Voiding Difficulties Research Articles

The urodynamic effect of colposuspension immediately after surgery for genuine stress incontinence.

AbstractExtensive reports on postoperative urodynamic evaluation of female patients with GSI have been published in the current literature. However, urodynamic data from immediate postoperative evaluation has not yet been presented.Urodynamic study was made in 33 out of 41 patients from 9th–12th postoperative day. Our results indicated that preoperative and postoperative FUL in erect and supine position were 2.90±0.71; 3.72±0.98; P<0.005 and 2.13±0.68; 3.55±1.67; P<0.005 respectively. Preoperative PFR was 23.4±11.2 and postoperative PFR was 8.1±5.2; P<0.001. Preoperative RU was 69.9±83.3 and postoperative RU was 194±179; P<0.005.On the basis of the foregoing figures and our previous study, the following conclusions can be drawn; edematous swelling, possible hematoma formation and possible damage of the nerve supplying the bladder during dissection may be causes of postoperative voiding difficulty. The results of FUL obtained immediately following operation may serve as a parameter for predicting the outcome of corrective surgery. This may provide a simple way to judge whether or not the proximal urethra has been successfully restored to the intra‐abdominal pressure zone if the medical centers are not equipped with sophisticated instruments for measuring transmission ratios.

Intraurethral Cocaine Administration

To Editor. —More than 100 years ago JAMA reported intraurethral administration of cocaine as an anesthetic for the introduction of a bougie. 1 To warn clinicians that this route has now become a method of self-administration of cocaine, 2 we report following case and its extravagant complications. Report of a Case. —A 34-year-old man was admitted to a local hospital with a three-day history of priapism and paraphimosis. During previous weeks he had occasionally administered cocaine intraurethrally prior to intercourse to enhance sexual performance. Except for priapism and paraphimosis, findings from initial evaluation were unremarkable. There was no evidence of intranasal or intravenous substance use or of any of usual causes of priapism. 3-5 Aspiration of corpus cavernosa was attempted without benefit and a Foley catheter was inserted to relieve his difficulty in voiding. On third hospital day priapism and paraphimosis spontaneously resolved,

A further assessment of the gauze hammock sling operation in the treatment of stress incontinence.

A further series of 100 consecutive gauze hammock sling operations for urinary stress incontinence is presented with preliminary urodynamic assessment in all cases and follow-up from 6 months to 5 years. In 63 women the operation was a primary procedure. Modification to the operation included redesign of the shape of the sling, use of increased tension where minor degrees of bladder detrusor instability exist, and use of a suprapubic catheter postoperatively. Of the 100 women 87 were reviewed directly and 12 indirectly; only one was lost to follow-up. After operation, 78% were continent, 17% showed improvement and there were 4% failures. The only serious complication was a pulmonary embolus in one woman but 15 had some voiding difficulty during the follow-up period which responded to urethral dilatation in all but three. There were no fistulas. This improved technique should overcome many of the objections to the sling procedure and is a suitable primary procedure for stress incontinence or for treatment of recurrence after previous alternative procedures.

Uroflowmetry for predicting postoperative voiding difficulties in women with stress urinary incontinence.

Pre-operative knowledge of uroflowmetry and postvoiding residual urine volumes in a group of 45 women undergoing urinary incontinence surgery failed to predict risks of postoperative voiding difficulties. Only one out of nine patients needing prolonged post-operative bladder drainage (greater than or equal to 7 days) gave a pre-operative history of voiding difficulties. More than half the patients (5/9) who needed prolonged catheterization had normal flow rates were able to resume spontaneous voiding within 7 days following incontinence surgery.

Self-inflicted foreign bodies involving lower urinary tract and male genitals

A great variety of self-inflicted foreign bodies have been removed from the lower urinary tract and male external genitalia. These foreign bodies were inserted or applied for autoerotic, psychiatric, therapeutic, or no definite reasons by the patient. Most patients were too ashamed to admit they had inserted or applied any object and usually presented when a complication had occurred from the foreign body such as difficulty voiding, hematuria, pain or swelling, extravasation, or abscess formation. Inspection and palpation diagnosed foreign bodies involving the male external genitalia in 3 patients and anterior urethra in 6. Radiographic studies with and without contrast medium and endoscopy were required to diagnose foreign bodies in the posterior urethra and bladder in 9 patients, and the exact location, shape, and orientation of the foreign bodies in all sites, radiolucent objects, and the complications of mucosal laceration and extravasation. All 16 foreign bodies in the anterior urethra (below urogenital diaphragm) were removed by endoscopic manipulation in the 6 patients. Nine foreign bodies in the posterior urethra or bladder (above the urogenital diaphragm) were removed by endoscopic manipulation in 2 females and 2 males, while suprapubic cystotomy was required in I female and 4 males. The 3 foreign bodies applied to the external genitalia of 3 males were removed carefully to avoid injury to the underlying skin. Foreign bodies lying below the urogenital diaphragm were palpable and readily removed endoscopically while foreign bodies above the urogenital diaphragm required greater endoscopic manipulation or open surgical procedures.

Overlapping sphincteroplasty for acquired anal incontinence.

When defects of the anal sphincter are caused by trauma, surgical correction can be successful even in long-standing cases. At the University of Minnesota, we used overlapping sphincteroplasty in 79 patients with fecal incontinence from 1952 to 1982. There were 62 women and 17 men. Ages ranged from 17 to 68 years. Incontinence had been present from three weeks to 40 years and had been caused by childbirth, previous anorectal surgery, trauma or rectal prolapse. Following overlapping sphincteroplasty, there was one postoperative death and 13 complications. Complications included temporary difficulty in voiding, excessive bleeding, abscess formation, fecal impaction, and hematoma. Seventy-six of the 78 surviving patients were followed for an average of 35 months. Results ranged from excellent to poor with only one failure. From our experience it was concluded that several factors were important for good surgical results. 1) The patient must have intact neuromuscular bundle with detectable voluntary sphincter contraction. 2) If a primary repair has failed, a minimum duration of three months should elapse before overlapping sphincteroplasty is attempted. 3) Scar tissue from the severed muscles should not be excised. 4) The internal and external sphincter muscles should not be separated. 5) A temporary concomitant colostomy is not necessary.

EFFECTS OF INTRATHECAL MORPHINE, INJECTIED WITH BUPIVACAINE, ON PAIN AFTER ORTHOPAEDIC SURGERY

Morphine hydrochloride 0.4 mg was administered with isobaric 0.5% bupivacaine intrathecally for orthopaedic surgery and produced good analgesia for about 24 h after operation in both elderly (60-80 yr) and middle-aged patients (30-50 yr). Morphine 0.2 mg (older patients only) was not as effective in preventing pain after operation, but even this dose postponed the requirement for analgesia. Morphine did not change the quality of spinal anaesthesia. In the older groups the capillary PCO2 was increased in two patients receiving morphine 0.2 mg and in one patient receiving 0.4 mg. Severe delayed respiratory depression was not noted. Urinary retention and minor voiding difficulties were the most disturbing side-effects. This complication did not appear to be dose-dependent, and also occurred in patients not receiving morphine.

Necrotizing Balanitis due to Herpes Simplex Type 1

A previously healthy, 26-year-old heterosexual man experienced necrotic penile ulcerations with fever, rigors, and difficulty voiding. Urethral instrumentation and treatment with antibiotics were associated with progression of the disease. Type 1 herpes simplex virus was isolated from the penile ulcerations and pustular lesions in the groin and antecubital fossae. Recovery was complicated by a urethral stricture requiring surgical treatment. Herpes simplex type 1 must be considered in the differential diagnosis of severe penile ulcerations; isolation of herpesvirus from such lesions may obviate further diagnostic and therapeutic measures that are unnecessary and, in some cases, counterproductive. (JAMA1982;248:215-216)

Bladder dysfunction following radical abdominal hysterectomy

Green and Meigs, in 1962, reported on the various urologic complications of Wertheim’s technique of radical hysterectomy [I]. Besides reporting on the major complications with the bladder and ureters, minor bladder problems referring to “temporary voiding difficulties” were mentioned to occur in 16% of the patients. These difficulties were believed to result from bladder atony since the patients had clinically distended bladders with large residual urines after voiding. Routine catheter drainage for 6 to 8 weeks was advocated to allow the “atonic bladder” to heal and to prevent bladder distension and fistula formation. Since 1962, numerous investigators using water and carbon dioxide cystometry in a small series of cases have demonstrated the cause of bladder dysfunction to be due to a hypertonic bladder, not bladder atony. The present paper analyzes our experience with patients having bladder dysfunction following radical hysterectomy.

Malignant presacral teratoma in children

Malignant presacral teratoma is a rare tumor seen predominantly in young female children. The introduction of planned multidisciplinary treatment has improved the outlook for patients with this once dismal disease. Six female children were seen at Memorial Hospital with the diagnosis of malignant presacral teratoma. Five children were age 17 mo to 3 yr and the sixth child was 13 yr old at diagnosis. Presenting symptoms included masses in the buttock or groin, constipation, difficulty voiding, and local pain. Pathological features were varied and complex but three had predominantly endodermal sinus features. One child had the malignant presacral teratoma develop 18 mo after successful resection of a benign sacrosoccygeal teratoma in the newborn period. Treatment varied in the six cases since all were referred after failure of treatment elsewhere. All children had surgery, irradiation, and multiple drug chemotherapy. Four of the six children are surviving disease-free, 3 more than 24 mo off treatment. Evolution of treatment up to the present protocol management is discussed.

The Bladder in Boys with Posterior Urethral Valves: A Urodynamic Assessment

Urodyrianiic evaluation was performed on 8 of 62 boys (13 per cent) with persistent voiding difficulties after fulgur ation of posterior urethral valves. All had varying degrees of incontinence when evaluated. The striated muscle component of the ezternal urethral sphincter was intact in each child. Five different types of bladder function were noted in the 8 children. Three boys had had a prior Y-V plasty of the bladder neck to improve upper and lower urinary tract emptying, which may have contributed to the subsequent incontinence. One additional boy had significant bladder neck obstruction requiring a unilateral bladder neck incision to improve voiding. Appropriate treatment plans were instituted based on the urodynamic findings of the bladder, bladder neck and external sphincter areas, and 6 of the 8 children are now completely continent.

Agranulocytosis from cephalosporins.

To the Editor.— Rare reports have associated neutropenia with prolonged administration of cephalothin. 1 We have recently had a patient with agranulocytosis caused by relatively low doses of cephalosporin antibiotics. Report of a Case.— A 44-year-old man had difficulty voiding and symptoms of myxedema. Results of the physical examination revealed typical signs of hypothyroidism. There were no palpable lymph nodes or other abnormalities. His hematocrit reading was 45% and white blood cell (WBC) count was 7,700/cu mm with a normal differential. Urinalysis showed no protein, sugar, bacteria, or cells. Radioactive iodine uptake and serum thyroxine content were well below normal. Serum cholesterol level was 359 mg/100 ml; blood urea nitrogen level, 15 mg/100 ml; and the creatinine level was 1.3 mg/100 ml. Chest roentgenogram was normal, and the electrocardiogram showed T-wave flattening. He was treated with desiccated thyroid starting at 0.16 mg/day. A week after admission he developed a dental

Metastatic tumors to the penis

Three cases of metastatic carcinoma to the penis are presented. Fewer than 200 cases have been reported in the world literature. Neighboring areas, including the bladder, prostate, and rectum, are responsible for the greatest number of metastases. While some of the penile metastatic lesions are asymptomatic, others may produce priapism with associated pain and difficulty in voiding. Therapeutic measures including penile amputation and radiotherapy have been employed with poor results. Patient survival is usually brief following the development of metastatic disease to the penis.

Obstructive uropathy secondary to phimosis and balanoposthitis.

Campbell 1 states that congenital phimosis is only preputial anomaly of grave concern and cites five cases of infant death secondary to uremia subsequent to congenital phimosis. Overzier 2 also alludes to severe fibrous phimosis with retention of urine leading to dilatation of the upper urinary tract. However, little emphasis has been placed upon acquired phimosis as etiologic in obstructive uropathy, and one is often guided to the meatus and more proximal structures in the search for the cause of urinary tract obstruction. The present case demonstrates how acquired phimosis and balanoposthitis can be obstructive with resultant stasis of urine, pyelocaliectasis, urinary tract infection, and bilateral acute pyelonephritis. Report of a Case A 16-year-old white boy presented to the Urology Clinic with symptoms of fever, chills, nausea, and difficulty in voiding of three days' duration. He had a history of difficulty in voiding, necessitating straining, which dated back many

On infections of the urinary tract. Communication to the editor from a urologist.

There is, at the present time, an interesting and persistent controversy between certain internists and certain urologists concerning the management of infections of the urinary tract. Before commenting on this controversy, it would be well to attempt to reach a clear understanding of the points at issue in the contention. Urologists generally have concluded, from their observation of human patients, that obstruction to the urinary passages is the most important element favoring infection. Laboratory investigators, whether they be urologists, internists, pathologists, bacteriologists or go by any other appelation, but working on animal subjects, have practically unanimously reached the same conclusion. The differences in concept spring from disagreement as to what constitutes obstruction. Twenty years ago one could say that obstruction was not demonstrated unless there was residual urine, marked difficulty in voiding, and roentgenographic showing of anatomical changes such as filling defects, trabeculation, cellules or diverticula of the bladder, hydroureter,

SIMILAR UROGENITAL ANOMALIES IN IDENTICAL TWINS

A pair of twin boys with identical anomalies of the urogenital system was seen in the Babies Hospital service of the Squier Urological Clinic in New York. Each twin had glandular hypospadias, stricture of the meatus, dilatation of the urinary system and mild hypertension. <h3>HISTORY AND EXAMINATION OF TWINS</h3> Twin "A."—On Nov. 3, 1942 a 10 year old Jewish boy was brought to the clinic because he had been having pain in the right side for three weeks. Since birth the child had been having urinary frequency and dribbling and had forced his urine out as a very fine spray. His urination was prolonged and often painful, and from time to time he had pains in the regions of both kidneys. His recent pains in the right flank had suggested renal infection on that side. The patient's only sibling was a twin brother who also had difficulty in voiding. Physical

X-Ray Assistance in Solving Genito-Urinary Problems

A SHORT discussion of the essential points of this subject, with a few illustrations, is all one can give in so brief a period. The development of the cystoscope, the discovery of the kidney functional test, and the evolution of the X-ray are the factors which brought about the urological department. After a careful cystoscopic examination, using kidney functional tests with catheters in both ureters, followed by painstaking chemical and bacteriologic examinations of the collected samples, together with proper visualization of the genito-urinary tract and X-ray films carefully studied, one can feel quite certain as to the condition of the urinary tract. The genito-urinary problems fall under five groups as to their symptomatology (Dr. F. J. Parmenter). 1. Pain in or near the affected organ. 2. Disturbances of urination, with or without pus or blood in urine. 3. Urethral discharge, with or without pain or discomfort around the genitals. 4. Constitutional disturbances from renal insufficiency due frequently to prostatic or other obstructions at the vesical neck or to bilateral renal lesions, as calculus, etc. 5. 5. Sexual disorders. 1. Pain in or near the affected organ may be produced by a. Disturbed physiology occasioned by the presence of some inflammatory process, active or chronic; b. Kinked ureter or stricture of ureter; c. Stone in kidney, ureter, bladder or prostate; d. Tumor in kidney or bladder; e. Diverticulum. 2. Disturbances of urination, with or without pus or blood in urine: a. May be an irritative disturbance, as by acute infection of tract; b. May be an obstructive disturbance, as produced by a foreign body. The obstructive symptoms differ from the irritative in that there is difficulty in voiding. 3. Urethral discharges, with or without pain or discomfort around the genitals:

PELVIRECTAL AND VAGINAL HEMATOMA: REPORT OF A CASE

Rarely does the proctologist find a tumor mass occluding the rectal lumen from without that is not inflammatory. Some of the more frequent causes are sarcoma, cold abscess, tumors of the prostate, fibroma of the sacrum and tumors of the vaginal septum and female reproductive organs, and also an occasional dermoid. Hematomas obliterating the rectal lumen from without are rare. REPORT OF CASE History. —Mrs. E., white, aged 21, had a normal spontaneous delivery, March 7, 1925. She had an apparently normal puerperium, with the exception of some pain in the lumbar region. She was examined vaginally and discharged on the tenth day, everything being normal. Four days later, I was called to see her for her complaint of pain in the rectum and lower back, inability to sit and marked weakness. Further questioning revealed that she had difficulty in passing flatus and difficulty in voiding. There had been no

MALAKOPLAKIA OF THE BLADDER

REPORT OF CASES Case 1. —In November, 1917, Mrs. H., aged 43, was referred to me. Her general health was good. She came complaining of a severe irritation of the bladder. There was undue frequency of urination (nocturnal and diurnal), a burning sensation, and difficulty in voiding. This had been more or less continuous for about six years. Eighteen months prior to her visit to me she had passed in the urine a small piece of tissue which had been submitted to a pathologist, who had reported the tissue to be carcinoma. The woman was well nourished, had lost no weight, and in general had the appearance of good health. The blood count was about normal save for a leukocytosis of mild degree. Vaginal examination revealed nothing of interest except that the vesicovaginal septum was not indurated at all, and no mass could be felt in the region of the