Simultaneous Urethrocystometry Research Articles

Tension-Free vaginal tape (TVT) in women with mixed urinary incontinence--a long-term follow-up.

In a prospective long-term study we evaluated the effect of TVT surgery in 80 women suffering from mixed urinary incontinence. Their mean age was 59 +/- 11 years with a mean parity of 2 (range 0-6). Mean follow-up was 4 years (range 3-5). The preoperative evaluation included a 24-hour pad test, quality of life evaluation, gynecologic examination and urodynamic investigations, including simultaneous urethrocystometry. From the patient history 96 patients were initially tentative candidates for TVT operation. Sixteen of these had only minor symptoms and signs of stress incontinence but significant symptoms and signs of detrusor instability, and were not considered suitable for TVT surgery. In the remaining 80 women the urodynamic investigation with filling urethrocystometry demonstrated stress incontinence and urge incontinence concomitant with urethral relaxation and/or 'premature micturition' reflex. At the postoperative long-term follow-up 85% of the patients were completely cured. Another 4% were significantly improved. In 11% of the patients the operation failed. Few intra- or postoperative complications occurred. Based on these results, we conclude that TVT surgery can be used for treatment of female mixed urinary incontinence. A proper urodynamic assessment is recommended before surgery is performed.

The Clinical and Urodynamic Effects of Anterior Vaginal Repair and Burch Colposuspension

The clinical and urodynamic effects of anterior vaginal repair and Burch colposuspension for correction of stress urinary incontinence were assessed in a prospective study. Ninety women undergoing surgery for the first time because of genuine stress incontinence were studied. A full clinical examination including simultaneous urethrocystometry according to a standardized methodology with the patients in the supine, sitting, and standing positions was performed preoperatively, 3 months postoperatively, and again 1 to 2 years later. Clinical follow-up continued for 5 to 7 years. Neither surgical anterior vaginal repair nor Burch colposuspension affected the resting variables of the urethral sphincter mechanism. After Burch colposuspensio? the transmitted intraabdominal pressure to the urethra significantly increased in all recording positions in all women who were successful!y treated. After successful anterior colporrhaphy, the increase in pressure transmission from the abdomen to the urethra was less prominent and was only present in the sitting and standing positions. The postural changes in the urethral pressure profile characteristic of stress urinary incontinence were still present even after successful restoration of continence. The impact of successful surgery for stress incontinence is the enhancement of transmission of the intraabdominal pressure rise to the proximal urethra. This is achieved primarily by anatomic alterations rather than by altering urethral sphincter function. Burch colposuspension was more effective for the correction of genuine stress incontinence than was anterior vaginal repair. (AM J OBSTET GYNECOL 1988;159:137-44.)

The clinical and urodynamic effects of anterior vaginal repair and Burch colposuspension

The clinical and urodynamic effects of anterior vaginal repair and Burch colposuspension for correction of stress urinary incontinence were assessed in a prospective study. Ninety women undergoing surgery for the first time because of genuine stress incontinence were studied. A full clinical examination including simultaneous urethrocystometry according to a standardized methodology with the patients in the supine, sitting, and standing positions was performed preoperatively, 3 months postoperatively, and again 1 to 2 years later. Clinical follow-up continued for 5 to 7 years. Neither surgical anterior vaginal repair nor Burch colposuspension affected the resting variables of the urethral sphincter mechanism. After Burch colposuspension the transmitted intraabdominal pressure to the urethra significantly increased in all recording positions in all women who were successfully treated. After successful anterior colporrhaphy, the increase in pressure transmission from the abdomen to the urethra was less prominent and was only present in the sitting and standing positions. The postural changes in the urethral pressure profile characteristic of stress urinary incontinence were still present even after successful restoration of continence. The impact of successful surgery for stress incontinence is the enhancement of transmission of the intraabdominal pressure rise to the proximal urethra. This is achieved primarily by anatomic alterations rather than by altering urethral sphincter function. Burch colposuspension was more effective for the correction of genuine stress incontinence than was anterior vaginal repair.

Urinary urgency following administration of thyrotropin releasing hormone during simultaneous urethrocystometry

To study the pathophysiology of urinary urgency frequently reported on administration of thyrotropin releasing hormone (TRH), simultaneous urethrocystometry was performed in 10 women before and after administration of 500 hg of TRH. Nine women in the control group received normal saline in place of TRH. The TRH group demonstrated a significant drop in urethral closure pressure (p < 0.01) within two minutes after TRH injection. Eight women complained of urinary urgency during the interval of observed drop in urethral closure pressure. No significant changes were seen in true detrusor pressure in both the TRH and in the control groups. The close association of drop in urethral pressure and urinary urgency suggests the presence of a motor component to this either centrally or peripherally mediated urinary urgency following TRH administration.

Ambulatory urethro‐cysto‐rectometry: A new technique

AbstractIn some patients complaining of urinary incontinence a leakage is not found during sitting simultaneous urethrocystometry (SUCM). In these patients, who often exhibit marked urethral pressure variations, the closure pressure frequently falls close to zero due to a decrease in the maximum urethral pressure without simultaneous detrusor contraction. In order to see what happens to urethral, bladder, and rectal pressures when these patients leak urine in daily‐life situations, a new ambulatory urethro‐cysto‐rectometric technique (AUCRM) has been developed.Twenty‐six female patients who had urethral pressure variations of 20–100 cm H2O during SUCM were reinvestigated with this new technique.Urinary leakage was found significantly more often during AUCRM than during SUCM (21 patients of 26, vs. 13 of 26; P &lt; 0.05).Twenty‐one of 26 patients complained of the symptom urge incontinence. In these patients urinary leakage was found to be highly significant more often during AUCRM than during SUCM (16 patients of 21, vs. 4 patients of 21; P &lt; 0.001). Leakage was always due to a combination of urethral pressure decrease and detrusor pressure increase, as in normal micturition. The condition unstable urethra was not found.During SUCM 17 patients were found to have sensory and 4 motor urgency. Performing AUCRM in the same patients, 5 were found to have sensory and 16 motor urgency. By the use of AUCRM the condition sensory urgency has been shown to be less frequent than was previously believed.The new technique of AUCRM used in the present study is compared to supine and sitting SUCM, judged to be superior for detection of the leakage mechanism.

Urethral pressure variations in women with neurourological symptoms: I. Relationship to urethral and pelvic floor striated muscle

AbstractSimultaneous urethrocystometry and electromyography (EMG) of the urethral and pelvic floor striated muscle were performed in 42 gynecological patients with neurourological symptoms. Their maximum urethral pressure varied between 20 and 124 cm H2O. A correlation analysis was performed between the maximum urethral pressure and the integrated EMG of the urethral striated muscle and the pelvic floor striated muscle. The analyses were performed on results obtained in 1‐min periods during bladder filling before first desire to void was reported, when first desire to void was reported, and when a strong desire to void was reported.In 21 patients no correlation was found between the urethral and pelvic floor striated muscle activity and the maximum urethral pressure at any stage of bladder filling. In the other 21 patients a correlation was found in at least 1 of the 3 stages. At all stages of bladder filling a correlation was found significantly more often between the maximum urethral pressure and the striated urethral muscle EMG than between the maximum urethral pressure and the striated pelvic floor muscle EMG. Thus, activity of the urethral striated muscle cannot be reliably studied in an EMG recording from the pelvic floor striated muscle. In the same patient, periods with a correlation could be succeeded by periods without a correlation. Thus, the urethral pressure variations may in the same patient sometimes be caused mainly by the urethral striated muscle and sometimes mainly by the urethral smooth muscle.

Urethral pressure variations in women with neurourological symptoms: II. Relationship to urethral smooth muscle

AbstractSimultaneous urethrocystometry and electromyography from the urethral striated muscle during bladder filling was performed on female patients complaining of neurourological symptoms. Their maximum urethral pressure varied between 20 and 84 cm H2O. To study the effect of the urethral smooth muscle on the urethral pressure variations, a bilateral pudendal block was applied successfully in 12 patients. It was found that in 1 patient the urethral pressure variations were caused by the urethral striated muscle only, in 4 patients they were caused mainly by the urethral striated muscle, in 2 other patients they were caused equally by urethral striated and smooth muscle, and finally in 5 patients mainly by urethral smooth muscle. By eliminating the urethral striated muscle activity by pudendal block the maximum urethral pressure was reduced 20 to 84%.

Use of preoperative uroflowmetry and simultaneous urethrocystometry for predicting risk of prolonged postoperative bladder drainage

To select patients at increased risk of needing prolonged postoperative bladder drainage after incontinence surgery, the data obtained from preoperative uroflowmetry and voiding urethrocystometry were analyzed in a group of 43 patients for presence and/or absence of reduced flow rates and detrusor contraction during voiding. All patients with adequate detrusor contraction and flow rates were able to resume spontaneous voiding by the seventh postoperative day. One third of patients voiding without detrusor contraction needed prolonged bladder drainage (p < 0.05). Presence of normal flow rates reduced their risk to 20 per cet while reduced flow rates enhanced their risk to 100 per cent (p < 0.05). Changes observed in urethral pressure, abdominal pressures, and flow rates individually were not significant predictors of the need for prolonged bladder drainage.

The effect of terodiline treatment in women with motor urge incontinence: Results from a double-blind study and long-term treatment

The effects of terodiline were evaluated in 24 women with genuine motor urge incontinence; Twelve patients participated in a double-blind crossover study and 12 in a subsequent long-term study. All patients were investigated by simultaneous urethrocystometry before and after treatment. During the controlled study the subjects were treated with placebo or 37.5 mg of terodiline daily for two 3-week periods. The long-term study covered a period from 6 months to 3. years. A significantly higher increase in both bladder volume at urinary leakage (from 170 to 270 ml, p < 0.001) and bladder, capacity (from 320 to 390 ml, p < 0.01) was registered after terodiline treatment compared to placebo. In the.long-term study the effects on these parameters were still more pronounced with an increase in bladder volume at leakage (from 180 to 300 ml, p < 0.001) and in bladder capacity (from 290 to 430 ml, p < 0.0001). Subjective improvement with terodiline treatment was reported by all but two patients in the double-blind study and by all in the long-term study. Side effects such as dryness of the mouth were reported by four patients receiving terodiline in the double-blind study and by six in the long-term study. No patient discontinued the treatment. Terodiline seems to be a promising alternative for treatment of motor urge incontinence in women.

Anatomical and functional changes in the lower urinary tract after radical hysterectomy with lymph node dissection as studied by dynamic urethrocystography and simultaneous urethrocystometry

Seventeen urologically healthy women undergoing standardized radical hysterectomy with lymph node dissection for stage I carcinoma of the cervix were evaluated urodynamically before, immediately after, and 1 year after surgery, by dynamic videourethrocystography and simultaneous urethrocystometry. The surgical technique had been developed in order to preserve as much of the nerve and blood supply to the bladder and urethra as possible. Major dysfunction was found in the early postoperative state, but the lower urinary tract almost always regained its preoperative functional status in the course of approximately 1 year. There were no long-lasting functional changes which interfered with daily life, although small static and dynamic changes were observed. The changes occurred chiefly above the urogenital diaphragm. The results of the two urodynamic examinations, each giving different information, corresponded well. Used together they gave a more complete picture than used separately. Dynamic videourethrocystography offered information about the function of the bladder and urethra which could not be obtained by urethrocystometry alone.

Simultaneous urethrocystometry and hyperactive bladders: A manometric differential diagnosis

AbstractThe authors reviewed simultaneous urethrocystometry (SUCM) in 96 patients with hyperactive bladders subclassified into four groups (pure detrusor instability, mixed instability, suprasacral spinal lesion, and CNS lesion) and compared the incidence of various urethral parameters. The absence of urethral relaxation before or during the augmentation of the detrusor pressure is the most specific sign of suprasacral spinal lesions. It constitutes what we call passive or tonic dyssynergia. When, at the beginning of SUCM, the maximal closure pressure is &gt; 30 cm H2O, or when a sphincteric contraction is associated with, either before (“kick”) or during (active or clonic dyssynergia) the detrusor contraction, this urethral nonrelaxation is pathognomic of such a spinal lesion. A “kick” is also specific of hyperreflexia but is less constant. On the contrary, in this series and with this technique, an active dyssynergia has no etiological significance; it only reflects the degree of the vesico‐urethral imbalance. This study further supports the importance of the brain stem in controlling and coordinating the vesicosphincteric unit.

Preoperative screening for latent stress incontinence in women with cystocele

AbstractA preoperative urodynamic investigation with and without a vaginal pessary ring including simultaneous urethrocystometry and urethral pressure profiles in supine and standing position during coughing was evaluated in 41 continent women with cystocele. Following the application of the vaginal pessary ring, loss of urine was demonstrated in six patients, in whom a negative urethral closure pressure was found only when the pessary ring was inserted, suggesting that latent stress incontinence might become manifest after surgical repair of the cystocele. These patients were all continent during the follow‐up period of 12–18 months after Manchester repair combined with urethrocystopexy. The remaining 35 patients with normal urodynamic registrations with and without an inserted pessary ring had no signs of urinary incontinence during the follow‐up period after the Manchester repair. Thus, the present urodynamic screening was found to be valuable for preoperative selection of an adequate surgical method in order to avoid postoperatively manifest stress incontinence after anterior colporaphy.

Effect of thyroid releasing hormone on bladder and urethral pressures.

In order to explain the pathophysiology of urinary urgency frequency observed following the administration of thyroid releasing hormone (TRH) during thyroid function testing, simultaneous urethrocystometry was performed in six females before and after TRH administration, and in another five females before and after administration of normal saline (control group). Within a few minutes following TRH administration, a statistically significant and consistent drop in maximal urethral pressure and concomitant sensation of urinary urgency in the absence of significant changes in true detrusor pressure suggested the presence of a reflex neuronally mediated motor component to this sensory effect of urinary urgency. The absence of urethral and detrusor pressure changes in the control group reinforced the TRH-mediated origin of urinary urgency.

Enuresis and urethral instability.

31 patients with refractory enuresis underwent simultaneous urethrocystometry. Pure urethral instability was encountered in 14, urethral and bladder instability in 11 and isolated uninhibited bladder in 3. This allows us to discuss the functional relationship between the urethra and the bladder. We consider urethral instability as being a trigger mechanism for detrusor contraction, and the explanation for the paradox of stable bladder enuresis. Phenylpropanolamine (Ornade), 25-50 mg at bedtime, stabilizes the vesicosphincteric unit and stopped bedwetting in 11 of 16 patients.

Urodynamic analysis of successful and failed incontinence surgery

Seventy-nine patients were investigated by simultaneous urethrocystometry before and, on average, 15 months after vaginal and/or suprapubic operations for stress urinary incontinence. Subjective and objective success rates were 78% and 60%, respectively, with no significant differences between operation types. Patients with a low (less than 0.6) index of urethral relaxation at stress pre-operatively indicating excessive loss of basal urethral pressure at stress, had objective success rates of 39% whereas a higher index was associated with a success rate of 70%. Maximal urethral closure pressure and functional urethral length did not correlate with the operative result and were virtually unchanged postoperatively. Successful operations increased the index of urethral relaxation at stress and urethral pressure peaks at stress especially in the distal functional urethra. No significant quantitative differences except for sling operations producing higher urethral closure pressure at stress in the proximal and lower in the distal functional urethra compared to the other operations were found. The results indicate, that successful operations eliminate the failure to maintain adequate basal urethral pressure at stress and emphasizes the importance of reflex activity of pelvic floor musculature at stress for continence.

Prevalence and pattern of unstable urethral pressure in one hundred seventy-four gynecologic patients referred for urodynamic investigation

Simultaneous urethrocystometry was performed in 174 gynecologic patients who complained of lower urinary tract symptoms. Thirty-five patients (20%) had a urethral pressure that fluctuated 20 cm H2O or more at two or more registrations. The degree of instability varied during urethrocystometry and from recording to recording in the same patient. No statistical difference was found between urethral pressure variation at 100 ml bladder volume, during bladder filling, or at bladder capacity. The prevalences of unstable urethral pressure in sensory urge incontinence and stress incontinence were 56% and 12%, respectively. The difference is highly significant. The prevalence of unstable urethral pressure in motor urge incontinence was 29%, and that in mixed incontinence was 22%. Three patients had unstable urethra, and six patients had unstable urethral pressure as the only sign. Thus, unstable urethral pressure can be considered to be a permanent sign that is recorded relatively often in patients with urinary incontinence. It may be an important part of the underlying mechanism in sensory urge incontinence and may, perhaps, be considered to be a clinical condition in itself.

Correlation between urethrovesical anatomy and urethral closure function in female stress urinary incontinence before and after operation: urethrocystographic and urethrocystometric evaluation.

32 patients with stress urinary incontinence were investigated by bead chain urethrocystography (UCG) and simultaneous urethrocystometry (UGM) before and after operation. 12 patients were incontinent

Reproducibility of simultaneous urethrocystometry measured with electronic microtransducers.

The reproducibility of simultaneous urethrocystometry in time and different rotational positions has not been sufficiently investigated. A prospective study with 16 patients assessed for incontinence was carried out, urethrocystometry with electronic microtransducers being performed at 1- to 3-week intervals, and with the catheter rotated to four different positions. Six parameters were analyzed on urethral profiles at rest and under stress. The reproducibility of all parameters in time was excellent. A comparison of values obtained after rotating the catheter showed significant differences for some parameters, but without clinical relevance.

Comparative urodynamic studies of women with prolapse and stress incontinence before and after abdomino-vaginal sling urethro-plasty

The effect of abdomino-vaginal sling urethro-plasty according to lyodura slings on the intravesical and intraurethral pressure was evaluated in 25 women with prolapse and stress incontinence. The investigations including a gynecological examination, urine and simultaneous urethro-cystometry. Prior to the operation, all incontinent women had a negative urethral closure pressure at stress. After surgery all 25 patients reported continence, which was confirmed by positive urethral closure pressures. The urethral pressure at rest was significantly decreased in all patients 2 weeks after operation but returned to the same value 1 year after surgery as before surgery. The functional and the absolute urethral lengths increased minimally after the operation.

The urethral pressure profile in pregnancy and after delivery in healthy nulliparous women

Simultaneous urethrocystometry by means of a dual microtransducer catheter was performed occording to a precise, standardized technique serially at 8, 16, 28, and 36 weeks of pregnancy and at 8 weeks post partum in 43 healthy nulliparous women. The urethral pressure profile at rest and the effect of stress (cough) on the urethral pressure profile during pregnancy and after delivery were measured. At each recording session, blood was obtained for determination of 17β-estradiol (E2), progesterone (P), and 17-alpha-hydroxyprogesterone (17-OH-P). The continence parameters functional urethral length and urethral closure pressure, as well as the urethral closure pressure response to stress, did not change systematically during the course of pregnancy. Engagement of the presenting part at 36 weeks did not influence the urethral pressure profile measurements. Alterations in hormone levels during pregnancy were not correlated with the changes in urethral pressure profile measurements. Both urethral pressure and length parameters in all women who underwent vaginal delivery were notably decreased 8 weeks post partum when compared with early pregnancy values and with values obtained in a group of healthy nulliparous women in the follicular phase of the cycle.1 The decrease in length parameters was not observed in the six women in whom delivery was by cesarean section. The postpartum changes were not significantly correlated with the duration of the second stage of labor or with the presence or absence of an episiotomy. Also, no relationship with infant birth weight was found. Values of the urethral pressure profile parameters below the median value and defective transmission of pressure over the urethra were observed in almost all women who experienced stress incontinence during pregnancy and/or after delivery. These observations suggest that an inherent weakness of the urethral sphincter mechanism plays a key role in the pathogenesis of stress incontinence.