Estrogen therapy and urinary incontinence: what is the evidence and what do we tell our patients?

Prevalência de diagnóstico médico auto-relatado de miomas uterinos em população brasileira: Padrões demográficos e socioeconômicos no Estudo Pró-Saúde *

Introdução: Os miomas uterinos (MU) são considerados os tumores mais comuns do sistema reprodutor feminino; no entanto, existem poucos estudos epidemiológicos sobre essa condição no Brasil. Objetivo: Estimar as prevalências de história auto-relatada de MU segundo características demográficas, socioeconômicas e de acesso a serviços de saúde. Métodos: Foram analisados dados de 1.733 trabalhadoras de universidade no Rio de Janeiro, participantes da linha de base do Estudo Pró-Saúde (1999-2001), em relação a três desfechos: (1) diagnóstico médico de MU, (2) MU com sintomas prévios ao diagnóstico e (3) casos que realizaram histerectomia pelo tumor. As prevalências e seus intervalos de 95% de confiança (IC 95%) foram estimadas em relação a estratos de variáveis demográficas (idade, cor/raça), socioeconômicas (escolaridade, renda) e marcadoras de acesso a serviços de saúde (teste Papanicolaou , exame de mama, plano de saúde). Resultados: A prevalência de diagnóstico médico de MU foi de 23,3% (IC 95% - 21,3; 25,2); a de MU com sintomas prévios ao diagnóstico, de 13,3% (IC 95% - 11,7; 15,0) e a de histerectomia pelo tumor, de 8,4% (IC 95% - 7,5; 10,3). Entre participantes abaixo de 45 anos de idade, foram observadas prevalências mais elevadas nos estratos de piores condições socioeconômicas e de cor/raça preta. Entre aquelas com 45 anos ou mais, foram encontradas maiores prevalências entre mulheres com melhor acesso a serviços de saúde. Conclusão: Entre as mulheres brasileiras investigadas, os MU constituem problema relevante de saúde, com prevalências e gradientes sociodemográficos similares aos observados em populações de outros países.

[Stress incontinence in elderly women]

Stress incontinence is one of the major challenges in geriatric medicine. This is becoming more apparent in routine urology practice with the demographic changes in the population. A thorough diagnosis for a correct treatment of stress incontinence is as important in elderly women as it is in younger patients. This includes assessing the risk factors of incontinence and obesity, parturition, pelvic surgery and changes in hormone levels are risk factors usually found in elderly women. These are the main reasons why this patient group is most frequently affected. Treatment options do not differ significantly from these of younger women. Lifestyle modification, weight loss and supervised pelvic floor training are the mainstays of conservative therapy and surgical treatment should only be considered after these options have been exhausted. In these cases minimally invasive surgical techniques offer clear advantages especially for elderly often multimorbid women.

The effect of long-term hormonal treatment on voiding patterns during filling cystometry and on urethral histology in a postpartum, ovariectomized female rat

OBJECTIVE

To study whether long-term treatment with oestrogen (E(2) ), selective E(2) receptor modulators (SERMs), or growth hormone (GH) can prevent the development of abnormal voiding patterns during filling cystometry (CMG) in a postpartum, ovariectomized (Ovx) female rat.

MATERIALS AND METHODS

Immediately after spontaneous delivery, 60 primiparous Sprague-Dawley rats were randomly divided into six equal groups. One group served as uninjured sham controls and five groups underwent intravaginal balloon dilatation. On day seven, previously dilated rats underwent bilateral Ovx and implantation of a subcutaneous hormone-delivery pump. The five treatment groups received normal saline (control), E(2) , raloxifene, levormeloxifene, or GH for 7 weeks. Conscious CMG was performed 7 weeks after Ovx. Urethral sphincter tissue was harvested for elastin immunohistochemistry and real-time polymerase chain reaction of α(1A) -adrenoceptor mRNA.

RESULTS

No abnormal voiding patterns were detected in the group treated with GH. The E(2) , raloxifene and levormeloxifene groups had greater detrusor overactivity and urethral relaxation incontinence than control rats. The raloxifene group had a significantly lower baseline bladder pressure and opening pressure. GH-treated rats had higher elastin content in the urethra. Urethral α(1A) -adrenoceptor mRNA concentration was significantly lower in the SERM-treated rats compared with controls.

CONCLUSIONS

GH prevents the development of abnormal voiding patterns during filling CMG in a rat model of parturition-induced incontinence; E(2) and SERMs may worsen voiding patterns.

Estrogen and urinary incontinence

Hormone therapy (HT) has been one of the most commonly used methods to treat postmenopausal disorders including lower urinary tract symptoms such as urinary incontinence (UI). Although it has been suggested that HT improves urinary tract symptoms, little evidence has so far been presented to support this. Recently however, large randomized clinical trials have shown the adverse effects of estrogen on UI and indicate that HT should not be used for prevention or relief of UI in postmenopausal women. Here we review the effects of HT on UI in the light of these clinical trials.

Is there a synergistic effect of topical oestrogens when administered with antimuscarinics in the treatment of symptomatic detrusor overactivity?

BACKGROUND

No authors have investigated whether the administration of local oestrogens in addition to antimuscarinics could have a synergistic effect in the therapy of overactive bladder (OAB).

OBJECTIVES

To compare the efficacy of antimuscarinics alone versus antimuscarinics in combination with local oestrogens for OAB; to verify whether risk factors for lower antimuscarinic efficacy can be overcome by the concomitant use of local oestrogens.

DESIGN, SETTING, AND PARTICIPANTS

Some 229 postmenopausal women with symptomatic urodynamically proven detrusor overactivity were prospectively enrolled at a tertiary level urogynaecology centre and divided into two groups.

INTERVENTION

Women in group 1 (n=129) were prescribed tolterodine extended release (ER) 4 mg once daily; women in group 2 (n=100) were prescribed both tolterodine ER 4 mg and concomitant oestriol cream application once daily.

MEASUREMENTS

All women underwent clinical evaluation and urodynamics in accordance with the Good Urodynamic Practices Guidelines. After 12 wk of treatment the two groups were compared in terms of subjective efficacy for OAB symptom improvement using a three-point scale. Nonresponders were compared to the patients who improved or were cured in order to identify risk factors for resistance to therapy.

RESULTS AND LIMITATIONS

There was no significant difference between the two groups in terms of efficacy of therapy: 80.6% in group 1 versus 82% in group 2 (p=0.86). Patients with urodynamically proven detrusor overactivity (DO) occurring during provocative manoeuvres and patients with coital incontinence during orgasm reported a higher failure rate both in the overall study population and in group 2. A possible limitation of the study is the nonrandomised design.

CONCLUSIONS

No synergistic effect of local oestrogens and antimuscarinics in the treatment of OAB was found. Antimuscarinic treatment has lower cure rates in women with symptomatic DO complaining of incontinence at orgasm or in patients with DO following provocative manoeuvres. The association of local oestrogens does not influence the role of the two mentioned risk factors.

Combined estrogen and ghrelin administration restores number of blood vessels and collagen type I/III ratio in the urethral and anal canal submucosa of old ovariectomized rats

We compare the effects of estrogen and/or ghrelin on vascular counts and collagen I/III ratio of urethral and anal canal submucosa in old vs young-adult ovariectomized rats. Ovariectomized Fisher 344 rats (18 and 3 months old, n = 24 x 2) received 42 daily intraperitoneal 17-ss estradiol (10 microg/kg), ghrelin (2 microg/kg), both, or vehicle (n = 6 x 4 per group). Blood vessel counts and collagen I/III ratio were measured, respectively, by light microscopy and Western blot analysis with immunohistochemistry of ghrelin receptors. Estrogen significantly increased urethral and anal vascular counts and collagen I/III ratio in young-adult rats. In old rats, only combined estrogen/ghrelin administration significantly increased both variables. This was not observed with estrogen or ghrelin separately. Ghrelin receptors were immunostained in urethral and anal submucosa of all samples. Combined estrogen/ghrelin administration restored postovariectomy urethral and anal canal submucosal vessel number and collagen I/III ratio in old rats suggesting independent ageing effect.