Stress Urinary Incontinence Group Research Articles

Microarray analysis of differentially expressed genes in vaginal tissues in postmenopausal women. The role of stress urinary incontinence

This study aimed to explore gene expression and their regulatory mechanisms in etiology of stress urinary incontinence (SUI). Tissue samples were taken from the paraurethral vaginal wall from three pairs of postmenopausal, age/body mass index/parity-matched SUI, and continent women and subjected to microarray analysis using the Affymetrix GeneChip® Human Genome U133 Plus 2.0 oligonucleotide chip set. The significantly differentially expressed genes and their protein expression were confirmed by quantitative PCR and Western blot. Seventy-five differentially expressed genes were listed; 31 genes were upregulated in SUI group, while 44 were downregulated. Gene metabolic pathway analysis showed that solutable N-ethylmaleimide-sensitive factor attachment protein receptor signaling pathway and neurodegenerative disorder pathway were the most predominant. Apolipoprotein E, growth factor receptor-bound protein 2, Golgi SNAP receptor complex member 1, and glucosidase, beta, acid may play a neurodegenerative role in SUI development.

Tension-Free Vaginal Tape—A Suitable Procedure for Patients With Recurrent Stress Urinary Incontinence

In a recent report, the 10-year reoperation rate for stress urinary incontinence (SUI) after primary failure of anti-incontinence surgery was 17%. A tension-free vaginal tape (TVT) procedure has been effective for primary surgical treatment of SUI and long-term results have been promising. A number of studies have investigated repeat surgery with TVT for recurrent SUI but only one—a retrospective study—used a control group. Moreover, the follow-up period after a repeat TVT has been short; there has been only one uncontrolled prospective 4-year study. This prospective follow-up study investigated the use of the TVT procedure in women with recurrent SUI and those with primary SUI with respect to cure rates, complications, and safety. All participants had a TVT—60 in the study group (recurrent SUI)—and 70 in the control group (primary SUI). The initial follow-up was at 2 months after surgery and patients completed a questionnaire 3 years later evaluating the success of the operation and urinary symptoms. At a mean of 8 years (range, 6–10 years), patient records were examined for data on any subsequent visits or additional surgery. The primary outcome measures were subjective cure, complications, and voiding symptoms. The rate of transient postoperative retention was similar in the 2 groups (recurrent SUI, 17% vs. primary SUI, 19%, P = 0.78). No significant difference was found between the groups in the number of complications (recurrent SUI, 20% vs. primary SUI, 13%, P = 0.27). Spontaneous micturition resumed in all patients by the 10th postoperative day. At the 2-month follow-up visit, 85% of the patients in recurrent SUI group and 94% of those in the primary SUI group were free of SUI and completely satisfied with the outcome (P = 0.096). These data were almost identical at 3 years. Major complications following surgery were rare. At 2 months, 22% of the recurrent SUI patients and 19% of the primary SUI patients had de novo urge symptoms (P = NS); at 3 years, the rate of voiding difficulties was 17% in the primary SUI group and increased to 33% in the recurrent SUI group (difference between groups, P = 0.037). Subjective voiding dysfunction (feeling of incomplete emptying with or without recurrent urinary tract infections) was reported by 5 patients (8.3%) in the recurrent SUI group and in 17 patients (24%) in the primary SUI group at 3 years after the operation (P = 0.022). These findings suggest that TVT is safe and effective when performed for primary or recurrent SUI. There are no apparent differences in cure and complication rates after TVT between patients with and without previous SUI surgery.

Postpartum stress urinary incontinence and associated obstetric factors

To evaluate the effect of cesarean section (CS) and vaginal delivery (VD) on postpartum stress urinary incontinence (SUI) and pelvic floor muscles strength and to find out the correlated obstetric factors and prevention for postpartum SUI. Totally, 788 women, who visited the antenatal clinics, delivered and had the follow-up at 6-8 weeks after delivery in Beijing Obstetrics and Gynecology Hospital in the year of 2008, were enrolled in this study and were divided into 3 groups: CS group (n = 212); normal vaginal delivery (NVD) group (n = 534) and forceps delivery (FD) group (n = 42). Women in the NVD and FD group were merged into one VD group and then divided into SUI and non-SUI group. Information of delivery mode and the correlated obstetric factors were obtained through questionnaires and medical records. Femiscan pelvic floor muscle examine system was applied to measure the pelvic floor muscle strength to understand the relationship between postpartum SUI and pelvic floor muscle strength. (1) Incidence of SUI: the overall proportion of women who complained of urinary incontinence (UI) during pregnancy was 15.4% (121/788), and it was 15.9% (85/534), 11.9% (5/42) and 14.6% (31/212) in the NVD, FD and CS group, respectively (P > 0.05). The overall incidence of postpartum SUI was 17.1% (135/788), and it was 19.1% (102/534), 26.2% (11/42) and 10.4% (22/212) in the NVD, FD and CS group, respectively, with significant difference between the NVD and FD group, and between the CS and NVD group (all P < 0.01). (2) The associated obstetric factors of postpartum SUI: among the VD group, 113 women were in the postpartum SUI group and 463 in the non-SUI group. Univariate analysis and logistic multivariate analysis showed that delivery mode, neonatal birth weight and UI during pregnancy were risk factors of postpartum SUI. CS decreased and higher neonatal birth weight and UI during pregnancy increased the risk of postpartum SUI. In the VD group, neonatal birth weight, forceps delivery and UI during pregnancy increased the incidence of postpartum SUI (P < 0.01), but no correlation was found with labor analgesia, duration of labor, episiotomy, breast feeding, volume of postpartum bleeding, gestational weeks at delivery, induction and pre-pregnant BMI, etc (all P > 0.05). (3) Pelvic floor electromyogram: pelvic floor muscles strength in the CS group was significantly higher than that of the VD group [activity value: (19.7 +/- 9.9) microv vs (14.8 +/- 8.4) microv; work value: (84.5 +/- 37.2) microv vs (78.8 +/- 28.2) microv; peak value: (25.5 +/- 12.5) microv vs (19.7 +/- 11.8) microv, all P < 0.01]. Among women in the VD group, the relaxation value and the ratio of relaxation value over activity value (r/a) in the postpartum SUI group were significantly lower than those in the non-SUI group [relaxation value: (1.7 +/- 1.8) microv vs (3.0 +/- 3.9) microv; r/a ratio: 0.2 +/- 0.2 vs 0.3 +/- 0.5, all P < 0.01]. The r/a ratio in the VD group showed no difference compared to that in the CS group (0.2 +/- 3.5 vs 0.2 +/- 0.2, P > 0.05). Women experienced vaginal delivery, either NVD or FD, have a higher incidence of postpartum SUI than those delivered through CS. UI during pregnancy, forceps delivery and neonatal birth weight are risk factors of postpartum SUI.

Tension‐free vaginal tape – a suitable procedure for patients with recurrent stress urinary incontinence

To evaluate the efficacy of the tension-free vaginal tape operation (TVT) in patients with and without previous anti-incontinence surgery. Prospective follow-up study. University hospital in Finland. A total of 130 women who had a TVT procedure from August 1998 to December 2002. Subjective cure, complications and voiding symptoms. Sixty women with recurrent (group A) and 70 women with primary stress urinary incontinence (SUI) (group B) were compared. One follow-up visit took place two months postoperatively and a questionnaire-based evaluation was carried out three years after operation. Further information was collected a mean of eight years after the operation. There was no difference in the transient postoperative retention rate (17 vs. 19%, p = 0.78) and number of complications (20 vs. 13%, p = 0.29) between group A and group B. At two months after operation, 85% of patients in group A and 94% in group B were cured of SUI and were satisfied with the operative result (p = 0.096). The satisfaction rates at three years were 86 and 91% in groups A and B, respectively, and cure rate of SUI was 93% in both groups. At follow-up, 20% of the patients in group A and 5.7% in group B (p = 0.013) had de novo urge symptoms and the rate of voiding difficulties increased especially in group B women over time. TVT results in the same cure and complication rates when performed for primary SUI and recurrent SUI. The procedure is effective and associated with a low and acceptable level of complications. It is well suited to treat also recurrent SUI.

Women with stress urinary incontinence demonstrate motor control differences during coughing

Introduction This study compared the patterns of pelvic floor muscle (PFM) activity during coughing between women with stress urinary incontinence (SUI) and continent women, using surface electromyography (EMG) and posterior vaginal wall (PVW) pressure. Methods Twenty-four women participated: eight continent, eight with mild SUI and eight with severe SUI. Volunteers performed three maximum coughs in supine and standing. Maximum PFM EMG and PVW pressure amplitudes and the timing of the EMG peak relative to the PVW pressure peak were determined. Ensemble average PVW pressure versus EMG curves were created. Results There were no significant differences among the groups in the maximum EMG or PVW pressure amplitudes. The EMG and PVW pressure peaked simultaneously in both positions in the continent group. In the mild SUI group, the EMG and PVW pressure peaked simultaneously in supine, but the EMG peaked before the PVW pressure in standing. In the severe SUI group, the EMG peaked before the PVW pressure in both positions. The shapes of the PVW pressure versus EMG curves were similar among the groups and positions, however the SUI groups displayed higher EMG-intercepts than the continent women. Conclusion: These findings suggest that urine leakage during coughing in women with SUI may be related to delays in force generation rather than PFM weakness.

Mechanisms of Pelvic Floor Muscle Function and the Effect on the Urethra during a Cough

BackgroundCurrent measurement tools have difficulty identifying the automatic physiologic processes maintaining continence, and many questions still remain about pelvic floor muscle (PFM) function during automatic events. ObjectiveTo perform a feasibility study to characterise the displacement, velocity, and acceleration of the PFM and the urethra during a cough. Design, setting, and participantsA volunteer convenience sample of 23 continent women and 9 women with stress urinary incontinence (SUI) from the general community of San Francisco Bay Area was studied. MeasurementsMethods included perineal ultrasound imaging, motion tracking of the urogenital structures, and digital vaginal examination. Statistical analysis used one-tailed unpaired student t tests, and Welch’s correction was applied when variances were unequal. Results and limitationsThe cough reflex activated the PFM of continent women to compress the urogenital structures towards the pubic symphysis, which was absent in women with SUI. The maximum accelerations that acted on the PFM during a cough were generally more similar than the velocities and displacements. The urethras of women with SUI were exposed to uncontrolled transverse acceleration and were displaced more than twice as far (p=0.0002), with almost twice the velocity (p=0.0015) of the urethras of continent women. Caution regarding the generalisability of this study is warranted due to the small number of women in the SUI group and the significant difference in parity between groups. ConclusionsDuring a cough, normal PFM function produces timely compression of the pelvic floor and additional external support to the urethra, reducing displacement, velocity, and acceleration. In women with SUI, who have weaker urethral attachments, this shortening contraction does not occur; consequently, the urethras of women with SUI move further and faster for a longer duration.

Decreased gene expression of fibrillin‐1 in stress urinary incontinence

Studies to show impairments in the pelvic floor extracellular matrix (ECM) associated with stress urinary incontinence (SUI) has earlier been performed, but the results are contradictory. Collagen I and III, the elastin associated proteins fibrillin-1 and fibulin-5 and the small leucine-rich repeat proteoglycans (SLRPs) decorin, lumican and fibromodulin are involved in giving the tissue its mechanical properties. Their gene signals and tissue localizations were investigated. Para-urethral punch biopsies were obtained from 24 women, 12 pre- and 12 postmenopausals, during surgery for SUI. As controls, biopsies were collected from 14 women, 8 pre- and 6 postmenopausals, undergoing surgery for other benign conditions. The mRNA expression by real-time RT-PCR and protein localization by immunohistochemistry were analyzed concerning collagen I and III, the small leucine rich repeat proteoglycans (SLRPs) decorin, lumican and fibromodulin and the elastic fiber associated proteins fibulin-5 and fibrillin-1. Statistical comparisons controlled for age changes in gene expressions. A significant decrease in mRNA expression of fibrillin-1 was discovered in all SUI women compared to all controls, P = 0.03. All molecules were down-regulated by age, but no other differences between SUI and controls reached significance. All proteins were adequately expressed by immunohistochemistry. A weaker staining for fibrillin-1 was seen in the pre-menopausal SUI group compared to the pre-menopausal controls. A decreased gene signal and weaker immunoreactivity for fibrillin-1, important for the elastic fiber assembly, was discovered in women with SUI. Loss of tissue elasticity could lead to increased urethra hypermobility and SUI.

ARE RISK FACTORS FOR FAILURE AFTER MID-URETHRAL SLING OPERATION DIFFERENT BETWEEN PURE STRESS AND MIXED URINARY INCONTINENCE?

INTRODUCTION AND OBJECTIVES: While mid-urethral sling (MUS) operation has expanded its application to more complicated cases such as the patients with mixed urinary incontinence (MUI), the success rates in the patients with MUI have been reported lower than the patients with pure stress urinary incontinence (SUI). If the failure of operation is predicted in the patients with MUI, one could change the therapeutic modalities to obtain the best results regarding continence and the risk factors for failure could help the physicians to counsel the patients ahead of operation. We evaluated and compared the risk factors for failure after MUS operation between pure SUI and MUI. METHODS: Two hundred and twenty-eight women were categorized into pure SUI (Group A, 163 patients) and MUI (Group B, 65 patients). Preoperative evaluations including symptom questionnaire, physical examination and urodynamic study were performed. Patients received the retropubic (17.5%) or trans-obturator (82.5%) MUS operations. RESULTS: Follow-up for Group A and B were 18.8 months (3-52) and 19.2 months (3-54), respectively. The demographic characteristics different between both group were body mass index, presence of cystocele, and severity of incontinence. The MUCP, VLPP, Q-tip and weight of 1-hour pad test were not significantly different in both groups. The success rate in Group A (95.7%) was higher than in Group B (84.6%) (p=0.015, Chi-Square test). In Group A, VLPP, PdetQmax and weight of 1-hour pad test were identified risk factors for failure of operation in univariate analysis, but, only weight of 1-hour pad test was independent risk factor in multivariate analysis (adjusted OR 3.5, 95% CI 1.204-8.895, p=0.045). In Group B, menopause without hormone replacement, AUA Symptom Index-QoL score, maximal cystometric capacity (MCC) and involuntary detrusor contraction (IDC) were the risk factors in univariate analysis, but MCC (adjusted OR 0.9, 95% CI 0.645-0.984, p=0.032) and IDC (adjusted OR 2.3, 95% CI 1.014-3.309, p=0.044) were independent risk factors in multivariate analysis. CONCLUSIONS: The risk factors for failure after MUS operation were different between pure SUI and MUI. Unlike pure SUI, weight of 1-hour pad test was not significant to predict the failure of operation in MUI. Meanwhile, MCC and IDC, indicating the pathophysiological status of the detrusor muscle itself, were important to predict the failure of operation in MUI.

FACTORS AFFECTING RESULT OF DIFFERENT TYPE OF MIDURETHRAL SLING PROCEDURE

INTRODUCTION AND OBJECTIVES: While mid-urethral sling (MUS) operation has expanded its application to more complicated cases such as the patients with mixed urinary incontinence (MUI), the success rates in the patients with MUI have been reported lower than the patients with pure stress urinary incontinence (SUI). If the failure of operation is predicted in the patients with MUI, one could change the therapeutic modalities to obtain the best results regarding continence and the risk factors for failure could help the physicians to counsel the patients ahead of operation. We evaluated and compared the risk factors for failure after MUS operation between pure SUI and MUI. METHODS: Two hundred and twenty-eight women were categorized into pure SUI (Group A, 163 patients) and MUI (Group B, 65 patients). Preoperative evaluations including symptom questionnaire, physical examination and urodynamic study were performed. Patients received the retropubic (17.5%) or trans-obturator (82.5%) MUS operations. RESULTS: Follow-up for Group A and B were 18.8 months (3-52) and 19.2 months (3-54), respectively. The demographic characteristics different between both group were body mass index, presence of cystocele, and severity of incontinence. The MUCP, VLPP, Q-tip and weight of 1-hour pad test were not significantly different in both groups. The success rate in Group A (95.7%) was higher than in Group B (84.6%) (p=0.015, Chi-Square test). In Group A, VLPP, PdetQmax and weight of 1-hour pad test were identified risk factors for failure of operation in univariate analysis, but, only weight of 1-hour pad test was independent risk factor in multivariate analysis (adjusted OR 3.5, 95% CI 1.204-8.895, p=0.045). In Group B, menopause without hormone replacement, AUA Symptom Index-QoL score, maximal cystometric capacity (MCC) and involuntary detrusor contraction (IDC) were the risk factors in univariate analysis, but MCC (adjusted OR 0.9, 95% CI 0.645-0.984, p=0.032) and IDC (adjusted OR 2.3, 95% CI 1.014-3.309, p=0.044) were independent risk factors in multivariate analysis. CONCLUSIONS: The risk factors for failure after MUS operation were different between pure SUI and MUI. Unlike pure SUI, weight of 1-hour pad test was not significant to predict the failure of operation in MUI. Meanwhile, MCC and IDC, indicating the pathophysiological status of the detrusor muscle itself, were important to predict the failure of operation in MUI.

Women with SUI demonstrate motor control differences during voluntary pelvic floor muscle contractions

To compare maximum abdominal and pelvic floor muscle (PFM) electromyographic (EMG) and intravaginal pressure (IVP) amplitudes and muscle activation patterns during voluntary PFM contractions between women with and without stress urinary incontinence (SUI). Twenty-eight continent women and 44 women with SUI performed single and repeated PFM contractions in supine. Surface EMG data were recorded simultaneously with IVP. Maximum EMG and IVP amplitudes and ensemble average IVP versus EMG curves were determined from the single contractions. Muscle activation timing was determined with cross-correlation functions from the repeated contractions. The continent group produced higher PFM EMG amplitudes than the SUI group; there were no between group differences in IVP. The women with SUI delayed activating rectus abdominus. The IVP versus EMG curves' shapes were similar between the groups, however the SUI group had higher abdominal muscle y-intercepts than the continent women. These findings suggest that women with SUI demonstrate altered motor control strategies during voluntary PFM contractions.

Are Risk Factors for Failure after Mid-Urethral Sling Operation Different between Patients with Pure Stress and Those with Mixed Urinary Incontinence in the Short-Term Follow-Up?

Purpose: Although application of the mid-urethral sling (MUS) operation has expanded to more complicated cases such as patients with mixed urinary incontinence (MUI), the success rates in patients with MUI have been reported to be lower than those in patients with pure stress urinary incontinence (SUI). We evaluated and compared the risk factors for failure after MUS surgery in patients with pure SUI and in those with MUI. Materials and Methods: Two hundred twenty-eight women were categorized as having pure SUI (Group A, 163 patients) or MUI (Group B, 65 patients). Preoperative evaluations including a symptom questionnaire, physical examination, and urodynamic study were performed. Patients underwent retropubic (17.5%) or trans-obturator (82.5%) MUS surgery. Results: The demographic characteristics that differed between the 2 groups were body mass index, presence of cystocele, and severity of incontinence. The success rate in Group A (95.7%) was higher than that in Group B (84.6%) (p=0.015, chi-square test). In Group A, VLPP, PdetQmax, and weight of the 1-hour pad test were identified as risk factors for failure of the operation in the univariate analysis, but only weight of the 1-hour pad test was an independent risk factor in the multivariate analysis (adjusted odds ratio [OR]=3.5; 95% confidence interval [CI]=1.204-8.895, p=0.045). In Group B, menopause without hormone replacement, AUA Symptom Index-QoL score, maximal cystometric capacity (MCC), and involuntary detrusor contraction (IDC) were the risk factors in the univariate analysis, but only MCC (adjusted OR=0.9; 95% CI=0.645-0.984, p=0.032) and IDC (adjusted OR=2.3; 95% CI=1.014-3.309, p=0.044) were independent risk factors in the multivariate analysis. Conclusions: Unlike in pure SUI, weight of the 1-hour pad test was not a significant predictor of failure of surgery in MUI. Meanwhile, MCC and IDC, which indicate the pathophysiologic status of the detrusor muscle itself, were important predictors of failure of surgery in MUI. (Korean J Urol 2009;50:573-580) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Neuropeptide Y expression in vaginal epithelium of women with pelvic organ prolapse and stress urinary incontinence

Objectives To determine the role of neuropeptide Y (NPY) in anterior and posterior vaginal epithelium in the etiologic development of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Methods Forty biopsy specimens from anterior and posterior vaginal epithelium were obtained from 40 POP/SUI patients and controls. The specimens were stained using hematoxylin and eosin and NPY immunohistochemical staining. NPY was measured semiquantitatively and NPY mRNA expression was assessed using DNA hybridization in situ. Results There were no significant differences in NPY between anterior and posterior vaginal epithelium. NPY profiles in posterior vaginal epithelium in the SUI group were significantly lower than in the POP ( P < 0.05) and control ( P < 0.05) groups. In the POP group, the NPY profile correlated negatively with advancing age and years post menopause. Conclusion The reduction in NPY in the anterior and posterior vaginal wall epithelium might be related to nerve damage or degeneration, resulting in a change in blood flow, atrophy, and pelvic floor laxity in patients with POP and SUI, especially post menopause and with advancing age.

Influence of Pelvic Floor Muscle Contraction on the Profile of Vaginal Closure Pressure in Continent and Stress Urinary Incontinent Women

We characterized the vaginal pressure profile as a representation of closure forces along the length and circumference of the vaginal wall. Vaginal pressure profile data were used to test the hypothesis that the strength of pelvic floor muscle contractions differs significantly between continent women and women with stress urinary incontinence. Vaginal pressure profile recordings were made in 23 continent subjects and in 10 patients with stress urinary incontinence. The recordings characterized closure forces along the entire length of the vagina and identified differences among the anterior, posterior, left and right sides of the vaginal wall. Using a novel, directionally sensitive vaginal probe we made vaginal pressure profile measurements with the women at rest and during pelvic floor muscle contraction while supine. The nature of the vaginal pressure profile was characterized in terms of force distribution in the anterior and posterior vaginal walls, which was significantly greater than that on the left and right sides. The continent group had significant greater maximum pressure than the stress urinary incontinence group on the posterior side at rest (mean +/- SE 3.4 +/- 0.3 vs 2.01 +/- 0.36 N/cm(2)) and during pelvic floor muscle contraction (4.18 +/- 0.26 vs 2.25 +/- 0.41 N/cm(2)). The activity pressure difference between the posterior and anterior vaginal walls in the continent group was significantly increased when the pelvic floor muscles contracted vs that at rest (3.29 +/- 0.21 vs 2.45 +/- 0.26 N/cm(2)). However, the change observed in the stress urinary incontinence group was not significant (1.85 +/- 0.38 vs 1.35 +/- 0.27 N/cm(2)). The results demonstrate that the voluntary pelvic floor muscles impose significant closure forces along the vaginal wall of continent women but not in women with stress urinary incontinence. The implication of these findings is that extrinsic urethral closure pressure is insufficiently augmented by pelvic floor muscle contraction in women with stress urinary incontinence.

Health‐related quality of life and sexual function in women with stress urinary incontinence and overactive bladder

We evaluated the impact of stress urinary incontinence (SUI) and overactive bladder (OAB) on health-related quality of life (HRQOL) and sexual function. A total of 245 women (SUI; n = 123 and OAB; n = 122) from 21 to 79 years old (mean 50.4) were included in the primary analyses. To obtain HRQOL and sexual function assessments, patients were asked to fill in the 'Bristol Female Lower Urinary Tract Symptoms (BFLUTS)' and the 'Medical Outcomes Study Short Form (SF-36)' questionnaires. Of the eight domains in the SF-36 questionnaire, only 'general health' was significantly different between the groups. Patients with SUI had a better general health than those with OAB (P = 0.016). When comparing the BFLUTS scores in the two groups, the score for 'BFLUTS-filling symptoms' was higher in the OAB group (P = 0.002) but that for 'BFLUTS-incontinence symptoms' was higher in the SUI group (P < 0.001). The score for 'BFLUTS-sex' was higher in the SUI group than in the OAB group but this was not statistically significant (P = 0.096). Of the 169 patients who had a sex life, the SUI group had experienced pain (P = 0.033) and leakage (P = 0.056) more frequently during intercourse than the OAB group. Both SUI and OAB have a detrimental impact on patient HRQOL in Korean women. In addition, our findings suggest that women with SUI had more frequently experienced pain during intercourse and coital incontinence than those with OAB.

Pelvic floor sex steroid hormone receptors, distribution and expression in pre‐ and postmenopausal stress urinary incontinent women

Hormonal influence on stress urinary incontinence (SUI) is under debate. Sex steroid hormonal activity is mediated by nuclear receptor proteins. The aim of this study is to identify receptor isoforms and their genetic expression in the pelvic floor extra cellular matrix (ECM), and to compare women with and without SUI before and after menopause. Sub-mucosal para-urethral biopsies from 4 pre-menopausal and 8 postmenopausal patients with SUI were analysed immunohistochemically regarding estrogen receptors (ER) alpha and beta, the progesterone receptor (PR) (A+B) and B, and the androgen receptor (AR). Six pre-menopausal and 5 postmenopausal women served as controls. All receptors were scored manually. Additionally, ER-alpha and ER-beta were quantified by image analysis. Biopsies from 7 pre-menopausal and 7 postmenopausal women suffering from SUI were studied by real-time RT-PCR for expression of ER-alpha, ER-beta, PR and AR. The control group consisted of 5 pre-menopausal and 5 postmenopausal women. Immunohistochemistry revealed receptor-positive cells for all isoforms in all groups. Higher ER-beta scores were seen in the pre-menopausal SUI group compared to controls. Lower PR-B scores were found after menopause in both groups. The image analysis confirmed that ER-beta was significantly increased in the pre-menopausal SUI group compared to controls (p=0.02). By real-time RT-PCR, no difference of mRNA expression regarding any receptor was detected between any SUI and control group. ER-beta mRNA levels were low or undetectable. There was a significant down-regulation of PR among postmenopausal women (p=0.001). The para-urethral ECM is a target for sex steroid hormones mediated by the respective receptor. The significant higher expression of ER-beta protein in the pre-menopausal SUI-group was not reflected by a corresponding up-regulation of mRNA which was poorly expressed in all groups.

Decrease in urethral pressure following repeated cough efforts: A new concept for pathophysiology of stress urinary incontinence

To describe the decrease in maximum urethral closure pressure (MUCP) following repeated coughs in women with stress urinary incontinence (SUI). MUCP was recorded at rest and after seven cough efforts in 70 women under age 40 referred for urodynamic investigation (47 women with SUI and 23 women without SUI). The intraclass correlation coefficient for repeatability was very good at 400 mL filling volume: 0.94 (95%CI: 0.85-0.98), as compared to the mean and standard-deviations of the MUCP measurements. A decrease in MUCP >20% after seven cough efforts was observed in 18(38%) patients in the SUI group and in just 1(4%) woman in the non-SUI group (P = 0.0069). Many women with SUI exhibit a sharp decrease in MUCP after repeated coughs. Many hypotheses may explain this phenomenon, including increased fatigue of the periurethral muscles.

External intercostal muscles and external anal sphincter electromyographic activity during coughing

Few studies focused on concomitant electromyographic recordings of pelvic floor muscles and muscles involved in cough initiation. The objective of this study was to investigate the temporal course of external anal sphincter activation during coughing. Informed consent was obtained from ten healthy volunteers and ten women presenting with stress urinary incontinence (SUI). Simultaneously, recordings of electromyographic activity of external intercostal muscles (EIC EMGi) and external anal sphincter (EAS EMGi) during coughing have been performed. It was chosen to study intercostals muscles because they are synchronous to diaphragmatic muscle during cough initiation. Median (interquartile range) latency between the onset of the EAS EMGi and the onset of the EIC EMGi was -210 ms (-398; -135) and 0 ms (-30; +111.7) in volunteers' group and in SUI group, respectively (p = 0.0009). Abnormal temporal course of external anal sphincter activation is observed during coughing in women presenting with SUI compared to healthy volunteers.

Spatial distribution of vaginal closure pressures of continent and stress urinary incontinent women

Clinically the strength of the contraction of the female pelvic floor is qualitatively evaluated by vaginal tactile palpation. We therefore developed a probe to enable the quantitative evaluation of the closure pressures along the vagina. Four force sensors mounted on the four orthogonal directions of an intra-vaginal probe were used to measure the vaginal pressure profile (VPP) along the vaginal wall. Clinical experiments on 23 controls and 10 patients with stress urinary incontinence (SUI) were performed using the probe to test the hypothesis that the strength of pelvic floor muscle (PFM) contractions, imposed by voluntary contraction, is related to urinary continence. The results show that VPPs, characterized in terms of pressure distribution on the anterior and posterior vaginal walls, are significantly greater than those in the left and right vaginal walls. When the PFM contracted, the positions of the maximum posterior pressures in continent females and SUI patients were 0.63 ± 0.15 cm and 1.19 ± 0.2 cm proximal from their peak points of anterior pressure, which are 1.52 ± 0.09 cm and 1.69 ± 0.13 cm proximal from the introitus of vagina, respectively. The statistical analysis shows that the maximum posterior vaginal pressures of the controls were significantly greater than those of the SUI patients both at rest (continent: 3.4 ± 0.3 N cm−2, SUI: 2.01 ± 0.36 N cm−2, p < 0.05) and during PFM contraction (continent: 4.18 ± 0.26 N cm−2, SUI: 2.25 ± 0.41 N cm−2, p < 0.01). In addition, the difference between the posterior and anterior vaginal walls is significantly increased when the controls contract the PFM. By contrast, there are no significant differences in the SUI group. The results show that the VPP measured by the prototype probe can be used to quantitatively evaluate the strength of the PFM, which is a clinical index for the diagnosis or assessment of female SUI.

Incontinencia urinaria de esfuerzo asociada a obstrucción del tracto urinario inferior en el cistocele

The association of stress urinary incontinence secondary to urethral hypermobility and lower urinary tract obstruction in the same patient with cystocele is rare, and even represents a contradiction. The objective of our work is to treat to define the characteristics that identify this entity, in comparison with isolated stress urinary incontinence or lower urinary tract obstruction in patients with cystocele. We performed a retrospective study in 1168 cases of cystocele in which urodynamic studies were performed. All patients underwent history and neurological and uro-gynecologycal physical examination. The urodynamic study included uroflowmetry, cystomanometry, voiding pressure/flow tests and voiding cystourethrograms. All data were collected in an Excel 2000 database and statistical analysis was performed with the SPSS software. A- General data: 25 cases qualified for the study in group I (isolated stress urinary incontinence with urethral hypermobility); 24 cases in group II (lower urinary tract obstruction); and 14 cases in group III (astress urinary incontinence associated with lower urinary tract obstruction). The proportion of each group in the whole group of cystoceles corresponded to a 4/1/0.05 ratio respectively. Mean age was 58.4 years for group I, 68.2 for group II and 71.2 for group III. A Statistically significant lower age was demonstrated for group I (p < 0.0005). B- The symptom "sensation of vaginal lump" was less frequent in group I (32%). A significant difference was demonstrated (p = 0.02). C- Group I showed a lower increase of daily voiding frequency (32%), p = 0.02. D- Group I showed less night-time voiding frequency (1 episode)(p < 0.04). E- Urinary incontinence with cough was less frequent in group 1 (84%) (p = 0.0004). F- Group I had more bladder capacity (243.6 ml) (p < 0.05).G- Group I showed less urethral resistances (URA = 37.9 cm H2O) (p = 0.01). H- W80-W20 was higher in group I: 1.3 W/m2 (p < 0.05). I- The symptom "sensation of vaginal lump appeared more often in group II (70.8%) (p = 0.02). J- Radiological degree of cystocele was greater in group II1 (1.7) (p < 0.05). K- Detrusor hyperactivity was more frequent in group III (64.3%) (p = 0.00009). L- No significant differences were found between groups II-III when comparing type of obstruction. The group of isolated stress urinary incontinence (group I) is characterized by a younger age, less frequency of sensation of vaginal lump, less daily frequency and nocturia, and urodynamic data of greater bladder capacity, lower urethral resistance and normal detrusor contractility. The group of isolated lower urinary tract obstruction (group II) could be characterized by a more frequent sensation of vaginal lump and increase of the radiological cystocele. The group of stress urinary incontinence associated with lower urinary tract obstruction had a higher percentage of cases of detrusor hyperactivity. All these data might enable a proper identification of different risk elements in the groups.

Alterations of estrogen receptor-α and -β in the anterior vaginal wall of women with urinary incontinence

Objectives The objective was to investigate the alterations in estrogen receptor-α and -β (ER-α and ER-β) in the anterior vaginal wall of women with stress urinary incontinence (SUI). Study design Samples of the anterior vaginal wall were taken from 57 women, including 12 women with premenopausal SUI (pre-M SUI), 12 with premenopausal control (pre-M control), 19 with postmenopausal SUI (post-M SUI), and 14 with postmenopausal control (post-M control). The expressions of ER-α and ER-β were assayed by immunohistochemistry and quantified with the H-score method. Results Serum estradiol was significantly lower in the pre-M SUI than in the pre-M control group ( P < 0.01), but the difference between the post-M SUI and post-M control groups was not significant ( P > 0.05). ER-α in endothelia, smooth muscle cells, and fibrocytes were significantly lower in pre-M SUI than in pre-M control ( P < 0.01), but there were no significant differences of ER-α between the post-M SUI and post-M control groups ( P > 0.05). ER-β in endothelia and fibrocytes were significantly lower in the pre-M SUI than in the pre-M control group ( P < 0.01), and ER-β in fibrocytes was significantly lower in the post-M SUI than in the post-M control group ( P < 0.01). Conclusions Alterations in serum estradiol and its receptors (ER-α and ER-β) in the anterior vaginal wall were demonstrated, suggesting their involvement in the occurrence of female SUI.