Pelvic floor dysfunction—Does menopause duration matter?

Urinary incontinence, faecal incontinence and pelvic organ prolapse symptoms 20-26 years after childbirth: A longitudinal cohort study

OBJECTIVE

To investigate pelvic floor dysfunction (PFD; urinary incontinence (UI), faecal incontinence (FI) and prolapse) ≥20 years after childbirth and their association with delivery mode history and demographic characteristics.

DESIGN

Cohort study with long-term follow-up.

SETTING

Maternity units in Aberdeen and Birmingham (UK) and Dunedin (NZ).

POPULATION

Women giving birth in 1993/1994.

METHODS

Postal questionnaires at 20 (New Zealand) or 26 (United Kingdom) years after index birth (n = 6195). Regression analyses investigated associations between risk factors and UI, FI and prolapse symptoms.

MAIN OUTCOME MEASURES

Prevalence of self-reported UI, FI, 'something coming down' from or in the vagina (SCD), and the Pelvic Organ Prolapse-Symptom Score, and relationships with delivery method.

RESULTS

Thirty-seven per cent (n = 2270) responded at 20/26 years, of whom 61% reported UI (59% of whom reported more severe UI), 22% FI and 17% prolapse symptoms. Having only caesarean section (CS) was associated with a significantly lower risk of UI (OR 0.63, 95% CI 0.46-0.85), FI (OR 0.63, 95% CI 0.42-0.96) and SCD (OR 0.44, 95% CI 0.27-0.74) compared to only spontaneous vaginal deliveries (SVDs). Having any forceps delivery was associated with reporting FI compared to only SVDs (OR 1.29, 95% CI 1.00-1.66), but there was no association for UI (OR 0.95, 95% CI 0.76-1.19) or SCD (OR 1.05, 95% CI 0.80-1.38). Higher current BMI was associated with all PFD outcomes.

CONCLUSIONS

Prevalence of PFD continues to increase up to 26 years following index birth, and differences were observed according to delivery mode history. Exclusive CS was associated with less risk of UI, FI and any prolapse symptoms.

Bidirectional Relationships between Sarcopenia and Pelvic Floor Disorders

Sarcopenia and pelvic floor disorders (PFDs) are prevalent and often cooccurring conditions in the aging population. However, their bidirectional relationship and underlying mechanisms remain underexplored. This narrative review aims to elucidate this relationship by exploring potential causative interplays, shared pathophysiological mechanisms, and common risk factors. A comprehensive literature search was conducted to identify relevant studies focusing on epidemiological associations, interaction mechanisms, and implications for patient care. While epidemiological studies demonstrate associations between sarcopenia and PFDs, our findings reveal a cyclical relationship where sarcopenia may exacerbate PFDs through mechanisms such as decreased muscle strength and mobility. Conversely, the presence of PFDs often leads to reduced physical activity due to discomfort and mobility issues, which in turn exacerbate the muscle atrophy associated with sarcopenia. Additionally, shared risk factors such as physical inactivity, nutritional deficiencies, metabolic syndrome, and menopausal hormonal changes likely contribute to the onset and progression of both conditions. These interactions underscore the importance of concurrently integrated care approaches that address both conditions. Effective management requires comprehensive screening, the recognition of contributing factors, and tailored exercise regimens supported by a multidisciplinary approach. Future research should focus on longitudinal studies tracking disease progression and evaluating the efficacy of multidisciplinary care models in optimizing patient outcomes.

Magnitude of Symptomatic Pelvic Floor Dysfunction and Associated Factors Amongst Women in Western Ethiopia: A Cross-Sectional Study

The goal of this research was to determine the extent of pelvic floor dysfunction and the factors that contribute to it. The study design was community-focused and cross-sectional, and participants were chosen using a systematic random sampling technique. For data entry and cleansing, we used EPI data version 3.1 software, and for analysis, we used Statistical Package for the Social Sciences version 26. The 95% confidence interval was predicted, and the factor with a significant level less than 0.05 was chosen for multivariate logistic regression analysis. The overall Magnitude of pelvic floor dysfunction was 37.7% [(95% confidence interval (31.7-42.5)]. The most common type of pelvic floor dysfunction is overactive bladder, which was reported by 135 of all participants. Pelvic organ prolapse accounted for 92 (30.4%) of all cases, and 4 factors were found to be significantly associated with pelvic floor dysfunction. In this study, age 55 years [(AOR = 2.1; 95% CI: (1.52-6.42)], heavy labor work for more than 10 years [(AOR = 3.21; 95% CI: (1.86-5.72) grand-multipara, and being menopause [(AOR = 4.03; 95% CI: (2.20-8.27)] were linked to symptoms of pelvic floor dysfunction. The magnitude of pelvic floor dysfunction in this study was slightly higher than in Ethiopian studies. Pelvic floor dysfunction has been linked to heavy load lifting, low socioeconomic status, recurrent vaginal deliveries, chronic cough, and menopause. Screening and treatment of pelvic floor disorders should be prioritized in collaboration with regional and zonal health departments.

Does preoperative locally applied estrogen treatment facilitate prolapse-associated symptoms in postmenopausal women with symptomatic pelvic organ prolapse? A randomised controlled double-masked, placebo-controlled, multicentre study

OBJECTIVE

To evaluate whether locally applied vaginal estrogen affects prolapse-associated complaints compared with placebo treatment in postmenopausal women prior to surgical prolapse repair.

DESIGN

Randomised, double-masked, placebo-controlled, multicentre study.

SETTING

Urogynaecology unit at the Medical University of Vienna and University Hospital of Tulln.

POPULATION

Postmenopausal women with symptomatic pelvic organ prolapse and planned surgical prolapse repair.

METHODS

Women were randomly assigned local estrogen cream or placebo cream 6 weeks preoperatively.

MAIN OUTCOME MEASURES

The primary outcome was differences in subjective prolapse-associated complaints after 6 weeks of treatment prior to surgery, assessed with the comprehensive German pelvic floor questionnaire. Secondary outcomes included differences in other pelvic floor-associated complaints (bladder, bowel or sexual function).

RESULTS

Out of 120 women randomised, 103 (86%) remained for the final analysis. After 6 weeks of treatment the prolapse domain score did not differ between the estrogen and the placebo groups (4.4 ± 0.19 versus 4.6 ± 0.19; mean difference, -0.21; 95% CI -0.74 to 0.33; P = 0.445). Multivariate analysis, including only women receiving the intervention, showed that none of the confounding factors modified the response to estradiol.

CONCLUSIONS

These results demonstrate that preoperative locally applied estrogen does not ameliorate prolapse-associated symptoms in postmenopausal women with symptomatic pelvic organ prolapse.

TWEETABLE ABSTRACT

Preoperative local estrogen does not ameliorate prolapse-associated symptoms in postmenopausal women with pelvic organ prolapse.

Characterizing Pelvic Floor Muscle Function and Morphometry in Survivors of Gynecological Cancer Who Have Dyspareunia: A Comparative Cross-Sectional Study

OBJECTIVE

More than one-half of gynecological cancer survivors are affected by pain during sexual intercourse, also known as dyspareunia. Oncological treatments may result in pelvic floor muscle (PFM) alterations, which are suspected to play a key role in dyspareunia. However, to our knowledge, no study has investigated PFM function and morphometry in this population. The aim of the study was to characterize and compare PFM function and morphometry between gynecological cancer survivors with dyspareunia and asymptomatic women.

METHODS

Twenty-four gynecological cancer survivors with dyspareunia and 32 women with a history of total hysterectomy but without pelvic pain (asymptomatic women) participated in this comparative cross-sectional study. PFM passive forces (tone), flexibility, stiffness, maximal strength, coordination, and endurance were assessed with an intra-vaginal dynamometric speculum. Bladder neck position, levator plate angle, anorectal angle, and levator hiatal dimensions were measured at rest and on maximal contraction with 3D/4D transperineal ultrasound imaging.

RESULTS

Compared with asymptomatic women, gynecological cancer survivors showed heightened PFM tone, lower flexibility, higher stiffness, and lower coordination and endurance. At rest, they had a smaller anorectal angle and smaller levator hiatal dimensions, indicating heightened PFM tone. They also presented fewer changes from rest to maximal contraction for anorectal angle and levator hiatal dimensions, suggesting an elevated tone or altered contractile properties.

CONCLUSIONS

Gynecological cancer survivors with dyspareunia present with altered PFM function and morphometry. This research therefore provides a better understanding of the underlying mechanisms of dyspareunia in cancer survivors.

IMPACT

Our study confirms alterations in PFM function and morphometry in gynecological cancer survivors with dyspareunia. These findings support the rationale for developing and assessing the efficacy of physical therapy targeting PFM alterations in this population.

Three-dimensional ultrasound evaluation of the pelvic floor in postmenopausal women using hormone therapy

OBJECTIVE

To evaluate the three-dimensional (3D) ultrasound characteristics of the pelvic floor muscles (PFM) in two groups of postmenopausal women: users and nonusers of menopausal hormone therapy (MHT).

STUDY DESIGN

Observational, cross-sectional cohort study.

MAIN OUTCOME MEASURES

In this study 226 sexually active heterosexual women, aged 45-60 years with amenorrhea >12 months and without clinical pelvic floor disorders or urinary incontinence were included. Women using MHT ≥ 6 months were classified as systemic users. PFM strength was assessed by digital vaginal palpation and scored on the Modified Oxford Scale. Biometry of the PFM was performed by 3D transperineal ultrasound for evaluation of total urogenital hiatus area, transverse and anteroposterior diameters, and levator ani muscle thickness.

RESULTS

The participants were divided into users (n = 78) and nonusers (n = 148) of MHT. There were no differences in clinical or anthropometric parameters between groups. The mean age was 55 years and the time since menopause was six years in both groups. The mean duration of MHT use was 43.4 ± 33.3 months. Users of MHT had greater levator ani muscle thickness (p = 0.001) and higher PFM strength (p = 0.029) than nonusers. Risk analysis adjusted for age, time since menopause, BMI, parity, and type of delivery showed an association of MHT use with greater levator ani muscle thickness (OR = 2.69; 95% CI 1.42-5.11, p = 0.029), and higher PFM strength (OR = 1.78; 95% CI1.01-3.29, p = 0.046). There was a weak positive correlation between levator ani muscle thickness and duration of MHT use (r = 0.25, p = 0.0002) and PFM strength (r = 0.12, p = 0.043).

CONCLUSIONS

Postmenopausal women using MHT had a greater levator ani muscle thickness associated with higher PFM strength than nonusers.

The mysteries of menopause and urogynecologic health: clinical and scientific gaps

OBJECTIVES

A significant body of knowledge implicates menopausal estrogen levels in the pathogenesis of the common pelvic floor disorders (PFDs). These health conditions substantially decrease quality of life, increase depression, social isolation, caregiver burden, and economic costs to the individuals and society.

METHODS

This review summarizes the epidemiology of the individual PFDs with particular attention to the understanding of the relationship between each PFD and menopausal estrogen levels, and the gaps in science and clinical care that affect menopausal women. In addition, we review the epidemiology of recurrent urinary tract infection (rUTI)-a condition experienced frequently and disproportionately by menopausal women and hypothesized to be potentiated by menopausal estrogen levels.

RESULTS

The abundance of estrogen receptors in the urogenital tract explains why the natural reduction of endogenous estrogen, the hallmark of menopause, can cause or potentiate PFDs and rUTIs. A substantial body of epidemiological literature suggests an association between menopause, and PFDs and rUTIs; however, the ability to separate this association from age and other comorbid conditions makes it difficult to draw definitive conclusions on the role of menopause alone in the development and/or progression of PFDs. Similarly, the causative link between the decline in endogenous estrogen levels and the pathogenesis of PFDs and rUTIs has not been well-established.

CONCLUSIONS

Innovative human studies, focused on the independent effects of menopausal estrogen levels, uncoupled from tissue and cellular senescence, are needed.

Expressions of homeobox, collagen and estrogen genes in women with uterine prolapse

OBJECTIVE

Genetic contribution is thought to be involved in the pathophysiology of pelvic organ prolapse (POP). We aimed to study the gene expression profiles of the genes HomeoboxA11 (HOXA11), HomeoboxA13 (HOXA13), Collagen Type I (COL1A), Collagen Type III (COL3A), estrogen receptor genes (ESR1 and ESR2) of round (RL) and uterosacral ligaments (USL) in postmenopausal women with uterine prolapse.

STUDY DESIGN

Gene expressions of 32 postmenopausal women with prolapse were analysed according to gene expressions of 8 postmenopausal women without prolapse. Quantitative real-time PCR (qRT-PCR) method was used for the detection of expression levels of the genes. Student's t-Test and Mann-Whitney U test were used for statistical analysis.

RESULTS

In the USL specimens of all women with uterine prolapse HOXA13 and ESR1 gene expressions were decreased compared to controls (0.5 fold, p = 0.04 and 0.82 fold, p = 0.04, respectively). In the RL specimens, ESR2 gene expression was decreased 0.7 fold in women with prolapse when compared to controls (p = 0.04). In the USL specimens of women with advanced stages of prolapse (stage ≥3), HOXA13 and COL3A gene expressions were decreased compared to controls (0.44 fold, p = 0.043 and 0.39 fold, p = 0.045, respectively). In the RL specimens, ESR2 gene expression was decreased 0.65 fold in women with prolapse when compared to controls (p = 0.052).

CONCLUSION

The significant decrease in the expression of the genes HOXA13, COL3A in the USL and ESR2 in the RL especially in advanced stages of prolapse, implicate that these gene expressions may play a role in the development of uterine prolapse.

Pelvic floor muscle training increases pelvic floor muscle strength more in post-menopausal women who are not using hormone therapy than in women who are using hormone therapy: a randomised trial

QUESTION

Are there differences in the effectiveness of pelvic floor muscle training on pelvic floor muscle strength and urinary incontinence symptoms in postmenopausal women who are and are not using hormone therapy?

DESIGN

Randomised, controlled trial with concealed allocation, blinded assessors, and intention-to-treat analysis.

PARTICIPANTS

Ninety-nine postmenopausal women, 38 of whom were using daily systemic oestrogen/progestogen therapy.

INTERVENTION

The experimental group (n=51) received an intensive supervised pelvic floor muscle training protocol, and the control group (n=48) received no intervention. The randomisation was stratified by hormone therapy use.

OUTCOME MEASURES

Change in pelvic floor muscle strength assessed with manometry at 12 weeks. Prevalence and severity of urinary incontinence symptoms were assessed using questionnaires.

RESULTS

Eighty-eight women provided data that could be included in the analysis. Pelvic floor muscle training increased pelvic floor muscle strength by 8.0 cmH₂O (95% CI 3.4 to 12.6) in women not using hormone therapy and by -0.9 cmH₂0 (95% CI -6.5 to 4.8) in women using hormone therapy (interaction p=0.018). A sensitivity analysis showed that the greater training effect in women who were not using hormone therapy was still apparent if the analysis was conducted on percentage change in strength rather than absolute change in strength. There was also a significantly greater effect of training in women not using hormone therapy on prevalence of urinary incontinence symptoms (ratio of odds ratios=7.4; interaction p=0.028). The difference in effects on severity of urinary incontinence symptoms was not statistically significant (interaction p=0.37).

CONCLUSION

Pelvic floor muscle training increases pelvic floor muscle strength more in women who are not using hormone therapy than in women using hormone therapy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02549729. [Ignácio Antônio F, Herbert RD, Bø K, Rosa-e-Silva ACJS, Lara LAS, Franco MdM, Ferreira CHJ (2018) Pelvic floor muscle training increases pelvic floor muscle strength more in post-menopausal women who are not using hormone therapy than in women who are using hormone therapy: a randomised trial. Journal of Physiotherapy 64: 166-171].

Expert Panel Recommendations on Lower Urinary Tract Health of Women Across Their Life Span

Urologic and kidney problems are common in women across their life span and affect their daily life, including physical activity, sexual relations, social life, and future health. Urological health in women is still understudied and the underlying mechanisms of female urological dysfunctions are not fully understood. The Society for Women's Health Research (SWHR^®) recognized the need to have a roundtable discussion where researchers and clinicians would define the current state of knowledge, gaps, and recommendations for future research directions to transform women's urological health. This report summarizes the discussions, which focused on epidemiology, clinical presentation, basic science, prevention strategies, and efficacy of current therapies. Experts around the table agreed on a set of research, education, and policy recommendations that have the potential to dramatically increase awareness and improve women's urological health at all stages of life.

Degree of bother from pelvic floor dysfunction in women one year after first delivery

OBJECTIVE

To investigate rates and range of pelvic floor dysfunction complaints, including anterior and posterior compartments and sexual function, in an unselected population of primiparous women one year from delivery, and examine the degree of bother they cause.

STUDY DESIGN

Cross sectional study. Primiparous women who delivered their first child in our delivery wards 10-14 months previously, were approached by phone and asked to complete the Pelvic Floor Symptom Bother Questionnaire (PFBQ) and provide general demographic information. Details regarding participants' labor and delivery were extracted from electronic medical records. PFBQ score was correlated to demographic and labor and delivery parameters.

RESULTS

198 women completed the questionnaire. Response rate was 94%. Scores ranged from 0 to 44.4 (out of a possible 100). At least one symptom of PFD was reported by 64% of respondents. Various degrees of urinary incontinence were reported by 9.1-12.1% of women. Some degree of fecal or flatus incontinence was reported by 10.1% of women; 11.1% reported some degree of obstructed defecation. Severe degree of bother from one or more PFD symptoms was reported by 40.1-90.9%. Some level of dyspareunia was reported by 37.3%. A "dose response" trend between mode of delivery and rate of dyspareunia was observed.

CONCLUSIONS

Two-thirds of primiparous women one year after delivery suffer PFD symptoms that cause some degree of bother. When asked, women are willing to discuss pelvic floor function; caregivers should initiate discussion and refer women promptly to interventions where necessary.

Effect of reproductive characteristics, body mass index, and anterior/posterior vaginal compartment defects on the short-term success of abdominal sacrocolpopexy

OBJECTIVE

Vaginal vault prolapse is caused by the loss of apical support in the cardinal-uterosacral ligament complex. Abdominal sacrocolpopexy (ASCP) is one means of repairing vaginal vault prolapse. In the present study, we investigated the effects of reproductive factors, body mass index (BMI), and anterior or posterior vaginal compartment defects on short-term outcomes of ASCP.

METHOD

We retrospectively studied 70 women who had undergone ASCP between February 2012 and November 2012 in our clinic.

RESULT

There were no significant differences in the complication rate among menopausal, nonmenopausal women, and grand multiparous patients. Operational success was not significantly affected by menopausal status. The long-term rate of grade ≥ 2 prolapse in the apical, anterior, or posterior vaginal wall after ASCP did not differ significantly by menopausal status. Correlation analysis showed that BMI was not associated with operational success in the early postoperative period in patients with vaginal prolapse and was not associated with the detection of grade ≥ 2 prolapse in apical, anterior, and posterior compartments after 1 year.

CONCLUSION

ASCP should be the first-line treatment for obese/overweight, menopausal, or grand multiparous patients with additional anterior or posterior vaginal vault prolapse.

Use of a visual analog scale for evaluation of bother from pelvic organ prolapse

OBJECTIVES

A specified anatomical degree of prolapse may cause no bother in one individual and a severe form of bother in another. The aim of this study was to determine the factors contributing to the degree of bother due to a given degree of prolapse, to help with the clinical evaluation of patients and planning of preventive intervention trials and surgical treatment.

METHODS

Consecutive patient records of 654 women who had attended a urogynecology unit between August 2011 and December 2012 were reviewed. All patients underwent a standardized interview, clinical examination and four-dimensional translabial ultrasound scan. The degree of bother was evaluated using a visual analog scale.

RESULTS

Six hundred and thirty-six women were included in the analysis, with ultrasound data available for cystocele, rectocele and enterocele descent and rectocele depth measurements and 442 for uterine descent. 313 women (49.2%) had subjective symptoms of female pelvic organ prolapse at a mean bother score of 6.0 ± 2.6. Average bother score for the complete dataset was 3.0 ± 3.5. Parity, vaginal delivery, levator avulsion, any significant clinical prolapse or prolapse seen on ultrasound were associated with prolapse bother and all clinical and ultrasound measures of pelvic organ descent remained significant or near significant on multivariate analysis.

CONCLUSIONS

Quantification of prolapse bother using a visual analog scale is valid and repeatable and may represent a simple tool for use in clinical practice.

Fibulin-5 (FBLN5) gene polymorphism is associated with pelvic organ prolapse

OBJECTIVE

FBLN5 encodes a key protein of elastic fiber matrix assembly and function that contributes to maintaining pelvic support and plays the important role in the pathophysiology of pelvic organ prolapse (POP). The aim of the study was to investigate whether there is an association between common single-nucleotide polymorphisms (SNPs) of the FBLN5 gene and POP.

STUDY DESIGN

A total of eleven tag SNPs of the FBLN5 gene were genotyped using the polymerase chain reaction with confronting two-pair primers (PCR-CTPP) in 210 patients with POP (stages III-IV) and 292 controls with no even minimal POP.

RESULTS

We revealed significant associations of tag SNPs rs2018736 and rs12589592 with POP. The top association signal was found for SNP rs2018736 (protective effect for the minor allele A) in the entire set: p=0.0026, OR=0.42, 95% CI: 0.24-0.75; in the stratum with pelvic floor trauma: p=0.0018, OR=0.27, 95% CI: 0.11-0.64; and in the stratum with fetal macrosomia: p=0.013, OR=0.14, 95% CI: 0.03-0.71. The results of the haplotype analyses were consistent with the single SNP analysis. In the strata without perineal trauma and fetal macrosomia effects were non-significant, possibly, due to the smaller effect sizes.

CONCLUSIONS

Current data provide, for the first time, strong evidence that common SNPs of the FBLN5 gene are associated with POP especially after pelvic floor injury.