压力性尿失禁患者尿道周围结缔组织中核心蛋白聚糖mRNA表达水平与Ⅲ型胶原含量的相关性研究

目的探讨压力性尿失禁(SUI)患者尿道周围结缔组织中,核心蛋白聚糖(DCN)mRNA表达水平及Ⅲ型胶原含量变化及其相关性。方法将43例绝经前后妇女根据是否存在SUI分为SUI组(20例)和对照组(23例)。应用免疫组化法检测两组妇女尿道周围结缔组织中Ⅲ型胶原含量(以免疫组化指数表示);RT-PCR法检测DCNmRNA表达水平[以DCN与β肌动蛋白吸光度(A)值的比值表示]。结果SUI组患者尿道周围组织中DCNmRNA表达水平为0.76±0.16,对照组为0.76±0.16,两组比较,差异有统计学意义(P<0.05);SUI组患者Ⅲ型胶原含量为23±4,对照组为34±6,两组比较,差异也有统计学意义(P<0.05)。SUI组患者尿道周围组织中Ⅲ型胶原含量与DCNmRNA表达水平呈显著负相关(r=-0.720,P<0.05)。结论(1)尿道周围结缔组织中Ⅲ型胶原含量减少,可能是SUI发生的原因之一;(2)SUI患者尿道周围结缔组织中Ⅲ型胶原含量减少可能是由于局部DCNmRNA表达增强所致;(3)DCNmRNA表达增强,可能通过影响结缔组织的胶原含量和弹性性能参与SUI的发生。     

Paraurethral abscess developing after mid-urethral Zuidex-injection in women with stress urinary incontinence -- management of complications and retrospective comparison with bladder neck located injection technique

PURPOSE: To evaluate the cause and management of paraurethral abscess developing after injection of a mixture of hyaluronic acid and dextranomer (Zuidex) for treating stress urinary incontinence. PATIENTS AND METHOD: A total of 127 women having undergone midurethral Zuidex injection and 34 women after endoscopically guided Deflux injection into the tissue around the bladder neck were followed up 1 to 24 months after the intervention. At follow-up, the paraurethral tissue was evaluated clinically by gynecologic examination and by introital ultrasound. RESULTS: Thirteen of 127 women (10 %) having undergone midurethral Zuidex injection had a sterile paraurethral abscess that was treated by transvaginal puncture (1 to 3 punctures with removal of 10-60 ml of fluid per patient). No case of postoperative paraurethral abscess formation was demonstrated in the control group treated by Deflux injection into the area around the bladder neck. CONCLUSIONS: Paraurethral abscess must be excluded in the postinterventional follow-up of patients after Zuidex injection. Patients in whom an abscess is demonstrated can be treated by transvaginal puncture. Abscess formation can be avoided by injecting dextranomer/hyaluronic acid into the area around the bladder neck.     

Urinary incontinence in the female over 60 years of age--urodynamic findings

A group of 20 urinary continent postmenopausal women and two stress incontinent groups in the age of 60-69 and 70-79 years have been examined concerning standardized conditions without and with stress. The measurements using the pneumatic-hydraulic pump perfusion were recorded under standardized conditions. The whole pressure profile without stress decreased with increasing age and with stress incontinence. The maximum urethra closure pressure has been displaced in the distal part of the urethra. The stress profile demonstrated a shortening of the continence zone, a clear decrease of the urethra closure pressure and a bad pressure transmission in the whole urethra, especially in its distal part. These fluctuations make us expect, that there are only a few promising possibilities of conservative treatment in stress incontinent postmenopausal women over 70 years.     

Young women with genital prolapse have a low collagen concentration

BACKGROUND: Genital prolapse is a common and handicapping form of pelvic floor dysfunction. To explain its genesis as a result of endopelvic connective tissue weakness, the collagen state was analyzed in women with and without genital prolapse. METHODS: Punch biopsies from the paraurethral ligaments were obtained during the operation from 22 women undergoing surgery for genital prolapse. As controls, similar biopsies were taken from 13 women who underwent gynecologic surgery for other benign reasons. Collagen concentration as hydroxyproline and its extractability by pepsin digestion were studied in relation to age by multiple regression, two-way anova, Levene's test, and Student's t-test. Histological examination was also performed. RESULTS: Women, younger than 53 years, with genital prolapse had a 30% lower collagen concentration than age-matched controls, which reached significance, P = 0.01. The extractability by pepsin digestion, an indicator of cross-links in the collagen molecule, did not significantly differ between groups. It did, however, decrease significantly with age in both prolapse patient and control groups. Morphology supported these findings with a less-dense extracellular matrix composition subepithelially in genital prolapse compared to a healthy control. CONCLUSION: For the first time, we show that young women with genital prolapse have a decreased collagen concentration, suggesting a different organization of the endopelvic connective tissue extracellular matrix. Furthermore, these alterations differ from those earlier found in younger women with stress urinary incontinence.     

3-D Ultrasonographic Appearance of Two Intermittent Paraurethral Cysts: A Case Report

IntroductionIn the adult female, a cyst of the Skene's duct is a rare event that may be either the late consequence of a congenital abnormality or the result of a chronic acquired inflammation.AimTo report a case of bilateral paraurethral Skene's duct cysts.MethodsA young (32 years old), eumenorrheic (menstrual cycle of >25 and <35 days) woman complained of a 6-month intermittent scarce lubrication during intercourse and a sensation of a small intravaginal “extraneous” body. The patient was repeatedly assessed with a detailed history, with a bimanual pelvic examination and with bi- and tridimensional ultrasonographic and color Doppler analyses of the urethrovaginal space.Main Outcomes MeasuresTransvaginal two-dimensional ultrasonographic evaluation of internal genitalia, bladder, and urethra and three-dimensional analysis of the paraurethral structures.ResultsThe evaluation of the structures comprised in the urethrovaginal space evidenced two small (1.7 and 1.1 cm in the maximum diameter) anechoic cysts with some debris in the most declivous part, laterally displaced to the middle/distal urethra. The cysts disappeared after a medical therapy.ConclusionsA sudden reduction of the vaginal lubrication requires a prompt gynecological and ultrasonographic evaluation of the urethrovaginal space. Battaglia C, and Venturoli S. 3-D ultrasonographic appearance of two intermittent paraurethral cysts: A case report.     

Changes in the MRI morphology of the stress continence control system after TVT (tension-free vaginal tape) insertion

OBJECTIVE: Magnetic resonance imaging (MRI) was used to investigate whether tension-free vaginal tape (TVT) insertion (according to Ulmsten) leads to morphologic changes of the stress continence control system. METHODS: Twenty women (mean age 53.4 years) with clinically and urodynamically proven stress urinary incontinence without prolapse were examined by MRI before and 13 months after TVT insertion. RESULTS: Postoperative MRI showed a signal intensity loss of the suburethral portion of the endopelvic fascia in the area of the anterior vaginal wall in 9/20 women with additional signal loss of the paraurethral portion of the fascia in 3/20 women. No morphologic changes of the levator ani muscle and the urethra were seen postoperatively. CONCLUSIONS: TVT insertion does not damage the structures of the stress continence control system or impact on their topographic relationships. MRI identified no excessive scar formation resulting from integration of the TVT.     

A prospective multisite study of radiofrequency bipolar energy for treatment of genuine stress incontinence

STUDY OBJECTIVE: To assess the efficacy of radiofrequency electrothermal energy to treat genuine stress incontinence (GSI). DESIGN: Multicenter, prospective, single-arm, longitudinal study (Canadian Task Force classification II-1). SETTING: Six North American university-affiliated and private clinic sites. PATIENTS: Ninety-four women undergoing laparoscopic treatment for GSI. INTERVENTION: Radiofrequency bipolar treatment of paravaginal tissue to induce tissue shrinkage causing bladder neck elevation. MEASUREMENTS AND MAIN RESULTS: Patients underwent complete urogynecologic evaluations, with urodynamic testing, including Valsalva leak point pressure, to confirm the diagnosis of GSI. Paravaginal tissue was treated lateral from the urethra and bladder neck out to the arcus white line, with bipolar electrothermal energy to shrink bladder-supporting connective tissue. Treatment resulted in 30% shrinkage in paravaginal endopelvic fascia surface area by direct measurement. At 1 year the objective cure rate was 79% by urodynamic testing, improvement in quality of life by questionnaire was 81%, decrease in leaking episodes and pad use was significant (p <0.001), and patient satisfaction was 83%. Complications (7%) were secondary to laparoscopy. There were no injuries from the radiofrequency probe. CONCLUSION: Radiofrequency bipolar electrothermal energy appears to be a safe an efficient means of treating mild to moderate GSI. It results in shrinkage and elevation of paravaginal connective tissue, stabilizing the urethra and bladder neck, thereby restoring continence. Long-term follow-up is necessary.     

Contribution of the Posterior Compartment to the Urinary Continence Mechanism

Objective: To describe the contribution of the posterior pelvic compartment to the urethral closure mechanism.Methods: Urethral profilometry at rest and during stress was performed in 32 continent women before and after inserting a weighted (1 kg) posterior speculum to displace the posterior vaginal wall and levator ani muscles away from the bladder neck and the urethra.Results: Insertion of the speculum decreased the pressure transmission ratios in the proximal quarter of urethra (from 81 to 76; P < .05) and the urethral closure pressure under stress in the proximal two urethral quarters (from 5 to −3 cm H₂O in the first and from 12 to 0 cm H₂O in the second urethral quarter; P < .05) in all 32 women. Before speculum insertion, 20 women had positive urethral closure pressure in the proximal urethra under stress, and 12 had negative urethral closure pressure in the proximal urethra under stress. In the 20 women with positive urethral closure pressures under stress in the proximal urethra without a speculum, the insertion of a posterior speculum decreased the pressure transmission ratios to the proximal urethral quarter (from 87 to 78; P < .05) and decreased the urethral closure pressures under stress in the proximal two urethral quarters (from 13 to −4 cm H₂O in the first urethral quarter and from 24 to 2 cm H₂O in the second urethral quarter; P < .01). In the 12 patients with negative urethral closure pressures under stress in the proximal urethra without a speculum, the profilometry values were unchanged by insertion of a speculum.Conclusion: These observations indicate that the posterior vaginal compartment may contribute to the closure mechanism of the proximal urethra in continent women.     

The human female prostate-immunohistochemical study with prostate-specific antigen, prostate-specific alkaline phosphatase, and androgen receptor and 3-D remodeling

IntroductionThe constitution of glands surrounding the human female urethra has been under debate; especially regarding as to what extent they equal the male prostate. Defining their composition may help to understand the development of neoplasms arising from this tissue.AimsThe aim of this study was to define the existence, structure, and arrangement of a possible human female prostate.MethodsUrethras of 25 women were investigated by immunohistochemistry and stained with specific monoclonal antibodies against prostate‐specific antigen (PSA, mono‐ and polyclonal antibody), prostate specific alkaline phosphatase (PSAP), and androgen receptor (AR). From two urethras, which underwent a totally serial work up with PSA‐staining, a three‐dimensional model of the urethra and the prostatic glands was created to enable 3D‐perception of the results.Main Outcome MeasureThe main outcome measures used in this study were identifying glandular structures in hematoxylin‐eosin‐staining, positive staining with the respective antibodies, and 3‐D orientation of described glands.ResultsFourteen of 25 patients had glandular structures encircling the urethra. Twelve of 14 showed positive staining for PSA, PSAP, and AR in gland acini, while the excretory ducts, the urethra, and the surrounding stroma did not express those proteins. The strongest PSA and PSAP expression was found in apical cytoplasm of the glandular cells, and AR was confined to cell nuclei. Prostatic glands were located laterally to the distal half of the urethra.ConclusionA female prostate was found in every second woman in this study and can be discriminated from other urethral caverns and immature paraurethral ducts. Possible neoplasms of this source tissue expressing the prostate‐specific markers may therefore be denominated as female prostate tumors. Dietrich W, Susani M, Stifter L, and Haitel A. The human female prostate—immunohistochemical study with prostate‐specific antigen, prostate‐specific alkaline phosphatase, and androgen receptor and 3‐D remodeling. J Sex Med 2011;8:2816–2821.     

Structure of the perineal membrane in females: gross and microscopic anatomy

OBJECTIVE: To re-examine the anatomy of the perineal membrane and its anatomical relationships in whole-pelvis and histologic serial section as well as gross anatomical dissection. METHODS: Serial trichrome-stained histologic sections of five female pelvic specimens (0-37 years old) were examined. Specimens included the urethra, perineal membrane, vagina, and surrounding structures. Macroscopic whole-pelvis sections of three adults, 28-56 years of age, in axial, sagittal, and coronal sections were also studied. Dissections of six female cadavers, 48-90 years of age, were also performed. RESULTS: The perineal membrane is composed of two regions, one dorsal and one ventral. The dorsal portion consists of bilateral transverse fibrous sheets that attach the lateral wall of the vagina and perineal body to the ischiopubic ramus. This portion is devoid of striated muscle. The ventral portion is part of a solid three-dimensional tissue mass in which several structures are embedded. It is intimately associated with the compressor urethrae and the urethrovaginal sphincter muscle of the distal urethra with the urethra and its surrounding connective. In this region the perineal membrane is continuous with the insertion of the arcus tendineus fascia pelvis. The levator ani muscles are connected with the cranial surface of the perineal membrane. The vestibular bulb and clitoral crus are fused with the membrane's caudal surface. CONCLUSION: The structure of the perineal membrane is a complex three-dimensional structure with two distinctly different dorsal and ventral regions; not a simple trilaminar sheet with perforating viscera.     

Reconstruction of the pubovesicocervical fascia following surgical failures of the anterior vaginal wall

Results of reconstruction of fascia pubo-vesico-cervicalis in 21 women are presented after operative failure on the anterior vaginal dropped wall. The former operation consisted of anterior incision, separation of the walls to the sides, vesical intussusception with purse-string suture or transverse suture and of application mattress sutures on paraurethral tissue. At present the reconstruction of selected fascia pubo-vesico-cervicalis based on the doubling like a waistcoat and suturing under the symphysis pubis. Such a management causes a correctly fibrous and connective tissue support for urinary bladder and elevates the cervix upwards.     

Adenocarcinoma of the paraurethral glands: Report of a case

A case of adenocarcinoma of the urethra originating in the paraurethral glands is reported. A method of therapy has been outlined. Review of the literature shows the rarity of the lesion in which only 50 cases have been reported.     

Magnetic Resonance Imaging of Female Prostate Pathology

IntroductionThe female prostate (paraurethral glands) is a well-known, yet poorly understood, anatomic structure. Imaging studies of the female prostate, its physiology, and pathologies are still highly controversial.AimTo study the anatomy of the female prostate with contemporary magnetic resonance imaging (MRI) techniques and correlate these findings to clinical features.Main Outcome MeasuresFemale prostate pathologic anatomy on MRI.MethodsWomen with clinical signs of function (or dysfunction) of paraurethral glands have been examined with 1.5 or 3 Tesla MRI and urethroscopy.ResultsSeven women aged 17 to 62 years (median 40 years) have been prospectively included into the study. Clinically, one of the seven women reported ejaculation at orgasm, whereas three women presented with occasional secretions independent of sexual stimulation. In two women, paraurethral glands have been randomly found on MRI that has been performed in the diagnostic workup of other diseases. One woman presented with swelling of the external urethral meatus at puberty. In this woman, a paraurethral gland has been found, besides the erectile tissue at the external meatus. Two women reported lower urinary tract symptoms (LUTS) with mainly urethral symptoms (recurrent infections in one and paraurethral stones in the other). On MRI, paraurethral glands could be visualized in six of the seven patients. There was no relation between glandular volume and ejaculation status. In cases where glands or related pathologies could be found on physical examination, there was a clear correlation with MRI anatomy.ConclusionsMRI has the potential to become the standard imaging modality for female prostate pathology. Exact visualization of this highly variable structure is possible by tailored MRI protocols. This tool can aid in understanding an individual woman's symptoms related to paraurethral glands with an impact on her sexual life. Wimpissinger F, Tscherney R, and Stackl W. Magnetic resonance imaging of female prostate pathology. J Sex Med 2009;6:1704–1711.     

Recurrent Postcoital Hematuria. A Case of Fibroepithelial Urethral Polyp in an Adult Female

IntroductionIn males, an isolated gross postcoital hematuria is a very rare clinical phenomenon. No cases of postcoital macroscopic hematuria have been previously reported in females.AimTo report a case of female urethral fibroepithelial polyp (FEP) associated with recurrent postcoital hematuria.MethodsA young (31 years old), eumenorrheic woman complained of three episodes of postcoital macrohematuria. The patient was assessed with a detailed history, with a bimanual pelvic examination and with bidimensional and tridimensional ultrasonographic and color Doppler analyses of the internal genitalia and of the urethrovaginal space.Main Outcomes MeasuresTransvaginal two‐dimensional (2‐D) ultrasonographic evaluation of internal genitalia, bladder and urethra and three‐dimensional (3‐D) analysis of the urethra and paraurethral structures.ResultsThe 2‐D transvaginal evaluation and the 3‐D reconstruction showed a polypoid hypervascularized structure arising from the anterior urethral wall. A cystourethroscopy confirmed the presence of a FEP arising from the anterior wall of the urethra and allowed its removal.ConclusionsA gross postcoital hematuria may be associated with a urethral polyp. The ultrasonographic evaluation of the urethrovaginal space can facilitate the diagnosis. Battaglia C, Battaglia B, Ramacieri A, Paradisi R, and Venturoli S. Recurrent postcoital hematuria. A case of fibroepithelial urethral polyp in an adult female.     

Histology of the connection between the vagina and levator ani muscles. Implications for urinary tract function

The proximal urethra is a mobile structure, and voluntary control of its position is an integral part of the initiation of urination and continence. This paper describes the histology of the vagina's attachment to the medial portion of the levator ani muscles, which, because of the intimate attachment of the vagina and urethra, is responsible, in part, for control of the urethral position. A histologic examination of 1,500 serial microscopic slides from eight women, dissection of four bodies and study of whole pelvis cross-sections from two cadavers were performed. Smooth muscle, collagen and elastin fibers of the vaginal wall and paraurethral tissues directly interdigitate with the muscle fibers of the most medial portion of the levator ani, in the region of the proximal urethra. This strong connection lies at a level just below the entry of the urethra into the bladder and extends downward to the level of the perineal membrane (urogenital diaphragm) in an area corresponding to the mobile portion of the urethra. The inseparable nature of the vagina and urethra in this region makes it possible for the connection of the levator ani to the vagina to control the proximal urethral position. These observations suggest a specific role of the medial levator ani muscle in controlling vesical neck position and open the question of the specific part played by this arrangement in voiding and continence relative to other factors known to influence lower urinary tract function.     

The Marlex sling operation for the treatment of recurrent stress urinary incontinence: a 16-year review

Between 1968 and 1983, 281 patients with recurrent stress urinary incontinence and nine patients with primary stress urinary incontinence were treated with a two-team (suprapubic vaginal) Marlex urethral sling operation. Selection was based on the patient's history and the clinical demonstration of an anatomic defect in the closure mechanism of the urethra. The operative technique as described in 1970 remains unchanged. The bladder neck is released from the scar and replaced in a midretropubic position on a hammock of Marlex mesh attached to Cooper's ligaments. Patients with a sloughed urethra had a sling operation in conjunction with the reconstruction of a neourethra. The overall success rate based on a minimum 5-year follow-up of 208 patients was 77.4%. There was a high failure rate in the sloughed urethra group. Significant overall complications include bladder neck obstruction and chronic cystitis.     

Urodynamic analysis of successful and failed incontinence surgery

Seventy-nine patients were investigated by simultaneous urethrocystometry before and, on average, 15 months after vaginal and/or suprapubic operations for stress urinary incontinence. Subjective and objective success rates were 78% and 60%, respectively, with no significant differences between operation types. Patients with a low (less than 0.6) index of urethral relaxation at stress pre-operatively indicating excessive loss of basal urethral pressure at stress, had objective success rates of 39% whereas a higher index was associated with a success rate of 70%. Maximal urethral closure pressure and functional urethral length did not correlate with the operative result and were virtually unchanged postoperatively. Successful operations increased the index of urethral relaxation at stress and urethral pressure peaks at stress especially in the distal functional urethra. No significant quantitative differences except for sling operations producing higher urethral closure pressure at stress in the proximal and lower in the distal functional urethra compared to the other operations were found.The results indicate, that successful operations eliminate the failure to maintain adequate basal urethral pressure at stress and emphasizes the importance of reflex activity of pelvic floor musculature at stress for continence.     

Modified retropubic cystourethropexy

A variation of retropubic suspension of the urethrovesical junction was performed on 26 patients with urinary stress incontinence. Access to the retropubic space was through a low transverse muscle-splitting incision. Surgical technique consisted of securing a helical Prolene suture in the paraurethral fascia at each side of the bladder neck. Each suture was then passed through the abdominal wall fascia, exiting just above the symphysis pubis on either side of the midline, and tied to the opposite suture above the rectus fascia. The desired amount of elevation of the vesical neck was gauged by a Q-tip applicator inserted into the urethra just before the Prolene sutures were tied down. A cystotomy was performed to rule out any inadvertent penetration of the bladder by the nonabsorbable suture material, and the bladder was drained suprapubicly. The small number of cases and short follow-up times do not allow conclusions to be drawn at this time, but results to date have been encouraging.     

Computer-assisted virtual urethral pressure profile in the assessment of female genuine stress incontinence.

OBJECTIVE: To compare computer-assisted virtual urethral pressure profile changes between women with and without genuine stress incontinence. METHODS: A full urogynecologic assessment including conventional urodynamic measurements and a clinical stress test were carried out. Computer-assisted virtual urethral pressure profile uses conventional urethral pressure profile measurements during stress, with the only change being that withdrawal of the catheter is stopped at distinct points along the whole urethra while the patient coughs. Cough-related changes of maximal urethral closure pressure, functional urethral length, and area under the urethral closure pressure curve were determined. RESULTS: Sixty-one women were enrolled in our study: 30 symptom-free women (group A) were continent, and genuine stress incontinence was present in 31 patients (group B) complaining of urinary loss. Significant differences between group A and group B women were found for all parameters of computer-assisted virtual urethral pressure profile including maximal urethral closure pressure (91.59 +/- 39.00 versus 20.70 +/- 22.61 cm H(2)O; P <.001), functional urethral length (31.81 +/- 9.02 versus 10.83 +/- 10.76 mm; P <.001), and the area under the urethral closure pressure curve (2036 +/- 1025.29 versus 253 +/- 206.69 cm H(2)O x mm; P <.001). CONCLUSION: Computer-assisted virtual urethral pressure profile is a new application of urethral pressure profile measurements during stress. Our data show significant differences between continent women and patients with genuine stress incontinence. Further studies are needed to assess the potential of computer-assisted virtual urethral pressure profile for diagnosing genuine stress incontinence.     

Bonney's test—fact or fiction?

Summary. A prospective urodynamic study in 61 incontinent women assessed the validity of the Bonney test in the diagnosis of true sphincter weakness stress incontinence. The urodynamic findings in all the patients indicated that the Bonney test produced significant increases in the urethral closure pressure and transmission of impulse from the abdomen to the urethra which indicated occlusion of the urethra rather than elevation of the bladder neck. The Bonney test does not differentiate between patients with sphincter weakness and those with bladder instability and therefore should be discarded.