Antiproliferative activity and toxicity of 2-methoxyestradiol in cervical cancer xenograft mice.

2-methoxyestradiol (2-ME) is considered to be an effective anticancer compound for many types of tumors. We have previously demonstrated that 2-ME inhibits the growth of human cervical cancer HeLaS3 cells in vitro. In this study, we investigated the antitumoral effects of 2-ME on human cervical carcinoma in severe combined immune deficient (SCID) mice. The potential side effects of 2-ME on the SCID mice were also investigated. SCID mice were injected with HeLaS3 cells (3 x 10(6) to 4 x 10(6)/mouse) and a 15-day administration of 2-ME followed after a 1-week cell implantation. Tumor weight, volume, body weight, and blood chemistry were determined. Tumor tissues were examined with an antibody against the proliferative cell nuclear antigen and terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) staining. Liver, spleen, kidney, heart, and lung were screened by pathologic examinations. 2-ME (75 mg/kg p.o.) inhibited growth of human cervical carcinoma by 34% (P < 0.05) as compared with control. Necrosis was found in both 2-ME-treated and untreated tumor tissues, but the necrotic area was larger in 2-ME-treated mice. A low expression of proliferative cell nuclear antigen and an increased number of apoptotic cells were found in 2-ME-treated tumor sections as compared to those in controls. No significant difference was detected in blood chemistry. In addition, the liver showed hyperplastic Kupffer cells, hydropic swelling of hepatocytes, and liquefactive necrosis. The spleen showed an increased number of megakaryocytes and apoptotic cells after 2-ME treatment. Thus, 2-ME has an antitumor effect on human cervical carcinoma, and it is toxic to liver and spleen in this mouse model.

Expression of estrogen receptor-alpha and -beta in anterior vaginal walls of genuine stress incontinent women.

Our objective was to study the expression of estrogen receptor (ER) isoforms, ER-alpha and ER-beta, in the anterior vaginal wall of menopausal and fertile women with genuine stress incontinence (SI) by immunohistochemistry and Western blot analysis. Eighteen menopausal women with SI who either were or were not taking estrogen/progestin replacement therapy and 14 fertile women with SI who either were or were not taking contraceptives were enrolled in the study. Biopsies from the suburethral anterior vaginal wall were obtained at tension-free vaginal tape (TVT) operation. Monoclonal antibody to ER-alpha and polyclonal antibody to ER-beta were used to stain frozen sections of vaginal tissue. The receptor expressions were scored based on percentage of positive cells. ER-alpha was detected in vaginal epithelial, stromal and smooth muscle cells. In menopausal SI women ER-alpha was detected significantly more frequently in the vaginal walls of estrogen/progestin-treated patients than in those who were untreated. Fertile SI women had significantly higher expression of ER-alpha than menopausal SI women. ER-alpha was not observed in vaginal blood vessels. ER-beta was detected in epithelial and vascular smooth muscle cells of the vagina. No significant difference in ER-beta expression was observed between different groups of patients. The expression of ER-alpha was not correlated with that of ER-beta. Both ER-alpha and -beta were detected, indicating a potential role for both types of estrogen receptor in the human vaginal wall. The expression of ER-alpha, but not of ER-beta, in menopausal SI women was regulated by estrogen/progestin replacement therapy. The presence of ER-beta in vaginal vascular smooth muscle cells raises the possibility of vascular effects of estrogen on the human vaginal wall.

Pre-pubic TVT: an alternative to classic TVT in selected patients with urinary stress incontinence.

OBJECTIVES: To evaluate in a prospective open study a pre-pubic route of TVT for surgical treatment of female stress incontinence. STUDY DESIGN: Consecutively, 74 patients were operated using a pre-pubic TVT tape application. All women were suffering subjectively and objectively from female stress urinary incontinence. The mean post-operative follow-up time was 5 months (range 2-10 months). The pre- and post-operative evaluations were performed according to a standard protocol. RESULTS: According to the protocol, 60 patients (81%) were cured of their stress incontinence symptoms. Another 10 patients (13%) were improved. Four patients (6%) were considered failures. There were no significant intra- or post-operative complications. CONCLUSION: The short-term results of pre-pubic TVT are consonant with those of classic TVT. The risks of intra-operative complications should be reduced by the pre-pubic route. If the long-term results of pre-pubic TVT are the same as those after classic TVT, then this surgical approach may be a tentative alternative in selected high-risk patients.

Efeitos de um implante de acetato de nomegestrol, um derivado de 19-nor-progesterona, na função tireoidiana / Effects of an implant of nomegestrol acetate, a 19-nor-progesterone derivative, on thyroid function

Este estudo foi realizado para avaliar tri-iodotironina (T3), tiroxina (T4), hormônio estimulante da tireóide (TSH), T3 uptake, T3 livre e T4 livre em usuárias do implante de acetato de nomegestrol (Uniplant). Dezoito voluntárias em idade reprodutiva, que desejavam fazer anticoncepção, foram recrutadas para o estudo e investigadas antes do início do tratamento. Amostras de sangue foram obtidas antes da inserção do implante, para análises hormonais. Em seguida, amostras de sangue foram colhidas 3,6,12 e 24 meses após a inserção do Uniplant. Todas as pacientes usaram contraceptivo não hormonal por um período mínimo de 6 meses, antes da inserção do implante. Os resultados observados no estudo mostraram que não houve diferença significante na tri-iodotironina (T3), tiroxina (T4) e hormônio estimulante da tireóide (TSH), durante dois anos de uso do Uniplant. Nenhuma diferença significante foi encontrada nos níveis de T3 livre, durante dois anos de uso do Uniplant. Um decréscimo significante foi abservado no T3 uptake (p<0,05) no 24º mês e no T4 livre (p<0,05) no 3º mês de uso do Uniplant. todas as alterações observadas no estudo foram inconsistentes e todos os níveis estavam dentro dos limites normais.

The basic understanding and clinical results of tension-free vaginal tape for stress urinary incontinence.

Since 1994, over 100,000 surgical reconstructions of the female lower urinary tract have been performed worldwide using tension-free vaginal tape (TVT). This technique, which differs from traditional methods, is effective against symptoms of stress urinary incontinence and may be performed as an ambulatory procedure with no need of indwelling catheterization. The primary indication is genuine stress incontinence, but it is also effective as a secondary procedure for relapse after other anti-incontinence measures such as the Burch procedure. The TVT operation was developed according to study results on the mechanisms of urethral closure in women and has become the primary surgical procedure at several Scandinavian clinics for combating genuine stress incontinence in women. It is also useful in reducing symptoms after prolapse repair for combined prolapse and stress incontinence and in cases of mixed stress and urge ("sensory") incontinence. The small incisions and canals involved with the TVT technique minimize surgical trauma and enable it to be performed under local anesthesia. By the same token, it makes fairly small demands on postoperative care and attendant costs. Here we describe the instrumentation, procedure, and risks of this minimally invasive operative technique.

Tension-Free vaginal tape (TVT) in stress incontinent women with intrinsic sphincter deficiency (ISD)--a long-term follow-up.

In a prospective long-term study 49 women with stress incontinence and ISD (intrinsic sphincter deficiency) were followed for a mean of 4 years (range 3-5) after TVT operation. Preoperatively all patients underwent urodynamic investigations, quality of life evaluation, a 24-hour pad test and a gynecologic examination to properly verify the incontinence symptoms. The same protocol was used for postoperative evaluation. The mean age of the women was 66 years (+/- 11) and mean parity 2 (range 0-4). A standard TVT operation was performed under local anesthesia. At the postoperative evaluations 36 patients (74%) were completely cured of their incontinence problems. In addition, 6 women (12%) were significantly improved. In 7 patients (14%) no improvement was found. The majority of these not cured patients were >70 years of age and had urethral resting pressure of <10 cmH2O. Few intra- and postoperative complications occurred. It is concluded that TVT can be used for surgical treatment of patients with ISD and stress incontinence. However, older patients (>70 years) with a very low resting urethral pressure and an immobile urethra seem to constitute a risk group where TVT surgery is less successful.

Tension-Free vaginal tape (TVT) in women with mixed urinary incontinence--a long-term follow-up.

In a prospective long-term study we evaluated the effect of TVT surgery in 80 women suffering from mixed urinary incontinence. Their mean age was 59 +/- 11 years with a mean parity of 2 (range 0-6). Mean follow-up was 4 years (range 3-5). The preoperative evaluation included a 24-hour pad test, quality of life evaluation, gynecologic examination and urodynamic investigations, including simultaneous urethrocystometry. From the patient history 96 patients were initially tentative candidates for TVT operation. Sixteen of these had only minor symptoms and signs of stress incontinence but significant symptoms and signs of detrusor instability, and were not considered suitable for TVT surgery. In the remaining 80 women the urodynamic investigation with filling urethrocystometry demonstrated stress incontinence and urge incontinence concomitant with urethral relaxation and/or 'premature micturition' reflex. At the postoperative long-term follow-up 85% of the patients were completely cured. Another 4% were significantly improved. In 11% of the patients the operation failed. Few intra- or postoperative complications occurred. Based on these results, we conclude that TVT surgery can be used for treatment of female mixed urinary incontinence. A proper urodynamic assessment is recommended before surgery is performed.

Influence of different sling materials on connective tissue metabolism in stress urinary incontinent women.

The aim of this study was to investigate the influence on the paraurethral connective tissue of different sling materials used in incontinence surgery. Biopsies from the paraurethral connective tissue were obtained intraoperatively from 16 women with stress urinary incontinence; all were operated on with the TVT procedure, 6 with Mersilene as the sling material and 10 with Prolene. Biopsies from 4 continent women with uterine bleeding irregularities, matched for age and parity, served as controls. New biopsies were obtained from all women after 2 years. The biopsies were examined histologically and analyzed for collagen concentration and solubility. An obvious inflammatory reaction with a significant increase in collagen extractability by pepsin was identified in patients where Mersilene was used as the sling material. A minimal inflammatory reaction without a significant change in collagen solubility was found in the Prolene group. In the control group no inflammatory reaction was seen. Mersilene gave rise to a significant foreign-body reaction in the paraurethral connective tissue after surgery. Such a reaction was not found with Prolene.

Long-term results of the tension-free vaginal tape (TVT) procedure for surgical treatment of female stress urinary incontinence.

In a prospective long-term Nordic multicenter study, 90 consecutive patients who had a tension-free vaginal tape (TVT) operation performed because of stress urinary incontinence were evaluated according to a strict protocol after approximately 5 years (range 48-70 months). Eighty-five patients could be evaluated according to the protocol. Another 5 elderly patients had to be interviewed by telephone at the final check-up after 5 years. The study protocol involved pre- and postoperative objective and subjective evaluation. The median follow-up time was 56 months. Seventy-two of the 85 patients who were fully evaluated (84.7%) were both objectively and subjectively completely cured. Another 9 patients (10.6%) were significantly improved and 4 (4.7%) were regarded as failures. No patient complained of long-term voiding difficulties and there were no signs of defective healing or rejection of the tape material. All patients had suffered from primary stress incontinence, and 25 also had preoperative complaints of urge. In 14 of these (56%) the urge symptoms were relieved postoperatively. We conclude that the TVT procedure seems to fulfil the expectations of high long-term cure rates, as suggested in previous short-term reports.

Tension-Free vaginal tape (TVT) in women with recurrent stress urinary incontinence--a long-term follow up.

In a prospective long-term follow-up study we evaluated the results of TVT surgery in 34 women with recurrent stress urinary incontinence in whom previous traditional surgical procedures had failed. The women were followed for a mean of 4 years (range 3-5) after TVT surgery. The mean age was 58.9 +/- 10 years and the mean parity 2 (0-4). Pre- and postoperative evaluation was performed according to a protocol which included gynecologic examination, urodynamic investigations, quality of life evaluation and 24-hour pad test. According to the protocol 28 patients (82%) were cured, 3 (9%) were significantly improved, and the operation failed in 3 cases (9%). There were no significant intra- or postoperative complications. All patients were operated on under local anesthesia with a short hospitalization and had no long-term postoperative voiding problems.

Multiple connexins localized to individual gap-junctional plaques in human myometrial smooth muscle.

The synchronous contractions of the uterus in labour depend on electrical coupling of myometrial smooth muscle cells by gap junctions. In the human myometrium, gap junctions are scarce in the non-pregnant uterus, but become abundant at term in preparation for labour. We have previously demonstrated that in the human myometrium at term, three different gap-junctional proteins are expressed, connexins 43, 45, and 40. These connexins are known to have distinctive functional capacities in in vitro expression systems but whether, in the human myometrium in vivo, they are co-assembled into the same gap junction or form different types of gap junction has previously been unclear. By applying triple immunogold labelling to sections of Lowicryl-embedded tissue for electron microscopy, together with complementary immunoconfocal microscopy, we demonstrate here that connexins 43, 45, and 40 are commonly present as mixtures within the same gap-junctional plaque. While all gap junctions contain connexin43, the relative signal for each connexin type varies between individual junctions. The presence within single gap-junctional plaques of three different connexins, each with the potential for conferring distinctive channel properties, suggests an inherent versatility for modulation of smooth muscle cell intercellular communication properties during human parturition.

In vivo controlled release of PGE2 from a vaginal insert (0.8 mm, 10 mg) during induction of labour.

OBJECTIVE: To measure the release rate of prostaglandin E2 (PGE2) in vivo from a controlled-release vaginal insert used for cervical ripening and induction of labour at term in women with intact membranes or pre-labour rupture of membranes (PROM). DESIGN: Open-label, single centre study. POPULATION: Women at term (> or = 37 gestational weeks) with unripe cervices (Bishop score < or = 6) scheduled for labour induction for mainly medical reasons. METHODS: sixty-eight women (47 with intact membranes and 21 with PROM) had the PGE2 vaginal insert placed in the posterior fornix of the vagina. Each insert was removed from the women at a predetermined time interval between 0.5 h and 24 h, or earlier if labour was induced, fetal distress was detected or maternal complications occurred. After removal, the vaginal insert was frozen and stored for subsequent assay of residual PGE2. Blood samples were collected immediately before insertion and at 4-hour intervals until removal of the vaginal insert to determine plasma concentrations of PGE2 and the major PGE metabolite, 15-Keto-13, 14-dihydro-PGF2alpha (PGEm). Vaginal pH was measured immediately before insertion and directly after removal of the vaginal insert. Bishop score was assessed before induction, after 8 h, 12 h and immediately after removal of the vaginal insert. RESULTS: There was a positive linear relationship between the amount of PGE2 released from the insert and the duration of treatment in women with intact membranes (rp = 0.95, P = 0.0001), with a calculated PGE2 release rate of 0.52 +/- 0.33 mg/h over 24 h. The PGE2 release rate in women with PROM was not linear. The PGE2 release rate was dependent on vaginal pH, with a faster release rate at higher vaginal pH. Forty-seven women (69.1%) had the insert removed due to the successful induction of labour and consequently discontinued study treatment before their allocated time period. At vaginal delivery, the released amount of PGE2 at onset of labour was 4.0 +/- 3.0 mg and 2.4 +/- 2.1 mg for nulliparous women with PROM and intact membranes, respectively (P = 0.1). In multiparous women, the equivalent mean released amount was 3.2 +/- 2.6 mg and 1.9 +/- 1.4 mg, respectively (P = 0.14). In women with intact membranes, the mean plasma concentrations of PGE2 and PGEm after treatment were not statistically different to those women with PROM (P = 0.27 and 0.64, respectively). In women who were delivered vaginally, the median induction to delivery time interval was 17.0 h (range 4-42) in nulliparous women and 8.7 h (range 5-19) in multiparous women (P = 0.003). Ten (14.7%) women, who were all nulliparous, were delivered by caesarean section. CONCLUSIONS: In women with intact membranes, the PGE2 release rate was linear over 24 hours. There was a positive linear relationship between vaginal pH and PGE2 release rate. The metabolite analysis revealed no evidence of dose dumping neither in women with intact membranes or in women with PROM.

The safety and efficacy of MenoTreat, a new balloon device for thermal endometrial ablation.

BACKGROUND: An evaluation of the performance and safety of the prototype of a new device, MemoTreat (Atos Medical) for thermal endometrial balloon ablation in patients with menorrhagia. The evaluation was performed at four Swedish hospitals. METHODS: In total 51 consecutive, premenopausal patients, suffering from menorrhagia due to benign causes and not responding to conventional treatment, were treated between March 1997 and March 1998. The treatment entailed heated (85 degrees C) sterile saline circulated in a uterine balloon at a treatment pressure of 200 mmHg for 11 minutes. The procedure was performed mainly under general anesthesia and no pre-treatment endometrial thinning was performed. A validated pictorial assessment technique was used to evaluate changes in menstrual blood loss before and after treatment. Changes in quality of life and severity of dysmenorrhea were also evaluated. Data analysis was based on the 'intention to treat' method. RESULTS: The success rate in terms of a 50% reduction in menstrual bleeding was 84.3% at 6 months after treatment. Five patients became amenorrheic. The quality of life assessment showed substantial improvement and the severity of dysmenorrhea was markedly reduced. No intra-operative treatment complications occurred and the post-treatment morbidity was similar to that reported for other similar treatment methods. CONCLUSIONS: MenoTreat significantly reduced menstrual bleeding in menorrhagic patients, with a concomitant improvement in quality of life. The findings in this study resulted in a redesigned device with a thinner balloon catheter, improved cervical protection and treatment temperatures kept at a constant level.

Symphyseal distention in relation to serum relaxin levels and pelvic pain in pregnancy.

OBJECTIVE: To elucidate whether there is an association between symphyseal distention, circulating relaxin levels and pelvic pain in pregnancy. METHODS: Serum relaxin and symphyseal width were assessed in 19 consecutive referral cases with severe pelvic pain at 35 weeks of pregnancy and in a cohort of 49 women at 12 and 35 weeks of pregnancy. The referral cases were received over a period of two years and four months and the cohort was recruited over a period of two months. Relaxin was measured with an ELISA test and symphyseal width assessed using ultrasonography. All women with pelvic pain were clinically assessed. The women were divided into three groups; Group A (n= 38), cohort cases with no or mild pain; Group B (n= 11), cohort cases with disabling pain; and Group C (n= 19), referral cases. RESULTS: At 35 weeks of pregnancy, mean symphyseal width was 4.5 mm (s.d. 1.0 mm) in Group A, 5.7 mm (s.d. 2.6 mm) in Group B, and 7.4 mm (s.d. 3.5 mm) in Group C. The difference between Groups A and B is statistically significant (p=0.044) as is that between Groups A and C (p<0.0001). Serum relaxin levels were not associated with symphyseal distention or disabling pain. CONCLUSION: Severe pelvic pain during pregnancy was strongly associated with an increased symphyseal distention. However, the severity of pain did not predict the degree of symphyseal distention in the individual case, indicating that other mechanisms are also involved. Serum relaxin levels were not associated with the degree of symphyseal distention or with pelvic pain in pregnancy.

Presence and localization of connexins 43 and 26 in cell cultures derived from myometrial tissues from nonpregnant and pregnant women and from leiomyomas.

OBJECTIVE: Our objective was to study the appearance and distribution of connexins 43 and 26 in various human myometrial cell cultures. STUDY DESIGN: Scrape loading, Western blotting, and immunohistochemical techniques were applied to cultured cells derived from myometrial tissues obtained from nonpregnant and pregnant women (upper and lower uterine segments) and from leiomyomas (tumor and analogous myometrial tissues). RESULTS: Scrape loading revealed the presence of metabolic coupling in all tissues. Indirect immunohistochemical studies showed membrane localization of connexin 43 in all myometrial cultures. Western blots and indirect immunohistochemical studies showed the presence and localization of the connexin 26 protein and associated gap junctions in tissues from myomas and from nonpregnant and pregnant women except for those derived from the upper segment of the pregnant uterus. CONCLUSION: These results show that human myometrial cultures express various gap junction proteins and that there are regional differences in expression of connexins in tissues from pregnant women.

Prostaglandin F2alpha-induced Ca++ oscillations in human myometrial cells and the role of RU 486.

OBJECTIVE: We sought to examine the change of cytosolic calcium concentration caused by prostaglandin F(2)(alpha) and RU 486 in cultured human myometrial cells. STUDY DESIGN: Human myometrial cells obtained from 16 nonpregnant women were loaded with fura 2, and the intracellular cytosolic calcium concentrations were measured by the use of wavelength spectrophotofluorometry. RESULTS: Application of prostaglandin F(2)(alpha) (2.8 micromol/L) caused an initial rapid rise in cytosolic calcium concentration followed by sustained cytosolic calcium oscillations at an average frequency of 0.43 +/- 0.04 min(-1) and an amplitude in the range of 296.82 +/- 27. 16 nmol/L. The oscillatory activity was not affected by increasing the concentration of prostaglandin F(2)(alpha) but varied by changing the concentration of extracellular cytosolic calcium concentration. The cytosolic calcium oscillations were suppressed by caffeine, 2,5-di-tert-butylhydroquinone, and lanthanum but not affected by ryanodine. Verapamil decreased the amplitude but not the frequency of oscillations. The progesterone antagonist RU 486 at a concentration of 10(-8) to 10(-5) mol/L had no significant effect on the basal intracellular cytosolic calcium. However, RU 486 (10(-5) mol/L) significantly increased the frequency but not the amplitude of intracellular cytosolic calcium oscillations induced by prostaglandin F(2)(alpha). CONCLUSION: The results indicate that prostaglandin F(2)(alpha)-stimulated cytosolic calcium oscillations are mediated by an increase in both cytosolic calcium release from inositol 1,4,5-trisphosphate-sensitive cytosolic calcium stores and a cytosolic calcium influx from the extracellular space. Moreover, RU 486 seems to directly regulate prostaglandin F(2)(alpha)-induced intracellular cytosolic calcium in human myometrial cells.

Human uterine myocytes retain their energy charge with No gross alterations in morphology for at least 8 days when cultured under anaerobic conditions.

OBJECTIVE: To investigate the ability of human uterine myocytes to grow under anaerobic conditions for a prolonged time period. METHODS: Cells were isolated from fundal myometrium and cultured until subconfluency. The cell type was confirmed by immunostaining for the smooth muscle cell-specific cytoskeletal proteins alpha-actin and desmin. Some cells were further cultured under aerobic conditions and others under anaerobic conditions. Cells were harvested after 0, 4 and 8 days in culture and analyzed for their content of adenylates. RESULTS: Immunostaining revealed that all three preparations contained almost only smooth muscle cells. Energy charge of the myocytes was 0.88 on average at the beginning of the culture experiment. A moderate decrease was noted on day 4 for myocytes grown under both aerobic and anaerobic conditions and no further decrease was noted between days 4 and 8. Morphologically the cells retained their normal appearance and they seemed healthy for at least 8 days in culture under both aerobic and anaerobic conditions. CONCLUSIONS: The results of this study suggest that human myometrial cells can survive for an extended period of time under in vitro conditions regardless of oxygen availability for energy metabolism. This means that anaerobic energy metabolism is enough to sustain vital processes during that period of time.

Oxytocin-induced oscillations of cytoplasmic Ca2+ in human myometrial cells.

BACKGROUND: To investigate the mechanisms of oxytocin (OT) induced oscillations of the cytoplasmic Ca2+ concentration ([Ca2+]i) in cultured human myometrial cells. METHODS: [Ca2+]i was measured in individual myometrial cells by dual wavelength spectrophotofluorometry using the fluorescent indicator fura-2. Myometrium was obtained at abdominal hysterectomy (n=8) and during cesarean section (n=7). RESULTS: OT (10-300 nM) typically induced [Ca2+]i oscillations with frequencies in the 0.6-0.8/min range. There were no obvious differences in the responses of cells taken from non-pregnant and term pregnant women. The frequency and amplitude of the oscillations were not significantly affected by OT concentrations up to 300 nM. The amplitude of the oscillations decreased in the presence of the voltage-dependent Ca2+ channel antagonist verapamil and gradually disappeared in Ca2+-free medium. The oscillations were further blocked by the inorganic Ca2+ antagonist La3+ and by the intracellular Ca2+-ATPase inhibitor 2.5-di-tert-butylhydroquinone (DTBHQ). Caffeine inhibited the OT-induced oscillations in a concentration-dependent manner. DTBHQ and high concentrations of OT made [Ca2+]i remarkably sensitive to changes in the external Ca2+ concentration. CONCLUSIONS: The results indicate that OT-induced [Ca2+]i oscillations in human myometrial cells are due to inositol 1,4,5-trisphosphate-mediated release of intracellular Ca2+ combined with capacitative as well as voltage-dependent influx of the ion.

Connective tissue in female urinary incontinence.

An effective closure of the female urethra in stress situations is dependent on an integrated action of various anatomical structures connected to the organ. The most important of these structures - from a functional aspect - are the suburethral vaginal wall, the pubourethral ligaments, the pubococcygeus muscles and the paraurethral connective tissues. In all these structures connective tissue is an essential ingredient. Hence, defects in the actual connective tissue - in particular the paraurethral connective tissue that connects the aforementioned structures to each other and to the urethra - will bring about an ineffective urethral closure. Female urinary incontinence may then be caused by defective connective tissue per se and/or by a disconnection of the aforementioned structures, whereby the urethra cannot be 'kinked' - that is, closed off in stress situations.