Association between pelvic organ prolapse and climacteric symptoms in postmenopausal women

The causal effect of reproductive factors on pelvic floor dysfunction: a Mendelian randomization study

BACKGROUND

Pelvic floor dysfunction (PFD) is an extremely widespread urogynecologic disorder, the prevalence of which increases with aging. PFD has severely affected women's quality of life and has been called a social cancer. While previous studies have identified risk factors such as vaginal delivery and obesity for PFD, other reproductive factors, including age at menarche (AAMA), have been largely overlooked. Therefore, we used a Mendelian randomization (MR) study for the first time to investigate the potential causal relationship between reproductive factors and PFD.

METHODS

We obtained summary statistics from genome-wide association studies (GWAS) for female genital prolapse (FGP), stress urinary incontinence (SUI), and five reproductive factors. Two-sample Mendelian randomization analysis (TSMR) was performed to explore the causal associations between these factors. The causal effects of reproductive factors on FGP and SUI were primarily estimated using the standard inverse variance weighting (IVW) method, with additional complementary and sensitivity analyses conducted using multiple approaches. A multivariate Mendelian randomization (MVMR) study was also conducted to adjust for pleiotropic effects and possible sources of selection bias and to identify independent exposure factors.

RESULTS

Our findings revealed that advanced age at first sexual intercourse (AFS) and age at first birth (AFB) exhibited negative causal effects on both FGP and SUI. AAMA showed negative causal effects solely on FGP, while age at last live birth (ALB) and age at menopause (AAMO) did not demonstrate any causal effect on either FGP or SUI. And the MVMR results showed that AFB and AFS had independent negative causal effects on FGP and SUI, respectively.

CONCLUSIONS

This study, for the first time, investigates the causal relationship between reproductive factors and PFD. The results suggested a causal relationship between some reproductive factors, such as AFB and AFS, and PFD, but there were significant differences between FGPand SUI. Therefore, future studies should explore the underlying mechanisms and develop preventive measures for reproductive factors to reduce the disease burden of PFD.

Predictors of Clinical Outcome in Women with Pelvic Organ Prolapse Who Underwent Transvaginal Mesh Reconstruction Surgery

Background and Objectives: To identify the predictors of clinical outcomes in women with pelvic organ prolapse (POP) who underwent transvaginal reconstruction surgery, especially with transobturator mesh fixation or sacrospinous mesh fixation. Materials and Methods: All women with POP who underwent transvaginal reconstruction surgery, especially with transobturator mesh fixation or sacrospinous mesh fixation, were reviewed. Results: Between January 2011 and May 2019, a total of 206 consecutive women were reviewed, including 68 women receiving POP reconstruction with transobturator mesh fixation and 138 women who underwent POP reconstruction with sacrospinous mesh fixation. The least experienced surgeon (hazard ratio = 804.6) and advanced stage of cystocele (hazard ratio = 8.80) were the predictors of POP recurrence, especially those women with stage 4 of cystocele. Young age (hazard ratio = 0.94) was a predictor for mesh extrusion, especially those women with age ≤67 years. Follow-up interval (odds ratio = 1.03, p = 0.02) was also an independent predictor of mesh extrusion. High maximum flow rate (Qmax, hazard ratio = 1.03) was the sole predictor of postoperative stress urinary incontinence, especially those women with Qmax ≥19.2 mL/s. Preoperative overactive bladder syndrome (hazard ratio = 3.22) were a predictor for postoperative overactive bladder syndrome. In addition, overactive bladder syndrome rate improved after surgery in the sacrospinous group (p = 0.0001). Voiding dysfunction rates improved after surgery in both sacrospinous and transobturator groups. Conclusions: Predictors of clinical outcome in women who underwent transvaginal POP mesh reconstruction are identified. The findings can serve as a guide for preoperative consultation of similar procedures.

International Urogynaecology Consultation chapter 1 committee 4: patients' perception of disease burden of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This manuscript from Chapter 1 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reports on the patients' perception of disease burden associated with pelvic organ prolapse.

MATERIALS AND METHODS

An international group containing a team of eight urogynaecologists, a physiotherapist and a statistician performed a search of the literature using pre-specified search terms in PubMed and Embase (January 2000 to August 2020). The division of sections within this report includes: (1) perception of POP and the relationship with body image and poor health; (2) a vaginal bulge as it impacts health and wellbeing in women; (3) the impact of POP on sexual life; (4) body image and pelvic floor disorders; (5) POP and mood; (6) appropriate use of treatment goals to better meet patients' expected benefits; (7) using health-related quality of life questionnaires to quantify patients' perception of POP; (8) The financial burden of POP to patients and society. Abstracts were reviewed and publications were eliminated if not relevant or did not include populations with POP or were not relevant to the subject areas as noted by the authors. The manuscripts were next reviewed for suitability using the Specialist Unit for Review Evidence (SURE) checklists for cohort, cross-sectional and case-control epidemiologic studies.

RESULTS

The original individual literature searches yielded 2312 references of which 190 were used in the final manuscript. The following perceptions were identified: (1) women were found to have varying perceptions of POP including shame and embarrassment. Some regard POP as consequence of aging and consider there is no effective therapy. (2) POP is perceived as a vaginal bulge and affects lifestyle and emotional wellbeing. The main driver for treatment is absence of bulge sensation. (3) POP is known to affect frequency of sexual intercourse but has less impact on satisfaction. (4) Prolapse-specific body image and genital self-image are important components of a women's emotional, physical and sexual wellbeing. (5) POP is commonly associated with depression and anxiety symptoms which impact HRQoL although are not correlated with objective anatomical findings. (6) Patient-centered treatment goals are useful in facilitating communication, shared decision-making and expectations before and after reconstructive surgery. (7) Disease-specific HRQoL questionnaires are important tools to assess bother and outcome following surgery, and there are now several tools with Level 1 evidence and a Grade A recommendation. (8) The cost of POP to the individual and to society is considerable in terms of productivity. In general, conservative measures tend to be more cost-effective than surgical intervention.

CONCLUSIONS

Patients' perception of POP varies in different patients and has a far-reaching impact on their overall state of health and wellbeing. However, recognizing that it is a combination of body image and overall health (which affects mental health) allows clinicians to better tailor expectations for treatment to individual patients. There are HRQoL tools that can be used to quantify these impacts in clinical care and research. The costs to the individual patient (which affects their perception of POP) is an area that is poorly understood and needs more research.

Diastasis recti abdominis and pelvic floor dysfunction in peri- and postmenopausal women: a cross-sectional study

Introduction: Diastasis recti abdominis (DRA) and pelvic floor dysfunction (PFD) occurs commonly with aging; however, little is known about what leads to these changes.Objective: We aimed to investigate and compare the presence or absence of DRA and PFD in peri- and postmenopausal women.Methods: This cross-sectional study involved 150 participants who answered questions on their sociodemographic and clinical profiles related to urinary and fecal incontinence and pelvic organ prolapse. Diastasis recti abdominis was diagnosed with a digital caliper.Results: Supra-umbilical diastasis occurred in 37.3% of cases, and 78.6% of participants with DRA had PFD. No significant differences existed between participants with and without DRA in terms of background and clinical variables. However, participants with DRA were 2.6 times more likely to have PFD than participants without DRA. Furthermore, the presence of DRA was significantly shown to be a risk factor for PFD on binary logistic regression analyses (p = .01, OR = 3.2).Conclusions: This cross-sectional study suggests that DRA is a predictive factor of PFD in women aged over 50 years.

Lower urinary tract symptoms and their relation to vaginal atrophy in women across the menopausal age span. Results from the ANGEL multicentre observational study

OBJECTIVES

To evaluate the relation between lower urinary tract symptoms (LUTS) and vaginal atrophy (VA) in 518 women across the menopausal age span (40-55 years of age).

STUDY DESIGN

Multicentre, cross-sectional study.

MAIN OUTCOME MEASURES

VA was evaluated by the contemporaneous presence of a pH > 5, vaginal dryness and at least one objective sign of VA (mucosal pallor, dryness, thinning, fragility or with petechiae)., LUTS were evaluated by the Urogenital Distress Inventory (UDI-6). Sexuality was evaluated by the Female Sexual Function Index (FSFI).

RESULTS

Women were categorized by age: group 1, 40-45 years; group 2, 46-48 years; group 3, 49-51 years; and group 4, 52-55 years. Similar rates of recurrent urinary infection (RUI) were present in different age groups. RUI rate was related to VA (OR 1.703, 95 %CI 1.037, 2.799) and dyspareunia (OR 2.060, 95 %CI 1.199, 3.539). The rates of LUTS were also similar in the different age groups or in the presence of VA. The LUTS rate was related to dyspareunia (OR 1.971, 95 %CI 1.020, 3.808). Distress from LUTS was similar among different age groups and in the presence of VA. It was related to RUI (CR 7.187, 95 %CI 3.532, 10.841; p < 0.0001) and being an ex-smoker (CR 5.189, 95 %CI 1.425. 6.952; p < 0.007), and was inversely related to FSFI score (CR -0.314, 95 %CI -0.478, -0.149; p < 0.0002), CONCLUSIONS: In women across the menopausal age span, RUI, but not LUTS, is related to VA. The presence of LUTS is related to dyspareunia, and distress from LUTS is inversely related to sexuality. These results obtained in women across the menopausal age span are not applicable to older postmenopausal women.

Treatment of genitourinary syndrome of menopause: the potential effects of intravaginal ultralow-concentration oestriol and intravaginal dehydroepiandrosterone on quality of life and sexual function

The climacteric is considered a natural phase in a woman's aging process and is defined as the period starting from the decline in ovarian activity until after the end of ovarian function. Genitourinary syndrome of menopause (GSM) is commonly observed in menopausal women and is characterised by a collection of symptoms resulting from changes to the internal and external genitalia as well as the lower urinary tract. Several studies have demonstrated the close association between sexual dysfunction and symptoms related to GSM. Many medications, at different doses, have been studied over the years for the treatment of the symptoms of GSM. More specifically, ultralow-dose intravaginal oestriol and intravaginal dehydroepiandrosterone (DHEA) are reported to improve symptoms, signs, and quality of life of women with GSM, and they are safe owing to their specific local effect. While the dosage and the administration of intravaginal DHEA are well defined, the literature on intravaginal oestriol is less uniform: different doses and times of administration are proposed with different possible combinations with other non-pharmacological therapies, although a more standardised treatment may be necessary. The aim of this review is to summarise the available data about the effects of ultralow-concentration oestriol and intravaginal DHEA on the menopause-related symptoms, quality of life, and sexual function of women affected by GSM.