The role of estrogens in female lower urinary tract dysfunction

Management of Menopause Symptoms

This summary is an update on the treatment of menopause symptoms, to include vasomotor symptoms, genitourinary symptoms, and hair loss. Treatment options discussed for vasomotor symptoms include menopausal hormone therapy, nonhormonal medication options, and nonmedication treatments. Treatments for isolated genitourinary symptoms include topical estrogen, bazedoxifene, and dehydroepiandrosterone.

Advancing our Understanding of the Urothelium and Lamina Propria, Hormone Receptors, Vascular Supply, and Sensory Aspects of the Female Human Urethra

OBJECTIVE

Urinary continence is important for women's health and wellbeing. The female urethra has been understudied and mechanisms of continence remain poorly understood. Our objective is to provide a summary of current knowledge of the epithelium and lamina propria, hormone receptors, vascular supply, and sensory aspects of the female urethra and highlight continued gaps in knowledge.

METHODS

In October of 2020, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) sponsored a virtual seminar series entitled "Female Urethral Function and Failure: Advancing Basic and Translational Research for Genitourinary Conditions". We summarize the information presented during session 3 presentations, provide additional information from recent studies, and highlight continued gaps in knowledge.

RESULTS

A sensory role for urethral mucosa seems apparent based on the dense innervation of sensory afferent neurons but how the sensory afferents contribute to continence remains poorly understood. There is a complex relationship with behavior that comes into play when evaluating the contribution of sex hormones to urinary physiology. We need to update our understanding of where hormone receptors are located in the female urinary tract. Many causes of impaired urethral blood flow are also common risk factors for urinary dysfunction but we don't know how vasculature contributes to continence. Altered afferent urethral function has been implicated in several disease states, but is largely understudied.

CONCLUSION

There is much that remains to be learned about the urothelium and lamina propria, expression and influence of sex hormones and hormone receptors, vascular supply, and sensory aspects of the female urethra.

TRIAL REGISTRATION

No new data was generated for this manuscript, no clinical trial was conducted, and therefore clinical trial registration was not necessary.

Suoquan Wan mitigates bladder overactivity via modulation of neuroimmune homeostasis in perimenopausal rats

BACKGROUND

Overactive bladder (OAB) is a common disorder in perimenopausal women, involving detrusor regulation by bladder neuro-immune interactions. While Suoquan Wan (SQW) has shown efficacy in alleviating OAB symptoms, its underlying mechanisms remain unclear.

PURPOSE

The aim of this study was to investigate the therapeutic effects of SQW on perimenopausal overactive bladder (OAB) and elucidate its underlying mechanisms in restoring bladder neuro-immune homeostasis.

METHODS

Initially, vaginal smears were performed to identify perimenopausal rats. The effects of SQW on the structure and function of the perimenopausal bladder were assessed using urodynamic studies, organ bath assays, and histological analyses, including hematoxylin and eosin (HE) and Masson staining. Subsequently, single-nucleus RNA sequencing (snRNA-seq) was conducted to investigate the mechanisms by which SQW modulates neuron-macrophage interactions. To validate the sequencing data, PCR and immunofluorescence (IF) assays were utilized to evaluate neural homeostasis. Further analyses involved IF, flow cytometry, and fluorescence bead assays to determine the function and proportion of bladder macrophages. The co-localization of neurons and macrophages was visualized using IF. Finally, transwell co-culture experiments were carried out to explore the regulatory effects of SQW on bladder neuro-immune homeostasis.

RESULTS

SQW significantly attenuates the frequency of non-micturition contractions and reduces residual urine volume, alleviates detrusor hyperactivity in OAB rats in response to external stimuli such as EFS, CCh, and KCl, and markedly improves urinary efficiency in perimenopausal OAB rats. SnRNA-seq data indicate that SQW modulates bladder neuro-immune homeostasis in these rats. Furthermore, SQW obviously decreases the proportion of ChAT-positive nerve fibers while enhancing the abundance of nNOS and MAP-positive nerve fibers in the bladder. SQW also reduces the proportion of CD45+ CD11b/C+MHCⅡ+ macrophages in the bladder muscle layer. Transwell co-culture assays reveal that the effects of SQW on MAP-2 and ChAT are mediated through the neuron-macrophage interaction mechanism.

CONCLUSIONS

SQW alleviated perimenopausal OAB by specifically modulating the neuron-macrophage interaction and enhancing bladder neuro-immune homeostasis.

Influence of equol production capacity on female lower urinary tract symptoms

AIM

We aimed to investigate the relationship between lower urinary tract symptoms in females and their equol production capacity.

METHODS

In this cross-sectional study, the production capacity of equol in Japanese women (aged 20-75 years), with (group L, n = 95) and without (group C, n = 122) lower urinary tract symptoms, was examined. Equol production was determined by measuring the concentration of urinary equol by immunochromatography. Equol production was defined as a urinary equol concentration of 1.0 μM or more. The presence of lower urinary tract symptoms was determined using three questionnaires that evaluated lower urinary tract symptoms.

RESULTS

The proportions of equol production in groups L and C were 28.4% and 52.5%, respectively (p = 0.0004). Multivariate analysis (logistic regression analysis) showed that the inability to produce equol was a significant risk factor for lower urinary tract symptoms (odds ratio, 2.21; p = 0.0144).

CONCLUSIONS

This study revealed that equol production capacity may be associated with lower urinary tract symptoms. Further research, including interventional studies, is required for verification. Additionally, because lower urinary tract symptoms include a variety of symptoms, the association between each symptom and equol production capacity needs to be investigated.

The relationship between neuropathic pain and lower urinary tract symptom scores in patients with primary Sjögren's syndrome

OBJECTIVE

To evaluate the effect of neuropathic pain on lower urinary tract symptoms (LUTS) scores in patients with primary Sjögren's syndrome (pSS).

METHODS

Seventy-two patients diagnosed with pSS were included in the study. The patients with pSS were divided into two groups according to the presence/absence of neuropathic pain. The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) questionnaire was recorded assess neuropathic pain. LUTS was evaluated using the International Prostate Symptom Score (IPSS), International Incontinence Consultation Questionnaire Short Form (ICIQ-SF) and Overactive Bladder Questionnaire (OAB-V8).

RESULTS

The mean age of the patients was 52.4 ± 11.2 years. Neuropathic pain was recorded in 21 (29.2%) patients. Among the patients, the number of patients with mild symptoms was recorded as 41 (56.9%), moderate symptoms in 25 (34.7%), and severe symptoms in 6 (8.3%) according to IPSS. IPSS and IPSS voiding subscores were statistically significantly higher in patients with neuropathic pain than non-neuropathic pain group (p = 0.035; p = 0.001, respectively). Although ICIQ-SF, OAB-V8 and IPSS storage subscores were found to be higher in patients with neuropathic pain group, there was no statistically significant difference between the groups (p = 0.299; p = 0.283; p = 0.237, respectively).

CONCLUSION

Neuropathic pain concomitant with PSS patients may negatively affect bladder voiding functions.

Effects of Nitric Oxide on Bladder Detrusor Overactivity through the NRF2 and HIF-1α Pathways: A Rat Model Induced by Metabolic Syndrome and Ovarian Hormone Deficiency

Metabolic syndrome (MetS) includes cardiovascular risk factors like obesity, dyslipidemia, hypertension, and glucose intolerance, which increase the risk of overactive bladder (OAB), characterized by urgency, frequency, urge incontinence, and nocturia. Both MetS and ovarian hormone deficiency (OHD) are linked to bladder overactivity. Nitric oxide (NO) is known to reduce inflammation and promote healing but its effect on bladder overactivity in MetS and OHD is unclear. This study aimed to investigate NO's impact on detrusor muscle hyperactivity in rats with MetS and OHD. Female Sprague-Dawley rats were divided into seven groups based on diet and treatments involving L-arginine (NO precursor) and L-NAME (NOS inhibitor). After 12 months on a high-fat, high-sugar diet with or without OVX, a cystometrogram and tracing analysis of voiding behavior were used to identify the symptoms of detrusor hyperactivity. The MetS with or without OHD group had a worse bladder contractile response while L-arginine ameliorated bladder contractile function. In summary, MetS with or without OHD decreased NO production, reduced angiogenesis, and enhanced oxidative stress to cause bladder overactivity, mediated through the NF-kB signaling pathway, whereas L-arginine ameliorated the symptoms of detrusor overactivity and lessened oxidative damage via the NRF2/HIF-1α signaling pathway in MetS with or without OHD-induced OAB.

The Link Between Menopause and Urinary Incontinence: A Systematic Review

This study aims to review the subsisting literature on the relationship between menopause and urinary incontinence (UI). To locate research that met the inclusion criteria, a thorough computerized search of relevant databases was carried out. A comprehensive search was carried out on PubMed, SCOPUS, Science Direct, Cochrane Library, and Web of Science to locate relevant material. Our data included 11 trials with 8547 post-menopausal women. The prevalence of UI among post-menopausal women ranged from 13.6% to 84.4%, with a total prevalence of 5394 (63.1%). Across studies, the mean age of menopause varies, with some studies reporting averages around 48 to 50 years. Several studies report that UI prevalence increases with age, particularly in the postmenopausal period. UI symptoms, such as burning micturition and mixed UI, are noted, often related to the genitourinary syndrome of menopause (GSM) and nocturia. These symptoms are linked to reduced quality of life and considerable morbidity. Among postmenopausal women, UI is still a common and complex problem that has a significant negative impact on well-being and life quality. There is no doubt that menopause, aging, and UI are related, but there is still much to learn about the underlying reasons and practical treatment options. The quality of care for postmenopausal women with UI can be improved by standardizing diagnostic procedures, emphasizing non-hormonal therapy, and addressing socioeconomic and lifestyle determinants. These and other initiatives will be addressed in future research and clinical practice.

Does Urodynamic Stress Incontinence Increase After the Menopause?: Results from 2,994 Urodynamic Studies in Australian Women

INTRODUCTION AND HYPOTHESIS

Most studies attempting to estimate the age-related prevalence of urinary incontinence (UI) have used questionnaires. In the present study we analysed a consecutive series of urodynamic test results to determine the distribution of the different types of UI in pre- and post-menopausal women. We hypothesised that the prevalence of urodynamic stress incontinence (USI) would be significantly greater in pre-menopausal than in post-menopausal women.

METHODS

All women from a large tertiary urogynaecology department, who underwent urodynamic tests during the years 2000-2015 were included. Patient history and test results were collected. A sample size of 1,475 was calculated, based on the hypothesis that the prevalence of USI will be 20% larger in the pre- versus the post-menopausal group.

RESULTS

A total of 2,994 women with UI on urodynamics were available. There was a significant difference between pre- and post-menopausal status for each of the three diagnoses: USI 483 (59.3%) versus 912 (41.8%), detrusor overactivity (DO) 125 (15.4%) versus 399 (18.3%) and USI with concomitant DO 206 (25.3%) versus 869 (39.9%). A bimodal pattern of age was seen in women with USI, with a peak in the 46-50 and 61-65 age group, before decreasing with age. DO generally increased with age. USI with concomitant DO increased steadily after the menopause, becoming the predominant type after the age of 66.

CONCLUSIONS

In this large cohort of women attending urodynamics, we have shown that USI is the predominant type of incontinence in pre-menopausal women; however, USI with concomitant DO increases after menopause, eventually predominating.

Effect of tibolone versus hormone replacement therapy on lower urinary tract symptoms and sexual function

BACKGROUND

Few studies have compared the effects of tibolone versus hormone replacement therapy (HRT) on lower urinary tract symptoms and female sexual function. The current study aimed to compare these treatments.

METHODS

Women with climacteric symptoms were recruited consecutively and allocated to receive tibolone (2.5 mg) or estradiol valerate (1 mg) and medroxyprogesterone acetate (2.5 mg). Patients were followed up at 4 weeks and 12 weeks after treatment.

RESULTS

Overall, there were no significance of improvement in the International Prostate Symptoms Score (IPSS) scores in the HRT group. However, nocturia and the IPSS storage score improved after tibolone treatment. In addition, orgasm, satisfaction and pain improved after HRT. However, desire, lubrication, and Female Sexual Function Index (FSFI) total scores improved after tibolone treatment. There was a between-group difference in the change from baseline in the nocturia score after 4 weeks of treatment (0.1 ± 0.9 for HRT vs. -0.4 ± 1.2 for tibolone, p = 0.02). Nonetheless, there were no significant differences of the changes from baseline in the other IPSS and FSFI domains between the tibolone and HRT groups.

CONCLUSION

Despite the limited effect, tibolone seems to have more benefit in nocturia than HRT. In addition, tibolone seems to have benefits on overall low urinary tract storage symptoms; and both tibolone and HRT seem to have beneficial effects on female sexual function, despite there were no significant differences between tibolone and HRT.

Prevalence and Antimicrobial Sensitivity Patterns of Uropathogens in Wad Medani, Sudan: A Three Years, Cross-Sectional Study

Purpose

Urinary tract infections exert a significant negative impact on an individual's quality of life and cause significant economic and public health burdens. Therefore, this study was conducted to identify the common bacterial uropathogens associated with urinary tract infections in Wad Medani patients and their susceptibility to antibiotics.

Patients and Methods

This was a cross-sectional study. All urine samples were collected from patients at Wad Medani and investigated at the Pathology Center for Diagnosis and Research, Faculty of Medicine, University of Gezira, Sudan, from the 1st of January 2021 to the 15th of October 2023.

Results

A total of 2698 urine samples were analyzed during the three years study period, with a mean age of 45.29 ± 18.9 years. Among these patients, 1108 (41.8%) were positive for bacterial growth, and 888 (80.14%) were female. A total of 522 (47.1%) were gram positive bacteria (GPB), and 586 (52.9%) were gram negative bacteria (GNB). The most frequently isolated bacteria were S. aureus 42% (465/1108) and E. coli 38.5% (427/1108), while P. aeruginosa was less detected 3.4% (38/1108). Amikacin 91.5% was the most sensitive drug to isolated GPB, while cotrimoxazole 20.9% was the least sensitive drug. In particular, amikacin 94.1% (144/153) was the most sensitive drug to S. aureus, while cotrimoxazole 20.7% (80/386) was the least sensitive drug. Moreover, amikacin 91.5% was the most sensitive drug to the isolated GNB, while ampicillin 5.7% was the least sensitive drug. Notably, amikacin was the most sensitive drug to all the isolated GNB, and ampicillin was the least sensitive drug to all the isolated GNB.

Conclusion

This study reported a moderate uropathogen isolation rate of 41.8%. S. aureus and E. coli were the most frequently isolated bacteria, most of which were from female patients. Remarkably, amikacin was the most sensitive drug to isolated GNB and GPB.

Lower Urinary Tract Symptoms in Greek Women After Menopause: The LADY Study

INTRODUCTION AND HYPOTHESIS

The genitourinary syndrome of menopause (GSM), apart from symptoms related to vulvovaginal atrophy (VVA), also consists of lower urinary tract symptoms (LUTS). Based on the common embryological origin of the genital and lower urinary system, the presence of estrogen receptors, and the high prevalence of VVA and LUTS in the menopausal population, the two conditions can coexist. This study is aimed at investigating the prevalence and risk factors of LUTS in a sample of Greek peri- and postmenopausal women.

METHODS

Four hundred and fifty (450) women, aged 40-70 years, attending three outpatient gynecology clinics for routine examination, completed a structured interview and responded to a validated questionnaire (International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms, ICIQ-FLUTS).

RESULTS

Urinary urgency or frequency affected 51.6% and dysuria 43.6% of the participants. Mild urgency or frequency was described by 25.6%, moderate by 14.4%, and severe by 11.6% of the women. Mild dysuria was reported by 26.26%, moderate by 5.8%, and severe by 11.6%. Age, weight, BMI, and number of pregnancies and abortions correlated with a higher ICIQ-FLUTS score. Women with moderate/severe symptoms of VVA, such as irritation, a burning sensation, and pruritus of the vulva or vagina, had a higher ICIQ-FLUTS score than women without such symptoms (beta coefficient 2.42, CI 1.204, 3.635, p < 0.001).

CONCLUSIONS

Lower urinary tract symptoms are very common among peri- and postmenopausal women and are linked to symptoms of VVA. Our data support the need for prompt evaluation of women transitioning to menopause, as these symptoms compromise the quality of life.

Menopause and High Altitude: A Scoping Review-UIAA Medical Commission Recommendations

Mateikaitė-Pipirienė, Kastė, Dominique Jean, Peter Paal, Lenka Horakova, Susi Kriemler, Alison J. Rosier, Marija Andjelkovic, Beth A. Beidleman, Mia Derstine, Jacqueline Pichler Hefti, David Hillebrandt, and Linda E. Keyes for the UIAA MedCom writing group on Women's Health in the Mountains. Menopause and high altitude: A scoping review-UIAA Medical Commission Recommendations. High Alt Med Biol. 25:1-8, 2024. Background: Older people are an important fraction of mountain travelers and climbers, many of them postmenopausal women. The aim of this work was to review health issues that older and postmenopausal women may experience at high altitude, including susceptibility to high-altitude illness. Methods: We performed a scoping review for the UIAA Medical Commission series on Women's Health in the mountains. We searched PubMed and Cochrane libraries and performed an additional manual search. The primary search focused on articles assessing lowland women sojourning at high altitude. Results: We screened 7,165 potential articles. The search revealed three relevant articles, and the manual search another seven articles and one abstract. Seven assessed menopausal low-altitude residents during a high-altitude sojourn or performing hypoxic tests. Four assessed high-altitude residents. We summarize the results of these 11 studies. Conclusions: Data are limited on the effects of high altitude on postmenopausal women. The effects of short-term, high-altitude exposure on menopause symptoms are unknown. Menopause has minimal effect on the physiological responses to hypoxia in physically fit women and does not increase the risk of acute mountain sickness. Postmenopausal women have an increased risk of urinary tract infections, which may be exacerbated during mountain travel. More research is needed on the physiology and performance of older women at high altitude.

Does local vaginal estrogen after tension-free transobturator vaginal tape reduce overactive bladder symptoms in postmenopausal women? A prospective randomized, controlled study

Objective

We aimed to evaluate the efficacy of topical estrogen after transvaginal tension-free vaginal tape-obturator (TVT-O) in the treatment of de novo overactive bladder symptoms that appear after surgery.

Methods

This is a prospective randomized controlled study performed in the Urology and Gynecology Departments, Kasr Al Ainy Hospital, Cairo University, Cairo, Egypt. Two hundred and ten postmenopausal females presenting during the period between January 2017 and November 2020 with stress urinary incontinence were included in the study. Patients were divided into two groups, 105 patients in Group A (treatment group) and 105 patients in Group B (control group). Patients in Group A underwent transvaginal TVT-O followed by local vaginal estrogen treatment for 6 months, while patients in Group B underwent transvaginal TVT-O only. The study included any postmenopausal female with urodynamic stress urinary incontinence. All patients had to fulfill a 3-day bladder diary, overactive bladder symptoms score, urine analysis, urodynamic study, and post-voiding residual urine measurement by abdominal ultrasound preoperatively and at 3-month and 6-month follow-ups.

Results

At 6-month follow-up, daytime frequency was reduced to 8% in Group A (increased to 21% in Group B) with a statistically significant difference between both groups (p=0.009). At 6-month follow-up, nocturia was 8% in Group A (11% in Group B) with no statistically significant difference between both groups (p=0.469). There was a statistically significant difference between both groups as regards to urinary urgency at 6-month follow-up (p=0.024). There was a statistically significant difference in postoperative wound healing events as regards to cure, hyperemia, gapping, and wound infection 1 week after intervention between both groups (p=0.008). No local or systemic side-effects were reported from local estrogen use.

Conclusion

Local vaginal estrogen treatment given to postmenopausal patients after midurethral sling procedures can reduce the symptoms of daytime frequency and urinary urgency. Long-term follow-up is needed.

Correlation of serum circulating testosterone levels with stress urinary incontinence in postmenopausal women

OBJECTIVES

Our study aimed to elucidate the possible relationship between endogenous circulating testosterone and the beginning and development of stress urinary incontinence (SUI) in postmenopausal women.

PATIENTS AND METHODS

The clinical data of female patients with SUI who underwent surgery at our hospital from January 2014 to February 2023 and healthy female volunteers recruited during the same period were retrospectively analyzed according to age and body mass index (BMI). Venous blood samples were taken from all subjects, and levels of estradiol, luteinizing hormone, prolactin, follicle-stimulating hormone, progesterone, and testosterone were measured by radioimmunoassay. After adjusting for age, BMI, hypertension, mode of delivery, hysterectomy, and profession, multiple logistic regression analysis was used to determine the relationship between SUI and serum testosterone levels in postmenopausal women.

RESULTS

Serum testosterone levels were significantly lower in women with SUI than in healthy control women (0.92 ± 0.67 vs. 1.28 ± 1.10; P < 0.05). Further comparison of testosterone levels between postmenopausal SUI women and healthy postmenopausal women in postmenopausal subjects revealed that testosterone levels were significantly lower in postmenopausal SUI women than in healthy postmenopausal women (0.84 ± 0.64 vs. 1.23 ± 1.10; P < 0.05). This difference in testosterone levels remained significant after controlling for age, BMI, hypertension, mode of delivery, hysterectomy, and profession in postmenopausal women.

CONCLUSION

The results of the present study indicate that low levels of serum testosterone are associated with an increased likelihood of stress urinary incontinence in women. Low serum testosterone levels may be a risk factor for SUI in postmenopausal women.

Injection Treatments for Vulvovaginal Atrophy of Menopause: A Systematic Review

BACKGROUND

Injection treatments have been proposed as novel treatment options for Vulvovaginal Atrophy of Menopause (VVA) also known as Genitourinary Syndrome of Menopause (GSM). However, to date data about these treatments are poor.

OBJECTIVE

To assess all available injection treatments for VVA.

METHODS

A systematic review was performed by searching five electronic databases for peer-reviewed studies that assessed injection treatments for VVA.

RESULTS

Eight studies (7 observational and 1 randomized) with 236 women were included. Assessed injection materials were: autologous platelet-rich plasma (PRP) + hyaluronic acid (HA), not cross-linked HA plus calcium hydroxyapatite (NCLHA + CaHA), micro-fragmented adipose tissue (MFAT), hyaluronan hybrid cooperative complexes (HCC), crosslinked HA, microfat and nanofat grafting + PRP, and PRP alone. Improvement in GSM symptoms after treatment was assessed through Visual Analogic Scale (VAS) for GSM symptoms or patient satisfaction, several validated questionnaires (FSFI, VHI, FSD, SF12, ICIQ UI SF, PGI-I, FSDS-R, VSQ), symptoms severity, changes in vaginal mucosa thickness, flora, pH, and expression on vaginal mucosal biopsies of Procollagen I and III and ki67 immunofluorescence or COL1A1 and COL3A1 mRNA. Injection treatments showing significant improvement in GSM-related symptoms were: (i) HCC in terms of VAS for GSM symptoms and FSFI score; (ii) Crosslinked HA in terms of VAS for GSM symptoms, FSFI and VHI score, COL1A1 and COL3A1 mRNA expression on vaginal mucosal biopsies; (iii) NCLHA + CaHA in terms of FSFI score; (iv) PRP + HA in terms of VHI, FSD and SF12 score; (v) microfat and nanofat grafting + PRP in terms of VHI score and FSDS-R score; (vi) PRP alone in terms of VHI and VSQ scores.

CONCLUSIONS

All assessed injection treatments except for MFAT seem to lead to significant improvement in VVA symptoms on validated questionnaires. Further studies are necessary in the field.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Genitourinary Syndrome of Menopause: A Narrative Review Focusing on Its Effects on the Sexual Health and Quality of Life of Women

Genitourinary syndrome of menopause (GSM) is a progressive condition due to a hypoestrogenic state affecting perimenopausal and menopausal women. GSM was previously known as urogenital syndrome, vulvovaginal atrophy, or atrophic vaginitis. The term vulvovaginal atrophy did not encompass the symptoms of the urinary tract like incontinence, urgency, and discomfort, or allude that it is due to a hypoestrogenic state. Although a significant segment of the population is affected by GSM, it is very sparsely studied, detected, and treated. GSM affects the quality of life and sexual health of most menopausal women suffering from it. Only a few healthcare providers ask about the symptoms of GSM and a tiny percentage of women seek consultation for it. This may be because they are either embarrassed or believe it to be a part of the natural process of aging. As the life expectancy of women has increased in general, the prevalence of GSM has also risen, while it still remains underdiagnosed and untreated. Properly educating women so that they can seek consultation regarding symptoms of GSM, and training healthcare professionals about communicating with the patient, as well as correctly identifying, diagnosing, and managing the patient are all important to overcome this communication barrier. Once we cross the barrier of diagnosing patients with GSM, we still have to manage the patients with tailor-made prescriptions according to the severity of the symptoms and their preferences. While there are various treatment options, the most effective one is low-dose topical estrogen therapy. In this review, we intend to explore the existing knowledge about GSM and its effect on the quality of life and sexual health of women along with the treatment options for managing and reversing the effects of GSM.

Stigmatization as a Barrier to Urologic Care: A Review

Heavy societal stigma of certain conditions has created an environment where individuals may be hesitant to seek professional care. Urology is a specialized field that focuses on many of these conditions that society has deemed taboo to discuss. In this review, we address barriers that have prevented patients from seeking urologic care in order to better understand and elucidate important concerns within development of the physician-patient relationship. Recognizing these concerns can also assist in public health outreach approaches to motivate patients for seeking urologic care. The scope of this review was limited to three highly prevalent conditions affecting both men and women, including urinary incontinence, erectile dysfunction, and genitourinary syndrome of menopause.

Urologic view in the management of genitourinary syndrome of menopause

Genitourinary syndrome of menopause (GSM) has a variety of effects on the urinary system and is an important consideration in the care provided to perimenopausal and postmenopausal patients when addressing urinary pathology. Here we discuss the common pathologies of the urinary system related to GSM including lower urinary tract symptoms and recurrent urinary tract infections. Female sexual dysfunction is not to be excluded as a critical part of a urologist's management of GSM but will be discussed elsewhere in this issue.

Current and Emerging Pharmacological Targets and Treatments of Urinary Incontinence and Related Disorders

Overactive bladder syndrome with and without urinary incontinence and related conditions, signs, and disorders such as detrusor overactivity, neurogenic lower urinary tract dysfunction, underactive bladder, stress urinary incontinence, and nocturia are common in the general population and have a major impact on the quality of life of the affected patients and their partners. Based on the deliberations of the subcommittee on pharmacological treatments of the 7th International Consultation on Incontinence, we present a comprehensive review of established drug targets in the treatment of overactive bladder syndrome and the aforementioned related conditions and the approved drugs used in its treatment. Investigational drug targets and compounds are also reviewed. We conclude that, despite a range of available medical treatment options, a considerable medical need continues to exist. This is largely because the existing treatments are symptomatic and have limited efficacy and/or tolerability, which leads to poor long-term adherence. SIGNIFICANCE STATEMENT: Urinary incontinence and related disorders are prevalent in the general population. While many treatments have been approved, few patients stay on long-term treatment despite none of them being curative. This paper provides a comprehensive discussion of existing and emerging treatment options for various types of incontinence and related disorders.

A multicenter, randomized, placebo-controlled study to select the minimum effective dose of estetrol in postmenopausal participants (E4Relief): part 2-vaginal cytology, genitourinary syndrome of menopause, and health-related quality of life

OBJECTIVE

A phase 2 study showed that 15 mg estetrol (E4) alleviates vasomotor symptoms (VMS). Here, we present the effects of E4 15 mg on vaginal cytology, genitourinary syndrome of menopause, and health-related quality of life.

METHODS

In a double-blind, placebo-controlled study, postmenopausal participants (n = 257, 40-65 y) were randomized to receive E4 2.5, 5, 10, or 15 mg or placebo once daily for 12 weeks. Outcomes were the vaginal maturation index and maturation value, genitourinary syndrome of menopause score, and the Menopause Rating Scale to assess health-related quality of life. We focused on E4 15 mg, the dose studied in ongoing phase 3 trials, and tested its effect versus placebo at 12 weeks using analysis of covariance.

RESULTS

Least square (LS) mean percentages of parabasal and intermediate cells decreased, whereas superficial cells increased across E4 doses; for E4 15 mg, the respective changes were -10.81% ( P = 0.0017), -20.96% ( P = 0.0037), and +34.17% ( P < 0.0001). E4 15 mg decreased LS mean intensity score for vaginal dryness and dyspareunia (-0.40, P = 0.03, and -0.47, P = 0.0006, respectively); symptom reporting decreased by 41% and 50%, respectively, and shifted to milder intensity categories. The overall Menopause Rating Scale score decreased with E4 15 mg (LS mean, -3.1; P = 0.069) and across doses was associated with a decreasing frequency and severity of VMS ( r = 0.34 and r = 0.31, P < 0.001).

CONCLUSIONS

E4 demonstrated estrogenic effects in the vagina and decreased signs of atrophy. E4 15 mg is a promising treatment option also for important menopausal symptoms other than VMS.

Effectiveness of vaginal estriol with lactobacilli on urinary symptoms in postmenopausal women: a randomized-controlled trial

OBJECTIVE

The aim of this study was to compare the effects of a vaginal tablet containing estriol (0.03 mg) plus lactobacilli (E3/L) with placebo on lower urinary tract symptoms (LUTS) in postmenopausal women (PMW).

METHODS

This randomized, double-blinded, placebo-controlled trial was conducted at Srinagarind Hospital in Khon Kaen, Thailand. PMW with at least one LUTS, such as frequency, nocturia, dysuria, urgency, or stress or urgency urinary incontinence, were recruited. Participants were randomly assigned to receive either an E3/L tablet or placebo, administered vaginally daily at bedtime for 2 weeks, then twice a week for another 2 weeks. Symptom severity score was assessed using a visual analog scale (VAS), and quality of life (QOL) was measured using the validated Thai version of the Incontinence Impact Questionnaire-Short Form. The primary outcome was proportion of the PMW with LUTS improvement. Secondary outcomes were symptom severity score, participant satisfaction, QOL, and adverse events. Relative risk and 95% confidence intervals (CIs) were calculated using the chi-square or Fisher's exact test. An independent-sample and paired t test were used to compare means.

RESULTS

Thirty-eight participants in each group completed the study. The proportion of PMW whose symptoms improved (both in terms of most bothersome symptom and overall) did not differ significantly between the two groups. Relative risk was 1.00 (95% CI, 0.74-1.36) and 0.90 (95% CI, 0.71-1.15), respectively. There were no differences in symptom severity score, participant satisfaction, or QOL.

CONCLUSIONS

A 1-month course of vaginal E3/L does not appear to improve LUTS in PMW.

Genitourinary Syndrome of Menopause

Introduced in 2014, genitourinary syndrome of menopause (GSM) describes a variety of unpleasant genital, sexual and urinary symptoms that can either be isolated or coexisting and are not related to other medical conditions. GSM is a chronic and progressive condition that requires early recognition and appropriate management to preserve urogenital health. Despite the importance of early detection and treatment, the condition is consistently underdiagnosed and undertreated. Herein, we emphasize how to diagnose GSM in postmenopausal, hypoestrogenic, and hypoandrogenic women and summarize evidence-based treatments focusing on prescription treatments and adjunctive therapies.

The effect of 12 weeks of estriol cream on stress urinary incontinence post-menopause: A prospective multinational observational study

OBJECTIVE

To quantitate the changes in stress urinary incontinence (SUI) outcome measures after 12 weeks of vaginal estriol cream in women with stress incontinence.

METHODS

A prospective multicentre observational study conducted in tertiary urogynaecology centers. Postmenopausal women with pure SUI or stress predominant mixed urinary incontinence (MUI), not receiving any other treatment for their incontinence were given written instructions regarding digital application of a standard dose of vaginal estriol cream. Outcomes were measured at baseline and 12 weeks. The primary objective outcome was vaginal pH. The primary subjective outcome was the stress domain of the Urogenital Distress Inventory-6 (UDI-6). The secondary objective outcome used was the erect cough stress test. Two quality of life questionnaires and two patient reported outcomes were also included.

RESULTS

The 46 postmenopausal recruits had a median age of 62.1 interquartile range (IQR 56.2-65.4). At follow up, the primary subjective outcome SUI domain [UDI-6] significantly improved from 83.3 (IQR 50-100) to 33.3 (33.3-66.7, p ≤ 0.001) as did vaginal pH [from 5.1 (4.9-5.9) to 4.9 (4.6-5.0] p ≤ 0.001; 18/43 patients (42%) were dry on cough stress test.

CONCLUSIONS

Twelve weeks of vaginal estriol cream significantly reduced symptoms of stress urinary incontinence in this sample of postmenopausal women.

Vaginal Hormone Therapy for Conditions of the Lower Urinary Tract

PURPOSE OF REVIEW

Up to half of postmenopausal women experience genitourinary symptoms secondary to hormone deficiency, and there is little consensus on the use of vaginal hormone therapy (VHT) for lower urinary tract symptoms (LUTS) in these patients. This is a review of the scientific literature in the last decade evaluating the use of VHT for disorders of the lower urinary tract including overactive bladder (OAB), stress urinary incontinence (SUI), recurrent urinary tract infections (UTI), and interstitial cystitis/bladder pain syndrome (ICS/BPS).

RECENT FINDINGS

Vaginal estrogen therapy improves OAB symptoms in postmenopausal women, but results are mixed when VHT is used in combination with other treatments. There is inconclusive or limited data for the use of VHT to treat SUI and IC/BPS. Vaginal estrogen and prasterone (DHEA) therapies have demonstrated efficacy as treatment modalities for patients who experience recurrent UTIs. VHT preparations show efficacy for the treatment of certain LUTS and can be considered in carefully selected patients when clinically indicated.

The regulatory effect of sex steroids on the RhoA/ROCK pathway in the rat distal vagina

BACKGROUND

Sex steroids have been demonstrated as important modulators of vaginal function. The RhoA/ROCK calcium-sensitizing pathway plays a role in genital smooth muscle contractile mechanism, but its regulation has never been elucidated.

AIM

This study investigated the sex steroid regulation of the vaginal smooth muscle RhoA/ROCK pathway using a validated animal model.

METHODS

Ovariectomized (OVX) Sprague-Dawley rats were treated with 17β-estradiol (E2), testosterone (T), and T with letrozole (T + L) and compared with intact animals. Contractility studies were performed to test the effect of the ROCK inhibitor Y-27632 and the nitric oxide (NO) synthase inhibitor L-NAME. In vaginal tissues, ROCK1 immunolocalization was investigated; mRNA expression was analyzed by semiquantitative reverse transcriptase-polymerase chain reaction; and RhoA membrane translocation was evaluated by Western blot. Finally, rat vaginal smooth muscle cells (rvSMCs) were isolated from the distal vagina of intact and OVX animals, and quantification of the RhoA inhibitory protein RhoGDI was performed after stimulation with NO donor sodium nitroprusside, with or without administration of the soluble guanylate cyclase inhibitor ODQ or PRKG1 inhibitor KT5823.

OUTCOMES

Androgens are critical in inhibiting the RhoA/ROCK pathway of the smooth muscle compartment in the distal vagina.

RESULTS

ROCK1 was immunolocalized in the smooth muscle bundles and blood vessel wall of the vagina, with weak positivity detected in the epithelium. Y-27632 induced a dose-dependent relaxation of noradrenaline precontracted vaginal strips, decreased by OVX and restored by E2, while T and T + L decreased it below the OVX level. In Western blot analysis, when compared with control, OVX significantly induced RhoA activation, as revealed by its membrane translocation, with T reverting it at a level significantly lower than in controls. This effect was not exerted by E2. Abolishing NO formation via L-NAME increased Y-27632 responsiveness in the OVX + T group; L-NAME had partial effects in controls while not modulating Y-27632 responsiveness in the OVX and OVX + E2 groups. Finally, stimulation of rvSMCs from control animals with sodium nitroprusside significantly increased RhoGDI protein expression, counteracted by ODQ and partially by KT5823 incubation; no effect was observed in rvSMCs from OVX rats.

CLINICAL IMPLICATIONS

Androgens, by inhibiting the RhoA/ROCK pathway, could positively contribute to vaginal smooth muscle relaxation, favoring sexual intercourse.

STRENGTHS AND LIMITATIONS

This study describes the role of androgens in maintaining vaginal well-being. The absence of a sham-operated animal group and the use of the only intact animal as control represented a limitation to the study.

Pelvic Floor Muscle Exercises as a Treatment for Urinary Incontinence in Postmenopausal Women: A Systematic Review of Randomized Controlled Trials

Women frequently suffer from urinary incontinence due to atrophic changes in the urogenital tract. Recommended conservative treatment includes evaluation of pelvic-floor strength and the functional use of pelvic-floor-muscle (PFM) training. Following the PRISMA 2020 guidelines, a search was conducted in the electronic databases PubMed, Web of Science, and Scopus for articles with at least one group performing PFM exercises in post-menopausal women with urinary incontinence. Eight articles were included, and each study had at least one group of PFM exercise-based intervention alone or combined. The volume or duration, frequency, and number of sessions were heterogeneous. All the studies reported significant differences in favor of PFM exercise in strength, quality of life, and/or severity of urinary incontinence. PFM exercise is a highly recommended intervention to treat urinary incontinence in postmenopausal women. However, more research is needed to establish specific factors such as dose-response relationships and to standardize methods for measuring effects.

Identification of the genetic basis of sow pelvic organ prolapse

Introduction: Pelvic organ prolapse (POP) is one contributor to recent increases in sow mortality that have been observed in some populations and environments, leading to financial losses and welfare concerns. Methods: With inconsistent previous reports, the objective here was to investigate the role of genetics on susceptibility to POP, using data on 30,429 purebred sows, of which 14,186 were genotyped (25K), collected from 2012 to 2022 in two US multiplier farms with a high POP incidence of 7.1% among culled and dead sows and ranging from 2% to 4% of all sows present by parity. Given the low incidence of POP for parities 1 and >6, only data from parities 2 to 6 were retained for analyses. Genetic analyses were conducted both across parities, using cull data (culled for POP versus another reason), and by parity, using farrowing data. (culled for POP versus culled for another reason or not culled). Results and Discussion: Estimates of heritability from univariate logit models on the underlying scale were 0.35 ± 0.02 for the across-parity analysis and ranged from 0.41 ± 0.03 in parity 2 to 0.15 ± 0.07 in parity 6 for the by-parity analyses. Estimates of genetic correlations of POP between parities based on bivariate linear models indicated a similar genetic basis of POP across parities but less similar with increasing distance between parities. Genome wide association analyses revealed six 1 Mb windows that explained more than 1% of the genetic variance in the across-parity data. Most regions were confirmed in several by-parity analyses. Functional analyses of the identified genomic regions showed a potential role of several genes on chromosomes 1, 3, 7, 10, 12, and 14 in susceptibility to POP, including the Estrogen Receptor gene. Gene set enrichment analyses showed that genomic regions that explained more variation for POP were enriched for several terms from custom transcriptome and gene ontology libraries. Conclusion: The influence of genetics on susceptibility to POP in this population and environment was confirmed and several candidate genes and biological processes were identified that can be targeted to better understand and mitigate the incidence of POP.

Sexual functioning more than 15 years after premenopausal risk-reducing salpingo-oophorectomy

BACKGROUND

Women with a BRCA1/2 pathogenic variant are advised to undergo premenopausal risk-reducing salpingo-oophorectomy after completion of childbearing, to reduce their risk of ovarian cancer. Several studies reported less sexual pleasure 1 to 3 years after a premenopausal oophorectomy. However, the long-term effects of premenopausal oophorectomy on sexual functioning are unknown.

OBJECTIVE

This study aimed to study long-term sexual functioning in women at increased familial risk of breast or ovarian cancer who underwent a risk-reducing salpingo-oophorectomy either before the age of 46 years (premenopausal group) or after the age of 54 years (postmenopausal group). Subgroup analyses were performed in the premenopausal group, comparing early (before the age of 41 years) and later (at ages 41-45 years) premenopausal risk-reducing salpingo-oophorectomy.

STUDY DESIGN

Between 2018 and 2021, 817 women with a high familial risk of breast or ovarian cancer from an ongoing cohort study were invited to participate in our study. Because of a large difference in age in the study between the premenopausal and postmenopausal salpingo-oophorectomy groups, we restricted the comparison of sexual functioning between the groups to 368 women who were 60 to 70 years old at completion of the questionnaire (226 in the premenopausal group and 142 in the postmenopausal group). In 496 women with a premenopausal risk-reducing salpingo-oophorectomy, we compared the sexual functioning between women in the early premenopausal group (n=151) and women in the later premenopausal group (n=345). Differences between groups were analyzed using multiple regression analyses, adjusting for current age, breast cancer history, use of hormone replacement therapy, body mass index, chronic medication use (yes or no), and body image.

RESULTS

Mean times since risk-reducing salpingo-oophorectomy were 20.6 years in the premenopausal group and 10.6 years in the postmenopausal group (P<.001). The mean age at questionnaire completion was 62.7 years in the premenopausal group, compared with 67.0 years in the postmenopausal group (P<.001). Compared with 48.9% of women in the postmenopausal group, 47.4% of women in the premenopausal group were still sexually active (P=.80). Current sexual pleasure scores were the same for women in the premenopausal group and women in the postmenopausal group (mean pleasure score, 8.6; P=.99). However, women in the premenopausal group more often reported substantial discomfort than women in the postmenopausal group (35.6% vs 20.9%; P=.04). After adjusting for confounders, premenopausal risk-reducing salpingo-oophorectomy was associated with substantially more discomfort during sexual intercourse than postmenopausal risk-reducing salpingo-oophorectomy (odds ratio, 3.1; 95% confidence interval, 1.04-9.4). Moreover, after premenopausal risk-reducing salpingo-oophorectomy, more severe complaints of vaginal dryness were observed (odds ratio, 2.6; 95% confidence interval, 1.4-4.7). Women with a risk-reducing salpingo-oophorectomy before the age of 41 years reported similar pleasure and discomfort scores as women with a risk-reducing salpingo-oophorectomy between ages 41 and 45 years.

CONCLUSION

More than 15 years after premenopausal risk-reducing salpingo-oophorectomy, the proportion of sexually active women was comparable with the proportion of sexually active women with a postmenopausal risk-reducing salpingo-oophorectomy. However, after a premenopausal risk-reducing salpingo-oophorectomy, women experienced more vaginal dryness and more often had substantial sexual discomfort during sexual intercourse. This did not lead to less pleasure with sexual activity.

An evidence-based microscopic hematuria care pathway optimizes decision-making among providers

INTRODUCTION AND HYPOTHESIS

Microscopic hematuria (MH) has many etiologies in women and requires specific gynecologic evaluation. We created a standardized MH pathway to serve as an evidence-based decision aid for providers in our practice.

METHODS

Using a modified Delphi process, a multidisciplinary team reviewed existing guidelines for MH diagnosis and treatment to reach consensus on care pathway components.

RESULTS

Entry into the care pathway by an advanced practice provider is determined by the finding of ≥3 red blood cells per high-power field (RBC/HPF) on microscopic urinalysis. Initial evaluation includes history and physical exam. If there are signs of a gynecologic cause of MH, the conditions are treated and repeat urinalysis is performed in 6 months. If repeat urinalysis shows persistent MH or there are no other apparent causes for MH, we proceed with risk stratification. Through shared decision-making, low-risk patients may undergo repeat urinalysis in 6 months or cystoscopy with urinary tract ultrasound. For intermediate-risk patients, cystoscopy and urinary tract ultrasound are recommended. For high-risk patients, cystoscopy and axial upper urinary tract imaging are recommended. If evaluation is positive, urology referral is provided. If evaluation is negative, low-risk patients are released from care, but intermediate-risk or high-risk patients undergo repeat urinalysis in 12 months. If repeat urinalysis is positive, shared decision-making is used to determine a plan.

CONCLUSIONS

We developed an MH care pathway to standardize care of women with MH across a multidisciplinary group. This pathway serves as a component of value-based care and supports evidence-based care by providers.

Hyaluronic Acid: A Valid Therapeutic Option for Early Management of Genitourinary Syndrome of Menopause in Cancer Survivors?

Genitourinary syndrome of menopause (GSM) is a chronic condition affecting a large number of women, with a major impact on their urogenital health and sexual function. It occurs at midlife because estrogen levels decline with menopause enhancing aging-related changes of the functional anatomy of the urogenital system. Unfortunately, GSM may occur early in the lifespan of women or be exacerbated following anticancer treatments, such as chemotherapy, ionizing radiation, or surgical removal of reproductive organs. Symptoms of GSM are often under-reported by women, under-estimated and under-diagnosed by health care providers (HCPs), and subsequently under-treated, despite their profound negative impact on the quality of life. The mainstay of vaginal treatments is local estrogen therapy (LET) ensuring an effective management of moderate to severe symptomatic GSM. However, LET is generally contraindicated in women with a history of hormone receptor positive cancer, due to the fear of increased recurrence or possible interference with endocrine adjuvant therapies. Among non-hormonal treatments, hyaluronic acid-based moisturizers have shown promising clinical results both in healthy women and in cancer patients or survivors. Its strong water-binding properties provide lubricating and moisturizing effects, which contribute to maintaining a proper level of hydration and viscoelasticity in several body parts, including the urinary tract and genital tissues. Hyaluronic acid-based moisturizers are effective, safe, and well tolerated; therefore, they may represent a valid option for the early management of GSM-associated symptoms in every woman with a history of cancer who is unable or unwilling to undergo hormone-based therapies. Hence, the aim of this review was to provide an overview of GSM etiology and treatment in women with natural or iatrogenic menopause, with a focus on the use of hyaluronic acid as a prophylactic treatment in the context of an integrated management protocol for cancer patients.

Sexual Function in Postmenopausal Women With Symptomatic Pelvic Organ Prolapse Treated Either with Locally Applied Estrogen or Placebo: Results of a Double-Masked, Placebo-Controlled, Multicenter Trial

BACKGROUND

Local estrogen therapy (LET) has beneficial effects on genitourinary atrophy; however it is currently unclear if LET improves sexual function in postmenopausal women with pelvic organ prolapse (POP).

AIM

To evaluate if LET vs placebo results in an improved sexual function in postmenopausal women with symptomatic POP.

METHODS

We performed a secondary analysis of sexual outcomes of a previous randomized controlled trial comparing LET and placebo in 120 postmenopausal women (60/group) with symptomatic POP stage ≥3 and planned prolapse surgery. Women were randomly assigned to receive local estrogen or placebo cream 6 weeks preoperatively. The effect of therapy vs placebo was assessed with ANOVA with interaction effect of time*group and a multivariable linear regression model was built to assess the impact of different variables on sexual function before therapy.

OUTCOMES

We evaluated the sexual function score in sexually active women of our study population using the German Pelvic Floor Questionnaire at recruitment time and again after 6 weeks of treatment.

RESULTS

Among 120 randomized women, 66 sexually active women remained for final analysis. There was no significant difference in the change of the sexual function score over time between the treatment groups (difference in changes in score from baseline to 6 weeks for Estrogen group vs control group was -0.110 with 95% CI -0.364 to 0.144) Multivariable analysis showed that no independent risk factor for unsatisfying sexual function score could be identified.

CLINICAL IMPLICATIONS

Based on our results, LET has no beneficial effect on sexual function in postmenopausal women with POP.

STRENGTHS AND LIMITATIONS

Main strength of our study lies in the study design and in the use of a condition- specific questionnaire. As this is a secondary analysis, this study may be insufficiently powered to identify differences in sexual data between groups.

CONCLUSION

LET had no impact on female sexuality in postmenopausal women with POP. Marschalek M-L, Bodner K, Kimberger O, et al. Sexual Function in Postmenopausal Women With Symptomatic Pelvic Organ Prolapse Treated Either with Locally Applied Estrogen or Placebo: Results of a Double-Masked, Placebo-Controlled, Multicenter Trial. J Sex Med 2022;19:1124-1130.

Clinical evaluation of autologous platelet rich plasma injection in post menopausal vulvovaginal atrophy; A pilot study

BACKGROUND

There is lack of published data investigating injection of autologous platelet rich plasma (A-PRP) alone in treatment of postmenopausal VVA.

OBJECTIVES

In this pilot study, we aimed to investigate the safety and efficacy of injection of A-PRP alone in postmenopausal VVA in women without history of cancer breast to explore its utility as a hormone free therapy for postmenopausal VVA and for vulvovaginal rejuvenation.

METHODS

In this pilot study, 47 women with postmenopausal VVA were included. Vulvovaginal condition was evaluated at the baseline by vaginal health index (VHI). Impact of VVA on quality of life and sexual life was evaluated at the baseline by vulvovaginal symptom questionnaire (VSQ). Treatment protocol was 2 sessions of A-PRP injection with one month interval. Response was evaluated one month after the last session by VHI and VSQ. Side effects were also evaluated.

RESULTS

Post menopausal VVA was significantly improved by A-PRP injection as indicated by significant improvement of total VHI score and its items at 1 month post treatment ( p vlue < 0.001). Also, there was significant improvement of burning, hurting, being irritated, being dry, discharge, desire to be intimate, sexual relationships, pain during sexual activity, and dryness during sexual activity at 1 month post treatment as indicated by VSQ ( p value = 0.045 for being dry and < 0.001 for other items).

CONCLUSIONS

A-PRP injection is safe and effective as minimally invasive monotherapy for postmenopausal VVA without history of cancer breast and hence for vulvovaginal rejuvenation.

The Er:YAG vaginal laser for management of women with genitourinary syndrome of menopause (GSM)

The purpose of our study was to investigate the effects of vulvovaginal erbium laser on the genitourinary syndrome of menopause (GSM) and sexual function of postmenopausal women. We conducted a retrospective study of sixty-four postmenopausal women with GSM, and these patients were scheduled for three times of vulvovaginal erbium laser treatment. A baseline and post-treatment vaginal status was assessed by measuring vaginal pH, patients' subjective vulvovaginal atrophy (VVA) symptoms, which included dryness, dyspareunia, itching, and burning. The urinary response to treatment was assessed using ICIQ-SF, UDI-6, IIQ-7, OABSS, and POPDI-6. Sexual function was evaluated using the Female Sexual Function Index (FSFI) before and after vulvovaginal laser therapy. Patient follow-ups were scheduled for 12 months after treatment. A total of sixty-four patients were enrolled in the study. We observed the significant improvement in the percentage of negative symptoms (dryness/dyspareunia/itching/burning) and in lower urinary tracts symptoms evaluated with ICIQ-SF, UDI-6, IIQ-7, OABSS, and POPDI-6 (P < 0.05). Patients' overall satisfaction regarding their sexual life, assessed via Female Sexual Function Index (FSFI), showed significant improvement in its six domains of sexual function (P < 0.05). The pH level of vaginal secretions significantly decreased. No long-term complications were found post-treatment. The Er:YAG vaginal laser procedure is associated with a significant improvement in GSM and sexual function of postmenopausal women. Our result demonstrates that it can be a safe and efficacious treatment for patients with GSM without any serious adverse effects up to 1-year post-treatment. The long-term effects of using vulvovaginal laser in the treatment of GSM should be investigated.

The role of hormone therapy in urogenital health after menopause

Menopause represents an endocrine challenge to urogenital health, as oestrogens deprivation and androgens decline significantly contributes to age-related involution of vulvovaginal tissues and lower urinary tract. Genitourinary syndrome of menopause (GSM) is a clinical entity including the chronic and progressive condition of vulvovaginal atrophy (VVA) and encompassing both anatomical and functional consequences of menopause. The term GSM describes genital, sexual and urinary symptoms with a detrimental impact on quality of life (QOL). Several treatment options are available, but many barriers are still present to adequately diagnose and treat GSM. This review aims to present current evidences about epidemiology, aetiology, diagnosis and treatment of GSM, with a focus on prescription medications [low-dose local oestrogen therapy (LET), prasterone (DHEA) and the SERM ospemifene] for urogenital symptoms in healthy postmenopausal women and in special populations, including women with premature ovarian insufficiency (POI) and breast cancer survivors (BCS).

Genitourinary Syndrome of Menopause: Epidemiology, Physiopathology, Clinical Manifestation and Diagnostic

Genitourinary syndrome of menopause (GSM) is a term used to define a compilation of signs and symptoms arising from decreased estrogenic stimulation of the vulvovaginal and lower urinary tract. Among 27–84% of women in postmenopausal are affected for symptoms of GSM, and these can unquestionably impair health, sexual function, consequently the quality of life of these women. The main signs and symptoms of GSM include, among others, burning, irritation, vulvovaginal dryness, dyspareunia, urinary symptoms of urgency, dysuria, or recurrent urinary tract infection. The diagnosis can be made through anamnesis, questionnaires, physical exams, and, sometimes, complementary exams. Objective vaginal assessment is essential and can be complemented by using the Vaginal Health Index (VHI), Vaginal Maturation Index (VMI), or vaginal pH measurement. The acknowledgment of this condition by health professionals is crucial for its identification and proper management and exclusion of other conditions that make a differential diagnosis with it.

Non-oestrogenic modalities to reverse urogenital aging

Urogenital aging is a common process affecting all women in the post-menopausal period of their life, and it is substantially due to oestrogen deprivation after ovarian function cessation. These changes can lead to a progressive, chronic, and complex association of symptoms identified as the genitourinary syndrome of menopause, which has a significant impact on quality of life. Genitourinary syndrome and urogenital aging do not resolve spontaneously and usually recur when treatment is stopped. Therefore, appropriate long-term management is of paramount importance, and local oestrogen is the most effective treatment to reverse urogenital aging and to improve symptoms of genitourinary syndrome as replacement therapy. In some women, topical oestrogen may be inconvenient, it may not achieve complete response, or it may be contra-indicated. Several non-hormonal therapies have been investigated, but few treatments have been reported as potentially able to reverse the urogenital aging process similarly to exogenous oestrogens. Laser seems the most promising, although further studies to define its safety and efficacy are mandatory. Vitamin D and E, and phytotherapy have returned conflicting results and require further confirmation. Lifestyle modifications, physiotherapy, and electrical stimulation represent inexpensive and applicable treatments that might slow urogenital aging. Among the hormonal non-oestrogenic therapies, the use of vaginal oxytocin and dehydroepiandrosterone have been found to be effective compared to placebo, as well as the use of oral ospemifene, which partially relieves vulvovaginal atrophy.

Development of Hormonal Intravaginal Rings: Technology and Challenges

Intravaginal rings (IVRs) are minimally invasive polymeric devices specifically designed to be used for the sustained and prolonged release of various type of drugs such as hormones. One of the benefits of using topical drug delivery systems (e.g., IVRs) is the fact that systemic drug delivery may cause drug resistance due to elevated drug levels. Topical drug delivery also provides higher concentrations of the drug to the target site and has fewer side effects. In addition, when a drug is administered vaginally, the hepatic first-pass effect is avoided, resulting in higher absorption. Contraception and treatments for specific diseases such as endometriosis and hormone deficiencies can be improved by the administration of hormones via an IVR. This article aims to classify and compare various designs of commercially available and non-commercial hormonal IVRs and to analyze their performance. Current challenges affecting the development of IVRs are investigated, and proposed solutions are discussed. A comprehensive search of publications in MEDLINE/PubMed and of commercial product data of IVRs was performed, and the materials, designs, performance, and applications (e.g., contraception, endometriosis, estrogen deficiency and urogenital atrophy) of hormonal IVRs were thoroughly evaluated. Most hormonal IVRs administer female sex hormones, i.e., estrogen and progestogens. In terms of material, IVRs are divided into 3 main groups: silicone, polyurethane, and polyethylene-co-vinyl acetate IVRs. As regards their design, there are 4 major designs for IVRs which strongly affect their performance and the timing and rate of hormone release. Important challenges include reducing the burst release and maintaining the bioavailability of hormones at their site of action over a prolonged period of administration as well as lowering production costs. Hormonal IVRs are a promising method which could be used to facilitate combination therapies by administering multiple drugs in a single IVR while eliminating the side effects of conventional drug administration methods. IVRs could considerably improve womenʼs quality of life all over the world within a short period of time.

Intravaginal 6.5 mg prasterone administration in postmenopausal women with overactive bladder syndrome: A pilot study

OBJECTIVE

The aim of this study was to evaluate the impact of vaginally prasterone administration on postmenopausal women with genitourinary syndrome of menopause (GSM) affected by overactive bladder syndrome (OAB). A secondary aim of this study was to assess the efficacy of prasterone on VVA and quality of life (QoL).

STUDY DESIGN

Thirty-two postmenopausal women with GSM and referred OAB symptoms received treatment with daily intravaginal prasterone 6.5 mg. We assessed urinary symptoms through approved ICIQ-OAB and ICIQ-UI questionnaires on incontinence. Women were also screened by the Vaginal Health Index (VHI) to investigate the vulvovaginal atrophy (VVA). Quality of life (QoL) was assessed by the SF-12 Health Survey. Each questionnaire was administrated at baseline (T0) and after a 12-week treatment (T1).

RESULTS

Incontinence questionnaires showed improvement at T1 (from 7.8 ± 2.7 to 2.7 ± 2.2, p < 0.001). Even if women referred an improvement of daily urine although the women reported improvement in daily urine leaks, their urine leak amount did not improve statistically significant [T0 (28.6%) Vs T1 (14.3%), p < 0.16]. Prasterone therapy improved significantly the VHI [T1(21 ± 3.7) Vs T0 (10.8 ± 4.1), p < 0.001]. Finally, women had a statistically significant improvement both in Mental [T1(49.9 ± 11.2) Vs T0 (42 ± 9.2), p < 0.009],) and Physical Health [T1(47.1 ± 9.1) Vs T0 (38.6 ± 8.4), p < 0.006], domains of the SF-12 questionnaire. No women referred side effects.

CONCLUSION

Prasterone is an inactive precursor converted into estrogens and androgens into vaginal tissue. It leads to positive effects on VVA through the activation of the vaginal androgen and estrogen receptors. Empirical evidence in this study suggests that intravaginal 6.5 mg prasterone administration could be an effective treatment for postmenopausal women with GMS affected by OAB.

Surgical Assessment of Tissue Quality during Pelvic Organ Prolapse Repair in Postmenopausal Women Pre-Treated Either with Locally Applied Estrogen or Placebo: Results of a Double-Masked, Placebo-Controlled, Multicenter Trial

The aim of this prospective randomized, double-masked, placebo-controlled, multicenter study was to analyze the surgeon’s individual assessment of tissue quality during pelvic floor surgery in postmenopausal women pre-treated with local estrogen therapy (LET) or placebo cream. Secondary outcomes included intraoperative and early postoperative course of the two study groups. Surgeons, blinded to patient’s preoperative treatment, completed an 8-item questionnaire after each prolapse surgery to assess tissue quality as well as surgical conditions. Our hypothesis was that there is no significant difference in individual surgical assessment of tissue quality between local estrogen or placebo pre-treatment. Multivariate logistic regression analysis was performed to identify independent risk factors for intra- or early postoperative complications. Out of 120 randomized women, 103 (86%) remained for final analysis. Surgeons assessed the tissue quality similarity in cases with or without LET, representing no statistically significant differences concerning tissue perfusion, tissue atrophy, tissue consistency, difficulty of dissection and regular pelvic anatomy. Regarding pre-treatment, the rating of the surgeon correlated significantly with LET (r = 0.043), meaning a correct assumption of the surgeon. Operative time, intraoperative blood loss, occurrence of intraoperative complications, total length of stay, frequent use of analgesics and rate of readmission did not significantly differ between LET and placebo pre-treatment. The rate of defined postoperative complications and use of antibiotics was significantly more frequent in patients without LET (p = 0.045 and p = 0.003). Tissue quality was similarly assessed in cases with or without local estrogen pre-treatment, but it seems that LET prior to prolapse surgery may improve vaginal health as well as tissue-healing processes, protecting these patients from early postoperative complications.

Bladder Hyperactivity Induced by Oxidative Stress and Bladder Ischemia: A Review of Treatment Strategies with Antioxidants

Overactive bladder (OAB) syndrome, including frequency, urgency, nocturia and urgency incontinence, has a significantly negative impact on the quality-of-life scale (QoL) and can cause sufferer withdrawal from social activities. The occurrence of OAB can result from an imbalance between the production of pro-oxidants, such as free radicals and reactive species, and their elimination through protective mechanisms of antioxidant-induced oxidative stress. Several animal models, such as bladder ischemia/reperfusion (I/R), partial bladder outlet obstruction (PBOO) and ovarian hormone deficiency (OHD), have suggested that cyclic I/R during the micturition cycle induces oxidative stress, leading to bladder denervation, bladder afferent pathway sensitization and overexpression of bladder-damaging molecules, and finally resulting in bladder hyperactivity. Based on the results of previous animal experiments, the present review specifically focuses on four issues: (1) oxidative stress and antioxidant defense system; (2) oxidative stress in OAB and biomarkers of OAB; (3) OAB animal model; (4) potential nature/plant antioxidant treatment strategies for urinary dysfunction with OAB. Moreover, we organized the relationships between urinary dysfunction and oxidative stress biomarkers in urine, blood and bladder tissue. Reviewed information also revealed the summary of research findings for the effects of various antioxidants for treatment strategies for OAB.

Hyaluronic acid in vulvar and vaginal administration: evidence from a literature systematic review

Vulvovaginal pathology impairs the quality of life of both women in menopause and those who are not. Different therapies have been proposed, mainly related to estrogen therapy in postmenopausal women. However, some contraindications limit its use, and different moisturizers or lubricants have been tested. Hyaluronic acid is a promising and widely used vaginal medical treatment with a moisturizing action and appears to provide a solution. For this reason, we performed a systematic review of the literature. We searched for original articles without date restriction until 30 April 2020. We included all clinical trials which administered local hyaluronic acid in the vulva or vagina. Only English studies and those performed in humans were eligible. Seventeen original studies were included in the review (from randomized controlled trials to longitudinal studies). Hyaluronic acid was generally found to be effective in improving vulvovaginal symptoms (dyspareunia, itching, burning, dryness) and signs (bleeding, atrophy, vaginal pH). In conclusion, hyaluronic acid has the properties to be an efficient moisturizer for women suffering from vulvovaginal atrophy who have contraindications for estrogen therapy and for vulvovaginal signs and symptoms affecting sexual well-being. However, a well-designed randomized controlled trial is needed in order to clarify its efficacy and safety profile.

Asiatic Acid, a Natural Compound that Exerts Beneficial Effects on the Cystometric and Biochemical Parameters in the Retinyl Acetate-Induced Model of Detrusor Overactivity

Scientists have been constantly looking for new synthetic and natural compounds that could have beneficial effects in bladder overactivity. Our attention was drawn by asiatic acid that influences a number of molecules and signaling pathways relevant for the proper functioning of the urinary tracts in humans. In the present project we wanted to check whether asiatic acid would have positive effects in the confirmed animal model of detrusor overactivity (DO) and whether it would affect the bladder blood flow, urothelium thickness, inflammatory and oxidative stress markers, neurotrophic and growth factors, and other parameters important for the activity of the urinary bladder. The outcomes of our study showed that a 14-day administration of asiatic acid (30 mg/kg/day) by oral gavage normalizes the cystometric parameters corresponding to DO and reduces the accompanying oxidative stress (measured by the levels of malondialdehyde-61,344 ± 24,908 pg/ml vs. 33,668 ± 5,071 pg/ml, 3-nitrotyrosine-64,615 ± 25,433 pg/ml vs. 6,563 ± 1,736 pg/ml, and NOS2-2,506 ± 411.7 vs. 3,824 ± 470.1 pg/ml). Moreover, it decreases the urinary secretion of neurotrophins (BDNF-304.4 ± 33.21 pg/ml vs. 119.3 ± 11.49 pg/ml and NGF-205.5 ± 18.50 vs. 109.7 ± 15.94 pg/ml) and prevents the changes in a range of biomarkers indicating the dysfunction of the urinary bladder, CGRP (421.1 ± 56.64 vs. 108.1 ± 11.73 pg/ml), E-Cadherin (773.5 ± 177.5 pg/ml vs. 1,560 ± 154.5 pg/ml), OCT3 (3,943 ± 814.6 vs. 1,018 ± 97.07 pg/ml), SNAP-23 (6,763 ± 808.9 pg/ml vs. 3,455 ± 554.5 pg/ml), SNAP-25 (2,038 ± 162.7 pg/ml vs. 833.3 ± 65.48), substance P (171.7 ± 16.86 pg/ml vs. 65.07 ± 8.250 pg/ml), SV2A (1,927 ± 175.3 pg/ml vs. 1,154 ± 254.9 pg/ml), tight junction protein 1 (360.1 ± 95.05 pg/ml vs. 563.4 ± 65.43 pg/ml), VAChT (16,470 ± 2,419 pg/ml vs. 7,072 ± 1,339 pg/ml), VEGFA (318.3 ± 37.89 pg/ml vs. 201.5 ± 22.91 pg/ml). The mentioned parameters are associated with smooth muscle contractions, urothelial barrier, transportation and release of transmitters, or bladder compensation. Thus, the presented findings allow to suggest a possible future role of asiatic acid in the prevention of conditions accompanied by DO, such as overactive bladder.

Updates on Therapeutic Alternatives for Genitourinary Syndrome of Menopause: Hormonal and Non-Hormonal Managements

Postmenopausal atrophic vaginitis, along with vasomotor symptoms and sleep disorders, is one of the most troublesome symptoms of menopause. However, many women do not manage this symptom properly due to insufficient knowledge of the symptoms or sexual embarrassment. With appropriate treatment, many postmenopausal women can experience relief from discomforts, including burning sensation or dryness of the vagina and dyspareunia. Topical lubricants and moisturizers, systemic and local estrogens, testosterones, intravaginal dehydroepiandrosterones (DHEAs), selective estrogen receptor modulators, and energy-based therapies are possible treatment modalities. Systemic and local estrogen therapies effectively treat genitourinary syndrome of menopause (GSM), but they are contraindicated in patients with breast cancer, for whom lubricants and moisturizers must be considered as the primary treatment. Intravaginal DHEA and ospemifene can be recommended for moderate to severe GSM; however, there is insufficient data on the use of intravaginal DHEA or ospemifene in patients with breast cancer, and further studies are needed. Energy-based devices such as vaginal laser therapy reportedly alleviate GSM symptoms; however, the U.S. Food and Drug Administration warning has recently been issued because of complications such as chronic pain and burning sensations of the vagina. To summarize, clinicians should provide appropriate individualized treatment options depending on women's past history, symptom severity, and chief complaints.

Association Between Estrogen Receptors and GATA3 in Bladder Cancer: A Systematic Review and Meta-Analysis of Their Clinicopathological Significance

BACKGROUND

Estrogen receptors alpha (ERα) and beta (ERβ) and the cooperating protein GATA-binding factor 3 (GATA3) have been implicated in bladder carcinogenesis and tumour progression. GATA3 and ER have been functionally linked in the establishment of luminal fate in breast tissue, but to date their relationship in bladder cancer has not been established. This information will be useful to advance diagnostic and prognostic markers.

AIM

To determine the relationship between the expression of ERα, ERβ and GATA3 in bladder cancer, disclose their prognostic and diagnostic value and their association with clinicopathological characteristics.

METHODS

A comprehensive literature search in PubMed database was performed for all immunohistochemical studies of ERα, ERβ and/or GATA3 in bladder cancer patients. We selected eligible studies in accordance with the PRISMA guidelines and evaluated methodological quality and risk of bias based on quality criteria from the reporting recommendations for tumour MARKer (REMARK) prognostic studies. Risk of bias assessment was performed using Review Manager 5. R software was used for all statistical analysis, the packages used were meta and dmetar for the standard meta-analysis, and netmeta for the network meta-analysis.

RESULTS

Thirteen studies were eligible for ERα, 5 for ERβ and 58 for GATA3 meta-analysis. Low grade tumours showed significantly lower ERα expression. GATA3 was widely expressed in bladder tumours, especially urothelial carcinomas, with higher expression of GATA3 in low grade and low stage tumours. Data was insufficient to determine the prognostic value of either ERα or ERβ, but GATA3-positivity was associated with higher recurrence free survival. A negative correlation between ERα or ERβ positivity and GATA3 expression was disclosed. Additionally, several sources of heterogeneity were identified, which can be used to improve future studies.

CONCLUSION

The clinicopathological value of ERα and ERβ was inconclusive due to low availability of studies using validated antibodies. Still, this meta-analysis supports GATA3 as good prognostic marker. On the contrary, ERα-positivity was associated to higher grade tumours; while ERα and ERβ were inversely correlated with GATA3 expression. Considering that it has previously been shown that bladder cancer cell lines have functional ERs, this suggests that ERα could be activated in less differentiated cells and independently of GATA3. Therefore, a comprehensive analysis of ERα and ERβ expression in BlaCa supported by complete patient clinical history is required for the identification of BlaCa subtypes and subgroups of patients expressing ERα, to investigate if they could benefit from treatment with hormonal therapy.

SYSTEMATIC REVIEW REGISTRATION

Prospero, CRD42021226836.

Effect of electroacupuncture in pre- and postmenopausal women with stress urinary incontinence: A subgroup analysis of two randomised clinical trials

OBJECTIVE

To evaluate the effect of electroacupuncture and assess the impact of menopausal status in women with stress urinary incontinence or stress-predominant mixed urinary incontinence.

METHODS

This study was conducted as a subgroup analysis of the data collected from two multicentre, randomised controlled trials conducted on 1004 women; 384 of these subjects were pre- or postmenopausal women who received the same electroacupuncture treatment for stress urinary incontinence or stress-predominant mixed urinary incontinence. The primary outcome evaluated in this study was the proportion of subjects who had at least a 50% reduction in the mean 72-hour incontinence episodes frequency from baseline and the difference between pre- and postmenopausal groups, as measured at the end of 6 weeks using the 72-hour bladder dairy.

RESULTS

Among the 384 women, 132 were premenopausal and 252 were postmenopausal. Compared with the baseline, measurement at the end of 6 weeks of treatment showed at least 50% reduction in the mean 72-hour incontinence episodes frequency in 61.83% and 58.85% of the women in the premenopausal and postmenopausal groups, respectively (difference 1.06%, 95% confidence interval, -13.87 to 15.99; P = .889). No statistically significant intergroup differences were noted in the changes from baseline in the International Consultation on Incontinence Questionnaire-Short Form score and the 1-hour amount of urine leakage. Electroacupuncture-related adverse events occurred in 1.52% of the premenopausal and 1.59% of the postmenopausal women.

CONCLUSION

This subgroup analysis indicated that electroacupuncture can improve the symptoms of urinary incontinence in women with stress urinary incontinence or stress-predominant mixed urinary incontinence and that menopausal status may not affect the effects of electroacupuncture in subjects.

Ultralow 0.03 mg vaginal estriol in postmenopausal women who underwent surgical treatment for stress urinary incontinence: effects on quality of life and sexual function

OBJECTIVE

To evaluate the efficacy of low-dose, intravaginal estriol ovules in postmenopausal women with stress urinary incontinence (SUI) before and after transobturator tape (TOT) placement, assessing vaginal health, quality of life (QoL), and sexual function.

METHODS

Ninety-six postmenopausal women affected by SUI and scheduled for TOT placement were enrolled. Women were randomized and divided into two groups through 1:1 at baseline (T0): study group (group A, n = 48) and control group (group B, n = 48). Group A was treated daily for 16 weeks with an intravaginal ovule containing 0.03 mg estriol. Vaginal epithelium maturation, QoL, and sexual function were investigated by using the Vaginal Maturation Index (VMI), Short Form-36 (SF-36) questionnaire, and Female Sexual Function Index (FSFI) questionnaire at baseline (T0), before surgery (T1), and 8 weeks after surgery (T2), respectively.

RESULTS

Thirty-six women from group A and 44 women from group B completed the study. The VMI improved in group A at T1 (T1 [43.1] vs T0 [38.1]; P = 0.04) and T2 (T2 [47.8] vs T0 [38.1]; P = 0.001). The physical index score of the QoL improved only after surgery in group A (T2 [49.4] vs T0 [39.7]; P = 0.001). On the contrary, the mental index score improved at T1 [T1 (41.9) vs T0 (37.9), (P = 0.02)] and at T2 [T2 (49.6) vs T0 (37.9), P = 0.001]. Group B had improvement of the physical (45.6 vs 39.4; P = 0.001) and mental (43.6 vs 38.9; P = 0.002) index scores at T2. Sexual function improved in group A at T1 (13.9 vs 18.6; P = 0.001) and at T2 (13.9 vs 25.2; P = 0.001), and in group B at T2 (14 vs 17.2; P = 0.001). Moreover, it improved after TOT placement more in group A than in group B (P = 0.001).

CONCLUSIONS

Ultralow-dose topical vaginal ovules containing 0.03 mg estriol administrated before and after TOT placement could improve the vaginal epithelium maturation of postmenopausal women affected by SUI. Moreover, vaginal estriol ovules also improved the surgical outcome investigated by SF-36 and FSFI.

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.

Reappraisal of the Definition Criteria for "Genitourinary Syndrome of Menopause," and its Effect on Quality of Life in Turkish Postmenopausal Women

OBJECTIVE

To reappraise the definition of Genitourinary syndrome of menopause (GSM) and to evaluate the prevalence and effect of GSM on quality of life in Turkish postmenopausal women.

METHODS

A multicenter, cross-sectional, and observational study was designed. Four hundred three postmenopausal women between the ages of 43-75 who attended Urology and Gynecology clinics between November 2019 and April 2020 were included.They were divided into 2 groups: Group I (GSM, n:288, 71.5%) and Group II (non-GSM, n:115, 28.5%). Demographic data, presence and intensity of genitourinary symptoms were recorded. The impact of menopause and urinary incontinence on quality of life was evaluated with the Menopause-Specific Quality of Life Questionnaire and the King's Health Questionnaire.

RESULTS

The most common symptoms were vaginal dryness (66.2%), reduced lubrication (55.3%), and urgency (54.8%). Urinary incontinence was present in 39.2% of women. Worse quality of life in terms of psychosocial and sexual domains of the Menopause-Specific Quality of Life Questionnaire was significant in Group 1 (P < .001). Group 1 had significantly worse scores for all domains of the King's Health Questionnaire. Only the rate of patients with stress incontinence was higher in Group 1. However, the percentage of moderate and severe symptoms for all types of incontinence was higher in Group 1. Although the prevalence of GSM was 71.5% according to our definition, the percentage of patients previously visiting healthcare professionals for their symptoms was low (52.8%).

CONCLUSION

Our findings show that urologists and gynecologists should question both symptom groups of postmenopausal women, even if patients do not bring up genitourinary symptoms.

The effects of menopause on the quality of life and long-term outcomes of transobturator tape treatment in women with stres urinary incontinence

Purpose:

We aimed to investigate the effects of menopause on long-term outcomes of transobturator tape (TOT) surgery.

Materials and Methods:

Patients who underwent TOT surgery were evaluated under two groups as postmenopausal and premenopausal. The International Consultation on Incontinence short-form questionnaire (ICIQ-SF), Incontinence Impact Questionnaire (IIQ-7) and Urogenital Distress Inventory-Short Form (UDI-6) questionnaires were completed by the patients at the 1^st and 5^th-year follow-up sessions. Patients with a postoperative UDI-6 and IIQ-7 score of <10 were considered as cured, those with lower postoperative scores compared to the preoperative period were regarded as improved, and the cases that had higher postoperative scores than preoperative values were interpreted as TOT failure. The TOT success rates were compared between the results obtained from UDI-6 and IIQ-7.

Results:

A total of 109 patients were included in the study (53 postmenopausal and 56 premenopausal). We contacted with 90 (48 premenopausal and 42 postmenopausal) women at 1^st year control and 80 (44 premenopausal and 36 postmenopausal) women at 5^th year control. There was a significant improvement in all of three questionnaires between the preoperative and post-operative 1^st year control (ICIQ-SF: 15.5±2.5 vs. 1.8±4.3, p <0.001; IIQ-7: 68.9±9.8 vs. 2.75±15.2, p <0.001; UDI-6: 27.1±11.1 vs. 6.0±14.6, p <0.001) and the preoperative and post-operative 5^th year control (ICIQ-SF: 15.5±2.5 vs. 3.1±5.3, p <0.001; IIQ-7: 68.9±9.8 vs. 9.6±26.7, p <0.001; UDI-6: 27.1±11.1 vs. 5.1±10.0, p <0.001). When we compared the premenopausal and postmenopausal patients in terms of recurrent urinary tract infection (UTI); 5 (12%) patients had recurrent UTI in postmenopausal group but no patients had recurrent UTI in premenopausal group at 1^st year follow-up (p=0.039) and similarly the same 5 (13.9%) patients in follow-up had recurrent UTI in postmenopausal group but no patients had recurrent UTI in premenopausal group at 5^th year follow-up (p=0.045). There were no significant differences between the premenopausal and postmenopausal patients in terms of TOT success rates at 1^st and 5^th year control, evaluated with UDI-6 (1st year: p=0.198 and 5^th year: p=0.687) and IIQ-7 (1^st year: p=0.489 and 5^th year: p=0.608) questionnaires.

Conclusions:

Transobturator tape surgery is an effective and reliable method according to the long-term outcomes reported in this paper. In the current study, we determined that the TOT success rates were not affected by the presence of menopause.

Effective Prevention of Recurrent UTIs With Vaginal Estrogen: Pearls for a Urological Approach to Genitourinary Syndrome of Menopause

OBJECTIVE

To review the available data related to the prevention of recurrent urinary tract infection (rUTI) in postmenopausal women with vaginal estrogen preparations and provide the urologic community with the confidence to identify and treat genitourinary syndrome of menopause (GSM).

MATERIALS AND METHODS

A literature search of MEDLINE and the Cochrane Central Register of Controlled Trials databases was performed to identify studies utilizing vaginal estrogen in the treatment of urological conditions related to rUTI and GSM.

RESULTS

In the setting of untreated GSM, the etiology of rUTIs (at least 3 episodes of UTIs in 12 months or at least 2 episodes in 6 months) is not fully elucidated, but estrogen deficiency is a contributing factor. The diagnosis of GSM is primarily a clinical diagnosis supported by other objective findings including: a vaginal pH >5, decreased content of superficial cells, and/or increased proportion of parabasal cells on vaginal maturation index. Local vaginal estrogen, dehydroepiandrosterone (prasterone), and ospemifene are commonly used GSM treatments. Thirty-one trials were identified utilizing estrogen preparations for rUTI in postmenopausal women.

CONCLUSION

Overall, multiple randomized clinical trials have successfully been completed to show the efficacy of local estrogen preparations for the treatment of rUTIs. This high yield review provides a framework for assessing GSM, prescribing recommendations for local vaginal hormone preparations, and a summary of the substantial evidence supporting the new 2019 American Urological Association/Canadian Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction Guidance for local vaginal estrogen use for rUTI.