Sphincter Deficiency In Women Research Articles

Long-term outcomes of autologous fascia lata sling for stress incontinence secondary to intrinsic sphincter deficiency in women

ObjectiveTo report our long-term pubovaginal sling (PVS) outcomes using fascia lata for stress urinary incontinence (SUI) secondary to intrinsic sphincteric deficiency (ISD). Methodology and methodsFollowing Institute Review Board approval, charts from women undergoing PVS with fascia lata, with at least 6 months of follow up, were reviewed. Preoperative and postoperative data collected included demographics, validated questionnaires, prior anti-incontinence procedures, associated repairs, urodynamic findings, and reoperation procedures for SUI. Success was defined as cure of SUI (no pad, UDI-6 Question 3 related to SUI at ≤ 1, and no SUI reoperation). ResultsBetween 1997 and 2013, 22 women met the inclusion criteria with mean age of 73 (52–88) years, mean BMI 29 (17–38) and mean parity 2.7 (1–4). Mean follow up was 96 months (8–190). Indication for fascia lata sling included obesity (13) and prior abdominal procedures (9), including abdominoplasty. Fifteen women had received one or more prior antiincontinence procedures and five a prior injectable agent. No perioperative complications were noted. Overall, 14 of 22 women met success criteria [UDI-6 Question 3 at 0 (10) and at 1 (4)]. Three women underwent a subsequent procedure for residual SUI with periurethral bulking agent and one is awaiting an artificial urinary sphincter. ConclusionAt long-term follow-up of over 8 years after fascia lata sling, women who underwent fascia lata sling had acceptable continence outcomes with minimal complications.

Stress Urinary Incontinence in Women With Multiple Sclerosis.

PurposeTo report the prevalence and risk factors of stress urinary incontinence (SUI) and the prevalence of intrinsic sphincter deficiency in women with multiple sclerosis (MS).MethodsWe conducted a retrospective study. Female patients with MS, followed for lower urinary tract symptoms (LUTS) during a 15-year period were included. Demographic data, MS history, expanded disability status scale (EDSS) score at the urodynamic visit, obstetrical past, birth weight, LUTS, and urodynamic findings were collected. SUI was defined as incontinence during cough, or any effort. A maximum urethral closure pressure less than 30 cm H2O defined intrinsic sphincter deficiency.ResultsWe included 363 women with a mean age of 46.7±10.8 years and a mean disease duration of 12.9±8.7 years. The incidence of relapsing remitting MS, a secondary progressive form, and a primary progressive form was 60.6%, 32.8%, and 6.6%, respectively. The prevalence of SUI was 31.4%. The prevalence of intrinsic sphincter deficiency was 1.4% and 0.8% of these patients had a SUI (P=0.300). In a multivariate analysis, women with a SUI had significantly higher birth weight (P=0.030), a pelvic organ prolapse (P=0.021), urgent urinary incontinence (P=0.006), a lower EDSS score (P=0.019), and a weaker containing effort (P<0.001).ConclusionsThe prevalence of SUI in women with MS was 31.4%. This symptom could affect the quality of life of women with MS.

Posterior vaginal wall pull down maneuver: A clinical test to diagnose intrinsic sphincter deficiency in women suffering from genuine urinary stress incontinence

To assess the predictive value of a simple clinical test (posterior vaginal wall pull down maneuver) in the diagnosis of intrinsic sphincter deficiency. The present prospective study included 62 women suffering from stress urinary incontinence. Every patient underwent a urogynecological examination including multichannel urodynamic testing (cystometry, urethral pressure profile, Valsalva Leak Point Pressure measurement) and a clinical examination including posterior vaginal wall pull down maneuver. Posterior vaginal wall pull down maneuver was carried out with the bladder filled with 400 mL of saline in a supine position, and was obtained by means of a split speculum allowing gentle pull down traction of the posterior vaginal wall. Posterior vaginal wall pull down maneuver was considered as positive when a urine leak was observed during the manoeuvre. Intrinsic sphincter deficiency was urodynamically defined by maximum urethral closure pressure ≤20 cmH2 O. Correlations between positive/negative posterior vaginal wall pull down maneuver and urodynamic intrinsic sphincter deficiency were calculated. There was a statistical correlation between age and low maximum urethral closure pressure (P < 0.0001), and between low maximum urethral closure pressure and positive posterior vaginal wall pull down maneuver (P < 0.0001). Regarding the intrinsic sphincter deficiency diagnosis, the posterior vaginal wall pull down maneuver positive predictive value was 94.67% and the negative predictive value was 95.4%, with a specificity of 97.6% and sensitivity of 90%. Posterior vaginal wall pull down maneuver is a reliable clinical test, easy to carry out, inexpensive and without significant risk. This test allows the diagnosis of intrinsic sphincter deficiency in women suffering from stress urinary incontinence, thus avoiding further invasive urodynamic testing (urethral pressure profile, Valsalva Leak Point Pressure measurement) in women with genuine stress urinary incontinence. Furthermore, it is helpful when choosing the type of sling procedure (retropubic vs transobturator) when a surgery is planned.

A Nonhuman Primate Model of Stable Urinary Sphincter Deficiency

The pathophysiology of urinary sphincter deficiency in women remains incompletely understood and current treatment options have limitations. Female nonhuman primates may represent a relevant animal model for studies of pathophysiology and treatment interventions because of their human-like reproductive and age associated stages of life (premenopause, perimenopause and postmenopause), lower urinary tract structure and bipedal posture. We developed and characterized a nonhuman primate model of defined injury to the urethral sphincter complex. We used 22 adult female cynomolgus monkeys in which injury to the sphincter complex was created by cauterizing and then transecting its pudendal innervation. Urodynamic studies were performed before and during pudendal and hypogastric nerve stimulation at baseline, and 3, 6 and 12 months after injury. We also analyzed sphincter structure in vivo by cystourethrography, and ex vivo by quantitative histology and immunohistochemistry at these time points. Injury produced a 47% to 50% decrease in maximal urethral pressure (vs baseline p <0.05). It also abolished the increase in maximal urethral pressure in response to pudendal and hypogastric nerve stimulation (vs baseline p >0.05), which persisted more than 12 months after injury. Urodynamic changes were consistent with decreased skeletal and smooth muscle content, decreased nerve responses and an associated decrease in somatic and adrenergic innervation in the sphincter complex. These structural and urodynamic changes are consistent with those in patients with stress urinary incontinence. They support the usefulness of nonhuman primates as translatable surrogates for pathophysiological studies of urinary sphincter deficiency and testing novel therapies for that condition.

Is it possible to diagnose intrinsic sphincter deficiency in women?

The diagnosis of intrinsic sphincter deficiency became important about 20 years ago when it influenced the choice of operative procedure for women with stress urinary incontinence. However, it was ill-defined and diagnosed by a variety of techniques. The contemporary surgical treatment of urinary stress incontinence is by suburethral sling; so this review addresses three questions: is it still important to identify intrinsic sphincter deficiency prior to surgical intervention for stress incontinence? What techniques are available to do so? How robust are these measurements? There is some evidence that women with intrinsic sphincter deficiency have a poorer outcome if they are treated by a transobturator tape compared with a tension-free vaginal tape or a pubovaginal sling. Intrinsic sphincter deficiency continues to be mainly identified by low urethral closure pressures or low abdominal leak point pressures or both but the methodology is variable. There have been some attempts at using ultrasound to identify intrinsic sphincter deficiency but without any definite conclusions. Intrinsic sphincter deficiency is an imprecise diagnosis, which continues to be defined by a low pressure urethra. This can be measured in different ways but there is poor standardization of the tests to do so. Intrinsic sphincter deficiency appears to be clinically important but the full implications of this diagnosis will remain unknown until this imprecision is addressed.

Adverse events of injectables, what kind of jet-skiers should be informed about serious vaginal injury, and what Kant thinks about it

The most important knowledge in the field of patient safety is how to prevent harm to patients during treatment and care. The fundamental role of patient safety reporting systems is to enhance patient’s safety by learning from failures of the health-care providers and system. If these failures are not reported–or if serious side effects after medical interventions are not reported–physicians all over the world will repeat the same mistakes. Therefore, publishing adverse events of a certain treatment is one form of safety reporting system. From critical incidence reporting systems (CIRS), we know that most problems are not just a series of random, unconnected on-off events, but are provoked by weak systems and often have common root causes, which can be generalized and corrected [1]. Although each event is unique, there are likely to be similarities and patterns in sources of risk that may otherwise go unnoticed if incidents are not reported and analyzed. Ultimately, it is the action we take in response to reporting–not reporting itself–that leads to change. Only few serious adverse events after the treatment using bulking agents for urinary incontinence are reported; by the way, there is a similar number of medlined papers on serious vaginal trauma in jet-skiers. Does this mean that we can neglect these side effects because there are so few? Only five papers deal with serious vaginal trauma in jetskiers, but estimating the number of people who do jet ski, there must be a couple of more accidents than those that are reported. It might be similar for serious side effects of bulking agents. We probably dislike reporting complications and negative findings–in sports, because it is meant to be a fun activity, in medicine because we want to offer successful treatments to patients who expect to have their condition improved. Bulking agents have been approved by the Food and Drug Administration (FDA) for use in women with intrinsic sphincter deficiency and are generally seen as the most minimally invasive surgical intervention with few side effects [2]. Due to its minimal invasiveness, some authors do not even consider this treatment as surgical but as belonging to conservative treatment. From our own experience, we know that the smaller the intervention is, the less preoperative information is usually given to the patient. Bulking agents have also been used off-label for the treatment of stress urinary incontinence in men, especially after radical retropubic prostatectomy in which incontinence varies from 2.5% to 87% [3, 4]. A recent publication reports a 41% urethral erosion rate in men who were injected with ethylene vinyl alcohol [5]. One patient suffered from extreme dysuria, urgency, and frequency and required multiple follow-up visits and cystoscopic removal of the extruded material. Urethral erosion of permanent injectable material is a scary condition and may result in a drainpipe urethra with concomitant recurrent infections, as well as deteriorating incontinence, which then is difficult to treat. In another study using the samematerial for the treatment of intrinsic sphincter deficiency in women, the same group reported a 37% erosion rate in 19 patients, with 4 suffering from extreme pain and dysuria and finally 1 requiring repeat cystoscopy to remove the eroding material [6]. Int Urogynecol J (2008) 19:1037–1038 DOI 10.1007/s00192-008-0672-1

1532: Analysis of Videourodynamic Results and the Utility of Leak Point Pressure as a Measure of Instrinsic Sphincter Deficiency in Women with Stress Urinary Incontinence

1532: Analysis of Videourodynamic Results and the Utility of Leak Point Pressure as a Measure of Instrinsic Sphincter Deficiency in Women with Stress Urinary Incontinence

Suburethral sling treatment of occult stress incontinence and intrinsic sphincter deficiency in women with severe vaginal prolapse of the anterior vs posterior/apical compartment

The purpose of this study was to compare the efficacy of a Mersilene mesh suburethral sling for occult stress urinary incontinence (SUI) and intrinsic sphincter deficiency (ISD) in women with severe vaginal prolapse of the anterior compartment to the posterior/apical compartment. This was a retrospective study that compared women with stage or grade III/IV prolapse of the anterior compartment (group 1) with the posterior/apical compartment (group 2); both groups demonstrated occult SUI (leakage only with prolapse reduced) and ISD on urodynamics, and underwent concurrent pelvic reconstructive surgery. The sling was defined as efficacious if SUI was prevented in 85% of women and if obstructive symptoms (de novo or worsening urge incontinence, or urinary retention greater than 2 weeks) occurred in less than 10% of women. There were 39 women in group 1 and 25 women in group 2. There were no differences between women in group 1 or group 2 in preoperative demographics (except parity) or urodynamic findings. SUI cure rates were lower for group 1 than group 2, but this difference was not significant (87% vs 100%, P = .15). Rates of de novo or worsening urge incontinence (8% vs 4%, P = 1.00) and urinary retention (none occurred) were similar between groups. In women with severe vaginal prolapse, slings effectively treat occult SUI and ISD, whether associated with anterior or posterior/apical prolapse.

Oral Poster 31: Suburethral Sling Treatment of Occult Stress Incontinence and Intrinsic Sphincter Deficiency in Women with Severe Anterior or Posterior/Apical Vaginal Prolapse

Oral Poster Presentations: AUGS-SGS Abstracts: 2004 Joint Scientific Meeting The American Urogynecologic Society and The Society of Gynecologic Surgeons

Surgical management of intrinsic sphincter deficiency in women.

The past decade has witnessed significant changes not only in our understanding of intrinsic sphincter deficiency, but also in our surgical approach to this problem. It became evident that the patient's medical condition, expectations, and degree of incontinence should define the approach in order to make the greatest impact on quality of life. The present review describes the current concepts and surgical approaches to intrinsic sphincter deficiency, namely slings, injectables, and artificial sphincters.

Periurethral collagen injection for stress incontinence with and without urethral hypermobility

Objective: To compare the use of periurethral collagen injection in the treatment of female stress urinary incontinence due to intrinsic sphincter deficiency in women with and without urethral hypermobility. Methods: A retrospective review was performed of 60 periurethral collagen injections performed on 40 consecutive women from January 1996 to December 1997. A review of the office chart and operative notes was performed to obtain demographic, urodynamic, and procedural data. Outcome data were obtained by personal or telephone interview, using patients’ subjective assessments including an analog satisfaction scale. Results: Nine of 40 patients (23%) had urethral hypermobility. Compared with patients without hypermobility, patients with hypermobility required a similar number of procedures (a mean of 1.9 compared with 1.4, P = .13) and required similar amounts of collagen on the first injection (5.6 mL compared with 5.3 mL, P = .69). Preoperative urodynamic parameters were similar in both groups. Rates of subjective dryness were equivalent in patients with and without hypermobility at 1 month (76% and 46%, P = .24) and at 6 months (71% and 32%, P = .09) following initial injection. A post hoc power analysis was performed to evaluate the primary study measures of continence at 1 and 6 months, and number of collagen injections. This revealed that a sample size of 40 patients would be sufficient to detect a 2.5-fold difference in number of injections and a 3-fold difference in subjective dryness. Conclusion: Coexisting urethral hypermobility should not preclude the use of collagen injections in women with stress urinary incontinence.

Endoscopic injection of glutaraldehyde cross-linked collagen for the treatment of intrinsic sphincter deficiency in women

Objectives To determine the clinical efficacy, safety, and durability of endoscopically injected glutaraldehyde cross-linked (GAX) collagen for the treatment of intrinsic sphincter deficiency (ISD) in women. Methods Forty-two women with a mean age of 64 years (range, 28 to 88) underwent injection of GAX collagen for ISD. Collagen was injected via a transurethral or periurethral approach. Treatment outcome was based on the change in stress leak point pressures (SLPP) and individual incontinence grades before and after collagen injection. Results With a mean follow-up of 46 months (range, 10 to 66), 83% were cured (n = 17), greatly improved (n = 5), or improved (n = 13), and 17% were unchanged (n = 3) or worse (n = 4). The median number of treatments was 2 (range, 1 to 8). The 22 women greatly improved or cured required a mean of 2.4 collagen injection treatments, whereas the 20 women who were improved, unchanged, or worse had a mean of 4.1 treatments ( P = 0.009). The mean amount of collagen injected per patient was 28.3 cc (range, 2.5 to 85). The group of women who were greatly improved or cured had a mean of 17.5 cc of collagen injected, whereas those who were improved, unchanged, or worse had a mean of 39.5 cc injected ( P = 0.002). Mean pretreatment SLPPs of women improved, greatly improved, or cured versus the women unchanged or worse were not significantly different ( P = 0.015). The 35 women who were improved or cured had a significant increase in mean SLPP of 65.4 cm H 2O ( P = 0.001) compared to a mean change in SLPP of 14.7 cm H 2O in those women who were unchanged or worse ( P = 0.038). Conclusions GAX collagen injection for the treatment of stress urinary incontinence secondary to ISD appears to be safe, effective, and durable; hence, it should be considered the treatment of choice in appropriately selected female patients.