I was wondering whether the systemic uptake of oestrogen would be, following bladder installation, as the low systemic uptake from vaginal application is one of the benefits of local use.

You are probably aware of the following publications but I have included the references: 

In a Cochrane Review, the work of Kurz et al. 1993 (RCT) is discussed when intravesical estrogen was used 'Intravesical application of estriol in sensory urge incontinence - a prospective study'. (Ref for the Cochrane Review: Cody, June D., et al. "Oestrogen therapy for urinary incontinence in post-menopausal women." Cochrane Database Syst Rev 4 (2009).) The work of Kurz et al. was also included in the 2012 update (ref: Cody, June D., et al. "Oestrogen therapy for urinary incontinence in post-menopausal women." Cochrane Database Syst Rev 10 (2012).) The concept of intravesical estrogen is also mentioned in "Legendre, Guillaume, et al. "Menopause, hormone treatment and urinary incontinence at midlife." Maturitas 74.1 (2013): 26-30" but no detail is given. 

Thank you, Mary C R Wilson, Actually I did not know these publications before and even when I tried to search for the subject I wrote in search title, intra vesical or bladder instillation specifically for the exact route of administration of oestrogen but result was Nil, ... from these references and others, I think this route of administration should be evaluated properly exactly as when we first heard about intra vesical oxybutenin for treating over active bladder with less side effects-almost no dry mouth.

Of course many factors will interplay , the estrogen form, or the preparation used, dose ,the interval of the estrogen preparation to stay in the bladder, ....hope to find such study....

The key factor as I see it is the urethra. Vaginal oestrogens thicken the vaginal epithelium and urothelium. As such, the thickened epithelium presents a barrier to the netry of bacteria along  a short urethra ,which is somimes only 1,5 cm long in the parous woman.  In this context, installation of E2 into the vagina would not be useful and could cause UTI.

Thank you Peter, the aim of the installation into bladder instead of vagina in those post menopausal women suffering from LUTS, may cause UTI but it may avoid the long term risk of inducing cervical cancer and the short term complications of using systemic oestrogens ( fluid and salt retention, hypertension, ...etc),  as you know the characters of the transitional epithelium is unique in its - less- absorption capacity, so that a minimal amount  passes through it to find the detrusor muscle as well as the estrogen receptors readily to attach. 

Hi Ahmed, Mary

Urge incontinence  in females is a major problem

According to the  Integral Theory, the cause is laxity in the vagina or  its supporting ligaments. Ponder the 50% cure of urge with the TVT which supports one of the ligaments, the pubourethral

You can test this theory directly with a "simulated operation"- supporting the ligaments or the anterior vaginal wall

If the patient also has urgency, nocturia abnormal emptying, examine the patient when she has a bladder sufficiently loose to provoke urge symptoms.

Then placing a finger directly behind the symphysis to gently support the urethra on one side .  Then gently suppory the bladder base. Then place the lower blade of a bivalve speculum into the posterior forn ix

You will find that some or all of these maneouvres relieve the urgency

look at www.integraltheory.org for more resources and papers

or my textbook "The Female Pelvic Floor 3rd Ed Springer espcially the DVD which comes as part of the book

Best regards

PP

Thank you Dr. Petros for your comment, but lower urinary symptoms in general and urge or urge incontinence specifically have multiple causes beside insults to  ligamentous and fascial  supports of the bladder and urethra which include hormonal changes, vascular aging, associated metabolic disease as DM, neurologic  changes...etc so in order to measure the effect of repairing or treating one factor I think we have to standardize the other factors...in other meaning  doing such maneuvers during vaginal examination may be due to effect of triggering on underlying nerve plexuses and not to reduction of position of the bladder base. An observation of such factors may be seen during urodynamic examination of cases of POP ,there may be abnormal bladder contractions which are not reduced or disappear with reduction of the prolapse. Integral theory is a great addition towards understanding and treating stress incontinence but for urge  or mixed incontinence there are still other factors which interplay in its causation. thank you

Hi Ahmed

Thank you for the clarification

Of course, you are correct

I am referring to non-neurological female patients

Re "to effect of triggering on underlying nerve plexuses "

Exactly that

Digital support prevents the stretch (nerve) receptors from firing off

we can't prove or exclude systemic effect of local oestrogen.

Thanks Hadi. Agree. We don't really know exactly what oestrogen does. From a pelvic floor perspective, there is a major change in collagen metabolism with the menopause and it is not coincidental that that is when bladder and bowel symptoms appear or worsen.

This was the philosophy behind the midurethral and other slings. The collagen had leached out of the ligaments, so native tissue repair couldn't work very well. It is like stitching frayed cloth to frayed cloth. The PROSPECT PROVED what everyone knows, native tissue repair does not work very well, certainy not in post-menopausal women. Why? The structures need collagen. Collagen works exactly like the steel in concrete. So in the late 1980s when all this started, we had to somehow create new collagen to reinforce the loose ligaments.

The concept of placing a ribbon of tape in exactly in the position of the damaged ligament (TVT) was to use the tissue reaction to the tape in a positive way.

In the dog experiments, we were able to examine the effect of tape insertion histologically. Initially there is a wound reaction, macrophages, fibroblasts etc, then collagen 3 formed and in 6-12 weeks this was replaced by collagen 1. The collagen fibres align in a linear way along the tape to form a collagenous neoligament. We have used it in other ligaments also.

For example, if you have a uterine prolapse, you can plicate the USLs and then place an artisan tape 12 cm long, exactly outside the plicated USls between the USLs and vagina. The results are satisfactory and you will cure many symptoms such as urge, nocturia, chronic pelvic pain.