Transrectal ultrasound versus cystography in the evaluation of anatomical stress urinary incontinence

Thirty-two female patients with clinical and urodynamic findings of genuine stress urinary incontinence were evaluated before and 6 months after surgery for stress urinary incontinence. Twenty-nine control patients had identical evaluations before and 6 months after surgery which did not involve the urethrovesical junction. Twenty-four patients with primary bladder instability had similar evaluations and served as a second control group. Anatomical landmarks indicating support to the urethrovesical junction were evaluated by the position of the urethra at the most dependent point in the bladder on straining and the urethral descent on straining to beneath the posterior ramus of the symphysis pubis on bead chain cystography. The urethrovesical junction drop on straining was evaluated by transrectal ultrasonography. Cystographic and ultrasonographic tests for the position of the urethrovesical junction at the most dependent position in the bladder during straining were very sensitive in women with stress urinary incontinence (94 and 87% respectively) but much less specific (45 and 48% respectively). When evaluating anatomical support to the urethrovesical junction and its descent on straining, these tests were both highly sensitive (97 and 94% respectively) and specific (76 and 96% respectively) in women with genuine stress urinary incontinence. Simple clinical tests for support of the urethrovesical junction, such as the Q tip test, are non-specific in patients with stress urinary incontinence. Transrectal ultrasonography is a simple and quick out-patient procedure. The availability of ultrasound equipment in most clinics and the high sensitivity and specificity of the test make it an attractive and cost-effective alternative to X-ray cystography in the pre-operative evaluation of anatomical support to the urethrovesical junction.     

Low urethral pressure and stress urinary incontinence in women: risk factor for failed retropubic surgical procedure

Nineteen women with stress urinary incontinence (SUI) and low urethral pressure were compared with 106 patients with SUI and normal urethral pressure. All underwent either a revised Pereyra procedure or Burch retropubic urethropexy, and all had detailed clinical and urodynamic evaluations before their operation and one year postoperatively. Surgical procedures effectively stabilized the bladder base and enabled adequate abdominal pressure transmission to the urethra in both groups of women. In spite of these urodynamic findings, the failure rate in women with stress urinary incontinence and low urethral pressure was significantly higher compared with women with good urethral pressure (50% vs 23% for the Pereyra procedure and 33% vs 12% for the Burch procedure [p less than 0.05]), indicating an etiology for their incontinence other than poor support to the urethrovesical junction; therefore, the need for another approach to cure stress incontinence.     

Correlation between urodynamics and perineal ultrasound in female patients with urinary incontinence

AIMS: We performed urodynamics and perineal ultrasound in female patients with urinary incontinence to assess morphology and function of the bladder base-urethra complex and of the detrusor muscle, and to find the correlation between these investigations in the diagnosis of (a) bladder neck and urethral hypermobility and (b) detrusor overactivity; we wanted to compare the tolerabililty of the urodynamic investigation and of the perineal ultrasound. METHODS: We considered 66 female patients referred to our outpatient clinic for urinary incontinence; we also studied 14 healthy control patients. After accurate case-history collection and physical examination, urodynamic investigation and perineal ultrasound were performed, with recording of parameters specific to both investigations. The statistical analysis was performed by ANOVA, Bonferroni post hoc test, and Spearman correlation test. The tolerability index between the diagnostic investigations performed was assessed by a 3-point scale suggested by the patient. RESULTS: In patients with stress incontinence the posterior urethro-vesical angle, the angle of urethral inclination, and the proximal pubo-urethral distance are significantly different under stress compared to the resting phase; in patients with urge incontinence, the detrusor wall is thicker and is accompanied by an increase in opening detrusor pressure and detrusor pressure at maximum flow; it is also accompanied by detrusor overactivity with increased urethral functional length. Increased urethral functional length is suggested on axial US images by alteration of its normal characteristic target-like appearance with four concentric rings of different echogenicity. In all cases the tolerability of perineal ultrasound has been higher than that of urodynamics. CONCLUSIONS: There is a good correlation between urodynamic and perineal ultrasound in the diagnosis of bladder neck and urethral hypermobility; perineal ultrasound can also be useful in the diagnosis of urge incontinence. Functional compressive urethral obstruction can be diagnosed on the basis of the ultrasound aspect of the urethral sphincter.     

Laparoscopic burch repair compared to laparotomy Burch for cure of urinary stress incontinence

Sixty-two women underwent either laparoscopic Burch urethropexy or open Burch urethropexy for surgical correction of genuine stress urinary incontinence. Only patients with no prior incontinence surgery and with demonstrated genuine stress incontinence were included. Clinical evaluations were done preoperatively, at 3 months and 1 year postoperatively for objective cure. The preoperative evaluation included a 24-hour urolog, urology questionnaire, Q-tip test, cough stress test, perineal ultrasound, cystourethroscopy and simple-channel cystometrics. At follow-up all patients had repeat Q-tip test, perineal ultrasound and cough stress test. If there was any sign of leaking a repeat single-channel cystometrogram was done. Only patients with a negative objective study were considered cured. Differences in laparoscopic versus laparotomy cure rates at 1 year were insignificant (94% versus 93%). Both procedures stabilized the urethrovesical junction and prevented its descent during straining, as demonstrated by the postoperative Q-tip test and the perineal ultrasound. The two bladder procedures had comparable operative times but patients with laparoscopy voided earlier, were outpatients, and returned to work earlier. In conclusion, short-term results suggest that the laparoscopic Burch urethropexy can give similar results to laparotomy Burch urethropexy for correction of genuine stress incontinence.Editorial Comment: This is one of the more complete comparative studies of the laparoscopic and open Burch procedures. Although the study is not prospectively randomized, nor were sophisticated urodynamic studies done in all patients, it contains valuable pre- and postoperative information, particularly about the correction of urethrovesical junction mobility as measured by perineal ultrasound. This test demonstrated that both procedures are equally successful in stabilizing the urethrovesical junction. Unfortunately, the cure of stress incontinence was based on stress test alone, with only 4 patients having a CMG postoperatively. By that standard the cure rates of both procedures do not differ. However, we should be cautious in recommending the laparoscopic procedures of research protocols until a prospective randomized comparison utilizing objective urodynamic studies is available. The American Urogynecologic Society has such a multicenter study under way, and we await the results.     

Urodynamic appraisal of the Marshall-Marchetti test in women with stress urinary incontinence

To determine the reliability of the Marshall-Marchetti test as a diagnostic and prognostic preoperative screening test for stress urinary incontinence, the changes observed in urethral pressure profiles under resting and stressful situations were recorded and compared following varying degrees of elevation of the urethra and the urethrovesical junction. The characteristic similarity of changes was evident in the functional profile length, urethral closure pressure, and cough pressure profile of the urethra during performance of the Marshall-Marchetti test and intentional urethral occlusion. This study clearly invalidated the Marshall-Marchetti test by objectively demonstrating that the Marshall-Marchetti test restored continence under stress of coughing by occluding the urethra and the urethrovesical junction.     

The pathophysiology of genuine stress incontinence

Urinary continence in the female is maintained as long as intraurethral pressure exceeds bladder pressure. The elements which maintain this condition at rest and during stress include: internal urethral sphincter, external urethral sphincter, anatomic support of the urethrovesical junction, and intact innervation. Urethral junction and presence of genuine stress incontinence may be best assessed by measurement of resting and stress urethral closure pressure profiles using multichannel urodynamic testing. The findings subsequent to urethral closure pressure profilometry influence the kind of therapy selected, including types of surgery, when this treatment option is chosen.     

The outcome of transvaginal cystourethropexy in patients with anatomical stress urinary incontinence and outlet weakness

Preoperative urodynamic and radiographic evaluation identified features of bladder neck and urethral weakness in 62 women undergoing cystourethropexy for the correction of anatomical stress urinary incontinence. Despite the coexistence of anatomical and outlet factors persistent stress incontinence due to intrinsic urethral weakness occurred in only 2 patients (3%), neither of whom was identifiable by preoperative urethral function evaluation. Preoperative coexisting urgency symptoms had no impact on the surgical outcome, resolving in the majority of patients with sensory urgency and responding to alternate postoperative management in those with bladder instability. We conclude that anatomical correction by cystourethropexy is appropriate for women with mixed etiology incontinence in whom urethrovesical hypermobility is present.     

Urodynamics of female urinary incontinence with emphasis on stress incontinence

More than 500 female patients with urinary incontinence were studied in our urodynamic laboratory by simultaneous recordings of urethral pressure at 2 levels, bladder pressure, intra-abdominal pressure, and by uroflowmetry and cine-fluoroscopy. Urethral pressure profile under basal conditions was compared to that in patients with a full bladder, under the stress of sharp or sustained increase in intra-abdominal pressure, voluntary perineal muscle activity and patient's position. From these studies stress and urge incontinence, and neurogenic varieties (or a combination of several types) could be differentiated. The clinical application of our findings will be discussed.     

Role of positive urethrovesical feedback in vesical evacuation. The concept of a second micturition reflex: the urethrovesical reflex

Upon feeling the urge to urinate, the urinary bladder contracts, the urethral sphincters relax and urine flows through the urethra. These actions are mediated by the micturition reflex. We investigated the hypothesis that vesical contraction is maintained by positive feedback through continuous flow of urine through the urethra, and that the cessation of urine flow aborts detrusor contraction. Normal saline was infused into the urinary bladders of 17 healthy volunteers (age 35.2 years±4.2(SD); ten women and seven men) at a rate of 100 ml/min. On urge, which occurred at a mean volume of 408.6 ml±28.7of saline, the subject micturated while the vesical and urethral pressures during voiding were being recorded; residual urine was measured. The test was repeated after anesthetizing the urethra with xylocaine gel or, on another occasion, after applying a bland gel . On micturition, the urine was evacuated as a continuous stream without straining; no residual fluid was collected. After urethral anesthetization, the fluid came out of the urethra in multiple intermittent spurts and only with excessive straining. There was a large amount of residual fluid (184.6 ml±28.4). The results of bland gel application showed no significant difference (P>0.05) from those without gel. Detrusor contraction during micturition is suggested to be maintained by positive urethrovesical feedback elicited by the continued passage of urine through the urethra. This feedback seems to be effected through the urethrovesical reflex, which produces vesical contraction on stimulation of the urethral stretch receptors. Abortion of this reflex by urethral anesthetization resulted in failure of detrusor contraction and excessive straining was needed to achieve bladder evacuation in multiple spurts. The urethrovesical reflex is thus assumed to constitute a second micturition reflex responsible for the continuation of detrusor contraction and urination. The role of this reflex in the pathogenesis of micturition disorders needs to be studied.     

Transrectal ultrasound scanning in urinary incontinence: the effect of the probe on urodynamic parameters

A linear array real time transrectal ultrasound technique was used to screen the bladder and urethra of female patients with urinary incontinence during urodynamic investigation. There was no significant difference in any of the urodynamic measurements with or without the probe in situ.     

Can simultaneous perineal sonography and urethrocystometry help explain urethral pressure variations?

Objective: To correlate urodynamic with perineal sonographic findings in pressure variations. Patients and methods: In 15 women presenting with urethral pressure variations a urodynamic evaluation with water filling cystometry, urethral pressure at rest and during coughing and uroflowmetry were performed. During water filling cystometry, there were simultaneous perineal video-sonography and urethrocystometry. Video ultrasound images and urodynamic curves were simultaneously monitored on a computer screen. Results: Simultaneous ultrasound and urodynamic evaluation in the 15 patients revealed movements in two areas leading to urethral pressure variations: activity of the pelvic floor muscles and of the urethral sphincter muscles. For the pelvic floor, we found either slow or fast contractions with, respectively, slow (15–30 cm H₂O for 3–10 sec) or fast (30–130 cm H₂O for 1–3 sec) urethral pressure changes. Urethral sphincter contractions were always fast, resulting in fast pressure changes of 30–170 cm H₂O for 1–3 sec. Conclusion: Evaluation of simultaneous perineal sonography and urethrocystometry shows the association of urethral pressure variations and muscle activity. Urethral pressure variations are caused by the activity of urethral sphincter or pelvic floor muscles. With ultrasound the activity of the urethral sphincter muscle can directly be seen whereas pelvic floor muscle activity is indirectly visible. Pelvic floor muscle contractions are either fast or slow, whereas the urethral sphincter muscle contractions are always fast contractions.     

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.     

Urodynamic evaluation and electrical and pharmacologic neurostimulation

Summary We introduce a rat model that allows simultaneous or independent recording of bladder and sphincteric activity. Via a polyethylene tube inserted into the bladder dome, bladder pressure is measured in response to constant intravesical saline perfusion. The electrical activity of the intra-abdominal urethra (a well-defined striated muscular tube which, in the rat, constitutes the external urethral sphincter) is recorded simultaneously with an electromyography needle electrode. Thus, precise statements can be made about detrusor/sphincter interrelationships. Changes in urodynamic parameters with the anesthetics urethane, methoxyflurane (Metofane), and thiobutabarbital sodium (Inactin) were investigated. High-frequency oscillations in intraluminal bladder pressure could be demonstrated during micturition cycles only in rats anesthetized with urethane or Metofane. As this high-frequency activity is generated by the striated muscle of the intra-abdominal urethra, the external sphincter of the rat is the force behind urine expulsion. The anesthetic Inactin combined with a low intravesical perfusion rate attenuated spontaneous bladder and sphincteric activity and abolished micturition cycles. This rat model can provide accurate and reproducible measurements of urodynamic changes in response to electrical stimulation of the pelvic and pudendal nerves and pharmacologic stimulation with neuropeptides at the lumbosacral spinal cord level. We recommend using this model with urethane or Metofane for physiologic studies of micturition and with Inactin for meticulous neuropharmacologic and electrostimulatory evaluation of urodynamic parameters.     

Urodynamic and ultrasound characteristics of incontinence after radical hysterectomy

AIMS: To test whether symptoms of urinary incontinence after radical hysterectomy could be objectified with urodynamics and ultrasound. METHODS: This case-control study comprised 100 women who underwent radical hysterectomy for cervical cancer without post-operative radiotherapy. Fifty women reporting urinary incontinence were matched with 50 women reporting continence. All women were assessed with ultrasound of the bladder neck movements and urodynamics. RESULTS: No differences were found in ultrasound or urodynamic findings regarding mobility of the bladder neck, maximal detrusor pressure, post-voiding residual urine, flow of urine, or bladder capacity. A significant reduction in urethral pressure at rest and at contraction among the incontinent women was, however, demonstrated. Among urge-incontinent women, urethral pressure at rest was significantly lower than among continent and stress-incontinent women, respectively. Stress-incontinent women had significantly lower urethral pressure at contraction than did urge-incontinent and continent women. CONCLUSIONS: No differences in urodynamic or ultrasound findings were observed between the two groups, except for an overall difference in the intraurethral pressure. A decrease in the urethral pressure could contribute to the characterization of incontinence after radical hysterectomy, indicating that the urethral sphincter mechanism plays a role in the pathophysiology. In this study design, the mobility of the bladder neck did not play any role.     

经会阴四维超声在女性压力性尿失禁诊断中的初步应用

目的探讨经会阴四维超声在女性压力性尿失禁（SUI）患者中的应用价值。方法应用经会阴四维超声技术,观察22例女性压力性尿失禁患者在静息和Valsalva动作（屏气并向下用力至最大腹压）两种状态下四维超声图像的变化,并分析平静呼吸状态下的尿道长度、膀胱逼尿肌厚度（DWT）;最大Valsalva动作后的膀胱颈移动度（BND）、尿道内口漏斗有无形成等指标。以26例正常女性作为对照。结果静息时,SUI组与对照组尿道长度及DWT比较,无统计学差异（P〉0．05）;最大Valsalva动作时,SUI组的膀胱颈移动度明显大于对照组,尿道内口漏斗形成率也明显高于对照组（P〈0．05）。结论经会阴四维超声可用于评估女性压力性尿失禁患者的盆底解剖和功能,值得临床推广应用。     

Perineal retraining in urinary stress incontinence]

Twenty patients suffering from urinary stress incontinence were treated by perineal reeducation. The assessment included a medical and urological questionnaire, a physical examination, a urine analysis and culture, a cystoscopy, urinary flow and cystometry, a urethral pressure profile and a subjective evaluation of the perineal musculature. The 20 patients selected had documented stress incontinence, had never been operated on for incontinence and had a stable bladder at urodynamic assessment. Treatment was identical for all patients and included 12 biofeedback and electrostimulation sessions over a 4 to 6 week period. The questionnaire, urodynamic and perineal assessment were repeated at the end of treatment. No complication occurred. Micturition frequency decreased in all patients. Clinical correction of incontinence was observed in ten patients, improvement in nine and no change in one for an overall cure or improvement rate of 95%. The urethrocystocele evaluation did not change. Perineal evaluation and urodynamic parameters were only slightly improved. At follow-up evaluation 6 to 9 months post treatment, a 75% cure or improvement rate was still present. Perineal reeducation is a non morbid and effective modality to correct urinary stress incontinence. Its long term efficacy and its use for other types of incontinence has to be demonstrated.     

Role of perineal ultrasound in the evaluation of urinary stress incontinence and pelvic organ prolapse: a systematic review

AIMS: A review of the international literature on urogynecology was performed to focus on the actual role of perineal ultrasound. It is an increasingly used tool for the assessment of pelvic floor dysfunction and incontinence. In recent years ultrasound studies have predominated but there is little information on normal values and confusion on methodology and measurements. The aim of this study is to report the data available in the Literature about ultrasound as investigational evaluation helpful in diagnosing of urinary incontinence and urethral hypermobility, to document pelvic floor anatomy and to assess anatomic and functional changes after surgery. METHODS: A MEDLINE search was conducted using combinations of heading terms: perineal, ultrasound, pelvic floor, urinary incontinence, pelvic organ prolapse. RESULTS: Ultrasound has become an indispensable diagnostic procedure in urogynecology. Perineal, introital, and endoanal ultrasound are the most recommended techniques and the results comprise qualitative and quantitative findings. These are important for determining the localization of the bladder neck and vesico-urethral junction and also for pre- and postoperative comparisons, and moreover for clinical applications and scientific investigations. CONCLUSIONS: There are as yet little data and there is a need to find in the near future more standard and objective parameters for the diagnosis of urinary incontinence. They will be obtained by means of more accurate analysis and comparison of the parameters, leading to a more clinically useful diagnostic test and assuring reliable and reproducible results.     

The role of the rhabdosphincter in female rat voiding

OBJECTIVES: To obtain information on the mechanisms of female rat micturition using a model in which pressure was measured in the bladder and distal part of the urethra corresponding to the location of the rhabdosphincter, providing information on the role of the sphincter in opening and closing the urethral lumen. MATERIALS AND METHODS: A micturition reflex was induced in adult anaesthetized (chloral hydrate and urethane) female rats by filling the bladder with saline. Bladder pressure (BP), urethral pressure (UP), electromyography (EMG) of the middle part of the rhabdosphincter, and urinary flow rate in the distal urethra were simultaneously recorded. RESULTS: There were four phases of the micturition contraction, the second characterized by intraluminal pressure high-frequency oscillations (IPHFOs) of BP. When a non-oscillatory micturition contraction started, the BP increased and exceeded UP for the rest of the micturition contraction. Even though the BP increased during this first phase, the urethral lumen stayed closed. Its opening was indicated by a simultaneous decrease in BP and increase of UP as the fluid flowed from the bladder to the urethra. When the rhabdosphincter closed, as indicated by an EMG-burst of the muscle, the UP declined, bladder pressure increased and the flow ceased. Because of momentary contractions of the rhabdosphincter, the UP and urine flow rate had the same periodicity as the IPHFOs of BP. CONCLUSIONS: The simultaneous recording of the BP, UP, EMG of the rhabdosphincter and urinary flow rate showed the sequence of events during micturition. The rhabdosphincter acts as an 'on-off' switch, causing interruptions in the urinary flow rate.     

Urodynamic evaluation of female stress urinary incontenence

To understand further the urodynamics of female stress urinary incontinence 6 patients with this condition were studied before and after anterior vesicopexy. The evaluation included uroflowmetry, cystometry, urethral pressure profilometry, anatomical urethral length measurement with the subject in the supine and standing positions, demonstration fo stress incontinence and cystourethroscopy. These procedures, except cystometry and cystourethroscopy, were repeated 7 days and 4 to 6 weeks postoperatively in most patients. All patients had short preoperative functional urethral lengths and standing anatomical lengths and all were lengthened after the anterior vesicopexy. The urinary flow rate demonstrated decreased peak and average flow rates 1 week postoperatively but complete recovery 4 to 6 weeks later. We believe that this study reaffirms the importance of urethral length in the pathophysiology of female stress urinary incontinence and, by demonstrating decreased flow rates in the immediate postoperative period, draws attention to the need for careful observation of voiding after catheter removal to avoid bladder decompensation. The marked improvement observed in the 4 to 6-week postoperative period reveals that anterior vesicopexy does not obstruct the urethra since no tissue posterior to the urethra is used. These urodynamic studies have proved to be valuable adjuncts in the evaluation of female stress incontinence.     

Suburethral duplication of the vaginal wall — An original operation for urinary stress incontinence in women

The ideal surgery for urinary stress incontinence should be represented by operations producing increases in urethral closure pressure only when the intra-abdominal pressure is elevated. Guided by this principle the author proposes an original vaginal operation creating a suburethral duplication of the anterior vaginal wall, together with Halban's fascia, located under the proximal urethra just below the bladder neck. Over this supportive duplication the urethra is compressed during its dorsocaudal physiologic displacements. The technical details and indications of the procedure are fully described. In the period from 1974 to 1991, at the Department of Obstetrics and Gynecology, Medical Faculty, Skopje, 481 operations were performed. In this series, 74 patients had pre- and postoperative urodynamic evaluations. At 2 years 93.3% were continent without demonstrable obstruction. The simple technique and the use of autologous tissue, together with the lack of major complications and low recurrence rate, are the best advocates for the surgical procedure.Editorial Comment: This article presents a vaginal approach to the correction of stress incontinence which utilizes the well known principle of differential support of the urethrovesical junction rather than the bladder. A suburethral bar is created using the vaginal wall. Urodynamic studies were done pre- and postoperatively on 71 patients, who were followed for 2 years. These studies demonstrated a 93.3% success rate, using the absence of urine loss with a full bladder during stress as the criterion for cure. Urethral closure pressure was also found to be increased. This is the same technique as proposed Goebell in 1910 and Ingleman-Sundberg in 1947, who utilized other structures to create a differential resistance between the proximal urethra and the base of the bladder. This is an interesting procedure and will wait for others to validate its success.