The safety of reusing injectable collagen: a multicenter microbiological study

We have previously reported pilot data regarding the safety of saving partially used syringes of a glutaraldehyde cross-linked collagen for use in subsequent treatment sessions with the same individual. That single institution study involved 56 partially used syringes cultured for aerobic bacteria. Only one weakly positive culture was detected among these 56 samples, which prompted us to carry out this expanded study involving multiple centers and different injection techniques. Samples were collected from four centers. Following periurethral injection in an office setting, 166 partially used syringes of glutaraldehyde cross-linked collagen were refrigerated for between 1 and 104 weeks (average 58). Material from all 166 syringes was then cultured qualitatively and quantitatively for both aerobic and anaerobic organisms. Collagen from one syringe grew >100,000 colonies of Escherichia coli. All other cultures were negative. In the pilot study, one culture of 56 syringes was weakly positive for coagulase-negative staphylococcus. When the results from both studies were considered together, only two of 222 partially used syringes (0.9%) were contaminated. The background risk of local infection associated with periurethral collagen injection is approximately 0.29%. Using the statistical equation 'number needed to harm', we found that a clinician would have to reuse 111 syringes at a saving of $34,965 before he or she would cause a single local injection by so doing. Therefore, we feel that it may be cost-effective and safe to reinject material from a partially used syringe of glutaraldehyde cross-linked collagen during a subsequent treatment session on an individual.

Urethral instability: clinical and urodynamic characteristics

Filling cystometry was performed on 397 patients with lower urinary tract complaints. The overall prevalence of urethral instability was 12.6% (50/397). Of these 187 patients had detrusor instability (DI). Within the DI group, clinical and urodynamic characteristics were compared. Patients with an unstable urethra had a shorter functional urethral length (P = 0.005). For those with DI, 28 of 187 (15%) had urethral instability. Forty (21%) women had a decrease in maximal urethral pressure that preceded the detrusor contraction (type II DI). When those with type II DI were excluded, the difference in functional urethral length was not observed. Patients with type II DI experienced an earlier sensation of fullness of 228 mL compared with 283 mL for the other patients with DI (P = 0.001). There was a positive association between urethral instability and type II DI. Four different patterns of urethral pressure changes were observed. Based on these findings, it appears that a urethral abnormality may be the primary disorder in patients with type II DI. The differentiation of the various subtypes of urethral instability and DI might be important for directing therapy.

Correlation of symptoms with location and severity of pelvic organ prolapse

OBJECTIVE

The purpose of this study was to compare the symptoms that are related to pelvic floor dysfunction with the location and severity of the coexisting prolapse.

STUDY DESIGN

Two hundred thirty-seven consecutive patients with symptomatic pelvic organ prolapse came to Johns Hopkins Medicine during a 24-month period beginning in July 1998 and completed a symptom-specific Likert scale questionnaire that included standardized questions that were compiled from commonly used validated instruments. All questionnaires were completed by the patients before they were seen by a physician. Further evaluation included a standardized physical examination that included the International Continence Society's system for grading uterovaginal prolapse. Symptoms were categorized according to both severity and associated anatomic compartment. Symptoms that were related to urinary and anal incontinence and voiding, defecatory, sexual, and pelvic floor dysfunction were analyzed with respect to location and severity of pelvic organ prolapse with the use of the nonparametric correlation coefficient, Kendall's tau-b.

RESULTS

The mean age of the women was 57.2 years (range, 23-93 years); 109 of the women (46%) had undergone hysterectomy. Overall, stage II was the most common pelvic organ prolapse (51%) that was encountered. In 77 patients (33%), anterior compartment pelvic organ prolapse predominated; 46 patients (19%) demonstrated posterior compartment prolapse, whereas 26 patients (11%) had apical prolapse. In 88 patients (37%), no single location was more severe than another. Voiding dysfunction that was characterized by urinary hesitancy, prolonged or intermittent flow, and a need to change position was associated with the increasing severity of anterior and apical pelvic organ prolapse. Pelvic pressure and discomfort along with visualization of prolapse were strongly associated with worsening stages of pelvic organ prolapse in all compartments. Defecatory dysfunction characterized by incomplete evacuation and digital manipulation was associated with worsening posterior compartment pelvic organ prolapse. Impairment of sexual relations and duration of abstinence were strongly associated with worsening pelvic organ prolapse. An inverse correlation was observed between increasing severity of pelvic organ prolapse and urinary incontinence and enuresis.

CONCLUSION

Women with pelvic organ prolapse experience symptoms that do not necessarily correlate with compartment-specific defects. Increasing severity of pelvic organ prolapse is weakly to moderately associated with several specific symptoms that are related to urinary incontinence and voiding, defecatory, and sexual dysfunction.

Collagen implant for treating stress urinary incontinence in women with urethral hypermobility

PURPOSE

We evaluated the use of collagen in women with stress urinary incontinence and urethral hypermobility.

MATERIALS AND METHODS

We treated 90 patients with stress urinary incontinence and urethral hypermobility with 1 to 3 injections of Contigen implant (C. R. Bard, Inc., Covington, Georgia) between June 1996 and October 1998. Observations at 3, 6 and 12 months included continence grade, 7-day voiding diaries and quality of life questionnaires. Abdominal leak point pressure was determined at baseline and 12 months.

RESULTS

At the 6-month followup 68 patients remained in the study, of whom 30 (44%) were dry and 24 (35%) were improved. Of the 58 patients who reached the 12-month followup 19 (33%) were dry and 19 (33%) were improved. Considering all patients entered into the study at 6 months 30 (33%) were dry and 24 (27%) were improved. Of the original 90 patients 19 (21%) were dry and 19 (21%) were improved at 12 months. The probability of maintaining initial improvement for 12 months was 44%. The success of bulking agent therapy was not predicted by the initial incontinence grade. Improved continence grade correlated with improved leak point pressure.

CONCLUSIONS

This therapy is appropriate in women with urethral hypermobility who wish to avoid surgical risks and in those in whom surgery is ill advised.

Treatment of intrinsic sphincter deficiency using autologous ear chondrocytes as a bulking agent

Intrinsic sphincter deficiency (ISD) is frequently treated with collagen bulking at the bladder neck. The standard material used, Contigen, biodegrades over 3-19 months requiring repeated injections to maintain efficacy. The study objective was to evaluate use of autologous ear chondrocytes for treatment of ISD. Women with documented ISD had harvest of auricular cartilage. Chondrocytes were isolated from the cartilage and expanded in culture and formulated with calcium alginate to form an injectable gel. Thirty-two patients received a single outpatient injection just distal to the bladder neck. Outcome measures included voiding diary, quality-of-life scores, incontinence severity grading, and pad weight testing. Incontinence grading indicated 16 patients dry, and 10 improved at 12 months for a total of 26 of 32 (81.3%) dry and improved after one treatment. Only four patients had a 12-month pad weight test over 2.2 g. Quality-of-life scores improved significantly after treatment. There was a decrease in incontinence impact scores in all categories. The urogenital distress inventory declined for all categories except bladder emptying and lower abdominal pain. Endoscopic treatment of ISD with autologous chondrocytes is safe, effective, and durable with 50 % of patients dry 12 months after one injection. Twenty-six of 32 patients dry or improved at 3 months after the injection maintained the effect at the 12-month visit.

Treatment of intrinsic sphincter deficiency using autologous ear chondrocytes as a bulking agent

Intrinsic sphincter deficiency (ISD) is frequently treated with collagen bulking at the bladder neck. The standard material used, Contigen, biodegrades over 3-19 months requiring repeated injections to maintain efficacy. The study objective was to evaluate use of autologous ear chondrocytes for treatment of ISD. Women with documented ISD had harvest of auricular cartilage. Chondrocytes were isolated from the cartilage and expanded in culture and formulated with calcium alginate to form an injectable gel. Thirty-two patients received a single outpatient injection just distal to the bladder neck. Outcome measures included voiding diary, quality-of-life scores, incontinence severity grading, and pad weight testing. Incontinence grading indicated 16 patients dry, and 10 improved at 12 months for a total of 26 of 32 (81.3%) dry and improved after one treatment. Only four patients had a 12-month pad weight test over 2.2 g. Quality-of-life scores improved significantly after treatment. There was a decrease in incontinence impact scores in all categories. The urogenital distress inventory declined for all categories except bladder emptying and lower abdominal pain. Endoscopic treatment of ISD with autologous chondrocytes is safe, effective, and durable with 50 % of patients dry 12 months after one injection. Twenty-six of 32 patients dry or improved at 3 months after the injection maintained the effect at the 12-month visit.

Uterosacral ligament: description of anatomic relationships to optimize surgical safety

OBJECTIVE

To determine the optimal site in the uterosacral ligament for suspension of the vaginal vault with regard to adjacent anatomy and suspension strength.

METHODS

Fifteen female cadavers were evaluated between December 1998 and September 1999. Eleven hemisected pelves were dissected to better define the uterosacral ligament and identify adjacent anatomy. Ureteral pressure profiles with and without relaxing incisions were done on four fresh specimens. Suture pullout strengths also were assessed in the uterosacral ligament.

RESULTS

The uterosacral ligament was attached broadly to the first, second, and third sacral vertebrae, and variably to the fourth sacral vertebrae. The intermediate portion of the uterosacral ligament had fewer vital, subjacent structures. The mean +/- standard deviation distance from ureter to uterosacral ligament was 0.9 +/- 0.4, 2.3 +/- 0.9, and 4.1 +/- 0.6 cm in the cervical, intermediate, and sacral portions of the uterosacral ligament, respectively. The distance from the ischial spine to the ureter was 4.9 +/- 2.0 cm. The ischial spine was consistently beneath the intermediate portion but variable in location beneath the breadth of the ligament. Uterosacral ligament tension was transmitted to the ureter, most notably near the cervix. The cervical and intermediate portions of the uterosacral ligament supported more than 17 kg of weight before failure.

CONCLUSION

Our findings suggest that the optimal site for fixation is the intermediate portion of the uterosacral ligament, 1 cm posterior to its most anterior palpable margin, with the ligament on tension.

Supine empty stress test as a predictor of low valsalva leak point pressure

Our objective was to determine whether a positive supine empty stress test is predictive of a low Valsalva leak point pressure (< or =60 cm of water). Evaluation was carried out on 179 patients with a history of genuine stress incontinence confirmed with urodynamic testing. All patients had a supine stress test performed after voiding. Residual urine determinations were all <100 cc. A vesical Valsalva leak point pressure determination (cough and strain) was performed during multichannel urodynamics with 150 cc in the bladder. Urethral profilometry was performed at maximum capacity. There was a statistically significant relationship between a low leak point pressure and a positive supine empty stress test (P < 0.000). The supine empty stress test had a sensitivity of 79% and a specificity of 62.5% for the detection of a low leak point pressure. The negative predictive value was high at 90%. For the age group 50 years and younger the negative predictive value was 95%. However, there was no significant relationship between a positive supine empty stress test and a low maximal urethral closure pressure. We conclude that the supine empty stress test is a useful screening test for a low leak point pressure but not a low urethral closure pressure. Its high negative predictive value is useful in excluding the presence of a low leak point pressure and may help the clinician to determine which patients with genuine stress incontinence need further assessment of the dynamic function of the urethral sphincter.

Leak-point pressure: clinical application of values at two different volumes

A prospective analysis of 306 consecutive patients with genuine stress incontinence was performed to evaluate the clinical usefulness of additional leak-point pressure (LPP) determination at 200 ml. LPP values at both volumes were compared to maximal urethral closure pressure (MUCP) in an attempt to determine a critical cut-off value for the detection of a low MUCP (< or =20 cmH2O). A positive LPP at 150 ml was found in 157 patients. The mean LPP for patients with a low MUCP was 58.5 cmH2O compared to 71.6 for those with a normal MUCP, which was statistically significant (p = 0.01). The correlation coefficient between LPP and MUCP was 0.317. A negative LPP was found in 30% (24/79) of the total having a low MUCP. The addition of values for LPP at 200 ml resulted in an increase in the number who leaked to 191, a 50% increase in the detection rate of low MUCP and a statistically significant relationship between LPP < or =60 cmH2O and low MUCP. Various critical cut-off values for LPP demonstrated good specificity but poor sensitivity for the detection of a low MUCP. It was concluded that there was a statistically significant relationship between LPP and MUCP. Performing LPP at 200 ml provides additional clinically useful diagnostic information.

Randomized trial of antibiotic prophylaxis for combined urodynamics and cystourethroscopy

OBJECTIVE

To determine the efficacy of prophylactic nitrofurantoin in preventing bacteriuria after urodynamics and cystourethroscopy.

METHODS

We assumed that nitrofurantoin prophylaxis would decrease the rate of infection after urodynamics and cystourethroscopy from 19% to 5%. All women presenting for urodynamics and cystourethroscopy during a 27-month period were offered enrollment, and 142 were randomly assigned to receive two doses of long-acting nitrofurantoin 100 mg (n = 74), or two doses of placebo (n = 68). Nitrofurantoin and placebo capsules were identical, and subjects and physicians were masked to group assignment. Differences were assessed using Student t test for continuous data and chi2 analysis for dichotomous data.

RESULTS

There were no statistical differences in demographic characteristics or final diagnoses between groups. Seven women (5%) who had bacteriuria on initial urine culture were not included in the final analysis. The frequency of bacteriuria in the postinstrumentation urine cultures was 6% overall, 7% in the treatment group, and 5% in the controls, a nonsignificant difference ([relative risk] 1.49, [confidence interval] 0.37, 5.95). The power of the study was 33% to detect a significant difference.

CONCLUSION

Bacteriuria after combined urodynamics and cystourethroscopy was not improved by a 1-day course of nitrofurantoin.

Surgical management of urinary incontinence

Surgery for stress incontinence is selected according to specific problems in each patient. Patients with ISD can be identified and selected for sling surgery or collagen injection therapy. Other patients may be managed successfully by retropubic urethropexy, either open or laparoscopic. Diagnostic evaluation should be thoughtful and extensive, with good correlation of findings and presenting symptoms to apply therapy in a specific manner to each patient.

Suburethral abscess: a complication of periurethral collagen injection therapy

BACKGROUND

Urinary tract infection after collagen injection is well documented. Other adverse reactions are rare.

CASES

Three women experienced suburethral abscess after repeat periurethral injections. All patients received local skin preparation and postprocedural antibiotics. Symptoms failed to resolve with antibiotics. The first two patients presented after 5 weeks and 10 days with irritative voiding symptoms and a tender suburethral swelling. The first patient was treated with excision. Spontaneous rupture into the urethra occurred with the second. The third woman presented with acute urinary retention at 102 days. A large suburethral mass was drained successfully in the office.

CONCLUSION

Suburethral abscess may be a delayed complication of periurethral collagen injections, not preventable by postprocedural antibiotics. Drainage is required.

Clinical and urodynamic predictors of delayed voiding after fascia lata suburethral sling

OBJECTIVE

To determine the time to resumption of normal voiding after a fascia lata sling and whether any clinical, operative, or urodynamic variables predict it.

METHODS

Between January 1993 and September 1996, 62 women underwent fascia lata suburethral sling operations for intrinsic sphincter deficiency or recurrent stress incontinence. The demographic, operative, and urodynamic data of 61 of these patients were analyzed.

RESULTS

The mean number of days to resumption of normal voiding was ten. Three patients (5%) developed permanent retention. Patients 65 years and older were more likely than younger patients to have prolonged catheterization (16 versus 7 days, P=.008). Women who had additional procedures voided at a mean of 15 days compared to nine days for those having slings only (P=.029). A preoperative urine flow rate less than 20 mL/sec was associated with late voiding. There was no significant relationship between preoperative voiding mechanism and voiding time.

CONCLUSION

Resumption of normal voiding occurred earlier than reported by others. Age over 65 years, additional surgical procedures, and low peak flow rates were risk factors for delayed voiding. Time to normal voiding was independent of the preoperative voiding mechanism.

Fascia lata suburethral sling vs. Burch retropubic urethropexy. A comparison of morbidity

OBJECTIVE

To compare morbidity from the fascia lata sling to that from the Burch procedure.

STUDY DESIGN

The charts of 64 consecutive patients undergoing the two procedures were reviewed for perioperative, immediate postoperative and delayed postoperative complications.

RESULTS

Mean age was significantly older and prior surgery more common in the sling group, but parity and weight were comparable for the two groups. Operative time, estimated blood loss, change in hematocrit, incidence of transfusion, use of narcotics and hospital stay were not statistically different. Duration of catheter use was 2.2 days longer in the sling group (8.96 vs. 6.75 days, P = .387). Comparison of the sling vs. Burch, respectively, showed persistent urge incontinence in 42.8% and 40.0%, new urge incontinence in 22.2% and 16.6%, and cystotomy in 11% and 0%.

CONCLUSION

The fascia lata sling procedure has morbidity comparable to that of Burch retropubic urethropexy. Urge incontinence needs to be specifically addressed preoperatively in both groups of patients.

Portable ultrasound determination of urinary residual volume

A portable ultrasound to determine bladder volume, the BladderScan 2500, was compared to transurethral catheterization in 72 women. Most measurements were made after voiding. Volumes measured by catheterization were 17 ml greater than those measured by ultrasound, which was not clinically significant. The BladderScan technique does not carry the risk of urinary tract infection or patient trauma, and patient dignity is preserved, while accurately determining urinary volume.

Sling incision with associated vaginal wall interposition for obstructed voiding secondary to suburethral sling procedure

Obstructed voiding is a well recognized complication following a suburethral sling procedure. Current methods of transvaginal and transabdominal urethrolysis have had variable success rates in relieving the obstruction, and do not restabilize the urethra to prevent potential postoperative stress incontinence. We report on a procedure used in 4 cases which addresses both of these issues. All patients had persistent urinary retention beyond 8 weeks after a suburethral sling procedure. An oupatient procedure consisting of sling incision and associated tissue interposition (vaginal wall in three cases and fascia lata in one) was successful in relieving the obstruction. Continence status was maintained in 3 of the 4 patients. There were no major complications of this outpatient procedure.

The contribution of urethrocystoscopy to evaluation of lower urinary tract dysfunction in women

The aim of this study was to determine whether the evaluation of lower urinary dysfunction with urodynamics and urethrocystoscopy provides unique information that is missed by urodynamics alone. Eighty-four women underwent multichannel urodynamics and urethrocystoscopy. Retrospective analysis included evaluation of the relationships between lower urinary tract lesions and risk factors using chi2 and Fisher's exact tests. Urethrocystoscopic findings changed the diagnosis and management in 6 patients. New urethrocystoscopic findings included papillary transitional-cell carcinoma, cystitis glandularis, an intravesical suture and a urethral diverticulum. Clinical parameters were not predictive of these findings. Urethrocystoscopic findings also contributed to the final diagnosis in 10 patients with intrinsic sphincter deficiency. Considered alone, maximum urethral closure pressure < or =20 cmH2O had a sensitivity of only 20% and a positive predictive value of 40% for this diagnosis. Urodynamics without urethrocystoscopy would have missed important diagnoses in 19% of women. Urethrocystoscopy and urodynamics complement one another, and both have a role in the evaluation of women with lower urinary tract dysfunction.

Evaluation of pressure transmission ratios in women with genuine stress incontinence and low urethral pressure: a comparative study

OBJECTIVE

To determine whether women with genuine stress incontinence and low urethral closure pressure (20 cm H2O or lower) had more severely impaired pressure transmission to the urethra than women with stress incontinence and normal urethral pressures.

METHODS

Seventy-six women who underwent multichannel urodynamic testing were included for comparative analysis. They were classified into the following groups: genuine stress incontinence with low urethral pressure (N = 20), genuine stress incontinence without low urethral pressure (N = 32), and continent controls (N = 24). Urodynamic indices and pressure transmission ratios were calculated from static and stress urethral pressure profiles, respectively. Multiple demographic cofactors, urethral mobility, and previous surgeries were correlated for associations with urodynamic results.

RESULTS

Women with stress incontinence and low urethral pressure were significantly older (57.6 years, P < .0071). There were no differences with regard to urethral mobility and previous surgeries. Mean maximum urethral closure pressure and the distance from the proximal margin of the urethra to the point of maximum urethral closure pressure were statistically less in women with low urethral pressure. There were no differences in pressure transmission ratios between any of the study groups.

CONCLUSION

Because there are no differences in pressure transmission ratios between women with genuine stress incontinence with and without low urethral closure pressure, the higher risk for surgical failure with low urethral pressure appears to result from another pathophysiologic process.

Tissue reaction to expanded polytetrafluoroethylene suburethral sling for urinary incontinence: clinical and histologic study

OBJECTIVE

The use of expanded polytetrafluoroethylene suburethral sling for recurrent urinary incontinence has shown an excellent cure rate but a number of complications. This study was designed to evaluate patients who had tissue reaction or removal of the sling, to determine potential causes, clinical course, and eventual outcome.

STUDY DESIGN

A retrospective review of consecutive charts was completed for 115 patients who had suburethral sling surgery with expanded polytetrafluoroethylene. Patients having tissue reaction or removal of sling material were identified, and eight removed sling specimens were analyzed histologically with Milligan's trichrome, hematoxylin and eosin, fibrin, Brown-Brenn bacteria, and Dahl's calcium stains.

RESULTS

Twenty-four patients had reactions to the sling material, and 23 slings were eventually removed. Seventeen of 23 patients having sling removal remained continent. Histologic evaluations revealed gram-positive cocci in all expanded polytetrafluoroethylene patch interstices. Fibrous tissue, fibroblasts, and collagen were present in one half of specimens.

CONCLUSION

There is a 23% reaction or removal rate for expanded polytetrafluoroethylene suburethral sling procedures. Seventeen of 23 patients remained continent in spite of sling removal. Histologic studies showed gram-positive cocci in the patch interstices, although prophylactic antibiotic coverage did not prevent infection and cultures from the vaginal or abdominal reaction sites did not reveal a significant growth of organisms. Patients need to be aware of the high complication rate for this suburethral sling procedure, and physicians need to work further to modify sling materials and techniques to reduce complications.

Urinary incontinence: correlation of history and brief office evaluation with multichannel urodynamic testing

OBJECTIVE

Patients' histories of urinary incontinence and the results of several standard clinical tests were correlated with final diagnoses obtained by multichannel urodynamic testing. We used a combination of clinical test results to predict the final diagnoses.

STUDY DESIGN

Ninety consecutive women with a primary complaint of urinary incontinence completed a standardized questionnaire and underwent a structured clinical examination consisting of several standard clinical tests. Each patient later underwent multichannel urodynamic testing to obtain a final diagnosis.

RESULTS

Although the symptoms of stress incontinence were significantly associated with genuine stress incontinence and mixed incontinence, overlap in patients with detrusor instability did not allow the histories to be useful diagnostically. The only clinical tests showing significant association with the final diagnoses of incontinence were the cough stress test and single-channel medium-fill cystometry. Reliable prediction of the urodynamic diagnosis of incontinence could not be achieved with either of these two tests or with a combination of variables obtained by discriminant analysis.

CONCLUSIONS

Women with complaints of urinary incontinence, especially those for whom surgery is contemplated, should undergo complete urodynamic evaluation when it is available.

Massive evisceration: a complication following sacrospinous vaginal vault fixation

This report describes a spontaneous vaginal vault prolapse in association with massive evisceration following sacrospinous vaginal vault fixation. Careful attention to surgical technique is critical to the success of the operation. In particular, good apposition of the vaginal vault to the sacrospinous ligament and adequate repair of an enterocele should avoid this complication.

Stress incontinence and low urethral closure pressure. Correlation of preoperative urethral hypermobility with successful suburethral sling procedures

Forty-eight women with genuine stress incontinence and low urethral closure pressure were treated with a suburethral sling procedure using polytetrafluoroethylene. All patients underwent a preoperative clinical evaluation and multichannel urodynamic testing. The clinical examination included a "Q-tip" test to determine the presence or absence of urethral hypermobility. Urethral hypermobility was defined as a maximal angle change of greater than or equal to 30 degrees from the horizontal, measured during straining or coughing in the lithotomy position. Thirty-four patients underwent repeat multichannel urodynamic testing three months postoperatively to determine the objective surgical success. Ninety-three percent of patients (27/29) with a positive preoperative Q-tip test were cured. Of patients with a negative preoperative Q-tip test, only 20% (1/5) were cured. Preoperative urethral hypermobility was a good prognostic indicator of operative success when a suburethral sling procedure was used to treat genuine stress incontinence and low urethral closure pressure.

Genital prolapse with and without urinary incontinence

Procidentia, vaginal vault prolapse and severe cystocele may be associated with potential urinary incontinence, which becomes overt only after surgical repair of the genital prolapse. The normal support of the pelvic organs is provided by the pelvic diaphragm (levator ani and coccygeus muscles). The levator plate is a firm, muscular plate between the coccyx and anus formed by fusion of the levator ani muscles on each side. Recent investigators have indicated that the main mechanism for weakening the pelvic muscles occurs as a result of childbearing, when stretch injury of the pudendal nerve causes denervation of the muscles. This injury is aggravated with the changes of aging and has effects on anogenital prolapse and stress incontinence. There may be iatrogenic causes of both prolapse and stress incontinence when an operation produces a change in the direction of tissue forces or removes a prior barrier to incontinence. The evaluation of patients must include the actual and potential aspects of genital prolapse and incontinence. Testing for stress incontinence must be performed before and after reduction of the genital prolapse. Surgical repair should be planned carefully to correct all the significant and potential defects in the urogenital tract. Ideally a normal vaginal axis with adequate length will be restored, and urinary function will not be compromised.

Endometrial ablation with the neodymium:Yag laser

The current study was designed to evaluate Nd:Yag laser endometrial ablation as an alternative to hysterectomy in women with uncontrolled benign uterine bleeding. The subjects were candidates for hysterectomy, had benign endometrial histology, had failed hormonal therapy and/or D&C, and did not desire future childbearing. Medication was given to render the endometrium atrophic, and treatment was carried out using a "touch" technique. Forty-two treated patients have been followed 3-36 months, with a success rate of 81%. Fourteen (33%) are amenorrheic and 13 (31%) estimate that they have less than 25% of their pretreatment flow. Those with uterine size over 10 cm or large submucous fibroids were usually excluded because of technical difficulty in performing the procedure. Treatment outcome was not related to patient weight, uterine size, or small intrauterine abnormalities. Twelve patients had medical conditions that were relative contraindications for hysterectomy, and 11 were treated successfully. Endometrial ablation with the Nd:Yag laser is an effective alternative to hysterectomy in patients with uncontrolled benign uterine bleeding.

Management of recurrent genuine stress incontinence

Recurrent stress incontinence is frequently a result of incomplete preoperative evaluation. Evaluation of surgical failures must include an assessment of urethral sphincter function by endoscopy, UCPP, or video-urodynamics. Patients with GSI and a mobile urethovesical junction and normal urethral closure pressure should be corrected by a Burch sling or MMK. Patients with low urethral closure pressure and normal or borderline UVJ mobility should have a suburethral sling procedure. Patients with a nonfunctioning urethral sphincter respond best to an artificial urinary sphincter.

Prospective study utilizing transdermal scopolamine in detrusor instability

Ten patients with pure detrusor instability were treated in a prospective fashion with transdermal scopolamine. Seventy percent of patients experienced moderate to severe untoward symptoms requiring discontinuation of medication. Three of 10 patients (30%) demonstrated a subjective improvement although only 1 was able to tolerate the medication. No objective change in detrusor instability was demonstrated.

Etiology and management of detrusor instability and mixed incontinence

The cause of detrusor instability and mixed incontinence remains elusive. Although DI is most prevalent at the extremes of age, GSI becomes more common with aging and child bearing, and therefore mixed incontinence is common, especially after menopause. Cystometry is used to diagnosis detrusor instability, but urethral closure pressure profilometry is required for assessment of mixed incontinence. DI is managed initially by behavioral therapy, and if this is not satisfactory then FES should be used depending upon availability. Drug therapy should start with oxybutynin at 2.5 to 5 mg twice-daily and increased as necessary to control symptoms. If the effects of therapy are minimal or side effects are too great, other medications or medication combinations should be tried. When the patient does not respond to this level of therapy, transvesical phenol injections should be considered, or, alternatively, a sacral selective neurolysis or neurectomy should be considered. Finally, invasive procedures will have to be considered starting with bladder transection, especially for the patient showing response to medication but intolerant of side effects. Mixed incontinence should be approached with conservative measures for each component. FES or imipramine therapy may help both conditions. If conservative therapy is not beneficial, surgical correction for GSI should be undertaken, with the knowledge that 35 to 50 per cent of patients will also have cure of DI, while the remainder can be treated medically for the DI.

Recurrent stress incontinence. Causes and treatment in the female patient

Recurrent urinary incontinence after surgery requires complete evaluation, including urodynamic testing, to make an accurate diagnosis. Documented genuine stress incontinence, if mild to moderate, may respond to nonsurgical treatment, but more severe cases require surgery. Numerous effective surgical procedures have been developed.

A suburethral sling procedure with polytetrafluoroethylene for the treatment of genuine stress incontinence in patients with low urethral closure pressure

One indication for suburethral sling procedures has been recurrent genuine stress incontinence after previous incontinence surgery. Patients with low urethral closure pressures (20 cm H2O or less) in association with genuine stress incontinence are at particular risk for failure of standard anti-incontinence procedures. Urodynamic evaluation was used to select 17 patients with genuine stress incontinence and low urethral closure pressures for surgical treatment with a sling procedure using polytetrafluoroethylene. The technique of the procedure, cure rate, and postoperative complications were assessed. An 85% subjective and objective cure rate was found on urodynamic testing three months postoperatively. Complications included wound seroma, urinary tract infection, and urinary retention.

Serum gonadotropin and ovarian steroid levels in women during administration of a norethindrone-ethinylestradiol triphasic oral contraceptive

We studied the inhibitory effect of a triphasic oral contraceptive (OC) regimen on the pituitary and ovarian function in 29 normal, healthy women. ORTHO* 7/7/7 Tablets contain a constant low dose of ethinylestradiol (EE) and a step-wise increasing level of norethindrone (NE). The pills for the first, middle and last weeks of the 21-day regimen contained, respectively, 0.5, 0.75, and 1.00 mg NE, and all contained 0.035 mg EE. The subjects were divided into 3 groups on the basis of their histories of OC use. Ten had not taken an OC in the previous 2 months, 10 were switched to this study from a fixed-dosage combination OC containing 0.050 mg estrogen, and 9 had been taking ORTHO 7/7/7 Tablets for 5 or more cycles. Serum levels of FSH, LH, estradiol and progesterone were measured and statistically compared with those from 5 normal, untreated women. The results from all study cycles showed that the four hormone profiles were significantly suppressed as compared to the normal patterns. Thus, one mode of action of this new triphasic OC is to inhibit ovulation by suppression of pituitary-ovarian function. This OC treatment appeared to be equally effective among women with varying prior histories of OC therapy.

Delayed reaction to the Dacron buttress used in urethropexy

Eleven patients developed a delayed reaction to the Dacron buttress used in Stamey urethropexy. The reaction was characterized by pain, dyspareunia, vaginal discharge and/or bleeding, induration of the abdominal incision, vaginal granulation tissue and draining abdominal or vaginal sinus tracts. This complication occurred in 5% of the 163 patients we treated with the Stamey procedure for stress urinary incontinence. Treatment consisted of removal of the nylon suture and Dacron buttress. None of the 11 patients developed recurrent incontinence. The subjective cure rate for stress urinary incontinence was 92% using the Stamey procedure.

The effect of uterovaginal prolapse on urethrovesical pressure dynamics

Complete urodynamic evaluations were performed on patients with severe uterovaginal prolapse with the prolapse protruding and after reduction with a pessary. These results were compared with those from patients with genuine stress incontinence without prolapse. There was a significant increase in urethral closure pressure in patients with prolapse on the assumption of a more erect posture or on Valsalva maneuver. The opposite relationship was observed in patients with genuine stress incontinence in whom the urethral closure pressure significantly decreased under similar conditions. These results strongly suggest that the mechanism of continence in patients with significant prolapse is urethral obstruction. Reduction of the prolapse with a pessary can differentiate those patients who will require urethrovesical neck suspension.

Diagnosis of lower urinary tract disorders in postmenopausal patients

One hundred patients over age 60 who had lower urinary tract symptoms were evaluated in detail. The five primary diagnoses were urethral syndrome (29%), genuine stress incontinence (21%), unstable bladder (19%), hypoestrogenism (7%), and pelvic relaxation (6%). Among patients with genuine stress incontinence, 95.2% had the symptom of stress incontinence. Of 43 patients with the symptom of stress incontinence, 67.4% had the diagnosis of genuine stress incontinence confirmed on urodynamic testing. Of the patients with an unstable bladder, 88.9% had urgency and/or urge incontinence; but of 40 patients with both of these symptoms, only 40% had the diagnosis of unstable bladder. Sixty-two patients who complained of urinary incontinence had the following primary diagnoses: genuine stress incontinence (36%), unstable bladder (29%), urethral syndrome (21%), and pelvic relaxation (5%). Because of the impossibility of clinically correlating symptom with diagnosis in the individual patient, extensive evaluation of postmenopausal patients to determine the etiology of incontinence is advised prior to surgical intervention.

Assessment of fetal lung maturity: relationship of gestational age and pregnancy complications to phosphatidylglycerol levels

Phosphatidylglycerol (PG) was measured in the pellet fraction of 863 amniotic fluid samples, and charts were reviewed for maternal disease, duration of gestation at collection, and outcome of pregnancy. PG was present at 32 to 34 weeks' gestation in 24.1% of samples; at 35 to 36 weeks, in 52.3%; and at 37 weeks, in 85.4%. Pre-eclamptic toxemia/hypertension, diabetes, premature rupture of membranes, and preterm labor all had earlier appearance of PG than a comparison group. There was no delay in lung maturity in gestational diabetics or Rh isoimmunization. Infants of patients with overt diabetes with PG greater than or equal to 0.5% did not develop respiratory distress syndrome. This value appeared in 30% of diabetic patients by 35 to 36 weeks and in 76.9% by 37 weeks' gestation.

Phosphatidylglycerol determination on amniotic fluid 10,000 x g pellet in the prediction of fetal lung maturity

Phosphatidylglycerol and the lecithin/sphingomyelin (L/S) ratio were determined, and the shake test was performed, as indicators of fetal lung maturity, in more than 600 patients. A clinical review of the outcome was made in all patients who underwent delivery within 2 days after collection of amniotic fluid. Correlation was made phosphatidylglycerol, shake test, and L/S ratio results. L/S ratio had a false positive rate of 5%, and a false negative rate of 58.1%. The shake test had a false positive rate of 1.1%, and a false negative rate of 63.5%. Phosphatidylglycerol determination had a false positive rate of 1.8%, and a false negative rate of 26.9%. Phosphatidylglycerol determination is an accurate predictor of fetal lung maturity, and predicts lung immaturity more correctly than do the L/S ratio and shake test.