Serum Reproductive Hormone Levels And Relationship With Female Bladder Outlet Obstruction

The early diagnosis of female bladder outlet obstruction (fBOO) becomes possible due to the development of urodynamics and the extensive application of urethrocystoscopy. The majority study focus on the non-nervous fBOO the present, which includes the functional and the anatomic obstruction. Most of the laters have specific causations. when they released from these causations, bladder obstructive symptoms become lighten or dissipated. So about fBOO, the majority study focus on primary bladder neck obstruction(PBNO).Voiding difficulties in women may lead to recurrent urinary tract infections and/or upper urinary tract damage. Early diagnosis and treatment may prevent development of these complications. Data concerning voiding difficulties in women are scarce. Most research on lower urinary tract function has focused on the filling phase of the micturition cycle, or the study of urinary incontinence. Furthermore, there are no standard definitions for the diagnosis of fBOO.At present, the best method of studying fBOO is by analyzing the characteristics of urodynamics parameters and urethrocystoscopic examination. Patients with fBOO may represent characteristics bladder neck uplift or hypertrophy, normal or increasedshrinkage of destrusor muscle, most fluid rate(MFR) less than 10ml/s.Obstruction can cause changes in bladder structure and function, which may at a certain point in time become irreversible.Information on underlying mechanisms causing fBOO is lacking, development of the best treatment wound require a greater understanding of these mechanisms. The most common symptoms is the feeling of incomplete emptying, followed by double voiding, intermittent stream, and weak or prolonged stream. Current fBOO treatment guideline involve watchful waiting, pharmacologic treatment with alpha-adrenergic blocker and surgery. Optimal therapy depends on symptom severity and patient preference. Bladder neck dissection are often used for persisting irritative symptoms, but efficacy is questionable and medication secondary effects are bothersome.fBOO are common occurred in perimenopause women, and aggravated after postmenopause period. So we presume that unbalances among serum reproductive hormones maybe concerned with fBOO. But we also have detected that not all perimenopause women appear urinary stimulate symptom and not all the women containing these symptoms appear significant urethrocystoscopic characteristics.At present, serum reproductive homone levels of periomenopause women are not reported in international. Possibly there are no standard definitions for the diagnosis of fBOO. Both the rabbit and the rat have proven to excellent models to study the morphological, biochemical and molecular changes that occur in the bladder following obstruction. Similarities between partial outflow obstruction in animals and obstructive dysfunction in woman include increased bladder mass, increased fibrosis, reduced compliance, increased incidence of detrusor instability and decreased instability and decreased contractile ability. Obstructed bladder function can remain relatively normal for prolonged periods of time, even though bladder mass in increased (compensated stage). If the obstruction is not relieved, bladder function destabilized and then decompensates, with subsequent risk of serious complications.This study consisted of two parts. In part 1, our study was conducted to examine the clinical and urodynamic characteristics of objectively confirmed urinary stimulate symptoms among periomenopause women ,to assay for E₂, P, T, FSH and LH levelsby radioimmunoassay methods and to study the expression of ER, PR, TR in different bladder wall among three groups. Through them we could evaluate whether any correlation is possible between serum reproductive hormone and bladder neck uplift or hypertrophy. In part 2, animal model was conducted to study the effects of hormones on female rat bladder structure. By examining the functional, histological and ultrastructural changes that occurred in the bladder of rats with estrogen depletion and estrogen, progensterone, testosterone supplementation, we studied the actions of them on bladder. thus we tried to provide the theory for the prevention and treatment offBOO.Part 1 serum homone levels in fBOO and ER, PR, TR expression in different bladder wallMaterial and MethodsThis was a prospective, randomized study undertaken in gynecologic and/or urologic department of the First Affiliated Hospital, School of Medicine, Zhengjiang University volunteered for this study. All perimenopause women had significant urinary stimulate symptom, and had not received any anti-inflammatory or hormonal treatment for at least 3 months. Among 68 patients, 39 cases with bladder outlet obstruction by examination of urethrocystoscopy and urodynamics were included. There were 14 cases between generational period in the control group, they included ureter calculus 4 cases, gland cystitis 3 cases, cyst-vaginal fistula 2 cases, cyst polypus 2 cases and 3 natural women.Blood samples were collected by venipuncture in 24 hours before operation in postmenopause women and in the second day of menstrual cycle in generational women. Serum were separated by centrifugation and stored at -20°C until assayed for estradiol(E₂), progesterone(P), testosterone(T), follicular stimulating hormone( FSH)and luteal hormone(LH) by radioimmunoassay.Two 5mm×5mm×5mm tissues in bladder neck position(section J) and in bladder triangle position(section B) were obtained respectively between operation or examination of urethrocystoscopy. ER, PR and AR expression in different bladder wall were assessed by immunohistochemistry (Enivision methods).Statiatical analysis were done by SPSS 13.0 for windows. Data were expressed by mean±SD.Results1. ordinary clinic informationThere were no significant differences in ages, history and menopause time between fBOO group and nBOO group(P > 0.05). the time of menarche was 142± 2.1 year in fBOO group and 13.7+2.4 year in nBOO group respectively, they were both lower than the data in control group, but there was no significant difference hi the number of menarche time either.2. serum reproductive hormone levelsSerum E₂ level was 19.8±14.2pg/ml in fBOO group and 23.7±15.8pg/ml in nBOO group respectively, there was no significant difference(P> 0.05). Serum E₂ level in control group was 78.2±51.7 pg/ml, it was higher than the others.Serum P level was 0.3±0.24ng/ml, 0.4±0.26ng/ml and 0.4±0.24ng/ml in three groups, there was no significant difference(P> 0.05).Serum T level was 72.4±37.5ng/dl in fBOO group and 43.6±28.4ng/dl in nBOO group respectively, there was significant difference(P<0.05). Serum T level in control group was 23.4±19.3 ng/dl, it was lower than the others.Serum FSH level was 71.2+33.1IU/L in fBOO group and 89.4+21.9IU/L in nBOO group respectively, they were higher than the data in control group. There was significant difference(P<0.05).Serum LH level was 29.3±23.8 IU/L in fBOO group and 34.6±24.2 IU/L in nBOO group respectively, they were higher than the data in control group. There was significant difference(P<0.05).3. ER, PR and TR expression in different bladder wallER, PR and TR expressions in control group were high in section J and in section B, and there were no significant difference between two sections(P> 0.05).In nBOO group, the three receptors expressions were lower than the data in control group both in two sections, and there were no significant difference between two sections(P> 0.05).In fBOO group, the level of ER and PR expressions were lower than the data in control group both in two sections, and there were no significant difference between two sections(P> 0.05). the level of AR expression were lower than the data in control group in two sections either, but it was much lower in section B than in section J, there were significant difference (P=0.018,<0.05).Conclusion1. Low serum E₂ level and lack of ER in bladder wall may be related with fBOO.2. There may be no relationship among serum P level, expression of PR in bladder wall and fBOO.3. High serum T level momently, AR increased relative in bladder neck tissue and lacked in other bladder wall tissue may be the most important endocrine factor on fBOO.Material and MethodsSeventy mature female Sprague-Dawley rats (SD rats) of 180-200 g (four months old) purchased from school of medicine, zhejiang university were studied four weeks after bilateral ovariectomy or sham surgery. They were assigned to seven groups: sham operated group (SHAM, 10 cases) and untreated ovariectomied group (OVX, 10 cases) received no medication; the others received estradiol benzoate (E₂) 0.25mg/kg(OVX+E,10 cases), or 1 mg/kg(OVX+Elmg,10 cases), progesterone (P) lmg/kg(OVX+P, 10 cases) , estradiol benzoate 0.25mg/kg combined with progesterone 1mg/kg( OVX+E+P, 10 cases) and testosterone propionate (T) 3mg/kg (OVX+T,10 cases) respectively via muscle injection every two days.Blood samples were collected by venipuncture after four weeks, respectively. Blood samples were allowed to clot, Serum were separated by centifugation and stored at -20℃ until assayed for E₂, P and T by radioimmunoassay. Animals were sacrificed under ether anesthesia. Immediately afterward the whole bladder, including the urethra and ureters, was removed, fixed in cold acetone and maintained in mis fixative for 24 hours at 4℃.The bladders were then finely minced and submitted to 2 changes of 24 hours each in 40 ml chloroform-methanol (2:1 volume per volume) at room temperature. The solvent was decanted and after incubation at 60V for 30 minutes a preparation of whole dry and defatted bladder was obtained and weighed. Light and electron microscopy was used to evaluate the morphologic changes in the bladder tissues. For in vitro studies hematoxylin and eosin staining was done on frozen tissue sections to examine tissue structure and determine tissue health. The bladder was removed, the tissue was sectioned on a frozen cryostat at 14 μm. and the sections were placed on histology slides. Specimens were cut in cross section from 3 areas of the bladderlabeled base, mid and dome or in sagittal sections. The slides were stored at -20℃. At staining the sections were first rehydrated with 0.1 M. phosphate buffered saline, pH 7.4, mixed with 0.3% Triton X-100. The standard Mayer hematoxylin and eosin staining procedure was followed. Thickness of the bladder wall structures, including mucosal layer, muscle layer, and total wall thicknesses, were also evaluated. The wall thickness in each element was calculated from 10 consecutive points of each specimen. Tissue blocks were prepared using detrusor dome tissue.2 An observer blinded to the study hypothesis selected 144 high magnification (₁0,000) photographs, each illustrating the whole cross-sectional profile of an individual myocyte. Five to 7 images per animal and 30 to 43 per experimental group were used (see table). Caveolae were defined as all noncoated vesicles present within 100 nm of the sarcolemma. Individual caveolae were then counted and myocyte perimeters were measured using (ImagePro I Media Cybernetics, Silver Spring, Maryland) image analysis software. Each 1,000 pixels of image obtained represented 7.1 μm of sarcolemmal length.Statistical analysis were done by SPSS13.0 for windows. Data were expressed by mean ± SD.Results1. serum reproductive hormone levelsSerum E₂ level was 11.43 ± 2.59pg/ml in OVX group and 70.74 ± 11.10pg/ml in SHAM group respectively, there was significant difference(P<0.05). Serum P level was 9.68 ± 3.06 mol/l in OVX group and 25.56 ± 8.08 mol/1 in SHAM group, the former is significantly lower than the latter(P < 0.05).Serum E₂ level was 2.5 times in OVX+E group and 7 times in OVX+Elmg than in SHAM group respectively. Serum T level was 13.38 ± 8.59nmol/l, it was significantly higher than others (P < 0.05).2. Rat bodyweight and lower urinary tract wet weightThe rat bodyweights in seven groups before sacrificed were 278.90 ± 14.16g,279.40 ± 15.42g, 268.70 ± 16.28g, 272.30 ± 12.19g, 279.50 ± 16.33g, 276.00 ± 14.63g, 269.50 ± 10.41g respectively, there were no significant differences. The lower urinary tract wet weight were 162.19 ± 17.45mg in OVX+E group and 160.34±14.43mg in OVX+T group, they were both higher than the weight in SHAM group (133.48 ± 15.78mg), there were significant difference( P < 0.01). The lower urinary tract wet weight were 127.43 ± 15.22mg, 123.13 ± 13.11mg in OVX group and in OVX+P group respectively, they were both lower than the weight in SHAM group, there were significant difference ( P < 0.01). The weight were 150.93 ± 20.81mg, 153.32 ± 22.27mg in OVX+Elmg group and in OVX+E+P group respectively, they were both little lower than the top levels, but they were higher than the levels in SHAM group (P<0.05).3. Histological changes in the bladders of the rats.The bladder musculature were atrophic and attenuative, the clearsance between detrusor cells were increscent in OVX group. They also represented abundant fibre tissue. Total thickness of the bladder walls in SHAM group and in OVX group were 1.10 ± 0.10mm , 0.97 ± 0.11mm respectively, there were difference( P < 0.05). The bladder musculature were much mick in OVX+E group, in OVX+Elmg group and in OVX+T group. In this three groups, we could see that the bladder musculature were incrassated, the detrusor cells arranged compact, fibre tissue reduced and mucous membrance attenuated. The thickness were no significant distinction in between OVX+E+T group and SHAM group ( P > 0.05). It was similar between OVX+P group and OVX group either.4. infrastructure of detrusor muscle fasciclesElectron microscopy showed lots of abnormities in OVX group. The distribution of detrusor muscle was not well-proportioned. The dilatation and degranulation of rough endoplasmic reticulum were obvious. Dropsy and vacuole denaturalization were found in mitochondria. The mitochondrial crista decreased or disappeared. Sometimes lysosomes were also found in the detrusor muscle cells. The cells junctionwere more compact after affiliated E₂ and T. but we also found a interesting phenomena which there were a lot of vacuoles in cellularity after affiliated E₂, especially in OVX+E1mg group. In addition, we also found that the membrane presented flexuous in OVX+E+P group.ConclusionEstrogen and testosterone can have a hypertrophic effect on bladder detrusor muscle. But large doze of estrogen also has some unexpected effects which may destroy bladder structure. In addition, progesterone can compromise the effect of estrogen.