Anatomic goals in the correction of female stress urinary incontinence

Association between Magnetic Resonance Imaging Findings of the Pelvic Floor and de novo Stress Urinary Incontinence after Vaginal Delivery

Objective

The study aimed to evaluate the contributions of levator ani muscle (LAM) injury, vesical neck movement, urethral length and mobility, and urethral sphincter dysfunction observed on magnetic resonance imaging (MRI) towards stress urinary incontinence (SUI) after vaginal delivery.

Materials and Methods

Fifty primiparous women after 6 months of delivery (15 with SUI and 35 without) and 35 nulliparous as continent controls underwent MRI at rest and Valsalva maneuver. A published levator ani scoring system was used to characterize morphological changes of LAM. The severity of the injury was divided into three categories as none, minor, and major. A series of common parameters including levator plate angle, iliococcygeal angle, and levator hiatus were used to describe the functional conditions of LAM. Urethral mobility was defined based on the rotation of the urethra between Valsalva and rest status. Vesical neck movement was evaluated by its distance to the pubococcygeal line. Urethral sphincter dysfunction was defined as the widening of the proximal urethra and/or funneling at the urethrovesical junction during Valsalva.

Results

Primiparous incontinent (PI) women had additional major levator ani defects (33.3% vs. 17.1%) while less minor defects (0.7% vs. 31.4%) than primiparous continent (PC) women. Vesical neck downward movement in PI women was more obvious than PC women (28.5 mm vs. 24.2 mm, p = 0.006). Urethral mobility was more active in primiparous women than in nulliparous continent controls (57.4 vs. 52.4), whereas no difference was observed on urethral mobility in the primiparous group (p = 0.25). Urethral sphincter dysfunction and funneling were present in 80% of PI women versus 22.9% in PC women (p < 0.001).

Conclusion

The MRI findings revealed that de novo SUI was associated with major LAM injury, vesical neck downward movement as well as urethral sphincter dysfunction. Vesical neck funneling on sagittal images can be treated as a valuable predictor for SUI. The intervention for the PI should focus on the elevation of vesical neck, rehabilitation of LAM as well as recovery of the urethral sphincter muscle.

Size Does Not Make the Difference: 3D/4D Transperineal Sonographic Measurements of the Female Urethra in the Assessment of Urinary Incontinence Subtypes

Purpose. The objective was to evaluate the usefulness of transperineal ultrasound in the assessment of the urethral length and urethral lumen by 3D/4D transperineal sonography to discriminate between female patients with subtypes of urinary incontinence. Methods. A total of 150 female patients underwent an examination because of urinary incontinence. 41 patients were diagnosed with urgency urinary incontinence (OAB), 67 patients were diagnosed with stress urinary incontinence (SUI), and 42 patients were in the control group (CTRL). Three diameters of the urethral lumen (proximal (U1), medial (U2), and distal (U3)) and the urethral length were measured. By the assessment of the urethral lumen, the presence of the urethral funneling was evaluated. Results. We found a significant difference in the urethral length and urethral lumen U2 of OAB and SUI versus CTRL. The urethral length was significantly greater (P < 0.05) and the urethral lumen was significantly wider (P < 0.05) in the patients with urinary incontinence. The incidence of the urethral funneling was significantly higher (P < 0.05) in the study groups with urinary incontinence than in the control group. Conclusions. Our results have shown the urethral changes obtained by ultrasound in patients with urinary incontinence, but they are still insufficient to distinguish between subtypes of urinary incontinence.

MR imaging of the female urethra and supporting ligaments in assessment of urinary incontinence: spectrum of abnormalities

The traditional methods for evaluation of urinary incontinence in women include urodynamics, cystourethroscopy, cystourethrography, and ultrasonography. Magnetic resonance (MR) imaging has not played a major role in the assessment of women with urinary incontinence. However, high-resolution MR imaging allows detailed visualization of the urethral sphincter and supporting ligaments in women and may contribute to the diagnosis and staging of sphincteric incompetence related to intrinsic sphincter deficiency or urethral hypermobility. Both the anatomy and the function of the female urethra can be depicted on MR images. The spectrum of abnormalities detected at MR imaging in women with stress urinary incontinence are classified as (a) findings related to the urethral sphincter deficiency and (b) defects of the urethral support ligaments and urethral hypermobility. These abnormalities include a small urethral sphincter, funneling at the bladder neck, distortion of the urethral support ligaments, cystocele, an asymmetric pubococcygeus muscle, abnormal shape of the vagina, enlargement of the retropubic space, and an increased vesicourethral angle.

Effect of tension-free vaginal tape operation on urethral closure function

OBJECTIVES

To evaluate whether the tension-free vaginal tape operation changes urethral hypermobility, funneling, and urethral urodynamic parameters in different parts of the urethra.

METHODS

We conducted a cohort study of our first 80 unselected female patients (age 36 to 78 years, median 53) undergoing a tension-free vaginal tape procedure. Urethral pressure profile measurements were done before and 6 and 12 months after the operation. Lateral cystography was performed before and after surgery in 50 patients. Of the 80 women, 29 had previously undergone prolapse or incontinence surgery. Parameter-free techniques were used for statistical evaluation.

RESULTS

Five patients were lost to follow-up. On an intention-to-treat basis, 66% of the patients were objectively and subjectively cured, 20% were objectively dry but subjectively occasionally incontinent, and 14% had treatment failure. The maximal urethral closure pressure at rest showed no significant changes (median baseline and 6 and 12 months postoperatively, 44, 40, and 38 cm H(2)O, respectively). The pressure transmission ratio increased in the proximal urethra (median 107.5%, 122.5%, and 123.5% at baseline and 6 and 12 months postoperatively, respectively, P <0.05) and distal urethra (median 80%, 112%, 107.5% at baseline and 6 and 12 months postoperatively, respectively, P <0.01). The downward movement of the bladder neck during the Valsalva maneuver decreased (median 2.3 cm preoperatively versus 1.7 cm postoperatively, P <0.001). Urethral rotation was diminished (median 35.5 degrees versus 23 degrees , P <0.01). Funneling was seen postoperatively in only 5 of 25 preoperative cases.

CONCLUSIONS

The tension-free vaginal tape procedure stabilizes the urethra anatomically and improves funneling and pressure transmission ratios all along the urethra. The maximal urethral closure pressure at rest decreased without statistical significance.

Relationship between ankle position and pelvic floor muscle activity in female stress urinary incontinence

OBJECTIVES

To assess the influence of ankle position on pelvic floor muscle (PFM) activity in women with stress urinary incontinence.

METHODS

A total of 39 women, ranging in age from 38 to 72 years and clinically diagnosed with stress urinary incontinence, participated in testing of PFM activity changes during various pelvic tilt angles created by horizontal, dorsiflexed, and plantar flexed ankle positions. PFM activity was measured by an intravaginal probe with surface electromyographic electrodes. An adjustable angle platform was used to set the ankle in each of the positions to create the various pelvic tilt postures.

RESULTS

Significant differences were found in resting PFM activity between horizontal standing with the ankle in the neutral position and standing with the ankle in plantar flexion (P = 0.01). Patients with ankle dorsiflexion also had greater resting PFM activity than with ankle plantar flexion (P < 0.01). Subjects showed significant changes in mean maximal PFM activity when standing with the ankle dorsiflexed and horizontal or in plantar flexion.

CONCLUSIONS

A standing posture that includes various ankle positions effectively facilitates PFM activity through enhanced pelvic tilt. We recommend these ankle positions as an adjunctive option combined with PFM training for stress urinary incontinence.

Oral and local anesthesia in the nonsurgical radiofrequency-energy treatment of stress urinary incontinence

STUDY OBJECTIVE

To demonstrate the feasibility, safety, and patient comfort associated with nonsurgical radiofrequency-energy (RF) tissue micro-remodeling in women with stress urinary incontinence (SUI) given oral and local anesthesia.

DESIGN

Prospective, open-label pilot clinical trial (Canadian Task Force classification II-2).

SETTING

Department of urology in a major academic teaching hospital in Mexico City, Mexico.

PATIENTS

Sixteen women with SUI and hypermobility (based on history and physical examination) with no history of previous definitive incontinence therapy.

INTERVENTIONS

Nonsurgical, transurethral, outpatient RF tissue micro-remodeling with women given oral plus local anesthesia.

MEASUREMENTS AND MAIN RESULTS

The women had a mean age of 49.7 years (range 30-76 years) and a mean duration of incontinence of 7.6 years (range 1-30 years). The nonsurgical RF micro-remodeling treatment, which was previously demonstrated to be of significant benefit when administered under intravenous (IV) sedation in an outpatient surgicenter setting, was successfully completed in all 16 women. Either the treating physician or the patient had the option to convert to IV sedation during the procedure if there was too much discomfort; however, this did not occur in any of the 16 patients. Thus neither the treating physician nor any patient determined that conversion to IV conscious sedation was required for treatment completion. The first six patients received an oral sedative and oral analgesic as well as a local periurethral anesthetic block with 10 mL of 2% lidocaine. The final 10 patients (63%) received only one oral sedative or analgesic and a total of 10mL lidocaine local anesthetic. Two women who received the maximum oral regimen (both oral sedation and analgesics) experienced nausea and emesis when drinking immediately after treatment, and one of these women also experienced urinary retention, which resolved after 24 hours of catheterization. Immediately before discharge, subjects classified their pain on a scale from zero ("no pain") to 10 ("terrible pain"). Mean score was 1.8, and 38% of subjects selected "zero."

CONCLUSION

This pilot trial demonstrated the feasibility, safety, and patient comfort associated with performing a novel new successful technique of nonsurgical RF of the urethra for treatment of SUI, which was previously studied under IV sedation in an outpatient surgery center, on women in an office-based setting using oral plus local anesthesia.

Rapid Communication: Externally Readjustable Device to Regulate Sling Tension in Stress Urinary Incontinence: Preliminary Results

BACKGROUND AND PURPOSE

Slings, especially those called "tension free," have low complication rates and good long-term success rates. However, they still have problems with either an excess or a lack of tension, which produces voiding difficulties or urinary leakage persistence, respectively. The effectiveness of a new adjustable sling for the treatment of stress urinary incontinence (SUI) has been evaluated.

PATIENTS AND METHODS

Between November 1999 and May 2002, 113 consecutive patients were operated for SUI by means of a new adjustable sling. The results were analyzed retrospectively. The average follow-up time was 22 months (range 6-36 months).

RESULTS

Objective success was achieved in 108 of 113 patients (95.5%), but subjectively, only 90.3% of the patients were completely satisfied with the procedure because of persistent urge incontinence in 6 cases (5.3%). Morbidity was minimal.

CONCLUSIONS

This new minimally invasive treatment allows readjustment of sling tension at the immediate or mid-term postoperative period. It is applicable to primary and recurrent SUI and has shown encouraging results.

Stress incontinence observed with real time sonography and dynamic fastscan magnetic resonance imaging--insights into pathophysiology

Our concepts of pathophysiology of stress urinary continence have been greatly shaped by developments in radiographic imaging. Simple radiographs with and without contrast initially revealed the importance of urethral descent in pathogenesis. More recently, magnetic resonance imaging (MRI) and real time ultrasonography are showing soft tissue detail within both a global pelvic and a local urethral context. Careful examination of these studies can extend our concepts of pathophysiology and lead us beyond existing paradigms. We propose a unified theory of stress incontinence based on our dynamic fastscan MRI and real time ultrasonograms of stress incontinence, incorporating known details of pelvic anatomy, sphincteric location and function. The hypothesis introduces the concept of a continence threshold at which the urethra is subjected simultaneously to both shearing and explusive forces. If these forces are sufficient to overcome urethral coaptation at threshold, leakage results. The model proposes an anatomical sequence of changes through which the incontinent urethra cycles between periods of rest and increased abdominal pressure, and suggests a way in which repeated episodes of prolpase and urethral traction by shearing forces exerted by the vagina on the urethra may contribute to the development of intrinsic sphincteric deficiency.

"Sandwich technique" for suburethral placement of Mersilene mesh sling during pubovaginal suspension surgery: preliminary results

OBJECTIVES

To evaluate the effectiveness of a new "sandwich technique" for heterologous sling placement during pubovaginal suspension for treatment of recurrent stress urinary incontinence.

METHODS

A new sling placement procedure was used in 31 women (mean age 65.4 years) who had undergone multiple operations. With this technique, a heterologous sling was placed without dissection over a de-epithelialized vaginal wall and later covered with a vaginal wall flap. Finally, the sling and the bladder neck were suspended from the pubic bone with metallic anchorages and nonabsorbable sutures.

RESULTS

The objective success rates for SUI resolution was 87.1% but, subjectively, 90.3% of patients were satisfied or very satisfied with the procedure. The median follow-up time was 34 months. Morbidity was minimal, and the mean hospitalization time was less than 5 days.

CONCLUSIONS

This original, simple, noninvasive treatment is applicable to all type II and type III SUI with or without associated cystoceles, regardless of patient age or sexual activity, and has shown encouraging results. This procedure is highly recommended for the treatment of SUI, especially in patients who have undergone multiple previous operations.

The tension-free vaginal tape procedure: correction of stress incontinence with minimal alteration in proximal urethral mobility

OBJECTIVES

To prospectively assess the degree of urethral hypermobility in the preoperative and postoperative periods after the tension-free vaginal tape (TVT) procedure and correlate our findings with surgical outcome.

METHODS

Twenty patients with stress incontinence underwent the TVT procedure. A Q-tip test was performed before the procedure and at the 3-week postoperative follow-up visit. Cure was defined as the absence of the subjective complaint of urine leakage and the absence of stress incontinence on stress testing at cystometric capacity.

RESULTS

Seventeen patients (85%) were cured by the TVT procedure, 2 patients (10%) were improved, and 1 patient (5%) was unchanged. The mean preoperative and postoperative Q-tip values were 42.75 degrees and 31.75 degrees, respectively. Twelve patients had a Q-tip test result of 30 degrees or greater after surgery and 11 (92%) of these 12 patients were cured by the procedure.

CONCLUSIONS

On the basis of these results, we propose that the cure of stress incontinence does not require the correction of proximal urethral hypermobility.

Videourodynamic results after pubovaginal sling procedure for stress urinary incontinence

OBJECTIVES

To determine the influence of surgery on bladder and urethral function by performing a videourodynamic study in female patients with stress urinary incontinence (SUI) before and after a pubovaginal sling procedure.

METHODS

A total of 14 women with type II SUI, 7 with type III SUI, and 3 with mixed type II/III SUI were included in the study. The pubovaginal sling procedure was carried out using a modified method that minimized interference with the endopelvic fascia. Videourodynamic study was performed before the procedure, within 7 to 14 days postoperatively, and at 3 to 6 months postoperatively.

RESULTS

Videourodynamic study within 7 to 14 days postoperatively revealed no change in the mean voiding detrusor pressure (Pdet), cystometric capacity, or maximal flow rate (Qmax) compared with the preoperative data. The bladder neck opening time and residual urine amount were significantly increased. Within 3 to 6 months after surgery, Pdet, Qmax, bladder neck opening time, and residual urine amount returned to preoperative levels. An elevation of the bladder neck was noted during coughing in 7 patients. After surgery, de novo detrusor instability was noted in 2 patients (8.3%). No infection or sling failure was noted at a mean follow-up time of 12 months. The success rate was 96%.

CONCLUSIONS

The pubovaginal sling procedure is an effective method for the treatment of type II or type III SUI. The postoperative videourodynamic results show that this procedure can re-establish a "hammock effect" on the proximal urethra during abdominal straining without compromising urethral resistance.

Surgical management of pelvic organ prolapse and stress urinary incontinence

There is no single operative approach to correct pelvic organ prolapse in conjunction with urinary and/or fecal incontinence or rectal prolapse. Each case needs to be individualized and dealt with surgically following the principles outlined in Table 1. In postmenopausal women, it is not only important to pretreat patients with estrogen prior to reconstructive pelvic surgery, but also maintain patients on long-term treatment after surgery. The genitourinary and reconstructive pelvic surgeon should have the skills to offer patients alternative approaches tailored to their individual symptomatology, and anatomic and pelvic pathology. Long-term follow-up of all patients is imperative to ascertain the clinical and cost effectiveness of these procedures.

The Gore-tex sling procedure for female sphincteric incontinence: indications, technique, and results

We constructed a pubovaginal sling using the Gore-tex Soft Tissue Patch and 2-0 polytetrafluoroethylene (PTFE) suspension suture and placed it in 122 consecutive incontinent women with urethral hypermobility and/or intrinsic sphincter deficiency. We performed a retrospective outcome analysis using a questionnaire-based telephone survey. The mean follow-up period was 24.4 months. Stress incontinence was cured in 88% of patients (equally effective in type II and type III incontinence), de novo postoperative urinary frequency occurred in 32% of cases, and preoperative urinary frequency resolved postoperatively in 51% of patients. Significant urinary obstruction occurred in 5% of patients. Vaginal granulation tissue with exposed sling occurred in 4% of patients. There was no urethral or bladder erosion. The treatment of female stress incontinence with a PTFE sling is effective and durable with minimal complications. Furthermore, this technique addresses many of the presumed technical shortcomings of endoscopic needle suspensions.