliveries, age group, primary racial background, weight category, and smoking status.

CONCLUSION

In this study, we could not find any association between hernias and PFDs.

Signs of connective tissue dysplasia in women with genital prolapse

Introduction. Despite a long history of the disease, genital prolapse still have not been definitively solved. A relevance of pelvic organ prolapse in women has been increasing in recent years largely due to a change in the quality of life and desire to sustain their youth. The number of studies pinpointing the cause of the disease in connective tissue dysplasia (CTD) has been increasing annually.Aim: to conduct a systematic analysis and determine most common signs of CTD in women with genital prolapse.Materials and methods. CTD criteria and the relationship with genital prolapse were analyzed. The study was conducted using questionnaires and including clinical studies examining residents of the Belgorod region (135 women). The main group included 91 patients who had signs of pelvic organ prolapse, and control group consisted of 44 healthy women. CTD intensity score proposed by T.Yu. Smolnova et al. (2003) was used to assess signs of dysplasia in women examined allowing to build up three groups in which each symptom was evaluated as severity score.Results. Asthenic constitution was noted in high percentage of women suffering from genital prolapse (16.70 ± 0.38 %) compared with healthy women (2.30 ± 0.15 %; p = 0.016). Mild bruising, increased tissue bleeding tended to rise in main vs. control group (16.50 ± 0.37 % in main group and 0.0 in control group; p = 0.016). Signs of varicose veins and hemorrhoids requiring no surgical treatment were found in 33.00 ± 0.47 % and 4.50 ± 0.21 % in main vs. control group (p = 0.0002), respectively. Genital prolapse and hernia in first-line relatives were recorded in 9.90 ± 0.30 % in main group (p = 0.031), women without signs of prolapse did not indicate prolapse in close relatives.Conclusion. Asthenic constitution, hernias, varicose veins and hemorrhoids, female pelvic and hernial prolapse in close female relatives, a tendency to mild bruising, skeletal anomalies, elastosis skin were among common CTD signs in women with genital prolapse.

Can pelvic organ prolapse in postmenopausal women be treated with laser therapy?

PURPOSE

This study aims to assess the effectiveness of the non-ablative photothermal erbium laser (Er:YAG laser) for managing anterior and/or posterior vaginal compartment prolapse.

METHODS

A randomized, single-blind, 1:1 trial was performed comparing Er:YAG laser treatment to watchful waiting in postmenopausal women with symptomatic cystocele and/or rectocele stage 2 or 3 who opted to undergo surgery due to bothersome prolapse symptoms. Three Er:YAG laser treatments at monthly intervals were applied for the Er:YAG laser group, while there was no treatment for the watchful-waiting group. The primary outcome was the proportion of patients with stage 0 or 1 following laser treatment, while secondary outcomes included the Pelvic Organ Prolapse Quantification System (POP-Q points), Pelvic Floor Distress Inventory Questionnaire short-form, Pelvic Floor Impact Questionnaire short-form, and Patients Global Impression of Improvement (PGI-I). All outcomes were evaluated at baseline and 4 months post baseline.

RESULTS

Thirty women (15 vs. 15) were eligible to be included. No participants (0%) in either group had POP-Q stage 0 or 1 at 4 months. Moreover, no change was present in the secondary outcomes. In the PGI-I, 2/15 (14%) and 0/15 (0%) participants declared much better/very much better in the laser and watchful-waiting group, respectively.

CONCLUSIONS

The findings of this study do not support use of the intravaginal Er:YAG laser for treatment of the anterior/posterior vaginal wall. Clinical trial identification number: NCT03714607.

Functional supramolecular bioactivated electrospun mesh improves tissue ingrowth in experimental abdominal wall reconstruction in rats

Development of biomaterials for hernia and pelvic organ prolapse (POP) repair is encouraged because of high local complication rates with current materials. Therefore, we aimed to develop a functionalized electrospun mesh that promotes tissue ingrowth and provides adequate mechanical strength and compliance during degradation. We describe the in vivo function of a new supramolecular bioactivated polycarbonate (PC) material based on fourfold hydrogen bonding ureidopyrimidinone (UPy) units (UPy-PC). The UPy-PC material was functionalized with UPy-modified cyclic arginine-glycine-aspartic acid (cRGD) peptide additives. Morphometric analysis of the musculofascial content during wound healing showed that cRGD functionalization promotes myogenesis with inhibition of collagen deposition at 14 days. It also prevents muscle atrophy at 90 days and exerts an immunomodulatory effect on infiltrating macrophages at 14 days and foreign body giant cell formation at 14 and 90 days. Additionally, the bioactivated material promotes neovascularization and connective tissue ingrowth. Supramolecular cRGD-bioactivation of UPy-PC-meshes promotes integration of the implant, accelerates tissue ingrowth and reduces scar formation, resulting in physiological neotissue formation when used for abdominal wall reconstruction in the rat hernia model. Moreover, cRGD-bioactivation prevents muscle atrophy and modulates the inflammatory response. Our results provide a promising outlook towards a new type of biomaterial for the treatment of hernia and POP. STATEMENT OF SIGNIFICANCE: Development of biomaterials for hernia and pelvic organ prolapse (POP) repair is encouraged because of high local complication rates with current materials. Ureidopyrimidinone-polycarbonate is a elastomeric and biodegradable electrospun mesh, which could mimic physiological compliance. The UPy-PC material was functionalized with UPy-modified cyclic arginine-glycine-aspartic acid (cRGD) peptide additives. Supramolecular cRGD-bioactivation of UPy-PC-meshes promotes integration of the implant, accelerates tissue ingrowth and reduces scar formation, resulting in physiological neotissue formation when used for abdominal wall reconstruction in rat hernia model. Moreover, cRGD-bioactivation prevents muscle atrophy and modulates the inflammatory response. These data provide a promising outlook towards a new type of biomaterial for the treatment of hernia and POP.

Anti-inflammatory effect of adipose-derived stem cells in the treatment of pelvic organ prolapse

Objective

This study investigated the effect of recombinant human connective tissue growth factor (hCTGF) on rat adipose-derived stem cells (ADSCs) and explored the feasibility of using ADSCs to treat pelvic organ prolapse.

Methods

ADSCs were isolated from rat inguinal adipose tissue and characterized by flow cytometry and for osteogenic and adipogenic differentiation. ADSCs were treated with recombinant hCTGF and qRT-PCR was performed to detect collagen I and III expression on post-treatment days 7, 14, and 28. Osteogenic and adipogenic differentiation of ADSCs was performed to evaluate the effect of hCTGF. ADSCs were seeded in biological grafting materials, acellular porcine pericardium (APP) and acellular bovine pericardium (ABP), then implanted in the rat vagina. Histology was performed to observe inflammation among different groups.

Results

Collagen I and III expression in ADSCs was significantly increased, and the ability to differentiate into osteogenic and adipogenic lineages was diminished after hCTGF treatment. APP and ABP seeded with ADSCs significantly decreased inflammation and protected from degradation in vivo compared with APP and ABP only; ABP seeded with ADSCs had the lowest inflammation.

Conclusion

hCTGF regulates collagen I and III expression and induces ADSC differentiation in vitro. ADSCs decrease inflammation associated with APP and ABP in vivo.

Prevalence of Functional GI Diseases and Pelvic Floor Symptoms in Marfan Syndrome and Ehlers-Danlos Syndrome: A National Cohort Study

BACKGROUND AND AIMS

Prior studies have shown a high prevalence of gastrointestinal (GI) symptoms, diagnoses of functional GI diseases (FGIDs), and pelvic floor symptoms associated with Ehlers-Danlos syndrome (EDS). It is unclear if Marfan syndrome (MFS), another common hereditary noninflammatory connective tissue disorder, is also associated these symptoms. This study evaluates the prevalence of and compares FGIDs and pelvic floor symptoms in a national cohort of EDS and MFS patients.

METHODS

A questionnaire was sent to members of local and national MFS and EDS societies. The questionnaire evaluated the presence of GI and pelvic floor symptoms and diagnoses. The presence of FGIDs was confirmed using Rome III criteria. Quality of life was evaluated and scored with the CDC quality of life.

KEY RESULTS

Overall, 3934 patients completed the questionnaire, from which 1804 reported that they had some form of EDS and 600 had MFS. In total, 93% of patients with EDS complained of GI symptoms and qualified for at least one FGID compared with 69.8% of patients with MFS. When comparing EDS prevalence of upper and lower GI symptoms as well as FGIDs, subjects with EDS reported significantly higher prevalence of Rome III FGIDs as compared with those with MFS. Irritable bowel syndrome (57.8% vs. 27.0%, P<0.001), functional dyspepsia (FD) (55.4% vs. 25.0%, P<0.001), postprandial distress (49.6% vs. 21.7%, P<0.001), heartburn (33.1% vs. 16.8%, P<0.001), dysphagia (28.5% vs. 18.3%, P<0.001), aerophagia (24.7% vs. 12.3%, P<0.001), and nausea (24.7% vs. 7.2%, P<0.001) were all significantly greater in the EDS population compared with MFS population. The prevalence of FGIDs was similar across subtypes of EDS. In general, participants with EDS were more likely to have nearly all pelvic floor symptoms as compared with participants with MFS.

CONCLUSIONS

The prevalence of FGIDs and pelvic floor symptoms in EDS is higher than that found in MFS. The prevalence of FGIDs were similar across EDS subtypes. This study supports the mounting evidence for FGIDs in those with connective tissue diseases, but more specifically, in EDS.

Correlation Between Autophagy and Collagen Deposition in Patients With Pelvic Organ Prolapse

OBJECTIVES

The aim of this study was to explore the link between autophagy and collagen metabolism in patients with pelvic organ prolapse (POP) by detecting the expressions of autophagy factors, collagen, desmin, cytokeratin, and vimentin.

METHODS

Histology of anterior vaginal wall and uterosacral ligament was assessed by hematoxylin-eosin staining in POP and non-POP control patients (n = 50 per group). Expressions of collagen types I and III, LC3II, beclin 1, and p62 were examined by Western blot analysis. Expressions of LC3, vimentin, desmin, and cytokeratin were detected by immunohistochemical staining. A linkage between the mean of LC3 integrated option density summation (IOD SUM) and POP clinicopathologic parameters including Pelvic Organ Prolapse Quantification (POP-Q) staging, age, body mass index, gravidity, and parity was analyzed by χ test, respectively.

RESULTS

Compared with the control group, the following differences were found both in the vaginal wall and in the uterosacral ligament of the POP group: hematoxylin-eosin staining showed that collagen was more fragmented and disorganized. Expressions of collagen types I and III, LC3II, and beclin 1 were diminished, whereas the p62 level was elevated in Western blotting. Immunohistochemical staining showed that expression of LC3 was down-regulated, whereas vimentin level was increased. There were no significant differences in the expressions of desmin and cytokeratin in the 2 groups (P > 0.05). Mean of LC3 IOD SUM was highly linked to the POP-Q stage in the POP group (P < 0.05), whereas there was no significant correlation between the mean of LC3 IOD SUM and POP groups in age, body mass index, gravidity, and parity, respectively(P > 0.05).

CONCLUSIONS

Autophagic activity is impaired in the POP group, which may relate to collagen deposition.

Evaluation of COLIA1-1997 G/T polymorphism as a related factor to genital prolapse

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse has a multifactorial etiology. There is increasing evidence that genetic factors greatly impact its development. This study aimed to evaluate the possible relation of the collagenous polymorphism -1997 G/T with genital prolapse in Brazilian women.

METHODS

A cohort study of 180 women with stage 0 or I (group A) pelvic organ prolapse disorder and 112 women with stage III or IV (group B) was conducted. Blood DNA was isolated, and the -1997 G/T polymorphism was identified by amplifying a region of the COLIA1 gene starting prior to the protein's coding sequence.

RESULTS

No significant difference in the prevalence of genotypes TG and TT was found between groups (p = 0.67); differences were not found even when patients were grouped by the presence of 0 or ≥ 1 polymorphic alleles (p = 0.46). Age and home birth were found to be independent risk factors for prolapse.

CONCLUSIONS

Our study could not find any association between the -1997G/T polymorphism and genital prolapse in Brazilian women.

Gynecologic Health and Disease Research at the Eunice Kennedy Shriver National Institute of Child Health and Human Development: A Scientific Vision

In May 2016, the newly formed Gynecologic Health and Disease Branch in the Eunice Kennedy Shriver National Institute of Child Health and Human Development invited experts to a 2-day meeting aimed at identification of emerging opportunities in gynecologic investigation. Four primary disorders were chosen for emphasis because they represent the majority of the current Gynecologic Health and Disease Branch portfolio: uterine leiomyomas, endometriosis, pelvic floor disorders, and gynecologic pain conditions. Discussions generated a set of seven cross-cutting themes, which encompass both gaps in our current knowledge and potential directions for further research. These themes formed a continuum for understanding these disorders beginning with the need for classification systems, improved understanding of the natural history and etiology of these disorders, development of novel diagnostics, identification of opportunities for prevention, and the generation of new treatments using cutting-edge approaches. Along with these themes, three broad strategies were proposed to facilitate future research. First, investigators should improve utilization of existing research resources and focus on developing new resources to include databases, biospecimen repositories, animal models, and patient cohorts. Second, multidisciplinary scientific partnerships should be strengthened to bring new insights and approaches to gynecologic research. Third, patient and health care provider education must be promoted to ensure timely and accurate diagnosis and optimize treatment of gynecologic disorders. This article provides a summary of the workshop themes and suggestions, several of which have already been implemented through the development of program priorities and funding opportunity announcements aimed at improving women's reproductive health.

Electrospun protein-CNT composite fibers and the application in fibroblast stimulation

Functional biopolymer scaffolds are in high demand for tissue regeneration. In this study, we incorporated functionalized CNT in collagen or silk protein solution to generate biocomposite fibers by electrospinning. The addition of CNT reinforced the strength of the scaffolds and rendered the fibers electrical conductivity to not only facilitate the E-spun fiber formation but also grant the fibers an additional functionality that can be utilized for cell stimulation. Considering fiber dimension, alignment, mechanical strength, electrical conductivity and biocompatibility, silk-CNT fibers containing a minute amount of CNT (0.05%) outperformed other fiber types. The modulation effect of these fibers was examined by their application in inducing polarization and activation of fibroblasts with cellular deficit. While the fibroblasts on both collagen-CNT and silk-CNT fibers synthesized a substantially higher level of collagen type III (COLIII) than cells on pure protein fibers to reduce the abnormally high COLI/COLIII ratio, electrical stimulation boosted the collagen productivity by 20 folds in cells on silk-CNT than on collagen-CNT due to silk-CNT's high electrical conductivity. The developed approach can be potentially utilized to remedy the dysfunctional fibroblasts for therapeutic treatment of diseases and health conditions associated with collagen disorder.

Hypermobile Ehlers-Danlos syndrome (a.k.a. Ehlers-Danlos syndrome Type III and Ehlers-Danlos syndrome hypermobility type): Clinical description and natural history

The hypermobile type of Ehlers-Danlos syndrome (hEDS) is likely the most common hereditary disorder of connective tissue. It has been described largely in those with musculoskeletal complaints including joint hypermobility, joint subluxations/dislocations, as well as skin and soft tissue manifestations. Many patients report activity-related pain and some go on to have daily pain. Two undifferentiated syndromes have been used to describe these manifestations-joint hypermobility syndrome and hEDS. Both are clinical diagnoses in the absence of other causation. Current medical literature further complicates differentiation and describes multiple associated symptoms and disorders. The current EDS nosology combines these two entities into the hypermobile type of EDS. Herein, we review and summarize the literature as a better clinical description of this type of connective tissue disorder. © 2017 Wiley Periodicals, Inc.

The effect of a human acellular amniotic membrane loaded with mechanical stretch-stimulated bone marrow mesenchymal stem cells for the treatment of pelvic floor dysfunction

Pelvic floor dysfunction (PFD) has a severe impact on the quality of life of middle-aged and elderly women and is closely related to the damage of pelvic support tissues, especially ligaments.

Gastrointestinal and nutritional issues in joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type

Gastrointestinal involvement is a well known complication of Ehlers-Danlos syndromes (EDSs), mainly in form of abdominal emergencies due to intestinal/abdominal vessels rupture in vascular EDS. In the last decade, a growing number of works investigated the relationship between a wide spectrum of chronic gastrointestinal complaints and various EDS forms, among which the hypermobility type (a.k.a. joint hypermobility syndrome; JHS/EDS-HT) was the most studied. The emerging findings depict a major role for gastrointestinal involvement in the health status and, consequently, management of JHS/EDS-HT patients. Nevertheless, fragmentation of knowledge limits its impact on practice within the boundaries of highly specialized clinics. In this paper, literature review on gastrointestinal manifestations in JHS/EDS-HT was carried out and identified papers categorized as (i) case-control/cohort studies associating (apparently non-syndromic) joint hypermobility and gastrointestinal involvement, (ii) case-control/cohort studies associating JHS/EDS-HT and gastrointestinal involvement, (iii) case reports/series on various gastrointestinal complications in (presumed) JHS/EDS-HT, and (iv) studies reporting gastrointestinal features in heterogeneous EDS patients' cohorts. Gastrointestinal manifestations of JHS/EDS-HT were organized and discussed in two categories, including structural anomalies (i.e., abdominal/diaphragmatic hernias, internal organ/pelvic prolapses, intestinal intussusceptions) and functional features (i.e., dysphagia, gastro-esophageal reflux, dyspepsia, recurrent abdominal pain, constipation/diarrhea), with emphasis on practice and future implications. In the second part of this paper, a summary of possible nutritional interventions in JHS/EDS-HT was presented. Supplementation strategies were borrowed from data available for general population with minor modifications in the light of recent discoveries in the pathogenesis of selected JHS/EDS-HT features.

Association between joint hypermobility and pelvic organ prolapse in women: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Abnormalities of common collagen proteins have been noted in individuals affected by POP and JHM, suggesting a common aetiology. We assessed strength, consistency and potential for bias in pooled associations of the relationship between JHM and POP.

METHODS

We searched MEDLINE, EMBASE and CINAHL, as well as International Continence Society (ICS) and International Urogynaecologic Association (IUGA) annual meeting abstracts, including reference lists, without language restrictions. We included case-control and cohort studies and applied strict criteria for choosing eligible studies. Methodologically trained reviewers independently screened abstracts and full texts to confirm eligibility. We extracted data on study and patient characteristics, clinical assessment tools, and methodology. We assessed comparability and representativeness of source populations, confidence in the assessment of JHM and POP and adjustment for confounding and missing data. Meta-analysis was performed using a random effects model.

RESULTS

We retrieved 39 full texts, of which 14 were used in the meta-analysis. Overall pooled odds ratio (OR) was 2.37 [95 % confidence interval (CI) 1.54-3.64, I(2) = 77.0 %]. We identified no significant factors in meta-regression, and there was no evidence of publication bias; six studies were at high risk of bias with frequent differences in sampling frames, limited validity for clinical assessments and failure to match for important prognostic variables.

CONCLUSIONS

We found a strong association between POP and JHM, with an effect size that is clinically relevant. Our findings are limited by high heterogeneity and the potential for residual confounding factors. JHM is an important early indicator for POP risk, and future longitudinal studies should explore the shared aetiology.

Association of matrix metalloproteinase-10 polymorphisms with susceptibility to pelvic organ prolapse

AIM

The aim of this study was to explore the correlation between genetic mutations in matrix metalloproteinase-10 (MMP-10) and susceptibility to pelvic organ prolapse (POP).

MATERIAL AND METHODS

From September 2011 to December 2013, 263 subjects were recruited, including 91 patients with POP (case group) and 172 non-POP patients (control group). Total MMP-10 concentrations in serum were measured by enzyme-linked immunosorbent assay. The genotyping of MMP-10 was achieved by quantitative real-time polymerase chain reaction. All data were analyzed with SPSS 18.0.

RESULTS

We found that parity, menopause, history of total hysterectomy, and family history of POP were all significantly higher in the POP group than in the control group (P = 0.017, P = 0.046, P = 0.0029 and P < 0.001, respectively). Serum MMP-10 levels were obviously higher in the POP group than in the control group (P < 0.05). In addition, there was a statistically significant difference between the two groups in the distribution frequency of the MMP-10 (rs17435959G/C) genotype (P < 0.05). However, the distribution frequency of the MMP-10 (rs17293607C/T) genotype between the two groups showed no significant differences (P > 0.05). Furthermore, the patients with parity > 2 and postmenopausal women had elevated serum MMP-10 levels, and the patients with parity > 2 and postmenopausal women who carried the G/C + C/C genotype in the MMP-10 gene had an increased risk of POP.

CONCLUSION

We support the view that the rs17435959 polymorphism of the MMP-10 gene may be associated with an increased risk of POP.

A Multicenter Collaboration to Assess the Safety of Laparoscopic Ventral Rectopexy

BACKGROUND

Concerns have been raised regarding the potential risk of mesh complications after laparoscopic ventral rectopexy.

OBJECTIVE

This study aimed to determine the risk of mesh and nonmesh morbidity after laparoscopic ventral rectopexy and to compare the safety of synthetic meshes with biological grafts.

DESIGN

This was a retrospective review.

SETTINGS

The study used data collated from prospective pelvic floor databases in 5 centers (3 in the United Kingdom, 1 in Australia, and 1 in Italy).

PATIENTS

All of the patients undergoing laparoscopic ventral rectopexy over a 14-year period (1999-2013) at these centers were included in the study.

MAIN OUTCOME MEASURES

The primary outcome was mesh morbidity, classified as vaginal erosion, rectal erosion, rectovaginal fistula, or perineal erosion. Secondary outcomes were nonmesh morbidity.

RESULTS

A total of 2203 patients underwent surgery; 1764 (80.1%) used synthetic mesh and 439 (19.9%) used biological grafts. There were 2 postoperative deaths (0.1%). Forty-five patients (2.0%) had mesh erosion, including 20 vaginal, 17 rectal, 7 rectovaginal fistula, and 1 perineal. Twenty-three patients (51.1%) required treatment for minor erosion morbidity (local excision of stitch/exposed mesh), and 18 patients (40.0%) were treated for major erosion morbidity (12 laparoscopic mesh removal, 3 mesh removal plus colostomy, and 3 anterior resection). Erosion occurred in 2.4% of synthetic meshes and 0.7% of biological meshes. The median time to erosion was 23 months. Nonmesh complications occurred in 11.1% of patients.

LIMITATIONS

This was a retrospective study including patients with minimal follow-up. The study was unable to determine whether patients will develop future erosions, currently have asymptomatic erosions, or have been treated in other institutions for erosions.

CONCLUSIONS

Laparoscopic ventral rectopexy is a safe operation. Mesh erosion rates are 2% and occasionally require resectional surgery that might be reduced by the use of biological graft. An international ventral mesh registry is recommended to monitor mesh problems and to assess whether type of mesh has any impact on functional outcomes or the need for revisional surgery for nonerosion problems.

Collagen structure deterioration in the skin of patients with pelvic organ prolapse determined by atomic force microscopy

We used atomic force microscopy (AFM) to diagnose pathological changes in the extracellular matrix (ECM) of skin connective tissue in patients with pelvic organ prolapse (POP). POP is a common condition affecting women that considerably decreases the patients' quality of life. Deviations from normal morphology of the skin ECM from patients with POP occur including packing and arrangement of individual collagen fibers and arrangement of collagen fibrils. The nanoindentation study revealed significant deterioration of the mechanical properties of collagen fibril bundles in the skin of POP patients as compared with the skin of healthy subjects. Changes in the skin ECM appeared to correlate well with changes in the ECM of the pelvic ligament tissue associated with POP. AFM data on the ECM structure of normal and pathologically altered connective tissue were in agreement with results of the standard histological study on the same clinical specimens. Thus, AFM and related techniques may serve as independent or complementary diagnostic tools for tracking POP-related pathological changes of connective tissue.

Relationship of advanced glycation end products and their receptor to pelvic organ prolapse

OBJECTIVE

The aims of this study are to detect levels of AGEs and RAGE and SNPs for RAGE in vaginal tissues of women with POP and rats in a repair location, and to explore the relationship between AGEs-RAGE pathway and POP.

METHODS

This study involved human vaginal tissues in fornix from 44 women with POP and 46 women without POP who were assigned to pelvic floor reconstruction or LAVH. The proteins of AGEs, collagen I, and RAGE were detected by immunohistochemistry and Western blot with appropriate primary antibodies. The entire RAGE gene of 24 women with POP and 25 controls were sequenced, and SNPs within were detected. Then, sixty 8-week-old female Sprague-Dawley rats subjected to abdominal defect were divided into three surgical pelvic floor reconstruction repair groups (n=20/group): A, repair with non-absorable prolene mesh; B, repair with absorbable SIS mesh; and C, a no repair control group. 3, 9, 15, and 21 months after operation, rats were sacrificed and the expression of AGEs, RAGE and collagen I in the tissues of repair location were detected in the various experimental groups. Statistical analysis included comparison of means (Student's t-test) and proportions (Chi-square test or Fisher test).

RESULTS

By both immunohistochemistry and Western blot, patients with POP showed higher protein expression of AGEs of POP than controls (P<0.05). In contrast, the expression of collagen I was lower in POP patients than in the control group (P<0.05). No differences in the expression of RAGE between the POP patients and controls were observed (P>0.05). In POP patients, the expression of collagen I decreased particularly in patients≥60 years old (P<0.05), but there were no different in the expression of AGEs and RAGE dependent on age (P>0.05). RAGE gene sequence variance analysis identified 18 variable loci, but only two of these were potential SNPs: rs184003 (1806), rs55640627 (2346) (P<0.05). Both rs184003 and rs55640627 are both intronic variants, indicating that they may not influence the structure of RAGE. In rat surgical repair model, group B showed a greater extent of abdominal prolapse than groups A and C (P<0.05). Consistent with this, the expression of AGEs in group B was higher than groups A and C (P<0.05), and collagen I in group B was lower than the two others, further supporting our notion that AGEs are inversely related to type I collagen content.

CONCLUSIONS

In summary, this study demonstrates that AGEs and RAGE might play important roles in the physiopathology of POP. Further studies are required to explore mechanisms of how AGEs-RAGE pathway may contribute to tissue degeneration and fragility in POP.

Neurovisceral phenotypes in the expression of psychiatric symptoms

This review explores the proposal that vulnerability to psychological symptoms, particularly anxiety, originates in constitutional differences in the control of bodily state, exemplified by a set of conditions that include Joint Hypermobility, Postural Tachycardia Syndrome and Vasovagal Syncope. Research is revealing how brain-body mechanisms underlie individual differences in psychophysiological reactivity that can be important for predicting, stratifying and treating individuals with anxiety disorders and related conditions. One common constitutional difference is Joint Hypermobility, in which there is an increased range of joint movement as a result of a variant of collagen. Joint hypermobility is over-represented in people with anxiety, mood and neurodevelopmental disorders. It is also linked to stress-sensitive medical conditions such as irritable bowel syndrome, chronic fatigue syndrome and fibromyalgia. Structural differences in “emotional” brain regions are reported in hypermobile individuals, and many people with joint hypermobility manifest autonomic abnormalities, typically Postural Tachycardia Syndrome. Enhanced heart rate reactivity during postural change and as recently recognized factors causing vasodilatation (as noted post-prandially, post-exertion and with heat) is characteristic of Postural Tachycardia Syndrome, and there is a phenomenological overlap with anxiety disorders, which may be partially accounted for by exaggerated neural reactivity within ventromedial prefrontal cortex. People who experience Vasovagal Syncope, a heritable tendency to fainting induced by emotional challenges (and needle/blood phobia), are also more vulnerable to anxiety disorders. Neuroimaging implicates brainstem differences in vulnerability to faints, yet the structural integrity of the caudate nucleus appears important for the control of fainting frequency in relation to parasympathetic tone and anxiety. Together there is clinical and neuroanatomical evidence to show that common constitutional differences affecting autonomic responsivity are linked to psychiatric symptoms, notably anxiety.

Systematic review and metaanalysis of genetic association studies of urinary symptoms and prolapse in women

OBJECTIVE

Family studies and twin studies demonstrate that lower urinary tract symptoms and pelvic organ prolapse are heritable. This review aimed to identify genetic polymorphisms tested for an association with lower urinary tract symptoms or prolapse, and to assess the strength, consistency, and risk of bias among reported associations.

STUDY DESIGN

PubMed and HuGE Navigator were searched up to May 1, 2014, using a combination of genetic and phenotype key words, including "nocturia," "incontinence," "overactive bladder," "prolapse," and "enuresis." Major genetics, urology, and gynecology conference abstracts were searched from 2005 through 2013. We screened 889 abstracts, and retrieved 78 full texts. In all, 27 published and 7 unpublished studies provided data on polymorphisms in or near 32 different genes. Fixed and random effects metaanalyses were conducted using codominant models of inheritance. We assessed the credibility of pooled associations using the interim Venice criteria.

RESULTS

In pooled analysis, the rs4994 polymorphism of the ADRB3 gene was associated with overactive bladder (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.7-3.6; n = 419). The rs1800012 polymorphism of the COL1A1 gene was associated with prolapse (OR, 1.3; 95% CI, 1.0-1.7; n = 838) and stress urinary incontinence (OR, 2.1; 95% CI, 1.4-3.2; n = 190). Other metaanalyses, including those for polymorphisms of COL3A1,LAMC1,MMP1,MMP3, and MMP9 did not show significant effects. Many studies were at high risk of bias from genotyping error or population stratification.

CONCLUSION

These metaanalyses provide moderate epidemiological credibility for associations of variation in ADRB3 with overactive bladder, and variation of COL1A1 with prolapse. Clinical testing for any of these polymorphisms cannot be recommended based on current evidence.

UVA-photoactivated riboflavin effect on isolated vaginal tissues derived from pelvic organ prolapse cases

PURPOSE

To determine the optimal riboflavin exposure time before UVA irradiation and to study the effects of exogenous collagen on the mechano-tensile stiffness of isolated vaginal tissue strips after riboflavin UVA photoactivation.

METHODS

Vaginal tissue strips from pelvic organ prolapse (POP) cases were soaked in 0.1% riboflavin (0, 10, 20, 30 min), exposed to UVA photoactivation, and tensile stiffness was measured with a tensiometer. Collagen solution was injected (0.2 mL) into each strip, exposed to riboflavin with or without UVA photoactivation, and tensile stiffness was measured (n=6).

RESULTS

Vaginal tissues treated with riboflavin for 10, 20 or 30 min followed by UVA irradiation displayed 21.2, 32.4 and 33.9% stronger tensile stiffness, respectively. Exogenous collagen administered before riboflavin UVA photoactivation resulted in 20% improvement in tensile stiffness. The tensile stiffness of vaginal tissues injected with collagen without the riboflavin UVA treatment was similar to control tissues.

CONCLUSION

The results demonstrated increased tensile stiffness in isolated POP-derived vaginal tissues after riboflavin UVA photoactivation suggesting improved mechanical properties from collagen cross-linking. Administering exogenous collagen before riboflavin UVA treatment also improved tensile stiffness. More studies are needed to corroborate the present minimally invasive approach for strengthening vaginal tissues.

Differential expression profiling of matrix metalloproteinases and tissue inhibitors of metalloproteinases in females with or without pelvic organ prolapse

Pelvic organ prolapse (POP) is a common disorder that can disturb the health and quality of life of females. However, the basic pathophysiology and underlying mechanism of POP are not fully understood. Matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) have been reported to be associated with the onset and development of POP. In the present study, to characterize the differential expression profile of MMPs and TIMPs in female patients with and without POP, a total of 72 POP patients were sampled as a patient group and 72 non-POP patients that underwent hysterectomy due to benign tumors were sampled as a control group. Immunohistochemistry and polymerase chain reaction analysis were used to detect the expression levels of MMP-1, -2, -3 and -9 as well as TIMP-1 protein and mRNA in the anterior vaginal wall tissues. The expression levels of MMP-1, -2, -3 and -9 in the patient group were found to be significantly higher than those in the control group. By contrast, TIMP-1 expression levels in the patient group were significantly lower than those in the control group. Correlational analysis revealed a significantly positive correlation among the expression levels of MMP-2, -3 and -9. TIMP-1 expression levels were significantly negatively correlated with the expression levels of MMP-3 and -9. In addition, the expression levels of MMP-1 exhibited a positive correlation with those of MMP-2, -3 and -9, but a negative correlation with those of TIMP-1. The results demonstrated that the increased expression levels of MMPs and the reduced expression levels of TIMPs were directly associated with the presence of uterine prolapse, indicating that the differential expression levels of MMPs and TIMPs were correlated with the occurrence and development of POP. This data may assist in elucidating the molecular mechanism of MMP and TIMP involvement in POP, and also provide an underlying theoretical basis for the prevention and treatment of POP.

Collagen type III alpha 1 polymorphism (rs1800255, COL3A1 2209 G>A) assessed with high-resolution melting analysis is not associated with pelvic organ prolapse in the Dutch population

INTRODUCTION AND HYPOTHESIS

The rs1800255, COL3A1 2209 G>A polymorphism in the alpha 1 chain of collagen type III has been associated with an increased risk of pelvic organ prolapse (POP). In one of our previous studies however, polymerase chain reaction-based restriction fragment length polymorphism (PCR-RFLP) misdiagnosed rs1800255, COL3A1 2209 G>A in 6 % of cases. The high-resolution melting (HRM) analysis on the contrary obtained a 100 % accordance for this specific polymorphism and was used in the present study to validate this risk factor for POP.

METHODS

In this case-control study, women with and without symptoms of POP were included and compared. DNA was extracted from blood samples. HRM analysis was used to assess for the presence of the homozygous rs1800255. Groups were compared using the Pearson chi-square, Mann-Whitney, and t tests. The discrepancy between HRM and PCR-RFLP results was investigated using PCR-RFLP results available from our previous study.

RESULTS

The study included 354 women: 272 patients with POP and 82 controls; 18 (7 %) cases versus 3 (4 %) controls had a homozygous rs1800255, COL3A1 2209 G>A polymorphism (odds ratio 1.9, 95 % confidence interval 0.5-6.9, compared to the wild type), and thus no association between POP and the homozygous polymorphism could be demonstrated. A discrepancy between HRM and PCR-RFLP results was found in 8 % of the samples.

CONCLUSIONS

The previously found statistically significant association between the rs1800255, COL3A1 2209 G>A polymorphism as measured with PCR-RFLP and POP could no longer be demonstrated. This raises concerns regarding the results of other association studies using PCR-RFLP.

Prevalence, etiology and risk factors of pelvic organ prolapse in premenopausal primiparous women

INTRODUCTION

The natural history of pelvic organ prolapse (POP) is poorly understood. We investigated the prevalence and risk factors of postnatal POP in premenopausal primiparous women and the associated effect of mode of delivery.

METHODS

We conducted a prospective cohort study in a tertiary teaching hospital attending 9,000 deliveries annually. Collagen-diseases history and clinical assessment was performed in 202 primiparae at ≥ 1 year postnatally. Assessment included Pelvic Organ Prolapse Quantification (POP-Q) system, Beighton mobility score, 2/3D-transperineal ultrasound (US) and quantification of collagen type III levels. Association with POP was assessed using various statistical tests, including logistic regression, where results with p < 0.1 in univariate analysis were included in multivariate analysis.

RESULTS

POP had a high prevalence: uterine prolapse 89 %, cystocele 90 %, rectocele 70 % and up to 65 % having grade two on POP-Q staging. The majority had multicompartment involvement, and 80 % were asymptomatic. POP was significantly associated with joint hypermobility, vertebral hernia, varicose veins, asthma and high collagen type III levels (p < 0.05). In multivariate logistic regression, only levator ani muscle (LAM) avulsion was significant in selected cases (p < 0.05). Caesarean section (CS) was significantly protective against cystocele and rectocele but not for uterine prolapse.

CONCLUSIONS

Mild to moderate POP has a very high prevalence in premenopausal primiparous women. There is a significant association between POP, collagen levels, history of collagen disease and childbirth-related pelvic floor trauma. These findings support a congenital contribution to POP etiology, especially for uterine prolapse; however, pelvic trauma seems to play paramount role. CS is significantly protective against some types of prolapse only.

Evaluation of antioxidative/oxidative status and prolidase parameters in cases of inguinal hernia with joint hypermobility syndrome

PURPOSE

Most previous reports have shown that the basic mechanism of inguinal hernia involves insufficient collagen strength and metabolism. The aim of this study was to evaluate whether joint hypermobility is involved in the development of inguinal hernia in children and to investigate oxidative stress parameters and prolidase activity in tissue samples from children with inguinal hernia.

METHODS

This cross-sectional study involving 41 patients (age, 6.36 ± 2.96 years) with inguinal hernia treated in the pediatric surgery department of our institution and 40 age- and sex-matched controls (age, 6.02 ± 3.13 years) was performed from May to December 2011. Joint hypermobility was assessed using the Beighton criteria in all patients. Hernia sacs were analyzed with respect to the total antioxidative/oxidative status and prolidase activity. The patients were divided into two groups (inguinal hernia with and without hypermobility) according to a Beighton score cut-off of ≥6.

RESULTS

A total of 81 subjects aged 3-10 years participated. The ratio of joint hypermobility was significantly higher in patients than in controls (p = 0.01). The prolidase activity, total oxidant status, and oxidative stress index were higher in tissue samples from patients with joint hypermobility (p < 0.001).

CONCLUSIONS

Our results show that joint hypermobility syndrome is associated with inguinal hernia in children and that increased prolidase activity and oxidative stress in tissue samples from patients with joint hypermobility syndrome are related to collagen tissue damage and turnover.

Association between pelvic organ prolapse and stress urinary incontinence with collagen

The aim of the present study was to investigate the ultrastructure and content of collagen in uterosacral ligaments and paraurethral tissues in patients with pelvic organ prolapse (POP) and stress urinary incontinence (SUI), analyzing the association between POP and collagen dysfunction. The study comprised three groups: Control, POP and POP with SUI (n=30 per group). Histological characteristics of collagen fiber were observed and the diameters were measured using light and electron microscopy to determine the Type I and Type III collagen content of the main ligament in the urethral specimens. In the POP and POP with SUI groups, observations included diffuse atrophy of smooth muscles, active fibroblast metabolism, swollen mitochondria and visible Golgi apparatus. The collagen fibril diameters in the cardinal ligaments, uterosacral ligaments and paraurethral tissues were significantly greater in the POP and POP with SUI groups compared with those in the control group (P<0.01). In addition, the expression levels of Type I and Type III collagen were significantly lower in the POP and POP with SUI groups when compared with the control group (P<0.01). In the POP with SUI group, pelvic tissues were frail, resulting in smooth muscle bundles comminuting and arranging in a disorganized pattern. Fibroblast and myoblast metabolisms were active and new microvascular cells were weak. However, the collagen fibril diameter increased. Thus, collagen and ultrastructural changes in the pelvic floor may be associated with the development of POP and SUI.