Pelvic organ prolapse (POP) reduces the quality of life of many older women in the U.S. There is an unmet need for non-surgical therapies based on POP pathophysiology, to prevent and/or regress this common condition. Towards pioneering the development of such a therapy, we propose an exploratory study to (a) assess aberrations of the structural extracellular matrix (ECM) as a pathophysiological basis for POP and (b) establish proof of concept of an innovative therapeutic strategy based on induced regenerative extracellular matrix repair. Recent data in humans and lysyl oxidase like protein-1 (LOXL1) knockout (KO) suggest that impaired ECM remodeling, particularly that of elastic matrix may be linked to POP. However, it is not known if decreased LOXL1 and aberrations of ECM homeostasis, occur in all POP patients, and if they are a cause of POP or a result of it. Since vaginal wall ECM mechanically supports pelvic floor tissues, restoring homeostasis of vaginal ECM in post-partum pelvic floor tissues may be an effective approach to prevent or reverse POP symptoms even though the clinical etiology may be varied and multifactorial. Elastic matrix does not usually regenerate well in adult tissues and will therefore be our primary target for regenerative therapy, although we will assess restoration of collagen homeostasis as well. We propose to utilize a LOXL1 knockout (KO) mouse model of POP to perform a first phase correlative study to elucidate these mechanistic aspects that, beyond this study, will be useful to assess in vivo therapeutic efficacy of our matrix regenerative approach. We propose two aims to test our hypotheses that LOXL1 deficiency results in aberrations in vaginal ECM assembly &repair after pup delivery, which together with enhanced matrix degradation are associated with POP, and that these aberrations can be attenuated or reversed by induced cellular regenerative ECM repair.
Aim 1 a. Determine the time course of changes to the homeostasis of structural ECM of the vaginal wall corresponding to POP in LOXL1 KO mice.
Aim 1 b. Determine how LOXL1 deficiency, pregnancy, vaginal delivery, and prolapse in LOXL1 KO mice, alter new ECM deposition by Non-Epithelial Vaginal Cells (NEVCs).
Aim 2. Assess ability of MRFs to restore indicators of structural ECM homeostasis in organ cultures of vaginal wall tissue isolated from LOXL1 KO mice with and without POP. The proposed project builds on an ongoing collaboration and expertise of the co-PIs, Damaser (animal models and POP pathophysiology) and Ramamurthi (ECM regeneration). The study will provide justification, rationale, and feasibility data to continue development of this paradigm-shifting, minimally invasive regenerative therapy with pre-clinical studies in animal models and cultured human vaginal tissue. These in turn will rationalize clinical trials to prevent and/or treat POP towards improvin quality of life for many women. The scientific impact of this study will be improved understanding of the mechanisms of POP development and testing of an innovative therapy for regenerative elastic matrix repair and restoration of ECM homeostasis.

Public Health Relevance

Pelvic organ prolapse (POP) is a slowly-developing condition wherein muscles and ligaments supporting a woman's pelvic organs weaken to result in their gradual slipping out (prolapse). While not life threatening, POP greatly reduces quality of life. Vaginal delivery of children is known to be a significant risk factor for POP. Current treatments for POP are primarily surgical and require frequent re-intervention. In addition, they do not take into account pregnancy or delivery-associated changes within female pelvic tissues that may lead to the condition. Prior work suggests that collagen, which provides stiffness to tissues, and elastin, a rubber-like protein that makes tissues stretchy, may not be replaced and may be broken down in individuals at risk for POP. This can result in gradual loss of flexibility and weakening of pelvic tissues, which likely results in POP. Also, it appears that these collagen and elastin matrix abnormalities may be related to decreased levels of a protein, lysyl oxidase like 1 (LOXL1), observed in many POP patients. Accordingly, this study first proposes to investigate in a mouse model of POP, if and how LOXL1 deficiency and changes to the matrix of vaginal tissues during pregnancy and following delivery correlate to POP development. Then, cultured vaginal cells from both non-prolapsed and prolapsed tissues extracted from the mouse model will be treated with a combination of biological agents that we have found to significantly increase elastin &collagen production and their crosslinking by diseased cells. We will investigate the efficacy of these agents to reduce matrix abnormalities and restore tissue structure typical of healthy vaginal tissues. We will also determine if the therapy is more effective if applied proactively before POP develops, or after. The project outcomes will increase our understanding of POP and will help develop new, non-surgical treatment strategies for POP.

National Institute of Health (NIH)
Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD)
Exploratory/Developmental Grants (R21)
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Special Emphasis Panel (ZRG1-UGPP-G (08))
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Parrott, Estella C
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Cleveland Clinic Lerner
Other Basic Sciences
Schools of Medicine
United States
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Tran, Christine; Damaser, Margot S (2015) Stem cells as drug delivery methods: application of stem cell secretome for regeneration. Adv Drug Deliv Rev 82-83:1-11
Gill, Bradley C; Damaser, Margot S; Chermansky, Christopher J (2014) Future Perspectives in Bladder Tissue Engineering. Curr Bladder Dysfunct Rep 10:443-448