Day wetting

About 1% of healthy children over the age of 5 years have troublesome daytime wetting. Two-thirds of those who wet by day are reliably dry at night. The problem is more common in girls and is usually the result of urge incontinence. Although the wetting may be exacerbated by giggling and/or stress, pure giggle micturition and isolated stress incontinence are both rare. There is a strong association with bacteriuria (50% prevalence) in girls who wet by day. A potentially important relationship exists between day wetting, infection, reflux and upper tract damage, which is expressed in an extreme form in the syndromes of incoordinated voiding and progressive renal damage. Most children who wet by day have unstable bladders. Many of them adopt characteristic holding postures. There is an increased incidence of emotional disorder compared with children who merely wet the bed. Between 10% and 15% of children who wet by day become dry during the next 12 months. The acquisition of dryness is accelerated by eradication of bacteriuria and a sympathetic and energetic management regime, which should place responsibility on the child and result in the child voiding more frequently and completely. Reminder alarms and other behaviour therapies have proved effective. There is no satisfactory evidence for the efficacy of drugs. More complex behavioural training regimes including biofeedback are valuable for severe cases.     

Pelvic floor exercise alone or with vaginal cones for the treatment of mild to moderate stress urinary incontinence in premenopausal women

The authors compared intensive pelvic floor exercise alone (A) with intensive pelvic floor exercise plus vaginal cones (B) in premenopausal women with mild to moderate stress urinary incontinence. Forty-six patients (mean 43±6 years) were randomized into two training groups and treated for 3 months. Pre- and post-therapy urethral pressure profiles at rest and under stress and subjective results were obtained from 29 patients. The subjective improvement rate of the compliant patients after 12 weeks was 85% in group A and 84% in group B. When the dropouts (9 in group A and 8 in group B) were included in the subjective results an overall improvement rate of 48% in group A and 52% in group B was obtained. In group A one pressure transmission ratio (PTR) improved significantly at 6 weeks and the position of maximum urethral closure pressure was shifted proximally at 12 weeks. In group B one PTR in the midurethra was improved significantly at 6 weeks. The other urodynamic parameters were unchanged. There were no differences between groups A and B in subjective results or urodynamic findings. These results suggest that intensive pelvic floor exercise with or without vaginal cones improves the symptoms of mild to moderate stress incontinence in about 85% of premenopausal women, but that it has little effect on urodynamic parameters. Vaginal cones provided no additional benefit but may be useful for women for whom closely supervised pelvic floor exercise is not available.Editorial Comment: It is becoming increasingly clear from the literature that pelvic floor muscle exercises are effective in improving continence in many women with straightforward stress incontinence. An appropriate quest continues to determine how the exercises can best be taught and done. This article demonstrates that with frequent supervision, similar continence status is achieved both with and without the use of vaginal cones. It would be interesting to compare outcomes with and without cones in women who saw a health care provider only once for their initial teaching. If cones were found to be more effective in this setting, that would be a great aid to primary care physicians.The authors state that there was no correlation between the cone weight and the degree of improvement of symptoms: however, only 2 of the subjects progressed to the next heaviest cone weight. My understanding of the principles of athletic muscles training is that as one increases the resistance the muscle fibers hypertrophy and strengthen. This is the principle behind building biceps. Body-builders or power-lifters continue to increase the amount of weight (resistance) they lift in order to increase bulk and strength. I wonder if this same principle is the reason for the differences in results between this study and the one by Peattie et al. quoted by the authors. My major concern is that people begin to devalue the amount of effort required to perform effective pelvic floor exercises and make assumptions that such exercises are not as good as a permanent surgical cure. I believe that we have not yet begun to develop really effective muscle strengthening regimens for the pelvic floor, and attitudes such as the above will only serve to inhibit our progress.     

Anatomy and physiology of the male urethral sphincter and its preservation in prostatic surgery

Radical prostatectomy is commonly used in the management of localized prostate cancer. Urinary incontinence after prostatectomy is of great concern to many patients. Improved understanding of the anatomy of the external urethral sphincter complex has resulted in a statistically significant decrease in the incidence of postprostatectomy incontinence. Most recent anatomic studies have described the external urethral sphincter complex as consisting of an intrinsic rhabdosphincter surrounding the smooth musculature of the urethra and an extrinsic sphincter incorporating the levator ani muscle and the pelvic floor. Both form a condensed striated muscle ring around the membranous urethra. Preservation of as much as possible of the normal anatomy of the sphincter mechanism and its nerve supply results in an excellent return to continence after radical prostatectomy. Received: 26 February 1999 / Accepted: 20 May 1999     

Fecal incontinence successfully managed by antegrade continence enema in children: A report of two cases

Two children with intractable fecal incontinence after correction of high anorectal malformations were successfully managed by the daily administration of a glycerin enema into the cecum via an appendicocecostomy or tubularized cecostomy, according to the method of Malone's antegrade continence enema (ACE). Fluoroscopic defecography performed during this procedure in each patient disclosed that the glycerin enema promptly evoked cecal peristalsis, which was transmitted to the distal colon and rectum, and squeezed out almost all the fecal matter, evacuating it from the anus. However, two enemas within a short interval were required to achieve a complete washout of feces. Although this report describes only two patients, our experience confirmed that the ACE was very effective and that adding the word continence to antegrade enema was justifiable. Moreover, fluoroscopic defecography was proven to play a significant role in determining the appropriate regimens of this technique to achieve complete washout of the feces.     

Retropublic colpourethropexy with transabdominal anterior and/or posterior repair for the treatment of genuine stress urinary incontinence and genital prolapse

A new operative technique combining retropublic colpourethropexy with transabdominal internal anterior and/or internal posterior repair for the treatment of genuine stress incontinence (GSI) and genital prolapse is described in 75 cases. The overall success rate in correcting GSI was 92.0%, with a 94.8% success rate in the primary surgical group (n=58) and an 82.4% in the secondary group (n=17). Average follow-up has been 1.31 years (range 6 weeks–6 years). There was a 3.4% incidence of residual prolapse. Nine patients also underwent concomitant colpourethropexy. Overall surgical complications include febrile morbidity 4/75 (5.3%), wound infection 1/75 (1.3%), deep vein thrombosis 1/75 (1.3%) and partial ureteric obstruction 1/75 (1.3%). There were no statistically significant changes in multichannel urodynamic studies preoperatively and at 1 year following surgery. Onethird (2/6) of the GSI failures had low MUCP (<20 cm H₂O) prior to surgery and continued so at 1 year follow-up.EDITORIAL COMMENT: Genital prolapse is often present in patients who have GSI. If an operation is performed to correct the GSI, and those areas of weakness in the pelvic support system that are contributing to the genital prolapse are not treated, the genital prolapse will become more severe. In the operation which has been described, the colpopexy sutures will correct any cystourethrocele, and the removal of the wedge of tissue from the anterior superior vaginal wall will correct the cystocele. The removal of the wedge of tissue from the posterior superior vaginal wall will reduce the redundancy of the posterior vaginal fornix, but a culdeplasty of the Moschcowitz or Halban type is recommended to treat or prevent an enterocele and to place the vaginal apex in the hollow of the sacrum. Any coexistent rectocele must always be treated vaginally. If it is not treated, it will appear to be more advanced following elevation of the anterior vaginal wall by retropubic urethropexy and the anterior repair which has been recommended.Genital prolapse is best treated by a vaginal approach. When one must une an abdominal approach, ancillary procedures such as the authors have described should be considered. A bulbous upper vagina is ideal for childbearing but if the apical support system and vaginal wall is weakened it is predisposed to prolapse. If the surgeon, in operating for genital prolapse, which involves the upper vagina, will taper the vaginal apex and support it by obliteration of the cul-desac and shortening and reattachment of the uterosacralcardinal complex, postoperative prolapse will be less likely to recur.     

筋膜悬带对女性压力性尿失禁的治疗作用

目的　对自体阔筋膜作为吊带行尿道悬吊术的疗效和安全性进行分析。方法　 2 0 0 0年 1月至 2 0 0 2年 7月 ,收治 1 3例压力性尿失禁伴子宫脱垂及前后壁膨出患者 ,取自体大腿外侧阔筋膜条作为吊带 ,经下腹阴道联合切口行尿道悬吊带手术 ,同时行阴道式全子宫切除及阴道前后壁修补术。结果　 1 3例患者均获得治愈 ,无阴道出血、感染、排斥反应等并发症发生。 5例患者在术后出现暂时性排尿困难 ,1个月内症状消失。结论　自体阔筋膜带尿道悬吊术是治疗女性压力性尿失禁的安全有效术式。     

The triangular vaginal patch sling for stress urinary incontinence and hypermobile urethra

OBJECTIVE: We describe an alternative sling procedure that permits concomitant correction of urethral hypermobility and urinary incontinence through a single surgical exposure. STUDY DESIGN: Fifteen women with severe urinary stress incontinence and urethral hypermobility underwent a sling procedure by creation of a simple triangular patch from the anterior vaginal wall. RESULTS: The mean operative time for the vaginal sling procedure was 38 minutes (range 29 to 65 minutes) in addition to other operations. The mean postoperative hospital stay was 7.7 days (range 5 to 13 days) and all patients were routinely discharged with an indwelling Foley catheter. Spontaneous micturition occurred in 12 patients after a mean period of 25 days (range 13 to 36 days). In three cases long-term catheterization was necessary. By subjective and objective evaluations, all the patients were cured of their stress incontinence. CONCLUSION: The triangular vaginal patch with the single sutures on each side provides an alternative approach for bladder neck stabilization that may permit a more anatomic suspension of a hypermobile urethra.(Am J Obstet Gynecol 1997;177:31)     

Scoring the short form ICSmaleSF questionnaire. International Continence Society

PURPOSE: The International Continence Society (ICS) ICSmale questionnaire was devised to provide a thorough evaluation of the occurrence and bothersomeness of lower urinary tract symptoms and their impact on the lives of men with benign prostatic disease. This report completes the developmental work on the questionnaire, producing the concise short form instrument, ICSmaleSF, with a valid, reliable and scientifically justified scoring system. MATERIALS AND METHODS: Two data sets were used. The short form version of the questionnaire was devised and initially evaluated using data on men with uncomplicated lower urinary tract symptoms who were involved in the CLasP randomized controlled trial comparing laser therapy with transurethral prostatic resection and conservative management or monitoring without active intervention. External validation of the scoring system was undertaken using data from phase II of the ICS benign prostatic hyperplasia (BPH) study, an observational study of outcome in men with lower urinary tract symptoms related to benign prostatic enlargement. All patients completed the developmental version of the ICSmale questionnaire. Parallel analysis on the CLasP data set identified items that were responsive to change or highly problematic, allowing other redundant and overlapping items to be eliminated. Factor analysis and Cronbach's alpha coefficients were used to examine the clustering of items. Regression models were used to investigate the validity of followup scores within and across treatment groups in the CLasP and ICS/BPH studies. RESULTS: The questionnaire, which originally comprised 22 items, was shortened to 11 items in the 2 distinct factors of voiding (ICSmaleVS) and incontinence (ICSmaleIS) symptoms. Cronbach's alpha coefficients were high at 0.76 for ICSmaleVS and 0.78 for ICSmaleIS. A simple additive score was calculated by adding the 5 items in ICSmaleVS and 6 in ICSmaleIS. ICSmaleVS and ICSmaleIS detected expected improvement in the laser therapy and transurethral prostatic resection groups, and stability in the conservative management group within CLasP. Similarly each subscore but particularly ICSmaleVS was sensitive to differences in the outcome of the range of treatments in the ICS/BPH study. While frequency and nocturia were highly problematic and sensitive to change individually, they did not load into the other main factors or correlate with each other. It is suggested that these symptoms should be evaluated separately with the additional inclusion of a single item measure of the impact of lower urinary tract symptoms on daily life. CONCLUSIONS: The ICSmaleSF represents a comprehensive, concise, valid and reliable instrument for evaluating men with lower urinary tract symptoms. Unlike other questionnaires in the field it contains subscores for the domains of voiding and incontinent symptoms as well as the separate consideration of frequency, nocturia and impact on daily life. We hope that it will become the tool of choice for the comprehensive evaluation of treatment of men with lower urinary tract symptoms associated with benign prostatic disease.     

女性尿失禁对生活质量影响的调查

目的了解尿失禁对生活质量的影响。方法问卷调查福州市某社区女性，回收应用SPSS10．0和SAS6．12统计分析尿失禁患者与非尿失禁人群生活质量的差异，不同程度尿失禁患者生活质量之间的差异以及各类型尿失禁对生活质量影响的不同。结果即使轻度尿失禁也影响患者的日常生活(对压力性、急迫性和混合性尿失禁，P均为0．000)，给患者带来生活的不适且疾病越严重对生活质量的影响越重。尿失禁主要影响患者的行为、心理以及社会的交往。在不同类型的尿失禁中，混合性尿失禁对患者生活质量影响最重。结论尿失禁是一种影响患者生活质量的疾患。