Urodynamics of the Female Lower Urinary Tract

Retrospective study on tension-free vaginal tape obturator (TVT-O)

INTRODUCTION AND HYPOTHESIS

We aim to report the 3-year outcome and complications of the tension-free vaginal tape obturator (TVT-O) in treating female stress urinary incontinence (SUI).

METHODS

Retrospective analysis for complications and outcome of surgery was performed in 419 women undergoing the TVT-O from 2004 to 2006.

RESULTS

Three patients (0.8%) with an isolated TVT-O had a blood loss of more than 200 ml. Two patients (0.5%) had bladder perforation. Out of 11 readmitted patients (2.6%), 10 were due to voiding difficulty. Six patients (1.4%) required tape loosening or division. Persistent pain occurred in 3.6% and erosion in 2.4% of patients. One hundred eighty-five patients (44.2%) came for follow-up at 3 years. The actual subjective and objective success rates were 89.7% and 99.9% at 3 years follow-up, respectively. With imputation, the 3-year subjective and objective success rates were 86.9% and 97.4%, respectively.

CONCLUSIONS

The TVT-O is effective in treating female SUI with minimal complications.

Neurobiology of stress urinary incontinence: New insights and implications for treatment

Stress urinary incontinence (SUI) is a significant problem for millions of women, many of whom remain untreated for years, sometimes for life. One reason for this is the lack of effective pharmacologic therapy. The drugs used for urge incontinence have little or no effect on leakage occurring without detrusor contraction under conditions of increased intra-abdominal pressure. Recent studies suggest that extrinsic urethral sphincter closure may be controlled by enhancing neurotransmission in pudendal pathways. A new agent, duloxetine, which inhibits serotonin-norepinephrine re-uptake in these pathways, is now in clinical trials and appears to be the first effective pharmacologic therapy for SUI.

Quantification of abdominal and pelvic floor muscle synergies in response to voluntary pelvic floor muscle contractions

The relative levels of pelvic floor muscle (PFM) activation and pressure generated by maximum voluntary PFM contractions were investigated in healthy continent women. The normal sequence of abdominal and PFM activation was determined. Fifteen women performed single and repeated maximum voluntary PFM contractions in supine, sitting and standing. PFM electromyographic (EMG) signals and associated intra-vaginal pressure data were recorded simultaneously. Surface EMG data were recorded from rectus abdominus (RA), external obliques (EO), internal obliques (IO) and transversus abdominus (TA). Abdominal and PFM EMG and intra-vaginal pressure amplitudes generated during voluntary PFM contractions were not different among the positions. Muscle activation sequence differed by position. In supine, EO activation preceded all other muscles by 27 ms (p = 0.043). In sitting, all of the muscles were activated simultaneously. In standing, RA and EO were activated 11 and 17 ms, respectively, prior to the PFMs and TA and IO were activated 10 and 12 ms, respectively, after the PFMs (p<<0.001). The results suggest that women are able to perform equally strong PFM contractions in supine, sitting and standing, however the pattern of abdominal and PFM activation varies by position. These differences may be related to position-dependent urine leakage in women with stress incontinence.

Stress Urinary Incontinence in Women: Review and Update on Neurological Control

BACKGROUND

Female stress urinary incontinence (SUI) is a common disease that involves leakage of urine during coughing, sneezing, or other increases in intraabdominal pressure. Treatments for SUI include pelvic floor muscle training, electrical stimulation, surgery, and off-label alpha-adrenergic agonists that stimulate contraction of the urethral smooth muscle. None of these treatments is universally or completely effective, and because drug therapy with the alpha- adrenergic agonists phenylpropanolamine and ephedrine can cause serious pressor adverse effects, the former has been banned in the United States, and the latter is under scrutiny. The central nervous system (CNS) affects reflexes that control urine storage and micturition, and norepinephrine and serotonin play a key role in maintaining storage capability by means of contraction of the external striated muscle of the urethral sphincter. Duloxetine hydrochloride, which inhibits reuptake of both of these neurotransmitters, has been shown to promote striated urethral sphincter contraction in animal models and to reduce the incidence of involuntary urine release in women with SUI without interfering with micturition.

CONCLUSION

Neuromodulation of noradrenergic and serotonergic neurotransmitters with such drugs as duloxetine provides an additional treatment option for women with SUI.

Electrovesicogram in stress urinary incontinence: a preliminary study

Electrovesicograms (EVG) were studied in 20 women with stress urinary incontinence (SUI) and 12 healthy female volunteers with a mean age of 44.8 and 48.2 years, respectively. Recordings were performed by means of three electrodes applied to the skin in the hypogastric area and one reference electrode to the lower limb. In the 12 healthy women pacesetter potentials (PPs) were recorded as regular triphasic waves. Of the 20 SUI patients 16 showed normal EVG, and the remaining 4 exhibited 'tachyvesica', i.e. increased PP frequency. These 4 patients proved to have combined urge and stress incontinence with detrusor hyperreflexia. It was concluded that SUI patients have normal EVG unless there is an associated pathology.

Uroflow in women: an overview and suggestions for the future

The literature on uroflowmetry in women is presented and evaluated. Uroflowmeters are described and found generally sufficiently accurate, although the errors arising from electronic evaluation may invalidate the test. Six flow curve patterns are proposed in accordance with described pathological conditions. From the literature it is summarized that the normal Qmax is 20-36 ml/s. Qmax is linearly correlated to the voided volume, increasing by 5.6 ml/s/100 ml. Pregnancy, age and menstrual cycle do not influence Qmax. Several pathological conditions have been associated with specific flow curve patterns. These conditions are described and associations with the proposed flow definitions made.

Urinary incontinence in women and the effects on their lives

The aim of this study was to assess and analyse the effects of urinary incontinence in women and to examine the relationship between these effects and the type and severity of incontinence. 110 women aged 20 to 65 who had reported urinary incontinence to their general practitioners underwent a comprehensive history and a complete urodynamic evaluation. The reported consequences of incontinence included low self-esteem, changing life-style in order to avoid potentially embarrassing situations, and all kinds of practical worries. Fear of the odour played the most important part and was mentioned as being the worst effect in 40% of the cases. Most of the women appeared to cope adequately with the unpleasant aspects of this condition. More effects were associated with urge incontinence than with stress incontinence, while there was a significant relationship between the objective severity of the incontinence and its psychosocial impact. The main conclusion is that although urinary incontinence is not a severe physical disability, a spectrum of psychological problems is associated with it. In particular, the fear of being smelt was of the utmost importance.

Usefulness of urodynamic investigations in female incontinence

Urinary incontinence in females has been evaluated in a prospective series of 408 patients by comparing the clinical diagnosis and the subsequent urodynamic findings. The presenting symptoms or combination of symptoms were shown to have only a limited diagnostic predictive value as measured by urodynamic diagnostic criteria. The symptom of stress incontinence was a sensitive detector of genuine stress incontinence (94% sensitivity) but was not very specific (65%). The symptoms of urgency and urge incontinence were found to have limited sensitivity (62%) and specificity (47%) in the detection of detrusor instability. Even patients with isolated complaints of stress incontinence have an incidence of detrusor instability of 52%, whereas 76% of those with a history of isolated urgency and urge incontinence had detrusor instability. An urodynamic evaluation should be performed on most female patients suffering from urinary incontinence and is essential for patients who are being considered for surgery of stress incontinence.

The anatomy of stress incontinence: magnetic resonance imaging of the female bladder neck and urethra

Clinical, urodynamic, radiological and endoscopic evaluations as well as operative results on more than 800 cases of stress incontinence treated at our medical center have led to a better understanding of the pathophysiology of female stress incontinence. We attempt to correlate these physiological concepts with information obtained from magnetic resonance images of the paraurethral and bladder neck areas in patients with known stress incontinence and normal controls. All magnetic resonance images were compared to cadaver step sections of the female pelvis. Normal controls without stress incontinence were used to define normal anatomy by magnetic resonance imaging. Etiology of incontinence was divided into either intrinsic urethral damage or anatomical malposition of an intact sphincteric unit. Our findings not only provide valuable support to basic concepts of the pathophysiology of stress incontinence but also help to establish normal findings of female paraurethral and bladder neck anatomy as seen by magnetic resonance imaging.

Urge incontinence can be a disease of bladder sensors

In many cases of urge incontinence the pathophysiology is unclear. Detrusor instability, detrusor hyperreflexia, urethral instability and poor sensory perception all have been suggested as requirements for urge incontinence. Sensory perception, as proposed recently, may be mediated by 2 bladder sensors. The first sensor, located at the trigone and posterior urethra, is sensitive to small changes in pressure and may function as an early warning system of bladder filling. In the diagnostic evaluation of urge incontinence 5 patients had a triad of absence of the first sensor, an intact second sensor, that is the urge to void when the bladder is stretched with fluid, and normal spontaneous detrusor contraction. Based upon these findings it is suggested that some instances of urge incontinence result when the early warning system fails and detrusor contraction occurs just shortly after the second sensor is stimulated. Detrusor instability was identified in 3 of the 5 patients with urge incontinence, and when present it was associated with urinary frequency. Thus, 2 forms of urge incontinence may be associated with loss of the first sensor: 1 with and the other without associated frequency, with the difference being the presence or absence of detrusor instability.

The value of clinical symptoms in the diagnosis of urinary incontinence in the female

In a study of 566 patients with urinary incontinence the presenting symptom or combination of symptoms were shown to have limited diagnostic predictive value as measured by urodynamic diagnostic criteria.