Delayed suture intravesical migration as a complication of a stamey endoscopic bladder neck suspension

We report our experience with two cases of latemigration of the suture and bolster occurring 2years after a modified Stamey endoscopicbladder neck suspension. Delayed migration ofthe suture and bolster after an endoscopicbladder neck suspension across tissue planes,with subsequent erosion into the bladder, isuncommon. Recurrent urinary tract infection andmild suprapubic discomfort were the onlysymptoms. Cystoscopy was the only helpfuldiagnostic tool and should be considered earlyin the evaluation of this kind of patients. Themechanism of migration of the cuff and theoperative technique are discussed.     

Side effects,feasibility, and adherence to treatment during home-managed electrical stimulation for urinary incontinence: a Norwegian national cohort of 3,198 women

AIM: To analyze side effects, feasibility, and adherence to treatment during home-managed electrical stimulation for urinary incontinence in women. METHODS: This was a prospective study of 3,198 Norwegian women treated with home-managed electrical stimulation from 1992 to 1994. Data were collected from both patients and physicians by questionnaires before and after treatment. RESULTS: Eighty-nine percent of the patients found the stimulator easy or acceptable to use. Fifty percent had no or little discomfort from stimulator use. Nine percent found the stimulator very unpleasant, difficult, or impossible to use. Fifty-one percent had one or more side effects related to the treatment, most of them mild. A wide range of side effects was reported; the majority of which related to local discomfort. Three hundred and six patients (12%) discontinued treatment. A total of 79% of the patients recommended the treatment to other women with similar problems. CONCLUSIONS: Home-managed electrical stimulation was practicable and well accepted. Half of the patients reported various degrees of side effects with treatment, but no serious events were reported.     

Urethral pressure profile: Is it affected by position?

The aim of this study was to investigate the difference between sitting and standing passive urethral pressure measurements, and to determine the accuracy of urethral pressure profilometry in each position. Urethral pressure profilometry was performed in the sitting and standing position in 98 women. Stress incontinence due to urethral sphincter incompetence was demonstrated in 59 of whom 6 also had detrusor instability. The others were normal volunteers (7), women with a normal cystometrogram (23), and women with detrusor instability (9). MUCP tended to be higher in the standing than the sitting position but this did not reach statistical significance. Urethral lengthening appeared to occur on standing with a mean increase of FUL of 5 mm on standing. For both FUL and MUCP, there was a wide variation in the difference between sitting and standing values. There was poor reproducibility of measurements of MUCP and FUL in the standing position, limiting its clinical applicability. The difference between sitting and standing MUCP and FUL was not affected by age, parity, weight, height, BMI, or oestrogen status. In women with genuine stress incontinence, there was less difference between sitting and standing MUCP, but this explained only a small part of the variability. The increase in FUL in the standing position was unaffected by diagnosis.     

Selective suppression of sphincter activation during sacral anterior nerve root stimulation

The purpose of this work was to electrically activate small-diameter motor fibers in the sacral anterior roots innervating the urinary bladder, without activating the large-diameter fibers to the sphincter. Quasitrapezoidal current pulses were applied through tripolar spiral nerve electrodes on selected anterior sacral roots during acute experiments on eight dogs, maintained under pentobarbital anesthesia. Pressures were recorded from the bladder and sphincter with catheter-mounted gauges. Stimulation with biphasic quasitrapezoidal pulses showed decrease in sphincter recruitment with increasing pulse amplitudes. The minimum current amplitude that resulted in maximum sphincter suppression was used to stimulate the roots with trains of 20 Hz pulses, with 60 mL of saline filling the bladder. Pressures were also recorded when 100 micros rectangular pulse trains at 20 Hz, both continuous and intermittent, were applied. Trains of stimuli were applied before and after dorsal root rhizotomy. Suppression of sphincter activation was defined to be a percentage, [(Maximum pressure -Minimum pressure)/Maximum pressure x100. The results from 22 roots in eight animals show that with single pulses, the average percentage suppression of sphincter activation was 76.3% (+/-14.0). The minimum current for maximum sphincter suppression was 1.29 mA (+/-0.62). The average bladder pressure evoked was 50 cm of water during pulse train stimulation, with no significant difference due to pulse type. With pulse trains, the sphincter pressures were significantly higher when the bladder was filled. Evacuation of fluid occurred in three animals with average flow rates of 1.0 mL/s.     

Bother arising from urinary frequency in women

Patients commonly express bother with the symptom of frequent urination. The relationship between actual voiding frequency and this symptom is undocumented. We reviewed records of 200 women who had completed 24-hour frequency-volume charts, and had indicated their degree of bother with urinary frequency utilizing the short form of the Urogenital Distress Inventory. The degree of bother was correlated with daytime and nighttime voiding frequency, maximum functional capacity, mean voided volume, and demographic variables. Among 200 women, 180 (90%) indicated at least a minor degree of bother with urinary frequency. A voiding frequency of eight or more times in 24 hours was reported by 166 (83%) of women. Among the 34 women voiding fewer than eight times/24 hours, 26 (76%) reported bother with urinary frequency. There was large variation in the degree of bother reported at a given voiding frequency. Postmenopausal women without hormone replacement therapy (HRT) recorded more nighttime voids than those on HRT. Among postmenopausal women without HRT, mean voided volume and maximum functional capacity were inversely related to patient age. Our study suggests that the currently utilized cutoff value of eight daily voids to define urinary frequency, may not be helpful in the management of women in this country. A racially diverse study of the voiding habits of asymptomatic North American women is mandated.     

The risk of lower urinary tract symptoms five years after the first delivery

AIM of the STUDY: To estimate the prevalence and 5-year incidence of lower urinary tract symptoms (LUTS) after the first delivery and to evaluate the impact of pregnancy per se and delivery per se on long-lasting symptoms. MATERIALS and METHODS: A longitudinal cohort study of 305 primiparae questioned a few days, 3 months, and 5 years after their delivery. The questionnaire used was tested and validated, and the questions were formulated according to the definitions of the International Continence Society (ICS). Maternal, obstetric, and neonatal data concerning every delivery and objective data concerning surgeries during the observation period were obtained from the records. From the sample of 278 women (91%) who responded 5 years after their first delivery, three subpopulations were defined: 1) women without initial LUTS before or during the first pregnancy or during the puerperal period, 2) women with onset of LUTS during the first pregnancy, and 3) women with onset of LUTS during the first puerperium. The risk of LUTS 5 years after the first delivery was examined using bivariate analyses. The obstetric variables in the bivariate tests with a significant association with long-lasting urinary incontinence were entered into a multivariate logistic regression. RESULTS: The prevalence of stress and urge incontinence 5 years after first delivery was 30% and 15%, respectively, whereas the 5-year incidence was 19% and 11%, respectively. The prevalence of urgency, diurnal frequency, and nocturia 5 years after the first delivery was 18%, 24%, and 2%, respectively, whereas the 5-year incidence was 15%, 20%, and 0.5%, respectively. The prevalence of all LUTS except nocturia increased significantly during the 5 years of observation. The risk of long-lasting stress and urge incontinence was related to the onset and duration of the symptom after the first pregnancy and delivery in a dose-response-like manner. Vacuum extraction at the first delivery was used significantly more often in the group of women with onset of stress incontinence during the first puerperium, whereas an episiotomy at the first delivery was performed significantly more often in the group of women with onset of stress incontinence in the 5 years of observation. The prevalence of urgency and diurnal frequency 5 years after the first delivery was not increased in women with symptom onset during the first pregnancy or puerperium compared with those without such symptoms. The frequency of nocturia 5 years after the first delivery was too low for statistical analysis. CONCLUSION: The first pregnancy and delivery may result in stress and urge incontinence 5 years later. Women with stress and urge incontinence 3 months after the first delivery have a very high risk of long-lasting symptoms. An episiotomy or a vacuum extraction at the first delivery seems to increase the risk. Subsequent childbearing or surgery seems without significant contribution. Long-lasting urgency, diurnal frequency, or nocturia cannot be predicted from onset during the first pregnancy or puerperium.     

Identifying cut-off scores with neural networks for interpretation of the incontinence impact questionnaire

We propose to determine cut-off scores for the Incontinence Impact Questionnaire (IIQ) based on the neural network (NN) approach. These cut-off scores should discriminate between patients having poor, moderate, or good quality of life (QoL) secondary to their incontinence problems. Data from two prospectively completed QoL questionnaires, the IIQ (n = 237) and the MOS 36-Item Short-Form Health Survey (SF-36) (n = 237), were analyzed using NN and conventional statistical tools. Kohonen networks identified three distinct clusters of IIQ scores. The three clusters represent the full spectrum of possible scores on the IIQ. We interpreted these clusters as reflecting good, moderate, and poor QoL. We estimated that a score of less than 50 on the IIQ would be representative of good QoL, between 50 and 70 would be moderate QoL, and greater than 70 would be indicative of poor QoL. Validation with the SF-36 data confirmed these categories. The present study demonstrated that the NN approach is opening new areas in the interpretation and clinical usefulness of QoL questionnaires. NN allowed the identification of three levels of QoL and should be useful in clinical decision making.     

Relationship between Stress Urinary Incontinence and Pelvic Organ Prolapse

We investigated the objective coexisting rate of stress urinary incontinence and pelvic organ prolapse, and also compared the treatment outcomes in patients who had both conditions, treated by a corrective operation on the basis of a precise preoperative evaluation. We reviewed 97 cases who underwent urodynamic studies and evaluation of the prolapse according to the Pelvic Organ Prolapse Quantification (POP-Q) system from among patients who were admitted for treatment of either stress urinary incontinence or pelvic organ prolapse. A Burch urethropexy, either alone or with a parvaginal repair, was done to correct the stress urinary incontinence, as well as additional operations to correct prolapse of stage II or more. The patients were evaluated postoperatively for the stress urinary incontinence and the degree of prolapse at every visit. Nineteen of 30 (63.3%) patients who were admitted with stress urinary incontinence had a coexisting pelvic organ prolapse, most often of the anterior wall. In 42 of 67 (62.7%) cases admitted with pelvic organ prolapse there was a coexisting stress urinary incontinence. A total of 61 patients who had both conditions were followed for 12 months postoperatively. The recurrence rate of stress urinary incontinence and prolapse (all of which were stage II) was 3.3% and 18.0%, respectively. It was noted that the greater the preoperative stage, the higher the recurrence rate (stage II 4.35%; stage III 25.0%; stage IV 33.6%). The coexisting rates of pelvic organ prolapse in patients having stress urinary incontinence, and stress urinary incontinence in patients having a pelvic organ prolapse, were both high. Therefore, when a preoperative evaluation that simultaneously considers both conditions and the correcting surgery is based on this evaluation, the recurrence rates of both conditions could be lowered.     

Stereoselective urinary excretion of formoterol and its glucuronide conjugate in human

AIMS: Formoterol is an inhaled beta2-adrenoceptor agonist used as a racemic mixture of the active (R; R)- and inactive (S; S)-enantiomers (rac-formoterol). Glucuronidation is an important route of metabolism in humans which occurs faster for (S; S)-formoterol in human liver microsomes. The aim of this study was to investigate the stereoselectivity of urinary excretion of formoterol and its glucuronide conjugate after oral dosing with rac-formoterol. METHODS: Seven nonsmoking volunteers (six males, one female) were included in the study. After an overnight fast, a single 60 micro g oral dose of rac-formoterol fumarate dihydrate was ingested. Urine samples were collected at 1 h intervals for the first 4 h, and at 6, 8, 12 and 24 h after dosing. Formoterol enantiomers were analysed by chiral h.p.l.c. assay and formoterol glucuronides were determined as formoterol enantiomers after enzymatic cleavage with beta-glucuronidase. RESULTS: The female subject displayed a different pattern of metabolism and statistical analysis was therefore limited to data for the six males. The median (range) of the total urinary excretion of formoterol was 37.8% (20.9-51.2%) of the dose. The medians (ranges) of the amounts of (R; R)- and (S; S)-formoterol and of (R; R)- and (S; S)-formoterol glucuronide excreted were 2.1 (1.0-2.9), 3.5 (2.6-3.8), 21.0 (13.1-31.0) and 10.3 (4.2-14.6)%, respectively, of the dose. Unchanged (S; S)-formoterol excretion was significantly greater than that of unchanged (R; R)-formoterol and (R; R)-formoterol glucuronide excretion was significantly greater than that of (S; S)-formoterol glucuronide. The total RR-formoterol (unchanged drug plus glucuronide) excreted was significantly greater than the total (S; S)-formoterol. CONCLUSIONS: Our study demonstrates that the urinary excretion of formoterol in male humans after oral administration of rac-formoterol is stereoselective with preferential excretion of the active (R; R)-formoterol as unchanged drug and glucuronide. The different pattern of metabolism in the female subject provides impetus for further studies of the effect of gender on the stereoselective metabolism and pharmacokinetics of formoterol.     

Determination of the relative bioavailability of salbutamol to the lungs and systemic circulation following nebulization

AIMS: Clinical studies comparing nebulized drug delivery systems could be flawed because of the high doses used. We have compared lung and total systemic delivery of salbutamol from a nebuliser with that from a metered dose inhaler by measuring urinary recovery of drug and its sulphate metabolite. METHODS: Twelve healthy volunteers provided urine samples at 0, 0.5, 1, 2, 4, 8, 12 and 24 h after the start of dosing. Formulations and doses were 5 x 100 microg oral solution (ORAL), 5 x 100 microg from a metered dose inhaler (MDI), 2.5 mg using a nebuliser (NEB) and NEB with 25 g oral charcoal (NEBC). Each study phase was separated by 7 days and the order of dosing was randomized. RESULTS: Mean (s.d.) 30 min urinary salbutamol excretion after ORAL, MDI, NEB and NEBC was 0.4 (0.7), 12.1 (3.7), 15.0 (3.9) and 18.2 (5.7) microg, respectively (all P<0.001 compared with ORAL). When normalized for the dose available for inhalation from MDI, NEB and NEBC, the mean (s.d.) 30 min urinary excretion of salbutamol was 2.4 (0.7), 2.9 (0.6) and 2.7 (0.6)%, respectively, with a mean ratio (90% confidence interval) between NEB and NEBC, of 95.3 (91.1, 99.5)%. The mean (s.d.) excretion of salbutamol plus its metabolite over 24 h post ORAL, MDI, NEB and NEBC dosing was 297.9 (38.3), 290.3 (41.4), 266.5 (44.6) and 151.7 (40.9) microg, respectively. The mean ratio (90% confidence interval) between MDI and ORAL, and NEB and ORAL were 97.5 (94.1, 101.0) and 90.7 (81.2, 100.2)%, respectively. The NEBC data indicate that 6.07 (1.04)% of the nominal nebulized dose was delivered to the lungs. CONCLUSIONS: The 30 min urinary recovery of salbutamol, an index of the relative systemic bioavailability of salbutamol following inhalation, can be used to compare the lung deposition of nebulized systems. Similarly, the urinary 24 h recovery of salbutamol plus its metabolite, an index of the relative systemic bioavailability of salbutamol following inhalation, can be used to compare the delivery of nebulized drug to the systemic circulation.