Stress incontinence of urine

At rest, continence of urine depends on intraurethral pressure being higher than intravesical pressure. Intraurethral pressure is produced by elastic fibres and engorged urethral venous sinuses. Low intravesical pressure is preserved by bladder muscle relaxation. Urgency incontinence will result if bladder muscle does not relax. A sudden increase in abdominal pressure may overcome this urethral-vesical pressure gradient and cause stress incontinence. The mechanisms that prevent this from happening are unclear. The pressure gradient would not change if the abdominal pressure was transmitted equally to the urethra and the bladder. Continence could also be protected by pressure of the urethra against the symphysis pubis or pelvic muscles. Stress and urgency incontinence cannot be differentiated clinically with certainty. If surgical correction of stress incontinence is planned, preoperative urethrocystometry is mandatory. The Burch colposuspension is the operative procedure of choice. The suspension is done with Prolene sutures; their correct placement is ensured through the use of intraoperative cystostomy.     

自体筋膜尿道悬吊治疗女性压力性尿失禁的探讨

目的：探讨自体筋膜尿道悬吊术在女性压力性尿失禁治疗中的效果。方法：采用经耻骨上人路自体筋膜尿道中段悬吊术治疗女性压力性尿失禁,回顾性分析2000年2月～2007年12月采用该手术方式治疗28例女性压力性尿失禁患者的临床资料和治疗效果。结果：所有患者无耻骨后血肿形成,无尿道损伤;膀胱损伤1例,延长导尿管留置时间后治愈;28例患者术后拔除尿管均能自行排尿并满意控尿,6例患者出现不同程度不稳定膀胱症状,经对症处理缓解。随访9～21个月,平均15个月,无压力性尿失禁症状复发及排尿困难。结论：自体筋膜尿道悬吊术治疗女性压力性尿失禁简单易行,操作安全,损伤性较小,费用低廉。     

Transvaginal closure of the bladder neck and placement of a suprapubic catheter for destroyed urethra after long-term indwelling catheterization

We report on 6 women with continuous urinary incontinence as a late complication of an indwelling urethral catheter for neurogenic bladder. Pressure necrosis by the balloon resulted in progressive destruction of the entire urethra, with subsequent incontinence despite the catheter. Surgical attempts at bladder neck closure to correct the incontinence generally have been unsuccessful. Instead of supravesical urinary diversion, we performed transvaginal closure of the bladder neck and percutaneous placement of a permanent suprapubic tube cystostomy. All 6 patients remained dry after closure and none has shown upper urinary tract deterioration at followup for as long as 5 years.     

Needle bladder neck suspension for female stress incontinence

A highly successful transvaginal bladder neck suspension for female stress urinary incontinence is described and illustrated. Precise lateral placement of sutures, maximum mobilization of the anterior vaginal wall and bladder neck, and ease of approach are keys to the technique. The procedure can be utilized in any setting with minimal complications and with neither obesity nor multiple previous surgeries as contraindications.     

URETHRAL AFFERENT NERVE ACTIVITY AFFECTS THE MICTURITION REFLEX; IMPLICATION FOR THE RELATIONSHIP BETWEEN STRESS INCONTINENCE AND DETRUSOR INSTABILITY

PURPOSE: A causative relationship between stress urinary incontinence (SUI) and detrusor instability has been suspected but never proven. Many women with mixed incontinence have resolution of detrusor instability after surgical correction of SUI. We sought experimental support that stimulation of urethral afferent nerves can induce or change reflex detrusor contractions. MATERIALS AND METHODS: Urethral perfusion pressure and isovolumetric bladder pressure were measured with catheters inserted through the bladder dome in urethane anesthetized female S.D. rats (250 to 300 grams; n = 12). The catheter assembly was seated securely in the bladder neck to block passage of fluid between the bladder and urethra without affecting the nerve supply to the organs. The external urethra was not catheterized. Responses were examined in the control state at a urethral saline perfusion speed of 0.075 ml. per minute. Intraurethral drugs were administered following blockade of striated sphincter activity with intravenous alpha-bungarotoxin (0.1 mg./kg.). RESULTS: Stopping the urethral saline infusion caused a significant decrease in micturition frequency in approximately 50% of the animals studied (n = 12). Intraurethral lidocaine (1%) infused at 0.075 ml. per minute caused a slight decrease in urethral perfusion pressure but no change in detrusor contraction amplitude. However, intraurethral lidocaine caused a significant (45%) decrease in the bladder contraction frequency (n = 5). The micturition frequency returned to baseline 30 minutes after stopping lidocaine infusion. Intraurethral infusion of nitric oxide (NO) donors (S-nitroso-N-acetylpenicillamine [SNAP] (2 mM) or nitroprusside (1 mM) immediately decreased urethral perfusion pressure by 30 to 37% (n = 5). A 45 to 75% decrease (n = 5) in bladder contraction frequency was also seen, which was similar to that observed following lidocaine. Neither NO donor changed the amplitude of bladder contractions. CONCLUSIONS: These results indicate that in the anesthetized rat activation of urethral afferents by urethral perfusion can modulate the micturition reflex. Thus in patients with stress urinary incontinence, leakage of urine into the proximal urethra may stimulate urethral afferents and facilitate voiding reflexes. This implies that stress incontinence can induce and/or increase detrusor instability. These findings have significant implications for the treatment of patients with mixed urge and stress incontinence. Correction of stress incontinence by surgery or pelvic floor exercise in patients with mixed incontinence may resolve the detrusor instability.     

Pressure response to rapid dilation of resting urethra in healthy women.

Rapid urethral dilations were performed by a balloon mounted on a double-tip transducer catheter for simultaneous measurement of pressure in urethra and bladder. The cross sectional area of the urethra was measured according to the field gradient principle. Pressure and cross sectional area were recorded synchronously. The response of the female urethra to rapid dilation is a typical stress relaxation effect with a pressure peak followed by a pressure decay over a few seconds. The peak pressure response represents the bladder pressure required in producing a corresponding urethral dilation by the ingression of urine. The increase in pressure response was statistically significant by increasing rate as well as size of dilation. The method enables experimental simulation of stress urinary incontinence in vivo which may bring further insight into the physiology of the urethral closure function and the pathophysiology of stress incontinence. For comparative studies rapid dilation should be performed under standardized circumstances.     

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 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.     

四种吊带手术经腹壁或闭孔固定治疗女性压力性尿失禁的效果比较

目的:探讨四种吊带手术经腹和闭孔途径治疗女性压力性尿失禁的效果.方法:采用人工合成材料的吊带经腹壁固定方式(TVT和IVS技术)治疗女性压力性尿失禁患者23例;用经闭孔固定方式(TOT和TVTO技术)治疗女性真性压力性尿失禁患者16例.并进行疗效比较.结果:绝大多数患者均排尿通畅,无尿失禁复发.但TVT组中有1例排尿不畅,3个月后剪断吊带后变为轻度尿失禁;有1例术中膀胱穿孔,术后停留导尿管1周.结论:用四种吊带手术治疗女性真性压力性尿失禁安全、微创和有效.经闭孔固定技术和用经腹壁固定技术这两种方法各有自己的优缺点.     

Perforación de la uretra proximal durante TVT-O,en paciente con desviación uretral secundaria a cirugía de Burch fallida

A 59 years old woman with laparoscopic Burch made during 2003 in another hospital. During 2006, the patient is evaluating in our center for a persistent urinary incontinence, the urodynamic study demonstrated stress urinary incontinence type II and overactive bladder without obstruction evidences. A TVT-O (tension-free vaginal tape obturador in-out route) was made, nevertheless when the right branch was passed blood was observed in the Foley catheter. A cystoscopy showed an important deviation of urethra and the tape through urethra in the proximal portion. The right branch went again inserted taking the necessary precautions. Two days after surgery the Foley catheter was removed and the stress urinary incontinence symptoms disappeared. The urge incontinence symptoms disappeared with the pharmacalogical treatment (Tolterodine 2 mg/day). We believe that the urethral deviation caused by a technically deficient laparoscopic Burch was the reason for the urethral perforation during the TVT-O.     

Colpovesical neck suspension for the correction of female stress urinary incontinence

A new surgical approach for the correction of female urinary stress incontinence has been devised. The retropubic space is entered through a dome-shaped incision in the vaginal vestibule. The bulbocavernosus muscles are separated from the urethra and the layers of the genitourinary diaphragm are opened beginning behind the symphysis pubis. The retropubic cavity is exposed and the junction of the vesical neck and vagina is identified. Double helical bites with 2-zero polypropylene sutures are taken from each side of the junction. The 2 ends of the sutures are brought ventrally with a suture carrier through a small incision just above the symphysis pubis in the midline and tied. This procedure moves the bladder neck forward and upward to the desired level by observing movement of the bladder neck through the vestibule. Of 20 patients treated 17 are fully continent and 3 remain much improved after 2 years.     

Suprapubic urethropexy: management with a transvesical exposure

Opening the bladder allows for excellent exposure and more accurate placement of sutures for correction of stress urinary incontinence. The results of our first 100 cases with a minimum 3-year followup are presented. Because of the high success rate with minimal morbidity or complications we recommend this procedure as the operation of choice for surgical correction of stress urinary incontinence.     

Endoscopic transurethral suspension of bladder neck and urethra. Experimental trials of new procedure in dogs

An endoscopic, transurethral suspension of the female urethra and bladder neck is achieved by placing sutures through the anterior urethral wall up to the anterior abdominal fascia. The sutures are placed under direct endoscopic vision using a specially designed suture passer. In 8 female dogs a mean increase in urethral length of 1.81 cm (SEM 0.21 cm) was obtained immediately postoperatively. Reevaluation three months postoperatively demonstrated the mean increase to be 1.56 cm (SEM 0.11 cm). Cystoscopy and postmortem dissection demonstrated integrity of the repair in all 8 dogs. A clinical trial in stress incontinent women is suggested.     

Injuries to the urethra and urinary bladder associated with fractures of the pelvis

The posterior urethra or urinary bladder may be injured in patients who sustain fractures of the bony pelvis. It is important to assess the urethra radiologically by retrograde urethrography before introducing a urethral catheter to avoid missing a urethral injury or causing further damage. The author's approach to the immediate management of urethral injury is suprapubic cystostomy. The urethra may be repaired later after other injuries have healed. With this approach the incidence of permanent impotence and incontinence will be low and the stricture cure rate high. If the urethra has not been injured, a catheter is introduced and cystography performed to rule out bladder injuries. If the bladder is ruptured, the area is explored, the perivesical space drained and urinary drainage is provided by either a suprapubic cystostomy or a urethral catheter.     

Sling operation for male stress incontinence by utilizing modified Stamey technique.

A modified Stamey operative technique was applied to 3 men with stress incontinence due to transurethral prostatectomy or transurethral resection of bladder neck. Two pieces of polytetrafluoroethylene grafts (Gore-Tex) were positioned at the membranous and bulbous urethra as sling loops, and hung up by nylon sutures that were brought to the abdominal wall along each side of the urethra by means of a modified Stamey needle and tied over the rectus fascia. Postoperatively, maximum urethral closure pressure and functional urethral length were increased, and urinary continence was achieved in all 3 patients, however, urinary retention developed in 1 patient with bladder arefrexia.     

Pelvic fracture-associated urethral injuries in girls: experience with primary repair

OBJECTIVE: To present our experience with four urethral injuries in females accompanying a pelvic fracture, managed with primary repair or realignment of the urethra. PATIENTS AND METHODS: There were three teenage girls and one adult (22 years old). All the patients had complete urethral injuries associated with a pelvic fracture from accidents. They were managed by immediate suprapubic cystostomy followed by repair or realignment of the urethra over a catheter on the same day. The catheter was removed after 3 weeks and a voiding cysto-urethrogram taken. Thereafter they were followed with regular urethral calibration. RESULTS: All patients voided satisfactorily with a good stream; three were fully continent and the fourth had transient stress urinary incontinence. One patient needed dilatation at 2 months and another visual internal urethrotomy at 5 months. At a mean (range) follow-up of 33 (9-60) months all the patients had a normal voiding pattern and were continent; none developed vaginal stenosis. CONCLUSION: Primary repair of the urethra, and if that is impossible, simple urethral realignment over a catheter, is the procedure of choice for managing female urethral injury associated with a pelvic fracture. The procedure has the additional advantage of reducing the risk of vaginal stenosis.     

Mechanism of continence after modified Pereyra bladder neck suspension. Prospective urodynamic study

Twenty females with genuine stress urinary incontinence who underwent modified Pereyra bladder neck suspension were urodynamically studied pre- and postoperatively in an attempt to determine the mechanism by which continence was restored. Detailed analysis demonstrated no significant change comparing the pre- and postoperative cystometry findings, uroflow parameters, maximal voiding pressure, urethral resistance, maximal urethral closure pressure, or functional urethral length. The only significant change identified as a result of the surgical procedure was an alteration of proximal urethral pressure transmission during stress from negative to positive gradients. It is concluded that the modified Pereyra bladder neck suspension restores continence by restoring proper urethral support with restoration of positive pressure transmission to the proximal urethra without causing outflow obstruction, changing functional length, or altering maximal urethral closure pressure.     

Diagnostic and therapeutic approach to stress urinary incontinence in women

This work concerns twenty eight cases of urinary stress incontinence treated between 1977 and 1987. The high incidence of previous perineal operations and multiparity are noted. The diagnosis has been established clinically in all cases. Different types of surgery for urinary stress incontinence have been used: endoscopic bladder neck suspension in 17 cases, and retropubic colpopexy in 9 cases. The results are good in respectively 88% and 78%. Correct diagnosis and operative indication are the main elements of treatment of urinary stress incontinence. Each procedure permitting reposition of the bladder neck and proximal urethra in abdominal manometric enclosure amends the urinary stress incontinence. This endoscopic bladder neck suspension procedure is indicated. Otherwise, this procedure is quick, simple, allowing an easy access even though for multi-operated and fat patients. The failure's factors are analysed.     

Valsalva leak point pressure: Steps toward standardization

Valsalva leak point pressure (VLPP) has been used as the urodynamic indicator of intrinsic sphincteric deficiency in patients with stress urinary incontinence. However, further validation of VLPP as a tool for diagnosis and assessment of treatment outcome has been delayed mainly because of the lack of a universally accepted standardized methodology. The urodynamic parameters in need of standardization for measurement of VLPP include urethral catheter size, zeroing of the transducer, patient position, bladder volume, type of stress, and timing of measurement. Such standard-ization likely will allow for further validation of VLPP and its use in distinguishing the right treatment options for the correction of stress urinary incontinence.     

Oncocytic adrenocortical carcinoma

The new minimally invasive transobturator sling for surgical treatment of female genuine stress urinary incontinence is designed to reproduce the natural suspension of the urethral fascia while eliminating the need for retropubic needle passage. We report 3 cases of bladder perforation during the transobturator sling procedure. All injuries were identified intraoperatively by cystoscopy, and successful reinsertion of the mesh was accomplished. Transurethral bladder drainage with a Foley catheter was maintained for 5 to 7 days postoperatively. All 3 patients recovered uneventfully. Routine intraoperative cystoscopy is, therefore, recommended for the identification of bladder injuries during the transobturator sling procedure.