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.     

A pelvic muscle precontraction can reduce cough-related urine loss in selected women with mild SUI

OBJECTIVES: To test the hypothesis that selected older women with mild-to-moderate stress urinary incontinence (SUI) can learn to demonstrate significantly reduced urine loss in 1 week by intentionally contracting the pelvic floor muscles before and during a cough (a skill we have termed "The Knack"). DESIGN: A prospective, randomized, single-blind interventional study. SETTING: The Older American Independence Center, a federally sponsored research program affiliated with the University of Michigan in Ann Arbor, Michigan. PARTICIPANTS: Twenty-seven women with a mean (SD) age of 68.0 (5.5) years, self-reported SUI, and demonstrable urine loss during a deep cough. INTERVENTION: Women were randomized to an immediate intervention group (Group I: n=13) who were taught the Knack after their first clinic visit, or a wait-listed control group (Group II: n=14) who were taught the Knack after 1 month. MEASUREMENTS: At 1 week after instruction, we tested the efficacy of the Knack in a standing stress test by (1) comparing the volumes of cough-related urine loss leaked by all subjects, with and without use of the Knack, and (2) comparing the volumes of cough-related urine loss leaked by Group I, using the Knack, with Group II, which had not yet been taught the Knack. RESULTS: Intra-individual results showed that at 1-week follow-up, the Knack was used to reduce urine loss resulting from a medium cough by an average of 98.2%, compared with that of a similar cough performed 1 minute before without the Knack (P=.009); likewise urine loss was reduced by an average of 73.3% (P=.003) in a deep cough. Reduction in urine loss was not significantly correlated with a digital measure of pelvic floor muscle strength. CONCLUSION: Within 1 week, selected older women with mild-to-moderate SUI can acquire the skill of using a properly-timed pelvic floor muscle contraction to significantly reduce urine leakage during a cough.     

Phospholipase C isozymes in the human brain and their changes in Alzheimer''s disease

OBJECTIVE: We compared the efficacy of bladder training, pelvic muscle exercise with biofeedback-assisted instruction, and combination therapy, on urinary incontinence in women. The primary hypothesis was that combination therapy would be the most effective in reducing incontinent episodes. STUDY DESIGN: A randomized clinical trial with three treatment groups was conducted in gynecologic practices at two university medical centers. Two hundred and four women diagnosed with genuine stress incontinence (n = 145) and/or detrusor instability (n = 59) received a 12-week intervention program (6 weekly office visits and 6 weeks of mail/telephone contact) with immediate and 3-month follow-up. Outcome variables included number of incontinent episodes, quality of life, perceived improvement, and satisfaction. Data analyses consisted of analysis of covariance using baseline values as covariates and chi2 tests. RESULTS: The combination therapy group had significantly fewer incontinent episodes, better quality of life, and greater treatment satisfaction immediately after treatment. No differences among groups were observed 3 months later. Women with genuine stress incontinence had greater improvement in life impact, and those with detrusor instability had less symptom distress at the immediate follow-up; otherwise, no differences were noted by diagnosis, incontinence severity, or treatment site. CONCLUSIONS: Combination therapy had the greatest immediate efficacy in the management of female urinary incontinence regardless of urodynamic diagnosis. However, each of the 3 interventions had similar effects 3 months after treatment. Results suggest that the specific treatment may not be as important as having a structured intervention program with education, counseling, and frequent patient contact.     

Transfusion-free treatment of Jehovah''s Witnesses: respecting the autonomous patient''s rights

OBJECTIVES: To find the acceptance and efficacy of our protocol for exercises of the pelvic floor over short and long periods for women with urinary stress incontinence seen at our health centre. DESIGN: A prospective intervention study. SETTING: Marquesado Health Area: a rural zone to the east of Granada. PARTICIPANTS: 72 women between the ages of 20 and 65 with genuine urinary stress incontinence. INTERVENTION: Application of a pelvic physiotherapy procedure of two simple exercises. At the consultation with doctor and nurse on inclusion in the programme, a questionnaire was filled, the exercises were explained and an explanatory leaflet was given out. Nursing staff attended the women on days 1, 2, 7, 15, 25, 40 and 60. MEASUREMENTS AND RESULTS: 72 women with genuine urinary stress incontinence were studied. Their ages ran from 20 to 65 (average 53). 55 women (76.3%) completed the treatment protocol at 60 days. Of these 55, 24 (43.8%) were dry at two months, 12 (21.1%) had improved, 18 (32.7%) experienced no change and 1 (1.8%) reported an increase in her incontinence. We assessed the amount of urine loss, by means of a continence apparatus and through the patients' subjective view. 67.7% of the women with slight incontinence were fully cured, whereas none of those with considerable incontinence were. CONCLUSIONS: Both the efficacy and efficacy of the protocol are highly satisfactory in our community. Our protocol is more efficacious for young women and those with little incontinence.     

The intravaginal slingplasty operation, a minimally invasive technique for cure of urinary incontinence in the female

The aim was to evaluate the intravaginal slingplasty operation, a minimally invasive technique for cure of urinary incontinence. Fifty-four unselected patients, aged from 26 to 79 years, mainly with mixed incontinence symptoms, underwent this procedure. It works by tightening the suburethral vagina ('hammock'), and by creating an artificial pubourethral neoligament. Where indicated, repair of uterine prolapse (24 cases), or infracoccygeal sacropexy (17 cases) was also performed. Almost all patients were discharged on the day of, or day after surgery, without requirement for postoperative catheterization, and returned to fairly normal activities, including jobs, within 7 to 14 days. At a mean follow-up time of 15 months, the cure rates for preoperative symptoms were, frequency 88%, nocturia 77%, urge incontinence 89%, stress incontinence (SI) 85%, symptoms of abnormal emptying, 77%, and reduction of mean residual urine from 67.5 mL to 32 mL. The objective cure rate (exercise pad testing) for stress incontinence was 88.6%; taking the group as a whole, urine loss was reduced from a mean of 11.6 g preoperatively to a mean of 0.5 g postoperatively. Urodynamically diagnosed detrusor instability was not a predictor of surgical failure in this study. According to the concepts presented here, symptoms of urinary dysfunction are mainly symptomatic manifestations of abnormal laxity in the vagina or its supporting ligaments. The surgical methods used to correct these defects are fairly simple, safe and easily learnt by an practising gynaecologist.     

Urinary incontinence and bacteriuria in women

We analyzed the urodynamic data and their relationship with significant bacteriuria in 103 consecutive female patients (mean age = 55.7 yrs) with urinary incontinence. Significant bacteriuria was observed in 25.2% of the cases. E. coli was the pathogen most frequently isolated (70.3%). Significant bacteriuria was demonstrated in 29.3% of the patients with urge-incontinence. The most frequent type of incontinence in patients with bacteriuria was no urodynamic reproduction of urinary incontinence (42.8%). Bladder instability was not associated with significant bacteriuria (27.2%). Significant bacteriuria was observed in 75% of the patients with lower urinary tract obstruction, 66.6% of the patients who voided by abdominal straining and 26.3% of those with postvoiding residual urine. These findings indicate that urine culture should be done in patients with no urodynamic reproduction of urinary incontinence. There was no statistically significant correlation between urge-incontinence/bladder instability and significant bacteriuria. Consequently, antibiotics should not be used routinely in female urinary incontinence.     

Effectiveness of a urinary control insert in the management of stress urinary incontinence: early results of a multicenter study

OBJECTIVES: The purpose of this study was to test the safety and effectiveness of a urethral insert for managing stress or mixed urinary incontinence. METHODS: We performed a prospective, multicenter study of 135 female patients who were treated for 4 months with the Reliance Urinary Control Insert. The effectiveness of the insert was measured objectively at the time of first use and after 4 months' use by standardized pad weight studies. Insert effectiveness was also measured by reports of symptom improvement during patient interviews and on patient diaries. Urine microscopy and culture were obtained monthly; cystoscopy and urodynamics were conducted at study entry and at 4 months. RESULTS: Significant improvement in involuntary urine loss was observed. Objective measurement of urine loss revealed that 80% of the patients were completely dry, and 95% of the patients achieved greater than an 80% decrease in urine loss. In addition, patients' perceptions of acceptability, incontinence symptom improvement, ease of learning, comfort, and time to habituation also showed improvements. Untoward events reported during the study included hematuria, bacteriuria, and bladder irritation. These events did not require significant medical intervention and did not result in any long-term clinical sequelae. CONCLUSIONS: These preliminary results indicate that the Reliance Urinary Control Insert may be a safe, effective, and well-tolerated alternative to other available methods for the management of stress or mixed incontinence in women. Additional long-term follow-up will be required to substantiate this conclusion.     

Halm-Zielke instrumentation for primary stable anterior scoliosis surgery: operative technique and 2-year results in ten consecutive adolescent idiopathic scoliosis patients within a prospective clinical trial

OBJECTIVE: To determine the efficacy and safety of a new continence procedure, tension-free vaginal tape (TVT) placement for surgical treatment of stress urinary incontinence in women. STUDY DESIGN: Eighty-three women with demonstrable stress urinary incontinence underwent a nonrandomized, prospective study using the TVT procedure. The procedure was previously described by Ulmsten et al. In the present study, instead of local anesthesia, epidural blockade with 20 mL of 2% xylocaine was used. Preoperatively the patients were evaluated with a one-hour pad test, full urodynamic testing using either a double-lumen catheter or microtip transducer catheter and were instructed to maintain an one-week baseline urinary diary one week before and two months after the operation. Another one-hour pad test and complete urodynamic evaluation using microtip transducer catheters were offered to 20 patients postoperatively. The period of follow-up ranged from 3 to 18 months. RESULTS: Thirteen women were excluded for various reasons; thus, 70 subjects were enrolled in the study. The urodynamic diagnosis of the 83 women revealed that 71 had genuine stress incontinence, 11 had mixed incontinence and 1 was normal. Mean operation time was 29 minutes (range, 20-51) and mean hospital stay 3 days (range, 2-8). Three bladder perforations occurred intraoperatively. No patients had intraoperative bleeding > 300 mL, but 11 (16%) had blood loss > 200 mL, necessitating an indwelling catheter and vaginal tamponade. No evidence of defect healing or rejection of the tape occurred. Urine leakage observed on the pad test was significantly reduced from a mean of 63 g (range, 10-213) before to a mean of 5 g (range, 0-42) after surgery. The objective cure rate was 83%, and the subjective rate was 87%. CONCLUSION: Although the follow-up period was short, the TVT procedure seemed to be a safe and effective method for the treatment of stress urinary incontinence.     

Use of spiral computed tomography for multiplanar dental reconstruction

This was a community-based study to evaluate the prevalence and characteristics of female urinary incontinence in women aged 18 and above in the Shatin District of Hong Kong. Of a total of 1018 female households contacted, 362 individuals were successfully interviewed and 123 women (34%) reported they had experienced at least one episode of urinary incontinence as adults. Of these, 18.5% reported persistent incontinence and 15.5% reported absence of incontinence after a single episode of urine loss. The risk factors for incontinence revealed by this study were body mass index and parity. Women who had never been incontinent had a lower body mass index and were usually nulliparous. Most of the respondents (43.9%) who had urinary incontinence considered the condition to be a minor problem and did not seek professional advice. This investigation indicates that a territory-wide study should be carried out to determine the incidence of urinary incontinence throughout Hong Kong.     

Failure to control postprostatectomy urinary incontinence by urethral compression

A modification of Kaufman's urinary incontinence device was implanted unsuccessfully in 5 patients. This device achieved passive urinary continence in each of these patients; however, all patients continued to experience moderate to severe stress incontinence. The results of this study challenge the concept that static urethral compression can achieve total urinary continence in patients with postprostatectomy incontinence.     

Regio- and stereoselective synthesis of carbocyclic 2'',3''-dideoxy-3''-fluoro nucleosides as potential antiviral agents

OBJECTIVE: To determine the prevalence of the symptom of urinary incontinence during athletic endeavors among a group of nulliparous, elite college varsity female athletes. METHODS: All women currently participating in varsity athletics at a large state university were asked to fill out a questionnaire about the occurrence of urinary incontinence while participating in their sport and during activities of daily life. One hundred forty-four of 156 eligible women (92%) responded. RESULTS: The mean age was 19.9 years, and all women were nulliparous. Overall, 40 athletes (28%) reported urine loss while participating in their sport. The proportions in different sports were: gymnastics 67%, basketball 66%, tennis 50%, field hockey 42%, track 29%, swimming 10%, volleyball 9%, softball 6%, and golf 0%. Two-thirds of the women who noted urine loss during athletics were incontinent more often than rarely. There were no statistically significant relations between incontinence and amenorrhea, weight, hormonal therapy, or duration of athletic activity. Activities most likely to provoke incontinence included jumping, high-impact landings, and running. Forty percent and 17% of the women first noted incontinence during their sport while in high school and junior high school, respectively. CONCLUSIONS: Incontinence during physical stresses is common in young, highly fit, nulliparous women. This suggests that there is a continence threshold which, when exceeded, can result in urine loss, even in the absence of known risk factors for incontinence.     

A method of determining the specific volume of liposomes with Turnbull blue]

OBJECTIVES: To present the results obtained in patients with stress urinary incontinence treated with periurethral collagen injection. METHODS: 26 female patients with stress urinary incontinence were treated with bovine collagen injection; mean volume 10.8 cc. The results achieved by this therapeutic modality are described herein. RESULTS: Control evaluations performed during a period of one year showed highly satisfactory results had been achieved initially and the success rate gradually increased over the 12 months follow-up. Overall the final results showed a success rate of 34.6%, 38.4% showed frank improvement and 26.9% had a failed procedure. There were no significant differences in the results for both types of stress urinary incontinence. The results correlated with the severity of incontinence; the success rate was higher in the patients with low grade incontinence. CONCLUSIONS: Periurethral collagen injection is indicated in patients with type I and type III stress urinary incontinence who cannot benefit from surgery. Patients with type II stress urinary incontinence, however, do not benefit from this therapeutic modality.     

Patient satisfaction with a reusable undergarment for urinary incontinence

PURPOSE: We investigated patient satisfaction with a reusable undergarment for urinary incontinence. SUBJECTS AND SETTING: One hundred seventy-five participants with reported urinary incontinence from two urology-based clinics at large teaching hospitals and one prostate cancer support group participated in the study. METHODOLOGY: Each participant was given a minimum of one reusable undergarment for urinary incontinence. Participants used the undergarment for an average of 10 days (range 1 to 60 days). During the trial period, subjects alternated the reusable undergarment with their previous urine-containment devices, usually disposable pads, while the undergarment was being washed. Patient satisfaction was evaluated with a questionnaire. PRIMARY OUTCOME MEASURES: Patient satisfaction with the reusable undergarment was measured for six categories: (1) physical comfort, (2) ability to keep skin dry, (3) ability to prevent wet spots, (4) discretion, (5) odor control, and (6) confidence when wearing the garment versus previously used containment devices. RESULTS: Of the 175 subjects, 126 (33% female and 67% male) completed and returned the 7-page questionnaire. All respondents reported at least one urinary incontinent episode while wearing the reusable undergarment. Occurrence and degree of leakage by self-report varied from light leakage (33%) to moderate leakage (48%) and heavy leakage (17%). Patient satisfaction was measured as follows: (1) 83% rated the overall comfort of the undergarment as very good or excellent; (2) 52% said they felt very dry or dry when wearing the product after an incontinent episodes; (3) 75% rated the ability to prevent wet spots on outer clothing as adequate or excellent; (4) 75% rated the discretion of this product as excellent; (5) 80% rated the ability to control odor as adequate or excellent; and (6) 67% felt more confidence with this reusable undergarment than with other products with which they were familiar. CONCLUSION: The reusable garment provided effective containment from urine loss among this group of incontinent women and men.     

Skin disorders and moisture in incontinent nursing home residents: intervention implications

OBJECTIVE: To provide data needed to design an intervention trial to prevent or treat skin disorders in a high risk, incontinent nursing home population. DESIGN: The incidence and prevalence of nine common skin disorders were measured prospectively over a 60-day period using trained observers. Urinary and fecal incontinence frequency were measured over 24 hours, and mobility was measured with subjects both in and out of bed. Direct measures of skin moisture were taken with an impedance device in the presence and absence of urinary incontinence. Multiple regression analyses were used to relate the incontinence and mobility variables to the presence and development of skin disorders. SETTING: Four nursing homes. PARTICIPANTS: One hundred incontinent nursing home residents. MAIN OUTCOME MEASURES: Prospective measures of nine common skin disorders and skin moisture in four perineal regions under continent and incontinent conditions. RESULTS: All subjects had at least one skin condition identified during the 60-day data collection period. The most commonly observed skin condition was blanchable erythema, which occurred in 94% of the subjects, predominantly in the front and back regions that were closest to the urethra and rectum. Twenty-one percent of residents developed either a Stage 1 (nonblanchable erythema) or 2 pressure ulcer. All skin conditions were transient when measured every 3 weeks with the exception of blanchable erythema, which showed stability. Stage 3 or greater pressure ulcers and edema were not observed, and interrater reliability for the measure of papules was poor. Measures of urinary and fecal incontinence severity were correlated with blanchable erythema severity, and blanchable erythema and low bed mobility were predictive of pressure ulcer severity. Blanchable erythema severity was also predictive of Stage 1 and 2 pressure ulcers. Skin moisture levels in the back perineal farthest from the rectum (peripheral) were affected most by urinary incontinence. CONCLUSION: A trial to detect a 50% preventive effect on Stage 1 and 2 pressure ulcers would require that 167 subjects be monitored for 60 days. The transient nature of the skin effects require that skin be monitored at least once a week. Because blanchable erythema is so prevalent and appears to be associated with more severe skin conditions, it would make an excellent marker for beginning to assess the potential preventive effects of various interventions on the incidence of pressure ulcers and other related skin disorders in incontinent patients. It is likely that the back area peripheral to the urethra and rectum would experience the greatest benefit from an intervention trial to reduce moisture caused by incontinence.     

Pelvic floor rehabilitation in women affected with stress urinary incontinence. Authors' experience

BACKGROUND: This study evaluated pelvic floor rehabilitation as a possible treatment for urinary stress incontinence: a challenge to tradition. METHODS: In this study 20 female subjects with urinary stress incontinence had rehabilitation therapy, at first in the outpatients clinic with motivated physiotherapists and afterwards by home exercises. RESULTS: At the end of 3 months of training, stress incontinence had disappeared in 7 patients (35%), while an improvement was recorded in 13 (65%). CONCLUSIONS: In summary, pelvic floor rehabilitation program can be an effective alternative to surgical approach in reducing the frequency of urinary leakage. Further studies are needed to identify factors predicting success and to improve the techniques of pelvic floor rehabilitation.     

Reasons for culling in French Holstein cows

OBJECTIVE: We sought to determine the safety and effectiveness of a new, simple noninvasive device, "FemAssist" for women suffering from urinary incontinence. METHODS: The "FemAssist" is a dome-shaped medical grade silicon device intended to be worn over the external urethral meatus and held in place by suction and an adhesive gel. Thirty eight women with varying degrees of genuine stress urinary incontinence (GSUI) or mixed incontinence on multichannel urodynamic testing were fitted with one of two sizes of "FemAssist" with regard to their anatomy and dexterity. RESULTS: Thus far, of the 38 women who have completed the study, there have been no reported significant increases in bacteriuria or urinary tract infection rates. Over half of the women reported an improvement in the quality of life including comfort, convenience, and overall satisfaction. The device was worn for a total of 886 days by the group; 82% of these were dry days. CONCLUSION: Our preliminary study suggests that the "FemAssist" device is safe and effective for some women with urinary incontinence.     

Cough-induced leak-point pressure--a valid measure for assessing treatment in women with stress incontinence

BACKGROUND: Presently available urodynamic methods are of little use for assessing the severity of urinary stress incontinence or for evaluating of treatment, Cough-induced leak-point pressure may prove to be a more useful urodynamic method in these respects. A vaginal anti-incontinence device was used to validate this new urodynamic method. AIM: The primary aim was to determine the extent to which cough-induced leak-point pressure was affected by the vaginal device. Secondary aims were to study the short-term effects of the vaginal device on leakage and urinary flow, and to relate the change in cough-induced leak-point pressure to the change in leakage as expressed by a short-term pad test. METHODS: In a prospective study of 22 women with a history of stress incontinence, the effect of a new vaginal anti-incontinence device (Conveen Continence Guard) on cough-induced leak-point pressure, a short-term pad test and urinary flow was studied. RESULTS: Cough-induced leak-point pressure increased from 99.9 to 138.9 cm H2O, while leakage, measured by a short-term pad test, decreased from 22.7 to 3.3 g when using the device. Urinary flow was not significantly reduced by the device. CONCLUSIONS: Cough-induced leak-point pressure is a valid, quantitative, dynamic measure of urethral closure function which can be used to study the effects of treatment in patients with stress incontinence. The vaginal device is effective for treatment of stress incontinence in the short-term, without reducing urinary flow.     

Parameters affecting the efficiency of affinity-based reversed micellar extraction and separation (ARMES) in glycoprotein purification

The Bladder Neck Support Prosthesis (BNSP) was used in 21 women with combined genuine stress incontinence (GSI) and detrusor instability (DI). Outcomes included frequency volume charts, pad tests, voiding cystometry and quality of life scores, up to the sixth month. Of the 21 recruits, 5 never wore the BNSP home, leaving 16 participants. A further 2 did not reach week 4 because of poor efficacy or inability to fit the device. In the 14 who reached week 4, the median number of leaks/day declined from 4.3 to 1.0 (p = 0.002). Median pad test loss fell from 53 to 7 mL (p = 0.012). Cystometry showed an increase in maximum bladder capacity (p < 0.05) and a modest reduction in severity of detrusor instability, with no evidence of outflow obstruction. Three further women discontinued because of poor efficacy (2) or a poorly fitting device (1), leaving 11 of 16 participants (69%) at week 8, when median pad test loss fell to 2 mL. The BNSP is a useful option in patients with the unfortunate combination of an unstable bladder and an incompetent urethra, but requires careful fitting and attention to detail.     

Our experience with pubovaginal slings in patients with stress urinary incontinence

PURPOSE: Pubovaginal slings successfully treat stress urinary incontinence in women with intrinsic sphincter deficiency. Because of its durability, it has been an attractive procedure in select patients with urethral hypermobility. We examine our experience with pubovaginal sling. MATERIALS AND METHODS: A total of 150 patients were evaluated for pelvic prolapse and urinary incontinence. An abdominal leak point pressure was determined in all patients. Of patients with type II stress urinary incontinence, 36 patients (80%) underwent additional gynecological procedures at the time of the pubovaginal sling, compared to 29% with intrinsic sphincter deficiency and 33% with coexisting urethral hypermobility and intrinsic sphincter deficiency. RESULTS: The overall cure rate was 93% with a mean followup of 22 months. At 1 week postoperatively spontaneous voiding was accomplished by 56% of the patients with urethral hypermobility and 57% with intrinsic sphincter deficiency. Only 2.8% of patients required surgical therapy for prolonged urinary retention. De novo urgency/urge incontinence occurred in 19% of women with a 3% incidence of persistent urge incontinence. CONCLUSIONS: Pubovaginal slings are effective and durable. Voiding dysfunction is uncommon and is temporary in most patients.