This Open Access site was

      originated September 2006

      Updated January 2009

 

  Estrogen Matters is a non profit global women’s health initiative to provide medical perspective

  about menstrual health, the menopausal transition and post-menopausal health

 

compassion

  An estimated 50-70% of women with urinary incontinence fail
  to seek medical evaluation and treatment because of social stigma.
   Source: Incontinence, Urinary: Nonsurgical Therapies
   Raymond Rackley, MD  May 2, 2006

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Bladder Weakness is a treatable condition at any age
 

Urinary incontinence is a treatable medical condition that affects more than 25 million American adults. It is a condition that is three times more likely to occur in women than in men and increases in frequency with age. For postmenopausal women with bladder weakness, symptoms do not lessen or go away with time and tend to become more troublesome if not treated.

In general bladder leakage, is an under-recognized and under-treated medical condition that effects nearly one third of adult women. Many, many postmenopausal women needlessly suffer from this treatable condition due to an outdated belief that bladder weakness is a part of normal aging.

Bladder weakness is often a consequence of reduced estrogen and structural changes (relaxation) of the vaginal wall. The support system of the uterus, urethra, and bladder is the vagina. The anterior vaginal wall supports the bladder and the urethra.

This overview relates issues of bladder weakness and the pharmaceutical and surgical treatment options for incontinence, and vaginal prolapse for postmenopausal women. Prescription medications bring significant relief to overactive bladder and urge incontinence. The most common side effect of these medications is dry mouth.

Surgical treatments for stress incontinence have advanced significantly. The newest surgical procedure is minimally invasive with minimal pain (Visual Analogue Pain Score of 2.3 out of 10) and an average proven cure rate between 86% and 90%.

 

Source:
New Mini-Sling an Option to Transvaginal Tape for Urinary Incontinence
Francisco Cruz, MD, PhD
Hospital De Sao Joao, Porto, Portugal
February 3, 2008

 

 

 

 

 

Weak pelvic muscles
allow for urine leakage
 
Strong pelvic muscles
keep the urethra closed
 
All types of
urinary incontinence
are treatable and
incontinence is
treatable at all ages.
 

 

 

 The urethra, bladder, pelvic connective tissue and muscles have a rich supply
 of estrogen receptors.
 
 Estrogen increases vaginal maturation, periurethral blood supply,
 alpha-adrenergic receptor sensitivity, and sympathetic nerve density in the pelvis.

 

  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 

 

 

Incontinence . . .

The bladder is a balloon-like organ. The bladder connects to the urethra, the tube through which urine leaves the body.


During urination, muscles in the wall of the bladder contract, pushing urine out of the bladder and into the urethra. At the same time, sphincter muscle surrounding the urethra relax, letting urine pass out of the body. Incontinence tends to occur if the bladder muscles suddenly contract or the sphincter muscle is not strong enough to hold back urine.


This overview focuses on stress incontinence, urge incontinence and overactive bladder:

Stress incontinence refers to loss of urine with coughing, sneezing, or laughing. The two primary causes are urethral sphincter weakness or weakness of pelvic floor and poor support of the vesicourethral sphincter unit resulting in a hypermobile urethra.

Urge incontinence is the sudden urge to urinate (void) associated with involuntary bladder (detrusor) contractions (detrusor instability). Drug therapy is the most common approach to treating urge incontinence.

Mixed incontinence is characterized by aspects of both stress and urge incontinence.

Overactive bladder is a condition with symptoms of frequency, urgency and urge incontinence. It is caused by inappropriate contractions of the detrusor muscle during the filling phase of the micturition cycle. The micturition cycle involves 2 processes: bladder filling and storage of urine and bladder emptying. Muscarinic receptor antagonists (blocks the action), such as oxybutynin and tolterodine, are the main prescription treatments for overactive bladder.

The symptoms of overactive bladder include:
Urinary frequency: urination eight or more times a day or two or more times at night.
Urinary urgency: the sudden, strong need to urinate immediately.
Urge incontinence: leakage or gushing of urine that follows a sudden, strong urge.
Nocturia:awaking at night to urinate.

 

 

 

 

 

 

 

 

The Role of Estrogen in Urinary Incontinence and Vaginal Prolapse/Relaxation

Postmenopausal women who use estrogen or hormone replacement tend to have less incidence of urinary incontinence and uterine prolaspe compared to postmenopausal women who do not use estrogen or hormone replacement.


Although the reasons for urinary incontinence and uterine prolapse are not completely understood, abnormalities of connective tissue structure and/or repair in response to stress and loss of elastic recoil in the cardinal ligaments are thought to be contributing factors. Cardinal ligaments provide the major support for the uterus and vagina.

Ligaments of prolapsed uteri are characterized by a higher expression of collagen III and tenascin and lower quantities of elastin and estrogen receptor B. The decrease in the ratio of collagen I/(III+V) seen in postmenopausal women who are not on hormone replacement therapy is thought to reduce the tensile strength of collagen and increase susceptibility to anterior (front) vaginal wall prolapse.

Estrogen, via estrogen receptor beta is thought to be involved in elastin and collagen homeostasis in the body either through transcriptional effects on the elastin and collagen genes or through regulation of some of the proteases that are involved in the degradation of these proteins.

Oral and transdermal estrogen replacement, the vaginal estrogen ring and vaginal creams/tablets all positively impact the integrity of the bladder, urethra and vagina.

 
 
Childbirth and other events can injuire the scaffolding that helps support the bladder in women. Pelvic floor muscles, the vagina, and ligaments support the bladder.
If these structures weaken, the bladder can move downward, pushing slightly out of the bottom of the pelvis toward the vagina. This prevents muscles that ordinarily force the urethra shut from squeezing as tightly as they should.
As a result, urine can leak into the urethra during moments of physical stress. Stress incontinence also occurs if the squeezing muscles weaken.

Stress incontinence can worsen during the week before the menstrual period. At that time, lowered estrogen levels might lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause.

Source:
National Kidney and Urological Disease Information ClearingHouse
kidney.niddk.nih.gov/kudiseases/pubs/uiwomen/

 
 
 
 
Dampening Bladder Contractions:
urge and overactive bladder

The bladder can empty too often (urinary frequency) or unexpectedly (incontinence). This is thought to be due to the bladder wall contracting uncontrollably. Certain prescription medications (oxybutynin and tolterodine) can dampen down these contractions and make the bladder more stable.


The detrusor muscle is the layer of involuntary muscle in the bladder wall. During urination, it contracts to squeese urine out of the bladder into the urethra.


Muscarinic receptors are located on the muscle cells of the bladder wall. Stimulation of these receptors causes the bladder to contract and empty. When these receptors are blocked the muscle of the bladder wall contracts less.

Acetylcholine is the primary contractile neurotransmitter in the human detrusor muscle. Antimuscarinics medications exert their effects on overactive bladder and detrussor overactivity by inhibiting the binding of acetylcholine at muscarinic receptors M2 and M3 on detrusor smooth muscle cells and other structures within the bladder wall. Worldwide, there are six antimuscarinic prescription medications currently marketed for the treatment of overactive bladder: oxybutynin, tolterodine, propiverine, trospium, darifenacin, and solifenacin.

Interesting:
Detrusor cells are bundles of smooth muscle fibers that form the muscular coat of the urinary bladder. They are arranged in a longitudinal and a circular layer: upon contraction the expel urine.


Muscarinic M3 receptors are primarily responsible for detrusor contraction.

The parasympathetic nervous system is responsible for maintaining normal intestinal and bladder function, contracting the smooth muscle by releasing the neurotransmitters acetylcholine (ACh) and ATP and relaxing sphincters by releasing nitric oxide.

Source:
Muscarinic receptor subtypes of the bladder

and gastrointestinal tract
Toshimitsu Uchiyama and Russell Chess-Williams
J. Smooth Muscle Res. (2004) 40 (6): 237–247.

 
 
 
When the Vaginal Walls Weaken:
Understanding Vaginal/Uterine Prolapse (Relaxation)

Types of vaginal prolapse:

Cystocele . . . is a medical term for the sinking of the bladder into the vagina. This occurs when the tissues between the bladder and the vagina weaken, allowing the bladder to bulge into the front of the vagina.

Urethrocele . . .  is the sinking of the urethra into the vagina.


Rectocele . . . is the bulging of the rectum into the vagina. Occurs when the tissue layers between the rectum and the vagina weaken, allowing the rectum to herniate and cause a bulging into the back of the vagina.

Uterine Prolapse is the falling or sliding of the uterus from its normal position in the pelvic cavity into the vagina. The uterus is normally supported by pelvic connective tissue and the pubococcygeus muscle, and held in position by special ligaments. Weakening of these tissues allows the uterus to descend into the vaginal canal.

 

 

 

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Information is provided for educational purposes to help individuals form an understanding of biological processes as they effect health. This information is not intended for medical diagnosis or treatment.