It has been established that the lower urinary tract is sensitive to the effects of estrogen, sharing a common embryological origin with the female genital tract, the urogenital sinus. Urge urinary incontinence is more prevalent after the menopause, and the peak prevalence of stress incontinence occurs around the time of the menopause. Many studies, however, indicate that the prevalence of stress incontinence falls after the menopause. Until recently, estrogen, usually as part of a hormone replacement therapy (HRT) regimen, was used for treatment of urinary incontinence in postmenopausal women. Although its use in the treatment of vaginal atrophy is well established, the effect of HRT on urinary continence is controversial. A number of randomized, placebo-controlled trials have examined the effects of estrogen, or estrogen and progestogen together, in postmenopausal continence and concluded that estrogens should not be used for the treatment of urge or stress incontinence. In this paper, we will review these recent studies and examine the evidence for the effects of estrogen on the postmenopausal urogenital tract.

Introduction: While the gold standard for evaluation of maternal urinary protein is a 24-hr urine collection, spot urine protein/creatinine ratio has been instituted as an alternative for quantification proteinuria. Though it seems intuitive to obtain a catheterized urine sample on patients with ruptured amniotic membranes, it is a common practice to forgo this step under the argument that there is no data to show its necessity. Data on the effect of amniotomy, spontaneous or artificial, on the accuracy of the protein/creatinine ratio are scant. The present study was designed to address this issue and objectively compare protein/creatinine ratio values on samples obtained from the same patient before and after amniotomy. Methods: We conducted a prospective non-interventional study. Women presenting in active labor or for labor induction with intact amnion were enrolled. Separate random catch urines for the protein/creatinine ratio were obtained prior to and immediately after spontaneous or assisted amniotomy. The urine samples were analyzed in the hospital chemistry department, and the results were compared. Results: Of the 137 patients consented, 63 had pre- and post-amniotomy protein/creatinine ratios collected. The mean age was 28.5±5.6 y, Gravidity 2.7±1.6, Gestational age 39.2±1.8 wks, and BMI 31.6±6.4 kg/m 2 . Comorbidities included gestational diabetes (5/63, 7.9%), chronic hypertension (3/63, 4.7%), and pre-eclampsia (5/63, 7.9%). Post-amniotomy protein/creatinine ratio was significantly higher than pre-amniotomy ratio (1.3±2.5 vs 0.34±0.83, p <0.001). In addition, the number of patients with protein/creatinine ratio greater than 0.3 was higher post-amniotomy than pre-amniotomy (41/63 vs 14/63, p <0.001). Conclusion: Amniotomy results in a false elevation of the protein/creatinine ratio in term patients. Urine samples should be obtained by catheterization in the setting of ruptured membranes to reduce falsely elevated results. Although the same can be assumed for other gestational ages, further studies including this population need to be conducted.

INTRODUCTION: Preeclampsia is a leading cause of obstetric related morbidity and mortality, making prompt diagnosis crucial. While the gold standard for evaluation of maternal urinary protein is a 24 hour urine collection, the spot urine protein creatinine ratio (Up/Ucr ratio) greater than 0.3 g/gcr has been instituted as an alternative. No studies have evaluated the effect of amniotomy, spontaneous or artificial, on the accuracy of the Up/Ucr ratio. We hypothesize the proteins and creatinine found in amniotic fluid may erroneously alter the test result leading to an incorrect diagnosis of preeclampsia. METHODS: We performed a case-control trial where each patient served as their own control. An initial random catch urine was obtained for Up/Ucr ratio in women with intact membranes. Following amniotomy a second random catch Up/Ucr ratio was obtained. The urine samples were analyzed in the hospital chemistry department and results compared for consistency. RESULTS: The 49 study patients had the following characteristics; Age: 28.8 ± 5.8y, Gravid: 2.7 ± 1.5, Gestational age: 39.1 ± 1.8wks, and BMI: 31.2 ± 6.6 kg/m2. Co-morbidities included 3 gestational diabetic, 2 chronic hypertensive and one preeclamptic patient. Post-amniotomy Up/Ucr ratio was significantly higher than Pre-aminotomy (1.1±2.1 vs 0.23 ± 0.15, p=0.001). The prevalence of Up/Ucr greater than 0.3 g/gcr was higher post amniotomy than pre-amniotomy (28 vs 8, p =0.001). CONCLUSION: Amniotomy results in false elevation of the Up/Ucr ratio. Obtaining urine via straight catheterization may be necessary to reduce false positive results.