Showing papers in "International Urogynecology Journal in 1990"
390 citations
TL;DR: Stress incontinence was improved subjectively in all treatment groups, although objective improvement was maximal in those treated with vaginal estrogen plus PPA, and in combination with the concurrent administration of PPA.
Abstract: Sixty postmenopausal women suffering from genuine stress incontinence were recruited into a double-blind study comparing the effects of oral and intravaginal estrogens and placebo, alone and in combination with the alpha-adrenoreceptor stimulant drug phenyl-propanolamine (PPA). Side effects were more common with orally administered estrogen, whereas symptomatic improvements were greater than the vaginal route. Plasma estrone and estradiol were both elevated more when estrogen was given by the oral (x 3–4) than vaginal (x 2) route, although the estradiol/estrone ratio was lower with oral therapy; the biochemical alterations increased with increasing chronological age and menopausal age, and were slightly enhanced by the concurrent administration of PPA. Diurnal and nocturnal urinary frequency were both reduced to a greater extent with vaginal than oral estrogen treatment, and more when used with PPA. Stress incontinence was improved subjectively in all treatment groups, although objective improvement was maximal in those treated with vaginal estrogen plus PPA.
73 citations
TL;DR: This vignette documents events surrounding the development of the operation, its subsequent evolution, and related biographical details of the life of Dr Pereyra.
Abstract: In January of 1959, Armand J. Pereyra introduced a new approach in the surgical treatment of female urinary stress incontinence. Pereyra spent two decades experimenting with operative materials and various surgical techniques, revising his needle suspension procedure into the form we recognize today: the modified Pereyra procedure. This vignette documents events surrounding the development of the operation, its subsequent evolution, and related biographical details of the life of Dr Pereyra. Documentation indicates that all significant modifications of the needle suspension were performed by Pereyra initially.
52 citations
TL;DR: Estriol 4mg daily and PPA 50 mg b.i.d. are effective in the treatment of stress urinary incontinence in postmenopausal women and the enhanced effect of combined treatment is moderate and of questionable importance.
Abstract: Twenty-eight postmenopausal women with objectively verified stress incontinence completed a randomized double-blind placebo-controlled study After an initial 4 weeks of placebo treatment the patients received either oral estriol (E3) (4mg daily) or oral phenylpropanolamine (PPA) (50 mg bid) alone for 4 weeks, followed by another 4 weeks of treatment with the two active drugs in combination
49 citations
TL;DR: The statistically significant improvements in pre- and postoperative urodynamic parameters involved a decrease in uroflow volumes and an increase in urethral functional length, but not in maximum urethal closure pressure.
Abstract: Sixty-five women underwent combined abdominovaginal Marlex sling procedures for recurrent stress urinary incontinence. Urodynamic evaluation consisted of uroflowmetry and simultaneous pelvic electromyographic (EMG) studies, carbon dioxide cystometry, urethral pressure profilometry, and cystometry and urethroscopy. Cure rates were 75% for urgency incontinence and 95.3% for stress incontinence. The statistically significant improvements in pre- and postoperative urodynamic parameters involved a decrease in uroflow volumes and an increase in urethral functional length, but not in maximum urethral closure pressure. Bladder capacity remained unchanged.
43 citations
TL;DR: Polytetrafluoroethylene and the use of GAX-Collagen presently under investigation provide excellent efficacy with over 80% of females rendered continent after two treatments, thus reducing the need for major surgery.
Abstract: The failure to store urine secondary to bladder outflow incompetence requires a method to increase outflow resistance. Injectable therapy is a modality which causes an additional resistance to the flow of urine. Polytetrafluoroethylene and the use of GAX-Collagen presently under investigation provide excellent efficacy with over 80% of females rendered continent after two treatments. Concerns over particle migration reduce the utility of polytetrafluoroethylene. Thus far the GAX-Collagen appears safe as well as efficacious. The best results with periurethral injections are those females who do not have detrusor abnormalities, who have adequate bladder capacity, and who have no anatomic abnormality. Injectable techniques in the treatment of urinary incompetence are well tolerated by patients of all ages thus reducing the need for major surgery. This modality of treatment should be added to the armamentarium of those individuals involved in the management of females with urinary incontinence.
28 citations
TL;DR: Physiotherapy has to be recommended more frequently to young nulliparous women as a preventive measure and to mothers after childbirth, and urogynecologic rehabilitation should also be routinely prescribed during the months preceding some surgical procedures.
Abstract: Pelvic floor disorders can be improved by various methods of conservative treatment. Urogynecologic rehabilitation involves pelvic floor physiotherapy, functional electrical stimulation and biofeedback. Recent urodynamic studies have revealed obstetric risk factors, and restoration of pelvic floor musculature after vaginal deliveries is essential. It would appear that urogynecologic rehabilitation should also be routinely prescribed during the months preceding some surgical procedures. Biofeedback has been used successfully in urologic disorders such as instability and enuresis. It is probably the most efficient therapy for learning “perineal blockage at stress”, which gives the patient functional control of the pelvic floor muscles during daily activities. Functional electrical stimulation, either on an outpatient basis or as a home program, is a practical and successful method for improving or curing incontinence. Physiotherapy has to be recommended more frequently to young nulliparous women as a preventive measure and to mothers after childbirth.
23 citations
TL;DR: The diagnosis, treatment, and associated complications will be reviewed.
Abstract: Urinary tract infections in pregnancy are common. The diagnosis, treatment, and associated complications will be reviewed.
22 citations
TL;DR: 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.
Abstract: 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.
20 citations
TL;DR: In women with genito-urinary prolapse, a test of urethral function is essential, even if there is no clinical evidence of incontinence after removal of the descensus, and a procedure for bladder neck stabilization should be added to routine prolapse surgery.
Abstract: In 19 patients with different types of severe descensus, all without clinical evidence of stress incontinence, urethral stress pressure profiles and stress tests were done before and after repositioning of the prolapse. In 13 of the 19 patients, continence was artificial, because during repositioning they showed leakage of urine; however, 6 of the patients remained continent. The pressure transmission ratios decreased in different parts of the urethra in all the patients when repositioning with a gynecological speculum was done. The drop was most significant in those patients who lost urine after repositioning, showing poor urethral function. In women with genito-urinary prolapse, a test of urethral function is essential, even if there is no clinical evidence of incontinence after removal of the descensus. In cases of severe stress incontinence under this condition, a procedure for bladder neck stabilization should be added to routine prolapse surgery.
18 citations
TL;DR: An ecological approach to the pathogenesis of uncomplicated urinary tract infections allows awareness of the continual battle being waged in the vagina, urethra, and bladder between the bacterial invaders and the host defense mechanisms.
Abstract: An ecological approach to the pathogenesis of uncomplicated urinary tract infections allows awareness of the continual battle being waged in the vagina, urethra, and bladder between the bacterial invaders and the host defense mechanisms. Despite overwhelming odds, the bacteria must be able to persist, colonize, and finally adhere to these various battlefields on their ascent to the bladder itself. The large number of patients presenting to physician offices with acute simple cystitis attests to the fact that the bacteria occasionally win the battle of the bladder. An understanding of the pathophysiology of this constantly raging battle may help us modify our clinical approach to women with simple uncomplicated urinary tract infections.
TL;DR: Between September 1985 and June 1988, 67 patients with stress urinary incontinence were treated with reinforced Silastic slings using an abdominovaginal approach, and six patients who are now continent require periodic intermittent self-catheterization.
Abstract: Between September 1985 and June 1988, 67 patients with stress urinary incontinence were treated with reinforced Silastic slings using an abdominovaginal approach. Of these patients, 54 were cured, 2 were improved and 10 were the same or worse (1 patient was not followed up). Six patients who are now continent require periodic intermittent self-catheterization; 3 patients had to have the sling removed, due to a persistent sinus or pain; and 16 patients had to have the sling adjusted.
TL;DR: The ultrasound evaluation was found to be a helpful adjunct in diagnosis and offers more safety, more comfort, more privacy, more viewing time, and less cost than radiologic techniques.
Abstract: Thirty women, 25 with incontinence and five asymptomatic volunteer control subjects, were evaluated urodynamically by a variety of techniques, including ultrasound cystourethrography. The ultrasound evaluation was found to be a helpful adjunct in diagnosis. In comparison with radiologic techniques it offers more safety, more comfort, more privacy, more viewing time, and less cost. Bladder and urethral morphology during voiding activity and the amount and direction of urethrovesical mobility are easily determined by utilizing ultrasound techniques.
TL;DR: A randomized trial of two postoperative suprapubic catheter clamping protocols was undertaken to compare their effect on the duration of both postoperative indwelling catheter time and hospital stay and recommended the avoidance of bethanechol chloride in the management of indwelled catheters after surgery for urinary incontinence.
Abstract: A randomized trial of two postoperative suprapubic catheter clamping protocols was undertaken to compare their effect on the duration of both postoperative indwelling catheter time and hospital stay. In addition, patients were given either bethanechol chloride or placebo in a double-blind fashion to test the proposal that the use of bethanechol chloride would enhance return of bladder function and shorten postoperative catheter time. Forty-nine patients who underwent an anterior repair, Burch colposuspension or Marshall-Marchetti-Krantz (MMK) procedure were preoperatively randomized to one of two catheter clamping protocols. Protocol I involved a continuous clamping regimen with residuals measured with each void. Protocol II involved an intermittent clamping (‘bladder training’) regimen with residuals measured at specified intervals while the catheter was in place. Each patient received either bethanechol chloride or placebo in identical capsules. Protocol I significantly shortened the duration of postoperative catheterization (P<0.01). The use of bethanechol chloride prolonged the duration of catheterization in Protocol I patients and made no difference in Protocol II patients. We would recommend our simplified catheter protocol and the avoidance of bethanechol chloride in the management of indwelling catheters after surgery for urinary incontinence.
TL;DR: The results of this investigation confirm the effectiveness of the Kelly plication either for prevention or therapy of SUI in patients with genital prolapse.
Abstract: From 1977 to 1983 at the 1st Clinic of Obstetrics and Gynecology of the University of Bologna, 264 patients affected by genital prolapse were studied. Of these, 104 who presented with stress urinary incontinence (SUI) underwent a vaginal hysterectomy with anterior vaginal repair and Kelly plication. Follow-up of these patients has demonstrated the effectiveness of this surgical procedure, with a success rate of 88.5% over 6–12 years. In a series of 160 patients without SUI who underwent preventive Kelly plication, urinary incontinence was prevented in 155 (96.9%). The results of this investigation confirm the effectiveness of the Kelly plication either for prevention or therapy of SUI in patients with genital prolapse.
TL;DR: It is concluded that, in the hands of experienced surgeons, colposacropexy and Ripstein procedure for combined vaginal vault and rectal prolapse can be a safe and effective treatment.
Abstract: The literature concerning the concurrent surgical correction for coexisting posthysterectomy vault and intussuscepting rectal prolapse is reviewed. Only two such papers have been published in the past, reporting a total of three cases. Five such cases and their surgical correction using Marlex mesh for both modified Ripstein procedure and colposacropexy are presented. The need for thorough preoperative urodynamic evaluation and defecography is discussed. All patients had good anatomic correction of their genital and rectal prolapse in follow-up. One patient, who had a prior retropubic urethropexy only, was treated by a combined Ripstein and colposacropexy and postoperatively developed recurrent stress urinary incontinence as a consequence of overcorrection by the colposacropexy. This was subsequently corrected by a combined abdominovaginal Marlex mesh sling procedure. There were no operative or postoperative complications, and it is concluded that, in the hands of experienced surgeons, colposacropexy and Ripstein procedure for combined vaginal vault and rectal prolapse can be a safe and effective treatment.
TL;DR: Between 1982 and 1987, 76 patients were identified retrospectively as having had a parturition complicated by postpartum urinary retention among 22 176 deliveries at the Mount Sinai Hospital, Toronto, giving an overall incidence of 3.4 per 1000 total deliveries and 4.4 for vaginal deliveries.
Abstract: Between 1982 and 1987, 76 patients were identified retrospectively as having had a parturition complicated by postpartum urinary retention among 22 176 deliveries at the Mount Sinai Hospital, Toronto, giving an overall incidence of 3.4 per 1000 total deliveries and 4.4 per 1000 vaginal deliveries. Predisposing influences include first delivery, operative vaginal delivery, epidural anesthesia, and episiotomy. The potential for recurrence was noted in 4 of the 21 multiparous patients. A delay in diagnosis of up to 48 hours emphasizes the need for a high index of suspicion for this condition. Bacteriuria, while present in one-third of patients was not a universal finding. No optimal management plan was identified; however, bladder drainage remains the cornerstone of management.
TL;DR: It was found that 22% of patients had a pad weight of ⩽1.0 g after the first hour, compared with 8% for the second hour, and 3% for both hours combined, and no association was found between pad weight gain and clinical incontinence severity score.
Abstract: Thirty-seven women with urodynamically proved genuine stress incontinence underwent 2 hours of perineal pad-weighing and answered a series of questions regarding perception of their incontinence. It was found that 22% of patients had a pad weight of ⩽1.0 g after the first hour, compared with 8% for the second hour, and 3% for both hours combined. No association was found between pad weight gain and clinical incontinence severity score. In contrast, answers to simple questions about frequency of leaking episodes and pad use were significantly associated with incontinence severity. Our results indicate that pad-testing is a poor predictor of incontinence severity and provides no improvement in its prediction over answers to simple questions about frequency of leaking episodes and pad use. The high false-negative rate of the 1-hour pad test precludes its use in differentiating continent from incontinent women.
TL;DR: Data do not support the contention that estrogen replacement therapy is beneficial for lower urinary tract dysfunction during the climacteric and suggest that depleted estrogen status is at least partially responsible.
Abstract: The incidence of lower urinary tract dysfunction increases during the climacteric, and there is embryological, biochemical and epidemiologic evidence to suggest that depleted estrogen status is at least partially responsible. Twelve climacteric women underwent full assessment before and 1 year after treatment with a 50 mg subcutaneous estradiol implant +5 mg norethisterone for 7 days per month. Assessment consisted of a symptoms questionnaire, midstream urine sample, uroflowmetry, videocystourethrography with pressure flow studies, and urethral pressure profilometry. Subjectively, only the symptom of nocturia significantly improved. There was no change in flow variables but there was a significant decrease in residual urine and the degree of bladder base descent. Cystometric capacity was slightly but significantly decreased, and two patients developed genuine stress incontinence whilst on treatment. Nonetheless, there was a significant improvement in urethral pressures at rest but not under stress. This effect was predominantly in the proximal urethra. These data do not support the contention that estrogen replacement therapy is beneficial for lower urinary tract dysfunction during the climacteric.
TL;DR: A prospective crossover study was performed to investigate the effect of a filling catheter upon closure pressure, functional length, and total urethral length in patients with and without a pediatric feeding tube in the urethra.
Abstract: A prospective crossover study of 35 patients was performed to investigate the effect of a filling catheter upon closure pressure, functional length, and total urethral length. Urethral pressure profiles were done while the patients were in the sitting position with a full bladder, both with and without a 6 F pediatric feeding tube in the urethra. Both closure pressure and functional length were significantly higher with the filling catheter in situ. Urethral pressure profiles were different in all patients with the filling catheter in place. Urethral pressure profiles and cystometrograms should be done without filling catheters, using the smallest microtransducer catheters available, to avoid artifactual effects.
TL;DR: A review of the literature shows great variety in the protocols for performing PFE, and inconsistent use of perineometers, palpation tests, or other biofeedback devices.
Abstract: Pelvic floor exercises (PFE) have become a standard nursing intervention, both to prevent as well as to treat incontinence. A review of the literature shows great variety in the protocols for performing PFE, and inconsistent use of perineometers, palpation tests, or other biofeedback devices. Results are difficult to compare because of methodological inconsistencies. Suggestions for further research are included.
TL;DR: Electrodiagnostic studies of the pelvic floor when associated with an understanding of pelvic floor anatomy and physiology may have clinical application in the field of Urogynecology.
Abstract: Pelvic floor disorders resulting in urinary and/or fecal incontinence have been shown to be related to neuropathy. Electrodiagnostic studies of the pelvic floor when associated with an understanding of pelvic floor anatomy and physiology may have clinical application in the field of Urogynecology. Possible clinical applications are discussed.
TL;DR: Patients with combined GSI and DI require detailed urodynamics and may be candidates for surgery, in spite of the coexistent DI, and responded favorably to medication and/or surgery.
Abstract: Forty-six patients with both genuine stress incontinence (GSI) and detrusor instability (DI), as determined by urodynamic evaluation, were treated with medication or surgery and followed for 6 months. It was found that 60% responded favorably to medical therapy with imipramine hydrochloride, oxybutynin chloride, or dicyclomine hydrochloride. Surgery for stress incontinence was performed in 24 patients, including 17 started initially on medication. Surgical cure was achieved in 38% of these 24 patients, and a further 29% of the surgical group were cured with additional drug therapy. Overall, 85% of patients responded favorably to medication and/or surgery. Patients with combined GSI and DI require detailed urodynamics and may be candidates for surgery, in spite of the coexistent DI.
TL;DR: Bacteriuria in pregnancy is now easily detected by various techniques adapted to the office setting, and this entity must be detected and treated as early as possible in pregnancy to prevent these adverse effects.
Abstract: Bacteriuria in pregnancy is now easily detected by various techniques adapted to the office setting. It is importtant to screen for bacteriuria in pregnancy because 3%–10% of pregnant women will be positive for occult infection. Up to 30% thus infected will subsequently develop pyelonephritis later in pregnancy, which in turn is associated with premature labor and delivery. This entity must be detected and treated as early as possible in pregnancy to prevent these adverse effects.
TL;DR: Various non-invasive methods for the relief of genuine stress incontinence are discussed, including pelvic floor exercises and the use of intravaginal cones and electrostimulation.
Abstract: This paper presents a review of the various factors believed to be involved in female urinary continence. Components within the wall of the urethra include smooth muscle, the striated muscle of the rhabdosphincter, elastic connective tissue, a subepithelial vascular component, and the urethral epithelium. Extramural factors comprise the fascial support of the bladder neck and proximal urethra, the transmission of intra-abdominal pressure to the urethra, and the periurethral muscles of the pelvic floor. Special emphasis is placed on the periurethral muscles, and the anatomy, innervation, and histochemistry of the levator ani are discussed. This account is followed by consideration of evidence that partial denervation of the levator ani may be an etiological factor in female genuine stress incontinence of urine. Finally, various non-invasive methods for the relief of genuine stress incontinence are discussed, including pelvic floor exercises and the use of intravaginal cones and electrostimulation.
TL;DR: Lower urinary tract physiology, the neurophysiology of voiding mechanisms and provides the clinician with a rational, objective, current neuropharmacologic approach to lower urinary tract disorders are reviewed.
Abstract: Recent advances in our understanding of the neurophysiology and neuropharmacology of the lower urinary tract have improved our ability to treat disorders of bladder and urethral function. Similarly, many classes of drugs currently used in treating various medical conditions can cause lower urinary tract symptoms and dysfunction. Based on objective modern techniques of urodynamic evaluation, the clinician is able to sort out bladder and urethral abnormalities and scientifically choose appropriate pharmacologic regimens to treat these conditions. This paper reviews lower urinary tract physiology, the neurophysiology of voiding mechanisms and provides the clinician with a rational, objective, current neuropharmacologic approach to lower urinary tract disorders.
TL;DR: Urodynamic assessment and knowledge of the morphology of pelvic floor muscles improves the understanding of pelvicfloor function as it relates to the support of the pelvic viscera and the urethral mechanism that maintains continence of urine.
Abstract: Damage to the pelvic floor muscles leads to an altered relationship of the uterus and the urethrovesical unit to the levator plate and creates conditions predisposing to pelvic relaxation associated with stress incontinence. Morphological changes of pelvic floor muscles are age dependent and associated with deterioration of the urethral closure mechanism. Urodynamic assessment and knowledge of the morphology of pelvic floor muscles improves the understanding of pelvic floor function as it relates to the support of the pelvic viscera and the urethral mechanism that maintains continence of urine.
TL;DR: The paper gives an overview of today's knowledge of urinary tract infection in pregnancy and different treatment procedures and finds that short-course treatment had significant effect.
Abstract: The paper gives an overview of today's knowledge of urinary tract infection in pregnancy and different treatment procedures Three different studies of urinary tract infection (UTI) in pregnancy and the postpartum period are reported Urinary screening of 1798 pregnant women showed a cumulative frequency of bacteriuria of 48%, recurrent infection in one-fifth of the cases, and pyelonephritis in 06% Chlamydial infection was observed as a cause of dysuria in pregnancy In the postpartum period bladder bacteriuria was demonstrated in 37% The condition persisted in 27%, while short-course treatment had significant effect
TL;DR: It is concluded that diuresis cystometry is especially suited for the detection of detrusor instability in patients with a clinical diagnosis of detRusor instability but with essentially normal findings at filling cystometers.
Abstract: Cystometry under rapid diuretic conditions (diuresis cystometry) was performed in 62 women with clinical diagnosis of detrusor instability but in whom during filling cystometry essentially no abnormalities were detected. It appeared that the prevalence of detrusor instability was significantly more pronounced during diuresis cystometry as compared with filling cystometry. Motor urge incontinence could be diagnosed by filling cystometry in only 3 patients and by diuresis cystometry in 23 patients. It is concluded that diuresis cystometry is especially suited for the detection of detrusor instability in patients with a clinical diagnosis of detrusor instability but with essentially normal findings at filling cystometry. Diuresis cystometry takes only slightly more time than filling cystometry, and filling systems and catheters are not required.
TL;DR: The results show that there is an objectively demonstrable neurological abnormality incurred as a result of hysterectomy which is pertinent to the subsequent development of disordered micturition.
Abstract: There is an increased awareness that total hysterectomy may be associated with subsequent vesicourethral dysfunction, but although several factors have been implicated in the cause, the precise etiology has yet to be defined. This study was carried out to determine whether damage to the pelvic innervation may be responsible for post-hysterectomy lower urinary tract dysfunction. Urodynamic evaluation and measurement of sacral latencies (SRLs) were performed in 36 women awaiting total hysterectomy. After operation vesicourethral function was altered in 30.6% of these patients, with the same incidence of neuropathy as detected by SRLs. Of the women with postoperative urinary dysfunction, 72.7% had evidence of pelvic neuropathy. The results show that there is an objectively demonstrable neurological abnormality incurred as a result of hysterectomy which is pertinent to the subsequent development of disordered micturition.