Experience with the use of cystometry and simultaneous cystometry and urethrometry to clarify urinary incontinence in women (author's transl)

Cystometry and simultaneous cystometry and urethrometry were conducted in 81 incontinent female patients (46 Grade I, 35 Grade II, according to the Ingelman-Sundberg Scale). The tonometric criteria for stress incontinence were presented and discussed by statistically comparing the pressure parameters for continent and incontinent patients. The results of both examinations indicated that, in almost all cases, the cause of incontinence (bladder, bladder obstruction or combination of both) can be determined with certainty. This method is well suited as a routine procedure to clarify urinary incontinence in women.     

Urinary Incontinence in Women

Despite the prevalence of urinary incontinence, most affected women don't seek help, primarily because of embarrassment or because they are not aware that effective treatment is available. Failure to store urine may be caused by an abnormality in any component of the lower urinary tract. Common abnormalities are poor bladder compliance and bladder outlet failure. Patients who experience failure to empty can present with recurrent urinary tract infections, retention or incontinence. Using a symptom-based classification of incontinence, this would be referred to as overflow incontinence. Other possible categories of urinary incontinence are failure to store and empty and functional incontinence. A combination of a failure to store and empty is difficult to diagnose and treat clinically. Treatments are directed at the particular cause of incontinence and can include medical or surgical therapies.     

Coronary flow reserve in the contralateral artery increases after successful coronary angioplasty in patients with spontaneously visible collateral vessels

Due to the large variability in the reported contribution of bladder dysfunction to postprostatectomy incontinence and the impact this dysfunction may have on the outcome of selected treatment, we retrospectively reviewed the videourodynamic findings of bladder and sphincteric function in patients with postprostatectomy incontinence. The contributions of bladder and sphincteric causes of incontinence are determined. Ninety-two patients had multichannel videourdynamic testing performed as part of a comprehensive evaluation for incontinence at least 1 year after prostatectomy. Using a 6-French double-lumen catheter in the bladder and a 10-French catheter in the rectum, all pressures were recorded continuously while in the upright position. Valsalva leak point pressures (VLPP) were measured in the absence of a bladder contraction at a 150-ml volume and at 50-ml increments thereafter until maximum functional capacity was reached. Bladder compliance and bladder capacity were determined and the presence of detrusor instability (DI) was documented. Sixty-five patients (71%) presented after radical prostatectomy (RP) and 27 patients (29%) after transurethral resection of the prostate (TURP). The predominant urodynamic finding was sphincteric incompetence as VLPP were obtained in 85 patients (92%) and ranged from 12 to 120 cm water. DI was a common finding, occurring in 34 patients (37%), and classified as follows: a) phasic instability in 22/34, b) tonic instability in 3/34, and c) mixed phasic and tonic instability in 9/34. However, we found DI to be the sole cause of incontinence in only 3/92 patients (3.3%). There was no statistically significant difference in the incidence of sphincteric incompetence after RP or TURP; however, TURP patients had a higher incidence of DI, which was statistically significant (P=0.019). There was no correlation of incontinence severity and VLPP when comparing preoperative pad usage to VLPP < or =70 or > or =71 cm water. Although bladder dysfunction may be contributing problem in patients with postprostatectomy incontinence, it is rarely the only mechanism for this disorder. VLPP does not correlate with incontinence severity. Although sphincteric incompetence is the most common mechanism contributing to incontinence after prostatectomy, bladder dysfunction may coexist or be an isolated cause of postprostatectomy incontinence. Therefore, urodynamic studies are important to illustrate the exact cause(s) of incontinence in each individual patient after prostatectomy.     

Urinary bladder incontinence after prostatectomy. Urodynamic evaluation and results of therapy

Forty-seven males referred due to postprostatectomy urinary incontinence (34 after transurethral resection of prostatic adenoma and 13 after open suprapubic adenomectomy) were retrospectively studied. Urodynamic evaluation identified 19 (40.4%) men with incontinence due solely to sphincter incompetence, and 19 (40.4%) men, in addition to sphincter incompetence, had urinary bladder dysfunction (unstable detrusor and/or reduced bladder compliance). Seven (14.8%) men had pure bladder dysfunction as the only cause of urinary incontinence. Two patients had normal urodynamic findings (N = 2; 4.2%). Men with urinary incontinence due only to sphincter incompetence were treated by insertion of artificial sphincter devices or condom catheter drainage (lack of artificial sphincters), while others were treated pharmacologically (imipramine, propantheline, oxybutynin or their combinations ... N = 25), or by augmentation cystoplasty using ileum after unsuccessful pharmacological treatment (N = 3). Out of 25 patients with pharmacological treatment, 21 were available for the final assessment of the treatment efficacy. Eleven (52.3%) patients were "socially continent" after the treatment. It is concluded that in the assessment of the cause of postprostatectomy urinary incontinence urodynamic evaluation is mandatory, and that the treatment should be based on the results of such studies. The role of bladder dysfunction as a cause of postsurgical urinary incontinence is again strongly emphasized.     

Fetal vascular responses to maternal glucose administration in streptozocin-induced ovine diabetes mellitus

Different pathophysiology causes different types of incontinence. Urge-, Stress-, Overflow-, Reflex- and Extrasphincteric incontinence therefore need different therapeutic strategies. The basic diagnostic work-up, which can be done by any doctor in free practice comprises history, clinical investigation, urine analysis, the micturition protocol (frequency-volume-chart = FVC) and post voiding residual urine (PVR). In 80% of the elderly incontinent persons incontinence can be evaluated by basic diagnostics to such an extent, that conservative therapy can be started. If after basic diagnostic work-up the type of incontinence remains unclear, if it is a postoperative recurrent urinary incontinence, if reflex incontinence is present, or if conservative therapy is not successful within 3 weeks a further diagnostic workup by the specialist is mandatory. The specialist will perform echography of the urinary tract, endoscopy and especially urodynamics to evaluate detrusor and sphincter dysfunction precisely, if necessary also combined with X-ray (video-urodynamics). In regards to urinary stress incontinence conservative treatment strategies e.g. pelvic floor training programs, if necessary combined with electrotherapy and biofeedback have gained increasing importance. For urge-incontinence continence training programs and pharmacotherapy as well as electrotherapy are the main therapies. Reflex-incontinence should be treated by the specialist. Overflow incontinence is easy to diagnose, however, the treatment of the underlying pathophysiology must be done by the urologist. Urinary incontinence in the elderly is a special problem. Treatment of incontinence with incontinence aids (pads) only is justified in immobile and demented people, in others active treatment, comprising continence training programs and pharmacotherapy should be the goal. A Foley catheter is only justified if urinary incontinence is combined with an insufficient bladder emptying with residual urine, which can not be treated otherwise.     

Treatment of urinary incontinence in women in general practice: observational study

OBJECTIVE: To examine what is attainable when treating urinary incontinence in women in general practice. DESIGN: Observational study with 12 months' follow up. Interview and clinical examination before, during, and after treatment of women seeking help for urinary incontinence in general practice. SETTING: General practice in the rural district of Rissa, Norway. SUBJECTS: 105 women aged 20 or more with urinary incontinence. INTERVENTIONS: Treatment with pelvic floor exercises, electrostimulation, oestrogen, anticholinergic drugs, bladder training, and protective pads. MAIN OUTCOME MEASURES: Subjective and objective measures of urinary incontinence; number of patients referred to a specialist. RESULTS: After 12 months' follow up 70% (69/99) of the women were cured or much better; the mean score on a 100 mm visual analogue scale decreased from 37 to 20 mm; and the proportion of women who were greatly bothered by their incontinence decreased by 62%. 20% (20/98) of women became continent, and the percentage of women with severe incontinence decreased from 64% (63/99) to 28% (27/98). Mean leakage per 24 hours measured by a pad test decreased from 28 g at the start of treatment to 13 g after 12 months. The number of light weight pads or sanitary towels decreased from 1.6 to 0.6 a day. In all, 17/105 (16%) patients were referred to a specialist. CONCLUSIONS: Urinary incontinence in women can be effectively managed in general practice with fairly simple treatment. Most women will be satisfied with the results.     

Value of transrectal ultrasonography in the assessment of failures of stress urinary incontinence surgery in women

OBJECTIVES: To describe the role of transrectal ultrasonography as an alternative imaging technique in the evaluation of women who continue to be incontinent following surgical management of female stress urinary incontinence. METHODS: The means of independent samples of transrectal ultrasound parameters of two groups of patients (group I, patients who were continent after surgery; group II, patients who remained incontinent after surgery) were compared. RESULTS: Patients who were continent after surgery showed scanty caudal and dorsal mobility of the bladder neck and proximal urethra during the periods of increased intraabdominal pressure. The US finding in this group of patients is characterized by a funnel surrounding the bladder neck and the proximal urethra. The existence of an intrinsically incompetent sphincter can also be determined with this technique. CONCLUSIONS: Transrectal ultrasonography constitutes an alternative imaging technique in the evaluation of women who continue to be incontinent following surgical management of female stress urinary incontinence. It permitis determining whether incontinence is due to a failed procedure, the existence of an intrinsically incompetent sphincter, or whether other causes of incontinence should be investigated.     

Induction of early and bioeffective antibody response in rodents with the luteinizing hormone-releasing hormone vaccine given as a single dose in biodegradable microspheres along with alum

Total urinary incontinence is a difficult problem faced by the urologist. Several techniques to increase ureteral resistance have been described. The majority of them rely on intermittent catheterization for bladder emptying, especially in neurogenic incontinence. We have developed a new procedure in which a bladder flap is used to create a neourethra. This urethral extension acts as a flap valve to provide continence. Bladder emptying is accomplished by clean intermittent catheterization. Urethral lengthening with an anterior bladder-wall flap was performed in 18 patients aged a mean of 8.9 years who had neurogenic incontinence (14) or exstrophy (4). Patients with previous bladder interventions received a lateralized anterior flap. Bladder augmentation was performed in 14 of the 18 patients [detubularized ileum (11), detubularized colon (3)]. The average follow-up period is currently 29.3 months. Continence was achieved in 13 of the 18 patients (72%). Complications included urethrovesical fistulae, which developed in two patients. Two patients could not perform catheterization due to pain but had no obstruction to passage of catheter (exstrophy). Ureteral lengthening with an anterior bladder-wall flap is a useful alternative for the surgical treatment of urinary incontinence. This technique achieves a good continence rate and presents few problems with catheterization.     

Acute nonoliguric renal failure in children associated with nonsteroidal antiinflammatory agents

The concept of using the pubic bone as a support for the bladder neck and urethra in the treatment of women with genuine stress urinary incontinence is well established, and is applied in traditional procedures such as Marshall-Marchetti-Krantz and the Burch colposuspensions. Recently, minimally invasive techniques, including the use of laparoscopic surgery and pubic bone anchoring systems, have been introduced. These new techniques, attempt to combine the advantages of retropubic procedures while remaining minimally invasive. A search of the English literature was carried out, traditional and new procedures using the pubic bone as a support for the bladder neck and urethra are described, and their efficacy and complications are reviewed and discussed. Traditional procedures have proved to be highly effective and well tolerated, with good long-term outcomes. The early results of innovative minimally invasive techniques are promising, but further experience and longer follow-up is needed to establish their role in the treatment of female stress urinary incontinence.     

Tolterodine--a new bladder selective muscarinic receptor antagonist: preclinical pharmacological and clinical data

Tolterodine is a new, potent and competitive muscarinic receptor antagonist in clinical development for the treatment of urge incontinence and other symptoms of unstable bladder. Tolterodine has a high affinity and specificity for muscarinic receptors in vitro and it exhibits a selectivity for the urinary bladder over salivary glands in vivo. A major active metabolite, (PNU-200577) the 5-hydroxymethyl derivative of tolterodine, has a similar pharmacological profile. Based on pharmacological and pharmacokinetic data, it has been concluded that this metabolite contributes significantly to the therapeutic effect of tolterodine. The bladder selectivity demonstrated by tolterodine and PNU-200577 in vivo cannot be attributed to selectivity for a single muscarinic receptor subtype. Moreover, this favourable tissue-selectivity seems to occur also in humans. Tolterodine is well tolerated and it exerts a marked effect on bladder function in healthy volunteers. Phase II data indicate that tolterodine is an efficacious and safe treatment for patients with idiopathic detrusor instability or detrusor hyperreflexia. An optimal efficacy/side-effect profile is obtained with tolterodine, at a dosage of 1 or 2 mg twice daily, which seems to have less propensity to cause dry mouth than the currently available antimuscarinic drugs.     

Improving combat casualty care and field medicine: focus on the military medic

Surgical treatments have a limited role in the treatment of geriatric urinary incontinence. Patterns of problems exist with incontinence, including pelvic support defects and bowel and bladder dysfunction. Each of the major elements must be treated to achieve the best outcomes. Urodynamic testing should be used to confirm the cause of incontinence before selecting a surgical procedure. Minimally invasive procedures include periurethral collagen injections.     

Bladder neck support prosthesis: a nonoperative treatment for stress or mixed urinary incontinence

PURPOSE: We evaluated the usefulness and safety of a bladder neck support prosthesis in patients with stress or mixed incontinence. MATERIALS AND METHODS: A total of 57 women with stress and 20 with mixed incontinence completed a 12-week prospective clinical trial of a bladder neck support prosthesis. While indexes of incontinence episodes, leakage amounts and urgency along with a bothersome index were subjectively evaluated, a 60-minute pad test and urinary flow parameters were objectively evaluated. Three patients scheduled to undergo surgery for stress incontinence voluntarily used the device, and provided urodynamic data and cystourethrograms. Two prongs at 1 end of the ring, a type of elastic vaginal pessary, elevate the bladder neck against the pubic bone and facilitate pressure transmission around the bladder neck, resulting in urinary continence. RESULTS: Four subjective indexes significantly improved. There was no urinary flow obstruction. Urine loss decreased from 20.6 to 4.8 gm. per hour (p < 0.001) on the 60-minute pad test. Of the patients 22 (29%) reported complete continence and 39 (51%) had decreased severity of incontinence by more than 50%. Minor adverse effects occurred in 26% of the patients. Taking subjective evaluation, changes in objective parameters and adverse effects into consideration, 62 patients (81%) had some or maximum benefit according to the global usefulness rating. CONCLUSIONS: The bladder neck support prosthesis is safe, well tolerated and clinically effective for the treatment of stress or mixed incontinence.     

Stress urinary incontinence in women. II. Abnormalities of glycogenolysis in tissues related to the lower urinary tract

The aim of the study was the investigation of the biochemical condition of elements likely to directly participate in active closing of the urethral lumen. We estimated glycogenolysis in urinary bladder, perivesical connective tissue and levator ani muscle (LAM) samples obtained intraoperatively from 80 stress incontinent women. Glycogen content as well as activities of active and total glycogen phosphorylase and acid exo-1,4-alpha-glucosidase were measured. Material from the urinary bladder and perivesical connective tissue was insignificantly altered, and glycogen contents in the bladder (2.03 +/- 1.38 g/100 g wet tissue) were considered to be normal. In the LAM glycogenolysis was much more activated than in other tissues (p < 0.001 by Fischer's exact test). Of LAM specimens 78% (22/28) revealed imbalanced biochemistry of glycogen with activation of hydrolytic decomposition. We conclude that stress urinary incontinence in women is frequently associated with metabolic alterations in the periurethral striated fibres. This study indirectly supports our recent hypothesis on the pathogenesis of the disease in terms of muscle fibre type transitions.     

Birth order in homosexual versus heterosexual sex offenders against children, pubescents, and adults

OBJECTIVE: The selection of patients amenable to treatment with a bladder neck sling remains a controversy. In this paper we review our experience with this technique and describe our patient selection criteria. METHODS: Since 1991, 30 patients (24 females and 6 males) aged 4 to 20 years (mean 10) received a bladder neck sling as part of the surgical treatment for their urinary incontinence. The cause of incontinence was neurogenic in 28 of the 30 patients. The 6 male patients were prepuberal. All patients had a preoperative video urodynamic study. The criteria for increasing cervico-urethral resistance included a passive leak point pressure of < 50 cm H2O, stress leak point pressure of < 100 cm H2O, radiological evidence of an open bladder neck and stress incontinence regardless of the other urodynamic and radiologic parameters. The technical aspects of the procedure are described in detail. Augmentation cystoplasty was performed concomitantly in 29 patients. RESULTS: Patient follow-up ranged from 2 to 70 months (mean 37.6). Twenty-eight patients (93%) were continent postoperatively. Two female patients remained incontinent at low leak point pressures. All patients emptied the bladder by intermittent catheterization. Twelve patients perform catheterization through the urethra without difficulty. CONCLUSION: The rectus fascia sling has several advantages over other surgical methods for increasing the cervico-urethral resistance. It is simple, effective, low-cost and has a low complication rate. In our view, the sling is the technique of choice for increasing cervico-urethral resistance in female and prepuberal male patients requiring a cystoplasty concomitantly.     

Use of ultrasonography in the bladder neck suspension

From 1988 to 1992, 78 patients with genuine stress urinary incontinence underwent bladder neck suspension under ultrasonic monitoring. Tightness of suspension was adjusted by setting posterior urethrovesical angle to approximately 90 degree by transrectal ultrasonography during operation. Urinary continence was achieved in 68 of 78 patients. In the remaining 10 patients, slight incontinence recurred within 6 months after operation. In 60 patients undergoing postoperative chain cystourethrogram, the posterior urethrovesical angles set during operation were about the same as those after operation. In 39 patients undergoing uroflowmetry under the condition that micturition volume was 200 ml or more, urinary flow rate did not decrease after operation. In 20 patients whose posterior urethrovesical angles were measured by transperineal and transabdominal as well as transrectal ultrasonography, angles measured by each ultrasonography were almost identical and neither manipulation could change the configuration of the bladder neck. The posterior urethrovesical angles set during operation were kept postoperatively and provided proper tightness of the suspension suture to achieve urinary continence without any difficulty of urination. Therefore, a posterior urethrovesical angle can be set by transperineal and transabdominal ultrasonography as well as transrectal ultrasonography. While transrectal approach provides the clearest image among the three approaches, transperineal and transabdominal approach carried out with a transabdominal convex or sectorial probe are more convenient than transrectal approach which needed a special probe.     

Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial

CONTEXT: Urinary incontinence is a common condition caused by many factors with several treatment options. OBJECTIVE: To compare the effectiveness of biofeedback-assisted behavioral treatment with drug treatment and a placebo control condition for the treatment of urge and mixed urinary incontinence in older community-dwelling women. DESIGN: Randomized placebo-controlled trial conducted from 1989 to 1995. SETTING: University-based outpatient geriatric medicine clinic. PATIENTS: A volunteer sample of 197 women aged 55 to 92 years with urge urinary incontinence or mixed incontinence with urge as the predominant pattern. Subjects had to have urodynamic evidence of bladder dysfunction, be ambulatory, and not have dementia. INTERVENTION: Subjects were randomized to 4 sessions (8 weeks) of biofeedback-assisted behavioral treatment, drug treatment (with oxybutynin chloride, possible range of doses, 2.5 mg daily to 5.0 mg 3 times daily), or a placebo control condition. MAIN OUTCOME MEASURES: Reduction in the frequency of incontinent episodes as determined by bladder diaries, and patients' perceptions of improvement and their comfort and satisfaction with treatment. RESULTS: For all 3 treatment groups, reduction of incontinence was most pronounced early in treatment and progressed more gradually thereafter. Behavioral treatment, which yielded a mean 80.7% reduction of incontinence episodes, was significantly more effective than drug treatment (mean 68.5% reduction; P=.04) and both were more effective than the placebo control condition (mean 39.4% reduction; P<.001 and P=.009, respectively). Patient-perceived improvement was greatest for behavioral treatment (74.1% "much better" vs 50.9% and 26.9% for drug treatment and placebo, respectively). Only 14.0% of patients receiving behavioral treatment wanted to change to another treatment vs 75.5% in each of the other groups. CONCLUSION: Behavioral treatment is a safe and effective conservative intervention that should be made more readily available to patients as a first-line treatment for urge and mixed incontinence.     

Epidemiology of toxoplasmosis in Kuwait. I. Detection of antibodies to Toxoplasma gondii and percentage distribution among the inhabitants

Sixty patients presented with postprostatectomy problems. The symptoms of slow stream and hesitancy were associated with the urodynamic finding of an underactive detrusor more often than with persistent obstruction. The symptoms of persistent urgency, frequency, and urge incontinence were associated with bladder hypersensitivity and bladder instability. Stress incontinence was associated with low sphincter pressures demonstrated by urethral profilometry. Urodynamic studies enabled accurate diagnosis of these problems and indicated which patients had persistent obstruction (17 per cent) and would therefore benefit from additional outflow tract surgery.     

Is antenatal bladder neck mobility a risk factor for postpartum stress incontinence?

OBJECTIVE: To assess the contribution of constitutional factors, as demonstrated by antenatal bladder neck mobility, in the development of postpartum urinary stress incontinence. DESIGN: A prospective investigational study. SETTING: General district hospital. POPULATION: One hundred and three primigravid women with no pre-existing urinary incontinence or neurological disorder. METHODS: Antenatal and postnatal measurement of bladder neck mobility using perineal ultrasound. MAIN OUTCOME MEASURE: Urinary stress incontinence at 10-14 weeks postpartum. RESULTS: Women with postpartum urinary stress incontinence have significantly greater antenatal bladder neck mobility than those women continent postpartum. There were no significant differences in any labour or delivery variables, including mode of delivery, between the postpartum continent and incontinent women. CONCLUSIONS: There is evidence for a constitutional risk factor (eg, defective pelvic floor connective tissue in the development of postpartum stress incontinence).     

Myofascial wrap to treat intractable urinary incontinence in children

OBJECTIVES: The management of intractable urinary incontinence in the patient with cloacal or bladder exstrophy/epispadias, failed bladder neck plasty, or failed augmentation cystoplasty remains a surgical challenge. The myofascial wrap, a modification of the rectus fascial wrap, was developed to treat intractable urinary incontinence due to sphincteric incompetence in these problematic cases. A full-thickness, vascularized pedicle of anterior rectus sheath, rectus abdominis muscle, and posterior rector sheath is incorporated into a bladder neck wrap to provide support, mucosal coaptation, and active muscular tone. METHODS: Eight patients (5 females and 3 males) with total urinary incontinence due to sphincteric incompetence underwent the myofascial wrap. Urinary tract pathology included cloacal exstrophy (2), female epispadias (2), classic bladder exstrophy (1), male epispadias (1), myelomeningocele (1), and a pelvic tumor (1). The procedure is performed by harvesting a full-thickness strip of pedicled rectus muscle along with the anterior and posterior fascial sheaths. The strip is passed underneath and then over the bladder neck in a near 360 degrees wrap. The free end of the wrap is anchored into the pubic bone in an ipsilateral subperiosteal pouch. RESULTS: Six of the 8 patients are completely continent, and 2 patients void spontaneously without the need for catheterization. CONCLUSIONS: The myofascial wrap provides support, mucosal coaptation, and muscular tone to an incompetent sphincter and bladder neck. Favorable results in a very difficult population of pediatric patients warrant its continued use.     

Stroke and incontinence

BACKGROUND: Urinary incontinence in the acute stage of stroke is seen as a predictor of death, severe disability, and an important factor on hospital discharge destination. Therefore, it is an important measure of stroke severity that not only affects the lives of stroke survivors but also those of caregivers. SUMMARY OF REVIEW: A number of studies have linked the presence of bladder dysfunction in stroke survivors to various neurological lesions in areas thought to be primarily involved in micturition. However, neurological deficits may affect management of bladder control secondarily by apraxia or aphasia, for example, and a significant number of strokes occur in individuals already experiencing incontinence. CONCLUSIONS: Despite incontinence being such an important prognostic feature, there are many gaps in our knowledge of the relationship of stroke and incontinence, particularly fecal incontinence. There are almost no studies on the influence of achieving continence on outcome or how this might be brought about. This article reviews the literature on this important topic and highlights deficiencies in our knowledge and areas of future research.