Showing papers in "International Urogynecology Journal in 1995"

Pelvic floor muscle exercise for the treatment of stress urinary incontinence: An exercise physiology perspective

Abstract: The aim of this article is to give an overview of the exercise science related to pelvic floor muscle (PFM) strength training, and to assess the effect of PFM exercises to treat stress urinary incontinence (SUI). Sixteen articles addressing the effect of PFM exercise alone on SUI were compiled by computerized search or found in other review articles. Studies with no statement that correct PFM contraction had been performed were excluded. Kegel's suggestion was to perform 3–500 PFM contractions per day. However, suggestions for effective strength training from the exercise science is 8–12 contractions in three series 3–4 times a week for 15–20 weeks or more. Frequency of training varies between 10 repetitions every waking hour to half an hour 3 days a week. Holding periods vary between 2 and 3 s and 30–40 s. Exercise periods vary between 3 weeks and 6 months. Only a few research groups have used methods to measure PFM strength that were reproducible and valid. Statistically significant strength increase has been found after PFM exercise lasting from 3 to 6 months. In all studies the exercises were conducted with thorough individual instruction, vaginal palpation, feedback and close follow-up. Self-reported cure and success rates vary between 17% and 84%. Statistically significant improvement has been demonstrated on self-grading instruments, urethral closure pressure during cough, resting urethral pressure, functional urethral profile length, leakage episodes and pad tests with standardized bladder volume. The results of the long-term studies are promising. It is therefore concluded that PFM exercises are effective in treating SUI. They are cost-effective and should be the first choice of treatment. To be effective, PFM exercise has to be thoroughly taught and performed with weekly or monthly follow-up.

Female urinary incontinence-A symptom, not a urodynamic disease. Some theoretical and practical aspects on the diagnosis and treatment of female urinary incontinence.

Abstract: Female urinary incontinence-A symptom, not a urodynamic disease. Some theoretical and practical aspects on the diagnosis and treatment of female urinary incontinence.

Oxybutynin and bladder training in the management of female urinary urge incontinence: A randomized study

Abstract: A randomized trial of 81 women with detrusor instability, low-compliance or sensory bladder was undertaken to compare the effects of 6 weeks' treatment with oxybutynin (5 mg t.i.d.) or bladder training for urge incontinence. Cystometry was repeated after treatment. Ten per cent of the 42 patients on oxybutynin discontinued the therapy; the cure rate decreased from 74% to 42% during the 6-month period following the treatment (from 93% to 57% in case of detrusor instability). The cure rate of bladder training remained quite high, being reduced only from 73% to 70% (from 81% to 75% in the case of sensory bladder). Twelve of the 13 patients with late relapse of incontinence were on oxybutynin. It was concluded that oxybutynin was not well tolerated and gave only early good results. Bladder training was well accepted and provided persistent results; it may be suggested as the first-line treatment for urge incontinence.

Suburethral duplication of the vaginal wall — An original operation for urinary stress incontinence in women

Abstract: The ideal surgery for urinary stress incontinence should be represented by operations producing increases in urethral closure pressure only when the intra-abdominal pressure is elevated. Guided by this principle the author proposes an original vaginal operation creating a suburethral duplication of the anterior vaginal wall, together with Halban's fascia, located under the proximal urethra just below the bladder neck. Over this supportive duplication the urethra is compressed during its dorsocaudal physiologic displacements. The technical details and indications of the procedure are fully described. In the period from 1974 to 1991, at the Department of Obstetrics and Gynecology, Medical Faculty, Skopje, 481 operations were performed. In this series, 74 patients had pre- and postoperative urodynamic evaluations. At 2 years 93.3% were continent without demonstrable obstruction. The simple technique and the use of autologous tissue, together with the lack of major complications and low recurrence rate, are the best advocates for the surgical procedure.

A randomized controlled trial of urodynamic investigations prior to conservative treatment of urinary incontinence in the female

Abstract: Sixty patients complaining of frequency, urgency, nocturia, urge incontinence and stress incontinence were randomly allocated to either undergo conservative treatment by way of combined physiotherapy and bladder retraining as an inpatient without prior urodynamics, or to have urodynamic investigations and treatment tailored to the urodynamic diagnosis. The assessment period was 3 months and assessment was made pre- and posttreatment by urinary diary, pad testing and subjective questionnaire. There was a significant improvement posttreatment for each parameter studied, with the exception of pad testing. There was no significant difference between the two groups for any parameter. Two-thirds of patients were cured to the extent that they did not require further treatment, and again there was no difference between the two groups. We conclude that patients attending for the first time with an uncomplicated story of urinary incontinence can be effectively treated conservatively without prior urodynamics.

Laparoscopic burch repair compared to laparotomy Burch for cure of urinary stress incontinence

Abstract: Sixty-two women underwent either laparoscopic Burch urethropexy or open Burch urethropexy for surgical correction of genuine stress urinary incontinence. Only patients with no prior incontinence surgery and with demonstrated genuine stress incontinence were included. Clinical evaluations were done preoperatively, at 3 months and 1 year postoperatively for objective cure. The preoperative evaluation included a 24-hour urolog, urology questionnaire, Q-tip test, cough stress test, perineal ultrasound, cystourethroscopy and simple-channel cystometrics. At follow-up all patients had repeat Q-tip test, perineal ultrasound and cough stress test. If there was any sign of leaking a repeat single-channel cystometrogram was done. Only patients with a negative objective study were considered cured. Differences in laparoscopic versus laparotomy cure rates at 1 year were insignificant (94% versus 93%). Both procedures stabilized the urethrovesical junction and prevented its descent during straining, as demonstrated by the postoperative Q-tip test and the perineal ultrasound. The two bladder procedures had comparable operative times but patients with laparoscopy voided earlier, were outpatients, and returned to work earlier. In conclusion, short-term results suggest that the laparoscopic Burch urethropexy can give similar results to laparotomy Burch urethropexy for correction of genuine stress incontinence.

Obstruction following anti-incontinence procedures: Diagnosis and treatment with transvaginal urethrolysis

Abstract: We reviewed the charts of 41 patients who underwent transvaginal urethrolysis and resuspension of the bladder neck by the Raz technique for urethral obstruction with or without stress urinary incontinence following anti-incontinence surgery. We sought to evaluate the effectiveness of the procedure as well as to determine any factors that had an effect on the outcome of surgery. Patients were evaluated for obstruction and stress urinary incontinence by history, physical examination, video urodynamics (or multichannel urodynamics plus cystogram and voiding cystourethrography) and cystoscopy. All patients reported normal emptying before the procedure that caused obstruction. Several variables were evaluated for individual predictive values for outcome, including type of surgery causing obstruction, number of previous anti-incontinence procedures, urodynamic evidence of obstruction (high pressure, low flow), instability, concomitant stress urinary incontinence and total urinary retention, which were evaluated by the Fisher exact test, and the amount of post-void residual, bladder capacity, maximum detrusor pressure, maximum urinary flow and interval since surgery causing obstruction, which were evaluated by logistic regression analysis. Mean patient age was 59 years (range 26 to 86 years) and mean followup was 21 months. A total of 19 patients (46%) suffered from concurrent stress urinary incontinence, 23 (56%) had urodynamic evidence of obstruction (high pressure/low flow) and 6 (15%) had only radiographic or endoscopic evidence with a deviated or kinked urethra. Postoperatively, 29 patients (71%) voided normally without significant residuals. Eight patients (20%) remain on self-catheterization and 1 has persistent stress urinary incontinence. When individual variables were evaluated to determine the predictive values with respect to outcome of urethrolysis, only the preoperative post-void residual was statistically significant (the greater the post-void residual, the more likely was failure, p = 0.021). The presence or strength of the detrusor contraction preoperatively and pressure-flow analysis did not predict outcome. Of the patients with stress urinary incontinence 15 (79%) were cured and 3 (16%) were significantly improved with rare stress urinary incontinence not requiring protection. Overall, 33 patients (80%) had some benefit from surgery. Patients who emptied normally before and anti-incontinence procedure that causes obstruction or impaired emptying should not be excluded from urethrolysis based on low detrusor pressures or pressure-flow analysis alone. Simultaneous radiographic imaging and endoscopy may help to select certain patients with obstruction.

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

Abstract: 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.

Paraurethral fascial sling urethropexy and vaginal paravaginal defects cystopexy in the correction of urethrovesical prolapse

Abstract: The authors sought to determine whether a vaginal paravaginal defects cystopexy combined with a paraurethral fascial sling urethropexy is an effective surgical procedure in restoring normal anatomic positioning of the anterior pelvic compartment in cases of genitourinary prolapse associated with overt or masked genuine urinary stress incontinence. In this observational study of 75 patients, each underwent repair of all defects of pelvic support accompanied by this combined procedure for anterior compartment restoration. Sixty-one patients (81%) complained primarily of protruding masses; 25 (33%) had had at least one prior attempt at cystocele repair. Follow-up ranging from 6 months to 3 years was obtained in 72 cases. Sixty-eight (94.4%) patients denied postoperative urinary incontinence. Symptoms of genital prolapse were relieved in all but one. The combined paraurethral fascial sling urethropexy and vaginal paravaginal defects cystopexy present a valuable approach in operative repair when multiple pelvic compartments are involved in prolapse.

MRI of voluntary pelvic floor contractions in healthy female volunteers

Abstract: The dynamic anatomical response of the normal pelvic floor to voluntary pelvic floor contractions was documented using magnetic resonance imaging. Sequences of coronal, sagittal and transverse images in the relaxed and the contracted state were obtained from 17 young, asymptomatic volunteers trained to perform pelvic floor exercises correctly. The images were processed digitally and computer colored to indicate dynamic changes produced as a result of contractions. Gross transverse sections through a human female cadaver were photographed and digitized to provide a reference of pelvic anatomy. A 3D rendition of the processed MR images was made to illustrate the extent of pelvic floor contraction. The results illustrate the changes produced by voluntary pelvic floor contractions in all planes scanned. Quantitative measurements of selective structures around the bladder were made to show the magnitude of pelvic floor displacement during contraction. The dynamic imaging illustrates the extent of changes in the normal pelvic floor that are produced by pelvic floor exercises and give a measure of the displacement of the bladder and the levator ani.

Comparison of 1 and 3 days' transurethral Foley catheterization after vaginal plastic surgery

Abstract: This prospective study was done to see whether reducing transurethral Foley catheterization from 3 days to 1 would lead to fewer urinary tract infections (UTI) without retention becoming a problem. One hundred and sixty-five women undergoing vaginal plastic repair were randomized to either 1 or 3 days catheterization. Of 82 patients catheterized for 1 day UTI was diagnosed in 12 (14.6%), retention occurred in 18 (22.0%) and 7 (8.5%) required a new catheter. Of 83 patients catheterized for 3 days, the respective figures were 17 (20.5%), 12 (14.5%) and 3 (3.6%). The differences are not statistically significant, therefore catheter time may safely be reduced to 1 day. This may be associated with a reduced infection rate but also somewhat greater rate of retention. If a transurethral catheter is to be used, on balance the two regimens are equivalent.

The ‘clitoromotor’ reflex

Abstract: The effect of glans clitoris (GC) stimulation on the vagina, uterus and pelvic floor muscles (levator ani (LA) or pubococcygeus, puborectalis (PR)) was studied in 16 healthy volunteers (mean age 34.9 years). The GC was stimulated mechanically and electrically while recording the vaginal and uterine pressures and the electromyographic activity of PR and LA. Stimulation caused a drop in the uterine (P<0.001) and upper vaginal (P<0.05) pressures (1.6 and 2.9 cmH2O, respectively) and an increase in the middle (P<0.001) and lower (P<0.001) vaginal pressures (58.6 and 89.2 cmH2O, respectively). It also effected an increase of EMG activity in the PR (P<0.01) and LA (P<0.01). Response was greater with electrical than with mechanical stimulation (P<0.05). No response occurred upon stimulation of the anesthetized GC or the anesthetized PR or LA. The reproducibility of the PR and LA contraction on GC stimulation postulates a reflex relationship which we call the ‘clitoromotor reflex’. This induces uterovaginal changes that enhance the sexual response of both partners, and also prepares the uterus and vagina for the reproductive process. LA contraction pulls open and reduces the pressure in the upper vagina as well as elevating the cervix uteri. PR contraction constricts the middle and lower vagina and increases their pressure.

The appropriateness of oral fluoroquinolone prescribing in the long-term care setting

Abstract: Objective: To evaluate the appropriateness of ciprofloxacin-prescribing in the long-term care setting. Design: Retrospective chart review. Setting: A large academically oriented long-term care facility. Patients: Institutionalized elderly patients with a mean age of 88 years. Methods: One hundred orders were randomly selected for review from all ciprofloxacin orders initiated over a 3-year period. Criteria for appropriateness of ciprofloxacin-prescribing were developed based on a comprehensive review of the medical literature. Evaluation of appropriateness of prescribing was based on the indication for therapy and the availability of more effective and/or less expensive alternative antibiotic regimens. Only information available to the physician at the time of the order was used to judge appropriateness. Abstracted medical records were evaluated independently by a geriatrician and an infectious diseases specialist. Results: With respect to site of infection, the urinary tract accounted for 43% of all ciprofloxacin orders; the lower respiratory tract, 28%; and skin and soft-tissue infections, 17%. Only 25% of orders were judged appropriate. Twenty-three percent of orders were judged less than appropriate based on indication, and 49% due to the availability of a more effective and/or less expensive alternative antibiotic choice. There was insufficient information in the medical record to judge 3% of the orders. Conclusion: These results indicate less than optimal prescribing of oral fluoroquinolones in the long-term care setting, with potential consequences including the development of resistant bacterial strains and increased health care costs. J Am Geriatr Soc 42:28–32, 1994

Suprapubic catheterization complicated by bowel perforation

Abstract: Inadvertent bowel injury can occur when utilizing trocar cystotomy technique for the placement of a suprapubic catheter. The authors present a patient who had a suprapubic catheter placed through a stab incision at the time of vaginal pelvic reconstruction for procidentia. Her presentation did not include the typical signs of peritonitis, but was characterized by low urine output and regression of bowel function due to ileus and third-spacing in the peritoneal cavity. The potential risk factors for bowel injury in this patient are enumerated and techniques to minimize the risk of bowel perforation are discussed. The risk of bowel injury is reduced by choosing a catheter introducer that minimizes impedance while piercing tissues, and by using a rigid cystoscope for visualization of the suprapubic trocar during entry into the bladder.

Federal guidelines for the management of urinary incontinence in the United States: Which patients should undergo urodynamic testing?

Abstract: In 1992, the United States Agency for Health Care Policy and Research (AHCPR) proposed a guideline for the management of adults with urinary incontinence. The purpose of this study is to evaluate the criteria proposed by the AHCPR for the selective use of urodynamic testing in women complaining of stress incontinence. In order to examine the efficacy of these criteria, we retrospectively determined urodynamic diagnoses for 101 women presenting with the complaint of stress incontinence. These were then compared to the AHCPR recommendations for each subject's management. We found that the AHCPR algorithm would have recommended treatment without urodynamic testing for 65% of the population. If the AHCPR guideline had been followed, 32% of the overall population could have received inappropriate treatment. These results suggest that the implementation of the AHCPR guideline could result in inappropriate treatment for onethird of women presenting with symptoms of stress incontinence.

Viscoelastic properties and muscular function of the human anterior vaginal wall.

Abstract: The aim of the study was to assess the viscoelastic properties of the isolated anterior vaginal wall and to test its tentative muscular functions in a specially designed in vitro model. Vaginal biopsies were obtained from 16 urologically healthy women not on hormonal therapy who had undergone hysterectomy because of menometrorrhagia and/or uterine fibroids. The biopsies were taken from the anterior vaginal wall during vaginal or abdominal surgical procedures. Tissues were immersed in ice-cold and oxygenated Hepes buffer. In the in vitro model, the elastic properties were evaluated from a stress-relaxation test. The muscular function was tested by stimulating the prepared vaginal strips with K+, noradrenaline (NE), and prostaglandin F2α (PGF2α). In addition, the distribution of muscle cells was analyzed histologically in cryostat sections of the vaginal strips. Under a resting tension of 20–40 mN, the vaginal strips displayed spontaneous contractile activity. The extent of relaxation initiated by stretching was greater in transverse than in longitudinal vaginal strips. Moreover, it was greater in postmenopausal than in premenopausal women (P<0.01). K+ (0.01–2 M) evoked contractions had caused a dose-dependent increase in basal tone of the strips. NE at concentrations of 10−6–10−3 M had similar effects to K+. PGF2α (0.15–2.5 μM) increased the vaginal contractile activity in a dose-dependent manner. The histological examination showed that the vaginal wall studied had an inner mucosal, a middle connective tissue and an external muscular layer. In the latter both longitudinal and circular smooth muscle layers were found. It was concluded that this in vitro model can be used to interpret the viscoelastic properties and muscular function of the human anterior vaginal wall. Stressrelaxation data indicate that the ability of relaxation of tissue strips obtained from a circular direction of the female anterior vaginal wall is greater than that of strips obtained from a longitudinal direction, and that this ability is greater in postmenopausal women than in premenopausal women. Histologically the anterior human vaginal wall consists mainly of smooth muscle cells arranged in both circular and longitudinal layers. Between these layers there is connective tissue similar to that seen in other organs of the urogenital tract.

Multimodality pelvic physiotherapy treatment of urinary incontinence in adult women

Abstract: The aim of the study was to evaluate the effectiveness of in-office physiotherapy for stress, mixed and urge incontinence. All subjects underwent urodynamics. Those with stress incontinence received pressure biofeedback pelvic floor exercises and electrical stimulation. Those with detrusor instability and mixed incontinence received bladder drills, anticholinergic medications, electrical stimulation and pressure biofeedback pelvic floor exercises. All those with atrophic vaginitis received vaginal estrogen. Weekly treatment sessions for 4 weeks and then monthly for 2 months were directed by a trained gynecologic nurse. Weekly bladder diaries were kept. Outcome measures included diary-recorded incontinence episodes and subjective reporting of continence. One hundred and four women completed the program. Weekly incontinence episodes decreased from 22 to 2 (<0.05) in both stress and detrusor instability/mixed incontinence groups. An average of 4.5 sessions over 6.1 weeks was necessary for optimal response; 86% reported subjective improvement. It was concluded that multimodality treatment of incontinence leads to a 90% reduction in incontinence episodes. The relative contribution of each treatment modality requires further study.

Neurophysiologic effect of vaginal cone application in continent and urinary stress incontinent women

Abstract: Simultaneous electromyographic (EMG) recordings with intramuscular wire electrodes from the left and right pubococcygeal muscles were performed to elucidate the neurophysiological effect of vaginal cones on the pelvic floor muscles. Ten continent nulliparous women (aged 22–32 years) and 20 stress urinary incontinent parous women (aged 27–60 years, average 2–4 deliveries) were examined before, during holding and after removal of the cone. All the continent nulliparous women could retain the cone in the vagina (mean weight 83.5 g (range 70–85 g). In the incontinent parous group 7 women could not hold any cone, 9 women could hold the 45 g cone, 1 the 32.5 g cone and 3 women the 57.5g cone. There was a significant voluntary holding time difference between continent nulliparous and incontinent parous women. The study reveals that vaginal cones may induce both strengthening of muscles as well as a learning effect leading towards a better coordinated muscle activation.

Long-term results after Burch colposuspension

Abstract: Objective : Our purpose was to review the long-term (5 to 10 years) clinical and urodynamic outcome in patients with stress urinary incontinence after Burch colposuspension. Study Design : A follow-up of 87 women with stress urinary incontinence who had a Burch colposuspension between 1979 and 1985 at the Department of Obstetrics and Gynecology, University of Berne, was performed by clinical and urodynamic reevaluation of the patients. Results : Stress incontinence was cured in 81.6% of patients. The cure rate was not significantly related to age, hormonal status, body weight, or previous surgical procedures for incontinence. Burch colposuspension stabilized the urethrovesical junction. Urodynamic measurement at follow-up compared with the preoperative evaluation showed in the cured group a significant increase in (1) the functional urethral length at rest and at stress, (2) maximum urethral closure pressure at stress, and (3) pressure transmission. On the contrary, in unsuccessful operations none of the recorded parameters had improved. Women with failed surgery had significantly lower preoperative maximum urethral closure pressures at rest and at stress, lower continence areas, smaller functional urethral lengths at stress, smaller length to peak pressures, and lower index values of urethral relaxation at stress. The procedure had a low operative and postoperative morbidity, with no significant disturbance of voiding function noted at 5 to 10 years' follow-up. Conclusions : Our results with the Burch colposuspension showed a high success rate at 5 to 10 years' follow-up. The high cure rate and low operative and postoperative morbidity were related to careful preoperative selection.

Simultaneous perineal ultrasound and urodynamic assessment of female urinary incontinence: Initial observations

Abstract: Simultaneous perineal ultrasound and urodynamic evaluation was performed in 35 female patients suffering from urinary incontinence of varying etiologies and in 5 healthy continent women. The digitized ultrasound signals and urodynamic curves were simultaneously monitored on a computer screen. During cystometry, urethral pressure profile during stress, and micturition, this simultaneous technique correlates pressure measurements with the behavior of the urethrovesical junction. The influence of intra-abdominal pressure changes (coughing, straining) on the anatomy of the urethra and the urinary bladder, or the effect of pelvic floor and urethral sphincter contractions on the intraurethral and intravesical pressure, thereby becomes evident. The synchronous imaging of pressure variations and structural changes provides valuable information about the functional anatomy of the urethrovesical junction. On the one hand urodynamic phenomena, and on the other hand ultrasound findings, can be better understood than when the techniques are performed separately. With this simultaneous evaluation additional knowledge is acquired about the pathyophysiology of micturition disorders and incontinence. An advantage of ultrasound compared with radiological techniques is that the urethrovesical anatomy and the surrounding tissues are clearly imaged without irradiation and without the need for contrast medium.

Twenty-four-hour pad weighing test: Reproducibility and dependency of activity level and fluid intake

Abstract: To evaluate the reproducibility of the 24 hour pad weighing test and the possible influence of fluid intake and level of activity to the test result. 14 women, referred for operation because of urinary incontinence, performed six 24 hour pad tests each under the following conditions: 2 tests on normal daily activity level and on normal fluid intake. 2 tests on high vs. low activity level, and 2 tests on high vs. low fluid intake. The study concludes that the results of the 24 hour pad weighing test are reproducible with moderate variation in fluid intake and activity level. Artificially low fluid intake or extreme variations in activity level could, however, significantly alter the urinary leakage. Small variations in fluid intake and activity level have no effect on the test result. © 1994 Wiley-Liss, Inc.

Permanent or absorbable sutures for Burch colposuspension

Abstract: There is no consensus in the present literature on the type of suture material to be used for Burch colposuspension. The authors reviewed the available literature and studied the cure rates of the various studies. Seventeen studies which specified the suture material could be analysed. The mean cure rate in those that used permanent sutures was equal (87%) to the studies which used absorbable sutures. It was concluded that both types of suture material have equal success rates and that, on the basis of the present review, no specific advice on the type of sutures can be given.

Which patients are at risk of voiding difficulty immediately after colposuspension

Abstract: The objective of the study was to determine preoperative factors (symptoms, history, clinical findings, urodynamic factors or operative findings) associated with voiding difficulties following colposuspension. This retrospective review was undertaken at a urogynaecological clinic in a large district general hospital. Fifty-one patients who had undergone colposuspension for genuine stress incontinence were included. Voiding difficulty was the main outcome measure. This was assessed by time of spontaneous voiding and time of catheter removal. Age was associated with postoperative voiding difficulty when this was assessed by time of catheter removal (P<0.02) and by time of spontaneous voiding (P<0.05). A low preoperative maximum voiding pressure was associated with delayed spontaneous voiding (P<0.05) but not with prolonged catheterization. It was concluded that older patients were at greater risk of voiding difficulty following colposuspension and that HRT did not prevent this complication.

Pelvic muscle profile types in response to pelvic muscle exercise

Abstract: The purpose of this research was to describe the contractile response of pelvic muscle to exercise (PME). Pelvic muscle pressure curves from ten randomly selected records from a larger study of 65 women with urodynamically demonstrated stress urinary incontinence (SUI) were analyzed. The subjects completed a PME protocol that lasted 16 weeks. Five pressure curves before and after 16 weeks of exercise were analyzed and classified according to pressure-time profile types. Descriptive statistics revealed decreases in urine loss variables and increases in pelvic muscle pressure curve variables. Changes in profile characteristics suggested an increase in type II muscle fiber recruitment; recruitment of type I fibers that appeared less fatigable; and increased contractile force of both type I and type II fibers. Changes were analyzed by descriptive statistics and by reference to putative types. Reference to profile types may be useful to PME prescription to enhance fiber type-specific performance.

Study of the response of the urinary bladder to stimulation of the cervix uteri and clitoris — The ‘genitovesical reflex’: An experimental study

Abstract: There is a debate as to whether, during the sexual act, some women eject a fluid that could be urine. As a part of investigation into this subject, the effect of stimulation of the clitoris and cervix on urinary bladder pressure and external urethral sphincter (EUS) activity was studied in 12 bitches. The clitoris and cervix were stimulated both electrically and mechanically. Upon clitoral or cervical stimulation, the vesical pressure dropped (P<0.05) and the EMG activity of EUS increased; action potentials increased and latency decreased when the stimulation frequency increased. No fluid came out of the external urethral orifice or the vagina. Stimulation of the anesthetized clitoris and cervix effected no vesical pressure or EUS response. These results were reproducible. The study has shown that on clitoral and cervical stimulation, which closely simulates the conditions during coitus, the bladder neck was firmly closed by EUS contraction, whereas the vesical detrusor was relaxed. A constant and reproducible reflex relationship existed between the clitoris, or the cervix, and the urinary bladder, which the author calls the ‘genitovesical reflex’ and which probably acts to prevent urinary leak during coitus. The genitovesical reflex may prove to be of diagnostic significance in genitourinary disorders.

An analysis of urethral viscoelasticity with particular reference to the sphincter function in healthy women

Abstract: Urine ingression into the urethra involves stretching of the fibers, resulting in a pressure increase. This study describes the pressure response following a rapid urethral dilation. A probe for simultaneous recording of cross-sectional area (dilatation) and pressure was used. The urethral dilatations were induced by a gravitationally operated pump. Fifteen healthy women were studied. The pressure response (viscoelastic reaction) is a steep increase with the maximum at the end of dilatation. The maximum pressure is followed by a pressure decay (stress relaxation) over the next few seconds. The pressure response was highly dependent on the size and rate of dilatation but not on the urethral site of measurement. The median pressure response to a dilatation of 10 mm2 at a rate of 150 mm2/s (chosen arbitrarily within the physiological range) is 45 cmH2O. The pressure response may account for 25% of the urethral resistance to dilatation.

Bladder dysfunction after repeat laparoscopic uterine nerve ablation (LUNA)

Abstract: The authors report a case of voiding dysfunction with reduced sensation and areflexia 13 months after a repeat LUNA due to pelvic nerve injury. Anatomic distortion and increased vascularity were likely contributing factors. Repeat procedures may expose patients to a risk of such injury due to anatomic distortion.

Physicians' Perception of Urinary Incontinence as a Health Care Problem in Women

Abstract: A mailed questionnaire was sent to 1500 family physicians and general practitioners in Ontario, Canada, to determine the primary care physician's perception of urinary incontinence as a health care problem. Questions involved their exposure to female patients with urinary incontinence, management of urinary incontinence, estimation of the extent of urinary incontinence as a health care problem, and the estimation of treatment success. The response rate to the survey was 18%. Fifty per cent of physicians see more than 1 patient per week with incontinence; 85% of physicians underestimated the prevalence of incontinence in the female population aged 25–64; 29% do not routinely ask about incontinence. In those patients complaining of urinary incontinence, 71% of physicians perform a physical examination and 32% try to demonstrate incontinence. Seventy per cent refer on to local urologists, and 58% to local gynecologists. The mean estimation for cure or significant improvement is 68%. It was concluded that, there is room for improved education of primary care physicians regarding the health care problem of female urinary incontinence.