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.     

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.     

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.     

Evaluation and management of mechanical dysfunction in continent colonic urinary reservoirs

PURPOSE: We analyze a group of patients who presented with mechanical dysfunction of the reservoir and/or efferent limb of a continent colonic urinary diversion, and establish an evaluation and management algorithm. MATERIALS AND METHODS: A total of 16 patients with a mean age of 58 years and 1 or more symptoms related to continent colonic urinary diversion were evaluated. Presenting symptomatology included difficult catheterization in 8 cases (50%), disabling incontinence in 8 (50%) and recurrent urinary tract infections in 6 (37.5%). All patients had normal, nonobstructed, nonrefluxing upper tracts and none presented with stone disease. Urological evaluation consisted of catheterization, fluoroscopy and urography of the pouch, retrograde urography of the external limb and urodynamics (enterocystometrogram and outlet pressure profilometry). RESULTS: Of the 8 patients with difficulty with catheterization 4 had stomal stenosis, 2 had an elongated and redundant external limb, and 2 had a false passage. Diagnosis was established by the inability to catheterize, fluoroscopy of the pouch and retrograde urography. Disabling incontinence occurred in 8 patients, including 7 who presented with an incompetent outlet and 2 with high pressure intestinal contractions of the reservoir. The aforementioned abnormalities were diagnosed by a combination of retrograde urography, urography of the pouch and urodynamics. Recurrent symptomatic urinary infections were observed in 5 patients of the previous groups and in another with an hourglass reservoir, which was primarily diagnosed by urography of the pouch. Surgical correction in 15 patients included outlet reinforcement, reservoir revision, stomal or external limb revision and conversion to a urinary conduit. Surgical treatment was successful in 14 of 15 patients (93%). CONCLUSIONS: Catheterization difficulty requires retrograde urography to define possible anatomical abnormalities (false passage, conduit elongation) if catheterization and fluoroscopy of the pouch do not demonstrate stomal stenosis. Urinary incontinence benefits from enterocystometry and outlet pressure measurement to determine reservoir and external limb function. Recurrent urinary tract infections not related to ureteral obstruction or reflux requires fluoroscopy of the pouch and external limb to determine abnormalities in patients with detubularization and localization of areas of urine pooling.     

压力性尿失禁初始发病时间分析

目的：对女性压力性尿失禁初始发病时间进行探讨，以便采取预防措施。方法：对我院2000年12月-2003年2月期间就诊的全部408例女性压力性尿失禁病例的初始发病时间做回顾性分析。结果：初始发病在分娩后12个月内者为166例，占40．69％，初始发病在更年期或绝经后2年者为115例，占28．19％。结论：分娩后12个月内及更年期或绝经后2年为患者初始发病比较集中的两个时期，应加强这两个时期的妇女保健。     

女性尿道括约肌控尿和压力性尿失禁发病的机制

女性尿道括约肌控尿机制和压力性尿失禁发病机理的研究经历了长期和曲折的过程,目前认为,女性尿道括约肌是由尿道横纹肌括约肌、尿道平滑肌括约肌和尿道固有膜等结构,共同参与组成的一个构造精细而有序的尿道括约肌复合体或称尿道括约肌系统.压力性尿失禁的发生主要与尿道括约肌本身解剖结构和功能缺陷,以及尿道周围附属结构和支撑结构缺陷有关.