Urethral axis and sphincteric function

Does assessing urethral function allow the selection of the optimal therapy for recurrent SUI? Report from the ICI-RS 2017

AIMS

The management of recurrent stress urinary incontinence following failed previous continence surgery remains challenging. Whilst the role of urodynamic investigations has been questioned in the management of primary stress incontinence there is a widely held view that women with recurrent symptoms require further investigation although there is no agreement regarding which tests are required. We sought to understand what testing is recommended prior to managing this difficult cohort of patients.

METHOD

This research proposal was presented at the International Consultation on Incontinence Research Society (ICI-RS) in order to clarify our current knowledge regarding the assessment of urethral function and to set research priorities for the future.

RESULTS

Whilst the majority of clinicians would advocate urodynamic evaluation of women with recurrent stress incontinence following previous surgery there is no consensus of opinion as to which tests should be performed, on whom or where. The available evidence to date suggests that urethral function tests do have a role with regard to prognosis following surgery and also in planning the most appropriate surgical intervention.

CONCLUSION

The ICI-RS developed a list of research questions which may be able to assist in improving the investigation and management of women with recurrent SUI. Questions included whether patients felt the information gained via urethral function tests had an important role in their counseling regarding outcome of repeat SUI surgery.

Mixed Incontinence: How Best to Manage It?

Although common in women, mixed urinary incontinence (MUI) is under-reported and under-treated. It is linked to concomitant disturbances, which may be due to childbirth, ageing, or other medical conditions, in the complex bladder-urethra coordinated system of urine storage and emptying. Primary care physicians can evaluate MUI through history and simple clinical assessment or they can avail of more complex device and tools, such as urodynamic assessment. There is a wide range of therapeutic options. The recent proliferation of new drug treatments and surgical devices for urinary incontinence offers innovative strategies for therapy but products risk being introduced without long-term safety and efficacy assessment. Direct-to-consumer advertising has increased public awareness of MUI.

Acquired urinary incontinence in the bitch: update and perspectives from human medicine. Part 3: The urethral component and surgical treatment

Urethral sphincter mechanism incompetence (USMI) is the most common cause of urinary incontinence in dogs. Surgery may be recommended if the animal does not respond to medical treatment or becomes refractory. In this third part of a three-part review, surgical options for the treatment of USMI are described. Colposuspension is the most frequently described procedure and offers a fair prognosis, with about 50% of the dogs being continent after surgery and most of the reminder being improved or more responsive to medical treatment. Urethropexy offers a similar success rate, but with a higher rate of complications. Endoscopic injection of collagen is an attractive technique due to its minimally invasive nature and low risk of adverse effects. Initial results may however deteriorate with time. Other procedures have been reported, but involve a low number of cases and have resulted in variable success rates. In women, stress urinary incontinence is mainly treated by minimally invasive procedures involving vaginal placement of sub-urethral slings.

Transobturator vaginal tape inside out for treatment of urethral sphincter mechanism incompetence in female dogs: cadaveric study and preliminary study in continent female dogs

OBJECTIVES

(1) To describe a surgical technique adapted from the "transobturator vaginal tape inside-out" (TVT-O) used in women and to define the trajectory of the tape on canine cadavers, and (2) to determine the urodynamic and morphological effects of the TVT-O in continent bitches.

STUDY DESIGN

Cadaveric and experimental in vivo study.

ANIMALS

Fresh female canine cadavers (n=12) and spayed female Beagle dogs (2).

METHODS

(1) TVT-O was inserted in 12 cadavers. Dissection was performed and distances between the tape and neighboring structures were recorded. (2) TVT-O was inserted in 2 continent female Beagle dogs. Urethral pressure profilometry and vaginourethrograms were performed preoperatively, immediately after surgery, and 2, 4, and 6 months postoperatively. Histopathology was performed 6 months after surgery.

RESULTS

(1) TVT-O tape was consistently located in a perineal space before entering the obturator foramina and was located at a safe distance from major neurovascular structures including the femoral vessels and obturator nerve. (2) TVT-O was performed without any surgical or postoperative complications in 2 continent bitches. Histopathologic examination of the tissues surrounding the tape revealed a mild fibroblastic proliferation with a mild to minimal lymphoplasmacytic inflammatory infiltration.

CONCLUSIONS

TVT-O is a feasible and accurate procedure that can be performed in continent bitches with a low risk of complications.

Transobturator vaginal tape inside out for treatment of urethral sphincter mechanism incompetence: preliminary results in 7 female dogs

OBJECTIVES

To evaluate the clinical efficacy of the transobturator vaginal tape inside-out (TVT-O) in incontinent female dogs affected with urethral sphincter mechanism incompetence (USMI) and to determine its urodynamic and morphologic effects.

STUDY DESIGN

Case series.

ANIMALS

Incontinent spayed female dogs (n=7).

METHODS

TVT-O tape was inserted in 7 incontinent female dogs diagnosed with USMI. Urethral pressure profilometry (UPP) and vaginourethrograms were performed preoperatively, and 1 and 3 months postoperatively. Clinical efficacy of the technique was evaluated and complications reported. Follow-up information was evaluated by a telephone questionnaire.

RESULTS

All dogs were continent immediately after the procedure. Incontinence recurred 2 months after surgery in 1 dog and was treated by phenylpropanolamine administration. At mean follow-up time of 11.3 months, 6 of 7 dogs were continent. An iatrogenic urethral tear occurred intraoperatively in 1 dog. No postoperative complications were encountered. The postoperative UPPs showed significantly increased maximal urethral closure pressure and integrated pressure. Postoperative vaginourethrograms were unremarkable. The surgical procedure did not modify the location of the urinary bladder neck in dogs with a "pelvic urinary bladder" preoperatively.

CONCLUSIONS

TVT-O was efficient in maintaining short term continence in 6 of 7 dogs affected with USMI.

Clinical approach and office evaluation of the patient with pelvic floor dysfunction

Pelvic floor disorders are common health issues for women and have a great impact on quality of life. These disorders can present with a wide spectrum of symptoms and anatomic defects. This article reviews the clinical approach and office evaluation of patients with pelvic floor disorders, including pelvic organ prolapse, urinary dysfunction, anal incontinence, sexual dysfunction, and pelvic pain. The goal of treatment is to provide as much symptom relief as possible. After education and counseling, patients may be candidates for non-surgical or surgical treatment, and expectant management.

Hormone-dependent aging problems in women

One of the major social issues nowadays is the aging society. Korea is already an aging society, and 63 cities and districts are ultra-aged societies where the rate of people older than 65 yr exceeds 20%. Among them, more than 67% are women. These statistics reveal the importance of healthcare for older women. Disease and disability of older women are very closely related to the loss of female sex hormones after menopause. Major hormone-dependent aging problems in women such as osteoporosis, Alzheimer's disease (AD), urinary incontinence, and coronary atherosclerosis were surveyed in this review, and the key role of hormones in those diseases and hormone replacement therapy (HRT) were summarized. We expect that this review would provide some understanding of factors that must be considered to give optimal care to older women for healthy lives.

Restoration of continence by pessaries: magnetic resonance imaging assessment of mechanism of action

OBJECTIVE

The objective of the study was to determine incontinence pessaries' mechanism of action by measuring changes on urodynamic studies (UDS) and dynamic magnetic resonance imaging (MRI) with and without pessaries in place.

STUDY DESIGN

Women with stress incontinence had UDS and MRI performed with and without incontinence dish pessaries.

RESULTS

Fifteen women were evaluated. Pessary insertion resulted in increased urethral resistance; detrusor pressures increased (33-45 cm H(2)O) and maximal flow rates decreased (30 to 19 mL/second). With Valsalva on MRI, pessaries were associated with decreased posterior urethrovesical angles (175-130 degrees), bladder neck elevation (0.3 below to 0 .8 cm above the pubococcygeal line) and increased urethral lengths (2.4 to 2.97 cm). Bladder neck funneling with cough occurred in 14 patients without pessaries and 3 with pessaries.

CONCLUSION

On UDS and MRI following pessary placement, continence restoration was associated with decreased posterior urethrovesical angles, bladder neck descent and funneling, and increased urethral lengths and resistance to urine flow.

Vaginal birth and de novo stress incontinence: relative contributions of urethral dysfunction and mobility

OBJECTIVE

To evaluate the relative contributions of urethral mobility and urethral function to stress incontinence.

METHODS

This was a case-control study with group matching. Eighty primiparous women with self-reported new stress incontinence 9-12 months postpartum were compared with 80 primiparous continent controls to identify impairments specific to stress incontinence. Eighty nulliparous continent controls were evaluated as a comparison group to allow us to determine birth-related changes not associated with stress incontinence. Urethral function was measured with urethral profilometry, and vesical neck mobility was assessed with ultrasound and cotton swab test. Urethral sphincter anatomy and mobility were evaluated using magnetic resonance imaging. The associations among urethral closure pressure, vesical neck movement, and incontinence were explored using logistic regression.

RESULTS

Urethral closure pressure (+/-standard deviation) in primiparous incontinent women (62.9+/-25.2 cm H(2)0) was lower than in primiparous continent women (83.9+/-21.0, P<.001; effect size d=0.91) who were similar to nulliparous women (90.3+/-25.0, P=.091). Vesical neck movement measured during cough with ultrasonography was the mobility measure most associated with stress incontinence; 15.6+/-6.2 mm in incontinent women compared with 10.9+/-6.2 in primiparous continent women (P<.001, d=0.76) or nulliparas (9.9+/-5.0, P=.322). Logistic regression disclosed the two-variable model (max-rescaled R(2)=0.37, P<.001) was more strongly associated with stress incontinence than either single-variable model, urethral closure pressure (R(2)=0.25, P<.001) or vesical neck movement (R(2)=0.16 P<.001).

CONCLUSION

Lower maximal urethral closure pressure is the measure most associated with de novo stress incontinence after first vaginal birth followed by vesical neck mobility.

LEVEL OF EVIDENCE

II.

Differences in urodynamic study, perineal sonography and treatment outcome according to urethrovesical junction hypermobility in stress urinary incontinence

AIMS

To evaluate the differences in urodynamic study (UDS) and the perineal ultrasonography parameters between stress urinary incontinence (SUI) patients with or without urethrovesical junction (UVJ) hypermobility. Treatment outcomes following a retropubic urethropexy were also compared.

METHODS

The records of 164 SUI patients (<or=stage II), treated with retropubic urethropexy at our department between January 2001 and February 2004 were reviewed. The patients were categorized into a hypermobility group when the measured Q-tip angle was >or=30, and a non-hypermobility group when <30. All patients underwent UDS and perineal ultrasonography (US) preoperatively. A Burch urethropexy was performed regardless of the Q-tip result. All patients were reevaluated at 1 month and 3 months, postoperatively, and every 3 months thereafter.

RESULTS

Ninety-eight patients (60%) had an accompanying UVJ hypermobility and 66 (40%) did not. No significant differences regarding age, parity, body mass index (BMI), menopausal status, hormone replacement status, history of previous gynecologic surgery, or other medico-surgical illness were noted. UDS parameters demonstrated a significant difference between the groups, but were in the normal range. The significant difference noted in the perineal US was the bladder neck descent (BND). Following retropubic urethropexy, the success rates after 1 year were 94% and 91% for the hypermobility group and the non-hypermobility group, respectively, showing no statistical significance.

CONCLUSION

The success rates of Burch urethropexy in the two groups were similar. This result suggests that either the Q-tip is an inaccurate method of evaluating UVJ hypermobility or the presence of UVJ hypermobility does not negatively affect the treatment outcome of a Burch urethropexy.

Reevaluating occult incontinence

PURPOSE OF REVIEW

Occult incontinence is a controversial subject without significant exposure in the literature. Conventionally, it has been assumed to be a marker for increased risk of postoperative stress urinary incontinence (POSUI) after repair of pelvic organ prolapse. The controversy surrounds the performance of prophylactic incontinence procedures based on this assumption. Until 2004 no article in the English language had been published demonstrating an association between occult incontinence and increased risk of stress urinary incontinence after repair of severe pelvic organ prolapse in previously continent women. We will explore the evidence regarding occult incontinence, review the data on intervention trials, and address questions that remain.

RECENT FINDINGS

The limited evidence suggests 11-22% of continent patients with severe pelvic organ prolapse will develop POSUI. New evidence suggests that patients with occult incontinence are at substantially more risk. Since anti-incontinence procedures in patients with occult incontinence reduces the incidence of POSUI (to 0-15%), there appears to be some benefit from screening and intervention. Most studies on the subject are small and limited by their design. Results differ regarding whether a negative stress test can be used to rule out the risk of POSUI.

SUMMARY

Minimal existing evidence in the English language suggests that patients with occult incontinence are at increased risk of POSUI. Outcomes in occult incontinence patients undergoing repair of pelvic organ prolapse need systematic study. Until there is adequate solid evidence on the predictive values of our screening test, we cannot counsel patients regarding our ability to prevent POSUI or protect them from unnecessary procedures.

Physiologic outcome measures for urinary incontinence

Physiologic outcome measures are divided into 2 groups: (1) measures that visualize, quantify, and analyze the reasons for urine loss and (2) measures that assess the anatomy and neuromuscular function of continence-related structures. Few of the frequently used physiologic outcome measures have been rigorously tested. The evidence in support of their use derives mainly from case series information and expert opinion. Perineal pad testing is used to quantify urine leakage associated with stress incontinence. One-hour pad tests are commonly used for clinical trials and office visits; 24- and 48-hour tests are more reliable and reproducible. Urodynamic testing simultaneously assesses bladder and urethral function during bladder filling and emptying to help guide therapy and identify patients who are at risk for surgical failure. Testing usually includes (1) uroflowmetry, an assessment of voiding without catheters in place; (2) cystometry, which assesses bladder sensation, capacity, compliance, and inappropriate detrusor activity during filling; (3) urethral pressure profilometry, to gauge urethral closing pressures and pressure transmission ratios; (4) leak-point pressure, the minimum intra-abdominal pressure required to cause incontinence, which serves as a measure of urethral function; and (5) pressure flow studies, which diagnose obstruction by evaluating detrusor pressure and flow rate during voiding. The cotton swab test is used to assess bladder neck mobility after surgical interventions. Using the Pelvic Organ Prolapse Quantification system, researchers can describe pelvic support in a standardized, reproducible fashion. Applications of ultrasonography and magnetic resonance imaging in urogynecology are promising but remain in the investigational stages.

Relationship between urinary profile of the endogenous steroids and postmenopausal women with stress urinary incontinence

AIMS

The aims of this study were to investigate whether endogenous steroid hormones are (1) related to pathogenesis of stress urinary incontinence after menopause, (2) are related to severity of stress urinary incontinence, and (3) are related to prognostic parameters of stress urinary incontinence.

METHODS

Twenty post-partum women with clinically diagnosed stress urinary incontinence and 20 age-matched postmenopausal women without stress urinary incontinence (control group) were evaluated. We compared urinary profile of the endogenous steroid hormones patients with stress urinary incontinence and controls, and between grade I and grade II of stress urinary incontinence. We also investigated the relationship between urinary profile of the endogenous steroid hormones and prognostic parameters of stress urinary incontinence (maximal urethral closure pressure, functional urethral length, Valsalva leak point pressure, cough leak point pressure, posterior urethrovesical angle, bladder neck descent, and stress urethral axis). The ages of the patients and those in the control group were 64.3 +/- 5.6 and 57.5 +/- 3.8 years old and the body mass indexes were 24.96 +/- 3.14 and 22.11 +/- 2.73 kg/m2 in patients and in normal subjects, respectively. Nine patients were grade I and 11 were grade II. Estrone and 17beta-estradiol only were detected in all subjects, regardless of control or patient group. It is noteworthy that there were no significant differences (P > 0.05) in the levels of estrone and 17beta-estradiol in the urine of postmenopausal normal subjects compared with in the urine of postmenopausal patients with urinary incontinence. E2/E1 ratio was not different between the two groups (P > 0.05). Among the objective steroids, DHEA, Delta4-dione, Delta5-diol, Te, DHT, 16alpha-DHT, 11-keto An, THDOC, and THB were not detected either in the urine of normal subjects and nor in the urine of the patients. After comparing androgen levels between normal subjects and patients, no significant differences (P>0.05) were detected, except for 5alpha-THB and 5alpha-THF. Neither 5alpha-THB or 5alpha-THF were detected in the patients' urine. Et/An (11beta-OH Et/11beta-OH An) concentration ratios were not significantly different between the two groups, either (P > 0.05). There were not significant differences of concentrations (micromol/g creatinine) of urinary steroids between grade I and grade II of stress urinary incontinence. Pregnanediol was significantly related to bladder neck descent in supine and sitting positions (R = 0.79, P = 0.01, and R = 0.73, P = 0.03, respectively), and pregnanetriol was significantly related to maximal urethral closure pressure and functional urethral length (R = 0.68, P = 0.04, and R = -0.79, P = 0.01, respectively). Androsterone was significantly related to bladder neck descent in supine and sitting positions (R = 0.68, P = 0.04, and R = 0.78, P = 0.01, respectively). 5-AT was significantly related to bladder neck descent in sitting position and stress urethral axis (R = 0.72, P = 0.03, and R = -0.71, P = 0.03). 11-keto Et was significantly related to bladder neck descent in supine and sitting positions and related to stress urethral axis (R = 0.82, P = 0.01, and R = 0.81, P = 0.01, R = -0.67, P = 0.04, respectively). THS was significantly related to bladder neck descent in supine and sitting positions and related to stress urethral axis (R = 0.76, P = 0.02, and R = 0.74, P = 0.02, R = -0.68, P = 0.04, respectively). THE was significantly related to bladder neck descent in sitting position (R = 0.67, P = 0.04).beta-Tetrahydrocortisol/alpha-tetrahydrocortisol (beta-THF/alpha-THF) and alpha-cortol were significantly related to maximal urethral closure pressure and functional urethral length (R = 0.74, P = 0.02, and R = -0.92, P = 0.01; R = 0.71, P = 0.36, and R = -0.87, P = 0.000, respectively). 17beta-estradiol (E2) was significantly related to bladder neck descent in supine position (R = -0.62, P = 0.04) and 17beta-estradiol/estrone (E2/E1) was significantly related to cough leak point pressure (R = 0.79, P = 0.01). In conclusion, the urinary concentrations of endogenous steroid metabolites in postmenopausal patients with stress urinary incontinence were not significantly different from normal patients and were not significantly different between grade I and grade II patients with stress urinary incontinence. Some endogenous steroid metabolites were positively or negatively significantly related to prognostic parameters of stress urinary incontinence.

Effects of pelvic floor muscle training on strength and predictors of response in the treatment of urinary incontinence

AIMS

The objectives of this study were (1) to determine the effect of training on pelvic floor muscle strength; (2) to determine whether changes in pelvic floor muscle strength correlate with changes in continence; and (3) to determine whether demographic characteristics, clinical incontinence severity indices, or urodynamic measures predict response to pelvic floor muscle training.

METHODS

One hundred thirty-four women with urinary incontinence (95=genuine stress incontinence [GSI]; 19=detrusor instability [DI]; 20=mixed incontinence [GSI+DI]) were randomized to pelvic floor muscle training (n=67) or bladder training (n=67). Urinary diaries, urodynamic evaluation, and vaginal pressure measurements by using balloon manometry were performed at baseline and after 12 weeks of therapy. Primary outcome measures consisted of incontinent episodes per week and vaginal pressure measurements.

RESULTS

Both treatment groups had a reduction in incontinent episodes (P</=0.004). Vaginal pressures increased more with pelvic floor muscle training than with bladder training (P=0.0003). Other than a weak correlation between a reduction in incontinent episodes/week and an increase in maximum sustained vaginal pressure in women with GSI (r=0.32, P=0.04), there were no significant correlations between increases in pelvic floor muscle strength and improvement in continence status. There were no significant correlations between baseline demographic characteristics, clinical incontinence severity, or urodynamic measures and increases in vaginal pressure or improvement in clinical severity after pelvic floor muscle training.

CONCLUSIONS

Pelvic floor muscle training improves continence and increases vaginal pressure measurements, but the direct correlations between these alterations are weak. A woman's response to behavioral treatment does not depend on her demographic characteristics, clinical incontinence severity, urodynamic measures, or initial pelvic floor muscle strength.

Bladder neck mobility in continent nulliparous women

OBJECTIVE

To evaluate the mobility of the vesical neck during coughing and valsalva in healthy nulliparous volunteers and to test the reliability of the technique applied.

DESIGN

Clinical observational study.

SETTING

Department of Obstetrics and Gynaecology, Cantonal Hospital Lucerne, Switzerland.

POPULATION

Thirty-nine nulliparous volunteers.

METHODS

Vesical neck motion was assessed with perineal ultrasound. Intra-abdominal pressure was controlled for with an intrarectal probe. Intra-rater reliability was evaluated.

RESULTS

Vesical neck mobility was significantly lower during coughing (8 mm, SD 4 mm) than during valsalva (15 mm, SD 10 mm) (P < 0.005). Between individuals mobility varied from 4 mm to 32 mm during coughing and from 2 mm to 31 mm during valsalva. Test-retest-studies showed a maximum difference between to tests during coughing of 4 mm and during valsalva of 5 mm.

CONCLUSION

The bladder neck is mobile in normal continent women and bladder neck mobility is lower during coughing than during Valsalva.

Racial differences in the structure and function of the stress urinary continence mechanism

OBJECTIVE

To compare the structure and function of the urethral sphincter and the urethral support in nulliparous black and white women.

METHODS

Eighteen black women (mean age 28.1 years) and 17 white women (mean age 31.3 years) completed this cross-sectional study. The following assessments were made: urethral function using multichannel cystometrics and urethral pressure profilometry, pelvic muscle strength using an instrumented speculum, urethral mobility using the cotton-swab test and perineal ultrasound, and pelvic muscle bulk using magnetic resonance imaging.

RESULTS

Black women demonstrated a 29% higher average urethral closure pressure during a maximum pelvic muscle contraction (154 cm H(2)O versus 119 cm H(2)O in the white subjects; P =.008). Although not statistically significant, black women had a 14% higher maximum urethral closure pressure at rest (108 cm H(2)O versus 95 cm H(2)O; P =.23) and a 21% larger urethral volume (4818 mm(3) versus 3977 mm(3); P =.06). In addition, there was a 36% greater vesical neck mobility measured with the cotton-swab test (blacks 49 degrees versus whites 36 degrees; P =.02) and a 42% difference in ultrasonically measured vesical neck mobility during a maximum Valsalva effort (blacks = -17 mm versus whites -12 mm; P =.08).

CONCLUSION

Functional and morphologic differences exist in the urethral sphincteric and support system of nulliparous black and white women.

Understanding lower urinary tract function in women soon after bladder neck surgery. Continence Program for Women Research Group

The aim of this work was to correlate anatomic and urodynamic measures with function following bladder neck surgery. Eighty-seven women who underwent bladder neck surgery at two tertiary academic medical centers in the southeastern U.S. were studied in this prospective outcomes analysis. Preoperative and 6-week and 6-month postoperative status was assessed with urodynamic testing, physical examination, and condition-specific quality of life instruments. Correlations of dynamic urethral obstruction (quantified by pressure transmission ratio, PTR, determinations) and urethral support (quantified by urethral axis measurements) with functional status were determined. At 6 weeks, 50% of the subjects with inadequate dynamic obstruction (PTR < 90%) had genuine stress incontinence (GSI) compared to 5% of those with PTR >/= 90% (P = .00002). Of those with excessive obstruction (PTR > 110%), 32% had detrusor instability (DI) and 47% had emptying phase dysfunction (EPD) compared to 6% and 24%, respectively, of those with PTR </= 110% (P = .006 and P = .04). At 6 months, subjects with excessive obstruction were more likely to have EPD than other subjects (75% vs. 27%, P = .001). Those with optimal dynamic obstruction (PTR >/= 90% but </= 110%) were more likely to have normal function (no GSI, no DI, and no EPD) than those with higher or lower PTRs (59% vs. 34%, P = .04). Urethral axis measurements did not correlate with functional status at either follow-up session. The magnitude of dynamic urethral obstruction is related to function after bladder neck surgery. Excessive obstruction is associated with DI and EPD, inadequate obstruction with GSI, and optimal obstruction with normal function. Neurourol. Urodynam. 18:629-637, 1999.

The effect of bladder training, pelvic floor muscle training, or combination training on urodynamic parameters in women with urinary incontinence. Continence Program for Women Research Group

The purpose of this study was to compare the effect of three conservative interventions: pelvic floor muscle training, bladder training, or both, on urodynamic parameters in women with urinary incontinence. Two hundred four women with genuine stress incontinence (GSI) or detrusor instability with or without GSI (DI +/- GSI) participated in a two-site trial comparing pelvic floor muscle training, bladder training, or both. Patients were stratified based on severity of urinary incontinence, urodynamic diagnosis, and treatment site, then randomized to a treatment group. All women underwent a comprehensive standardized evaluation including multi-channel urodynamics at the initial assessment and at the end of 12 weeks of therapy. Analysis of covariance was used to detect differences among treatment groups on urodynamic parameters. Post-treatment evaluations were available for 181 women. No differences were found among treatments on the following measurements: maximum urethral closure pressure, mean urethral closure pressure, maximum Kegel urethral closure pressure, mean Kegel urethral closure pressure, functional urethral length, pressure transmission ratios, straining urethral axis, first sensation to void, maximum cystometric capacity, and the MCC minus FSV. The effect of treatment did not differ by urodynamic diagnosis. Behavioral therapy had no effect on commonly measured urodynamic parameters. The mechanism by which clinical improvement occurs remains unknown. Neurourol. Urodynam. 18:427-436, 1999.

Histologic analysis of needle biopsy of urethral sphincter from women with normal and stress incontinence with comparison of electromyographic findings

OBJECTIVE

Our goal was to compare urethral sphincter biopsy and needle electromyography between women who had genuine stress incontinence and those who did not.

STUDY DESIGN

Seventeen continent women and 10 women with stress incontinence had urethral sphincter needle electromyography and urethral biopsy specimens blindly processed for light and electron microscopy.

RESULTS

The continent group had greater skeletal muscle content and percentage in each muscle fascicle and each urethral sphincter. The group with genuine stress incontinence had higher connective tissue content. All urethral skeletal muscle was type 1. The smooth muscle was "multiunit" type and was morphologically indistinguishable between the 2 groups. On electromyography, patients with genuine stress incontinence had significantly more fibrillation potentials, fewer motor unit action potentials, a higher percentage of polyphasia, and less maximum voluntary electrical activity than control subjects.

CONCLUSIONS

Women with stress incontinence differ from continent women in skeletal muscle volume, amount of fibrosis, and electromyographic parameters; these differences support a neurogenic contribution to genuine stress incontinence. Urethral sphincter has only type 1 skeletal muscle and "multiunit" type smooth muscle.

Physiologic evaluation of the pelvic floor

This article has addressed the value, technique, rationale, and limitations of the commonly performed physiologic tests of the pelvic floor. Urodynamics provides a means for evaluation of the lower urinary tract and for assessment of the filling and emptying phases of the bladder. Neurophysiologic tests including EMG and nerve conduction studies offer methods to assess the neuromuscular integrity of the urethral and anal sphincteric mechanisms and the pelvic floor. Anorectal manometry studies provide a means of measuring pressure in the rectum and anal canal, rectal compliance, and anorectal reflexes and sensation in patients with anal incontinence and select patients with constipation. Colonic transit studies permit an assessment of functional constipation and may be helpful in the evaluation of patients in whom standard management of constipation has failed. Any test used in the evaluation of patients with pelvic floor dysfunction should be validated and found to be reliable. Most patients in need of complex physiologic evaluation are identified on the basis of their history and physical examination findings.

The clinical evaluation of pelvic floor dysfunction

Although Baden concluded that "the pelvic exam is just the pelvic exam," the history and examination are tools of no less merit than the cystometrogram or scalpel for clinicians treating patients with symptomatic pelvic floor dysfunction. An effective history and physical examination provide the basis for effective management of the patient's symptoms.

Reliability and correlation of measurements during and after bladder neck surgery. The Continence Program for Women Research Group

OBJECTIVES

To assess the reliability of seven intraoperative measurements of the effects of bladder neck suspension and correlate these measurements with postoperative dynamic urethral obstruction, quantified as the cough-pressure transmission ratio.

PATIENTS AND METHODS

Sixty women undergoing surgery for bladder neck hypermobility had seven measurements performed in duplicate: (i) the endoscopic appearance of the bladder neck: (ii) the bladder neck-retropubic surface distance (BN-RP distance); (iii) urethral axis; (iv) slow urethral pressure profilometry (UPP); (v) fast UPP; (vi) straining UPP; and (vii) dynamic UPP. Reliabilities were assessed by computing the intraclass correlation coefficient (R) for continuous data or Kappa statistic (K) for ordinal data. Pearson correlation coefficients were used to assess the relationships between the intra-operative measures and postoperative pressure transmission.

RESULTS

The intra-operative reliabilities for maximum pressure, length and area from the three UPP techniques were high (R=0.88-0.98) as were those for urethral axis measurements (R=0.98). In contrast, reliabilities were poor for pressure transmission ratios (R=0.15-0.33), BN-RP distance (R=0.55), and endoscopic appearance (K=0.10). There were significant correlations of the pressures from the UPPs and intra-operative pressure transmission ratios with postoperative pressure transmission ratios; however, the poor intra-operative reliability of intra-operative pressure transmission limits their usefulness. None of the other measures correlated significantly with postoperative pressure transmission ratios.

CONCLUSIONS

Of the measures studied, only intra-operative UPPs had both high reliability and good postoperative correlations.

Comparative efficacy of behavioral interventions in the management of female urinary incontinence. Continence Program for Women Research Group

OBJECTIVE

We compared the efficacy of bladder training, pelvic muscle exercise with biofeedback-assisted instruction, and combination therapy, on urinary incontinence in women. The primary hypothesis was that combination therapy would be the most effective in reducing incontinent episodes.

STUDY DESIGN

A randomized clinical trial with three treatment groups was conducted in gynecologic practices at two university medical centers. Two hundred and four women diagnosed with genuine stress incontinence (n = 145) and/or detrusor instability (n = 59) received a 12-week intervention program (6 weekly office visits and 6 weeks of mail/telephone contact) with immediate and 3-month follow-up. Outcome variables included number of incontinent episodes, quality of life, perceived improvement, and satisfaction. Data analyses consisted of analysis of covariance using baseline values as covariates and chi2 tests.

RESULTS

The combination therapy group had significantly fewer incontinent episodes, better quality of life, and greater treatment satisfaction immediately after treatment. No differences among groups were observed 3 months later. Women with genuine stress incontinence had greater improvement in life impact, and those with detrusor instability had less symptom distress at the immediate follow-up; otherwise, no differences were noted by diagnosis, incontinence severity, or treatment site.

CONCLUSIONS

Combination therapy had the greatest immediate efficacy in the management of female urinary incontinence regardless of urodynamic diagnosis. However, each of the 3 interventions had similar effects 3 months after treatment. Results suggest that the specific treatment may not be as important as having a structured intervention program with education, counseling, and frequent patient contact.

The pathophysiology of stress urinary incontinence in women and its implications for surgical treatment

Stress urinary incontinence is a symptom that arises from damage to the muscles, nerves, and connective tissue of the pelvic floor. Urethral support, vesical neck function, and function of the urethral muscles are important determinants of continence. The urethra is supported by the action of the levator ani muscles through their connection to the endopelvic fascia of the anterior vaginal wall. Damage to the connection between this fascia and muscle, loss of nerve supply to the muscle, or direct muscle damage can influence continence. In addition, loss of normal vesical neck closure can result in incontinence despite normal urethral support. Although the traditional attitude has been to ignore the urethra as a factor contributing to continence, it does play a role in determining stress continence since in 50% of continent women, urine enters the urethra during increases in abdominal pressure, where it is stopped before it can escape from the external meatus. Perhaps one of the most interesting yet least acknowledged aspects of continence control concerns the coordination of this system. The muscles of the urethra and levator ani contract during a cough to assist continence, and little is known about the control of this phenomenon. That operations cure stress incontinence without altering nerve or muscle function should not be misinterpreted as indicating that these factors are unimportant.

The sign of stress incontinence--should we believe what we see?

The accuracy of the clinical sign of stress incontinence in the diagnosis of genuine stress incontinence (GSI) was evaluated in 863 (consecutive) women, 779 of whom were referred with the symptom of urinary incontinence. Subjects were assessed clinically and urodynamically by the one clinician (PLD). The positive and negative predictive values of the clinical sign of stress incontinence for a diagnosis of GSI were 91% and 50% respectively. Of the 569 women with GSI, 335 (59%) had GSI as their sole diagnosis and 234 (41%) had an additional urodynamic diagnosis. The clinical sign of stress incontinence when present was a reliable guide to a final diagnosis of GSI. Clinical assessment of incontinent women requires the back-up of urodynamic studies in order to make an accurate diagnosis.

Diagnosing intrinsic sphincteric deficiency: comparing urethral closure pressure, urethral axis, and Valsalva leak point pressures

OBJECTIVES

Our purpose was to compare three measures proposed to diagnose intrinsic sphincteric deficiency: maximum urethral closure pressure, Valsalva leak point pressure, and straining urethral axis.

STUDY DESIGN

A total of 159 women with pure genuine stress incontinence had the three measures determined in a standardized fashion. Critical cutoff values for the Valsalva leak point pressure (52 cm) and urethral axis (22 degrees) were established by examining relative frequency distribution curves, using closure pressure of 20 as the arbitrary benchmark value for the prevalence of intrinsic sphincteric deficiency. The distribution of cutoff values is described and differences among the measures with respect to risk factors for intrinsic sphincteric deficiency and incontinence severity were determined.

RESULTS

Half the subjects fell below at least one cutoff value, but only 10% fell below all three. Sixty-four percent of subjects with either low closure pressure or leak point pressure had low values for the other, whereas 21% had discordance between them. Only 53% of subjects with low closure pressure and 40% with low leak point pressure had an axis < or = 22 degrees. Conversely, a substantial portion (36%) of subjects with pure genuine stress incontinence without urethral hypermobility had neither low urethral or leak point pressures. All three cutoff-values were associated with risk factors for intrinsic sphincteric deficiency, but only low closure and leak point pressures had significant associations with the severity of incontinence.

CONCLUSIONS

Intrinsic sphincteric deficiency should be diagnosed by a composite of historic, urodynamic, anatomic, and clinical severity criteria. We would include a maximum urethral closure pressure < or = 20, a Valsalva leak point pressure < or = 50, and a stress urethral axis < or = 20 in this composite.

Clinical predictors of urinary incontinence in women

OBJECTIVE

Our purpose was to characterize historic and clinical parameters in incontinent women to determine the predictive value for urodynamic diagnoses.

STUDY DESIGN

The analysis includes 535 consecutive women with final diagnoses of genuine stress incontinence, detrusor instability, or both. Evaluations included a standardized history, examination, urinary diary, quantitation test, and urodynamics. The analysis used one-way analysis of variance, chi 2 analysis with Yates' correction, and Fisher's exact test.

RESULTS

A total of 351 (66%) women were diagnosed with genuine stress incontinence, 102 (19%) with detrusor instability, and 82 (15%) with both. Half had symptoms of both stress incontinence and urge incontinence, of whom only 21% had both genuine stress incontinence and detrusor instability. Fewer than half of women diagnosed with genuine stress incontinence or detrusor instability had just symptoms of stress incontinence or urge incontinence, respectively. Evaluation of historic, examination, and urinary diary data for their influences on the predictive value of pure stress incontinence or urge incontinence revealed statistical differences for urethral hypermobility, estrogen deficiency, and incontinent episodes, yet they were not clinically practical predictors.

CONCLUSIONS

Pure symptoms identify fewer than half of patients with pure genuine stress incontinence or detrusor instability; historic and clinical parameters do not improve the sensitivity of these symptoms.

Stress urinary incontinence: where are we now, where should we go?

Stress urinary incontinence results from specific damage to the muscles, fascial structures, and nerves of the pelvic floor. Scientific data are accumulating about the nature of each of these injuries. As we begin to define the damage occurring in each element of the continence mechanism, we should be able to precisely select treatment plans on the basis of the abnormality found in individual patients. For example, a woman who has lost all neural control of her pelvic muscles could be saved the useless frustration of attempting pelvic muscle strengthening, whereas a woman with intact but weak muscles can be made continent with exercise. Before these advances can be realized, we must change our current empiric approach that assigns women to treatment because they have stress urinary incontinence to one that asks about the status of each part of the continence mechanism.

Randomized prospective comparison of needle colposuspension versus endopelvic fascia plication for potential stress incontinence prophylaxis in women undergoing vaginal reconstruction for stage III or IV pelvic organ prolapse. The Continence Program for Women Research Group

OBJECTIVE

Severe prolapse may mask potential genuine stress urinary incontinence in women. Some have suggested that a suspending urethropexy be performed in women who have potential genuine stress incontinence demonstrated by barrier reduction of the prolapse preoperatively. Our aim was to compare outcomes after prolapse surgery that included a formal bladder neck suspension with those operations that did not.

STUDY DESIGN

This prospective randomized clinical trial assigned 32 women with bladder neck hypermobility and stage III or IV pelvic organ prolapse to receive either a needle colposuspension or bladder neck endopelvic fascia plication as part of the vaginal reconstructive surgery. Twenty-nine subjects underwent detailed clinical, anatomic, urodynamic, and quality-of-life evaluations before and 6 weeks and 6 months after surgery; 23 completed urinary diary and quality-of-life evaluations after a mean of 2.9 years.

RESULTS

Needle colposuspension increased short-term complications without providing additional protection from de novo stress incontinence. Barrier testing before surgery predicted urethral sphincteric resistance after surgery; however, such testing neither predicted a patient's function after surgery nor indicated the need for a suspending urethropexy. The combination of a needle colposuspension with a sacrospinous ligament suspension predisposed to the early development of support defects of the upper anterior vaginal segment and to failure of bladder neck support.

CONCLUSIONS

Preoperative barrier testing in women with severe prolapse is not useful in identifying individuals who require a suspending urethropexy. Needle colposuspension increases short-term complications, lacks durability, and may predispose to early and severe recurrent anterior prolapse when performed with a sacrospinous ligament vault suspension.

Valsalva leak point pressures in women with genuine stress incontinence: reproducibility, effect of catheter caliber, and correlations with other measures of urethral resistance. Continence Program for Women Research Group

OBJECTIVES

The Valsalva leak point pressure has been promoted as an alternative to urethral pressure profilometry as a measure of urethral resistance in women with genuine stress incontinence. Our aims were to evaluate the reproducibility of the Valsalva leak point pressure, to assess the effect of catheter caliber on the Valsalva leak point pressure, and to compare vesical Valsalva leak point pressure to other measures of urethral resistance.

STUDY DESIGN

Sixty consecutive women with genuine stress incontinence underwent duplicate Valsalva leak point pressure determinations by use of 8F and 3F vesical and 8F vaginal catheters. Subjects also underwent a standard resting urethral pressure profilometry, cough leak point pressure determinations, and pressure-flow micturition studies.

RESULTS

Leakage was demonstrated on both Valsalva maneuvers in approximately 80% of subjects with both catheters. In subjects who leaked with both strains there was an extremely high correlation between the test-retest Valsalva leak point pressure within both catheters. The intercatheter correlation between the 8F and 3F Valsalva leak point pressures was significant but much weaker than the intracatheter correlations; 8F Valsalva leak point pressures were significantly higher than 3F Valsalva leak point pressures, although there were individual exceptions to this observation. Urethral pressure profilometry measures and micturition opening pressures were poorly correlated with Valsalva leak point pressure. Cough and vaginal Valsalva leak point pressures were significantly correlated with vesical Valsalva leak point pressure, but cough leak point pressures were significantly higher and vaginal Valsalva leak point pressures were significantly lower than the vesical Valsalva leak point pressure.

CONCLUSIONS

Valsalva leak point pressure is a simple and reproducible technique for evaluating urethral resistance in women with genuine stress incontinence. However, variations in Valsalva leak point pressure measurement must be precisely described, standardized, and validated before a technique can be advocated for clinical use.

Comparison of "subjective" and "objective" measures of severity of urinary incontinence in women. Program for Women Research Group

The aims of this study were to compare "subjective" measures of severity of urinary incontinence to similar "objective" measures, establish their statistical correlation, and determine the effect of specific urodynamic diagnosis on such correlations. Baseline data was available from 265 women entered into a clinical trial studying pharmacologic and behavioral interventions for urinary incontinence. The "subjective" measures of incontinence were obtained by patient recall during history taking and included: the number of incontinent episodes in 1 week, the number of perineal pads used during 1 week, and the number of clothing changes required due to wetness. The "objective" measures of severity included: the number of incontinent episodes per week as recorded on a 7-day diary, the number of perineal pads used per week, also recorded on a diary, and the amount of fluid lost during a standardized pad test. Analysis consisted of Pearson correlations and linear regressions to determine equations for the prediction of objective measurement on the basis of the corresponding subjective measure. Significant positive correlations were seen between "subjective" and "objective" measurements for the comparisons of number of weekly incontinent episodes (R = 0.63), and for the weekly number of pads used (R = 0.81). The comparison between the number of clothing changes and the amount of fluid lost during pad testing was also significantly but less strongly correlated (R = 0.24). For the correlations between subjective and objective determinations of urinary incontinent episodes and for those between clothing changes and pad testing, the urodynamic diagnosis had no effect on the correlation coefficients, but did have a statistically significant effect on the intercept.(ABSTRACT TRUNCATED AT 250 WORDS)

Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis

OBJECTIVE

This study examines the anatomic factors that could explain the mechanical basis for transmission of abdominal pressure to the urethra.

STUDY DESIGN

Dissection of 19 embalmed and 42 fresh cadavers and examination of 13 sets of serial pelvic sections were performed to study the structures involved in urethral support. The effect of simulated increases in abdominal pressure on the pelvic floor and urethra was observed in fresh specimens.

RESULTS

The urethra lies on a supportive layer that is composed of the endopelvic fascia and the anterior vaginal wall. This layer gains structural stability through its lateral attachment to the arcus tendineus fascia pelvis and levator ani muscle. Pressure from above compresses the urethra against this hammock-like supportive layer, compressing its lumen closed. The stability of the suburethral layer depends on the intact connection of the vaginal wall and endopelvic fascia to the arcus tendineus fasciae pelvis and levator ani muscles.

CONCLUSION

Increases in urethral closure pressure during a cough probably arise because the urethra is compressed against a hammock-like supportive layer, rather than the urethra being truly "intraabdominal."

Urodynamic parameters in patients with slight and severe genuine stress incontinence: is the stress profile useful?

This study evaluates the usefulness of the urethral pressure profile (UPP) parameters in assessing the severity of genuine stress incontinence (GSI). Functional length (FL), maximum urethral closure pressure (MUCP), pressure transmission ratio (PTR), residual area at stress (RAS), number of patients with incontinent spikes (IS), and distribution of IS on UPP were determined in supine and standing position for 54 patients (group 1) with a 1-hour pad test < 2 g and compared with the values of 63 patients (group 2) with a 1-hour pad test > 2 g. The results were similar: FL (supine: 24 mm +/- 6/26 mm +/- 7 [P:0.2]; standing: 26 mm +/- 8/24 mm +/- 11 [P:0.5]); MUCP (supine: 51 cm H2O +/- 23/47 cm H2O +/- 20 [P:0.3]; standing: 45 cm H2O +/- 21/38 cm H2O +/- 18 [P:0.1]); and PTR (supine: 83% +/- 27/84% +/- 31 [P:0.9]; standing: 81% +/- 25 and 88% +/- 27 [P:0.3]). But the RAS was lower (supine: 502 mm2 +/- 497/246 mm2 +/- 268 [P < 0.009]; standing: 500 mm2 +/- 534/271 mm2 +/- 306 [P < 0.05]) in group 2. If the percentage of patients with IS was higher (supine: 57/93% [P < 0.001]; standing: 54/84% [P < 0.01]) in group 2, the distribution of IS over the entire FL demonstrated no differences between group 1 and 2. In conclusion, except for the RAS, standard UPP parameters cannot be considered determinant in assessing the severity of GSI.

Obesity and lower urinary tract function in women: effect of surgically induced weight loss

OBJECTIVE

The subjective and objective effects of massive weight loss on lower urinary tract function in morbidly obese women were examined.

STUDY DESIGN

Thirteen subjects underwent a comprehensive evaluation of lower urinary tract function before and 1 year after surgically induced weight loss.

RESULTS

We demonstrated significant improvements in lower urinary tract function after weight loss. Of 12 subjects who complained of incontinence before surgery only three complained of incontinence (p = 0.004) and only one requested treatment after weight loss. Objective and subjective resolution of both stress and urge incontinence was documented. Statistically significant changes were seen in measures of vesical pressure, the magnitude of bladder pressure increases with coughing, bladder-to-urethra pressure transmission with cough, urethral axial mobility, number of incontinence episodes, and the need to use absorptive pads.

CONCLUSION

Weight reduction is desirable for obese women complaining of urinary incontinence and may obviate the need for further incontinence therapy.

Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction

Forty-seven women had urethral pressure profile determinations performed at rest and during a Kegel pelvic muscle contraction, after brief standardized verbal instruction. Twenty-three (49%) had an ideal Kegel effort--a significant increase in the force of urethral closure without an appreciable Valsalva effort. Twelve subjects (25%) displayed a Kegel technique that could potentially promote incontinence. Age, parity, weight, estrogen deprivation, prior continence surgery or hysterectomy, and passive urethral function did not predict a successful effort. We concluded that simple verbal or written instruction does not represent adequate preparation for a patient who is about to start a Kegel exercise program.

Urinary incontinence in community-dwelling women: clinical, urodynamic, and severity characteristics

Descriptive data on 145 community-dwelling older women with urinary incontinence are presented. Assessment included history, physical and functional examinations, and urodynamic and severity evaluations. Patients were 67 +/- 8 years old, mentally and functionally intact, predominantly white, and of middle-to-upper socioeconomic strata. Specific urodynamic criteria were used to establish the diagnosis of sphincteric incompetence and detrusor instability. Fifteen (10%) did not fulfill either criteria, 90 (62%) had sphincteric incompetence, 17 (12%) had detrusor instability, and 23 (16%) had both. Detrusor and urethral function variables showed some impairment in all patients. Impairment was least in subjects without demonstrable diagnosis and worst in those with both disorders (p less than 0.01). The findings suggest that detrusor and urethral functions are impaired in all incontinent women and that the degree of impairment varies. The impairment seems worse when both urodynamic diagnoses are demonstrable. The data support the pathophysiologic association of urethral and detrusor dysfunctions.

Urinary incontinence: medical and psychosocial aspects

Recognition has been growing over the past two decades that urinary incontinence is a rather widespread condition among older adults. Prevalence rates of about 30% for any incontinence and about 5% for severe incontinence among older adults were suggested by several European studies and have recently been confirmed by American studies. The rates are typically higher among women than men. Despite these findings, much about the true distribution of urinary incontinence remains to be firmly established. The proportion of different types and the differences between sexes, ages, and races need to be confirmed using representative population samples and valid measures of incontinence. These distributions cannot be accurately described using clinical populations. Perhaps because urinary incontinence is viewed as highly embarrassing, it has not been a focus of media coverage or public discussion. More attention by the media and by health-care professionals would build public awareness of the condition. Older adults and their caregivers need to know that urinary incontinence is common and treatable, so that they will identify it promptly and bring it to their physicians' attention. Health-care providers and social workers must also be alert to the possibility of incontinence among their clients. They should be prepared to ask older patients directly, because many patients may disregard urine loss or be too embarrassed to mention it. Currently, much of the management of urinary incontinence appears to be self-devised. Many incontinent persons have not talked to a physician about their problem. The largest proportion of those who attempt to control their urine loss use absorbent products or try to avoid loss by awareness of toilet locations and frequent toileting. Reliance on these methods is unfortunate because much progress has been made in developing diagnostic and treatment procedures for urinary incontinence. For example, surgical procedures to rectify an incompetent sphincter have been shown to be effective and are generally accepted. There are a number of medications effective for controlling detrusor instability. Further, various behavioral techniques appear to be promising as noninvasive initial interventions for many patients. We are on weaker ground regarding the prevention of and early intervention in urinary incontinence. The existing epidemiological data on the development of incontinence are poor. We do not know the proportion of urinary incontinence that is transient and the proportion that is chronic or established. Nor do we know the risk factors for onset and progression of the condition.(ABSTRACT TRUNCATED AT 400 WORDS)