Dudley Robinson

The role of estrogens in female lower urinary tract dysfunction

The urogenital tract and lower urinary tract are sensitive to the effects of estrogen and progesterone throughout adult life. Epidemiologic studies have implicated estrogen deficiency in the etiology of lower urinary tract symptoms that occur after menopause. Although the role of estrogen replacement therapy in the management of postmenopausal urinary incontinence (UI) remains controversial, its use in the treatment of women with urogenital atrophy is now well established. This review summarizes recent evidence of the urogenital effects of hormone therapy, particularly emphasizing management of postmenopausal UI and recurrent lower urinary tract infections. Estrogen therapy alone has little effect in the management of urodynamic stress UI, although in combination with an alpha-adrenergic agonist, it may improve urinary leakage. Estrogen therapy may be of benefit for the irritative symptoms of urinary urgency, frequency, and urge UI, although this effect may result from reversal of urogenital atrophy rather than a direct action on the lower urinary tract. The role of estrogen replacement therapy in the treatment of women with recurrent lower urinary tract infections remains to be determined, although there is now some evidence that vaginal administration may be efficacious. Low-dose, vaginally administered estrogens have a role in the treatment of urogenital atrophy in postmenopausal women and appear to be as effective as systemic preparations.

Can ultrasound replace ambulatory urodynamics when investigating women with irritative urinary symptoms

Objective To determine whether transvaginal ultrasound measurement of bladder wall thickness could replace ambulatory urodynamics when investigating women with lower urinary tract dysfunction not explained by conventional laboratory urodynamic studies.

A randomized double-blind placebo-controlled multicentre study to explore the efficacy and safety of tamsulosin and tolterodine in women with overactive bladder syndrome

To evaluate the efficacy of tamsulosin oral‐controlled absorption system (OCAS) vs placebo in overactive bladder (OAB), to evaluate the safety and tolerability of once‐daily dosing with tamsulosin OCAS, and to compare the efficacy and safety with tolterodine extended‐release (ER).

Estrogens and the lower urinary tract

The urogenital tract is sensitive to the effect of oestrogen and progesterone throughout adult life. Epidemiological studies have implicated oestrogen deficiency in the aetiology of lower urinary tract symptoms occurring following the menopause. Although to date the role of oestrogen replacement therapy in the management of postmenopausal urinary incontinence remains controversial its use in the management of women complaining of urogenital atrophy is now well established.

The effect of hormones on the lower urinary tract.

The female genital and lower urinary tracts share a common embryological origin, arising from the urogenital sinus and both are sensitive to the effects of the female sex steroid hormones throughout life. Estrogen is known to have an important role in the function of the lower urinary tract and estrogen and progesterone receptors have been demonstrated in the vagina, urethra, bladder and pelvic floor musculature. In addition estrogen deficiency occurring following the menopause is known to cause atrophic change and may be associated with lower urinary tract symptoms such as frequency, urgency, nocturia, urgency incontinence and recurrent infection. These may also co-exist with symptoms of urogenital atrophy such as dyspareunia, itching, vaginal burning and dryness. Epidemiological studies have implicated estrogen deficiency in the aetiology of lower urinary tract symptoms with 70% of women relating the onset of urinary incontinence to their final menstrual period. Whilst for many years systemic and vaginal estrogen therapy was felt to be beneficial in the treatment of lower urinary and genital tract symptoms this evidence has recently been challenged by large epidemiological studies investigating the use of systemic hormone replacement therapy as primary and secondary prevention of cardiovascular disease and osteoporosis. The aim of this paper is to examine the effect of the sex hormones, estrogen and progesterone, on the lower urinary tract and to review the current evidence regarding the role of systemic and vaginal estrogens in the management of lower urinary tract symptoms and urogenital atrophy.

Experiences and expectations of women with urogenital prolapse: a quantitative and qualitative exploration.

Objective  To explore the expectations and goals of women undergoing surgery for urogenital prolapse using both a quantitative quality of life approach exploring symptom bother and a qualitative interview‐based approach exploring patient goals and expectations.

Special considerations in premenopausal and postmenopausal women with symptoms of overactive bladder.

The term overactive bladder (OAB) is used to describe the symptoms of urinary frequency and urgency with or without urge incontinence. Commonly reported symptoms are nocturia, urgency, frequency, and urge incontinence. However, some of these symptoms may be because of other lower urinary tract conditions or may simply represent a variant of normal physiologic function. Consequently, special considerations need to be made when diagnosing OAB in women. In women of all ages, lower urinary tract infection is the most common cause of irritative urinary symptoms, and midstream urine microscopy and culture should be performed. A chronic urinary residual secondary to voiding difficulties may also result in symptoms of frequency and overflow incontinence and may be diagnosed using a postmicturition ultrasound scan. In premenopausal women, pregnancy should also be excluded. In postmenopausal women, urogenital atrophy can cause irritative symptoms that may be improved with hormone replacement therapy. Vaginal administration has been shown to be most effective and may be used to supplement systemic replacement therapy. In addition, estrogen replacement may be beneficial in the management of OAB as an adjunct to anticholinergic therapy. When investigating elderly women with OAB, special consideration should be given to comorbidities, such as constipation and fecal impaction, mobility problems, and the loss of independence. Concomitant medication, such as diuretics and alpha-adrenergic blockers, should also be noted and the need for therapy reviewed. In conclusion, OAB is a subjective diagnosis that should only be made when other lower urinary tract conditions have been excluded.

Validity and reliability of the patient’s perception of intensity of urgency scale in overactive bladder

Study Type – Prognosis (outcomes research) 
Level of Evidence 2c

Psychological characteristics and motivation of women seeking labiaplasty.

BACKGROUND Labiaplasty is an increasingly popular surgical intervention but little is known about the characteristics and motivation of women who seek the procedure or the psychosexual outcome. METHOD A total of 55 women seeking labiaplasty were compared with 70 women who did not desire labiaplasty. Various general measures of psychopathology as well as specific measures (Genital Appearance Satisfaction; Cosmetic Procedure Screening for labiaplasty) were used. Labia measurements of the women seeking labiaplasty were also obtained. RESULTS Women seeking labiaplasty did not differ from controls on measures of depression or anxiety. They did, however, express increased dissatisfaction towards the appearance of their genitalia, with lower overall sexual satisfaction and a poorer quality of life in terms of body image. Women seeking labiaplasty reported a significantly greater frequency of avoidance behaviours on all the domains assessed, and greater frequency of safety-seeking behaviours for most of the domains. Key motivations reported for labiaplasty were categorized as cosmetic, functional or sexual. Of the 55 women seeking labiaplasty, 10 met diagnostic criteria for body dysmorphic disorder. CONCLUSIONS This is the first controlled study to describe some of the characteristics and motivations of women seeking labiaplasty. We identified a wide range of avoidance and safety-seeking behaviours, which occurred more frequently in the labiaplasty group than the control group. These could be used clinically as part of a psychological intervention for women seeking labiaplasty.

Oestrogens and overactive bladder

Estrogens are known to have a major role in the function of the lower urinary tract although the role of exogenous estrogen replacement therapy in the management of women with lower urinary tract dysfunction remains controversial. Whilst for many years systemic and vaginal estrogen therapy was felt to be beneficial in the treatment of lower urinary and genital tract symptoms this evidence has recently been challenged by large epidemiological studies investigating the use of systemic hormone replacement therapy. Consequently the role of estrogen in the management of postmenopausal women with Overactive Bladder (OAB) remains uncertain. In addition the evidence base regarding the use of exogenous estrogen therapy has changed significantly over the last decade and has led to a major changes in current clinical practice. The aim of this article is to review the evidence for the role of estrogen therapy in the management of OAB focusing on current knowledge with regard to both systemic and local estrogen therapy as well as investigating the emerging role of combination therapy with antimuscarinic agents. Neurourol. Urodynam. 33:1086–1091, 2014.