Doppler Velocimetry Parameters of Periurethral Vessels in Postmenopausal Incontinent Women Receiving Estrogen Replacement

Estrogen deficit causes significant alterations in the lower urinary tract of women, largely affecting urinary continence mechanisms. The urethral vascular bed accounts for about one-third of urethral pressure, and as it undergoes marked hormonal influence we became interested in investigating its behaviour both prior to and during estrogen replacement. We selected 25 postmenopausal patients with urinary stress incontinence and studied the periurethral vessels by means of Doppler velocimetry, analyzing the number of vessels, systolic peak, minimum diastole, resistance and pulsatility indexes and the A/B ratio, prior to estrogen replacement and after 1 and 3 months of hormone use. We concluded that estrogen replacement alone in postmenopausal women with urinary stress incontinence increased the number of periurethral vessels, systolic peak and minimum diastole; however, a trend of no statistical significance towards the reduction of resistance and pulsatility rates of periurethral vessels was found; nor was a significant difference in the A/B ratio shown.     

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.     

Carbon dioxide urethral pressure profiles in males

Carbon dioxide urethral pressure profiles were obtained in a group of continent and incontinent male patients. Cystometry, needle electromyography of the striated urinary sphincter, and cystourethroscopy were also performed in most patients. A characteristic reproducible urethral pressure profile can be obtained in the continent, obstructed, and incontinent groups. The results also showed that the urethral pressure profile is influenced by the activity of the periurethral striated muscle. The urethral profile when performed with other established urodynamic procedures is a useful test in delineating normal and abnormal urinary sphincter function.     

The Use of Short-Form Quality of Life Questionnaires to Measure the Impact of Imipramine on Women with Urge Incontinence

Short-form questionnaires were used to measure the change in quality of life (QOL) of women with urge-predominant urinary incontinence treated with imipramine hydrochloride. Short forms of the Incontinence Impact Questionnaire (IIQ-7) and the Urogenital Distress Index (UDI-6) were integrated into a patient questionnaire, which was given to 25 patients with urge-predominant urinary incontinence before and after treatment with imipramine. Demographic data and self-reports of the number of incontinent episodes were also recorded. Total and subscale QOL scores and number of incontinent episodes were recorded and compared with Wilcoxson’s signed ranks test, as well as correlated to the change in number of incontinent episodes with Pearson’s correlation coefficient. Treatment with imipramine resulted in a clinical improvement or cure in 16/22 patients (72.7%), with an average reduction in incontinent episodes of 78.7% (P<0.001). The average per cent improvement in QOL scores for total IIQ-7 was 42.1% (P<0.01) and total UDI-6 score was 44.1% (P<0.001). All subscale QOL differences were also significant (P<0.01). The incidence of side effects to imipramine was 41%, which resulted in dose changes. Fourteen per cent eventually discontinued therapy. Neither total nor subscale QOL improvement scores were correlated with improvement in number of incontinent episodes. The short form IIQ-7 and UDI-6 are effective tools to determine change in QOL, as evidenced by the effectiveness of imipramine for the treatment of urge-predominant urinary incontinence. Significant reductions in incontinent episodes and improvements in IIQ-7 and UDI-6 QOL scores were both seen, but were not correlated. Short-form QOL measures can easily be integrated into a patient questionnaire to objectively measure a very subjective topic.     

Effects of the Menstrual Cycle on Urodynamic Work-up: Should We Change our Practice?

The aim of this study was to compare urinary symptoms and urodynamic parameters during follicular and luteal phases of the menstrual cycle of women with lower urinary tract symptoms. Fifteen women were eligible and agreed to participate in the study. The subjects underwent urodynamic work-up, including filling urethrocystometry, urethral pressure profile and Valsalva leak-point pressure, cough stress test and subjective assessment of severity of symptoms in the mid-follicular and mid-luteal phases of the menstrual cycle. Mean age was 37 years (range 18–43), mean parity 1 (range 0–3). Five women were found to have genuine stress urinary incontinence, 6 detrusor instability, 3 mixed incontinence and 1 urethral instability. Clinical diagnosis did not change and the urodynamic parameters were not statistically different in the two separate evaluations. A trend toward worsening of symptoms in the luteal phase in women with detrusor instability was identified. Our study suggests that the menstrual cycle does not significantly affect the work-up of women with lower urinary tract complaints.     

Mechanism of Postoperative Urinary Continence

Stress incontinence used to be attributed mostly to urethral hypermobility, and consequently most surgical techniques focused on the region of the bladder neck and proximal urethra. This article reviews our knowledge about the mechanism of postoperative urinary continence based on anatomic, imaging and urodynamic studies. Reduction of urethral mobility, as measured by cotton swab testing or imaging studies, is not the only reason why continence surgery succeeds. Imaging techniques are of limited value for elucidating the continence mechanism because radiologic landmarks and criteria are not reproducible. Urodynamically, the increased pressure transmission after successful continence surgery is attributed to the retropubic repositioning of the urethra, its compression against the anterior vaginal wall, and improved transmission of intra-abdominal pressure during stress. The role of the ‘functional’ urethral obstruction remains to be studied. In incontinent patients with hypermobility of the bladder neck and proximal urethra continence can be achieved by surgical correction. However, stress incontinence is possible in the absence of urethral hypermobility, and standard surgical techniques can fail to restore continence in these patients.     

Effects of tamoxifen on Doppler velocimetry parameters of periurethral vessels in postmenopausal women

The purpose of the present study was to assess the effect of tamoxifen on periurethral vessels by Doppler velocimetry examination. Increase in the number of these vessels as well as decrease in resistance and pulsatility indices by tamoxifen were observed.Editorial Comment: This study of the effects of a SERM on the periurethral vessels is quite timely in light of the rampant decrease in hormone therapy. We expect to see an increase in women using a SERM for the indication of osteoporosis. In future, we look forward to studies that will demonstrate a connection between the flood flow to the urethra and lower urinary tract function. This may lead to more directed topical therapies     

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.     

A Comparison of Urethral Profilometry using Microtip and Fiberoptic Catheters

This paper compares urethral profilometry measurements using two different types of catheter: the Millar microtip transducer and the FST fiberoptic catheter. Outcome variables were functional urethral length (FUL), maximum urethral closure pressure (MUCP), and mean pressure/transmission ratio (PTR). Thirty women presenting to the urodynamics laboratory with symptoms of stress urinary incontinence were evaluated with both catheters. All subjects underwent two passive urethral pressure profiles and two dynamic (cough) urethral pressure profiles with each catheter. For FUL and MUCP, the means of the two passive measurements were compared between catheters. For PTR, the means of the two dynamic measurements were compared between catheters. There was no difference in FUL between the two catheter types. The FST measurements of MUCP and PTR were lower than the microtip measurements. Twenty per cent of patients would have been diagnosed with low-pressure urethra with the FST catheter, but not with the microtip catheter. Caution must be used when applying urethral measurements taken with the fiberoptic catheters to standards set with microtip catheters.     

Colposuspension or Sling for Low Urethral Pressure Stress Incontinence?

The aim of this study was to compare Burch colposuspension with the pubovaginal sling in the management of low urethral pressure urinary stress incontinence. Forty-five women with low urethral pressure stress incontinence were retrospectively reviewed: 21 underwent colposuspension and 24 a pubovaginal sling. The subjective success rate of the Burch colposuspension and the pubovaginal sling was 90% and 71% (P= 0.12), respectively; the objective success rate was 67% and 50% (P= 0.26), respectively. The incidence of postoperative complications, including de novo detrusor instability and symptomatic voiding dysfunction following the colposuspension, was 5% compared to 25% following the pubovaginal sling (P= 0.06). Colposuspension should be considered in the management of women undergoing surgical correction of low urethral pressure stress incontinence. In a clinically similar group of women, the Burch colposuspension had a superior subjective and objective success rate with a lower incidence of complications than did the pubovaginal sling. Although these differences failed to reach statistical significance, colposuspension can be safely considered in the management of women with low urethral pressure GSI.     

Virtual Reality of the Lower Urinary Tract in Women

Advances in computerized and imaging technology permit both students and doctors to depict the anatomy of the human pelvis more realistically than with previous methods. Further refinements outline fine pelvic structures, such as the nerve plexus, which may as a result be spared during major pelvic surgery, thus preserving the function of the bladder neck and urethra. Dynamic computerized tomography or magnetic resonance imaging, coupled with three-dimensional depiction of the lower urinary tract and its adjacent structures, enable visualization of the whole lower urinary tract and the pelvic floor musculature in both continent and incontinent women. In patients with a reconstructed lower urinary tract computer-assisted image processing shows the postoperatively altered topographical anatomy. This may be clinically useful for interpretation of unexpected findings with conventional imaging modalities, postoperative morbidity, and surgical planning of a lower abdominal reoperation. Examples of our own work regarding the innervation of female pelvic organs, dynamic depiction of the bladder and pelvic floor musculature during straining in normal and incontinent women, and the situation of female patients after undergoing an anterior pelvic exenteration with subsequent orthotopic neobladder procedure, are given. In addition, the data of these patients have been compiled for virtual reality endoscopy, which is useful for patient consent and for teaching residents, students and nurses.     

Urinary Retention and Intravesical Hemorrhage following Urethral Collagen Injections in Women Using Warfarin

Two women on warfarin anticoagulation experienced urinary retention following urethral collagen bulk injections. Both women developed implant site hematomas, with urinary retention and intravesical hemorrhage. One woman was supratherapeutic and the other was therapeutic on warfarin therapy. Both women required transfusion and prolonged catheterization.     

Treatment of Stress Urinary Incontinence in Women with Urethral Hypermobility and Intrinsic Sphincter Deficiency

Purpose

We compared 2 treatment modalities (sling cystourethropexy and periurethral collagen injection) in patients with intrinsic sphincter deficiency alone or with urethral hypermobility (combined stress urinary incontinence).

Materials and Methods

We retrospectively reviewed a series of 50 consecutive patients treated surgically for intrinsic sphincter deficiency during a 2-year period. All patients were evaluated by history and physical examination to assess urethral hypermobility and urodynamic testing. Intrinsic sphincter deficiency was assessed by abdominal leak point pressure and video urodynamics. Of the 50 patients 28 underwent a pubovaginal sling operation and 22 received a periurethral injection of collagen.

Results

Of the patients studied 40 percent had combined stress urinary incontinence. A pubovaginal sling procedure resulted in a cure rate of 81 percent in this group, compared to 25 percent for periurethral injection of collagen.

Conclusions

A subgroup of women exists with combined stress urinary incontinence due to urethral hypermobility and intrinsic sphincter deficiency. When treated with sling cystourethropexy women with combined stress urinary incontinence do as well or better than those with intrinsic sphincter deficiency alone and those treated with periurethral collagen injection do worse.     

The Urethral Pressure Profile and Ultrasound Imaging of the Lower Urinary Tract

In a prospective study 105 patients with symptoms of stress incontinence underwent videourodynamic testing, including resting urethral pressure profilometry and translabial ultrasound. The urethral pressure profile (UPP) included maximum urethral closure pressure (MUCP), functional length (FL) and area under the curve (AUC). Ultrasound parameters included urethral thickness, urethral rotation and bladder neck descent, as well as funneling/opening of the internal urethral meatus on Valsalva maneuver. Levator contraction strength was assessed measuring the cranioventral displacement of the internal meatus. Negative correlations between UPP data and age, parity and previous surgery were observed which were consistent with literature data. There was a positive correlation between the urethral AP diameter on ultrasound and the MUCP, which agrees with reports showing reduced sphincter thickness or volume in stress-incontinent women. Hypermobility on ultrasound did not correlate with UPP data. However, a lower MUCP correlated with extensive opening of the bladder neck. Finally, there was a trend towards poorer pelvic floor function with lower MUCP measurements.     

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.     

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.     

Pad Testing in Incontinent Women: A Review

This article reviews the literature on pad-weighing tests used for objectifying and quantifying incontinence in urinary incontinent women. The patients wear pads weighed before and after the test period. A weight gain is taken as a measure of the amount of urine loss. The tests are in principle of two different types: short-term office tests and long-term home tests, and measure different aspects of urinary control and dysfunction. Both have an inherent large intra- and interindividual variability. Pad weight gains obtained from patients referred for incontinence and those from self-reported continent controls overlap to a certain degree, and it is not possible to identify distinct numerical cut-off values separating continence from incontinence. This suggests that incontinence is a complex condition in which the amount of leakage, other sources of weight gain, and differences in the individual patients’ personal characteristics influence the identification and quantification of the problem. In spite of the shortcomings the pad tests remain a valuable tool for both the clinician and the researcher. The home pad tests are superior to the office tests in terms of authenticity, and should be performed with a concomitant systematic registration of the participant’s voidings, fluid intake and episodes of incontinence.     

Does Weight Loss Improve Incontinence in Moderately Obese Women?

The aim of this study was to evaluate the effect of weight reduction on urinary incontinence in moderately obese women. This prospective cohort study enrolled moderately obese women experiencing four or more incontinence episodes per week. BMI and a 7-day urinary diary were collected at baseline and on the completion of weight reduction. The study included 10 women with a mean (tSD) baseline BMI of 38.3 (t10.1) kg/m² and 13 (t10) incontinent episodes per week. Participants had a mean BMI reduction of 5.3 (t6.2) kg/m² (P<0.03). Among women achieving a weight loss of ≥5%, 6/6 had ≥50% reduction in incontinence frequency compared to 1 in 4 women with <5% weight loss (P<0.03). Incontinence episodes decreased to 8 (t10) per week following weight reduction (P<0.07). The study demonstrated an association between weight reduction and improved urinary incontinence. Weight reduction should be considered for moderately obese women as part of non-surgical therapy for incontinence.     

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.