Bernhard Schuessler

Experience With 100 Cases Treated With Botulinum-A Toxin Injections in the Detrusor Muscle for Idiopathic Overactive Bladder Syndrome Refractory to Anticholinergics

PURPOSE In this prospective, nonrandomized, ongoing study we evaluated the efficacy and safety of botulinum-A toxin injections in the detrusor muscle to treat patients with idiopathic overactive bladder resistant to conventional treatment, such as anticholinergic drugs. MATERIALS AND METHODS A total of 23 men and 77 women with a mean age of 63 years (range 24 to 89) with nonneurogenic overactive bladder, including urgency-frequency syndrome, and incontinence despite the administration of maximal doses of anticholinergics were consecutively treated with injections of 100 U botulinum-A toxin in the detrusor muscle at 30 sites under cystoscopic guidance. Micturition diary, full urodynamics, neurological status and urine probes were performed in all participants before treatment. Bladder biopsies were done only in cases of suspected bladder fibrosis or unclear findings. Special attention was given to reflex volume, maximal bladder capacity, detrusor compliance, post-void residual urine, urgency and frequency/nocturia. Clinical, urodynamic and quality of life assessments were performed at baseline, and 4, 12 and 36 weeks after botulinum-A toxin treatment. RESULTS Overall after 4 and 12 weeks 88% of our patients showed significant improvement in bladder function in regard to subjective symptoms, quality of life and urodynamic parameters (p <0.001). Urgency disappeared in 82% of the patients and incontinence resolved in 86% within 1 to 2 weeks after botulinum-A toxin injections. Mean frequency decreased from 14 to 7 micturitions daily (-50%) and nocturia decreased from 4 to 1.5 micturitions. Mean maximal bladder capacity increased 56% from 246 to 381 ml, mean detrusor compliance increased from 24 to 41 ml/cm H(2)O and pretreatment detrusor instability (mean reflex volume 169 ml) resolved in 74% of patients. Mean volume at first desire to void increased from 126 to 212 ml and mean urge volume increased from 214 to 309 ml. There were no severe side effects except temporary urine retention in 4 cases. Only in 8 patients was the clinical benefit poor and analysis revealed preoperative low detrusor compliance. Mean efficacy duration +/- SD was at least approximately 6 +/- 2 months and then symptoms began to increase. CONCLUSIONS Our results show that intradetrusor botulinum-A toxin injections may be an efficient and safe treatment option in patients with severe overactive bladder resistant to all conventional treatments.

Perineal ultrasound for evaluating the bladder neck in urinary stress incontinence

Objective To assess the reproducibility of a new method for evaluation of the bladder neck with perineal ultrasound and to compare it with lateral chain urethrocystography. Methods In the first phase, two investigators examined 40 patients using perineal ultrasound to assess the reproducibility of a new measurement method for the determination of the bladder neck position. In the second phase, 60 patients were evaluated by perineal ultrasound and lateral chain urethrocystography. Results With perineal ultrasound, there was good interexaminer agreement for determining bladder neck position, funneling, and bladder neck descent at rest and during the Valsalva maneuver, but not for the posterior angle β during straining. Comparisons of sonographic and x-ray assessments showed good agreement for the bladder neck position at rest, but not during Valsalva, whereas the posterior angle, funneling, and bladder base descent differed between the two techniques at rest as well as during Valsalva. Conclusion With our new method for determining the position of the bladder neck, perineal ultrasound is reliable technique that allows reproducible static and dynamic evaluation. Lateral chain urethrocystography is superior to perineal ultrasound only if bladder neck funneling is the aim of the evaluation; it is inferior if bladder neck mobility during maximal Valsalva is being investigated.

Changes in Vesical Neck Mobility Following Vaginal Delivery

Objective To assess changes in urethral movement during the Valsalva maneuver and pelvic floor muscle contraction following vaginal delivery. Methods In a prospective repeated-measures study, 25 primigravidas, 20 multiparas, and ten women who were to have elective cesarean delivery were examined sonographi-cally at 36–42 weeks of pregnancy and 6–10 weeks after delivery. Vesical neck position at rest and excursion during Valsalva maneuver and maximum pelvic muscle contraction were measured with perineal ultrasound. Data about resting bladder neck position and bladder neck elevation at contraction were compared with findings in age-matched nulli-gravid volunteers. Results The bladder neck was significantly lower at rest in women after vaginal delivery than in those who had an elective cesarean delivery and in nulligravid controls. Bladder neck mobility had increased during the Valsalva maneuver in 16 of 25 primigravidas and 15 of 20 multiparas 6–10 weeks after vaginal delivery. The ability to elevate the vesical neck during pelvic muscle contraction was decreased in six of 25 primigravidas and in two of 20 multiparas 6–10 weeks after birth. Two women, one primigravid and one para 2 (with a previous elective cesarean delivery), both of whom had forceps delivery, completely lost the ability to contract voluntarily the pelvic floor muscles. Conclusion Vaginal delivery alters vesical neck descent during the Valsalva maneuver, and the ability of the pelvic muscles to elevate the urethra in some women.

Severe mesh complications following intravaginal slingplasty

OBJECTIVE: Synthetic meshes are increasingly used in the management of stress urinary incontinence and pelvic organ prolapse. This report describes severe complications following anterior and/or posterior intravaginal slingplasties employing a multifilament polypropylene mesh. METHODS: We describe the symptoms, findings, subsequent management, and outcome of 19 consecutive women who have been referred with complications following anterior (n = 11) and/or posterior intravaginal slingplasty (n = 13) employing the multifilament polypropylene tape. RESULTS: The main indications for removal of the 11 anterior intravaginal slings were intractable mesh infection in 6 women, retropubic abscess with cutaneous sinus in one, and vesico-vaginal fistula in one, intravesical mesh and pain syndrome in one, and voiding difficulties and pain syndrome in two. The main indications for removal of the 13 posterior intravaginal slings were intractable mesh infection in three and pain syndrome and dyspareunia in 10 women. Removal of the slings was performed after a median time of 24 months post-slingplasty. At follow-up between 6 weeks and 6 months, in all women genital pain, chronic vaginal discharge and bleeding, voiding, and defecation difficulties had been markedly alleviated (5) or they had ceased (14). Twelve of 17 sexually active women (71%) resumed sexual intercourse without difficulties. Ten women required subsequent surgery for stress incontinence and pelvic organ prolapse. CONCLUSION: Surgeons should be aware of the potential complications of synthetic meshes. Until data on the safety and efficacy of the intravaginal slingplasties are available, these procedures cannot be recommended. LEVEL OF EVIDENCE: III

Levator ani function before and after childbirth.

Objective To evaluate pelvic floor muscle strength before and after vaginal birth.

Updated recommendations on ultrasonography in urogynecology

Ultrasound is a supplementary, indispensable diagnostic procedure in urogynecology; perineal, introital, and endoanal ultrasound are the most recommended techniques. The position and mobility of the bladder neck can be demonstrated. In patients undergoing diagnostic work-up for urge symptoms, ultrasound occasionally demonstrates urethral diverticula, leiomyomas, and cysts in the vaginal wall. These findings will lead to further diagnostic assessment. The same applies to the demonstration of bladder diverticula, foreign bodies in the bladder, and bullous edema. With endoanal ultrasound, different parts of the sphincter ani muscle can be evaluated. Recommendations for the standardized use of urogenital ultrasound are given.

Abdominal sacrocolpopexy and anatomy and function of the posterior compartment.

Objective To assess the effect of abdominal sacrocolpopexy with obliteration of the pouch of Douglas on anatomy and function of the posterior compartment. Methods We prospectively studied 33 consecutive women with pelvic organ prolapse who had abdominal sacrocolpopexies [expanded polytetrafluoroethylene (Gore-Tex)] with pouch of Douglas obliterations and posterior extensions of mesh, using a standardized questionnaire, urodynamic studies, pelvic floor fluoroscopies, and vaginal-rectal examinations (Baden-Walker classification). Concomitant colpoperineorrhaphy was done if rectoceles remained at rectovaginal examination at the end of sacrocolpopexy. The goal was to correct rectoceles transabdominally. Results Thirty-one women returned for follow-up investigations after 12–48 months (mean 26 months). Mean age was 61 years (range 41–77 years). There was no recurrence of vaginal vault prolapse, enterocele, or anterior rectal wall prolapse. Among 28 preoperative rectoceles, 16 recurred (57%) and one occurred de novo. Defecation problems (outlet constipation) were present in 21 women (64%) preoperatively and persisted or were altered in 12 (57%) after sacrocolpopexy. Grade of rectocele was associated significantly with symptoms of outlet constipation preoperatively, but not postoperatively (P = .002). Conclusion Abdominal sacrocolpopexy with obliteration of the pouch of Douglas and posterior extension of the mesh was effective for vaginal vault prolapse, enterocele, and anterior rectal wall procidentia, but not concomitant rectocele. Twenty-eight percent of women described altered defecation with stool stopping higher in the rectosigmoid colon (“high outlet constipation”), which might have been caused by denervation during rectal mobilization.

Bladder neck mobility in continent nulliparous women

Objective To evaluate the mobility of the vesical neck during coughing and valsalva in healthy nulliparous volunteers and to test the reliability of the technique applied.

Exoanal ultrasound of the anal sphincter: normal anatomy and sphincter defects

Objective To describe the sonographic appearance of normal anal sphincter anatomy and sphincter defects evaluated with a conventional 5 MHz convex transducer placed on the perineum.

Improvement of perineal sonographic bladder neck imaging with ultrasound contrast medium

Objective To assess the efficacy of ultrasound contrast medium when imaging bladder neck anatomy in perineal ultrasound. Methods In 39 women with clinically and urodynamically proven urinary stress or stress-urge incontinence, a new echogenic contrast medium (Echovist) was administered transurethrally and perineal ultrasound was performed. Women were examined in the upright position both without and with ultrasound contrast medium at rest and during Valsalva maneuver, and the pictures of the bladder base, bladder neck, and urethra were compared. Results With the subject in the upright position, the contrast medium lay at the lowest point of the bladder and resulted in a reverse picture of the bladder base and bladder neck and clear visualization of these structures. In women with urinary stress incontinence, the ultrasound contrast medium entered the urethra during Valsalva, and bladder neck funneling was identified more accurately than without contrast medium. With Echovist, bladder neck funneling was detected in 38 of the 39 cases, compared with only 19 when it was not used. Furthermore, when the bladder neck, urethra, or bladder base were not visible with plain perineal ultrasound, they were seen when ultrasound contrast medium was used. The contrast agent was well tolerated, and there were no adverse side effects. Conclusion The use of ultrasound contrast medium improves visualization of the bladder neck anatomy. Bladder neck funneling and urinary leakage are seen more distinctly, and this improves the diagnostic reliability in female urinary stress incontinence.