Pelvic Organ Prolapse Group Research Articles

Association between pelvic organ prolapse and bone mineral density in postmenopausal women

Both pelvic organ prolapse (POP) and osteoporosis are age-related diseases in older aged women. Both POP and bone metabolism may be associated with collagen metabolism. Our study determined the relationship between POP and bone mineral density (BMD) of the lumbar spine and femur neck in postmenopausal women. We selected 554 postmenopausal women (aged 50–79 years) and divided them into two groups (moderate to severe POP and absent to mild POP). We compared the BMDs of the lumbar spine and femur neck between the moderate to severe POP and absent to mild POP groups. Lumbar spine BMD was inversely correlated with POP severity (p = 0.001). However, after adjusting for age, time since menopause, height, weight, body mass index (BMI), and vaginal delivery, the BMDs of both the lumbar spine and femur neck were not significantly different between the moderate to severe POP and absent to mild POP groups (p = 0.583 and p = 0.305, respectively). A lower BMD is associated with increased fracture risk and we postulated that women with severe POP would have an increased risk of osteoporotic fracture.

HOXA11 and MMP2 gene expression in uterosacral ligaments of women with pelvic organ prolapse.

Pelvic organ prolapse (POP) is a common disorder that negatively impacts the quality of life in many women. Uterosacral ligaments (USLs) are supportive structures of the pelvic organs that are often attenuated in women with POP. The HOXA genes regulate the development of the uterosacral ligaments. We compared expression of HOXA11 and MMP2 in USLs of women with and without POP. A prospective sequential cross sectional study was conducted in ZTB Women's Health Research and Education Hospital. We compared expression of HOXA11 and MMP2 in USLs of women with (n:18) and without (n: 15) POP. Total RNA was isolated from patient (n:18) and control (n:15) uterosacral ligament tissues with TriPure isolation reagent according to the manufacturer's instructions. Expression levels of HOXA11 and MMP2 were determined using semiquantitative RT-PCR in a Light Cycler 480 system. Real-time ready catalog assays, which are short FAM-labeled hydrolysis probes containing locked nucleic acid, were used for RT-PCR reactions. There was no difference in patients' mean age, parity, body mass indexes, and menopausal status between two groups. Means of RNA expression of MMP2 were 1.27±0.6 and 0.75±0.4 in the POP group vs control group, respectively (p:0.007). Means of RNA expression of HOXA 11 were 2.57±2.4 and 1.94±1.4 in the POP group vs control group, respectively (p:0.376). The POP group was divided as mild and severe POP; there was no difference in HOXA11 and MMP2 RNA expression between groups (p>0.05). Although there was no difference HOXA11 RNA expression in USLs with the POP group vs control, there was a significant difference MMP2 RNA expression in USLs with the POP group vs control. There are limited studies on this subject, and study results are contradictory. Further investigations with larger numbers of cases are needed to clarify this subject.

Alteration of apoptosis-related genes in postmenopausal women with uterine prolapse

We aimed to compare expression levels of antiapoptotic and proapoptotic genes in parametrial and vaginal tissues from postmenopausal women with and without pelvic organ prolapse (POP). We hypothesized that the expression of genes that induce apoptosis may be altered in vaginal and parametrial tissues in postmenopausal women with POP. Samples of vaginal and parametrial tissues were obtained from postmenopausal women with (n = 10) and without (n = 10) POP who underwent vaginal or abdominal hysterectomy. Expression levels of antiapoptotic (BCL-2, BCL-XL) and proapoptotic (BAX, BAD) genes were studied by real-time reverse-transcription polymerase chain reaction (RT-PCR). Gene expression levels of BCL-2 (P < 0.001), BCL-XL (P < 0.001), BAX (p = 0.001), and BAD (p = 0.004) were all higher in vaginal tissues from the POP group compared with the non-POP group. Similarly, gene expression levels of BCL-2 (p < 0.001), BCL-XL (p < 0.001), BAX (p < 0.001), and BAD (p < 0.001) in parametrial tissues were also significantly higher in the POP group compared with the non-POP group. Additionally, expression levels of BCL-2 (p = 0.05), BCL-XL (p < 0.05), BAX (p = 0.05), and BAD (p = 0.07) in the POP group were higher in parametrial tissue than in vaginal tissue samples. Antiapoptotic and proapoptotic gene expression levels differed significantly between postmenopausal women with and without POP. Bcl-2 family genes were overexpressed in the parametrium of patients with POP compared with vaginal tissue, suggesting that the processes responsible for POP have a greater effect on parametrial tissue than vaginal tissue during the development of POP.

The Association of Vaginal Wind and Abdominal Striae with Pelvic Organ Prolapse

Objectives: Little is known about involuntary passage of air from the vagina, also known as vaginal wind, garrulous vaginalis, and other slang terms. Similarly, minimal data exist regarding the potential association between abdominal wall striae and pelvic organ prolapse (POP). The objective of this study was to describe the presence of vaginal wind and striae in patients with and without POP. Materials and methods: This was an IRB approved cross-sectional study of women R18 years seeking care at a single academic institution between December 2012 and August 2013. We excluded women with rectovaginal fistulae, prior POP or incontinence surgery, pregnancy, and the inability to complete forms. After obtaining informed consent, all patients completed a questionnaire about vaginal wind and striae, the Pelvic Floor Distress Inventory Short Form (PFDI-20), and the revised Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-IR). Additionally, POP-Q data, mid-vaginal width, and quantification of abdominal striae were recorded. Women were dichotomized into normal support (POP-Q stage 0-1) or POP (POP-Q stage 2-4) groups for analysis. Forty-six patients were needed in each group to detect a 13% difference in the prevalence of vaginal wind between groups with an a of 0.05 and power of 80%. Results: One hundred thirty-two patients were approached for participation. One hundred twenty-three patients (93%) agreed to participate, of which 110 (83%) completed study questionnaires. The mean age was 55.5 years and mean BMI was 27.5. The majority were white (65%), married (73%), sexually active (71%), and had a college education (76%). Fifty-one of 110 patients (46%) had normal support while 59/110 (54%) had POP. Those with POP had more vaginal deliveries (mean 2.4 vs. 1.3, p 0.001). There was no difference in medical comorbidities, smoking status, or steroid use between groups (p > 0.05 for all). Overall, 76/110 (69%) women experienced vaginal wind an average of 2.3 times per week and this was not statistically significant between groups (p = 0.47). Ninety-nine percent of women with vaginal wind experienced it during intercourse. Other activities associated with vaginal wind included cunnilingus (45%), digital stimulation (17%), jogging (45%), and sit-ups (44%). Sixty-four percent of women were at least somewhat bothered by vaginal wind, although only 22% reported a negative effect on quality of life. Women with vaginal wind had a longer mean vaginal length (9.5 vs. 8.8 cm, p = 0.004) and better apical support than those without vaginal wind (C -5.1 vs. -3.0 cm, p = 0.02). There was no difference in midvaginal width or other POP-Q points (p > 0.05 for all). Sixty-five of 110 (59%) women had striae: 23/51 (45%) with normal support and 42/59 (71%) with POP (p = 0.006). Women with POP were more likely to have striae compared to women with normal support, adjusting for skin color and smoking status (OR = 2.5, 95% CI, 1.036.06, p = 0.04). Conclusion: Vaginal wind is a common and bothersome complaint among women with and without POP and is associated with a longer total vaginal length and better apical support. Women with POP are more likely to have striae. Future studies are needed to further investigate these findings with regard to the impact on care-seeking and surgical intervention. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS:

Association between susceptibility to advanced pelvic organ prolapse and glutathione S-transferase P1 Ile105Val polymorphism

ObjectiveOxidative stress is associated with the pathogenesis of pelvic organ prolapse (POP). Because glutathione S-transferases (GSTs) are the major detoxification enzymes which protect cells against oxidative stress, genetic variations in the GST gene may modulate the risk of POP. This study aimed to determine the association between advanced POP and the polymorphisms of GSTM1, GSTT1 and GSTP1 (rs1695). Study designThis is a hospital-based case-control study. The POP group consisted of 189 women diagnosed with POP stage III or IV, and the control group consisted of 156 postmenopausal women with POP stage 0 or I. The GSTM1 and GSTT1 null mutations were detected by multiplex PCR, and the GSTP1 Ile105Val polymorphism was genotyped by real-time PCR analysis using a TaqMan assay. ResultsThere was no significant association between the GSTM1 and GSTT1 null mutations and advanced POP (p>0.05). The distribution of the GSTP1 Ile105Val genotypes, however, was significantly different between the POP and control groups (AA/AG/GG rates=74.1%/25.9%/0% vs. 64.1%/32.1%/3.8%, p=0.008), and the G allele frequency was significantly lower in the POP group than in the control group (13.0% vs. 19.9%, p=0.014). Women with the non-AA genotype had a 0.63-fold lower risk of developing advanced POP than women with the AA genotype (95% CI, 0.39–0.99), and women with the G allele had a 0.60-fold lower risk of advanced POP than women with the A allele (95% CI, 0.40–0.90). ConclusionsThe GSTP1 Ile105Val polymorphism is a protective factor against advanced POP.

Association between the poly(ADP-ribose) polymerase-1 gene polymorphism and advanced pelvic organ prolapse

Apoptotic cell death, probably induced by oxidative stress, contributes to the development of pelvic organ prolapse. Because poly(ADP-ribose) polymerase-1 is an important mediator of cellular response to oxidative stress, genetic variations in the poly(ADP-ribose) polymerase-1 gene may play a role in the pathogenesis of pelvic organ prolapse. This study aimed to determine the association between advanced pelvic organ prolapse and Val762Ala polymorphism in the poly(ADP-ribose) polymerase-1 gene. A total of 340 women were enrolled in the study. The pelvic organ prolapse group consisted of 185 women with stage III or IV pelvic organ prolapse, whereas the control group consisted of 155 postmenopausal women with stage 0 or I pelvic organ prolapse who visited the hospital for treatment of benign gynecologic disease or routine gynecologic checkup. Genotyping of the poly(ADP-ribose) polymerase-1 Val762Ala polymorphism was performed by real-time polymerase chain reaction analysis using a TaqMan assay. Genotype distribution in the pelvic organ prolapse group was different from that in the control group (P = 0.024). Furthermore, C-allele frequency was lower in the pelvic organ prolapse group than in the control group (P = 0.029). Women with the CC genotype had a 0.461-fold lower risk of developing advanced pelvic organ prolapse than women with the TT genotype (95% CI, 0.245-0.870; P = 0.017), and women with the C-allele had a 0.716-fold lower risk of developing advanced pelvic organ prolapse than women with the T-allele (95% CI, 0.527-0.973; P = 0.033). These findings suggest that the poly(ADP-ribose) polymerase-1 Val762Ala polymorphism is associated with a decreased risk of advanced pelvic organ prolapse.

Relationship between the expressions of mitofusin-2 and procollagen in uterosacral ligament fibroblasts of postmenopausal patients with pelvic organ prolapse

ObjectivesTo compare the mRNA and protein expressions of mitochondrial fusion protein-2 (mitofusin-2, Mfn2), and procollagen 1A1/1A2/3A1 in uterosacral ligament fibroblasts of postmenopausal patients with or without pelvic organ prolapse (POP). The effect of Mfn2 on the expression of procollagen in fibroblasts was also investigated. Study designThirty-seven POP patients and 23 non-POP postmenopausal patients were included in the POP (study) and non-POP (control) groups, respectively. Laser capture microdissection (LCM) was combined with quantitative real-time polymerase chain reaction (qRT-PCR) and western blotting to detect the mRNA and protein expressions of Mfn2, and types I and III procollagen in uterosacral ligament fibroblasts of the two groups, and the differences in expression levels were compared between the groups. The correlation between Mfn2 and procollagens was also investigated. ResultsFibroblasts were successfully isolated from frozen sections of the uterosacral ligament using LCM. The results of qRT-PCR and western blot showed that the expressions of types I and III procollagen were significantly lower and those of Mfn2 were significantly higher in the POP group than in the non-POP group (p<0.05, all). In POP, opposite trends of protein expression changes of Mfn2 and procollagens were observed along with the duration of postmenopause (P<0.05), while this was not the case in POP accompanied by stress urinary incontinence and frequency of vaginal delivery (P>0.05). The expressions of type I and III procollagen were negatively associated with Mfn2 in POP patients (−1<r<0, P<0.001, all). ConclusionsMfn2 expression changed along with the duration of postmenopause and had a negative association with the expression of procollagens. Our results suggest that the Mfn2 protein may affect the synthesis of procollagen of fibroblasts in postmenopausal patients with POP. Changes in Mfn2 and procollagen expression may play a role in the development of POP.

Expression of matrix metalloproteinase-1 in round ligament and uterosacral ligament tissue from women with pelvic organ prolapse

To evaluate the matrix metalloproteinase-1 (MMP-1) expression in different parts of pelvic connective tissue in postmenopausal women with and without pelvic organ prolapse (POP). Ninety-one samples were obtained from only postmenopausal women (42 with POP and 49 non-POP subjects). All women were evaluated by pelvic organ prolapse quantitation. The POP group had stage 2 or more, and the controls had stage 1 or less. Round ligament (RL) and uterosacral ligament (USL) biopsies were obtained from women with POP and controls. Immunohistochemistry for MMP-1 was performed on formalin-fixed and paraffin-embedded sections. The two groups were matched for age, body mass index, parity and postmenopausal status. MedCalc Statistical Software Programme Version 12.0.5 was used for statistical analysis. Expression of MMP-1 were significantly higher in both RL and USL tissue from postmenopausal women with POP, compared with controls. MMP-1 immunoreactivities were identified in both RL and USL biopsies from all women with and without POP. The expression pattern of MMP-1 were similar in these ligaments and were significantly higher in POP group compared with control subjects. These changes indicate a possible relation between MMP-1 expression of RL and USL in women with and without POP.

Genes responsible for vaginal extracellular matrix metabolism are modulated by women's reproductive cycle and menopause

To analyze the expression of genes involved in extracellular matrix (ECM) biogenesis and remodeling in vaginal tissue of women with clinically normal pelvic floor support (defined as controls) according to the phase of menstrual cycle and postmenopausal women with and without pelvic organ prolapse (POP). This study examined the expression of matrix metalloproteinases (MMPs), their tissue inhibitors (TIMPs), and the Lysyl oxidase (LOX) family genes in the anterior vaginal wall of Caucasian women by real-time RT-PCR. Initially, mRNA expression was assessed in premenopausal controls in the secretory (group 1, n = 10) vs. proliferative (group 2, n = 8) phase of menstrual cycle. In addition, we compared premenopausal controls in the proliferative phase (group 2) vs. postmenopausal controls (group 3, n = 5). Finally, we analyzed postmenopausal controls (group 3) vs. postmenopausal women with advanced POP (group 4, n = 13). According to the phase of menstrual cycle, MMP1 was significantly reduced (p = 0.003), whereas the expression of TIMP1 and LOXL4 was significantly up-regulated during proliferative phase (both p < 0.01) when compared to the secretory phase in premenopausal control women. Regarding menopausal status/ageing, all MMPs were down-regulated, while TIMP3, TIMP4 and LOXL2 were significantly up-regulated in postmenopausal control women when compared to premenopausal controls (p = 0.005, p = 0.01 and p < 0.001, correspondingly). TIMP4 and LOXL2 mRNA levels were significantly decreased in postmenopausal POP patients compared to asymptomatic postmenopausal controls (p < 0.01 for both). Our results indicate that ovarian cycle and age-related changes influence the expression of genes encoding proteins responsible for ECM metabolism in human vagina. Moreover, POP is associated with alteration in vaginal ECM components after menopause.

Etiological study of pelvic organ prolapse and stress urinary incontinence with collagen status and metabolism

To explore the alteration of collagen ultrastructure and content in uterine ligaments and paraurethral tissue and explore whether the alteration may contribute to stress urinary incontinence (SUI) and pelvic organ prolapse (POP). The cardinal ligament, uterosacral ligament and paraurethral tissue samples were obtained from 90 subjects undergoing hysterectomy. Collagen ultrastructure was examined with transmission electron microscopy. And collagen content and expression of vasoactive intestinal peptide (VIP) were examined with immunohistochemistry. The smooth muscle fascicles were thinner in the patients of SUI and POP. Arrangement of smooth muscle fascicles was disorderly. Fibroblast was metabolically active. The mean collagen fibril diameters in the SUI and POP groups were larger than that in the control group (P < 0.01). The mean contents of collagen I and III in the SUI and POP groups were lower than that in the control group (P < 0.01). The expression of VIP was lower (P < 0.05). Predominance of collagen degradation during tissue repair may contribute to and promote POP and SUI. The decrease of VIP might be related with nerve damage or degeneration to cause or accelerate the progress of pelvic organ prolapse.

Expression and significance of lysyl oxidase-like 1 and fibulin-5 in the cardinal ligament tissue of patients with pelvic floor dysfunction

Pelvic organ prolapse (POP) is a disabling disorder in women characterized by a loss of pelvic floor support, leading to the herniation of the uterus into or through the vagina. POP is a complex problem that likely involves multiple mechanisms with limited therapies available, and is associated with defects in connective tissue including elastic fibers. This study was designed to investigate the expression of fibulin-5 and lysyl oxidase-like 1 (LOXL1) in the cardinal ligament in samples taken from the POP group compared to the non-POP group. Specimens were obtained during abdominal hysterectomy from the cardinal ligament of 53 women with POP and 25 age- and parity- matched women with non-POP among post-menopausal women with benign gynecologic pathology. Protein expression was evaluated using the immunohistochemical staining method. For statistical analyses, chi-square test and Spearman's correlation were used with the statistical package SPSS13.0 system. Our results showed that both fibulin-5 and LOXL1 expressions were decreased in the cardinal ligament in the POP group compared to the non-POP group (P < 0.05). The expression of fibulin-5 and LOXL1 were correlated closely with the stage of POP, accompanied by stress urinary incontinence and frequency of vaginal delivery (P < 0.05), but had no relationship with post-menopausal state (P > 0.05). The expression of fibulin-5 was positively associated with LOXL1 in POP (P < 0.05). We conclude that changes in fibulin-5 and LOXL1 expression may play a role in the development of POP.

Pelvic organ prolapse contributes to sexual dysfunction: a cross‐sectional study

To evaluate the effect of pelvic organ prolapse (POP) on female sexual dysfunction. Cross-sectional, observational study. Gynecological outpatient and urogynecological university clinics in Greece. One hundred and one women with POP seen in the urogynecology clinic (study group) and 70 women without POP seen in the gynecology outpatient department (control group). Women with and without POP completed a condition-specific sexual dysfunction questionnaire (DYSQ) comprising four domains: sexual behavior; physical problems other than urinary incontinence; urinary incontinence problems; and satisfaction. Pelvic organ prolapse was assessed by the International Continence Society Pelvic Organ Prolapse Quantification System grading system. The primary outcome of the study was the assessment of sexual function by DYSQ in women with and without POP. We compared sexual function in women with and without POP and evaluated the extent of the effect of various grades of POP on sexual function. One hundred and seventy-one women were recruited, 101 in the POP group and 70 in the control group. The total and factor-specific DYSQ scores in the POP group were worse than those in the control group (p < 0.001) but did not seem to worsen with an increasing grade of prolapse. Linear regression showed that the best model to describe the DYSQ score includes the presence of POP and years of menopause. These variables explain 15.6% of the total variability in DYSQ scores. The presence of prolapse only partly explains impaired sexual functioning in women with POP. Sexual dysfunction is related to the presence of POP and not the grade of POP.

Decreased expression of elastin, fibulin‐5 and lysyl oxidase‐like 1 in the uterosacral ligaments of postmenopausal women with pelvic organ prolapse

Pelvic organ prolapse is associated with defects in connective tissues, including elastic fibers. The purpose of this study was to investigate the expression of fibulin-5 and lysyl oxidase-like 1 (LOXL1), which play an essential role in the synthesis and assembly of elastic fibers, in the uterosacral ligaments of women with advanced pelvic organ prolapse (POP) compared with controls. Specimens were obtained prospectively during transvaginal or abdominal hysterectomy from 30 women with advanced pelvic organ prolapse and 30 controls matched to the POP group for age and parity among postmenopausal women with benign gynecologic diseases. The expressions of elastin, fibulin-5 and LOXL1 in uterosacral ligaments were measured by immunohistochemistry. We detected a decreased, sometimes absent, expression of fibulin-5 and LOXL1 in the uterosacral ligaments of women with POP, despite a positive expression of elastin. There was a decrease in positive percentage of LOXL1 in the POP group (23.3%) compared with the controls (60%) (P = 0.004). With immunolabeling intensity classified as negative, weak, moderate or strong, there was a decrease in the expression of fibulin-5 in the POP group (P = 0.049). We also detected a significantly decreased expression of LOXL1 in the POP group (P = 0.001). There was decreased expression of fibulin-5 and LOXL1 in the uterosacral ligaments of patients with pelvic organ prolapse, while the elastin expression was equivalent, which may suggest the possibility of defects in elastic fiber remodeling in the postpartum period and contribute to POP.

Diagnostic delay in secondary care for lower urinary tract and pelvic organ prolapse symptoms in women

Many women suffering from lower urinary tract symptoms (LUTS) and pelvic organ prolapse (POP) symptoms. However, only a fraction actually seeks medical advice shortly after the onset of these symptoms. In this study, we sought to evaluate and compare the delay in seeking medical help in this patient population. A prospective cohort study was performed among 223 consecutive women who were referred to the urogynecology outpatient clinic for secondary assessment of LUTS and POP symptoms. The exclusion criteria included previous evaluation for the same symptoms, inability to communicate, or refusal to participate in the study. Each patient completed a detailed questionnaire of all pelvic floor symptoms (urinary, bowel and prolapse and sexual). Delay was measured from the time the symptoms were first noted by the patient to the first visit to our clinic. Mean length of delay was 43.8 months without significant difference between the LUTS and POP groups. The symptoms affected daily activities in 41.7% of the total group with no significant between-group difference. The POP group had significant decrease in intercourse (11.8%) than the LUTS group (4.3%) (p = 0.043). The main reason for the delay was patients' delay in 65.9% of the total group with no significant between-group difference. About 22.5% of all women thought that their primary health physician was responsible for the delay and only 2.2% blamed the medical system for the delay. There is a significant delay in seeking secondary medical help in women with POP and LUTS.

Prevalence of and quality of life related to anal incontinence in women with urinary incontinence and pelvic organ prolapse

To investigate the prevalence of anal incontinence (AI) in woman with urinary incontinence (UI) and pelvic organ prolapse (POP). We also evaluated the impact on quality of life (QoL). One hundred and ninety patients with UI or POP and 73 controls were recruited. AI was investigated by the Wexner index and the prevalence rates were obtained in all groups. Patients with AI completed the Fecal Incontinence Quality of Life questionnaire (FIQL). QoL was assessed using the Medical Outcome Study 36-item Short Form Health Survey (SF-36). AI prevalence was 40.54% in the UI group and 27.91% in the POP group (p<0.0001). In the UI and POP groups correlations were found between the Wexner score and the domains of the FIQL and SF36. The UI group had higher prevalence of AI than the other groups. The AI adversely affected the QoL of patients.

Biochemical evaluation of the supporting structure of pelvic organs in selected numbers of premenopausal and postmenopausal Malaysian women

Pelvic organ prolapse (POP) is associated with menopause and changes in the proteins of the pelvic supporting system, but there is scant data on the precise alterations in Malaysian women. The aim of this study is to determine the differences in the extracellular matrices (ECM) of uterosacral ligaments in premenopausal and postmenopausal Malaysian women with or without POP. The observational study was conducted for 9 months in three general hospitals involving 30 women who underwent hysterectomies for various indications except for carcinoma of pelvic organs. Three groups were identified: Premenopausal women (Group 1), postmenopausal women without POP (Group 2), and postmenopausal women with POP (Group 3). Age, duration of menopause, body mass index (BMI), parity, and vaginal deliveries were documented. Only 21 samples of the uterosacral ligaments were stained immunohistochemically for collagen I and III, matrix metalloproteinases (MMPs) 1 and 2, elastin, and tenascin. Image J software analysis was utilized for quantification, while non-parametric statistics (Kruskal-Wallis with post-hoc Dunns Multiple Comparison test) was used for result analysis. The profile parameters were not significantly different except for mean age and duration of menopause in Group 3. Samples from Group 2 showed lower expression of almost all proteins except MMP1 and tenascin (higher) as compared to Group 1. The changes appeared to be exaggerated in Group 3, though statistically insignificant. A significant difference in the expression of ECM was apparent in postmenopausal subjects as compared to premenopausal (P=0.05), compromising the uterosacral ligament tensile strength. The findings are proven similar as those changes in women from other studies.

Sexual function and health-related quality of life following anterior vaginal wall surgery for stress urinary incontinence and pelvic organ prolapse

To assess female sexual function (FSF) and health-related quality of life (HRQOL) following anterior vaginal wall surgeries for stress urinary incontinence (SUI) and pelvic organ prolapse (POP). The retrospective study consisted of 116 patients. Chinese translations of the modified Lemack Questionnaire (not validated) and Pelvic Floor Distress Inventory-Short Form 20 were used to assess FSF and HRQOL, 3 months pre-operatively and 12-24 months (mean 16.8 months) post-operatively. Sixty-one (52.6%, 29 in SUI group and 32 in POP group) of patients were sexually active before and after the operation. Overall, 12 (19.7%, six in SUI group and six in POP group) reported an improvement in overall intercourse satisfaction, 21 (34.4%, 8 in the SUI and 13 in the POP group) were decreased and 28 (45.9%, 15 in SUI group and 13 in POP group) were unchanged. Incidence of coital incontinence decreased significantly in SUI group. Frequency of intercourse decreased, vaginal dryness and pain due to it and asymptomatic vaginal narrowing increased significantly, following the surgery in POP group. There were no statistically significant differences in the frequency of intercourse in SUI group, patients' perception of intercourse, frequency of orgasm and the importance of sex life in both groups. Partner discomfort remained unchanged. HRQOL improved significantly after the operation in both groups. There was no association between HRQOL and FSF in the post-operative period. In most patients, overall FSF did not impaired. All trans-anterior vaginal wall surgery positively impacted on the patients' HRQOL. A prospective study with validated questionnaire is necessary in future.

Increased expression of matrix metalloproteinase‐1 in uterosacral ligament tissue from women with pelvic organ prolapse

Mechanical stability of the urogenital tract depends on intact collagen fibers. Because of difficulties in quantitating collagen, some authors have investigated collagen breakdown by measuring matrix metalloproteinases expression. We biopsied 68 post-menopausal women during operation to evaluate matrix metalloproteinase-1 (MMP-1) expression in uterosacral ligament biopsies from women with pelvic organ prolapse (POP) (n = 34) and controls with normal pelvic support (n = 34). The controls were matched to the POP group by age, body mass index, parity and duration of postmenopausal state. Immunohistochemistry for MMP-1 was performed on formalin fixed and paraffin embedded sections. Women with POP had a significantly higher MMP-1 expression (p = 0.047) which confirms an association, although not a causal relation, between POP and increased MMP-1 expression.

Expression and significance of elastin and fibulin-5 in anterior vaginal tissue of women with pelvic organ prolapse

To investigate the expression and significance of elastin and fibulin-5 in anterior vaginal tissue of women with pelvic organ prolapse (POP). Between November 2006 and June 2008, 68 patients with POP underwent surgical treatment in Shengjing Hospital of China Medical University were enrolled in this study, who were classified into 10 patients with grade I, 21 patients with grade II, 25 patients with grade III and 12 patients with grade IV in accordance with pelvic organ prolapse quantitation (POP-Q). Meanwhile, 18 cases with early cervical cancer at stage of I b were treated by total hysterectomy and bilateral salpingo-oophorectomy, their anterior vaginal tissues were selected as controls. Immunohistochemical staining was performed to detect the expression of elastin and fibulin-5. (1) Elastin and fibulin-5 were mainly expressed at extracellular matrix(ECM). (2) The positive rate of fibulin-5 expression in anterior vaginal wall were 5% (2/37) in grade III/IV and 26% (8/31) in grade I/IV POP patients, which reached statistical difference (P = 0.035). However, no statistical different expression was found between postmenopausal (13%, 8/60) and non-menopausal patients (2/8), vaginal delivery < or =2 (19%, 5/27) and >2 patients (12%, 5/41, P > 0.05). (3) The positive rate of elastin expression in anterior vaginal wall in POP group was 31% (21/68), which was significantly lower than 72% (13/18) of control group (P = 0.002). Among POP group, 19% (7/37) of elastin expression in grade III/IV POP was significantly lower than 45% (14/31) in grade I/II of POP patients. However, no statistical difference was found between postmenopausal (30%, 18/60) and non-menopausal patients (3/8), vaginal delivery < or =2 (26%, 7/27) and >2 patients(34%, 14/41, P > 0.05). (4) In POP group, both positive expression of fibulin-5 and elastin of anterior vaginal wall was in 6 cases, both negative expression of fibulin-5 and elastin was in 43 cases. It was illustrated that elastin and fibulin-5 had an positive relationship (P = 0.031). The decreased expression of elastin and fibulin-5 was correlated with degree of POP, which indicated that elastin and fibulin-5 may play a role in the pathogenesis of POP.

Diminished vaginal HOXA13 expression in women with pelvic organ prolapse

Homeobox genes are transcriptional regulators that orchestrate embryonic development. The HOXA13 gene is responsible for the development of the vagina and regulates extracellular matrix constituents. We hypothesized that vaginal expression of HOXA13 may be decreased in women with pelvic organ prolapse (POP) and sought to determine if hypoestrogenism affects its expression. Biopsy specimens were obtained from the anterior apex of the vagina from women with and without POP. Immunohistochemistry and real-time polymerase chain reaction were used to determine HOXA13 expression in premenopausal controls, in premenopausal women receiving leuprolide acetate, and in premenopausal and postmenopausal women with POP. HOXA13 was expressed in all specimens. HOXA13 expression was 14-fold lower in premenopausal women with prolapse than in premenopausal controls (P < 0.001). In both POP groups, HOXA13 expression was lower than in the leuprolide group (P <or= 0.001). There were no differences in HOXA13 expression between premenopausal controls and women treated with leuprolide acetate (P = 1.0) or between the premenopausal and postmenopausal POP group (P = 1.0). Vaginal HOXA13 expression is diminished in women with POP compared with women with normal support. In women with POP, expression of HOXA13 was not affected by menopause. Expression of HOXA13 was also not affected by exposure to leuprolide acetate, suggesting that estrogen and HOXA13 work through separate pathways in the extracellular matrix metabolism of the vagina. Understanding genetic predispositions to developing POP may identify younger patients at risk who may benefit from preventive strategies such as weight loss or smoking cessation and not necessarily from estrogen therapy.