Changes in the Lower Urinary Tract in Continent Women and in Women with Stress Urinary Incontinence, According to Menopausal Status

The aim of this study was to assess the impact of the postmenopausal period on clinical and urodynamic parameters and on the mobility of the bladder neck in continent women and in women with stress urinary incontinence. Fifty-seven postmenopausal women were studied: 30 were continent and 27 had stress urinary incontinence. They were subdivided according to postmenopausal stage into groups A (<5 years) and B (>5 years). Five years was a good marker to separate those women with mild and severe estrogen deficiency. Fifteen premenopausal incontinent women were selected for bladder neck ultrasound as controls. All underwent history, general physical and gynecologic examinations, LH and FSH determinations, type 1 urine and uroculture, circadian voiding diary, cotton-swab test, bladder neck ultrasound and urodynamic investigations. Analysis of the voiding diaries revealed a higher frequency of daytime micturition in both groups of incontinent patients than in the continent ones. Increased bladder neck mobility was also found, both in the cotton-swab test and an ultrasound, in group A and an ultrasound in the premenopausal incontinent women. Urodynamic investigation showed decreased bladder capacity at the first micturition urge, as well as decreased urinary volume in the group A patients compared to the continent ones. Decreased urethral closure maximum pressure was also found in group B patients in relation to the continent ones. We concluded that the effect of hypoestrogenism, manifested postmenopause, causes changes in the lower urinary tract of women, particularly those who are incontinent.     

Evaluation and Management of Lower Urinary Tract Disorders in Women with Multiple Sclerosis

This paper outlines the evaluation and management of the lower urinary tract abnormalities related to voiding function in women with multiple sclerosis (MS). For the pelvic floor reconstructive surgeon, it is important to realize that every patient with MS may have voiding dysfunction unrelated to lower urinary tract symptoms, duration of disease or disability status. Proper evaluation and individualized management of the urinary tract reduces the morbidity and improves the quality of life of patients with this degenerative neurologic disorder.     

Urodynamic Assessment of Voiding Dysfunction and Dysfunctional Voiding in Girls and Women

Voiding dysfunction is defined as impaired bladder emptying, and presents with a mixture of lower urinary tract symptoms. Dysfunctional voiding is a condition in which there is a lack of coordination between the sphincter and detrusor during emptying in a patient without overt uropathy or neuropathy. Assessment of voiding dysfunction is important in women and girls in the prevention and treatment of urinary incontinence, retention, urinary tract infection and subsequent kidney damage. Accurate diagnosis is essential in order to select the correct treatment. Screening can be done by history-taking: symptom scores can help to guide the screening. More objective measures are uroflowmetry, ultrasonography and videourodynamics. The latter is the gold standard for the diagnosis of voiding dysfunction and consists of simultaneous registration of pressure in the bladder and rectum and external sphincter behavior, either by electromyographic recording of pelvic floor activity or by pressure recording at the external sphincter, during the whole bladder cycle of filling and emptying. On fluoroscopy the bladder can be visualized throughout the filling and emptying phase. In dysfunctional voiding, hypertonicity and instability of the external urethral sphincter during filling cystometry and impaired external sphincter relaxation during emptying are pathognomonic findings. Pressure–flow analysis reveals no obstruction and the detrusor contractility is low.     

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.     

The Influence of Posture on Perineal Ultrasound Imaging Parameters

A prospective clinical study was carried out to evaluate the influence of posture on perineal ultrasound imaging parameters. One hundred and thirty-two consecutive women presenting with symptoms of lower urinary tract dysfunction were examined by multichannel videourodynamics and perineal ultrasound, both supine and standing. Ultrasound included color Doppler imaging when available, i.e. in a subgroup of 99 patients. The position of the bladder neck at rest was higher in the supine position (P<0.001) and it descended further on Valsalva (P<0.001), to reach an almost identical final position. There was a higher degree of urethral rotation on supine imaging (P= 0.001). Urethral funneling on Valsalva was more likely in the erect position (P<0.001), as was urine leakage documented by color Doppler imaging (P<0.001). The effect of a pelvic floor contraction was not significantly influenced by posture. Imaging of the urethrovesical junction should be undertaken in both supine and erect positions to document optimally both hypermobility and funneling or leakage.     

Pelvic floor anatomy in classic bladder exstrophy using 3-dimensional computerized tomography: initial insights

PURPOSE: We present the pelvic floor anatomy of the major pelvic floor musculature in classic bladder exstrophy, including the levator ani, obturator internus and obturator externus. By improving our knowledge of pelvic floor anatomy we hope to understand better the relationship of the pelvic floor to the bony anatomy as well as the role of osteotomy in changing pelvic floor anatomy to enhance urinary control after surgery. MATERIALS AND METHODS: 3-Dimensional computerized tomography was done in 6 boys and 1 girl, including 5 patients 2 days to 5 months old (mean age 7 months) undergoing primary closure and 2 who were 4 and 8 years old undergoing repeat closure. The pelvic floor musculature, including the levator ani, obturator internus and obturator externus, in these cases was compared to that in 26 age and sex matched controls. RESULTS: The levator ani musculature encompasses a significantly wider area of 9.5 cm.2 in patients with classic bladder exstrophy than in controls. The anterior segment of the levator ani was shorter (1.2 cm.) and the posterior segment of the levator ani was longer (2.5 cm.) than in controls. The degree of divergence of the levator ani in classic exstrophy was significantly more outwardly rotated (38.8 degrees) than controls. In addition, the transverse diameter of the levator hiatus was 2-fold that in our control group and in that of published controls, while the length of the hiatus was 1.3-fold that in normal controls. There was also significant flattening, involving a 31.7 degree decrease in steepness between the right and left halves of the levator ani, of the puborectal sling in classic bladder exstrophy versus controls. Because of these findings, there is more anterior superior rotation in the pelvic floor in exstrophy cases. The obturator internus was more outwardly rotated (15.1 degrees) in exstrophy and the obturator externus also showed more outward rotation (16.9 degrees) than in controls. CONCLUSIONS: This study provides better understanding of the pelvic floor anatomy in classic bladder exstrophy. Significant differences have been documented in the pelvic floor in classic bladder exstrophy cases and controls. Hopefully these differences may have a pivotal role in providing new insight into long-term issues, such as urinary and fecal incontinence, and pelvic organ prolapse, in classic bladder exstrophy.     

Bladder Neck Mobility and Urethral Closure Pressure as Predictors of Genuine Stress Incontinence

Two hundred and seventy-five consecutive patients with symptoms of lower urinary tract dysfunction underwent urodynamic evaluation, including multichannel urodynamics, urethral pressure profilometry, X-ray and ultrasound imaging. After women with previous incontinence or prolapse surgery or pelvic radiotherapy and those with evidence of urethral kinking on ultrasound had been excluded, 179 datasets were analyzed. Both bladder neck descent (P<0.0001) and maximum urethral closure pressure (P<0.0001) were strongly associated with a fluoroscopic diagnosis of GSI. Only weak correlations between bladder neck mobility and urethral pressure parameters (highest r=−0.17) were observed. Regression analysis yielded a mathematical model that demonstrated a wide spread of odds ratios for GSI for the measured values (from <0.2 to >100). Bladder neck descent explained 29% and urethral closure pressure 12% of overall variability. Both bladder neck mobility and maximum urethral closure pressure are strong predictors of the diagnosis of GSI, provided major confounders are excluded. Bladder neck mobility appears to be the stronger predictor.     

Exstrophy of Bladder Associated with Unilateral Renal Agenesis and Bicornuate Uterus: A Case Report

Upper urinary tract anomalies are rare in patients with classic exstrophy of the urinary bladder. We report a case of bladder exstrophy associated with unilateral renal agenesis and bicornuate uterus in a female patient. The embryological basis for this rarity and its management are discussed.     

Suture Injury to the Urinary Tract in Urethral Suspension Procedures for Stress Incontinence

The case histories of women attending the Urogynecology Department at the Royal Women’s Hospital and Mercy Hospital for Women were reviewed between 1986 and 1998 to determine the incidence and postoperative morbidity caused by suture injury to the urinary tract following urethral suspension surgery for stress incontinence. In our department 1103 Burch colposuspensions and 61 Stamey urethral suspensions have been performed. Intraoperative cystourethroscopy was performed routinely for the early detection and treatment of urinary tract injury. Intravesical sutures were found by routine intraoperative cystoscopy in 1 Stamey suspension, 1 open Burch colposuspension and 3 laparoscopic Burch colposuspensions. Ureteric suture ligation was diagnosed in 2 women intraoperatively and 1 woman postoperatively after laparoscopic Burch colposuspension. Two women presented with late complications from intravesical sutures following open Burch colposuspension. A further 7 women referred with urinary symptoms were found to have intravesical sutures, 2 following Burch colposuspension, 4 following Stamey urethral suspension and 1 following the Marshall–Marchetti–Kranz procedure. Seven of the 9 women diagnosed with intravesical sutures presented with bladder or pelvic pain, frequency or urinary tract infection. Two women had recurrent stress incontinence and were found to have a intravesical suture on routine cystoscopy at the time of stress incontinence surgery. Suture removal, with any accompanying calculus, was achieved cystoscopically with almost immediate resolution of symptoms without loss of urinary control in all cases. Non-absorbable intravesical sutures occurring as a result of suture misplacement or erosion is an infrequent but important complication of stress incontinence surgery, but should be suspected if pain and irritative bladder symptoms or recurrent urinary infection occur postoperatively. Cystourethroscopy performed intraoperatively or postoperatively is essential for early diagnosis and treatment.     

MRI of voluntary pelvic floor contractions in healthy female volunteers

The dynamic anatomical response of the normal pelvic floor to voluntary pelvic floor contractions was documented using magnetic resonance imaging. Sequences of coronal, sagittal and transverse images in the relaxed and the contracted state were obtained from 17 young, asymptomatic volunteers trained to perform pelvic floor exercises correctly. The images were processed digitally and computer colored to indicate dynamic changes produced as a result of contractions. Gross transverse sections through a human female cadaver were photographed and digitized to provide a reference of pelvic anatomy. A 3D rendition of the processed MR images was made to illustrate the extent of pelvic floor contraction. The results illustrate the changes produced by voluntary pelvic floor contractions in all planes scanned. Quantitative measurements of selective structures around the bladder were made to show the magnitude of pelvic floor displacement during contraction. The dynamic imaging illustrates the extent of changes in the normal pelvic floor that are produced by pelvic floor exercises and give a measure of the displacement of the bladder and the levator ani.Editoral Comment: Magnetic resonance imaging has recently been found useful in the evaluation of the pelvic floor in patients with stress incontinence. Firm, convincing information in normal subjects has been lacking, however. This study of normal volunteers provides a great deal of information on the activity of the pelvic floor. We are grateful to the authors for the opportunity to present these illustrations in color. They are to be congratulated on this fine study and we trust that they will also provide similar information in stress incontinent and prolapse patients in the future.     

Conservative Treatment of Stress Urinary Incontinence in Women: Who will Benefit?

The aim of the study was to find out which factors can predict the outcome of conservative treatment of urinary stress incontinence in women. One hundred and four women with stress urinary incontinence were evaluated by recall, and by clinical and urodynamic investigation and were given pelvic floor muscle exercises with or without the use of biphasic low-frequency electrostimulation and visual biofeedback. Two groups could be distinguished. The first consisted of 37 patients in whom conservative therapy proved successful; the second consisted of 67 patients in whom incontinence continued. The study investigated whether there was a significant difference in patients’ characteristics between the two groups. The number of conservative treatment sessions was not different between the two groups. The presence of a high body mass index, previous pelvic surgery, strong levator muscles and urethral hypermobility appeared to be poor prognostic features. More research is required to evaluate which patients can benefit from conservative treatment and which criteria can predict the outcome of pelvic floor physiotherapy in women with stress incontinence. This way, patients selection is possible and excessive costs can be saved.     

Simultaneous Upper and Lower Urinary Tract Obstruction Associated with Severe Genital Prolapse: Diagnosis and Evaluation with Magnetic Resonance Imaging

Genital prolapse causing both urethral and ureteral obstruction is an infrequent occurrence, especially in the absence of uterine prolapse. We report on a patient with massive genital prolapse causing both urethral and ureteral obstruction in whom magnetic resonance imaging demonstrated the level of obstructive uropathy and, after surgical repair of the prolapse, confirmed restoration of the normal pelvic and upper urinary tract anatomy.     

Prevalence of Urinary Incontinence During Pregnancy and Postpartum

The purpose of the study was to investigate the prevalence of urinary incontinence during pregnancy and the postpartum, and to examine postpartum pelvic floor muscle strength. Eight weeks postpartum the prevalence of urinary incontinence and pelvic floor muscle strength was registered. All women in a Norwegian community, delivering at the local hospital during a 1-year period, were included in the study. The final study group consisted of 144 women (72%). Data concerning the prevalence of urinary incontinence was collected by a structured interview and clinical assessment (pad test) 8 weeks postpartum. Pelvic floor muscle strength was also measured. The prevalence of urinary incontinence during pregnancy was 42%. Eight weeks after delivery the prevalence of self-reported urinary incontinence was 38%. There was a difference between self-reported symptoms and urinary incontinence as assessed by the pad test. Symptoms of fecal incontinence postpartum were reported by 6 women (4.2%). The prevalence of urinary incontinence was found to be nearly the same 8 weeks postpartum as during pregnancy. This documents the need for a strategy to prevent and treat urinary incontinence during these periods.     

Asymptomatic Microscopic Hematuria in Women: Case Series and Brief Review

Recommendations for the work-up of asymptomatic microscopic hematuria (AMH) often derive from studies including both men and women. This study was undertaken to determine whether that work-up is appropriate for a female patient population. We studied 49 women referred to a urogynecologist for AMH. Patients underwent formal urinalysis, urine culture and cytology, cystoscopy, and either renal ultrasound or intravenous urography (IVU). Highly significant lesions diagnosed were one renal cell carcinoma and one acute tubular necrosis (ATN). Moderately significant lesions included one candidal urinary tract infection. Insignificant lesions included bladder inflammation in 46 patients and renal cysts in 5. Our findings confirm the importance of the work-up of AMH in women. Ultrasound was effective in diagnosing upper tract lesions, with less cost and morbidity than IVU. Larger studies are needed to determine who should be screened, whether the work-up should differ for younger women, possible treatments for benign findings, and appropriate follow-up.     

Pharmacologic Causes of Female Incontinence

The etiology of female urinary incontinence is complex and multifactorial. Many medications have adverse effects on the lower urinary tract, including the promotion of incontinence in certain women. Medications may cause incontinence through three main mechanisms: decreased intraurethral pressure, increased intravesical pressure, and indirect effects on the lower urinary tract. Careful adjustments of a patient’s medications based on a knowledge of pharmacologic mechanisms of action may restore continence in some women.     

Urodynamic Techniques

Appropriate investigation is essential to a full evaluation of any patient with urinary incontinence, as accurate diagnosis leads to correct treatment. This paper describes the various investigations for lower urinary tract dysfunction, and their main indications. They include the pad test, uroflowmetry, subtracted cystometry, and more complex investigations such as videocystourethrography, ambulatory urodynamics, urethral pressure profilometry, magnetic resonance imaging and electromyography. Although not every patient requires extensive investigation, appropriate use of tests of lower urinary tract function provides useful information on which to base appropriate treatment.     

Management of the Very Weak Pelvic Floor. Is there a Point?

Conservative treatment in the form of pelvic muscle exercises is effective in the treatment of stress urinary incontinence. There are no studies specifically looking at women who have extremely weak pelvic muscles and their response to conservative treatment. This study looks at the effectiveness of pelvic muscle therapy in women with very weak pelvic muscles. Out of 965 women attending the bladder clinic at Kirwan Hospital, 219 were assessed to have weak pelvic muscles by digital palpation. All patients were subjected to a detailed urogynecological questionnaire, a frequency/volume chart, and clinical assessment. All patients were then given detailed verbal and written instructions on good bladder habits, including posture, dietetic habits and pelvic muscle exercises. Of the 219 women, 163 were able to complete their treatment and presented for review. Out of 163 women 118 (72%) reported a subjective improvement; 89 (54%) demonstrated an objective improvement in pelvic muscle strength. Correspondence and offprint requests to: Assoc. Prof. Rane, Department of Urogynecology, 100 Angus Smith Drive, Douglas, Townsville, 4812, Queensland, Australia.     

Reconstructive surgery of the lower urinary tract following exenterative resection of gynecological tumors

Summary In locally advanced or recurrent tumors of the female genital tract anterior or total exenteration may be mandatory in case of tumor invasion into the lower urinary tract or if a second course of radiation therapy is not feasible. The management of resection and reconstruction of the affected lower urinary tract has to be well integrated into the gynecological therapeutic concept. In 11/32 patients the reconstruction of the partially resected lower urinary tract was feasible with preservation of a functionally intact urinary bladder. Urinary diversion following pelvic exenteration was achieved in 13/17 patients with a continent urinary reservoir and in 4/17 patients with an ileal conduit. Operative reinterventions were needed only in patients with continent urinary diversion in 5 cases. All these patients had a past history of primary radiation therapy of their gynecological tumor. In the remaining other 11 patients with a history of primary radiation therapy no complications occurred. 9 of 32 patients survived the operative procedure 40,8 (25–57) month with no evidence of recurrent tumor. Continent urinary diversion represents an excellent therapeutic option for replacement of function lost due to exenterative pelvic surgery. Stringent selection of patients is mandatory to consider the presented therapeutic concept a reasonable tool in the management of the described clinical situations.      

Video urodynamics using transrectal ultrasonography for lower urinary tract symptoms in women

AIMS: To understand the properties of lower urinary tract disorders in women, we evaluated 60 female patients with lower urinary tract disorders or symptoms of recurrent cystitis by free uroflowmetry and video urodynamics using transrectal ultrasonography (VU-TRUS). METHODS: Results of urodynamic studies or symptoms of stress incontinence were used to divide 60 women into 7 normal controls and 53 with voiding dysfunctions. RESULTS: In normal controls, VU-TRUS showed that the mean posterior urethrovesical angle and anteroposterior diameter of the proximal urethra at maximum flow was 151.4 degrees and 4.9 mm, respectively. In patients with voiding dysfunction, VU-TRUS during voiding revealed various urethral abnormalities, including 16 detrusor sphincter dyssynergia, 4 detrusor bladder neck dyssynergia, and 13 insufficient opening of the entire urethra. VU-TRUS also showed pelvic floor abnormalities, including 24 urethral hypermobilities (group 1) and 11 cystoceles (group 2). Eighteen patients had neither urethral hypermobility nor cystocele (group 3). Major pressure-flow abnormalities in the 53 patients with voiding dysfunctions were weak detrusor (72%) and/or bladder outlet obstruction (25%). There were no significant differences in the distribution of the pressure-flow abnormalities among the three groups. However, the mean values of abdominal pressure at maximum flow of group 1 (20.9 cm H(2)O) and group 2 (17.9 cm H(2)O) were significantly higher than that of group 3 (6.3 cm H(2)O; each P < 0.05). The mean values of residual urine volume of group 2 (60.8 mL) and group 3 (77.6 mL) were significantly higher than that of group 1 (23.5 mL; each P < 0.05). CONCLUSIONS: The symptoms of women with lower urinary tract disorders were frequently accompanied by urethral and/or pelvic floor abnormalities during voiding that were clearly detected by VU-TRUS. VU-TRUS is useful for objective evaluation of female lower urinary tract symptoms.     

Effects of Epidural Analgesia on Pelvic Floor Function after Spontaneous Delivery: A Longitudinal Retrospective Study

The aim of the study was to assess the effects of epidural analgesia on pelvic floor function. Eighty-two primiparous women (group 1, consisting of 41 given an epidural, and group 2 of 41 not given an epidural) were investigated during pregnancy and at 2 and 10 months after delivery by a questionnaire, clinical examination, and assessment of bladder neck behavior, urethral sphincter function and intravaginal/intra-anal pressures. The prevalence of stress urinary incontinence was similar in both groups at 2 months (24% vs. 17%, P = 0.6) and 10 months (22% vs. 7%, P = 0.1), as was the prevalence of decreased sexual vaginal response at 10 months (27% vs. 10%, P = 0.08). Bladder neck behavior, urethral sphincter function and intravaginal and intra-anal pressures showed no significant differences between the two groups. Ten months after spontaneous delivery, there were no significant differences in the prevalence of stress urinary incontinence and decreased sexual vaginal response, or in bladder neck behavior, urethral sphincter function and pelvic floor muscle strength between women who had or had not had epidural analgesia. RID="*" ID="*"^*This author participated equally to this publication. Correspondence and offprint requests to: Dr Sylvain Meyer, Urogynecology Unit, Department of Gynecology and Obstetrics, CHUV, 1011 Lausanne, Switzerland. Tel: +(41) 21.803.23.29; Fax: +(41) 21.804.23.17; E-mail: Sylvain.Meyer@chuv.hospvd.ch