Kathleen A. Connell

HOXA11 is critical for development and maintenance of uterosacral ligaments and deficient in pelvic prolapse.

Pelvic organ prolapse (POP) is a common, debilitating disorder affecting millions of women. Uterosacral ligaments (USLs) are the main supportive structures of the uterus and vagina and are often attenuated in women with POP. Although the mechanical strength of USLs is known to be dependent on collagen synthesis and catabolism and the degradation protein MMP2 has been implicated in POP, the molecular mechanisms involved in the development of POP are currently unknown. Homeobox (HOX) genes are transcriptional regulators that orchestrate embryonic development of the urogenital tract. We demonstrated here that HOXA11 was essential for organogenesis of the USL by showing that USLs were absent in Hoxa11-null mice. We compared expression of HOXA11, collagen type I, collagen type III, MMP2, and MMP9 in USLs of women with and without POP. Expression of HOXA11 and both collagens was dramatically decreased while MMP2 was increased in women with POP. Constitutive expression of Hoxa11 in murine fibroblasts resulted in significantly increased expression of collagen type III and decreased expression of MMP2. These results identified HOXA11 as an essential gene for the development of the USL and suggested that women with POP might have weakened connective tissue due to changes in a signaling pathway involving HOXA11, collagen type III, and MMP2.

ORIGINAL RESEARCH—WOMEN’S SEXUAL HEALTH: Genital Sensation and Sexual Function in Women Bicyclists and Runners: Are Your Feet Safer than Your Seat?

INTRODUCTION Bicycling is associated with neurological impairment and impotence in men. Similar deficits have not been confirmed in women. AIM To evaluate the effects of bicycling on genital sensation and sexual function in women. METHODS Healthy, premenopausal, competitive women bicyclists and runners (controls) were compared. MAIN OUTCOME MEASURES (1) Genital vibratory thresholds (VTs) were determined using the Medoc Vibratory Sensation Analyzer 3000. (2) Sexual function and sexually related distress were assessed by the Dennerstein Personal Experience Questionnaire (SPEQ) and the Female Sexual Distress Scale (FSDS). RESULTS Forty-eight bicyclists and 22 controls were enrolled. The median age was 33 years. The bicyclists were older, had higher body mass indices (BMIs), were more diverse in their sexual orientation, and were more likely to have a current partner. Bicyclists rode an average of 28.3 +/- 19.7 miles/day (range 4-100), 3.8 +/- 1.5 days/week, for an average of 2.1 +/- 1.8 hours/ride. The mean number of years riding was 7.9 +/- 7.1 years (range 0.5-30). Controls ran an average of 4.65 +/- 2.1 miles/day (range 1.5-8) and 5.0 +/- 1.2 days/week. On bivariate analysis, bicyclists had significantly higher VTs than runners, indicating worse neurological function at all sites (P < 0.05). Multivariate analysis found significant correlations between higher VTs and bicycling at the left and right perineum, posterior vagina, left and right labia. Increasing VTs at the clitoris, anterior vagina, and urethra were associated with age. In bicyclists, there were no correlations between VTs and miles biked per week, duration of riding, or BMI. Composite SPEQ scores indicated normal sexual function in all sexually active subjects. Neither group suffered from sexually related distress. CONCLUSION There is an association between bicycling and decreased genital sensation in competitive women bicyclists. Negative effects on sexual function and quality of life were not apparent in our young, healthy premenopausal cohort.

Effects of age, menopause, and comorbidities on neurological function of the female genitalia

The aim of this study was to investigate the effects of age, menopause, and comorbidities on neurological function of the female genitalia using a noninvasive, validated technique. In all, 58 consecutive women were enrolled in the study. Biothesiometry was performed at five genital sites and one peripheral site with S2 dermatome distribution. Kruskal–Wallis one-way ANOVA on ranks was used to evaluate the relationship between age and vibratory sensation. Bivariate and regressional analyses were performed to evaluate the effects of age, menopause and comorbidities on genital sensation. The mean age was 44.6+14.8 y (range 20–78 y). Vibration thresholds increased with advancing age at all six sites. Multilinear regression analysis indicated that menopause and increasing age negatively affect sensation. History of herniated lumbar disc, vaginal delivery, and diabetes variably affected genital sensation. There is a significant increase in vibration thresholds (indicating worsening neurological function) in women as they age and undergo menopause. Biothesiometry is a technique for evaluating genital neurological function in women with coexisting morbidities.

Knockdown of Hoxa11 In Vivo in the Uterosacral Ligament and Uterus of Mice Results in Altered Collagen and Matrix Metalloproteinase Activity

ABSTRACT Homeobox (HOX) genes are evolutionarily conserved genes encoding transcription factors that regulate mammalian embryonic growth and development of the urogenital tract. In both humans and mice, HOXA11 persists in the adult reproductive tract and is thought to play an important role in maintaining tissue developmental plasticity by regulating the expression of genes involved in extracellular matrix metabolism in the reproductive organs. Previously, we have shown that HOXA11 is necessary for development of the uterosacral ligaments in mice and is deficient in women with pelvic organ prolapse. Therefore, we hypothesized that Hoxa11 regulates the synthesis and/or metabolism of collagens in the uterosacral ligaments and uterus, and tested this by establishing an in utero and peritoneal Hoxa11 gene knockdown system in C57/BL6 mice using vectors bearing Hoxa11 short hairpin RNA. Specific knockdown of Hoxa11 transcripts and protein levels were confirmed versus control vectors. Protein and mRNA expression of collagen types I and III exhibited significant decreases following Hoxa11 knockdown according to Western blot analysis and real-time PCR. Tissue inhibitor of matrix metalloproteinase 1 (MMP1) expression also exhibited a significant decrease. Gelatinase zymography confirmed increases in pro-MMP2 and MMP9, as well as activated MMP2, following Hoxa11 knockdown. These results reveal that Hoxa11 knockdown in the uterosacral ligaments and uterus increases extracellular matrix degradation. More importantly, it suggests a mechanism in the weakening of the pelvic floor support in women, because decreased HOXA11 gene expression has been reported to be associated with decreased collagen and increased MMP2 expression in the uterosacral ligaments of women with pelvic organ prolapse.

Women's Bike Seats: A Pressing Matter for Competitive Female Cyclists

INTRODUCTION There are numerous genital complaints in women cyclists, including pain, numbness, and edema of pelvic floor structures. Debate ensues about the best saddle design for protection of the pelvic floor. AIM To investigate the relationships between saddle design, seat pressures, and genital nerve function in female, competitive cyclists. METHODS We previously compared genital sensation in healthy, premenopausal, competitive women bicyclists and runners. The 48 cyclists from our original study comprise the study group in this subanalysis. MAIN OUTCOME MEASURES Main outcome measures were: (i) genital vibratory thresholds (VTs) determined using the Medoc Vibratory Sensation Analyzer 3000 and (ii) saddle pressures as determined using a specially designed map sensor. RESULTS More than half of the participants (54.8%) used traditional saddles, and the remainder (45.2%) rode with cut-out saddles. On bivariate analysis, use of traditional saddles was associated with lower mean perineal saddle pressures (MPSP) than riding on cut-out saddles. Peak perineal saddle pressures (PPSP) were also lower; however, the difference did not reach statistical significance. Saddle design did not affect mean or peak total saddle pressures (MTSP, PTSP). Saddle width was significantly associated with PPSP, MTSP, and PTSP but not with MPSP. Women riding cut-out saddles had, on average, a 4 and 11 kPa increase in MPSP and PPSP, respectively, compared with women using traditional saddles (P = 0.008 and P = 0.010), after adjustment for other variables. Use of wider saddles was associated with lower PPSP and MTSP after adjustment. Although an inverse correlation was seen between saddle pressures and VTs on bivariate analysis, these differences were not significant after adjusting for age. CONCLUSION Cut-out and narrower saddles negatively affect saddle pressures in female cyclists. Effects of saddle design on pudendal nerve sensory function were not apparent in this cross-sectional analysis. Longitudinal studies evaluating the long-term effects of saddle pressure on the integrity of the pudendal nerve, pelvic floor, and sexual function are warranted.

HOXA11 Promotes Fibroblast Proliferation and Regulates p53 in Uterosacral Ligaments

The uterosacral ligaments (USLs) are key support structures of the uterus and upper vagina. Previously, we have shown that HOXA11 is necessary for the development of the USLs, is deficient in women with pelvic organ prolapse (POP) and regulates expression of extracellular matrix (ECM) proteins. Here we sought to determine if HOXA11 regulates cell proliferation in the USLs in women. Like others, we have found that, there is decreased cellularity in prolapsed USLs compared to USLs in women with normal pelvic support. We have also demonstrated that HOXA11 promotes cell proliferation in murine fibroblasts and primary human USL cells in vitro. These findings support a relationship between HOXA11 expression, rates of proliferation and phenotypic abnormalities in the USL. Based on these findings, we sought to determine if HOXA11 regulates p53, a tumor suppressor gene which controls progression through the cell cycle and regulates ECM genes. We have demonstrated that expression of HOXA11 represses expression of p53, suggesting a mechanism by which HOXA11 regulates of the morphology and integrity of the USLs. A better understanding of the influence of these genes on the homeostasis of the ECM and interactions with each other may prove beneficial in defining the underlying etiologies of the development of POP and aid in the development of new treatment options for women with this disorder.

Racial Disparities in Knowledge of Pelvic Floor Disorders Among Community-Dwelling Women.

Objective To evaluate racial and ethnic differences in knowledge about preventative and curative treatments for pelvic floor disorders (PFD). Methods The is a secondary analysis of responses from 416 community-dwelling women, aged 19 to 98 years, living in New Haven County, CT, who completed the Prolapse and Incontinence Knowledge Questionnaire. Associations between race/ethnicity (categorized as white, African American, and other women of color [combined group of Hispanic, Asian or “other” women] and knowledge proficiency about modifiable risk factors and treatments for PFD were evaluated. Associations were adjusted for age, marital status, socioeconomic status, education, working in a medical field, and PFD history. Results Compared to white women, African American women were significantly less likely to recognize childbirth as a risk factor for urinary incontinence (UI) and pelvic organ prolapse (POP), to know that exercises can help control leakage, and to recognize pessaries as a treatment option for POP. Other women of color were also significantly less likely to know about risk factors, preventative strategies, and curative treatment options for POP and UI; however, these findings may not be generalizable given the heterogeneity and small size of this group. Conclusions Significant racial disparities exist in womens baseline knowledge regarding risk factors and treatment options for POP and UI. Targeted, culturally sensitive educational interventions are essential to enhancing success in reducing the personal and economic burden of PFD, which have proven negative effects on womens quality of life.

Diminished vaginal HOXA13 expression in women with pelvic organ prolapse.

Objective: Homeobox genes are transcriptional regulators that orchestrate embryonic development. The HOXA13 gene is responsible for the development of the vagina and regulates extracellular matrix constituents. We hypothesized that vaginal expression of HOXA13 may be decreased in women with pelvic organ prolapse (POP) and sought to determine if hypoestrogenism affects its expression. Methods: Biopsy specimens were obtained from the anterior apex of the vagina from women with and without POP. Immunohistochemistry and real-time polymerase chain reaction were used to determine HOXA13 expression in premenopausal controls, in premenopausal women receiving leuprolide acetate, and in premenopausal and postmenopausal women with POP. Results: HOXA13 was expressed in all specimens. HOXA13 expression was 14-fold lower in premenopausal women with prolapse than in premenopausal controls (P < 0.001). In both POP groups, HOXA13 expression was lower than in the leuprolide group (P ≤ 0.001). There were no differences in HOXA13 expression between premenopausal controls and women treated with leuprolide acetate (P = 1.0) or between the premenopausal and postmenopausal POP group (P = 1.0). Conclusions: Vaginal HOXA13 expression is diminished in women with POP compared with women with normal support. In women with POP, expression of HOXA13 was not affected by menopause. Expression of HOXA13 was also not affected by exposure to leuprolide acetate, suggesting that estrogen and HOXA13 work through separate pathways in the extracellular matrix metabolism of the vagina. Understanding genetic predispositions to developing POP may identify younger patients at risk who may benefit from preventive strategies such as weight loss or smoking cessation and not necessarily from estrogen therapy.

The role of cystourethroscopy in patients with previous pelvic surgery

Abstract Objectives: 1) To determine the frequency of lower urinary tract injury (LUTI) in patients with previous pelvic surgery and 2) to evaluate the role of routine cystourethroscopy (CUS) in these patients. Materials and Methods: The records of all women who had previous pelvic surgery without a documented intraoperative cystoscopy who later underwent postoperative office CUS at Montefiore Medical Center between January 1999 and May 2000 were retrospectively reviewed. All patients underwent a detailed urogynecologic history and physical examination, urine analysis, and urine culture. All patients then underwent routine office CUS. Results: Sixty-seven patients met the inclusion criteria. All but one had their primary surgery at other institutions. The mean age was 64 (range, 54–77). Previous surgical procedures included 35 abdominal hysterectomies, 5 vaginal hysterectomies, 1 hysteropexy, 9 suburethral slings, 10 anterior colporrhaphies, 2 retropubic suspensions, and 15 bladder repairs. The cystourethroscopic diagnoses were as follows: 54 with atrophic urethritis, 14 with interstitial cystitis, and 2 with intravesical sutures. The rate of LUTI was 3% (95% CI 0.2,7). Conclusions: The rate of LUTI is low. The use of CUS is essential to appropriate diagnosis and treatment for patients with lower urinary tract injury consequent to pelvic surgery. We suggest routine intraoperative CUS for patients undergoing pelvic surgery. Prospective studies are warranted.