JOURNAL OF THE
VOLUME XXlV
Copyright 6 1976 by the American Geriatrics Society
A U G U S T 1976
NUMBER 8 Printed in U.S.A.
Hormone Implants for Urinary Disorders in Postmenopausal Women E. SCHLEYER-SAUNDERS, MD, FICS* London, England
ABSTRACT: Urinary disorders associated with the menopause were studied in 300 postmenopausal women between the ages of 45 and 85; 210 were multiparous and 90 nulliparous. The presenting urinary symptom was dysuria in 60 patients and incontinence in 100 patients. In the latter group, 25 had urgency-incontinence, 45 stressincontinence, and 30 a combined form. The distal part of the urethra, being of the same embryologic origin as the genital tract, is estrogen-dependent. Hormone replacement in the form of implants resulted in improvement in 70 percent of the patients and thus reduced the need for surgical intervention. In the course of a study of the menopause (1)I was impressed by the large number of women with urinary disorders and by the beneficial effect of treatment by hormone implantation (2). Women of this age group are predisposed to urinary disorders because of: 1) the special anatomic structure and the intimate relationship of the urethra and trigone of the bladder to the genital tract; 2) the high incidence of injuries during childbirth; and 3) the estrogen-dependency of the urethral as well as the vaginal mucosa. Physiology of micturition. The intravesical pressure caused by bladder filling stimulates receptors in the bladder wall and by a reflex process
via the spinal cord stimulates contractions of the smooth muscle of the bladder; this opens the bladder ostium and forms a funnel-shaped opening into the urethra. At the same time the voluntary muscles around the outer part of the urethra relax to enable the urine to be voided. Normal urinary control depends on the efficiency of the urethral sphincter, on the tone of the muscles and elastic fibers around the urethra and on an intact vesico-urethral angle. URINARY DISORDERS The most common symptoms of urinary disorders are dysuria and incontinence. Dysuria (painful micturition) accompanied by urgency often implies a urinary infection. It usually is successfully treated by antibiotics and antispasmodics, though there is a tendency for the symptoms to recur.
* Hon. Consultant Gynaecologist and Governor Italian Hospital. Address for correspondence: E. Scheyler-Saunders, MD, 56, Wimpole Street, London, England W1M 7DF.
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Vol. XXIV
E. SCHLEYER-SAUNDERS
Urinary incontinence may be manifested as urgency-incontinence or stress-incontinence or a combination of both. Urgency-incontinence is a n urgent desire to pass urine associated with painful contractions of the detrusor muscles of the bladder. The patient has to empty the bladder quickly; otherwise leakage of urine will occur. It usually is caused by intravesical irritation from inflammation of the trigone, a calculus, or hypersensitivity of the detrusor muscles (irritable bladder). Leakage occurs when the bladder is full, indeppdent of abdominal stress. Stress-incontinence is a spontaneous leakage of urine without any preliminary feeling of bladder fullness, following an increase of abdominal pressure such as is produced by coughing, sneezing or laughing. It is caused by an incompetent urethral sphincter mechanism and lack of support of the bladder trigone with disappearance of the vesicourethral angle. There is no relationship between the severity of stress-incontinence and the degree of vaginal prolapse. Some women begin to have urinary disorders during the menopause, or even after repair of a prolapse that results in distortion of the urethra by scar tissue. Atrophic changes in the urethral structures caused by estrogen deficiency as a consequence of ovarian failure play a major role in the causation of stress-incontinence in postmenopausal women. These two forms of urinary incontinence often are not distinguished. It is reported (3) that two out of three patients referred for treatment of incontinence have urgency-incontinence or a combination of the urgency and stress forms. Lack of proper diagnosis may account for the failure of many repair operations. EFFECT OF ESTROGEN
On the genito-urinary tract The secretion of estrogen is a major factor in the physiologic life of a woman. It is generally accepted that cessation of ovarian function leads to the menopausal syndrome with regressive changes in the genital tract, atrophy of the vaginal mucosa and shrinkage of the vulva. Estrogen production by the aging ovaries declines at the age of 40 to about half that present a t age 30, and reaches its lowest level a t age 60 (4). Estrogens increase the vascularity of the vaginal tissue; therefore hormone implantation before an operation for vaginal prolapse facilitates dissection and promotes healing (1).
338
On the urethra The distal part of the urethra, being of the same embryologic origin as the vagina, is lined with similar epithelium and is under the same hormonal control. Estrogen deficiency leads to similar changes is both structures. The mucosa becomes atrophic and the canal lumen loses its stellate shape. There is a decrease in elastic tissue and muscular tone. Increased fibrosis transforms the urethra into a rigid canal. The proximal part of the urethra is then kept open by the always-present urine. This leads to stasis and the formation of sediments and infection. Impaired defenses, caused by lack of estrogen, facilitate growth of pathogenic bacteria. Incontinent women are mostly menopausal and have various other symptoms. Incontinence makes their lives so miserable that they feel like social outcasts and rarely leave home. They become depressed, and avoid meeting other people. Hormone replacement not only improves other menopausal symptoms but, by improving urinary disorders, relieves the mental depression. Fibrosis around the bladder neck with increased formation of periurethral glands leads to the syndrome of bladder-neck obstruction, which acts in a manner functionally similar to that of an enlarged prostate gland in the male. Estrogen is reported to relieve the symptoms of obstruction in both sexes, including the symptoms of prostatism in the male (5). CLINICAL STUDY Three hundred women (age range, 45-85) were specially studied as to the relationship between the menopause and urinary disorders; 210 were multiparous and 90 nulliparous (10 virginal). Of the 300 women, 160 complained of urinary troubles, chiefly dysuria or incontinence. Of these, 90 underwent various repair operations with a 20 percent failure rate; 5 had 3 operations. The majority of these women had been previously treated with antibiotics for recurrent attacks of cystitis. During the period 1942-1972, with the aim of not only relieving menopausal symptoms but of preventing or a t least delaying the development of degenerative changes of the aging process, implants of estradiol, testosterone and progesterone were given to 1,000 women. The results, published in 1972 (2), showed that apart from other beneficial effects, there was definite improvement in urinary disorders in 70 percent of the cases (good results in 30 percent and fair results
August 1976
HORMONE IMPLANTS FOR POSTMENOPAUSAL URINARY DISORDERS
in 40 percent). The remaining 30 percent of patients in whom there was no improvement of urinary symptoms needed further urologic investigation and treatment. Favorable results with hormonal treatment in menopausal urinary disorders have also been reported by others (6-9). ADVANTAGES OF HORMONE IMPLANTS Hormones usually are given in the form of tablets or injections. The advantages of the implantation method are as follows: 1) Hormone concentration need be only about two-thirds of that required by other routes, 2) There are no untoward gastric effects, 3) Implantation allows for the fact that elderly patients often forget to take tablets, 4) Psychologically, the patient is not continously reminded of her condition by having to take tablets, and 5) The effective dose of combined estradiol, progesterone and testosterone is less than that of either hormone given separately, as they act synergistically. This combination also reduces the incidence of postmenopasual uterine bleeding. The method of supplying hormones by implants is gaining popularity. In the reply to a question about estrogen and aging, the expert of the British Medical Journal (issue of November 10, 1974) stated that most doctors practicing estrogen replacement therapy use implants. PREVENTION AND TREATMENT OF MENOPAUSAL URINARY DISORDERS Some urinary disorders in postmenopausal women can be prevented by: 1) Avoidance of overstretching the perineum during labor, the repair of all tears (including cervical), and the use of postnatal perineal exercises. 2) Hormone replacement as soon as menopausal symptoms occur, and always after hysterectomy. 3) During hysterectomy, dissection of the vesico-cervicalfascia from the cervix and its fixation
to the base of the bladder, to retain bladder support. This technique usually obviates the necessity for using an indwelling catheter. The round ligaments are fixed to the corner of the vaginal cuff, to prevent vaginal prolapse.
COMMENT Urinary disorders in the form of dysuria and incontinence are common among menopausal women, some of whom have been treated previously with antibiotics and with various surgical operations. The failure rate of surgical cure is 2030 percent, partly due to the fact that no distinction is made preoperatively between urgencyincontinence and stress-incontinence. It is essential to treat urgency-incontinence before surgical intervention is undertaken. Estrogen deficiency due to failure of ovarian function leads to atrophic changes in the urethra similar to those in the vagina. In postmenopausal women with urinary disorders, hormone replacement in the form of implants had proved to be beneficial in about 70 percent of cases. REFERENCES 1. Schleyer-Saunders E: The management of the menopause, Medical Press 244: 337, 1960. 2. Schleyer-Saunders E: Results of hormone implants in the treatment of the climacteric, J Am Geriatrics SOC19: 114, 1971. 3. Jeffcoate TN and Tindall V P Venous thrombosis and embolism in obstetrics and gynaecology, Aust New Zealand J Obst Gynaecol 94: 604, 1966. 4. Pincus G , Romanoff LP and Carlo J: The excretion of urinary steroids by men and women of various ages, J Gerontol 9: 113, 1954. 5. Roberts HJ: Estrogenic management of benign prostatism, including early and poor-risk cases: 7-year experience, J Am Geriatrics SOC14: 657, 1966. 6. Geist SH and Salmon UJ: Relationship of estrogens to dysuria and incontinence in post-menopausal women, J Mt Sinai Hosp 1 0 208, 1943. 7. Greenblatt RB: Symposium: constructive medicine in aging: metabolic and psychosomatic disorders in menopausal women, Geriatrics 10: 165, 1955. 8. Eckering B and Goldman JA: Conservative treatment of uterovaginal prolapse and stress urinary incontinence, Internat Surgery 57: 221, 1972. 9. Greenhill JP: The nonsurgical management of vaginal relaxation, Clin Obst Gynecol 15: 1083, 1972.
339
VOLUME XXlV
Copyright 6 1976 by the American Geriatrics Society
A U G U S T 1976
NUMBER 8 Printed in U.S.A.
Hormone Implants for Urinary Disorders in Postmenopausal Women E. SCHLEYER-SAUNDERS, MD, FICS* London, England
ABSTRACT: Urinary disorders associated with the menopause were studied in 300 postmenopausal women between the ages of 45 and 85; 210 were multiparous and 90 nulliparous. The presenting urinary symptom was dysuria in 60 patients and incontinence in 100 patients. In the latter group, 25 had urgency-incontinence, 45 stressincontinence, and 30 a combined form. The distal part of the urethra, being of the same embryologic origin as the genital tract, is estrogen-dependent. Hormone replacement in the form of implants resulted in improvement in 70 percent of the patients and thus reduced the need for surgical intervention. In the course of a study of the menopause (1)I was impressed by the large number of women with urinary disorders and by the beneficial effect of treatment by hormone implantation (2). Women of this age group are predisposed to urinary disorders because of: 1) the special anatomic structure and the intimate relationship of the urethra and trigone of the bladder to the genital tract; 2) the high incidence of injuries during childbirth; and 3) the estrogen-dependency of the urethral as well as the vaginal mucosa. Physiology of micturition. The intravesical pressure caused by bladder filling stimulates receptors in the bladder wall and by a reflex process
via the spinal cord stimulates contractions of the smooth muscle of the bladder; this opens the bladder ostium and forms a funnel-shaped opening into the urethra. At the same time the voluntary muscles around the outer part of the urethra relax to enable the urine to be voided. Normal urinary control depends on the efficiency of the urethral sphincter, on the tone of the muscles and elastic fibers around the urethra and on an intact vesico-urethral angle. URINARY DISORDERS The most common symptoms of urinary disorders are dysuria and incontinence. Dysuria (painful micturition) accompanied by urgency often implies a urinary infection. It usually is successfully treated by antibiotics and antispasmodics, though there is a tendency for the symptoms to recur.
* Hon. Consultant Gynaecologist and Governor Italian Hospital. Address for correspondence: E. Scheyler-Saunders, MD, 56, Wimpole Street, London, England W1M 7DF.
337
Vol. XXIV
E. SCHLEYER-SAUNDERS
Urinary incontinence may be manifested as urgency-incontinence or stress-incontinence or a combination of both. Urgency-incontinence is a n urgent desire to pass urine associated with painful contractions of the detrusor muscles of the bladder. The patient has to empty the bladder quickly; otherwise leakage of urine will occur. It usually is caused by intravesical irritation from inflammation of the trigone, a calculus, or hypersensitivity of the detrusor muscles (irritable bladder). Leakage occurs when the bladder is full, indeppdent of abdominal stress. Stress-incontinence is a spontaneous leakage of urine without any preliminary feeling of bladder fullness, following an increase of abdominal pressure such as is produced by coughing, sneezing or laughing. It is caused by an incompetent urethral sphincter mechanism and lack of support of the bladder trigone with disappearance of the vesicourethral angle. There is no relationship between the severity of stress-incontinence and the degree of vaginal prolapse. Some women begin to have urinary disorders during the menopause, or even after repair of a prolapse that results in distortion of the urethra by scar tissue. Atrophic changes in the urethral structures caused by estrogen deficiency as a consequence of ovarian failure play a major role in the causation of stress-incontinence in postmenopausal women. These two forms of urinary incontinence often are not distinguished. It is reported (3) that two out of three patients referred for treatment of incontinence have urgency-incontinence or a combination of the urgency and stress forms. Lack of proper diagnosis may account for the failure of many repair operations. EFFECT OF ESTROGEN
On the genito-urinary tract The secretion of estrogen is a major factor in the physiologic life of a woman. It is generally accepted that cessation of ovarian function leads to the menopausal syndrome with regressive changes in the genital tract, atrophy of the vaginal mucosa and shrinkage of the vulva. Estrogen production by the aging ovaries declines at the age of 40 to about half that present a t age 30, and reaches its lowest level a t age 60 (4). Estrogens increase the vascularity of the vaginal tissue; therefore hormone implantation before an operation for vaginal prolapse facilitates dissection and promotes healing (1).
338
On the urethra The distal part of the urethra, being of the same embryologic origin as the vagina, is lined with similar epithelium and is under the same hormonal control. Estrogen deficiency leads to similar changes is both structures. The mucosa becomes atrophic and the canal lumen loses its stellate shape. There is a decrease in elastic tissue and muscular tone. Increased fibrosis transforms the urethra into a rigid canal. The proximal part of the urethra is then kept open by the always-present urine. This leads to stasis and the formation of sediments and infection. Impaired defenses, caused by lack of estrogen, facilitate growth of pathogenic bacteria. Incontinent women are mostly menopausal and have various other symptoms. Incontinence makes their lives so miserable that they feel like social outcasts and rarely leave home. They become depressed, and avoid meeting other people. Hormone replacement not only improves other menopausal symptoms but, by improving urinary disorders, relieves the mental depression. Fibrosis around the bladder neck with increased formation of periurethral glands leads to the syndrome of bladder-neck obstruction, which acts in a manner functionally similar to that of an enlarged prostate gland in the male. Estrogen is reported to relieve the symptoms of obstruction in both sexes, including the symptoms of prostatism in the male (5). CLINICAL STUDY Three hundred women (age range, 45-85) were specially studied as to the relationship between the menopause and urinary disorders; 210 were multiparous and 90 nulliparous (10 virginal). Of the 300 women, 160 complained of urinary troubles, chiefly dysuria or incontinence. Of these, 90 underwent various repair operations with a 20 percent failure rate; 5 had 3 operations. The majority of these women had been previously treated with antibiotics for recurrent attacks of cystitis. During the period 1942-1972, with the aim of not only relieving menopausal symptoms but of preventing or a t least delaying the development of degenerative changes of the aging process, implants of estradiol, testosterone and progesterone were given to 1,000 women. The results, published in 1972 (2), showed that apart from other beneficial effects, there was definite improvement in urinary disorders in 70 percent of the cases (good results in 30 percent and fair results
August 1976
HORMONE IMPLANTS FOR POSTMENOPAUSAL URINARY DISORDERS
in 40 percent). The remaining 30 percent of patients in whom there was no improvement of urinary symptoms needed further urologic investigation and treatment. Favorable results with hormonal treatment in menopausal urinary disorders have also been reported by others (6-9). ADVANTAGES OF HORMONE IMPLANTS Hormones usually are given in the form of tablets or injections. The advantages of the implantation method are as follows: 1) Hormone concentration need be only about two-thirds of that required by other routes, 2) There are no untoward gastric effects, 3) Implantation allows for the fact that elderly patients often forget to take tablets, 4) Psychologically, the patient is not continously reminded of her condition by having to take tablets, and 5) The effective dose of combined estradiol, progesterone and testosterone is less than that of either hormone given separately, as they act synergistically. This combination also reduces the incidence of postmenopasual uterine bleeding. The method of supplying hormones by implants is gaining popularity. In the reply to a question about estrogen and aging, the expert of the British Medical Journal (issue of November 10, 1974) stated that most doctors practicing estrogen replacement therapy use implants. PREVENTION AND TREATMENT OF MENOPAUSAL URINARY DISORDERS Some urinary disorders in postmenopausal women can be prevented by: 1) Avoidance of overstretching the perineum during labor, the repair of all tears (including cervical), and the use of postnatal perineal exercises. 2) Hormone replacement as soon as menopausal symptoms occur, and always after hysterectomy. 3) During hysterectomy, dissection of the vesico-cervicalfascia from the cervix and its fixation
to the base of the bladder, to retain bladder support. This technique usually obviates the necessity for using an indwelling catheter. The round ligaments are fixed to the corner of the vaginal cuff, to prevent vaginal prolapse.
COMMENT Urinary disorders in the form of dysuria and incontinence are common among menopausal women, some of whom have been treated previously with antibiotics and with various surgical operations. The failure rate of surgical cure is 2030 percent, partly due to the fact that no distinction is made preoperatively between urgencyincontinence and stress-incontinence. It is essential to treat urgency-incontinence before surgical intervention is undertaken. Estrogen deficiency due to failure of ovarian function leads to atrophic changes in the urethra similar to those in the vagina. In postmenopausal women with urinary disorders, hormone replacement in the form of implants had proved to be beneficial in about 70 percent of cases. REFERENCES 1. Schleyer-Saunders E: The management of the menopause, Medical Press 244: 337, 1960. 2. Schleyer-Saunders E: Results of hormone implants in the treatment of the climacteric, J Am Geriatrics SOC19: 114, 1971. 3. Jeffcoate TN and Tindall V P Venous thrombosis and embolism in obstetrics and gynaecology, Aust New Zealand J Obst Gynaecol 94: 604, 1966. 4. Pincus G , Romanoff LP and Carlo J: The excretion of urinary steroids by men and women of various ages, J Gerontol 9: 113, 1954. 5. Roberts HJ: Estrogenic management of benign prostatism, including early and poor-risk cases: 7-year experience, J Am Geriatrics SOC14: 657, 1966. 6. Geist SH and Salmon UJ: Relationship of estrogens to dysuria and incontinence in post-menopausal women, J Mt Sinai Hosp 1 0 208, 1943. 7. Greenblatt RB: Symposium: constructive medicine in aging: metabolic and psychosomatic disorders in menopausal women, Geriatrics 10: 165, 1955. 8. Eckering B and Goldman JA: Conservative treatment of uterovaginal prolapse and stress urinary incontinence, Internat Surgery 57: 221, 1972. 9. Greenhill JP: The nonsurgical management of vaginal relaxation, Clin Obst Gynecol 15: 1083, 1972.
339
