Skip to main content
SpringerLink
Log in

Morphology and neuropathology of the pelvic floor in patients with stress incontinence

  • Original Article
  • Published:
International Urogynecology Journal Aims and scope Submit manuscript

Abstract

Urinary incontinence imposes a considerable workload on urological and gynecological practice. Many treatments exist, but recurrent stress incontinence remains a significant problem and the reasons remain unclear. Pathological and electrophysiological studies have shown that significant pelvic nerve damage and consequent denervation and reinnervation are associated with stress incontinence, and furthermore there are collagenous changes in the pelvic floor which are related to childbirth, endogenous hormone changes and the effects of increasing age. These changes include increased nerve fiber density and pudendal nerve terminal motor latency, hypertrophy of fiber types 1 and 2, type 1 fiber predominance and fiber type grouping. Connective tissue changes involve a reduction in hydroxyproline excretion, increased cross-linking and increased muscle collagen. It is only through a better understanding of the anatomy and pathophysiology of the pelvic floor that we will be able to improve outcome in women with stress incontinence and identify patients that may not be appropriate for surgical therapy. This paper reviews recent advances in the understanding of the etiology of stress incontinence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. DeLancey JOL. Pubovesical ligament: a separate structure from the urethral supports (pubo-urethral ligaments).Neurourol Urodyn 1989;8:53–61

    Google Scholar 

  2. Richardson AC, Edmonds PB, Williams NL. Treatment of stress urinary incontinence due to paravaginal defect.Obstet Gynecol 1981;57:357–362

    PubMed  Google Scholar 

  3. DeLancey JOL. Structural aspects of the extrinsic continence mechanism.Obstet Gynecol 1988;72:296–301

    PubMed  Google Scholar 

  4. Gosling JA, Dixon JS, Critchley HOD, Thompson SA. A comparative study of the human external sphincter and periurethral levator ani muscles.Br J Urol 1981;53:35–41

    PubMed  Google Scholar 

  5. Parks AG, Porter NH, Melzak J. Experimental study of the reflex mechanism controlling muscles of the pelvic floor.Dis Colon Rectum 1962;5:407–414

    PubMed  Google Scholar 

  6. Burke RE, Levine DN, Zajac FE, Tsairis P, Engel WK. Mammalian motor units—physiological-histochemical correlation in three types in cat gastrocnemius.Science 1971;174:709–712

    PubMed  Google Scholar 

  7. Porter NH. A physiological study of the pelvic floor in rectal prolapse.Ann Roy Coll Surg Lond 1962;31:379–401

    Google Scholar 

  8. Parks AG. Anorectal incontinence.Proc Roy Soc Med 1977;68:681–690

    Google Scholar 

  9. Beersiek F, Parks AG, Swash M. Pathogenesis of idiopathic anorectal incontinence.J Neurol Sci 1979;42:111–117

    PubMed  Google Scholar 

  10. Lubowski DZ, Nicholls RJ, Burleigh DE, Swash M. The internal anal sphincter in anorectal incontinence.Gastroenterology 1988;95:997–1102

    PubMed  Google Scholar 

  11. Parks AG, Swash M, Ulrich H. Sphincter denervation in anorectal incontinence.Gut 1977;18:656–667

    PubMed  Google Scholar 

  12. Swash M, Snooks SJ, Henry MM. A unifying concept of pelvic floor disorders and incontinence.J Roy Soc Med 1985;78:906–911

    Google Scholar 

  13. Henry MM, Swash M.Coloproctology and the pelvic floor. London: Butterworths, 198:407–413

    Google Scholar 

  14. Neill ME, Swash M. Increased motor unit fibre density in the external anal sphincter muscle in anorectal incontinence: a single fibre EMG study.J Neurol Neurosurg Psychiatry 1980;43:343–347

    PubMed  Google Scholar 

  15. Bartolo DCC, Jarratt JA, Read NW. The use of conventional EMG to assess external sphincter neuropathy in man.J Neurol Neurosurg Psychiatry 1983;46:1115–1118

    PubMed  Google Scholar 

  16. Kiff ES, Swash M. Normal proximal and delayed distal conduction in the pudendal nerves of patients with idiopathic (neurogenic) anorectal incontinence.J Neurol Neurosurg Psychiatry 1987;47:820–823

    Google Scholar 

  17. Snooks SJ, Barnes PRH, Swash M. Damage to the innervation of the voluntary anal and periurethral straited sphincter musculature in incontinence: an electrophysiological study.J Neurol Neurosurg Psychiatry 1984;47:1269–1273

    PubMed  Google Scholar 

  18. Snooks SJ, Badenoch DF, Tiptaft RC, Swash M. Perineal nerve damage in genuine stress urinary incontinence.Br J Urol 1985;57:422–426

    PubMed  Google Scholar 

  19. Smith ARB, Hosker GL, Warrell DW. The role of partial denervation of the pelvic floor in the aetiology of genitourinary prolapse and stress incontinence of urine. A neurophysiological study.Br J Obstet Gynaecol 1989;96:24–28

    PubMed  Google Scholar 

  20. Snooks SJ, Swash M, Setchell M, Henry MM. Injury to innervatio of pelvic sphincter musculature in childbirth.Lancet 1984;2:546–550

    PubMed  Google Scholar 

  21. Allen RE, Hosker GL, Smith ARB, Warrell DW. Pelvic floor damage and childbirth.Br J Obstet Gynaecol 1990;97:770–779

    PubMed  Google Scholar 

  22. Laurberg S, Swash M. Effects of aging on the anorectal sphincters and their innervation.Dis Colon Rectum 1989;32:737–742

    PubMed  Google Scholar 

  23. Jones PN, Lubowski DZ, Swash M, Henry M. Relation between perineal descent and pudendal nerve damage in idiopathic faecal incontinence.Int J Colorect Dis 1987;2:93–95

    Google Scholar 

  24. Henry MM, Parks AG, Swash M. The pelvic floor musculature in the descending perineum syndrome.Br J Surg 1982;69:470–472

    PubMed  Google Scholar 

  25. Percy JP, Neill ME, Kandiah TK, Swash M. A neurogenic factor in faecal incontinence in the elderly.Age Ageing 1982;11:175–179

    PubMed  Google Scholar 

  26. Tomlinson BE, Walton JN, Rebeiz JJ. The effects of ageing and cachexia upon skeletal muscle.J Neurol Sci 1969;9:321–346

    PubMed  Google Scholar 

  27. Gardner E. Decrease in human neurones with age.Anat Rec 1940;77:529–536

    Google Scholar 

  28. Morley R, Wellor R, Cumming J. Morphological changes in patients with stress incontinence: a histochemical study of the levator ani muscle.Br J Urol (in press)

  29. Dubowitz V, Brook MH Muscle biopsy—a modern approach. London: Saunders 1985:77–101

    Google Scholar 

  30. Brook MH, Engel WK. The histographic analysis of human muscle biopsies with regard to fibre types. 2 Diseases of the upper and lower motor neurone.Neurology 1969;19:378–393

    PubMed  Google Scholar 

  31. Swash M, Gray A, Lubowski DZ, Nicholls RJ. Ultrastructural changes in internal anal sphincter in neurogenic anorectal incontinence.Gut 1988;29:1692–1698

    PubMed  Google Scholar 

  32. Gilpin SA, Gosling JA, Smith ARB, Warrel DW. The pathogenesis of genitourinary prolapse and stress incontinence of urine: a eistological and histochemical study.Br J Obstet Gynaecol 1989;96:15–23

    PubMed  Google Scholar 

  33. Koebl H, Strasseger H, Gruber H. Morphologic and functional aspects of pelvic floor muscles in patients with pelvic relaxation and genuine stress incontinence.Obstet Gynecol 1989;74:789–793

    PubMed  Google Scholar 

  34. Fischer W, Pfister C, Tunn R. Comparison between histological, histochemical and clinical findings from musculature of pubococcygeal repair in urinary incontinence.Int Urogynecol J 1992;3:124–128

    Google Scholar 

  35. Roman WJ, Fleckenstein J, Stray-Gundersen J, Gonyea WJ. Adaptions in the elbow flexors of elderly males after heavy resistance training.J Appl Physiol 1993;74:750–754

    PubMed  Google Scholar 

  36. Huisman AB. Aspects on the anatomy of the female urethra with special relation to urinary continence.Contrib Gynecol Obstet 1983;10:1–31

    PubMed  Google Scholar 

  37. Carlile A, Davies I, Rigby A, Brocklehurst JC. Age changes in the human female urethra: a morphometric study.J Urol 1988;139:532–535

    PubMed  Google Scholar 

  38. Rud T. Urethral pressure profile in continent women from childhood to old age.Acta Obstet Gynecol Scand 1980;59:331–335

    PubMed  Google Scholar 

  39. Iosif CS, Batra S, Ek A, Astedt B. Estrogen receptors in the human female lower urinary tract.Am J Obstet Gynecol 1981;141:817–820

    PubMed  Google Scholar 

  40. Bhatia NN, Bergman A, Karram MM. Effects of estrogen on urethral function in women urinary incontinence.Am J Obstet Gynecol 1989;160:176–181

    PubMed  Google Scholar 

  41. Karram MM, Yeko TR, Sauer MW, Bhatia NN. Urodynamic changes following hormonal replacement therapy in women with premature ovarian failure.Obstet Gynecol 1989;74:208–211

    PubMed  Google Scholar 

  42. Kielty C, Hopkinson I, Grant ME. The collagen family: structure, assembly and organisation in the extracellular matrix. In Connective tissue and its heritable disorders. Ed. P. M. Royce, B. Steinmann New York, Chichester, Wiley-Liss, 1993:103–147

    Google Scholar 

  43. Falconer C, Ekman G, Malmstom A, Ulmsten U. Decreased collagen synthesis in stress incontinent women.Obstet Gynecol 1994;84:583–586

    PubMed  Google Scholar 

  44. Ulmsten U, Ekman G, Giertz G, Malmstrom A. Different biochemical composition of connective tissue in continent and stress incontinent women.Acta Obstet Gynecol Scand 1987;66:455–457

    PubMed  Google Scholar 

  45. Versi E, Cardozo L, Brincat M, Cooper D, Montgomery J, Studd J. Correlation of urethral physiology and skin collagen in postmenopausal women.Br J Obstet Gynaecol 1988;95:147–152

    PubMed  Google Scholar 

  46. Bergman A, Giovanni E, Cheung D, Perelman N, Nimm M. Biochemical composition of collagen in continent and stress incontinent women.Gynecol Obstet Invest 1994;76:48–51

    Google Scholar 

  47. Rechberger T, Donica H, Baranowski W, Jakowicki J. Female urinary stress incontinence in terms of connective tissue biochemistry.Eur J Obstet Gynaecol Reprod Biol 1993;72:187–191

    Google Scholar 

  48. Virtanen P, Tolunen U, Savolainen J, Takala T. Effect of reinnervation on collagen synthesis in rat skeletal muscle.J Appl Physiol 1992;72:2069–2074

    PubMed  Google Scholar 

  49. Lehto M, Sims T, Bailey A. Skeletal muscle injury: molecular changes in collagen during healing.Res Exp Med 1985;185:95–106

    Google Scholar 

  50. Stephens HR, Duance VC, Dunn MJ, Bailey AJ, Dubowitz V. Collagen types in neuromuscular diseases.J Neurosci 1982;53:45–62

    Google Scholar 

  51. Peltonen L, Myllyla U, Tolonen U, Myllyla V. Changes in collagen metabolism in diseased muscles 11. Immunohistochemical studies.Arch Neurol 1982;39:756–759

    PubMed  Google Scholar 

  52. Salonen V, Lehto R, Kalimo R, Penttinen R, Aro H. Changes in intramuscular collagen and fibronectin in denervation atrophy.Muscle Nerve 1985;8:125–131

    PubMed  Google Scholar 

  53. Kovanen V, Suominen H. Age and training related changes in the collagen metbolism of rat skeletal muscle.Eur J Appl Physiol 1989;58:765–71

    Google Scholar 

  54. Morley R, Cumming J, Weller R, Steart P. Changes in collagen immunohistochemistry in stress incontinent women.Br J Urol (in press)

  55. Savolainen J, Myllyla V, Myllyla R, Vihko V, Vaananen K, Takala T. Effects of denervation and immobilization on collagen synthesis in rat skeletal muscle and tendon.Am J Physiol 1988;254:R897–902

    PubMed  Google Scholar 

  56. Zimmerman SD, McCormick RJ, Thomas PD, Vadlamadi RK. Age and training alter collagen characteristics in fast and slow twitch rat limb muscle.J Appl Physiol 1993;75:1670–1674

    PubMed  Google Scholar 

  57. Laurent GJ. Dynamic state of collagen: pathways of collagen degradation in vivo and their possible role in regulation of collagen mass.Am J Physiol 1987;252:C1-C9

    PubMed  Google Scholar 

  58. Nimni ME, Harkness RD. Molecular structure and function of collagen.Collagen Biochem 1988;1:17–71

    Google Scholar 

  59. Reiser KM, Hennessey SM, Last JA. Analysis of age associated changes in collagen cross-linking in the skin and lung of monkeys and rats.Biochem Biophys Acta 1987;92:339–348

    Google Scholar 

  60. Palokangas HV, Kovenen V, Duncan A. Age related changes in the concentration of hydroxyproline cross-links in functionally different muscles.Matrix 1992;8:291–296

    Google Scholar 

  61. Jackson S, Avery N, Eckford S, Shepherd A, Bailey A. Connective tissue analysis in genitourinary prolapse.Neurourol Urodyn 1995;14:412–413

    Google Scholar 

  62. Mallett V, Hosker G, Smith ARB, warrell D. Neurophysiological predictors of surgical outcome.Neurourol Urodyn 1994;13:442–443

    Google Scholar 

  63. Morley R, Cumming J, Wellor R. Pelvic floor neuropathy and surgical outcome in patients with stress incontinence.Neurourol Urodyn 1995;14:495–496

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Urology, Southampton University Hospital, Tremona Rd., Southampton, UK

    R. Morley, J. Cumming &  R. Weller

Authors
  1. R. Morley
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. Cumming
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. R. Weller
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Morley, R., Cumming, J. & Weller, R. Morphology and neuropathology of the pelvic floor in patients with stress incontinence. Int Urogynecol J 7, 3–12 (1996). https://doi.org/10.1007/BF01895096

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF01895096

Keywords

Search

Navigation