Summary
Symptomatic clinical changes and urodynamic changes are apparent in the female urinary tract system during pregnancy, the menstrual cycle and following the menopause. The sex hormones exert physiological effects on the female urinary tract, from the ureters to the urethra, with oestrogens having an additional influence on the structures of the pelvic floor. High affinity oestrogen receptors have been identified in bladder, trigone, urethra and pubococcygeus muscle of women. Oestrogen pretreatment enhances the contractile response of animal detrusor muscle to a-adrenoceptor agonists, cholinomimetics and prostaglandins, as well as enhancing the contractile response to a-agonists in ureter and urethra. Progesterone on the other hand decreases tone in the ureter, bladder and urethra by enhancing β-adrenergic responses.
The dependence on oestrogens of the tissues of the lower urinary tract contributes to increased urinary problems in postmenopausal women. Urinary symptoms due to atrophic mucosal changes respond well to oestrogen replacement therapy. However, because they recur when treatment is stopped, continuous therapy with low dose natural oestrogens is recommended. Oestrogens may be of benefit in postmenopausal women with stress incontinence but the doses necessary for clinical effect are higher than for the treatment of atrophic urethritis. The practice of adding a progestagen to long term oestrogen therapy to reduce the risk of endometrial carcinoma may, however, exacerbate stress incontinence by decreasing urethral pressure. Cyclical therapy with oestrogens may therefore be more appropriate particularly in women who are not suitable for surgery or have a mild degree of stress incontinence, along with other conservative measures such as pelvic floor exercises and a-adrenoceptor agonists. The place of oestrogen therapy in motor urge incontinence has not been determined.
The risk of developing endometrial carcinoma as a result of long term high dose oestrogen replacement therapy must be borne in mind but remains to be clarified. However, oestriol has less of a uterotrophic effect compared to other oestrogens in standard therapeutic doses and is to be preferred. Side effects are usually dose related and tend not to be a problem with low dose therapy.
Similar content being viewed by others
References
Abrams PH, Feneley RCL. The actions of prostaglandins on the smooth muscle of the human urinary tract in vitro. British Journal of Urology 47: 909–915, 1976
Andersson KE, Ek A, Persson CGA. Effects of prostaglandins on the isolated human bladder and urethra. Acta Physiologica Scandinavica 100: 165–171, 1977
Andersson KE, Henriksson L, Ulmsten U. Effects of prostaglandin E2applied locally on intravesical and intraurethral pressures in women. European Urology 4: 366–369, 1978
Asmussen M, Ulmsten U. A new technique for measurements of the urethral pressure profile. Acta Obstetricia et Gynecologica Scandinavica 55: 167–173, 1976
Åstedt B. Cancer and other risk factors with oestrogen replacement. Acta Obstetricia et Gynecologicia Scandinavica (Suppl. 140): 46–51, 1987
Awad SA, Bruce AW, Carro-Ciampi G, Downie JW, Lin M, et al. Distribution of α and β adrenoceptors in human urinary bladder. British Journal of Pharmacology 50: 525–529, 1974
Awad SA, Downie JW, Kiruluta HG. Alpha-adrenergic agents in urinary disorders of the proximal urethra. Part 1, Sphincteric incontinence. British Journal of Urology 50: 332–335, 1978
Batra SC. Estrogen and smooth muscle function. Trends in Pharmacological Sciences 1: 388–391, 1980
Batra SC, Iosif CS. Female urethra: a target for oestrogen action. Journal of Urology 129: 418–420, 1983
Baudouin-Legros M, Meyer P, Worcel M. Effects of prostaglandin inhibitors on angiotensin, oxytocin and PGF2alpha contractile effects on the rat uterus during the oestrus cycle. British Journal of Pharmacology 52: 393–399, 1974
Beistand HO, Fossberg E, Moer A, Sander S. Urethral sphincter insufficiency in postmenopausal females: treatment with phenylpropanolamine and estriol separately and in combination. Urologia Internationalis 39: 211–216, 1984
Benson GS, McConnell JA, Wood JG. Adrenergic innervation of the human bladder body. Journal of Urology 122: 189–191, 1979
Bigby MAM. Pentovis in the treatment of senile vaginitis, report of a trial series. Clinical Trials Journal 3: 411–415, 1966
Borda E, Chaud M, Gutnisky R, Contreras-Ortiz N, Gimeno MF, et al. Relationships between prostaglandins and oestrogens on the motility of isolated rings from the rat urinary bladder. Journal of Urology 129: 1250–1253, 1983
Brandberg A, Mellstrom D, Samsioe G. Low dose oestriol treatment in elderly women with urogenital infections. Acta Obstetricia et Gynecologica Scandinavica (Suppl. 140): 33–38, 1987
Brincat M, Moniz CF, Studd JWW, Darby AJ, Magoa A, et al. Sex hormones and skin collagen content in postmenopausal women. British Medical Journal 287: 1337–1338, 1983
Brown ADG. Postmenopausal urinary problems. Clinical Obstetrics and Gynecology 4: 181–206, 1977
Bulbring E, Tomita T. The effects of catecholamines on the membrane resistance and spike generation in the smooth muscle of guinea pig Taenia coli. Journal of Physiology 194: 74–76, 1968
Bultitude MI, Hill NH, Shuttleworth KED. Clinical and experimental studies on the action of prostaglandins and their synthesis inhibitors on detrusor muscle in vivo and in vitro. British Journal of Urology 48: 631–637, 1976
Byrne JE. A case against the ‘pill’? Missouri Medicine 63: 900–903, 1966
Callahan SM, Creed KE. The effects of oestrogens on spontaneous activity and responses to phenylephrine of the mammalian urethra. Journal of Physiology 358: 35–46, 1985
Castleden CM, George CF, Renwick AG, Asher MJ. Imipramine: a possible alternative to current therapy for urinary incontinence in the elderly. Journal of Urology 125: 318–320, 1981
Clow WM. Effect of posture on bladder and urethral function in normal pregnancy. Urologia Internationalis 30: 9–15, 1975
Corriere JN, Lipshultz LI, Wallach EE. Bacteriuria in young women; effect of oestrogen, progestogen and oestrogen-progestogen combination. Urology 3: 539–541, 1973
Coupar IM, Turner P. Relative potencies of sympathetic amines in human smooth muscle. British Journal of Pharmacology 36: 213–214, 1969
Dale HH. On some physiological actions of ergot. Journal of Physiology 34: 163–206, 1906
Del Castillo EB, Argonz J, Galli-Mainini C. Smears from the female urethra and their relationship to smears of the urinary sediment. Journal of Clinical Endocrinology and Metabolism 9: 1362–1371, 1949
Diamond J, Brody TM. Hormonal alteration of the response of the rat uterus to catecholamines. Life Sciences 5: 2187–2193, 1966
Eckerling B, Goldman JA. Conservative treatment of uterovaginal prolapse and stress urinary incontinence. International Surgery 57: 221–222, 1972
Edvardsen P, Setekleiv J. Distribution of adrenergic receptors in the bladder of cats, rabbits, and guinea pigs. Acta Pharmacologica et Toxicologica 26: 437–445, 1968
Edwards L, Malvern J. The urethral pressure profile: theoretical considerations and clinical application. British Journal of Urology 46: 325–336, 1974
Ek A, Alm P, Andersson KE, Persson CGA. Adrenergic and cholinergic nerves of the human urethra and urinary bladder: a histochemical study. Acta Physiologica Scandinavica 99: 345–352, 1977
Ek A, Andersson KE, Gullberg B, Ulmsten U. Effects of oestradiol and combined norephedrin and oestradiol treatment on female stress incontinence. Zentralblatt für Gynäkologie 102: 839–844, 1980
Faber P, Heidenreich J. Treatment of stress incontinence in postmenopausal women. Urologia Internationalis 32: 221–223, 1977
Foster RW. An uptake of radioactivity from DL3H-isoprenaline inhibition by drugs which potentiate the response to L-isoprenaline in the guinea pig isolated trachea. British Journal of Pharmacology 35: 418–427, 1969
Francis WJA. Disturbances of bladder function in relation to pregnancy. Journal of Obstetrics and Gynaecology of the British Empire 67: 353–366, 1960
Gambrell RD, Massey FM, Castaneda TA. Use of progestogen challenge to reduce the risk of endometrial cancer. Obstetrics and Gynecology 55: 732–738, 1980
Gillespie JS. Uptake of noradrenaline by smooth muscle. British Medical Bulletin 29: 136–141, 1973
Gitsch E, Brandstetter F. Phasen-sphinctero-cystometrie. Zentralblatt für Gynäkologie 76: 1746–1754, 1954
Gosling JA, Dixon JS, Lendon RG. The autonomic innervation of the human male and female bladder neck and proximal urethra. Journal of Urology 118: 302–305, 1977
Greenhill JP. The non surgical management of vaginal relaxation. Clinical Obstetrics and Gynecology 15: 1083–1097, 1972
Guyer PB, Delany D. Urinary tract dilatation and oral contraceptives. British Medical Journal 4: 588–590, 1970
Hills NH. Prostaglandins and the tone in isolated strips of mammalian bladder. British Journal of Pharmacology 57: 464–465, 1976
Hilton P, Stanton SL. The use of intravaginal oestrogen cream in genuine stress incontinence. British Journal of Obstetrics and Gynaecology 90: 940–944, 1983
Hodgson BJ, Dumas S, Boiling DR, Heesch CM. Effect of estrogen on sensitivity of rabbit bladder and urethra to phenylephrine. Investigative Urology 16: 67–69, 1978
Hundley JM, Diehl WK, Diggs ES. Hormonal influences upon the ureter. American Journal of Obstetrics and Gynecology 44: 858–872, 1942
Ingelman-Sundberg A, Rosen J, Gustafsson SA, Carlstrom K. Cytosol oestrogen receptors in the urogenital tissues in stress incontinent women. Acta Obstetricia et Gynecologica Scandinavica 60: 585–586, 1981
Iosif CS, Batra SC, Ek A, Astedt B. Estrogen receptors in the human female lower urinary tract. American Journal of Obstetrics and Gynecology 141: 817–820, 1981
Iosif CS, Bekassy Z. Prevalence of genito-urinary symptoms in the late menopause. Acta Obstetricia et Gynecologica Scandinavica 63: 257–260, 1984
Iosif CS, Ingemarsson I, Ulmsten U. Urodynamic studies in normal pregnancy and in puerperium. American Journal of Obstetrics and Gynecology 137: 696–700, 1980
Iversen LL. Role of transmitter uptake mechanisms in synaptic transmission. British Journal of Pharmacology 41: 571–591, 1971
Iversen LL, Salt PJ. Inhibition of catecholamine uptake by steroids in the isolated rat heart. British Journal of Pharmacology 40: 528–530, 1970
Judge TG. The use of quinestradol in elderly incontinent women: a preliminary report. Gerontologia Clinica 11: 159–164, 1969
Kalsner S. Steroid potentiation of responses to sympathetic amines in aortic strips. British Journal of Pharmacology 36: 582–593, 1969
Kalsner S. Sensitisation of noradrenaline responses by inhibitors of extraneuronal uptake in coronary artery preparations. British Journal of Pharmacology 51: 453–455, 1974
Kaumann AJ. Potentiation of the effects of isoprenaline and noradrenaline by hydrocortisone in cat heart muscle. Naunyn-Schmiedeberg’s Archives of Pharmacology 273: 134–153, 1972
Khan AR. Effects of diethyl-stilboestrol on single fibres of frog skeletal muscle. Acta Physiologica Scandinavica 106: 69–73, 1976
Kubacz GJ, Catchpole BN. The role of adrenergic blockade in the treatment of ureteric colic. Journal of Urology 107: 949–951, 1972
Kuriyama H, Csapo A. A study of the parturient uterus with the microelectrode technique. Endocrinology 68: 1010–1025, 1961
Langer SZ, Trendelenburg U. The effect of a saturable uptake mechanism on the slopes of dose-response curves for sympathetic amines and on the shifts of dose-response curves produced by a competitive agonist. Journal of Pharmacology and Experimental Therapeutics 167: 117–142, 1969
Langworthy OR, Brack CB. Effect of pregnancy and corpus luteum upon vesicle muscle. American Journal of Obstetrics and Gynecology 37: 121–125, 1939
Lawson DH, Jick H, Hunter JR, Madsen S. Exogenous oestrogens and breast cancer. American Journal of Epidemiology 114: 710–713, 1981
Levin RM, Jacobowitz DJ, Wein AJ. Autonomic innervation of rabbit urinary bladder following oestrogen administration. Investigative Urology 17: 449–453, 1981
Levin RM, Shofer FS, Wein AJ. Estrogen induced alterations in the autonomic responses of the rabbit urinary bladder. Journal of Pharmacology and Experimental Therapeutics 215: 614–618, 1980
Lindskog M, Sjogren C, Ulmsten U, Andersson KE. Estrogen binding sites in nucleolar fractions from the rat urogenital tract. Proceedings of the 10th Annual Meeting of the International Continence Society, Los Angeles, 1980
Luraschi S. II quinestrolo nel trattamento delFincontinenza urinaria senile. Progresso Medico (Napoli) 22: 270–276, 1966
Malin JM, Deane RF, Boyarsky S. Characterisation of adrenergic receptors in human ureter. British Journal of Urology 42: 171–174, 1970
Marshall S, Lyon RP, Minkler D. Ureteral dilatation following use of oral contraceptives. Journal of the American Medical Association 198: 782–783, 1966
Mattsson L, Cullberg G. Vaginal absorption of two estriol preparations. Acta Obstetricia et Gynecologica Scandinavica 62: 393–396, 1983
McLennan MT, McLennan CE. Oestrogenic status of menstruating and postmenopausal women assessed by cervico-vaginal smears. Obstetrics and Gynecology 37: 325–331, 1971
Mohr JA, Rogers J, Brown TN, Starkweather G. Stress urinary incontinence: a simple and practical approach to diagnosis and treatment. Journal of the American Geriatrics Society 31: 476–478, 1983
Musiani U. A partially successful attempt at medical treatment of urinary stress incontinence in women. Urologia Internationalis 27: 405–410, 1972
Nergardh A, Boreus LO. Autonomie receptor function in the lower urinary tract of man and cat. Scandinavian Journal of Urology 6: 32–36, 1972
Öbrink A, Bunne G, Ulmsten U. Intraurethral and intravesical pressure in continent women. Acta Obstretricia et Gynecologica Scandinavica 56: 525–529, 1977
Poggesi L, Nicita G, Castellani S, Selli G, Galanti G, et al. The role of prostaglandins in the maintenance of the tone of the rabbit urinary bladder. Investigative Urology 17: 454–458, 1980
Punnonen R, Kilkku P, Kiukko P, Rauramo L. Conservative treatment of urinary incontinence in women with special reference to the use of oestrogens. Maturitas 3: 309–313, 1981
Raz S, Caine M. Adrenergic receptors in the female canine urethra. Investigative Urology 9: 319–323, 1972
Raz S, Kaufman JJ. Carbon dioxide urethral pressure profile in female incontinence. Journal of Urology 117: 765–769, 1977
Raz S, Zeigler M, Adoni A. Hormonal environment and uterine response to epinephrine. American Journal of Obstetrics and Gynecology 111: 345–349, 1971
Raz S, Zeigler M, Caine M. Hormonal influence on the adrenergic receptors of the ureter. British Journal of Urology 44: 405–410, 1972
Raz S, Zeigler M, Caine M. The effect of progesterone on the adrenergic receptors of the urethra. British Journal of Urology 45: 131–135, 1973
Raz S, Zeigler M, Caine M. The role of female hormones in stress incontinence. XVIe Congrès de la Société Internationale Urologie, vol. 2, Paris, 1973
Roberts JM, Insel PA, Goldfien RD, Goldfien A. Alpha receptors but not beta receptors increase in rabbit uterus with oestrogen. Nature 270: 624–628, 1977
Roberts M, Smith P. Non-malignant obstruction of the female urethra. British Journal of Urology 40: 694–702, 1968
Robinson JM. Is oestrogen deficiency related to urinary incontinence? German Medicine 14: 173–175, 1984
Rud T. Urethral pressure profile in continent women from childhood to old age. Acta Obstetricia et Gynecologicia Scandinavica 59: 331–335, 1980
Rud T. The effects of estrogens and gestagens on the urethral pressure profile in urinary continent and stress incontinent women. Acta Obstetricia et Gynecologica Scandinavica 59: 265–270, 1980
Rud T, Andersson KE, Asmussen M, Hunting A, Ulsten U. Factors maintaining the intraurethral pressure in women. Investigative Urology 17: 343–347, 1980
Salmi T. Risk factors in endometrial carcinoma with special reference to use of oestrogens. Acta Obstertricia et Gynecologica Scandinavica (Suppl. 86): 1–119, 1979
Salt PJ, Iversen LL. Inhibition of extraneuronal uptake of catecholamine in the isolated rat heart by cholesterol. Nature: New Biology 238: 91–92, 1972
Samsioe G, Jansson I, Mellstrom D, Svanborg A. Occurrence, nature and treatment of urinary incontinence in a 70 year old female population. Maturitas 7: 335–342, 1985
Schleyer-Saunders E. Hormone implants for urinary disorders in postmenopausal women. Journal of the American Geriatrics Society 24: 337–339, 1976
Schoultz B. Estrogens and urogenital epithelial function. Acta Obstetricia et Gynecologica Scandinavica (Suppl. 140): 28–32, 1987
Schreiter E, Fuchs P, Stockamp K. Estrogenic sensitivity of α receptors in the urethral musculature. Urologia Internationalis 31: 13–19, 1976
Silk M, Perez-Varela MR. Effect of oral contraceptives on urinary bacterial growth rate. Investigative Urology 8: 239–241, 1970
Sjöberg NO. The adrenergic transmitter of the female reproductive tract: distribution and functional change. Acta Physiologica Scandinavica (Suppl. 305): 1–32, 1968
Spiro FI, Fry IK. Ureteric dilatation in non-pregnant women. Proceedings of the Royal Society of Medicine 63: 462–466, 1970
Stanton SL. The role of oestrogens in the maintenance of urinary continence: female urinary incontinence. Lloyd-Luke, London, 1977
Stanton SL, Kerr-Wilson R, Harris V. The incidence of urological problems in normal pregnancy. British Journal of Obstetrics and Gynaecology 87: 897–900, 1980
Stumpf WE, Madhabananda S, Joshi SG. Estrogen target cells in the skin. Experientia 30: 196–198, 1974
Sundin T, Dahlstrom A, Norlen L, Svedmyr N. The sympathetic innervation and adrenoceptor function of the human lower urinary tract in the normal state and after parasympathetic denervation. Investigative Urology 14: 322–328, 1977
Susset J, Plante P. Studies of female urethral pressure profile. Part II. Urethral pressure profile in female incontinence. Journal of Urology 123: 70–74, 1980
Tyler DE. Stratified squamous epithelium in the vesical trigone and urethra: findings correlated with the menstrual cycle and age. American Journal of Anatomy 111: 319–325, 1962
Urner F, Weil A, Herrmann WL. Estradiol receptors in the urethra and the bladder of the female rabbit. Gynecologic and Obstetric Investigation 16: 307–313, 1983
Vane JR, Williams KI. The contribution of prostaglandin production to contractions of the isolated uterus of the rat. British Journal of Pharmacology 48: 629–639, 1973
VanGeelen JM, Doesburg WH, Thomas CMG, Martin CB. Urodynamic studies in the normal menstrual cycle: the relationship between hormonal changes during the menstrual cycle and the urethral pressure profile. American Journal of Obstetrics and Gynecology 15: 384–392, 1981
VanGeelen JM, Lemmens WAJG, Eskes TKAB, Martin CB. The urethral pressure profile in pregnancy and after delivery in healthy nulliparous women. American Journal of Obstetrics and Gynecology 144: 636–649, 1982
VanWagener G, Jenkins RH. An experimental examination of factors causing ureteral dilatation in pregnancy. Journal of Urology 42: 1010–1020, 1939
Versi E, Cardozo L, Brincat M, Studd J. Lower urinary tract symptoms, urodynamic findings and skin collagen in normal postmenopausal women. Maturitas 6: 204, 1984
Versi E, Cardozo L. Urethral vascular pulsations. Proceedings of the 15th Annual Meeting of the International Continence Society, London, September 1985, pp. 503–504. 1985
Walker AHC. Urological symptoms and senile vaginitis. Clinical Trials Journal 2: 278, 1965
Walter S, Wolf H, Barlebo H, Jensen HK. Urinary incontinence in postmenopausal women treated with estrogens. Urologia Internationalis 33: 135–143, 1978
Zacco M, LaSelva V. Trattamento dell’incontinenza urinaria negli anziani. Giornale di Gerontologia 14: 59–64, 1966
Zahran MM, Kamel M, Mooro H, Osman MI, Fayad M, et al. Effects of contraceptive pills and intrauterine devices on urinary bladder. Urology 8: 567–574, 1976
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Miodrag, A., Castleden, C.M. & Vallance, T.R. Sex Hormones and the Female Urinary Tract. Drugs 36, 491–504 (1988). https://doi.org/10.2165/00003495-198836040-00006
Published:
Issue Date:
DOI: https://doi.org/10.2165/00003495-198836040-00006