Urinary incontinence in women: non-pharmacologic approaches and newer pharmacotherapies

Stress urinary incontinence (SUI) is a common and bothersome problem for women. Sling surgery is the mainstay of surgical treatment of SUI. A review of PubMed literature using the following keywords was performed: stress urinary incontinence, women, sling, midurethral sling, mini-sling, outcomes, and complications. Literature within the last 10 years, systematic reviews, and meta-analyses were given preference. Slings placed at the bladder neck and the midurethra each corrects a particular anatomic weakness, as described in the "hammock hypothesis" and the "integral theory," respectively. At present, the literature suggests that the autologous bladder neck sling (BNS) and retropubic midurethral sling (MUS) have similar success rates, while the retropubic MUS appears to be more successful than the transobturator approach. The literature supporting single-incision mini-sling (SIMS) is still in the early stages and data to support its use over another MUS is absent. Each approach is associated with unique complications and adverse outcomes. While both BNS and MUS are effective in improving SUI in women, the ultimate choice of material and approach should be based both on surgeon experience and patient preference. Detailed informed consent discussion prior to any sling surgery cannot be overemphasized.

Clinical safety, tolerability and efficacy of combination tolterodine/pilocarpine in patients with overactive bladder

AIMS

The purpose of this study was to assess the safety, tolerability and impact on overactive bladder (OAB) symptoms of a novel combination of tolterodine immediate-release (IR) 2 mg and delayed-release pilocarpine 9 mg in patients with OAB.

METHODS

Eligible patients with OAB were randomised to each of three treatments [tolterodine/pilocarpine (2/9 mg), tolterodine IR 2 mg or placebo] twice daily for 4 weeks in a double-blind, crossover fashion. At the end of the 12-week, double-blind treatment period, patients could enter an open-label extension during which they were re-randomised to either tolterodine/pilocarpine (3/13.5 mg) twice daily or tolterodine extended-release 4 mg once daily for 12 weeks.

RESULTS

A total of 138 patients were randomised to double-blind medication. Both tolterodine/pilocarpine (2/9) and tolterodine IR 2 mg significantly reduced incontinence episodes and daily micturitions (p < 0.001 vs. placebo), with similar reductions in symptoms observed between active treatment groups. Tolterodine/pilocarpine (2/9) was associated with consistently lower Visual Analogue Scale (VAS) scores for all dry mouth parameters compared with tolterodine alone. Salivary flow over a 3 h period remained fairly constant after tolterodine/pilocarpine (2/9) administration, similar to placebo, but decreased markedly after administration of tolterodine alone. In the extension study, patients receiving tolterodine/pilocarpine (3/13.5) reported comparable dry mouth VAS scores to tolterodine extended-release alone without additional side effects or loss of efficacy. The combination was well tolerated, and the adverse effects observed were consistent with the known safety profiles of tolterodine and pilocarpine.

CONCLUSIONS

A combination of tolterodine/pilocarpine (2/9) effectively reduced the incidence of dry mouth compared with tolterodine IR alone while maintaining treatment efficacy in OAB.

Persistence and adherence in the treatment of overactive bladder syndrome with anticholinergic therapy: a systematic review of the literature

Overactive bladder syndrome (OAB) is a chronic condition that has an impact on patients' daily activities and health-related quality of life (HRQL). Anticholinergic therapy is often prescribed following insufficient results with behaviour modification alone; however, rates of treatment discontinuation are consistently high. This study systematically reviewed persistence and adherence data in patients with OAB treated with anticholinergic therapy. A search focused on the intersection of OAB, persistence/adherence, and anticholinergic therapy was conducted in MEDLINE and EMBASE. Articles published after 1998 were reviewed and selected for inclusion based on prespecified criteria. A total of 147 articles and two abstracts were included in the review. Results from 12-week clinical trials showed high rates of discontinuation, ranging from 4% to 31% and 5% to 20% in treatment and placebo groups, respectively. Unsurprisingly, rates of discontinuation found in medical claims studies were substantially higher, with 43% to 83% of patients discontinuing medication within the first 30 days and rates continuing to rise over time. Findings from medical claims studies also suggest that over half of patients never refill their initial prescription and that adherence levels tend to be low, with mean/median medication possession ratio (MPR) values ranging from 0.30 to 0.83. The low levels of persistence and adherence documented in this review reveal cause for concern about the balance between the efficacy and tolerability of anticholinergic agents. Strategies should be identified to increase persistence and adherence. New agents and non-pharmacologic alternatives with good efficacy and minimal side effects should be explored.

Trospium chloride once-daily extended release is effective and well tolerated for the treatment of overactive bladder syndrome: an integrated analysis of two randomised, phase III trials

BACKGROUND

Trospium chloride is an antimuscarinic agent with a hydrophilic polar quaternary amine structure that is minimally metabolised by hepatic cytochrome P450 and is actively excreted in the urine, each of which confers a potential benefit with regard to efficacy and tolerability.

PURPOSE

We analysed pooled data from two identically designed phase III trials of a once-daily, extended-release (XR) formulation of trospium chloride (trospium XR 60-mg capsules) in subjects with overactive bladder syndrome (OAB).

METHODS

Adults with OAB of > or = 6 months' duration with urinary urgency, frequency and > or = 1 urge urinary incontinence (UUI) episode/day were enrolled in these multicentre, parallel-group, double-blind trials. Participants were randomised (1 : 1) to receive trospium XR 60 mg or placebo for 12 weeks. Primary efficacy variables were changes in urinary frequency and the number of UUI episodes/day. Adverse events (AEs) were recorded throughout.

RESULTS

In total, 1165 subjects were randomised (trospium XR, 578; placebo, 587). At baseline, subjects averaged 12.8 toilet voids/day and 4.1 UUI episodes/day. Compared with placebo, subjects treated with trospium XR had significantly greater reductions from baseline in the mean number of toilet voids/day (-1.9 vs. -2.7; p < 0.001) and UUI episodes/day (-1.8 vs. -2.4; p < 0.001) at week 12. The most frequent AEs considered possibly related to study treatment were dry mouth (trospium XR, 10.7%; placebo, 3.7%) and constipation (trospium XR, 8.5%; placebo, 1.5%). Notably, rates of central nervous system (CNS) AEs were lower with trospium XR vs. placebo (dizziness: 0.2% vs. 1.0%; headache: 1.4% vs. 2.4%).

CONCLUSIONS

Treatment with trospium XR resulted in statistically significant improvements in both of the dual primary and all of the secondary outcome variables. Trospium XR demonstrated favourable rates of AEs, particularly CNS AEs (numerically lower than with placebo) and dry mouth (lower than previously reported with trospium immediate-release, although not compared in a head-to-head study).

Multicenter prospective randomized 52-week trial of calcium hydroxylapatite versus bovine dermal collagen for treatment of stress urinary incontinence

OBJECTIVES

To evaluate the safety and effectiveness of soft-tissue augmentation of the urethral sphincter with calcium hydroxylapatite (CaHA; Coaptite) compared with glutaraldehyde cross-linked bovine collagen (Contigen) in female patients with stress urinary incontinence due to intrinsic sphincter deficiency and without associated urethral hypermobility.

METHODS

This 12-month prospective, randomized, comparative, multicenter, single-blind, parallel, clinical trial of CaHA and collagen for soft-tissue augmentation of the urethral sphincter in the treatment of stress urinary incontinence enrolled 296 women. Up to five injections were performed in the first 6 months of the trial. Twelve-month postinjection efficacy data were available for 231 patients.

RESULTS

The results indicated that CaHA and collagen were both well tolerated in this study. No systemic adverse events were observed with either product. We used the Stamey Urinary Incontinence Scale to grade the improvement, which was the primary endpoint of the study. At 12 months, 83 (63.4%) of 131 CaHA patients compared with 57 (57.0%) of 100 collagen patients showed improvement of one Stamey grade or more (P = 0.34). More CaHA patients required only one injection (n = 60; 38.0%) during the study compared with the Contigen patients (n = 36; 26.1%; P = 0.034). Also, the average total volume of material injected during the course of the study was less for CaHA than for collagen (4.0 mL versus 6.6 mL, respectively; P <0.0001).

CONCLUSIONS

The results of the study have demonstrated that Coaptite is an appropriate and well-tolerated treatment for patients with incontinence due to intrinsic sphincter deficiency. This new soft-tissue augmentation material has a good safety profile and appears to provide durable improvement.

Delivery of injectable agents for treatment of stress urinary incontinence in women: evolving techniques

PURPOSE

Periurethral bulking agents continue to be used as a minimally invasive alternative for management of stress urinary incontinence in men and women. Agents and delivery techniques will be evaluated and compared.

MATERIALS AND METHODS

The only agents currently approved by the United States Food and Drug Administration (FDA) include glutaraldehyde cross-linked collagen, autologous fat, and carbon bead/carrier gel technology. Several other agents are undergoing FDA trial evaluation. These agents differ in material characteristics (particle size, viscosity) that, in some cases, produce different immediate and delayed tissue responses or reactions.

RESULTS

Initial subjective cure rates with collagen are acceptable, but the majority of women require reinjection. The risk of allergic phenomena complicates collagen use. Carbon-based material appears to parallel collagen in durability, with the significant advantage of a nonimmunogenic response within host tissues. Autologous fat injection achieves early results similar to those with collagen, but is limited by resorption and fibrous replacement as well as local discomfort associated with harvesting procedures. Experience with newer agents is limited. Patient characteristics also influence response to injectable agents.

CONCLUSIONS

Injectable agent materials and delivery techniques continue to evolve. The optimal material is yet to be defined.

Inducible nitric oxide synthase in the bladder of spinal cord injured patients with a chronic indwelling urinary catheter

PURPOSE

Spinal cord injured patients are at increased risk for bladder carcinoma. Nitric oxide production in areas of chronic inflammation may provide a stimulus for carcinogenesis by serving as a source of nitrosating agents that generate potentially carcinogenic nitrosamines from secondary amines normally present in urine.

MATERIALS AND METHODS

To determine whether inducible nitric oxide synthase is expressed as a catalyst for sustained nitric oxide production by cellular elements in chronically inflamed bladder mucosa immunohistochemical studies were performed on mucosal biopsies obtained from 37 adults with spinal cord injury. All participants had required a chronic indwelling urethral or suprapubic catheter for greater than 8 years.

RESULTS

Histopathological studies revealed active inflammatory infiltrates in all 37 biopsy specimens, squamous metaplasia in 20, epithelial dysplasia in 3 and carcinoma in 1. Inducible nitric oxide synthase was detected in inflammatory cells localized to the lamina propria. Inducible nitric oxide synthase positive cells were identified as macrophages using monoclonal antibodies to macrophage antigen. There was no inducible nitric oxide synthase expression in the urothelial cell layers. Immunostaining for inducible nitric oxide synthase was not detected in bladder mucosal biopsy specimens obtained from cadaveric organ donors.

CONCLUSIONS

Inducible nitric oxide synthase is expressed in inflammatory macrophages in areas of chronic inflammation in the bladder mucosa of spinal cord injured patients with a chronic indwelling bladder catheter. The expression of inducible nitric oxide synthase may potentially lead to the sustained production of nitric oxide and its oxidative products, the nitrosation of urinary amines and the formation of potentially carcinogenic nitrosamines in the bladder.

Neuroanatomy of the female continence complex: clinical implications

OBJECTIVES

Improved understanding of pelvic neuroanatomy in women has led to modified surgical approaches and additional considerations in pelvic surgery. The innervation of the external urinary sphincter and urethra is not well defined in women, and, as such, the continence complex is not well understood.

METHODS

Fourteen pelvic sections from seven fresh female cadavers were dissected to investigate the neuroanatomy of the female continence complex.

RESULTS

Neuroanatomic dissections of the continence mechanism revealed that branches of the pelvic nerve travel beneath the fascia of the levator ani muscle and approach the urinary sphincter in near midline position, posterolateral to the rectum. This pelvic nerve branch passes laterally around the vagina and rectum to enter the sphincter musculature at the 5-o'clock and 7-o'clock positions. The pudendal nerve, traveling in the pudendal canal, gives an intrapelvic branch that courses to the urinary sphincter. At the level of the proximal urinary sphincter, it joins the pelvic nerve branch to the urinary sphincter.

CONCLUSIONS

These neuroanatomic dissections provide a basis for surgical modifications that may address a variety of concerns regarding urinary continence in female surgical patients. With improved understanding of the female continence complex, we may now have a more precise anatomic explanation for the high failure rates associated with transvaginal urethral suspension procedures. Additionally, awareness and preservation of the continence nerves during cystectomy may allow for greater use of orthotopic bladder replacement in women.

The standardization of terminology for researchers in female pelvic floor disorders

The lack of standardized terminology in pelvic floor disorders (pelvic organ prolapse, urinary incontinence, and fecal incontinence) is a major obstacle to performing and interpreting research. The National Institutes of Health convened the Terminology Workshop for Researchers in Female Pelvic Floor Disorders to: (1) agree on standard terms for defining conditions and outcomes; (2) make recommendations for minimum data collection for research; and (3) identify high priority issues for future research. Pelvic organ prolapse was defined by physical examination staging using the International Continence Society system. Stress urinary incontinence was defined by symptoms and testing; 'cure' was defined as no stress incontinence symptoms, negative testing, and no new problems due to intervention. Overactive bladder was defined as urinary frequency and urgency, with and without urge incontinence. Detrusor instability was defined by cystometry. For all urinary symptoms, defining 'improvement' after intervention was identified as a high priority. For fecal incontinence, more research is needed before recommendations can be made. A standard terminology for research on pelvic floor disorders is presented and areas of high priority for future research are identified.

Advancements in pharmacologic management of the overactive bladder

Continued developments in the understanding of lower urinary tract function have led to improvements in the pharmacologic manipulation of bladder dysfunction. Drug delivery changes have produced drugs that provide better efficacy and tolerability, thus improving patient compliance. Improvements in drug delivery systems have altered drug bioavailability and pharmacokinetics. Active current investigation in new agents and delivery systems for intravesical delivery has yielded intriguing early results that may substantially add to the armamentarium for the management of the overactive bladder (urgency, frequency, urge incontinence). New developments in the understanding of the neuropharmacology of the bladder, peripheral pelvic nerves, and sacral cord may provide agents with entirely new drug effects, either as primary agents or agents to be used in combination with currently available drugs. We herein review newer agents and drug delivery systems.

Injectable agents in the treatment of stress urinary incontinence in women: where are we now?

Periurethral bulking agents have been used for decades. The only currently available agents (in the United States) include glutaraldehyde cross-linked collagen, autologous fat, and carbon bead technology. Initial subjective cure rates with collagen are acceptable, but with the majority of women requiring reinjection. The risk of allergic phenomena complicates collagen use. Autologous fat injection is initially effective in >50% of women, but resorption and fibrous replacement hamper the stability of the transplanted graft. Polytetrafluoroethylene and silicone are not currently approved by the US Food and Drug Administration because of particle migration. Materials in development include biologic agents such as allogeneic human collagen and autologous cartilage. Developmental synthetic agents include microballoon technology, hyaluronic acid with or without microsphere technology, hydroxylapatite, and a variety of polymeric technologies. Patient selection and material characteristics influence the optimal choice for injectable agent.

Influences on renal function in chronic spinal cord injured patients

PURPOSE

The optimal method of bladder management in the spinal cord injured population remains controversial. We determined the significance of bladder management and other factors on renal function in this population.

MATERIALS AND METHODS

We retrospectively reviewed the medical records and upper tract imaging studies of 308 patients with a mean followup of 18.7 years since injury. Renal function was assessed by serum creatinine, creatinine clearance and proteinuria measurement, and by upper tract abnormalities on renal ultrasound and nuclear medicine renal scan. Independent variables evaluated for an influence on renal function included patient age, interval since injury, injury level and completeness, vesicoureteral reflux, history of diabetes mellitus and bladder management method.

RESULTS

Mean serum creatinine plus or minus standard deviation in patients on chronic Foley catheterization, clean intermittent catheterization and spontaneous voiding was 1.08 +/- 0.99, 0.84 +/- 0.23 and 0.97 +/- 0.45 mg./dl. (analysis of variance p = 0.05, Student's t test p = 0.10), and mean creatinine clearance was 91.1 +/- 46.5, 113.4 +/- 39.8 and 115 +/- 49 ml. per minute, respectively (analysis of variance and Student's t test p <0.01), respectively. Proteinuria was present in 19 patients (6.2%) in the Foley catheterization, 3 (1%) in the clean intermittent catheterization and 4 (1.3%) in the spontaneous voiding group (chi-square test p <0.01), while there were upper tract abnormalities in 56 (18.2%), 20 (6.5%) and 24 (7.8%) patients, respectively (chi-square test p <0.01). Multiple regression analyses revealed no significant predictors of serum creatinine, although older patient age and Foley catheterization significantly predicted low creatinine clearance. Additional logistic regression analyses showed that Foley catheterization was associated with proteinuria and vesicoureteral reflux was associated with upper tract abnormalities.

CONCLUSIONS

While renal function may be preserved by all forms of bladder management, chronic indwelling catheters may contribute to renal deterioration.

Neuroanatomy of the pelvis: implications for colonic and rectal resection

PURPOSE

Urinary dysfunction remains a common complication of radical pelvic surgery, particularly after abdominoperineal resection. In treating rectal carcinoma, the extent of primary resection and lymphadenectomy are major determinants in the degree of postoperative urologic morbidity.

METHODS

Twelve male and eight female hemipelves from fresh cadavers were dissected with reference to the neuroanatomy of the lower genitourinary tract. These cadavers were dissected within twelve hours of thaw from frozen state. The cadavers were hemisected at the level of the sacral promontory for better exposure of neural trunks and vascular structures leading into the pelvis. These structures were followed down sequentially into the true pelvis, using magnified dissection under operating microscope or loupe dissection or both.

RESULTS

Coordinated lower urinary tract function relies on both autonomic and somatic nerve activity. Emanating from the inferior hypogastric plexus, the pelvic nerve supplies sympathetic and parasympathetic innervation to the pelvic viscera. The course of the pelvic nerve is as follows: 1) from the inferior hypogastric plexus, it has multiple branches forming a web-like complex within the endopelvic fascial sleeve, some of which innervate the bladder detrusor; 2) a main branch traveling inferolateral to the rectum remains deep to the fascia of the levator ani muscle and courses to the external urinary sphincter; 3) at the level of the prostatic apex (or bladder neck in females), this pelvic nerve branch sends direct branches to the urinary sphincter. The pudendal nerve traverses the pelvis in the pudendal canal, and before leaving the pelvis to enter the perineum, it gives an intrapelvic branch that courses alongside the ischium to enter the external urinary sphincter. In the ischiorectal fossa, terminal branches of the pudendal nerve (i. e., perineal nerve) can be seen inserting into the urinary sphincter.

CONCLUSIONS

Urinary retention and urinary incontinence represent two distinct urologic complications after abdominoperineal resection. Injury to detrusor branches of the pelvic nerve can cause detrusor denervation and urinary retention. In addition, injury to intrapelvic branches of the pelvic and pudendal nerves to the urinary sphincter can result in intrinsic sphincter deficiency and urinary incontinence. A better understanding of the neuroanatomy of the lower genitourinary tract can give a physiologic basis for clinical findings of postoperative voiding dysfunction and may help the surgeon refine surgical technique by more precisely determining resection limits to minimize urologic complications.

Clinical significance of detrusor sphincter dyssynergia type in patients with post-traumatic spinal cord injury

OBJECTIVES

To investigate the significance of categorizing detrusor sphincter dyssynergia (DSD) by type in patients with chronic spinal cord injury.

METHODS

A retrospective review of the charts, video-urodynamic studies, and upper tract radiographic studies of 269 patients with post-traumatic, suprasacral spinal cord injuries was performed. The patients were categorized according to the DSD type (intermittent or continuous), level and completeness of injury, intravesical pressure at leak, upper tract complications, and interval since injury.

RESULTS

Of the 269 patients, 20 (7.4%), 216 (80.3%), and 33 (12.3%) had no DSD, intermittent DSD, and continuous DSD, respectively. No significant association between the specific level of injury and the DSD type was found (P = 0.71). The presence of DSD was associated with complete injuries, elevated intravesical pressures, and upper tract complications (P <0.01); these associations were more prominent with continuous DSD than with intermittent DSD. The proportion of patients with no DSD, intermittent DSD, and continuous DSD was unchanged during the chronic follow-up period.

CONCLUSIONS

The clinical significance of DSD type is not crucial, since patients with both intermittent and continuous DSD require urodynamic surveillance and expedient treatment to minimize urologic complications. However, the presence of continuous DSD is one of several factors that may require earlier urodynamic follow-up.

Association of level of injury and bladder behavior in patients with post-traumatic spinal cord injury

OBJECTIVES

The expected urodynamic findings of patients with suprasacral and sacral spinal cord injury have previously been reported. However, the associations between the radiographically determined level or levels of injury and urodynamic findings are ill defined. This study investigated these relationships, specifically the bladder behavior of patients with post-traumatic spinal cord injury with combined suprasacral and sacral injuries.

METHODS

A retrospective review of the patient records, spinal imaging studies, and video-urodynamic studies of 316 patients with post-traumatic spinal cord injury was performed. Of these patients, 243 had complete spinal computed tomography or magnetic resonance imaging studies and constitute the study population. Patients were categorized by the radiographically determined level or levels of injury, clinical neurologic level and completeness of injury, and urodynamic findings.

RESULTS

Of the 196 patients with suprasacral injuries, 186 (94.9%) demonstrated hyperreflexia and/or detrusor sphincter dyssynergia, 82 (41.8%) had low bladder compliance (less than 12.5 mL/cm H(2)O), and 79 (40.3%) had high detrusor leak point pressures (greater than 40 cm H(2)O). Of the 14 patients with sacral injuries, 12 (85.7%) manifested areflexia, 11 (78.6%) had low compliance, and 12 (85.7%) had high leak point pressures. Of the 33 patients with combined suprasacral and sacral injuries, urodynamic studies showed 23 with hyperreflexia and/or detrusor sphincter dyssynergia (67.7%), 9 with areflexia (27.3%), 19 (57.6%) with low compliance, and 20 (60.6%) with high leak point pressures.

CONCLUSIONS

In patients with a single level of spinal cord injury, this study revealed a significant association between the level of injury and the type of voiding dysfunction. Patients with combined suprasacral and sacral injuries, as identified with precise spinal imaging techniques, had relatively unpredictable urodynamic findings. Management of the urinary tract in patients with spinal cord injury must be based on urodynamic findings rather than inferences from the neurologic evaluation.

Differences in bladder compliance with time and associations of bladder management with compliance in spinal cord injured patients

PURPOSE

Controversy continues on the optimal method of bladder management in spinal cord injured patients. We investigated the effects of bladder management on bladder compliance and changes in compliance with time.

MATERIALS AND METHODS

We retrospectively reviewed the charts, and video urodynamic and upper tract radiographic studies of 316 patients with spinal cord injury. Patients were categorized according to interval since injury and bladder management method, including clean intermittent catheterization, spontaneous voiding and chronic Foley catheterization. Those with upper tract complications were compared with asymptomatic controls at the bladder compliance threshold values of 10.0, 12.5, 15.0 and 20.0 cc/cm. water.

RESULTS

No significant differences were noted among bladder management method groups for followup, level, completeness or mechanism of injury. A bladder compliance threshold of 12.5 cc/cm. water was selected for the remaining comparisons based on the frequency of complications compared with asymptomatic controls. Patients using intermittent catheterization had a significantly higher incidence of normal compliance than the Foley management group for suprasacral, complete and incomplete injury (p<0.01). Normal bladder compliance was more common in patients with suprasacral than sacral and incomplete than complete spinal cord injury for each bladder management type. Logistic regression analysis of compliance versus bladder management and age of injury (interval since injury) revealed that intermittent catheterization and spontaneous voiding were associated more with normal compliance than Foley catheterization (RR = 9.2, 5.4 and 1.0, respectively). Combined data showed that each successively older age of injury cohort was at 23% greater risk for loss of normal compliance than the preceding cohort. Low compliance was statistically associated with vesicoureteral reflux, radiographic upper tract abnormality, pyelonephritis and upper tract stones (p<0.01, <0.01, 0.04 and <0.01, respectively).

CONCLUSIONS

Clean intermittent catheterization protects bladder compliance in spinal cord injured patients regardless of the level or completeness of injury and helps to prevent low compliance with time. Also, in the population studied low compliance was associated with upper tract complications. Therefore, clean intermittent catheterization is the superior method for preserving bladder compliance and preventing the upper tract complications associated with low compliance.

Effect of bladder management on urological complications in spinal cord injured patients

PURPOSE

The optimal method of bladder management in spinal cord injured patients remains controversial. We investigated the association of type of bladder management with urological complications in these patients.

MATERIALS AND METHODS

We retrospectively reviewed the medical records, upper tract imaging and video urodynamics of 316 posttraumatic spinal cord injured patients. Mean followup plus or minus standard deviation since injury was 18.3+/-12.4 years. Patients were categorized according to bladder management method, including chronic urethral catheterization, clean intermittent catheterization, spontaneous voiding and suprapubic catheterization in 114, 92, 74 and 36, respectively. No significant differences in patient age at injury, followup interval, or level, completeness or mechanism of injury were noted among bladder management method groups. Infection, stone disease, urethral complications and radiographic abnormalities were recorded.

RESULTS

Of the 398 complications recorded 236 developed in 61 (53.5%) patients on chronic urethral catheterization, 57 in 25 (27.2%) on clean intermittent catheterization, 57 in 24 (32.4%) who voided spontaneously and 48 in 16 (44.4%) on suprapubic catheterization. The intermittent catheterization group had statistically significant lower complication rates compared with the urethral catheterization group and no significantly higher complication rates relative to all other management methods for each type of complication studied. The percent of patients with complications was greater in the chronic urethral catheterization group only 5 years after injury, while the percent in all other management groups remained similar up to 15 years after injury.

CONCLUSIONS

Clean intermittent catheterization is the safest bladder management method for spinal cord injured patients in terms of urological complications. Inappropriate selection of a bladder management method not only adversely affects patient quality of life, but also has a significant detrimental impact on the economic status of the health care system.

Female voiding dysfunction and movement disorders

Voiding dysfunction associated with Parkinson's disease has been well described in male patients. Few studies detail voiding dysfunction in female Parkinson patients. Apparent differences between patients with Parkinson's subtypes have also not been sufficiently defined. The majority of female Parkinson patients who have urinary symptoms (>70%) will manifest symptomatic urgency with or without urge incontinence. The remaining patients will have mixed irritative and obstructive or purely obstructive symptoms. Urodynamic evaluation demonstrates detrusor hyperreflexia in 70%-80% of female patients. However, women with Parkinson-related syndromes demonstrate detrusor hypocontractility or areflexia in 20%-30% of cases. Electromyography reveals sphincteric dysfunction (pseudodyssynergia, bradykinesia) in 30%-50% of female Parkinson patients. Also, in patients with Parkinson-related syndromes a high prevalence of peripheral denervation can be documented on electromyographic study of the pelvic floor. Voiding dysfunction associated with Parkinson's disease in female patients is complex and not always congruent with symptoms. Urodynamic evaluation is crucial to fully elucidate lower urinary tract dysfunction in female patients with Parkinson's and Parkinson-related disorders.

Bladder histological changes associated with chronic indwelling urinary catheter

PURPOSE

Chronic urinary catheters induce histological changes in the bladder with time. The exact etiology of these changes is postulated to arise from inflammation and local tissue response. We elucidate the incidence of nonmalignant histological change in bladder biopsies of patients with chronic indwelling urinary catheters.

MATERIALS AND METHODS

During 7 years 208 spinal cord injured patients underwent bladder biopsies as part of a surveillance program for vesical malignancy. All patients had chronic (more than 8.5 years) indwelling urethral or suprapubic catheters as definitive management for neurogenic voiding dysfunction. Biopsies were obtained from 4 to 6 sites within the bladder, including areas that were visually abnormal. All samples were routinely fixed with hematoxylin and eosin staining, and interpreted by an experienced pathologist.

RESULTS

A total of 17 patients were identified with malignancy, including 10 with squamous cell carcinoma, 5 with transitional cell carcinoma and 2 with adenocarcinoma. Nonmalignant changes occurred in 48 patients (23%) with keratinizing squamous metaplasia or cystitis glandularis, each of which is considered a premalignant lesion.

CONCLUSIONS

To our knowledge our study represents the largest group of spinal cord injured patients to undergo biopsy evaluation after chronic catheter use. A spectrum of inflammatory and proliferative pathological conditions were identified, which were predominantly inflammatory and squamous. The need to survey ongoing transitional mucosal changes in this population is underscored by the spectrum of histological abnormalities and the significant occurrence of malignant pathologies in our patients.

Preservation of putative continence nerves during radical retropubic prostatectomy leads to more rapid return of urinary continence

OBJECTIVES

Urinary incontinence is a significant complication of radical pelvic surgery. A better understanding of the neuroanatomy of the rhabdosphincter has led to the modification of the radical retropubic prostatectomy to optimize the recovery of postoperative urinary control.

METHODS

Mock radical retropubic prostatectomy was performed on fresh cadavers to determine which surgical maneuvers could injure what may be the continence nerves. To assess the clinical significance of modifying the radical retropubic prostatectomy based on these anatomic studies, a contemporary series of 60 consecutive patients who underwent radical retropubic prostatectomy with continence nerve preservation was compared with a control group of 38 consecutive patients who had a standard anatomic radical retropubic prostatectomy.

RESULTS

At the level of the prostatic apex, both the pelvic and pudendal nerves gave intrapelvic branches that bilaterally coursed to the external urinary sphincter to enter at the 5 and 7 o'clock positions. The mock radical prostatectomy revealed that the nerves to the external urinary sphincter were most prone to injury when a right angle clamp was used to develop a plane between the posterior rhabdosphincter and anterior rectum and if the urethral anastomotic sutures were placed at the 5 and 7 o'clock positions. In addition, blunt dissection of the tips of the seminal vesicles injured the inferior hypogastric plexus. Modifications to preserve the continence nerves were incorporated in the anatomic radical prostatectomy. Although overall continence rates were similar for the two groups (98.3% for continence nerve-preserving radical prostatectomy versus 92. 1% for standard prostatectomy), continence nerve preservation decreased the time to achieve continence.

CONCLUSIONS

During radical retropubic prostatectomy, surgical maneuvers that avoid injury to the continence nerves resulted in the more rapid return of urinary control.

Traumatic injuries of the female external genitalia and their association with urological injuries

PURPOSE

To date trauma to the female external genitalia has been incompletely characterized. At our institution a large number of such patients have been identified and many had associated urological injuries. We characterize these injuries and their association with urological injuries.

MATERIALS AND METHODS

We reviewed the charts of all female patients presenting with trauma to the genitalia unrelated to parturition between 1991 and 1996. Type and mechanism of injury, associated injuries and blood transfusion requirements were noted. Vaginal injuries were classified as complex (greater than 3 cm., multiple or involving deeper structures) or simple (all others).

RESULTS

We identified 20 women a mean 20.7 years old with traumatic injuries to the genitalia, including motor vehicle accidents in 6, injury from consensual intercourse in 5, sexual assault in 4 and other penetrating injuries in 5. There were 15 patients with vaginal injuries (complex in 8 and simple in 7) and vulvar injuries in 5. Six of the 20 women (30%) had associated urological injuries (urethra in 1, bladder in 4, ureter in 1 and kidney in 3) [corrected], including 3 associated with blunt trauma (all complex vaginal injuries) and 3 associated with penetrating trauma (simple vaginal or vulvar injuries).

CONCLUSIONS

Traumatic injury to the female genitalia unrelated to parturition is more common than previously reported. Of the women with such injuries 30% have coexisting urological injuries. Thus, it is important to assess completely all women who present with external genitalia trauma for possible coexisting urological injury.

Fournier's gangrene: therapeutic impact of hyperbaric oxygen

Many controversial issues exist surrounding the disease pathogenesis and optimal management of Fournier's gangrene. In Fournier's original descriptions, the disease arose in healthy subjects without an obvious cause. Most contemporary studies, however, are able to identify definite urologic or colorectal etiologies in a majority of cases. To investigate disease presentation, treatment modalities, and overall mortality, a retrospective analysis of Fournier's gangrene from a single institution is presented. Since 1990, 26 cases of Fournier's gangrene have been diagnosed at the University of Tennessee. An evaluation of intercurrent disease revealed that 38 percent of the patients had diabetes mellitus, 35 percent manifested ethanol abuse, and 12 percent were systemically immunosuppressed. Fifteen patients (58 percent) presented with identifiable etiologies for their disease: 31 percent (8) urethral disease or trauma, 19 percent (5) colorectal disease, and 8 percent (2) penile prostheses. Management in all cases involved prompt surgical debridement with initiation of broad-spectrum antibiotics. Multiple debridements, orchiectomy, urinary diversion, and fecal diversion were performed as clinically indicated. Fourteen patients received hyperbaric oxygen as adjuvant therapy. Statistically significant results were noted with mortality rates of 7 percent in the group receiving hyperbaric oxygen (n = 14) versus 42 percent in the group not receiving hyperbaric oxygen (n = 12). Overall mortality was 23 percent. Controversy still surrounds disease pathogenesis in Fournier's gangrene, particularly in regard to etiology. Our study corroborates current trends in that a clear focus or origin was identified in a majority of the cases. Although a grim prognosis usually accompanies the diagnosis, this study shows significant improvement combining traditional surgical and antibiotic regimens with hyperbaric oxygen therapy.

Female Stress Urinary Incontinence Clinical Guidelines Panel summary report on surgical management of female stress urinary incontinence. The American Urological Association

PURPOSE

The American Urological Association convened the Female Stress Urinary Incontinence Clinical Guidelines Panel to analyze the literature regarding surgical procedures for treating stress urinary incontinence in the otherwise healthy female subject and to make practice recommendations based on the treatment outcomes data.

MATERIALS AND METHODS

The panel searched the MEDLINE data base for all articles through 1993 on surgical treatment of female stress urinary incontinence. Outcomes data were extracted from articles accepted after panel review. The data were then meta-analyzed to produce outcome estimates for alternative surgical procedures.

RESULTS

The data indicate that after 48 months retropubic suspensions and slings appear to be more efficacious than transvaginal suspensions, and also more efficacious than anterior repairs. The literature suggests higher complication rates when synthetic materials are used for slings.

CONCLUSIONS

The panel found sufficient acceptable long-term outcomes data (longer than 48 months) to conclude that surgical treatment of female stress urinary incontinence is effective, offering a long-term cure in a significant percentage of women. The evidence supports surgery as initial therapy and as a secondary form of therapy after failure of other treatments for stress urinary incontinence. Retropubic suspensions and slings are the most efficacious procedures for long-term success (based on cure/dry rates). However, in the panel's opinion retropubic suspensions and sling procedures are associated with slightly higher complication rates, including longer convalescence and postoperative voiding dysfunction.

Female Stress Urinary Incontinence Clinical Guidelines Panel summary report on surgical management of female stress urinary incontinence. The American Urological Association

PURPOSE

The American Urological Association convened the Female Stress Urinary Incontinence Clinical Guidelines Panel to analyze the literature regarding surgical procedures for treating stress urinary incontinence in the otherwise healthy female subject and to make practice recommendations based on the treatment outcomes data.

MATERIALS AND METHODS

The panel searched the MEDLINE data base for all articles through 1993 on surgical treatment of female stress urinary incontinence. Outcomes data were extracted from articles accepted after panel review. The data were then meta-analyzed to produce outcome estimates for alternative surgical procedures.

RESULTS

The data indicate that after 48 months retropubic suspensions and slings appear to be more efficacious than transvaginal suspensions, and also more efficacious than anterior repairs. The literature suggests higher complication rates when synthetic materials are used for slings.

CONCLUSIONS

The panel found sufficient acceptable long-term outcomes data (longer than 48 months) to conclude that surgical treatment of female stress urinary incontinence is effective, offering a long-term cure in a significant percentage of women. The evidence supports surgery as initial therapy and as a secondary form of therapy after failure of other treatments for stress urinary incontinence. Retropubic suspensions and slings are the most efficacious procedures for long-term success (based on cure/dry rates). However, in the panel's opinion retropubic suspensions and sling procedures are associated with slightly higher complication rates, including longer convalescence and postoperative voiding dysfunction.

The use of urine cytology for diagnosing bladder cancer in spinal cord injured patients

PURPOSE

The diagnosis of bladder cancer in spinal cord injured patients is complicated by inflammatory changes caused by long-term indwelling catheters, which make cystoscopic followup difficult. We evaluated cytology as an aid in diagnosing bladder cancer in spinal cord injured patients.

MATERIALS AND METHODS

The charts of 208 spinal cord injured patients were reviewed retrospectively from January 1988 to July 1995 to define the value of cytology in the diagnosis of bladder cancer in this population. In all patients at least 1 urine cytology study was done less than 3 months before bladder biopsy. We examined 272 bladder biopsies (several patients underwent more than 1 biopsy at least 1 year apart) with 1 to 6 cytology studies done before biopsy.

RESULTS

Cytology results were classified as negative-no malignant cells, inflammation or benign urothelial cells, reactive-atypia or atypical reactive and suspicious-atypical suspicious, keratinizing squamous metaplasia, suspicious for cancer, cancer or dysplastic. A total of 960 cytology specimens was obtained before the 272 biopsies (average 3 before each biopsy). Of 17 patients with cancer 12 had at least 1 prior suspicious urine cytology result. The sensitivity and specificity of cytology were 71 and 97%, respectively, when evaluating only patients with suspicious findings.

CONCLUSIONS

The high sensitivity and specificity of multiple cytology studies in this population suggest that cytology is a useful adjunct to improve the detection of bladder cancer in spinal cord injured patients with chronic (longer than 5 years) indwelling catheters. We recommend a minimum of yearly cytology in all high risk spinal cord injured patients with subsequent biopsies in all patients with any suspicious finding.

Lower urinary tract dysfunction in patients with gastroparesis

PURPOSE

We characterized the bladder dysfunction in patients with idiopathic gastroparesis and compared it to findings in those with gastroparesis secondary to diabetes mellitus.

MATERIALS AND METHODS

The clinical and urodynamic records of 17 patients with gastroparesis (10 idiopathic and 7 secondary to diabetes mellitus) were retrospectively reviewed.

RESULTS

Urinary frequency and difficulty emptying were the predominant symptoms that led to patient referral. Overall this population demonstrated diminished bladder sensation, increased capacity, decreased flow rates, elevated post-void residuals and increased rates of abdominal straining. Patients with idiopathic gastroparesis had more severe dysfunction than those with gastroparesis secondary to diabetes mellitus.

CONCLUSIONS

An association between idiopathic gastroparesis and bladder dysfunction exists. These patients have bladder dysfunction that parallels but is more severe than that in patients with gastroparesis secondary to diabetes mellitus. A common autonomic neuropathic syndrome may account for both problems.

Neuroanatomy of the male rhabdosphincter

OBJECTIVES

The external striated urethral sphincter (rhabdosphincter) is a tubular muscle sleeve that extends from the prostato-membranous urethra and perineal membrane to the bladder neck. The male rhabdosphincter neuroanatomy remains unclear, and a better understanding of its innervation may provide insight into potential modifications of radical pelvic surgery to improve urinary continence.

METHODS

Fresh cadaveric dissections of 12 male hemipelves were undertaken to investigate the neuroanatomy of the urinary rhabdosphincter.

RESULTS

Neuroanatomic courses of the nerve supply to the rhabdosphincter revealed that, in the perineum, the perineal nerve (a terminal branch of the pudendal nerve) provided branches directly to the bulbospongiosus muscle and the urinary rhabdosphincter. In the pelvis, the course of the pelvic nerve was as follows: (1) arising from the inferior hypogastric plexus, it had a weblike course beneath the muscle fascia of the levator ani muscle; (2) traveling posterolateral to the rectum, it gave many branches that perforated into the lateral rectum; and (3) at the level of the prostatic apex, still beneath the levator ani muscle fascia (superior fascia), it sent multiple direct branches to the inferolateral aspect of urinary rhabdosphincter. The pudendal nerve traversed the pelvis in the pudendal canal, and, before leaving the pelvis to enter the perineum, it gave an intrapelvic branch that courses with the pelvic nerve to innervate the rhabdosphincter.

CONCLUSIONS

Our understanding of the neuroanatomy of what may be the continence nerves has been improved by fresh cadaveric dissection. The rhabdosphincter receives nerve fibers from the pelvic nerve and dual innervation from an intrapelvic branch and a perineal branch of the pudendal nerve. Better understanding of these anatomic findings may have potential surgical significance with respect to improvement in postoperative urinary continence.

Role of the four-corner bladder neck suspension to correct stress incontinence with a mild to moderate cystocele

OBJECTIVES

Women undergoing four-corner bladder neck suspension were evaluated for subjective and objective results of the procedure. Patients were evaluated for continence, prolapse, and symptomatic status postoperatively.

METHODS

Forty-seven women underwent four-corner bladder neck suspension for moderate cystocele with (44) or without (3) stress urinary incontinence. Mean and median follow-up were 37 months (range 15 to 80). To assess results of the four-corner bladder neck suspension, two sets of outcome measures were used (subjective questionnaire, including patient satisfaction, and objective physical examination, with standing voiding cystourethrogram) to compare pre- and postoperative data.

RESULTS

At the time of follow-up, 25 patients (53%) reported no incontinence, 14 (30%) reported one incontinent episode per week, and 8 (17%) reported daily loss of urine. Twenty-seven (57%) had grade I or grade II cystoceles on follow-up examination and voiding cystourethrogram; however, only 12 (26%) experienced recurrent prolapse symptomatology. Overall patient acceptance of the procedure was high (70%).

CONCLUSIONS

The four-corner bladder neck suspension is an effective option in the management of moderate cystocele.

Urologic emergencies. Trauma injuries and conditions affecting the penis, scrotum, and testicles

Urologic emergencies involving the penis, scrotum, and testicles include priapism, paraphimosis, testicular torsion, and Fournier's gangrene. Familiarity with the signs and symptoms of these conditions can lead to prompt diagnosis. Special care is needed in differentiating testicular torsion from the more common condition of epididymitis. Evaluation of trauma injuries of the genito-urinary tract includes classification (blunt or penetrating), assessment of the extent of injury, and urologic consultation if appropriate.

Urologic emergencies. Conditions affecting the kidney, ureter, bladder, prostate, and urethra

Prompt, thorough evaluation is needed when patients present with symptoms of renal colic, acute urinary retention, prostatitis, pyelonephritis, and other urologic emergencies. Primary care physicians have an important role in initial workup and treatment. Once the diagnosis is determined, urologic consultation may be necessary for definitive treatment.

Percutaneous bladder neck suspension: technique and results

Percutaneous bladder neck stabilization (PBNS) represents a minimally invasive surgical procedure for the treatment of stress incontinence caused by hypermobility of the proximal urethra and bladder neck. Since the initial description of the procedure, technique and instrumentation modifications have added to the reproducibility of this operation. Three specific modifications have been incorporated into this procedure: strong anchoring of the suspension suture to the symphysis pubis using a bone anchor, incorporation of a broad segment of vaginal wall with a Z suture, and loose resuspension of the proximal urethra. Cystoscopic verification of suture location precludes bladder entry or distal suture placement. This procedure has been currently used in 71 women with an overall cure rate of 94% (no stress incontinence) at follow-up of 12 months. One retropubic abscess required drainage. A second patient required excision of a skin sinus tract cause by an infected bone anchor. Urinary retention of > 3 weeks has not been encountered. Overall morbidity has been minimal. Long-term follow-up of continence status and other procedure-related complications is ongoing. PBNS provides equivalent continence results and complication rates as compared with other retropubic and transvaginal procedures with a minimally invasive outpatient technique.

Vesica percutaneous bladder neck stabilization

The Vesica percutaneous bladder neck stabilization (PBNS) represents a minimally invasive surgical procedure for the treatment of stress incontinence caused by hypermobility of the proximal urethra and bladder neck. Since the initial description of the procedure, technique and instrumentation modifications have added to the reproducibility of this operation. Three specific modifications have been incorporated: strong attachment of the stabilization suture to the pubic bone utilizing a bone anchor; incorporation of a full-thickness broad segment of tissue including the endopelvic, pubocervical, and subvaginal fascia as well as vaginal wall in a Z suture; and loose resuspension of the proximal urethra to stabilize the continence mechanism. Cystoscopic verification of suture location precludes bladder entry or distal suture placement. This procedure has been utilized in 71 women with an overall cure rate (no stress incontinence) of 94% at follow-up of 12 months. One retropubic abscess required drainage, and a second patient required excision of a skin sinus tract caused by an infected bone anchor. Urinary retention longer than 3 weeks has not been encountered. Overall morbidity has been minimal. Long-term follow-up of continence status and other procedure-related complications is ongoing. The PBNS provides continence results and complication rates equivalent to those of other retropubic and transvaginal procedures using a minimally invasive outpatient technique.

Risk factors for bladder tumors in spinal cord injury patients

PURPOSE

We evaluated risk factors for the development of bladder tumors in spinal cord injury patients.

MATERIALS AND METHODS

A retrospective review was done of all bladder tumors at 1 institution with matched controls for 7 years.

RESULTS

We identified 17 malignant and 2 benign tumors. Indwelling bladder catheters and a history of bladder stones were statistically significant risk factors. Four patients with negative biopsies underwent repeat biopsy due to suspicious cytology and cancer was found.

CONCLUSIONS

An indwelling urinary catheter and a history of bladder stones are statistically significant risk factors. Cytology and biopsy are complimentary in the evaluation of urothelial malignancy in this population. A high index of suspicion and thorough evaluation are needed in spinal cord injury patients.

Penetrating trauma to the penis: functional results

PURPOSE

The erectile function, cosmetic appearance, indications for surgical exploration and need for specific diagnostic tests were evaluated in patients with penetrating penile trauma.

MATERIALS AND METHODS

We reviewed 26 cases of penetrating penile trauma seen during a 4-year period.

RESULTS

All patients with corporeal injuries who were followed (73%) were potent. Two patients with minimal corporeal injury who did not undergo exploration did well. Retrograde urethrography did not identify any previously unsuspected urethral injuries.

CONCLUSIONS

Excellent functional results may be obtained after penetrating trauma to the penis. Select patients may not require retrograde urethrography and some with minimal wounds, even if involving the corpora, can be treated nonoperatively.

Non-operative management of the urinary tract in spinal cord injury

Various options exist for the management of the lower urinary tract in chronic spinal cord injury. These options include chronic indwelling catheterization, urethral sphincterotomy, and intermittent catheterization supplemented with anticholinergic agents. Sixty-four spinal cord injured patients, treated with intermittent catheterization and anticholinergic therapy, were evaluated for long-term efficacy in maintaining upper tract status and preservation or improvement in continence. Complications of therapy were also evaluated. Therapy was based upon initial urodynamic evaluation followed by limited subsequent evaluation of the urinary tract. Mean follow-up was 54 months. Only 1 patient developed hydronephrosis. Fifty-nine patients either became continent or experienced improved continence on therapy. Eight patients required surgical procedures either to increase outlet resistance (2) or to decrease intravesical pressures (6). The most common complication of therapy was urinary tract infection. Thirty-nine infections occurred in 23 patients, 16 of which were febrile. Fifteen patients were non-compliant with treatment recommendations. The only factor related to therapeutic complications which reached statistical significance was non-compliance with therapy. The combined use of intermittent catheterization and anticholinergic agents provides an effective means to prevent hydronephrosis and establish continence in chronic spinal injury.

The risk of rhabdomyolysis and acute renal failure with the patient in the exaggerated lithotomy position

Rhabdomyolysis with subsequent renal failure has been well documented as a complication of major trauma. However, this complication from elective urological procedures is less well recognized. In 10 patients who underwent elective urethroplasty serum levels of creatine kinase and urinary myoglobin were examined preoperatively and postoperatively. These patients were placed in the lithotomy position for several hours and had minimal muscle dissection. Serum creatine kinase was noted to increase significantly postoperatively to greater than 1,000 units and in 1 patient myoglobin was detected in the urine. This finding indicates that there is, indeed, a risk of muscle injury and potential rhabdomyolysis in these patients from the use of the exaggerated lithotomy position.

Segmental infarction of the testicle: atypical presentation of a testicular mass

Segmental infarction of the testis represents a rare entity. To our knowledge 11 cases have been reported in the literature. We report 4 additional cases of segmental testicular infarction masquerading as testis tumors. Inability to distinguish these benign lesions from malignant testis tumors resulted in orchiectomy in all 4 cases.

Simple cyst of the testis

We report 5 cases of simple cyst of the testis, the largest series to date, and review the literature. Included are 2 autopsy cases, a case of a multilocular simple cyst and 1 case treated nonoperatively. Based on our experience, simple cyst of the testis should be suspected particularly in an enlarged but otherwise palpably normal testis. High resolution real-time scrotal sonography revealing an anechoic mass in the testis with well defined walls, and enhanced posterior through transmission and edge shadowing is diagnostic for a simple cyst. An asymptomatic simple cyst of the testis may be treated with observation alone. The symptomatic simple cyst should be treated ideally with local parenchyma-sparing excision.

Bladder injury and uroascites from umbilical artery catheterization

Umbilical artery catheterization in the newborn can lead to perforation of the bladder or urachal remnant with extravasation of urine into the peritoneal cavity. We present a case of such an injury that led to uroascites and respiratory distress. This injury usually requires prompt surgical repair for resolution.