Pelvic floor changes in the older woman

Improvement of Cell Growth of Uterosacral Ligament Fibroblast Derived from Pelvic Organ Prolapse Patients by Cold Atmospheric Plasma Treated Liquid

Pelvic organ prolapse (POP) is a chronic disorder that affects quality of life in women. Several POP treatments may be accompanied by abrasion, constant infection, and severe pain. Therefore, new treatment methods and improvements in current treatments for POP are required. Non-thermal atmospheric-pressure plasma is a rising biomedical therapy that generates a mixed cocktail of reactive species by different mechanisms. In this study, we applied a cylinder-type dielectric barrier discharge plasma device to create a plasma-treated liquid (PTL). The PTL was added to primary cultured human uterosacral ligament fibroblast (hUSLF) cells from POP patients at each stage. Surprisingly, treatment with diluted PTL increased hUSLF cell viability but decreased ovarian cancer cell viability. PTL also decreased cell apoptosis in hUSLF cells but increased it in SKOV3 cells. Our results suggest that PTL protects hUSLF cells from cell apoptosis by controlling the p53 pathway and improves cell viability, implying that PTL is a promising application for POP therapy.

Transvaginal management of severe pelvic organ prolapse in nulliparous women

AIM

The aim of this study was to evaluate the management outcomes of advanced pelvic organ prolapse (POP) in nulliparous women.

METHODS

Eight nulliparous women diagnosed with POP ≥ stage 3 between January 2005 and August 2013, according to the Pelvic Organ Quantification System (POPQ), were reviewed. Seven were managed surgically and one was managed with pessary. Primary outcome was surgical objective cure (POP-Q ≤ 1) and subjective cure, defined as negative response to questions 2 and 3 on Pelvic Organ Prolapse Distress Inventory 6. Secondary outcomes were complications, symptoms' severity and quality of life according to validated questionnaires.

RESULTS

A total of 1275 prolapse patients with POP-Q ≥ stage 3 were managed surgically, among whom seven (0.55%) were nulliparous. Each woman had at least one risk factor associated with POP. Risk factors identified were history of pelvic trauma, obesity, menopause, chronic cough, hard physical labor and constipation. Five patients underwent surgical correction (vaginal hysterectomy with sacrospinous fixation) with mesh (Perigee, n = 3; Avaulta, n = 2). Two patients had uterine preservation without mesh (hysteropexy with sacrospinous ligament fixation). One patient preferred treatment with pessary. The total cure rate (objective and subjective cure rates) was 86% after surgical reconstructive surgery.

CONCLUSION

Management of nulliparous advanced POP poses significant challenges with regard to uterine preservation, future pregnancy and childbirth. Conservative management with pessary insertion should be offered followed by surgical correction. Reconstructive surgery with mesh may improve prolapse symptoms objectively and subjectively.

Pelvic organ prolapse and endogenous circulating sex steroids in postmenopausal women: A case control-study

OBJECTIVE

We compared sex steroid levels of postmenopausal patients with symptomatic pelvic organ prolapse (POP) with postmenopausal matched patients without any sign of POP. Furthermore, we evaluated a possible relationship between sex steroid levels and various urogynecologic parameters in cases with POP. Main outcome of interest were differences in circulating estradiol levels between the two groups.

STUDY DESIGN

We conducted a case-control study and 46 postmenopausal women with symptomatic POP≥stage 2 were matched 1:1 with 46 urogynecologic healthy women. Blood samples were drawn from all patients for assessment for estradiol (E2), Follicle-stimulating hormone (FSH), Luteinizing hormone (LH), testosterone (T), androstendion (AEON), dehydroepiandrosterone sulphate (DHEAS) and sex hormone binding globulin (SHBG) with an Electrochemiluminescence immunoassay.

RESULTS

Our study failed to show any statistically significant differences in sex steroid levels between women with and without POP (p>0.05). However, serum concentration of E2 (p<0,0001), free testosterone (p=0,034) and DHEAS (p=0,024) was statistically significant lower in patients with severe prolapse stage. Serum levels of E2 were statistically significant higher in cases with moderate-strong Oxford Grading Scale (p<0,0001). Low circulating E2 (p=0,019) as well as menopausal age (p=0,022) remained independent risk factors for POP in multiple logistic regression analysis.

CONCLUSION

The significant low hormonal levels in cases with high POP-Q stage as well as the significant higher estradiol levels in patients with strong Oxford Grading Scale may indicate that endogenous circulating sex steroids might have a potential role in the severity and progression of POP.

Role of bariatric surgery in the pelvic floor disorders

Pelvic floor disorders are very frequent among women. Weight loss can help them to achieve urinary and faecal continence again. In this narrative review, the possible mechanisms of pelvic floor disorders in obese women, their symptoms and the role of bariatric surgery in changing their quality of life are presented. We retrieved the included results of our study after performing a systematic, electronic search in PubMed (December 17, 2012) and Scopus (December 17, 2012). The main mechanism causing the development of pelvic floor disorders is chronically increased abdominal pressure as it overts structural damage or neurologic dysfunction predisposing to prolapse and incontinence. The symptoms include a sensation of vaginal fullness or pressure, uterine descent, sacral back pain with standing, vaginal spotting from ulceration of the protruding cervix or vagina, coital difficulty, lower abdominal discomfort, and voiding and defecatory difficulties. Evidence indicates that massive weight loss (45 to 50 kg) improves incontinence in morbidly obese women after bariatic surgery. Faecal incontinence is also improved after bariatric surgery. This review highlights the role of bariatric surgery in weight reduction of obese women that could act as a treatment for the pelvic floor disorders faced by those women offering improvement in incontinence as well as quality of life.

Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery

OBJECTIVE

To investigate prevalence and risk factors for symptomatic pelvic organ prolapse (sPOP) and sPOP concomitant with urinary incontinence (UI) in women 20 years after one vaginal delivery or one caesarean delivery.

DESIGN

Registry-based national cohort study.

SETTING

Women who returned a postal questionnaire in 2008 (response rate 65.2%).

POPULATION

Singleton primiparae with a birth in 1985-88 and no further births (n = 5236).

METHODS

The SWEPOP study used validated questionnaires about sPOP and UI.

MAIN OUTCOME MEASURES

Prevalence rate and risk of sPOP with or without concomitant UI.

RESULTS

Prevalence of sPOP was higher after vaginal delivery compared with caesarean section (14.6 versus 6.3%, odds ratio [OR] 2.55; 95% confidence interval [95% CI] 1.98-3.28) but was not increased after acute compared with elective caesarean section. Episiotomy, vacuum extraction and second-degree or more laceration were not associated with increased risk of sPOP compared with spontaneous vaginal delivery. Symptomatic POP increased 3% (OR 1.03; 95% CI 1.01-1.05) with each unit increase of current BMI and by 3% (OR 1.03; 95% CI 1.02-1.05) for each 100 g increase of infant birthweight. Mothers ≤ 160 cm who delivered a child with birthweight ≥ 4000 g had a doubled prevalence of sPOP compared with short mothers who delivered an infant weighing < 4000 g (24.2 versus 13.4%, OR 2.06; 95% CI 1.19-3.55). Women with sPOP had UI and UI > 10 years more often than women without prolapse.

CONCLUSION

The prevalence of sPOP was doubled after vaginal delivery compared with caesarean section, two decades after one birth. Infant birthweight and current BMI were risk factors for sPOP after vaginal delivery.

Relaxin and gonadal steroid receptors in uterosacral ligaments of women with and without pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This study evaluates the expression of estrogen receptor isoforms alpha (ERα) and beta (ERβ), progesterone receptor (PR), and relaxin receptor isoforms 1 and 2 (LGR7, LGR8) in uterosacral ligament (USL) tissue of women with pelvic organ prolapse and controls.

METHODS

Tissue samples of USL from women with and without pelvic organ prolapse (POP) were subjected to immunohistochemistry against ERα, ERβ, PR, and LGR7 proteins. The respective mRNA expression as well as of LGR8 was assessed by quantitative real-time polymerase chain reaction.

RESULTS

The cellular distribution of the receptor proteins was different due to cell types, independent of POP: ERα and PR were found in smooth muscle cells, but not in endothelial cells, whereas ERβ was found in endothelial cells, but not in connective tissue. ERα, ERβ, PR, and LGR7 mRNAs could be detected in all patients of both groups. ERα mRNA expression was significantly and ERβ mRNA borderline significantly higher in USL of patients with POP: ERα: p < 0.001, ERβ: p = 0.057.

CONCLUSIONS

Enhanced effects of estrogen via altered mRNA expression patterns of ERα and ERβ--but not those of progesterone--may exist in USL of patients affected by POP. A local effect of relaxin needs to be further clarified because of this first report of prevalent ligamental expression of LGR7.

Differential elastin and tenascin immunolabeling in the uterosacral ligaments in postmenopausal women with and without pelvic organ prolapse

Connective tissue, consisting mainly of collagen and structural glycoproteins, is an important part of the supportive structures of the genitourinary region. Relatively few data have been published with respect to the role of elastin and glycoproteins in pelvic organ prolapse (POP). Connective tissue of the uterosacral ligament in postmenopausal women with and without genital prolapse was compared. Fifty-nine consecutive women referred for hysterectomy were included in the study. The patients had POP or benign gynecological disease (e.g. myoma of the uterus). Tissue samples from the uterosacral ligament were investigated for localization and distribution of tenascin and elastin using immunofluorescence microscopy. Tissue samples of women with prolapse showed a significantly (p<0.001) weaker immunofluorescent labeling of tenascin compared to samples taken from women without prolapse. Tenascin was detectable in tissues of all women with POP, whereas its immunolabeling was decreased in the uterosacral ligament in women without POP. Intact elastin fibers were observed in tissues of all women without POP, whereas elastin was undetectable or sometimes fragmented in the uterosacral ligament in women with POP. Greater amounts of tenascin and lesser amounts of elastin were therefore found in patients with POP. These results suggest that an altered turnover of connective tissue in the uterosacral ligament might be responsible for the presence of pelvic floor relaxation in postmenopausal women. These data indicate a complex architecture of the extracellular matrix in the uterosacral ligaments, with marked differences in tenascin and elastin expression between postmenopausal women with or without POP.

17β-Estradiol suppresses proliferation of fibroblasts derived from cardinal ligaments in patients with or without pelvic organ prolapse

BACKGROUND

Estrogen replacement therapy (ERT) has been used in the treatment of pelvic organ prolapse (POP) but clinical results are inconclusive. The purpose of this study was to investigate the effect of 17beta-estradiol (E(2)) on the proliferation of fibroblasts derived from cardinal ligaments in women with or without POP.

METHODS

Fibroblasts were derived from seven patients with POP and seven age-matched controls. The growth rate of POP fibroblasts was compared with that of control by 3-(4,5,-dimethyl thiazolyl-2)-2,5-diphenyl tetrazolium bromide (MTT) assay. Four cell strains from each patient and control group were treated with different concentrations of E2 (10(-4), 10(-8), 10(-9) and 10(-10) mol/l). The effect of E2 on cell proliferation was then measured by MTT assay.

RESULTS

The overall growth rate of POP fibroblasts was significantly slower than that of controls under normal culture conditions. Addition of E2 suppressed cell proliferation of all the fibroblasts, especially in POP fibroblasts. POP fibroblasts showed a significantly lower proliferative rate than that of controls at all E2 concentrations, with the most prominent inhibitory effect at physiological concentration (10.83 34.41% versus 81.56 48.10% at 10(-8) mol/l).

CONCLUSIONS

Our results suggest that decreased fibroblast turnover may contribute to the development of POP; and ERT may not be an effective POP treatment.

Different expression of calpains in the anterior vaginal wall of women with and without uterovaginal prolapse

OBJECTIVE

Tissue ischemia-hypoxia can activate the calpain proteolytic system. Mechanical trauma to the upper vaginal wall and pelvic floor could compromise vascular perfusion and could also result in calpain expression. The aims of this investigation were to assess the expression messenger RNA and proteins for m-calpain and micro-calpain in the vaginal walls of women with and without uterovaginal prolapse.

METHODS

The anterior vaginal walls of 22 women with and without uterovaginal prolpase were evaluated using a reverse transcription polymerase chain reaction and western blotting for detecting calpain expression.

RESULTS

The number of messenger RNA transcripts of m- and micro-calpain was significantly less in women with uterovaginal prolapse than in women without uterovaginal prolapse (two of 11 and zero of 11 versus eight of 11 and five of 11, P < .05). All women had m-calpain protein expression in the anterior vaginal wall. However, the concentration of m-calpain protein was less, but not significantly different, in women with uterovaginal prolapse than in the women without uterovaginal prolapse (0.386 +/- 0.018 versus 0.439 +/- 0.011 optical density/mm2, P > .05). None of the women with uterovaginal prolapse had expression of micro-calpain mRNA or protein (zero of 11). Expression of protein of calpains in the anterior vaginal wall is not consistent with mRNA transcripts.

CONCLUSION

Calpain expression may be compromised in the anterior vaginal wall of women with uterovaginal prolapse who have abnormal histologic changes in the vaginal connective tissues or have anterior vaginal laxity.

Pelvic floor dysfunction: a conceptual framework for collaborative patient-centred care

BACKGROUND

Pelvic floor dysfunction is a disorder predominantly affecting females. It is common and undermines the quality of lives of at least one-third of adult women and is a growing component of women's health care needs. Identifying and supporting these needs is a major public health issue with a strong psychosocial and economic basis. The importance of the interdependence of mechanical, neural, endocrine and environmental factors in the development of pelvic floor dysfunction is well recognized. There is a paucity of data investigating the true prevalence, incidence, specific risk factors, poor outcome of treatment and subsequent prevention strategies for women with multiple pelvic floor symptomatology.

AIM

The aim of this paper is to present a critical review of the literature on the mechanism, presentation and management of multiple symptomatology in pelvic floor dysfunction and to propose a conceptual framework by which to consider the impact and problems women with pelvic floor dysfunction face.

METHODS

A comprehensive although not exhaustive literature search was carried out using medical and nursing databases BIOMED (1966-2002) NESLI (1989-2002) and EMBASE (1980-2003) CINAHL (1982-2003) and Cochrane databases using the key words 'pelvic floor dysfunction', 'incontinence (urinary and faecal)', 'genital prolapse', sexual dysfunction, 'aetiology', epidemiology' and 'treatment'. Retrospective and prospective studies and previous clinical reviews were considered for review. The articles retrieved were hand searched for further citations and referrals were made to relevant textbooks. Particular attention was paid to papers that focused on multiple pelvic floor symptoms.

FINDINGS

Pelvic floor dysfunction affects women of all ages and is associated with functional problems of the pelvic floor. Pelvic floor dysfunction describes a wide range of clinical problems that rarely occur in isolation. Inaccurate knowledge, myths and misconceptions of the incidence, cause and treatment of pelvic floor dysfunction abound. Given the significance of the aetiological contribution of factors such as pregnancy and obstetric trauma, ageing, hormonal status, hysterectomy and lifestyle in the development of pelvic floor disorders, the assessment, management and prevention of pelvic floor dysfunction remains a neglected part of many health care professionals educational preparation. This not only has major economic but also psychosocial implications for women, the general population and women's health care providers. A conceptual framework is also discussed that considers not only the impact and difficulties women with pelvic floor dysfunction face but also areas in which health care professionals can improve assessment and eventual treatment outcomes.

CONCLUSION

This paper demonstrates gaps in the current provision of women's health care services. Functional pelvic floor problems are perceived to have low priority compared with other health disorders, and treatment remains sub-optimal. Inherent in achieving and promoting better health care services for women is the need for better collaborative approaches to care. There is a need to identify and develop comprehensive interdisciplinary, multi-professional strategies that improve the assessment and treatment of pelvic floor dysfunction in primary, secondary and tertiary settings. If this area of women's health care is to be improved nurses, whether community- or hospital-based, must play a front-line role in challenging and changing current practices. Education needs to be given greater priority and the development of a specialist pelvic floor nurse role explored. Such strategies could substantially influence a more effective approach to women's health care needs, result in improved treatment outcomes and liberate women from the embarrassment, social and sexual isolation, restriction to employment and leisure opportunities and potential loss of independence that multiple symptomatology can generate.