Estrogens and phenylpropanolamine in combination for stress urinary incontinence in postmenopausal women

Risk factors for 5-year complications after midurethral sling surgery for stress urinary incontinence: a retrospective cohort study from Taiwan

Midurethral sling surgery is the current gold standard worldwide for stress urinary incontinence (SUI) surgery, with over 90% of surgeons worldwide using the midurethral sling for SUI between 2008 and 2018. However, concerns surround mesh-related adverse events associated with the midurethral sling. The decision to use the midurethral sling for surgical treatment has become a challenging one for clinicians, surgeons and patients. We sought to determine the factors for 5-year complications after midurethral sling surgery, to improve the clinical decision-making process. Records were reviewed from a total of 1961 female patients who underwent their first midurethral sling surgery for SUI between 2003 and 2018 at a single teaching hospital in Taiwan. A multivariable Cox proportional hazard model calculated the hazard ratios of risk factors for surgical complications, after adjusting for confounders. Surgical complications (i.e., secondary surgery and urinary retention) occurred in 93 (4.7%) patients within 5 years following the index operations. These patients were more likely to be older, to have a history of menopausal syndrome within 1 year prior to the index operation, a medication history of oral antidiabetic drug use, hormone replacement therapy (HRT), slower average flow rate, and longer voiding time compared with patients without surgical complications. In the multivariate analysis, HRT (adjusted hazard ratio, 1.787; 95% confidence interval, 1.011-3.158, p = 0.04) was significantly associated with surgical complications at 5 years, after adjusting for age, gender, diabetes, menopause syndrome, average flow rate, and sling type. Our findings suggest that a medication history of HRT may be a risk factor associated with surgical complications, especially urinary retention, at 5 years in women undergoing midurethral sling surgery for SUI.

Neuroprotective Effects of Estradiol plus Lithium Chloride via Anti-Apoptosis and Neurogenesis Pathway in In Vitro and In Vivo Parkinson's Disease Models

Few pharmaceutical agents for slowing Parkinson's disease (PD) progression existed, especially for perimenopause females. The current general medications are mostly hormone replacement therapy and may have some side effects. Therefore, there is an urgent need for a novel treatment for PD. This study examined the possibility of estradiol plus lithium chloride (LiCl), one of the metal halides used as an alternative to salt. We showed that the combination of LiCl and estradiol could enhance neurogenesis proteins GAP-43 and N-myc in the human neuronal-like cells. We also further confirmed the neurogenesis activity in zebrafish. LiCl and LiCl plus estradiol could enhance 6-OHDA-induced upregulation of TGase-2b and Rho A mRNA expression. Besides, LiCl plus estradiol showed a synergic effect in anti-apoptotic activity. LiCl plus estradiol protected SH-SY5Y cells and zebrafish against 6-OHDA-induced damage on neurons than LiCl or estradiol alone groups via p-P38, p-Akt, Bcl-2, and caspase-3 cascade. The potential for developing this combination as a candidate treatment for PD is discussed.

Effect of a 5-HT2c receptor agonist on urethral closure mechanism in healthy women

AIMS

To evaluate the effect of ASP2205, a selective serotonin 5-HT_2c receptor agonist, and Duloxetine on the urethral pressure in healthy female subjects.

METHODS

Healthy females aged 18 to 55 years were recruited for this phase 1, single site, placebo-controlled, randomized, four-period, cross-over study. The interventions were single oral doses of 10 and 60 mg ASP2205, 80 mg duloxetine, and placebo. As a pharmacodynamics endpoint, opening urethral pressure (OUP), corrected for placebo, was measured using urethral pressure reflectometry under both resting and squeezing condition of the pelvic floor at predose and 3, 6, 12, and 24 hours after dosing. Safety and tolerability of ASP2205 were also compared with duloxetine and placebo.

RESULTS

Eighteen healthy women signed informed consent, however, one dropped out before dosing and one dropped out after the first period, therefore, 16 subjects completed the study. Duloxetine significantly increased the OUP during both resting and squeezing condition (maximal increase 18.1 and 16.8 cmH₂ O, respectively). Both doses of ASP2205 did not increase OUP at any time point. During squeezing OUP decreased significantly in the ASP2205 60 mg group from 6 to 24 hours after dosing. All subjects experienced predominantly central nervous system-related side effects (eg, dizziness and nausea) during ASP2205 treatment, which was most pronounced at 60 mg.

CONCLUSIONS

ASP2205, a serotonin 5-HT_2c receptor agonist, does not increase the urethral pressure and it is therefore unlikely that 5-HT _2c receptor agonists can be used as a treatment for stress urinary incontinence. ASP2205 was less well tolerated than the high dose of duloxetine.

Combined Tolterodine and Vaginal Estradiol Cream for Overactive Bladder Symptoms After Randomized Single-Therapy Treatment

OBJECTIVES

The aims of this study were to compare 12-week outcomes of single-therapy tolterodine (Detrol LA) extended release to intravaginal estrogen (Estrace) for overactive bladder (OAB) symptoms and characterize 24- and 52-week outcomes in women undergoing combined therapy.

METHODS

A single-site randomized, open-label trial in women with urinary frequency, urgency, nocturia, and/or urgency urinary incontinence symptoms was performed. Fifty-eight participants were randomized to oral tolterodine extended release daily or intravaginal estradiol cream nightly for 6 weeks then twice per week. The primary outcome was change in Overactive Bladder Questionnaire (OAB-q) symptom bother score at 12 weeks. Secondary outcomes included the Health-Related Quality of Life Questionnaire (HRQL) of the OAB-q and a 3-day bladder diary. At 12 weeks, subjects were offered addition of the alternative therapy with follow-up at 24 and 52 weeks.

RESULTS

There was no difference in symptom bother score improvement between the tolterodine and intravaginal estradiol groups baseline to 12 weeks (20.6 ± 21.7, -15.8 ± 23.3, respectively, P = 0.45). There was a significant within-group decrease in symptom bother score from baseline to 12 weeks (tolterodine, P < 0.0001, and intravaginal estradiol, P = 0.002). Secondary outcome improvement within groups was noted in the HRQL total, urinary incontinence episodes, and median voiding frequency (all P ≤ 0.03) in the tolterodine group and in the HRQL total score (P = 0.03) in the intravaginal estradiol group, with no differences between groups. Combined therapy outcomes at 24 and 52 weeks compared with single therapy at 12 weeks revealed significant improvement in symptom bother score in the intravaginal estradiol + tolterodine group at 24 and 52 weeks (20.0 ± 23.9, P = 0.008; -16.7 ± 23.3, P = 0.02, respectively).

CONCLUSIONS

Significant within-group improvement in OAB-q symptom bother was noted in both the intravaginal estradiol and tolterodine groups for OAB symptoms, with no difference between groups. Greater improvement from 12-week single therapy to 24 and 52 weeks of combined therapy was noted in the group originally assigned to intravaginal estradiol. The role of combined medical therapy for OAB symptoms needs further investigation.

The effect of hormones on the lower urinary tract

The female genital and lower urinary tracts share a common embryological origin, arising from the urogenital sinus and both are sensitive to the effects of the female sex steroid hormones throughout life. Estrogen is known to have an important role in the function of the lower urinary tract and estrogen and progesterone receptors have been demonstrated in the vagina, urethra, bladder and pelvic floor musculature. In addition estrogen deficiency occurring following the menopause is known to cause atrophic change and may be associated with lower urinary tract symptoms such as frequency, urgency, nocturia, urgency incontinence and recurrent infection. These may also co-exist with symptoms of urogenital atrophy such as dyspareunia, itching, vaginal burning and dryness. Epidemiological studies have implicated estrogen deficiency in the aetiology of lower urinary tract symptoms with 70% of women relating the onset of urinary incontinence to their final menstrual period. Whilst for many years systemic and vaginal estrogen therapy was felt to be beneficial in the treatment of lower urinary and genital tract symptoms this evidence has recently been challenged by large epidemiological studies investigating the use of systemic hormone replacement therapy as primary and secondary prevention of cardiovascular disease and osteoporosis. The aim of this paper is to examine the effect of the sex hormones, estrogen and progesterone, on the lower urinary tract and to review the current evidence regarding the role of systemic and vaginal estrogens in the management of lower urinary tract symptoms and urogenital atrophy.

Oestrogen therapy for urinary incontinence in post-menopausal women

BACKGROUND

It is possible that oestrogen deficiency may be an aetiological factor in the development of urinary incontinence in women. This is an update of a Cochrane review first published in 2003 and subsequently updated in 2009.

OBJECTIVES

To assess the effects of local and systemic oestrogens used for the treatment of urinary incontinence.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register of trials (searched 21 June 2012) which includes searches of MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL) and handsearching of journals and conference proceedings, and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that included oestrogens in at least one arm in women with symptomatic or urodynamic diagnoses of stress, urgency or mixed urinary incontinence or other urinary symptoms post-menopause.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for risk of bias and appropriateness for inclusion by the review authors. Data were extracted by at least two authors and cross checked. Subgroup analyses were performed by grouping participants under local or systemic administration. Where appropriate, meta-analysis was undertaken.

MAIN RESULTS

Thirty-four trials were identified which included approximately 19,676 incontinent women of whom 9599 received oestrogen therapy (1464 involved in trials of local vaginal oestrogen administration). Sample sizes of the studies ranged from 16 to 16,117 women. The trials used varying combinations of type of oestrogen, dose, duration of treatment and length of follow up. Outcome data were not reported consistently and were available for only a minority of outcomes.The combined result of six trials of systemic administration (of oral systemic oestrogens) resulted in worse incontinence than on placebo (risk ratio (RR) 1.32, 95% CI 1.17 to 1.48). This result was heavily weighted by a subgroup of women from the Hendrix trial, which had large numbers of participants and a longer follow up of one year. All of the women had had a hysterectomy and the treatment used was conjugated equine oestrogen. The result for women with an intact uterus where oestrogen and progestogen were combined also showed a statistically significant worsening of incontinence (RR 1.11, 95% CI 1.04 to 1.18).There was some evidence that oestrogens used locally (for example vaginal creams or pessaries) may improve incontinence (RR 0.74, 95% CI 0.64 to 0.86). Overall, there were around one to two fewer voids in 24 hours amongst women treated with local oestrogen, and there was less frequency and urgency. No serious adverse events were reported although some women experienced vaginal spotting, breast tenderness or nausea.Women who were continent and received systemic oestrogen replacement, with or without progestogens, for reasons other than urinary incontinence were more likely to report the development of new urinary incontinence in one large study.One small trial showed that women were more likely to have an improvement in incontinence after pelvic floor muscle training (PFMT) than with local oestrogen therapy (RR 2.30, 95% CI 1.50 to 3.52).The data were too few to address questions about oestrogens compared with or in combination with other treatments, different types of oestrogen or different modes of delivery.

AUTHORS' CONCLUSIONS

Urinary incontinence may be improved with the use of local oestrogen treatment. However, there was little evidence from the trials on the period after oestrogen treatment had finished and no information about the long-term effects of this therapy was given. Conversely, systemic hormone replacement therapy using conjugated equine oestrogen may worsen incontinence. There were too few data to reliably address other aspects of oestrogen therapy, such as oestrogen type and dose, and no direct evidence comparing routes of administration. The risk of endometrial and breast cancer after long-term use of systemic oestrogen suggests that treatment should be for limited periods, especially in those women with an intact uterus.

[Conservative treatment of female stress urinary incontinence]

OBJECTIVES

To synthethise evidence based results related to non surgical management for urinary incontinence in women.

MATERIALS AND METHODS

Electronic search in Pubmed, Cinahl, Cochrane Library, National Library for Health.

RESULTS

There were 72 randomized control studies and 8 reviews from the Cochrane Library.

CONCLUSION

Moderate to high levels of evidence suggest that pelvic muscle training and bladder training may resolve urinary incontinence in women. A weight loss program from obesity state improve urinary continence. The effects of electrical stimulation of pelvic floor, oestrogene therapy were inconstant or inhomogeneous. Duloxetine may improve continence and quality of life but it's range in therapeutic algorithm is still to be defined.

Oestrogen therapy for urinary incontinence in post-menopausal women

BACKGROUND

It is possible that oestrogen deficiency may be an aetiological factor in the development of urinary incontinence in women.

OBJECTIVES

To assess the effects of local and systemic oestrogens used for the treatment of urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register of trials (2 April 2009) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that included oestrogens in at least one arm, in women with symptomatic or urodynamic diagnoses of stress, urgency or mixed urinary incontinence or other urinary symptoms post-menopause.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for methodological quality and appropriateness for inclusion by the review authors. Data were extracted by at least two authors and cross checked. Subgroup analyses were performed grouping participants under local or systemic administration. Where appropriate, meta-analysis was undertaken.

MAIN RESULTS

Thirty- three trials were identified which included 19,313 (1,262 involved in trials of local administration) incontinent women of whom 9417 received oestrogen therapy. Sample sizes ranged from 16 to 16,117. The trials used varying combinations of type of oestrogen, dose, duration of treatment and length of follow up. Outcome data were not reported consistently and were available for only a minority of outcomes.Systemic administration (of oral oestrogens) resulted in worse incontinence than on placebo (RR 1.32, 95% CI 1.17 to 1.48). This result is heavily weighted by a subgroup of women from the Hendrix trial, which had large numbers of participants and a longer follow up of one year; all the women had had a hysterectomy and the treatment used was conjugated equine oestrogen. The result for women with an intact uterus where oestrogen and progestogen combined were used also showed a statistically significant worsening of incontinence (RR 1.11, 95% CI 1.04 to 1.18).There was some evidence that oestrogens used locally (for example vaginal creams or tablets) may improve incontinence (RR 0.74, 95% CI 0.64 to 0.86). Overall, there were around one to two fewer voids in 24 hours and nocturnal voids amongst women treated with local oestrogen, and there was less frequency and urgency. No serious adverse events were reported although some women experienced vaginal spotting, breast tenderness or nausea.Women who were continent and received systemic oestrogen replacement, with or without progestogens, for reasons other than urinary incontinence were more likely to report the development of new urinary incontinence in one large study.The data were too few to address questions about oestrogens compared with or in combination with other treatments, different types of oestrogen or different modes of delivery.

AUTHORS' CONCLUSIONS

Local oestrogen treatment for incontinence may improve or cure it, but there was little evidence from the trials on the period after oestrogen treatment had finished and none about long-term effects. However, systemic hormone replacement therapy, using conjugated equine oestrogen, may make incontinence worse. There were too few data to reliably address other aspects of oestrogen therapy, such as oestrogen type and dose, and no direct evidence on route of administration. The risk of endometrial and breast cancer after long-term use suggests that oestrogen treatment should be for limited periods, especially in those women with an intact uterus.

17beta-estradiol induces the proliferation of the in vitro cultured human urothelium

OBJECTIVE

The genitourinary tract is considered to be a target for the actions of sex steroid hormones. Decreased ovarian function and lack of estrogen after menopause are associated with lower genitourinary tract symptoms as well as bladder dysfunctions such as incontinence. Estrogen may also affect urothelial cells. The estrogen receptors (ERs) are found in the mucosa of the urinary tract. The purpose of this study was to culture human urothelial cells (HUCs) originating from urothelial tissue biopsies and to use them as a reproducible test platform to evaluate the effect of 17beta-estradiol (E2).

MATERIAL AND METHODS

Urothelial tissue biopsies were obtained from 95 patients undergoing gynaecological open surgery for urinary incontinence, paediatric vesicoureteral reflux or transurethral resection of the prostate (TURP) for benign prostatic hyperplasia. HUCs originating from biopsies were cultured in vitro in the absence or in the presence of 0.1 nmol, 0.01 micromol and 1 micromol of E2. ER expression of the cultured HUCs was examined by Western analysis and immunofluorescence microscopy, which was also used for HUC characterization. The effect of E2 in the proliferation of the HUCs was determined by tetrazolium salt 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT)-assay.

RESULTS

HUCs were cultured successfully in four to six passages but there was variation between samples. The cultured cells showed expression of beta(4)-integrin, E-cadherin and cytokeratins 7, 8, 9 and 19, indicating the epithelial origin of the cells. Both types of ERs, ERalpha and ERbeta, were found in the in vitro cultured HUCs. E2 treatment of HUCs did not affect remarkably the expression of ERalpha but cell proliferation was induced. However, no concentration-dependent effect was seen.

CONCLUSIONS

This study indicates that HUCs originating from small tissue biopsies can be cultured in several passages in vitro and could have potential in repairing or restoring urinary tract tissue by tissue engineering therapy. HUCs serve as a good in vitro test platform, as shown by analysing E2-treated HUCs. E2 induced the proliferation of cultured HUCs even though concentration dependency was not observed. The findings of this study may have relevance in determining the mechanisms of estrogen therapy in postmenopausal urinary tract symptoms and in the future development of tissue engineering technology.

Effects of 17beta-oestradiol on rat detrusor smooth muscle contractility

The aim of this study was to investigate the effect of 17β-oestradiol (E₂) on detrusor smooth muscle contractility and its possible neuroprotective role against ischaemic-like condition, which could arise during overactive bladder disease. The effect of E₂ was investigated on rat detrusor muscle strips stimulated with carbachol, KCl and electrically, in the absence or presence of a selective oestrogen receptor antagonist (ICI 182,780) and, by using confocal Ca²⁺ imaging technique, measuring the amplitude (ΔF/F₀) and the frequency of spontaneous whole cell Ca²⁺ flashes. Moreover, the effect of 1 and 2 h of anoxia–glucopenia and reperfusion (A-G/R), in the absence or presence of the hormone, was evaluated in rat detrusor strips perfused with Krebs solution which underwent electrical field stimulation to stimulate intrinsic nerves; the amplitude and the frequency of Ca²⁺ flashes were also measured. 17β-Oestradiol exhibited antispasmogenic activity assessed on detrusor strips depolarized with 60 mm KCl at two different Ca²⁺ concentrations. 17β-Oestradiol at the highest concentration tested (30 μm) significantly decreased detrusor contractions induced by all the stimuli applied. In addition, the amplitude and the frequency of spontaneous Ca²⁺ flashes were significantly decreased in the presence of E₂ (10 and 30 μm) compared with control detrusor strips. In strips subjected to A-G/R, a significant increase in the amplitude of both spontaneous and evoked flashes was observed. 17β-Oestradiol was found to increase the recovery of detrusor strips subjected to A-G/R. The ability of E₂ to suppress contraction in control conditions may explain its ability to aid recovery following A-G/R.

Hormone-dependent aging problems in women

One of the major social issues nowadays is the aging society. Korea is already an aging society, and 63 cities and districts are ultra-aged societies where the rate of people older than 65 yr exceeds 20%. Among them, more than 67% are women. These statistics reveal the importance of healthcare for older women. Disease and disability of older women are very closely related to the loss of female sex hormones after menopause. Major hormone-dependent aging problems in women such as osteoporosis, Alzheimer's disease (AD), urinary incontinence, and coronary atherosclerosis were surveyed in this review, and the key role of hormones in those diseases and hormone replacement therapy (HRT) were summarized. We expect that this review would provide some understanding of factors that must be considered to give optimal care to older women for healthy lives.

MR imaging of the female urethra and supporting ligaments in assessment of urinary incontinence: spectrum of abnormalities

The traditional methods for evaluation of urinary incontinence in women include urodynamics, cystourethroscopy, cystourethrography, and ultrasonography. Magnetic resonance (MR) imaging has not played a major role in the assessment of women with urinary incontinence. However, high-resolution MR imaging allows detailed visualization of the urethral sphincter and supporting ligaments in women and may contribute to the diagnosis and staging of sphincteric incompetence related to intrinsic sphincter deficiency or urethral hypermobility. Both the anatomy and the function of the female urethra can be depicted on MR images. The spectrum of abnormalities detected at MR imaging in women with stress urinary incontinence are classified as (a) findings related to the urethral sphincter deficiency and (b) defects of the urethral support ligaments and urethral hypermobility. These abnormalities include a small urethral sphincter, funneling at the bladder neck, distortion of the urethral support ligaments, cystocele, an asymmetric pubococcygeus muscle, abnormal shape of the vagina, enlargement of the retropubic space, and an increased vesicourethral angle.

Urodynamic and morphologic changes in the lower portion of the urogenital tract after administration of estriol alone and in combination with phenylpropanolamine in sexually intact and spayed female dogs

OBJECTIVE

To compare the urodynamic and morphologic effects of the administration of estriol alone and in combination with phenylpropanolamine on the lower portion of the urogenital tract in female dogs.

ANIMALS

3 sexually intact and 3 spayed female Beagles without urinary incontinence.

PROCEDURE

Dogs received estriol (2 mg, PO) once daily for 7 days followed by estriol (2 mg, PO) and phenylpropanolamine (1.5 mg/kg, PO) once daily for 7 days. Urethral pressure profilometry, diuresis cystometry, and vaginourethrography were performed before treatment (day 0) and at days 7 and 14. The maximum urethral pressure (MUP) and closure pressure (MUCP), urethral functional and anatomic profile lengths, integrated pressure (IP), plateau, distance before MUP, maximum meatus pressure, threshold pressure, threshold volume, compliance, urethral length, and vaginal length and width were measured.

RESULTS

Before treatment, no urodynamic differences were observed between the 2 groups; however, vaginal length and width were significantly shorter in spayed dogs. Compared with day 0 values, estriol treatment significantly increased MUP, MUCP, and IP values at day 7, but at day 14, this effect decreased despite phenylpropanolamine administration. No morphologic changes from baseline were detected after either treatment in any dog.

CONCLUSIONS AND CLINICAL RELEVANCE

Data suggest that estriol mainly acts on the urethral sphincter mechanism by increasing urethral resistance in sexually intact and spayed female dogs without urinary incontinence. Administration of estriol and phenylpropanolamine did not increase the urethral resistance more than estriol alone. The urodynamic effects of estriol in female dogs with urinary incontinence remain to be elucidated.

Adrenergic drugs for urinary incontinence in adults

BACKGROUND

Adrenergic drugs have been used for the treatment of urinary incontinence. However, they have generally been considered to be ineffective or to have side effects which may limit their clinical use.

OBJECTIVES

To determine the effectiveness of adrenergic agonists in the treatment of urinary incontinence in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group specialised trials register (searched 9 March 2005) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in adults with urinary incontinence which included an adrenergic agonist drug in at least one arm of the trial.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Reviewers' Handbook.

MAIN RESULTS

Twenty-two eligible randomised trials were identified, of which 11 were crossover trials. The trials included 1099 women with 673 receiving an adrenergic drug (phenylpropanolamine in 11 trials, midodrine in two, norepinephrine in three, clenbuterol in another three, terbutaline in one, eskornade in one and Ro-115-1240 in one). No trials included men. The limited evidence suggested that an adrenergic agonist drug is better than placebo in reducing the number of pad changes and incontinence episodes, as well as improving subjective symptoms. In two small trials, the drugs also appeared to be better than pelvic floor muscle training, possibly reflecting relative acceptability of the treatments to women but perhaps due to differential withdrawal of women from the trial groups. There was not enough evidence to evaluate the use of higher compared to lower doses of adrenergic agonists nor the relative merits of an adrenergic agonist drug compared with oestrogen, whether used alone or in combination. Over a quarter of women reported adverse effects. There were similar numbers of adverse effects with adrenergics, placebo or alternative drug treatment. However, when these were due to recognised adrenergic stimulation (insomnia, restlessness and vasomotor stimulation) they were only severe enough to stop treatment in 4% of women.

AUTHORS' CONCLUSIONS

There was weak evidence to suggest that use of an adrenergic agonist was better than placebo treatment. There was not enough evidence to assess the effects of adrenergic agonists when compared to or combined with other treatments. Further larger trials are needed to identify when adrenergics may be useful. Patients using adrenergic agonists may suffer from minor side effects, which sometimes cause them to stop treatment. Rare but serious side effects, such as cardiac arrhythmias and hypertension, have been reported.

Vaginal estrogen therapy and overactive bladder symptoms in postmenopausal patients after a tension-free vaginal tape procedure: a randomized clinical trial

OBJECTIVE

To evaluate whether the frequency of overactive bladder (OAB) symptoms increases in menopause patients after a tension-free vaginal tape (TVT) procedure, and to determine if topical estrogen therapy can help prevent these symptoms.

DESIGN

After undergoing a preoperative assessment, enrolled patients were randomly allocated to receive TVT plus postoperative vaginal estrogen therapy (ET group) or TVT without adjunctive medical treatment (No ET group). The pre- and postoperative assessments included: acquisition of a urogynecologic history with standardized questions regarding urinary function (including a 10-grade visual analogue scale score), urogynecologic clinical examination, and urodynamic assessment. Follow-up assessments were performed at 1, 3, and 6 months after surgery.

RESULTS

Fifty-six of 59 patients were evaluable; 28 received topic vaginal estrogen after surgery (ET group) and 28 did not receive adjunctive medical treatment (No ET group). The overall OAB syndrome rate in menopause patients (No ET group) was 7% (2 of 28 patients) at baseline and 32% (9 of 28 patients) 6 months after surgery (P = 0.04). At the 6-month follow-up assessment, the incidence of urinary urgency was 4% (1 of 28 patients) and 29% (8 of 28 patients) in the ET and No ET groups, respectively (P = 0.01). Differences in frequency and nocturia were not statistically significant. Analysis of the visual analogue scale scores revealed that at the 6-month follow-up assessment, urgency significantly improved in the ET group compared with the No ET group (0.23 +/- 1.0 vs 2.30 +/- 3.7, respectively; P = 0.02).

CONCLUSIONS

The TVT procedure seems to increase the frequency of OAB syndrome in menopause patients. Vaginal estriol therapy significantly reduces symptoms of urinary urgency, has a high rate of patient satisfaction, and can be used to treat postmenopausal women for at least 6 months after a TVT procedure.

Influence of estradiol pretreatment on antimuscarinic action of oxybutynin in rat detrusor muscle

OBJECTIVES

To investigate the antimuscarinic effect of oxybutynin in the rat detrusor muscle after estrogen pretreatment because, to our knowledge, no study has been done on the interaction of estrogen with antimuscarinic drugs. Estrogen has been shown to affect muscarinic receptors in the detrusor muscle of animals. In addition, oxybutynin has been shown to block muscarinic receptors in the bladder.

METHODS

Estradiol benzoate (150 microg/kg) or saline was given subcutaneously to virgin female Wistar albino rats (n = 6, each group) for 10 consecutive days. On the 11th day, isolated detrusor muscle strips were taken, and acetylcholine (ACh)-induced contractions were evaluated in the absence or presence of oxybutynin (10 and 100 nM).

RESULTS

ACh induced concentration-dependent contractions in the detrusor muscle. In the estradiol-pretreated group, the maximum of the ACh-induced contractions was diminished compared with that in the control group (P < 0.05). Oxybutynin (10 and 100 nM) inhibited ACh-induced contractions competitively (pK(B) 8.85). In the estradiol-pretreated group, the concentration-response curve to ACh was shifted further to the right in the presence of oxybutynin (100 nM).

CONCLUSIONS

We have demonstrated for the first time that oxybutynin further inhibits ACh-induced and muscarinic receptor-mediated contractions in rat detrusor muscle after pretreatment with estrogen.

Early structural effects of oestrogen on pudendal nerve regeneration in the rat

OBJECTIVE

To determine the early effects of oestrogen on the ultrastructure of the pudendal nerve and distal nerve fascicles near the external urethra sphincter (EUS) after a pudendal nerve crush injury. The pudendal nerve is one of the pelvic floor tissues injured during vaginal delivery, possibly contributing to the development of stress urinary incontinence (SUI) in women, the symptoms of which often do not appear until menopause, implicating hormonal factors.

MATERIALS AND METHODS

Twenty-seven virgin female Sprague-Dawley rats were anaesthetized and underwent ovariectomy. Three days later, they had one of four procedures: bilateral pudendal nerve crush plus implant of a subcutaneous oestrogen-containing capsule (NC+E); nerve crush plus implant of a sham saline-containing capsule (NC+S); no nerve crush with an oestrogen capsule; or no nerve crush with a sham capsule. After 2 weeks the pudendal nerves and urethral tissues were prepared for light and electron microscopy. The number of axons, myelin figures and endoneurial nuclei in the pudendal nerve segment distal to the lesion were counted. Nerve fascicles near the EUS were also counted and categorized as normal or showing signs of degeneration and/or regeneration. The location of each nerve fascicle was specified as either ventral or dorsal.

RESULTS

As there were no significant differences between the two control groups they were combined to form a single control group. In the distal pudendal nerve there were significantly fewer myelinated axons and large myelinated axons in the NC+E and NC+S groups than in the control group. There were three times as many large unmyelinated axons in the NC+E group than in either the NC+S or control groups (P < 0.05). There were only half as many nerve fascicles near the ventral side of the EUS in the NC+S group than in both the control and NC+E groups (P < 0.05).

CONCLUSION

Oestrogen appears to affect large unmyelinated axons in both the injured pudendal nerve and at the denervated EUS target. After pudendal nerve crush, nerve fascicles with evidence of degeneration or regeneration near the EUS appear to be spared with oestrogen treatment, particularly in the ventral region. These observations may reflect the early stages of a neuroregenerative effect of oestrogen. Additional studies are needed to confirm these results at later periods and with functional methods.

Pharmacologic treatment of stress urinary incontinence: expectations for outcome

Several classes of drugs have been investigated for their efficacy in treating stress urinary incontinence (SUI). Despite targeting the mechanisms known to be involved in maintaining continence, few have provided the desired benefits without causing significant adverse effects. Duloxetine, the newest drug to be extensively evaluated for SUI treatment, appears to be both safe and effective. None of the drugs tested thus far has proved to be curative, however. Treatment strategies therefore are aimed at improving the quality of life of patients and should take into account their individual needs and preferences.

The role of estrogens in female lower urinary tract dysfunction

The urogenital tract and lower urinary tract are sensitive to the effects of estrogen and progesterone throughout adult life. Epidemiologic studies have implicated estrogen deficiency in the etiology of lower urinary tract symptoms that occur after menopause. Although the role of estrogen replacement therapy in the management of postmenopausal urinary incontinence (UI) remains controversial, its use in the treatment of women with urogenital atrophy is now well established. This review summarizes recent evidence of the urogenital effects of hormone therapy, particularly emphasizing management of postmenopausal UI and recurrent lower urinary tract infections. Estrogen therapy alone has little effect in the management of urodynamic stress UI, although in combination with an alpha-adrenergic agonist, it may improve urinary leakage. Estrogen therapy may be of benefit for the irritative symptoms of urinary urgency, frequency, and urge UI, although this effect may result from reversal of urogenital atrophy rather than a direct action on the lower urinary tract. The role of estrogen replacement therapy in the treatment of women with recurrent lower urinary tract infections remains to be determined, although there is now some evidence that vaginal administration may be efficacious. Low-dose, vaginally administered estrogens have a role in the treatment of urogenital atrophy in postmenopausal women and appear to be as effective as systemic preparations.

Clinical pharmacology of old age syndromes

Several syndromes occur in old age. They are often associated with increased mortality and in all there is a paucity of basic and clinical research. The recent developments in the clinical pharmacology of three common syndromes of old age (delirium, urinary incontinence, and falls) are discussed along with directions for future research.

What is the available evidence for hormone replacement therapy in women with stress urinary incontinence?

OBJECTIVE

To examine the evidence for the effectiveness of estrogen replacement therapy, with or without progesterone, for the treatment of stress urinary incontinence (SUI) in hypoestrogenic women.

METHODS

MEDLINE, DARE, CINAHL, Cochrane Central Register of Controlled Trials, and EMBASE databases were searched for studies, in all languages, that used estrogen therapy, with or without progesterone, in hypoestrogenic women with SUI. The following key words were used in the search: estrogen, hormone replacement therapy, female urinary incontinence, stress urinary incontinence, and urodynamic stress incontinence. Studies that did not specify a subgroup with SUI among women with mixed incontinence were excluded.

RESULTS

Of the papers included in this evaluation, 14 were non-randomized studies of estrogen treatment with or without progesterone; 6 were randomized trials of estrogen alone, combined with other treatments; 4 were placebo-controlled randomized trials, 2 of which were with progesterone; and 2 were meta-analyses. A symptomatic or clinical improvement was detected only in nonrandomized studies; randomized trials did not suggest a benefit of estrogen therapy, with or without progesterone, among postmenopausal women with SUI.

CONCLUSIONS

Further research, ideally randomized placebo-controlled trials, is required to determine the risks and benefits of estrogen treatment alone in the management of SUI in postmenopausal women.

The menopause and HRT. Urogenital effects of hormone therapy

The urogenital tract and lower urinary tract are sensitive to the effects of oestrogen and progesterone throughout adult life. Epidemiological studies have implicated oestrogen deficiency in the aetiology of lower urinary tract symptoms occurring following the menopause. Although to date the role of oestrogen replacement therapy in the management of post-menopausal urinary incontinence remains controversial, its use in the management of women complaining of urogenital atrophy is now well established. This aim of this chapter is to review the recent evidence regarding the urogenital effects of hormone therapy with a particular emphasis on the management of post-menopausal urinary incontinence, recurrent lower urinary tract infections and urogenital atrophy.

Oestrogens for urinary incontinence in women

BACKGROUND

It is possible that oestrogen deficiency may be an aetiological factor in the development of urinary incontinence in women.

OBJECTIVES

To assess the effects of oestrogens used for the treatment of urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (November 2002) and the reference lists of relevant articles. Date of the most recent searches: November 2002.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that included oestrogens in at least one arm, in women with symptomatic or urodynamic diagnoses of stress, urge or mixed incontinence or other urinary symptoms.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for methodological quality and appropriateness for inclusion by the reviewers. Data were extracted by all three reviewers and cross checked. Trial results were analysed within clinical subgroups or by intervention. Where appropriate, meta-analysis was undertaken.

MAIN RESULTS

Twenty eight trials were identified which included 2926 women. Sample sizes ranged from 16 to 1525. The trials used varying combinations of type of oestrogen, dose, duration of treatment and length of follow up. Outcome data were not reported consistently and were available for only a minority of trials. In the 15 trials that compared oestrogen with placebo, 374 women received oestrogen and 344 placebo. Subjective impression of cure was higher amongst those treated with oestrogen for all categories of incontinence (36/101, 36% versus 20/96, 21%; RR for cure 1.61, 95% CI: 1.04 to 2.49). When subjective cure and improvement were considered together, a statistically higher cure and improvement rate was shown for both urge (35/61, 57% versus 16/58, 28% on placebo) and stress (46/107, 43% versus 29/109, 27%) incontinence. For women with urge incontinence, the chance of cure or improvement was approximately a quarter higher again than in women with stress incontinence. Taking all trials together, the data suggested that about 50% of women treated with oestrogen were cured or improved compared with about 25% on placebo. Overall, there were around 1 to 2 fewer voids in 24 hours amongst women treated with oestrogen. The effect again appeared to be larger amongst women with urge incontinence. There were no statistically significant differences in respect of frequency, nocturia or urgency. No serious adverse events were reported although some women experienced vaginal spotting, breast tenderness or nausea. In a large trial conducted amongst women with heart disease, data from a subset who had incontinence suggested that women treated with a combination of oestrogen and a progestogen had lower subjective cure or improvement rates compared to the placebo group (RR 0.85, 95% CI 0.76 to 0.95). The data were too few to address other questions about oestrogens compared with, or in combination with, other treatments, different types of oestrogen or different modes of delivery.

REVIEWER'S CONCLUSIONS

Oestrogen treatment can improve or cure incontinence and the evidence suggests that this is more likely with urge incontinence. There was little evidence from the trials after oestrogen treatment had finished and none about long-term effects. Combined oestrogen and progesterone appeared to reduce the likelihood of cure or improvement. There were too few data to address reliably other aspects of oestrogen therapy such as oestrogen type, dose and route of administration. However, the risk of endometrial and breast cancer after long-term use suggests that oestrogen treatment should be for limited periods, especially in women with an intact uterus.

Adrenergic drugs for urinary incontinence in adults

BACKGROUND

Adrenergic drugs have been used for the treatment of urinary incontinence. However, they have generally been considered to be ineffective or to have side effects which may limit their clinical use.

OBJECTIVES

To determine the effectiveness of adrenergic agonists in the treatment of urinary incontinence in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (January 2002) and the reference lists of relevant articles. Date of the most recent searches: January 2002.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials which include an adrenergic agonist drug in at least one arm for adults with urinary incontinence.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Collaboration Handbook.

MAIN RESULTS

Fifteen randomised trials were identified, which included 832 women, of whom 506 received an adrenergic drug (phenylpropanolamine in 11 trials, Midodrine in two and Clenbuterol in another two). Of these, six were crossover trials. No trials included men. The limited evidence suggested that an adrenergic agonist drug is better than placebo in reducing number of pad changes and incontinence episodes, as well as improvement in subjective symptoms. The drugs also appeared to be better than pelvic floor muscle training in two small trials, possibly reflecting relative acceptability of the treatments to women but perhaps due to differential withdrawal of women from the trial groups. There was not enough evidence to evaluate the use of higher compared to lower doses of adrenergic agonists nor the relative merits of an adrenergic agonist drug compared with oestrogen, whether used alone or in combination.

REVIEWER'S CONCLUSIONS

There was weak evidence to suggest that use of an adrenergic agonist is better than placebo treatment. There was not enough evidence to assess the effects of adrenergic agonists when compared to or combined with other treatments. Patients using adrenergic agonists may suffer from minor side effects, only occasionally leading them to stop treatment. Rare but serious side effects such as cardiac arrhythmias and hypertension have been reported, however.

Overactive bladder in the female patient: the role of estrogens

The prevalence of urinary incontinence is known to increase with age, affecting 15% to 35% of community-dwelling women over 60 years of age. Other studies report a prevalence of 49% in women over 65 years of age. Epidemiologic studies have implicated estrogen deficiency in the etiology of lower urinary tract symptoms, although the role of estrogen replacement therapy remains controversial. This review presents recent evidence regarding the role of estrogen in lower urinary tract dysfunction, with a particular emphasis on the management of postmenopausal women with symptoms suggestive of overactive bladder.

Drug therapy for urinary incontinence

Drugs used for treatment of urinary incontinence may act on the central nervous system (CNS) or peripherally. Few drugs with a defined CNS site of action are available for treatment of urine storage disorders; most of those currently used have a peripheral site of action. To treat bladder overactivity associated with urgency and urge incontinence, antimuscarinic drugs, alpha-adrenoceptor antagonists, beta-adrenoceptor agonists, prostaglandin synthesis inhibitors, and several other agents most often developed for non-urological indications, are employed. Current treatment is based on the use of antimuscarinic drugs, and oxybutynin is, despite a high incidence of side-effects, the gold standard. Pharmacological treatment of stress incontinence has had limited success, and only alpha-adrenoceptor agonists, with and without combination with oestrogens have had a documented effect. New drugs, specifically directed at treatment of urine storage disorders, are desirable.

Pharmacologic management of pelvic floor dysfunction

Pharmacologic therapy is an important part of the treatment armamentarium for urogynecologic disorders. Current and future research will determine the utility of such therapy as medications with fewer side effects and more targeted efficacy are developed.

Reproductive and hormonal risk factors for urinary incontinence in later life: a review of the clinical and epidemiologic literature

OBJECTIVES

To review and integrate the current literature on the role of reproductive factors in the development of urinary incontinence in later life.

DESIGN

An extensive literature review using Medline and Science Citation Index for the period 1966 through 1997 was undertaken to identify published studies of the association between parturition events, hysterectomy, menopause, estrogen therapy, and later urinary incontinence.

RESULTS

Vaginal delivery is an established risk factor for both transient postpartum incontinence and the development of incontinence in later life. Several studies have found evidence of nerve and muscle damage that provide a physiologic basis for this association. Prospective studies of incontinence after hysterectomy have generally found no increased risk in the first few years. In contrast, cross-sectional epidemiologic studies have consistently found an increased risk many years after hysterectomy. Although menopause is often considered a risk factor for urinary incontinence, epidemiological studies have generally not found an increase in the prevalence of incontinence in the perimenopausal period. Oral estrogen replacement therapy seems to have little short-term clinical benefit in regard to incontinence and is associated consistently with increased risk of incontinence in women aged 60 years and older in epidemiologic studies.

CONCLUSIONS

This review provides a framework for further investigation of the complex relationships between reproductive risk factors and urinary incontinence. Integration of physiologic, clinical, and epidemiologic studies is needed to address the compelling health care issue of urinary incontinence. Suggestions are made for further areas of research.

Nonsurgical therapies for urinary incontinence

Many nonsurgical treatments for incontinence are available and all offer benefit to some patients. Patients with mild to moderate incontinence usually benefit the most from these modalities and, for many, it may obviate the need for surgery. Several factors influence the success of nonsurgical treatments for incontinence. Most important is the patient's motivation and ability to comply with the therapy. Selection of therapy appropriate for a given patient is, therefore, important. Compliance is better when the patient has a better understanding of the therapy and expected results. When appropriate, combinations of therapy may be very useful.

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.

Direct effect of amezinium on rabbit urethra: effect of estrogen and progesterone treatment

The effect of amezinium, a new anti-hypotensive agent, and hormonal treatment on the female rabbit urethra was investigated. Cumulative dose responses were obtained for amezinium and norepinephrine on strips of muscle from the urethras of ovariectomized female rabbits by means of the tissue-bath system. Amezinium enhanced the response to electrical field stimulation and showed a direct contractile response on the urethra. These responses were only about 20% of the maximum norepinephrine response. The contractile response to amezinium was completely blocked by prazosin. When rabbits were pretreated with estrogen, with or without progesterone, for 4 weeks, the response to amezinium increased to 40% of the maximum norepinephrine response. Although amezinium enhances muscle contractile responses to electrical stimulation, this effect is strong when amezinium is used alone; concurrent estrogen treatment improves the effects of amezinium.

Sex hormones, the menopause and urinary problems

To date, there have been few appropriate placebo-controlled studies using both subjective and objective parameters to assess the efficacy of estrogen therapy for the treatment of urinary incontinence. Further confusion arises from the heterogeneity of different study protocols. Consequently, the best treatment in terms of type and dose of estrogen and route of administration is unknown. From these studies, however, there is clear evidence to suggest that recurrent urinary tract infection can be prevented or even treated by the use of estrogen therapy. Furthermore, systemic estrogen replacement appears to alleviate the symptoms of urgency, urge incontinence, frequency, nocturia and dysuria, and low-dose topical estrogen is effective in the management of atrophic vaginitis. Although the latter example appears to be free from side-effects, even following prolonged administration, it is unclear whether low-dose therapy has a sufficient effect on the lower urinary tract to treat urinary incontinence. There is no conclusive evidence that estrogen replacement alone is sufficient to cure stress incontinence, but in combination with an alpha-adrenergic agonist there may be a role for estrogen therapy in the conservative management of genuine stress incontinence. On the other hand, estrogen supplementation definitely improves the quality of life of many postmenopausal women and, therefore, makes them better able to cope with other disabilities. Perhaps the role of estrogen in the management of postmenopausal urinary disorders is as an adjunct to other methods of treatment such as surgery, physiotherapy and drugs. This is certainly a hypothesis which should be tested.

Estrogen and urinary incontinence in women

OBJECTIVE

The purpose of this study was to review the efficacy of estrogen therapy for urinary incontinence by examining published trials and to review the epidemiologic and physiologic evidence for its action.

DATA SOURCES

Controlled and uncontrolled trials of estrogen therapy in the English literature were collected. Eight controlled and 14 uncontrolled trials were identified.

METHODS OF STUDY SELECTION

Trials were selected if they were prospective. All types of estrogen treatment were included. All types of outcome measurements were included.

DATA EXTRACTION AND SYNTHESIS

Trials were categorized by type of estrogen used; outcome variables (subjective improvement vs objective urodynamic data); and cure/improvement rates.

CONCLUSIONS

Published trials do not support estrogen replacement as efficacious therapy for stress urinary incontinence. It may be useful for incontinence associated with urgency and frequency. Adequately large controlled trials that evaluate estrogen replacement regimens used in the USA remain to be done.

Effects of long-term treatment with estrogen and progesterone on in vitro muscle responses of the female rabbit urinary bladder and urethra to autonomic drugs and nerve stimulation

Ovariectomized virginal rabbits were treated with either estrogen or progesterone for 4 to 6 months. In vitro responses of muscle strips of the bladder and circular urethra were examined. Estrogen resulted in bladder contractions in response to noradrenaline and phenylephrine, whereas these agonists were without effect or evoked weak relaxations in castrated animals (and normals). Estrogen also caused a rightward shift of the frequency-contraction curve to nerve stimulation. Progesterone increased bladder sensitivity to contraction-evoking bethanechol. Contractile urethral responsiveness to bethanechol increased after both steroids. Urethral sensitivity to noradrenaline, evoking contraction, increased following estrogen. Further, estrogen abolished the marked relaxatory urethral response to nerve stimulation of castrated (and normal) rabbits and caused contraction only, which was abolished by a combination of alpha-adrenoceptor antagonists and scopolamine. When comparing the present results with those of other studies, it is evident that hormone-induced changes become manifest at an early stage. The present animal study gives support for the use of estrogen in the therapy of stress incontinence and, further, it provides no objections to the use of progesterone in combination with estrogen in this condition.

The menopause: health implications and clinical management

OBJECTIVE

To review the anatomy, physiology, clinical symptoms, long-term health effects, and treatment of the menopause and climacteric syndrome, with a special emphasis on features, such as incontinence, particularly relevant to geriatric medicine.

DATA SOURCES

English-language publications on menopause and the climacteric.

STUDY SELECTION

Articles and books containing recent information pertinent to the topics covered. Studies in human subjects were given priority, but primate studies that amplify physiologic concepts are included.

DATA SYNTHESIS

Due to increased longevity, the average US woman will spend one-third of her life as a postmenopausal individual. Anatomic and physiologic changes associated with the peri- and postmenopausal state include hot flushes, genitourinary atrophy, and bone loss. Possible correlates of the menopausal transition and postmenopause include affective changes and unfavorable alterations in lipoproteins and other cardiac risk factors. Clinical correlates of these changes can include incontinence, sexual dysfunction, increased risk of fracture, dysphoric mood, and increased risk of cardiovascular disease. Formal indications for estrogen therapy are hot flushes, genital atrophy, and osteoporosis prevention; other common clinical uses are reviewed. Non-contraceptive estrogens can be administered orally, transdermally, vaginally, or by injection. Each route and preparation has some unique features with respect to actions and side effects. Progestins, in adequate doses, protect against the unwanted side effect of endometrial hyperplasia; alternatives to progestin use are presented. Non-hormonal alternatives for some peri- and postmenopausal symptoms are described.

CONCLUSIONS

A discussion of the menopause and the benefits and risks of hormone therapy should be part of the routine health care of older women. Since the use of hormone therapy is elective, health care providers must elicit the goals, needs, and preferences of each patient, supply her with relevant information, and serve as a facilitator of her individual decision.