Intrinsic Sphincter Dysfunction Research Articles

Clinical anatomy of uretheric constraints: A systematic review

Introduction: The ureter is a channel responsible for carrying urine to the urinary bladder, through peristalsis and contractions, however, this channel can be affected by three types of constrictions, at the junction of the ureter with the renal pelvis called the ureteropelvic, from the edge of the pelvis to the passage of the iliac blood vessels called the abdominopelvic and at the intersection of the external iliac artery and the bladder wall called the vesicoureteral. These points, then, are relevant for clinical analysis, since they are the cause of several pathologies such as urinary incontinence, intrinsic urinary sphincter dysfunction, and obstruction by kidney stones. Objective: This study aims to carry out a systematic review study of the three points of ureteral contractions. Methodology: The present proposed literature review on the anatomical points of ureteric constrictions, carried out between August and September 2018. Result: It was found that the most widely used medications for pain relief are antispasmodics, non-opioid analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs) and narcotics. Conclusion: It is concluded that, for a better diagnosis, tests such as uroflowmetry, voiding urethrocystography, cystoscopy, and ultrasound are used

"ReMeEx", the adjustable-tension suburetral sling in the treatment of stress urinary incontinence due to intrinsic sphincteric dysfunction (type III)

The anti-incontinence methods "tension free" may be insufficient in the treatment of stress urinary incontinence (IUS) due to intrinsic sphincteric dysfunction (ISD). We report our findings on the use of the suburetral sling with adjustable tension "Remeex" sistem in the treatment of 24 patients. METHODS. Between May 2002 and February 2008, 24 patients with IUS of type III, were subjected to suburetral sling "Reemex." Positioning. The intervention provides a vaginal access to the positioning of suburetral sling and an access to the positioning of a varitensor which the wires are connected at the sling seats, recovered by the passage of a Stamey needle carrier of. The average operative time was approximately 70 minutes, the resignation was in I-II day. The tension of the sling was adjusted the day following intervention by turning the screw connected to the varitensor. Patients were followed with physical examination and completed the Korman's questionnaire about the quality of life. RESULTS. At a follow-up average 30 months, 21 patients (87.5%) were perfectly continent with improvement of quality of life. Among the complications, wound infection occurred in 2 patients (8%); 1 (4%) with mild recurrence IUS; 1 (4%) reported "de novo" urgency, 1 (4%) reported urinary retention. CONCLUSIONS. Our data show that the use of the suburetral sling "ReMeEx" is a effective option in the treatment of IUS due to ISD which is a condition often secondary to urogynecologic surgery and refractory to common techniques antincontinence.

Electrophysiological evaluation of the pudendal nerve and urethral innervation in female stress urinary incontinence

Although still a matter of debate, stress urinary incontinence (SUI) may be accompanied by damage to urethral and pelvic floor innervations, thus promoting dysfunctions of the urethral support and sphincteric closure mechanisms. The aim of this study was to analyze the pelvic floor and urethral innervations through pelvic electrophysiological tests to identify whether neurological alterations interfere with urinary continence and urethral functional activity. This prospective study included 52 women, 33 with clinically and urodynamically proven SUI and 19 continent volunteers matched for age, height, parity, and number of vaginal deliveries by the propensity score method. The patients were divided according to the severity of urinary loss evaluated by measuring abdominal leak point pressure (ALPP). Pudendal nerve terminal motor latency (PNTML), pudendal somatosensory evoked potential (SSEP) latencies, urethral and clitoral sensory thresholds, and urethroanal reflex latency were tested. SUI and control subjects did not differ in PNTML, SSEP latency, and clitoral sensory thresholds. However, reduced responsiveness to urethral electrosensitivity and prolonged urethroanal reflex latency were detected in most incontinent patients. In addition, urethral electrosensitivity was altered in suspected intrinsic sphincteric dysfunction. Urethral afferent pathways can be altered in women with SUI and may play an important role in evoking intrinsic sphincteric dysfunction.

“ReMeEx”, The Adjustable-Tension Suburetral Sling in the Treatment of Stress Urinary Incontinence Due to Intrinsic Sphincteric Dysfunction (Type III)

The anti-incontinence methods “tension free” may be insufficient in the treatment of stress urinary incontinence (IUS) due to intrinsic sphincteric dysfunction (ISD). We report our findings on the use of the suburetral sling with adjustable tension “Remeex” sistem in the treatment of 24 patients. Methods Between May 2002 and February 2008, 24 patients with IUS of type III, were subjected to suburetral sling “Reemex.” Positioning. The intervention provides a vaginal access to the positioning of suburetral sling and an access to the positioning of a varitensor which the wires are connected at the sling seats, recovered by the passage of a Stamey needle carrier of. The average operative time was approximately 70 minutes, the resignation was in I-II day. The tension of the sling was adjusted the day following intervention by turning the screw connected to the varitensor. Patients were followed with physical examination and completed the Korman's questionnaire about the quality of life. Results At a follow-up average 30 months, 21 patients (87.5%) were perfectly continent with improvement of quality of life. Among the complications, wound infection occurred in 2 patients (8%); 1 (4%) with mild recurrence IUS; 1 (4%) reported “de novo” urgency, 1 (4%) reported urinary retention. Conclusions Our data show that the use of the suburetral sling “ReMeEx” is a effective option in the treatment of IUS due to ISD which is a condition often secondary to urogynecologic surgery and refractory to common techniques antincontinence.

The Volume at Which Women Leak First on Urodynamic Testing is Not Associated With Quality of Life, Measures of Urethral Integrity or Surgical Failure

We determined if the bladder volume at which urodynamic stress incontinence is first detected is related to preoperative quality of life, urethral sphincter assessment or surgical outcome in women undergoing continence surgery. Charts of consecutive women who underwent a sling or Burch procedure were reviewed. Preoperative and postoperative assessment included the Incontinence Impact Questionnaire and Urogenital Distress Inventory. Urodynamic stress incontinence volume is the bladder volume at which urodynamic stress incontinence was first detected. Women were divided into 4 groups according to urodynamic stress incontinence volume, and compared with respect to maximum urethral closure pressure, Valsalva leak point pressure, Incontinence Impact Questionnaire and Urogenital Distress Inventory. Urodynamic stress incontinence persistence was evaluated only in patients who had sling surgery. A total of 168 women were recruited for the study. Urodynamic stress incontinence volume was 100 ml for 31% of women, 200 ml for 17%, 300 ml for 17% and 400 ml or greater for 35%. Baseline and postoperative Urogenital Distress Inventory, Incontinence Impact Questionnaire, maximal urethral closure pressure and Valsalva leak point pressure did not differ by urodynamic stress incontinence volume. Among the 116 patients who had the sling procedure, urodynamic stress incontinence persistence did not differ by urodynamic stress incontinence volume (p=0.72). Women who demonstrate urodynamic stress incontinence at lower bladder volumes do not report greater bother from incontinence than women who leak at higher volumes, suggesting leakage severity on urodynamics is not an adequate reflection of incontinence related quality of life.

The Relationships Among Measures of Incontinence Severity in Women Undergoing Surgery for Stress Urinary Incontinence

We assessed the relationships among severity measures of urinary incontinence in women with stress predominant symptoms enrolled in a randomized clinical trial comparing 2 surgical techniques (Burch colposuspension vs pubovaginal sling) for stress urinary incontinence. A total of 655 women underwent a standardized preoperative assessment that included the Medical, Epidemiological and Social Aspects of Aging questionnaire, Urogenital Distress Inventory, Incontinence Impact Questionnaire, 3-day voiding diary, 24-hour pad test, a supine empty bladder stress test and Valsalva leak point pressure measurements. Correlations were estimated using Spearman correlation coefficients and 95% confidence intervals. T tests at alpha=0.05 were conducted to compare the distributions of the continuous severity measure between patients with positive and negative supine empty bladder stress test. Baseline mean scores on Medical, Epidemiological and Social Aspects of Aging, Urogenital Distress Inventory and Incontinence Impact Questionnaire were 25.8, 151 and 171, respectively. Mean incontinence episode frequency and pad weight were 3.2 per day and 43.5 gm, respectively. Supine empty bladder stress test was positive in 218 patients, and 428 patients had valid Valsalva leak point pressure measurements with a mean Valsalva leak point pressure of 80 cm H(2)O. Weak to moderate correlations were observed between Medical, Epidemiological and Social Aspects of Aging, incontinence episode frequency, pad weight, Incontinence Impact Questionnaire and Urogenital Distress Inventory. On the other hand, Valsalva leak point pressure correlated poorly with all variables measured. The sensitivity and specificity of the supine empty bladder stress test to predict intrinsic sphincter dysfunction were 49% and 60%, respectively. Urinary incontinence severity measures correlate moderately with each other at best. While Medical, Epidemiological and Social Aspects of Aging demonstrated stronger correlations with the other measures of severity and quality of life, Valsalva leak point pressure did not. Supine empty bladder stress test did not demonstrate a clinically significant association among severity measures.

The role of angiotensin II in stress urinary incontinence: A rat model

Pharmacological treatment for stress urinary incontinence (SUI) is limited to the use of non-selective alpha-agonists, which are often ineffective. Non-adrenergic mechanisms have also been implicated in urethral closure, including angiotensin II (Ang-II), which has been demonstrated throughout the urinary tract. We investigate the role of Ang-II in urethral tone in a rat model of SUI. Abdominal leak point pressure (ALPP) and retrograde urethral pressure profilometry (RLPP) were measured in 70 female virgin rats. Thirty rats underwent pudendal nerve injury (PNT), 30 had circumferential urethrolysis (U-Lys), and 10 had sham surgery. Rats received daily doses of Angiotensin Type 1 (AT-1) receptor inhibitor (20 mg/kg), Angiotensin Type 2 (AT-2) receptor antagonist (10 mg/kg), or Ang-II (2 mg/kg). Following U-Lys, RLPP and ALPP decreased from 21.4 +/- 2.0 and 39.2 +/- 3.3 mm Hg, to 13.1 +/- 1.5 and 21.6 +/- 1.9 mmHg, respectively (P < 0.01). After PNT, RLPP, and ALPP decreased from 21.0 +/- 1.6 and 41.9 +/- 3.0 mmHg to 13.1 +/- 1.5 and 24.7 +/- 3.3 mmHg, respectively (P < 0.01). AT-1 inhibitor caused significant decrease in RLPP and ALPP from 21.0 +/- 6.2 and 41.8 +/- 9.4 mmHg, to 12.0 +/- 3.8 and 25.6 +/- 6.6 mmHg, respectively (P < 0.01). Likewise, AT-2 treatment reduced RLPP and ALPP from 21.4 +/- 6.3 and 40.1 +/- 1.7 mmHg, to 13.5 +/- 5.7 and 31.0 +/- 7.2 mmHg, respectively (P < 0.01). Following surgery, Ang-II administration restored RLPP and ALPP to baseline presurgical values. AT-1 and AT-2 receptor inhibition significantly lowers urethral resistance, comparable to either neurogenic or urethrolytic injury. Ang-II treatment restored urethral tone in rats with intrinsic sphincter dysfunction. Ang II appears to serve a functional role in the maintenance of urethral tone and stress continence.

New objective measures to quantify stress urinary incontinence in a novel durable animal model of intrinsic sphincter deficiency

Existing animal models of stress urinary incontinence (SUI) are limited because of the low rate of incontinence seen in the animals and to their relatively low durability. In addition, most methods described to measure incontinence are operator-dependent. The aim of this study was to develop a new durable animal model of SUI and establish objective measures to quantify SUI. We subjected female rats to transabdominal urethrolysis. At baseline and at 1, 4, 8, 12, and 24 wk after intervention, animals underwent cystometry and evaluation with abdominal leak point pressure (ALPP). Urethral resistance was evaluated by retrograde urethral perfusion pressure (RUPP). Tissues were obtained for histology and immunohistochemistry. Normal female rats had an average ALPP of 19.4 cmH2O and RUPP of 22.6 cmH2O at baseline. More than 93% of the animals had significantly decreased ALPP and RUPP after the procedure. The mean ALPP and RUPP decreased to 9.8 cmH2O and 11.2 cmH2O, respectively, by 1 wk after urethrolysis. These changes were maintained for up to 24 wk. Changes seen in urethral resistance and ALPP appear to be mediated by apoptosis, decreased neuronal mass, and smooth muscle atrophy. These results indicate that transabdominal urethrolysis is a reliable method of achieving durable decreased urethral resistance in a SUI model. RUPP and ALPP are objective and reproducible methods of assessing urethral resistance. Changes in continence and urethral resistance appear to be mediated by denervation and smooth muscle atrophy, which are seen in both elderly incontinent patients and in patients with intrinsic sphincter dysfunction.

Male slings in the treatment of sphincteric incompetence

Sling procedures in men can be performed with little morbidity and few complications. This article discusses treatment of sphincteric incompetence with the bulbourethral sling and treatment of neurogenic bladder with the prostatic urethral sling. Men with mild-to-moderate intrinsic sphincteric dysfunction after prostatectomy seem to be appropriate candidates for the bone-anchored bulbourethral sling, and the prostatic urethral sling may be an acceptable substitute in patients with neurogenic bladder with intrinsic sphincteric dysfunction.

COMPLICATIONS AND INITIAL CONTINENCE RATES AFTER A REPEAT PUBOVAGINAL SLING PROCEDURE FOR RECURRENT STRESS URINARY INCONTINENCE

No AccessJournal of UrologyCLINICAL UROLOGY: Female Urology1 Jun 2001COMPLICATIONS AND INITIAL CONTINENCE RATES AFTER A REPEAT PUBOVAGINAL SLING PROCEDURE FOR RECURRENT STRESS URINARY INCONTINENCE STEVEN P. PETROU and IGOR FRANK STEVEN P. PETROUSTEVEN P. PETROU Financial and/or other relationship with Bard, American Medical Systems, Upjohn Pharmacia and Timm Medical. More articles by this author and IGOR FRANKIGOR FRANK More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(05)66257-XAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: We evaluated the safety and efficacy of repeat pubovaginal sling procedures for recurrent stress urinary incontinence. Materials and Methods: We retrospectively reviewed the records of 14 patients in whom an initial suburethral sling procedure failed, who then underwent a repeat pubovaginal sling procedure for recurrent stress urinary incontinence at our institution and who were available for followup evaluation. Mean followup after re-operation was 17 months (range 5 to 41). The response to surgery was assessed using the Blaivas-Groutz anti-incontinence surgery response score. Results: There were no intraoperative complications. Mean blood loss was 155 cc (range 50 to 750) and average operative time was 101 minutes (range 80 to 145). Long-term urinary retention developed in 1 of the 14 patients (7%). There were no deaths. Two patients (14%) had postoperative complications, including a pelvic abscess and osteomyelitis pubis in 1 each. Based on the Blaivas-Groutz anti-incontinence scale 7 of the 14 patients (50%) were cured, 1 (7%) had a good response, 4 (29%) had a fair response, 2 (14%) had a poor response and none had treatment failure. Subjectively 12 of the 14 women (86%) considered themselves cured or improved and 2 (14%) considered the operation to have failed. Conclusions: Our data imply that a repeat pubovaginal sling procedure after an initial failed operation is associated with low complication and acceptable continence rates. It should be considered a reasonable treatment option in select women with recurrent stress urinary incontinence. References 1 : Pubovaginal sling procedure for stress incontinence. J Urol1978; 119: 82. Link, Google Scholar 2 : Pubovaginal fascial sling for all types of stress urinary incontinence: long-term analysis. J Urol1998; 160: 1312. Link, Google Scholar 3 : Favorable outcome of pubovaginal slings for geriatric women with stress incontinence. J Urol1997; 157: 125. Link, Google Scholar 4 : Expanded indications for the pubovaginal sling: treatment of type 2 or 3 stress incontinence. J Urol1996; 156: 1620. Link, Google Scholar 5 : An assessment of the surgical outcome and urodynamic effects of the pubovaginal sling for stress incontinence and the associated urge syndrome. J Urol1999; 162: 135. Link, Google Scholar 6 : Our experience with pubovaginal slings in patients with stress urinary incontinence. J Urol1998; 159: 1195. Link, Google Scholar 7 : A simplified urinary incontinence score for the evaluation of treatment outcomes. Neurourol Urodyn2000; 19: 127. Google Scholar 8 : Results of pubovaginal sling for the treatment of intrinsic sphincter deficiency determined by questionnaire analysis. J Urol1997; 158: 1738. Link, Google Scholar 9 : The effect of study methodology on reported success rates of the modified Pereyra bladder neck suspension. J Urol1995; 154: 1732. Link, Google Scholar 10 : A follow up of silastic sling for genuine stress incontinence. Br J Obstet Gynaecol1995; 102: 143. Google Scholar 11 : Vaginal wall sling for anatomical incontinence and intrinsic sphincter dysfunction: efficacy and outcome analysis. J Urol1996; 156: 166. Link, Google Scholar From the Department of Urology, Mayo Clinic, Jacksonville, Florida© 2001 by American Urological Association, Inc.FiguresReferencesRelatedDetailsCited byRutman M, Deng D, Shah S, Raz S and Rodríguez L (2018) Spiral Sling Salvage Anti-Incontinence Surgery in Female Patients With a Nonfunctional Urethra: Technique and Initial ResultsJournal of Urology, VOL. 175, NO. 5, (1794-1799), Online publication date: 1-May-2006.CHOE J (2018) Suprapubic Sling Adjustment: Minimally Invasive Method of Curing Recurrent Stress Incontinence After Sling SurgeryJournal of Urology, VOL. 168, NO. 5, (2059-2062), Online publication date: 1-Nov-2002. Volume 165Issue 6 Part 1June 2001Page: 1979-1981 Advertisement Copyright & Permissions© 2001 by American Urological Association, Inc.Keywordsurinary incontinence, stressurethrareoperationMetricsAuthor Information STEVEN P. PETROU Financial and/or other relationship with Bard, American Medical Systems, Upjohn Pharmacia and Timm Medical. More articles by this author IGOR FRANK More articles by this author Expand All Advertisement PDF downloadLoading ...

Minimally Invasive Endoscopic Treatment of Vesicoureteral Reflux and Urinary Incontinence

In the last two decades, convincing evidence of the utility of endoscopic correction of primary vesicoureteral reflux and urinary incontinence owing to intrinsic sphincter dysfunction has become available. However, the ideal bulking material has not yet been found. Polytetrafluoroethylene and purified crosslinked bovine collagen are most often used. Dextranomer microspheres suspended in sodium hyaluron solution and detachable microballoons are being studied, as are various types of beads and autologous chondrocytes.

THE SUPINE STRESS TEST: A SIMPLE METHOD TO DETECT INTRINSIC URETHRAL SPHINCTER DYSFUNCTION

Purpose A new clinical test for intrinsic urethral sphincter dysfunction is proposed and compared to abdominal leak point pressure determination by video urodynamics. Materials and Methods Patients were prospectively included in the study if they had stress urinary incontinence symptoms and were to undergo video urodynamic testing. Patients with urinary tract infection, cystocele, rectocele and vaginal vault prolapse were excluded from study. A supine stress test using cough and Valsalva's maneuvers was performed after bladder filling to 200 ml. with sterile normal saline solution by gravity. Efflux of the bladder solution from the meatus coinciding with the cough or Valsalva maneuver indicated a positive clinical test. A video urodynamic study, including abdominal leak point pressure, was performed. Intrinsic urethral sphincter dysfunction was diagnosed if abdominal leak point pressure was less than 100 cm. water. Test indexes were calculated based on the results of the supine stress test and the abdominal leak point pressure measurements. Results Results were positive in 30 of 41 consecutive patients and negative in 11. Using abdominal leak point pressure measurement, the supine stress test had 93.5% sensitivity, 90.0% specificity, 96.7% positive predictive value and 81.8% negative predictive value for detecting intrinsic urethral sphincter dysfunction. Conclusions The supine stress test is easy, quick and inexpensive, and a positive test is a reliable predictor of intrinsic urethral sphincter dysfunction. A negative test is highly correlated with the absence of intrinsic urethral sphincter dysfunction during video urodynamic testing. This test is more reliable in diagnosing intrinsic urethral sphincter dysfunction than other nonurodynamic tests reported in the literature. The supine stress test can be a useful supplement to cotton swab testing for urethral hypermobility in determining the appropriate management for stress urinary incontinence.

Surgical treatment of stress urinary incontinence

The treatment of stress urinary incontinence (SUI) is one of more controversial aspects of pelvic floor surgery. The indications for the surgical approach are related to the international classification as: Type 1 and Type 2 (Anatomical Incontinence), and Type 3 urinary incontinence (Intrinsic Sphincteric Dysfunction). The procedure of choice for Type 1 and Type 2 is Bladder Neck Suspension (BNS) that create a strong hammock against which the urethra can be compressed with sudden changes of abdominal pressure. Type 3 has to be treated by coaptation or compression of the deficient sphinteric unit (slings or injections). The mean cure rate after Marshall–Marchetti–Krantz is 77%, that of the Burch is 81%, and that of the Needle Suspension is 79%. Laparoscopy, Bone Anchors BNS and Tension-Free Vaginal Tape represent a promising option to the traditional techniques. The contribution of minimal invasive surgery consisting in: short recovery or possibility of day surgery, reduced trauma and pain, and success rate similar to the conventional techniques, is changing the SUI treatment.

New advances in injectable therapies for the treatment of incontinence and vesicoureteral reflux

Clinical experience over the last two decades has demonstrated that the endoscopic correction of primary vesicoureteral reflux and urinary incontinence caused by intrinsic sphincteric dysfunction is both possible and effective. The ideal material for use in these regards has yet to be developed. As a result, there has been a continuing research effort directed towards the development of new injectable substances. Nonautologous substances, such as Teflon, collagen, and Deflux, and autologous substances such as fat, chondrocytes and muscle, have been used either clinically or are under investigation. Although the ideal substance has yet to be determined, many of the substances currently under development appear promising. The use of a particular substance may best be determined by the clinical circumstance involving each individual patient.

Our changing strategies on bladder neck suspension operations.

With currently changing strategies, we retrospectively reviewed our operative results in female stress incontinence to find a suitable solution to correct both urethral hypermobility and intrinsic sphincter dysfunction with reasonable success rates. No Incision Bladder Neck Suspension (NIBNS), Modified Four Corner Bladder Neck Suspension (MFCBNS) and in situ vaginal wall sling operation with bone fixation were performed on 24, 26, 25 patients from 1992 to 1994, 1994 to 1996, 1996 to 1998, respectively, with pre- and postoperative evaluations and success rate determinations. Cure rates for NIBNS operations were 90.47, 72.2 and 50 per cent after 6 months, 2 years and 5 years, respectively. For MFCBNS operations cure rates were 96 and 75 per cent after 6 months and 2 years; for in situ vaginal wall sling by bone fixation the rates were 100 per cent in primary cases and 80 per cent in secondary cases after one year of follow-up. After two years the cure rate was 88.8 per cent in primary cases. By fixation and elevation of the urethrovesical junction and by external compression from under the urethra, in situ vaginal wall sling by bone fixation offers a better solution to urethral hypermobility and intrinsic sphincter dysfunction for urinary stress incontinence.

Terminal Nerve Distribution to the Urethra and Bladder Neck: Considerations in the Management of Stress Urinary Incontinence

Purpose Recent reports have suggested an increased incidence of intrinsic sphincter dysfunction, most of which seems to appear following the failure of a previous, usually vaginal, surgical repair. Our studies attempt to define more precisely the neuroanatomical relationships that exist in the region of the bladder neck and proximal urethra, and between the urethra and anterior vaginal wall. Materials and Methods We dissected the pelves of adult female cadavers and step sectioned them at 4 mm. intervals. Several staining methods were used on each section to identify and document the position of the nerves and vascular structures between the vaginal wall and urethra. Results A rich plexus of blood vessels and nerves with ganglia is located between the vaginal wall, and the proximal urethra and bladder neck. The greatest concentrations of nerves are in the 4 o'clock and 8 o'clock positions but nerve fibers are identified throughout the loose areolar tissue planes through which vaginal surgery for stress urinary incontinence is often performed. Conclusions When performing surgical procedures for the correction of stress urinary incontinence, the possibility that denervation and devascularization of the terminal urethra and bladder neck secondary to surgical dissection could contribute to the subsequent development of intrinsic sphincter dysfunction should be considered.

Terminal nerve distribution to the urethra and bladder neck: considerations in the management of stress urinary incontinence.

Recent reports have suggested an increased incidence of intrinsic sphincter dysfunction, most of which seems to appear following the failure of a previous, usually vaginal, surgical repair. Our studies attempt to define more precisely the neuroanatomical relationships that exist in the region of the bladder neck and proximal urethra, and between the urethra and anterior vaginal wall. We dissected the pelves of adult female cadavers and step sectioned them at 4 mm. intervals. Several staining methods were used on each section to identify and document the position of the nerves and vascular structures between the vaginal wall and urethra. A rich plexus of blood vessels and nerves with ganglia is located between the vaginal wall, and the proximal urethra and bladder neck. The greatest concentrations of nerves are in the 4 o'clock and 8 o'clock positions but nerve fibers are identified throughout the loose areolar tissue planes through which vaginal surgery for stress urinary incontinence is often performed. When performing surgical procedures for the correction of stress urinary incontinence, the possibility that denervation and devascularization of the terminal urethra and bladder neck secondary to surgical dissection could contribute to the subsequent development of intrinsic sphincter dysfunction should be considered.

The repair of intrinsic sphincter dysfunction with hypermobile urethra by the laparoscopic Burch–Ball procedure

Treatment of intrinsic sphincter dysfunction in association with genuine stress incontinence has a high surgical failure rate. The Ball modification of the laparotomy Burch colposuspension has been used with a high degree of success by some authors. In the present study, 11 patients were shown to have genuine stress incontinence by transperineal ultrasound, cough stress test, and multichannel urodynamics. Each subject had a hypermobile urethra, an abnormal valsalva leak‐point pressure, and a low urethral closure pressure. A laparoscopic Burch–Ball colposuspension was performed and patients were then re‐evaluated at 6 weeks and 1 year. There was a 90% objective cure rate at 1 year and the hospital stay and the postoperative recovery time was short. This preliminary study suggests that the laparoscopic procedure is as effective as laparotomy.

Vaginal Wall Sling for Anatomical Incontinence and Intrinsic Sphincter Dysfunction: Efficacy and Outcome Analysis

Purpose A prospective cohort study was done to determine the efficacy and clinical outcome of a new technique for anterior vaginal wall sling construction to treat urinary incontinence due to intrinsic sphincter dysfunction or anatomical incontinence. Materials and Methods Preoperative evaluation included lateral cystography, video urodynamics, cystoscopy and incontinence staging. Postoperative subjective and objective staging outcome measures were prospectively assigned at predetermined regular intervals by a third party. Results Of the patients 95 had intrinsic sphincter dysfunction and 65 had anatomical incontinence. The repair failed in 7 percent of the 160 patients who had recurrent incontinence during followup and 9 percent had de novo urgency incontinence. Time to failure comparing patients with intrinsic sphincter dysfunction and anatomical incontinence was modeled using Kaplan-Meier survival curves, and the log rank test showed no significant difference between the groups (p greater than 0.05). Logistic regression covariates revealed no significant predictive factors for postoperative failures. Preoperative patient age was the only predictive factor for de novo instability (logistic regression model p less than 0.05). Conclusions Our initial results indicate that the 2 groups are indistinguishable to date based on current clinical and experimental statistics except for time to full recovery of postoperative voiding and incidence of postoperative instability (regression model p less than 0.05).

The empty supine stress test as a predictor of intrinsic urethral sphincter dysfunction

To assess the usefulness of a proposed test for intrinsic urethral sphincter dysfunction. Subjects were included in the study if they had complaints of incontinence, did not have substantial pelvic prolapse, and had undergone multichannel urodynamic testing. The initial evaluation involved uroflowmetry, catheterized residual urine, history, urogenital examination, and a cough stress test within 20 minutes after catheterization. Standardized multichannel urodynamic testing was performed at a follow-up appointment. Test indices were calculated based on the result of the empty supine stress test, the presence of genuine stress incontinence, and maximum urethral closure pressures. Three hundred four women met the inclusion criteria; 124 had a positive empty supine stress test and 180 had a negative test. Genuine stress incontinence was diagnosed in 238 subjects. A positive empty supine stress test was found to have 70% sensitivity and 90% negative predictive value for detecting very low urethral closure pressures, and 98% positive predictive value for genuine stress incontinence; in low-risk populations, the test had 95% negative predictive value for excluding urethral dysfunction. The empty supine stress test is easy to perform, inexpensive, and without significant risk. By itself, a positive empty supine stress test is essentially diagnostic for genuine stress incontinence, and in combination with a fixed urethra, it is diagnostic for intrinsic urethral sphincter dysfunction. In low-prevalence populations, a negative test reliably excludes the presence of intrinsic urethral sphincter dysfunction. However, for high-prevalence and referral populations, the low predictive values of the test limit its usefulness.