Childbirth-induced trauma to the urethral continence mechanism: review and recommendations

Transcriptomic Analysis of Human Mesenchymal Stem Cell Therapy in Incontinent Rat Injured Urethra

Periurethral human mesenchymal stem cell (hMSC) injections are associated with functional improvement in animal models of postpartum stress urinary incontinence (SUI). However, limited data exist on the role of hMSCs in modulating gene expression in tissue repair after urethral injury. To this end, we quantified temporal gene expression modulation in hMSCs, and in injured rat urethral tissue, using RNA-seq in an animal model of SUI, over a 3-day period following urethral injury, and local hMSC injection. We injected PKH fluorescent-labeled hMSC into the periurethral space of rats following a 4 h vaginal distention (VD) (three rats per time point). Control rats underwent VD injury only, and all animals were euthanized at 12, 24, 36, 72 h postinjury. Rat urethral and vaginal tissues were frozen and sectioned. Fluorescent labeled hMSCs were distinguished from adjacent, unlabeled rat urethral tissue. RNA was prepared from hMSCs and urethral tissue obtained by laser dissection of frozen tissue sections and sequenced on an Illumina HiSeq 2500. Differentially expressed genes (DEGs) over 72 h were evaluated using a two-group t-test (p < 0.05). Our transcriptional analyses identified candidate genes involved in tissue injury that were broadly sorted by injury and exposure to hMSC throughout the first 72 h of acute phase of injury. DEGs in treated urethra, compared with untreated urethra, were functionally associated with tissue repair, angiogenesis, neurogenesis, and oxidative stress suppression. DEGs included a variety of cytokines, extracellular matrix stabilization and regeneration genes, cytokine signaling modification, cell cycle regulation, muscle differentiation, and stabilization. Moreover, our results revealed DEG changes in hMSCs (PKH-labeled) harvested from injured urethra. The expressions are related to DNA damage repair, transcription activation, stem cell regulation, cell survival, apoptosis, self-renewal, cell proliferation, migration, and injury response. Impact statement Stress urinary incontinence (SUI) affects nearly half of women over 40, resulting in reduced quality of life and increased health care cost. Development of SUI is multifactorial and strongly associated with vaginal delivery. While stem cell therapy in animal models of SUI and limited preliminary clinical trials demonstrate functional improvement of SUI, the role of stem cell therapy in modulating tissue repair is unclear impeding advanced clinical trials. Our work provides a new understanding of the transcriptional mechanisms with which human mesenchymal stem cells improve acute injury repair thus guiding the development of cell-based therapies for women with nonacute established SUI.

Active delivery of the anterior arm and incidence of second-degree perineal tears: a clinical practice evaluation

BACKGROUND

Evaluate the feasibility of active delivery of the anterior arm during spontaneous delivery. This maneuver could decrease incidence of second-degree perineal tears because it reduces fetal biacromial diameter.

METHODS

An observational comparative prospective study was conducted at our teaching maternity from July 2012 to March 2013. The study included 199 nulliparous women ≥18 years, who met the following criteria: singleton pregnancy, vaginal delivery with occiput anterior presentation, on epidural analgesia, from 37 weeks of gestation onward. The distribution of rate and type of perineal tears were compared between two groups: a non-exposed group and a group exposed to the maneuver.

RESULTS

A total of 101 patients were exposed to Couder's maneuver (CM) and 98 patients were not exposed. In the intervention group, 3 failures of the maneuver were reported. The maneuver was considered easy in 80% of cases, moderately easy in 12% and difficult in 8% of cases. There was a significant difference (p = 0.03) in the distribution of perineal tears between the two groups. There was a significant reduction (p < 0.001) in the number of second-degree perineal tears in the patients exposed to CM. There was no significant difference in the rate of anterior perineal trauma between the exposed and non-exposed arms.

CONCLUSIONS

CM in primiparous women at term is feasible with a low failure rate and influences the distribution of perineal tears by lowering second-degree perineal tears in a highly significant manner (p <0.01).

The potential role of stem cells in the treatment of urinary incontinence

Voiding dysfunction encompasses a wide range of urologic disorders including stress urinary incontinence and overactive bladder that have a detrimental impact on the quality of life of millions of men and women worldwide. In recent years, we have greatly expanded our understanding of the pathophysiology of these clinical conditions. However, current gold standard therapies often provide symptomatic relief without targeting the underlying etiology of disease development. Recently, the use of stem cells to halt disease progression and reverse underlying pathology has emerged as a promising method to restore normal voiding function. Stem cells are classically thought to aid in tissue repair via their ability for multilineage differentiation and self-renewal. They may also exert a therapeutic effect via the secretion of bioactive factors that direct other stem and progenitor cells to the area of injury, and that also possess antiapoptotic, antiscarring, neovascularization, and immunomodulatory properties. Local injections of mesenchymal, muscle-derived, and adipose-derived stem cells have all yielded successful outcomes in animal models of mechanical, nerve, or external urethral sphincter injury in stress urinary incontinence. Similarly, direct injection of mesenchymal and adipose-derived stem cells into the bladder in animal models of bladder overactivity have demonstrated efficacy. Early clinical trials using stem cells for the treatment of stress urinary incontinence in both male and female patients have also achieved promising functional results with minimal adverse effects. Although many challenges remain to be addressed prior to the clinical implementation of this technology, novel stem-cell-based therapies are an exciting potential therapy for voiding dysfunction.

Prolonged second stage of labor and levator ani muscle injuries

Objective:

To determine the effect of pregnancy and vaginal delivery on the pelvic floor and levatorani morphology and function.

Methods:

Design. Cross-sectional study. Setting. Tertiary care teaching hospital. Population. 75 primigravid women were recruited for assessment at 6 weeks postpartum compared with 25 nulliparous women. Hiatal morphology and levator ani muscle avulsion were assessed by 4-dimensional translabial ultrasound examination. The volume achievement obtained by ultrasound was performed in supine position with empty bladder at rest, on maximum Valsalva maneuver, and on maximum pelvic floor muscle contraction. Main Outcome Measures. Hiatal diameter and area were measured at the plane of minimal hiatal dimension as defined in the midsagittal plane and Levator avulsion was assessed.

Results:

There were significant differences in hiatal area morphology at rest, on Valsalva maneuver and during contraction of muscles among the study groups, but there was no difference in pelvic diameter at rest, on Valsalva maneuver, and during contraction. There were 21 cases of puborectalis avulsion (42%) with no significant difference between non-progressive labor (8 cases) and Normal Vaginal Delivery (NVD) (13 cases) groups.

Conclusions:

The results of the present study showed that non-progressive labor is the main risk factor for pelvic muscle injuries, indicating the necessity of a better management and timely cesareans in women with prolonged second stage of labor.

Comparison of pelvic floor muscle strength evaluations in nulliparous and primiparous women: a prospective study

OBJECTIVE

This study aimed to compare the pelvic floor muscle strength of nulliparous and primiparous women.

METHODS

A total of 100 women were prospectively distributed into two groups: Group 1 (G1) (n = 50) included healthy nulliparous women, and Group 2 (G2) (n = 50) included healthy primiparous women. Pelvic floor muscle strength was subjectively evaluated using transvaginal digital palpation. Pelvic floor muscle strength was objectively assessed using a portable perineometer. All of the parameters were evaluated simultaneously in G1 and were evaluated in G2 during the 20th and 36th weeks of pregnancy and 45 days after delivery.

RESULTS

In G2, 14 women were excluded because they left the study before the follow-up evaluation. The median age was 23 years in G1 and 22 years in G2; there was no significant difference between the groups. The average body mass index was 21.7 kg/m² in G1 and 25.0 kg/m² in G2; there was a significant difference between the groups (p = 0.0004). In G2, transvaginal digital palpation evaluation showed significant impairments of pelvic floor muscle strength at the 36th week of pregnancy (p = 0.0006) and 45 days after vaginal delivery (p = 0.0001) compared to G1. Objective evaluations of pelvic floor muscle strength in G2 revealed a significant decrease 45 days after vaginal delivery compared to nulliparous patients.

CONCLUSION

Pregnancy and vaginal delivery may cause weakness of the pelvic floor muscles.

Incontinência urinária autorreferida no pós-parto

Trata-se de um estudo epidemiológico, transversal, que entrevistou 288 mulheres com até seis meses de pós-parto, frequentadoras de um serviço de saúde do município de São Paulo. Teve como objetivo caracterizar a ocorrência de incontinência urinária autorreferida pela mulher no período pós-parto. Os resultados mostraram que, dentre as 71 mulheres autorreferidas como incontinentes, 20 (28%) relataram que a perda involuntária de urina interferia na sua vida diária; 38 (53,5%) eram primíparas; 277 mulheres (96%) não foram orientadas sobre o preparo do períneo na gestação ou no pós-parto. Verificou-se que, no pós-parto, as mulheres não informam sobre a ocorrência de incontinência urinária ao profissional de saúde, e aquelas que o fazem, não recebem tratamento. A gestação e o pós-parto são momentos importantes para a prevenção desta morbidade.

Vaginal delivery and pelvic floor dysfunction: current evidence and implications for future research

Vaginal delivery is the major risk factor for the development of pelvic organ prolapse and urinary and fecal incontinence, resulting from damage to the pelvic floor muscles, nerves and connective tissue. This article reviews the perineal trauma mechanism during vaginal delivery and discusses implications of current and future research projects.

Prevalence of urinary incontinence and its association with body mass index among women in Puerto Rico

OBJECTIVE

Urinary incontinence (UI) affects the quality of life of millions of women world-wide. Prevalence estimates for UI range from 10% to 40%, but information on young and mid-life women, especially among Hispanics, is limited. This study estimated UI prevalence and its association with body mass index (BMI) in a population-based sample of 276 female residents of Bayamón, Puerto Rico (PR) aged 21-64 years.

METHODS

A cluster sampling design was employed. Women were interviewed to gather data on sociodemographic, clinical, gynecologic, and UI characteristics. Descriptive statistics were used to characterize the study sample. Bivariate analyses of factors potentially associated with UI and BMI were conducted using generalized linear models (GLM). Multivariate GLM was used to determine the covariate adjusted association between BMI and UI.

RESULTS

The prevalence of UI was 34.8% (95% confidence interval [CI]: 29.4-40.6%). Among women with UI, stress incontinence was most frequent (46.8%), followed by mixed (41.5%) and urge incontinence (11.7%). More than 45% of participants were either overweight (25 kg/m(2) or= 30 kg/m(2)). The adjusted analysis revealed that women with a BMI >or= 30 kg/m(2) had 1.96 (p = 0.06) times the probability of having UI compared to women with a BMI < 25 kg/m(2).

CONCLUSIONS

UI is a public health problem among this population, and obesity marginally increases the possibility of having this condition. Public health efforts should focus on reducing obesity in PR, in order to have an impact on UI morbidity.

Tailoring systematic reviews to meet critical priorities in maternal health in the intrapartum period

Health care practitioners and researchers commonly call for greater reliance on evidence as a means to achieve improvement in quality of care. Systematic reviews provide a means to accelerate the use of evidence-based clinical interventions and public health practices. The extent to which these time- and resource-intensive systematic reviews currently address critical maternal health priorities in the intrapartum period is unclear. This analysis summarises key maternal health and research priorities, maps these priorities to existing reviews, identifies gaps in the literature that can be addressed with systematic reviews, and highlights key methodological concerns in conducting systematic reviews. The analysis draws on published data on maternal morbidities and an overview of 108 systematic reviews in Medline in the past 5 years using the MeSH terms 'Delivery, Obstetric,' to draw the links between health priorities, research priorities, existing evidence and missing evidence. Key causes of morbidity during labour and delivery in the United States include haemorrhage, pre-eclampsia and eclampsia, obstetric trauma and infection. Analyses of maternal morbidity and mortality suggest that key concerns include racial and ethnic disparities in health outcomes and the prevention of adverse events. Systematic reviews, however, generally tend to focus on the reduction of harms associated with interventions, are frequently limited to randomised designs, and do not address issues of health disparities. The results suggest that advances in evidence-based care in maternal health require that systematic reviews address issues of prevention of adverse events, include a larger variety of study designs when necessary and pay closer attention to health disparities.

ORIGINAL RESEARCH–COUPLES' SEXUAL DYSFUNCTIONS: Does Mode of Delivery Affect Sexual Functioning of the Man Partner?

INTRODUCTION

Recent surveys showed that the major reasons for avoiding vaginal delivery were the fear of childbirth and the concern for postpartum sexual health. Although sexual dysfunction is a disorder that affects a couple rather than an individual, all studies investigating the relationship between the mode of delivery and sexual problems have been conducted only in cohorts of women.

AIM

To determine the effect of mode of delivery on quality of sexual relations and sexual functioning of men by using the Golombock-Rust Inventory of Sexual Satisfaction (GRISS).

MAIN OUTCOME MEASURE

Mean score of sexual function and prevalence of sexual dysfunction in overall and specific areas of the GRISS were compared among the three groups.

METHODS

A total of 107 men accompanying their wives in outpatient clinics of obstetrics and gynecology met inclusion/exclusion criteria. Three groups of men were defined; men whose partners had: (i) "elective cesarean delivery" (N = 21; mean age 32.2 +/- 3.8 years); (ii) "vaginal delivery with mediolateral episiotomy" (N = 36; mean age 31.4 +/- 4.5 years); and (iii) "not given birth" (N = 50; mean age 28.8 +/- 4.0 years).

RESULTS

Mean overall sexual function score (normal value < 25 points) was 20.5 +/- 8.2 in the elective caesarean group, 19.3 +/- 6.5 in the vaginal delivery group, and 18.8 +/- 9.3 in the nulliparae group (P = 0.731). Prevalence of sexual dysfunction in men was 28.6% in the elective caesarean group, 19.4% in the vaginal delivery group, and 30.0% in the nulliparae group (P = 0.526).

CONCLUSION

Overall sexual function of men was not affected by their partner's parity and mode of delivery. An elective cesarean section simply because of concerns about sexual function would not provide additional benefit to men, and could deny women a possible vaginal delivery, which is generally assumed to be safer than cesarean section.

A urogynecologist's view ofthe pelvic floor effects of vaginal delivery/cesarean section for the urologist

Pregnancy and parturition have been implicated in the development of pelvic floor dysfunction. These disorders include urinary incontinence, fecal incontinence, pelvic organ prolapse, and other pelvic and sexual dysfunctions. The urologist caring for women with urinary dysfunction needs to be familiar with the causes of pelvic floor dysfunction and their implications. Defects of the pelvic floor have clearly resulted from the traumatic effect of vaginal delivery. The likely mechanisms of injuries during vaginal delivery involve stretching and compression of the pudendal nerve and peripheral branches, as well as an additional tearing of muscles and connective tissue. Optimal management of labor and optimal techniques of repair of unavoidable sphincteric lacerations, ante- and postpartum pelvic floor muscle conditioning, and timely and proper indications for cesarean delivery will minimize the effect of incidental traumatic delivery.

Combined urinary and faecal incontinence

Combined urinary and faecal (liquid or solid) incontinence (double incontinence) is the most severe and debilitating manifestation of pelvic floor dysfunction. The community prevalence is 9-19% (urinary) and 5-10% (faecal), increasing with age. Pathophysiological factors include childbirth-associated external anal sphincter injury and pudendal nerve damage, pelvic floor descent, menopause, collagen disorders and multiple sclerosis-like conditions. The presence of crossed reflexes between the bladder, urethra, anorectum and pelvic floor in animal studies may explain the comorbidity of urinary and faecal urgency. Surgical treatment is based on aetiology and combined optimum techniques such as colposuspension or suburethral sling with overlapping sphincteroplasty. Other methods for improving sphincteric control include sacral nerve neuromodulation, bulking agents and artificial sphincters.

Mode of delivery and pelvic floor muscle strength and sexual function after childbirth

OBJECTIVE

To investigate the respective roles of the mode of delivery and strength of pelvic floor muscles in the sexual function of women.

METHOD

Thirty-two women who were delivered vaginally and 21 women who underwent cesarean delivery at the Celal Bayar University School of Medicine Obstetrics Department were enrolled in the study, and 15 nulliparas were recruited as controls. Sexual function was assessed in all women by a validated questionnaire (the Female Sexual Function Index). Desire, arousal, lubrication, orgasm, satisfaction, and pain were measured separately, and pelvic floor muscle strength was assessed by a perineometer. Sexual function was compared among the 3 groups. The correlation between pelvic floor muscle strength and sexual function was also investigated.

RESULTS

Pelvic floor muscle strength was significantly lower in the group vaginally delivered compared with the group delivered by cesarean section and the nulliparous group (P<0.05). There was no difference between the groups regarding sexual function (P>0.05), and there was also no correlation between sexual function and pelvic muscle strength.

CONCLUSION

Pelvic floor muscle strength and mode of delivery did not affect sexual function in our study participants. The muscular component of female sexual function should be further investigated.

Pelvic floor muscle evaluation in incontinent patients

The aim of this study was to assess pelvic floor muscle (PFM) strength and perception and its correlation with stress urinary incontinence (SUI). One hundred and one women were divided into two groups according to the presence (G1=51 patients) or absence (G2=50 patients) of SUI. Subjective [urine stream interruption test (UST), visual survey of perineal contraction and transvaginal digital palpation to assess pelvic muscle contraction] and objective evaluations of pelvic floor muscles in all patients were performed (vaginal manometry). During the UST, 25.5% of G1 patients and 80% of G2 patients were able to interrupt the urine stream (p<0.05). Digital evaluation of pelvic muscular contraction showed higher strength in G2 than in G1 patients (p<0.0001). Perineometer evaluation of PFM strength was significantly higher in the continent group (p<0.001). Pelvic floor muscle weakness in incontinent patients demonstrates the importance of functional and objective evaluation of this group of muscles.

Effect of vaginal distension on blood flow and hypoxia of urogenital organs of the female rat

Vaginal delivery of children causes traumatic injury to tissues of the pelvic floor and is correlated with stress urinary incontinence; however, the exact mechanism of organ and tissue injury leading to incontinence development is unknown. The purpose of this project was to test the hypothesis that vaginal distension results in decreased blood flow to, and hypoxia of, the urogenital organs responsible for continence, which would suggest an ischemic and/or reperfusion mechanism of injury. Thirteen female rats underwent vaginal distension for 1 h. Thirteen age-matched rats were sham-distended controls. Blood flow to the bladder, urethra, and vagina were determined using a microsphere technique. Hypoxia of these organs was determined by immunohistochemistry. Blood flow to all three organs was significantly decreased just before release of vaginal distension. Bladder blood flow decreased further immediately after release of vaginal distension and continued to be significantly decreased 15 min after the release. Blood flow to both the urethra and vagina tripled immediately after release, inducing a rapid return to normal values. Vaginal distension resulted in extensive smooth muscle hypoxia of the bladder, as well as extensive hypoxia of the vaginal epithelium and urethral hypoxia. Bladders from sham-distended rats demonstrated urothelial hypoxia as well as focal hypoxic areas of the detrusor muscle. We have clearly demonstrated that vaginal distension results in decreased blood flow to, and hypoxia of, the bladder, urethra, and vagina, supportive of hypoxic injury as a possible mechanism of injury leading to stress urinary incontinence.