P. D. Wilson

A randomized controlled trial of pelvic floor muscle exercises to treat postnatal urinary incontinence

A randomized controlled trial was carried out to evaluate the extent to which a program of reinforced pelvic floor muscle exercises (PFME) reduces urinary incontinence 1 year after delivery. Two hundred and thirty women who were incontinent 3 months postpartum were randomized to either a control group doing standard postnatal pelvic floor muscle exercises (n=117) or to an intervention group (n=113) who saw a physiotherapist for instruction at approximately 3, 4, 6 and 9 months postpartum. Results collected 12 months after delivery included prevalence and frequency of incontinence and PFME, sexual satisfaction, perineometry measurements and pad tests. Twenty-six (22%) of the control group and 59 (52%) of the intervention group withdrew before the final assessment. The prevalence of incontinence was significantly less in the intervention group than in the control group (50% versus 76%,P=0.0003), and this group also did significantly more PFME. There were no significant differences between the groups as regards sexual satisfaction, perineometry measurements or pad test results.

The influence of bladder volume on the position and mobility of the urethrovesical junction.

Abstract: The influence of bladder volume on the position, mobility and funneling of the bladder neck and proximal urethra was determined by transperineal ultrasound in a prospective comparative clinical study at Dunedin Hospital, Dunedin, New Zealand. One hundred and nine women underwent urodynamic assessment, either as part of the investigation of urinary incontinence or as follow-up after incontinence-correcting surgery. Bladder neck descent, retrovesical angle, rotation of the proximal urethra, and simple and extensive funneling/opening of the proximal urethra on Valsalva maneuver were assessed using ultrasound imaging at approximately 50 ml bladder volume and maximum bladder capacity (mean 355 ml, range 125–470 ml). The position of the bladder neck at rest was slightly higher at 50 ml than at maximum capacity (50 ml: 2.6 ± 0.4 cm, max. cap. 2.5 ± 0.4 cm; P=0.003) and it descended further with the Valsalva maneuver (50 ml: 1.9 ± 1.2 cm, max. cap. 1.7 ± 1 cm; P=0.004). There was also a higher degree of urethral rotation (50 ml: 41 ± 30°, max. cap. 39 ± 20°) with an empty bladder (P=0.072). As regards funneling of the bladder neck on Valsalva, equivalent results were obtained for 90 patients. In 19 cases there were discrepancies (Cohen’s κ 0.64). For extensive funneling to the midurethra the respective numbers were 83 and 26 (κ 0.41). Generally simple and extensive funneling was more frequently seen with a full rather than an empty bladder, simple funneling being diagnosed in an additional 14 cases (P= 0.06) and extensive funneling in an additional 19 (P=0.03). It was concluded that bladder filling influences the position and mobility of the bladder neck and the proximal urethra, which are both more mobile when the bladder is nearly empty. Funneling of the proximal urethra, however, is more easily observed with a full bladder. Imaging of the lower urinary tract should be undertaken at defined bladder volumes.

Anatomical assessment of the bladder outlet and proximal urethra using ultrasound and videocystourethrography.

In a prospective blinded comparative clinical study 125 women underwent videocystourethrography and cystometry as well as transperineal ultrasound as part of their diagnostic work-up for urinary incontinence or after incontinence-correcting surgery. Comparisons between ultrasound and X-ray imaging were carried out on 117 women for whom complete data sets were available. Mean bladder neck descent was significantly greater with ultrasound compared to VCU (US: 2.1±1.2 cm vs. VCU: 1.8±0.9;P=0.003). Rotation of the proximal urethra was not always seen on X-ray, but when it was (44 patients) there was good correlation with US (US rotation 55±27° vs. VCU rotation 55°±29). There was also good agreement between both tests regarding visualization of funneling or opening of the proximal urethra, with both tests showing equivalent results in 95 out of 117 patients (Cohens κ 0.58). On comparing extensive funneling to the midurethra on US with frank leakage on VCU the methods were in agreement for 90 out of 117 patients (κ 0.54). Overall a good correlation between ultrasound and radiological findings was observed. Both methods allow anatomic assessment of the bladder neck and have different strengths and weaknesses. Ultrasound imaging may be preferable as it is chaper, requires less technological back-up and avoids the risks of radiation exposure and allergic reactions to contrast medium.

TVT and Sparc suburethral slings: a case–control series

Two midurethral slings, TVT and Sparc, are the subject of this case–control series aimed at assessing sling placement, voiding function, bladder symptoms and patient satisfaction. Thirty-seven Sparc and 69 TVT patients were matched for age, body weight, pre-existing urge incontinence, preoperative voiding, concomitant surgery and length of follow-up (mean 0.6, range 0.1–1.5 years). There were no significant differences for subjective cure/improvement, satisfaction or symptoms of incontinence. The clinical stress test was positive in 8/37 Sparc vs 4/69 TVT patients (p=0.019). The TVT had a more negative effect (p=0.001) on postoperative voiding. The Sparc was situated more cranially at rest and further from the symphysis pubis, and was more mobile (p<0.001) on Valsalva. There are significant differences in medium-term outcomes after TVT and Sparc, affecting tape placement, mobility, effect on voiding function and objective stress continence. Patient satisfaction and subjective cure rates seem similar.

Colposuspension Success and Failure: A Long-term Objective Follow-up Study

The Burch colposuspension is regarded as one of the most successful procedures for the operative treatment of genuine stress incontinence. In this study the authors have attempted to define long-term subjective and objective success rates. Of 121 patients operated on between 1985 and 1995, 83 were fully assessed: 77% (64/83) had no stress leakage, but 41% (34/83) were suffering from urge incontinence. On clinical assessment 6 cases of uterine prolapse or vault descent, 21 cystoceles (25%) and 47 rectoceles or rectoenteroceles (57%) were detected, all but 8 being asymptomatic. On ultrasound 64/83 patients (77%) had a normal result. Ten patients demonstrated bladder neck hypermobility and in 9 there was urethral funneling without hypermobility. Survival analysis showed that the likelihood of all types of failure and of abnormal ultrasound findings increased over time. It is proposed that long-term results after incontinence surgery be presented as survival analysis.

Voiding function after tension‐free vaginal tape: A longitudinal study

Background:u2002 The tension‐free vaginal tape (TVT) has become popular for the surgical treatment of urodynamic stress incontinence. It seems to function via an intermittent obstructive effect that is easily demonstrated on imaging, although there is no agreement regarding its effect on voiding.

Maternal birth trauma: why should it matter to urogynaecologists?

Purpose of review There is increasing awareness of the importance of intrapartum events for future pelvic floor morbidity in women. In this review, we summarize recent evidence and potential consequences for clinical practice. Recent findings Both epidemiological evidence and data from perinatal imaging studies have greatly improved our understanding of the link between childbirth and later morbidity. The main consequences of traumatic childbirth are pelvic organ prolapse (POP) and anal incontinence. In both instances the primary etiological pathways have been identified: levator trauma in the case of POP and anal sphincter tears in the case of anal incontinence. As most such trauma is occult, imaging is required for diagnosis. Summary Childbirth-related major maternal trauma is much more common than generally assumed, and it is the primary etiological factor in POP and anal incontinence. Both sphincter and levator trauma can now be identified on imaging. This is crucial not only for clinical care and audit, but also for research. Postnatally diagnosed trauma can serve as intermediate outcome measure in intervention trials, opening up multiple opportunities for clinical research aimed at primary and secondary prevention.

Laparoscopic colposuspension versus urethropexy: a case-control series

Laparoscopic colposuspension (LC) was first described in the early 1990s as a technique distinct from open Burch colposuspension. Subsequently, however, LC was closely modelled along the lines of the Burch technique, and the distinct features of the original urethropexy (UP) were largely disregarded. In this case-control series the authors aimed to compare symptoms and anatomical outcomes after standard LC and urethropexy ± paravaginal repair. The design was a clinical retrospective case-control trial. The setting was the urogynaecology and endogynaecology services of tertiary hospitals. Fifty patients after LC and 50 women after UP surgery, matched for age, body mass index, previous surgery, pre-existing urge incontinence and length of follow-up (1.01xa0year, range 0.02–3.54xa0years) for LC and 0.98xa0years (range 0.06–3.55xa0years) for UP). Intervention consisted of standardised interview and translabial ultrasound imaging. There were no significant differences for subjective cure of stress incontinence (80% for UP vs. 74% for LC), postoperative urge incontinence, frequency and nocturia. Significantly more UP patients complained of voiding dysfunction (p=0.01). Significant differences were found for urethral rotation, position of the bladder neck on Valsalva and bladder neck descent on Valsalva (all p<0.001). Both procedures were shown to be effective in curing stress incontinence. The incidence of bladder symptoms was comparable, with the exception of voiding difficulty. Significant differences were observed regarding anatomical appearances, with urethropexies showing more recurrent bladder neck hypermobility and cystocele.

Vaginal electrostimulation for the treatment of genuine stress incontinence.

Summary: The value of vaginal electrostimulation for genuine stress incontinence was evaluated in 30 women with this condition. Subjective and objective measurements were made before and after 3 and 15 months of treatment using urinary diaries, perineometry and pad tests. After 3 months use, 21 women (70%) reported a subjective improvement, but this had fallen to 9 (30%) by 15 months. There were significant reductions in the numbers of daily incontinent episodes and pad/pant changes and significant increases in the perineometry readings at both 3 and 15 months. There were no side‐effects observed with electrostimulator use, but 1 patient withdrew due to a dislike of the method of treatment. Vaginal electrostimulation would seem to be a simple and well tolerated means of managing genuine stress incontinence in a selected group of women.

Ureteric injury following laparoscopic colposuspension

needle aspiration of the remaining fluid in the sac was required. In our study, under the guidance of endovaginal sonography, a 22-gauge needle was introduced transvaginally into the gestational sac through the cervix, 8 MEq KCI (2 MEq/mL) were injected directly into the fetal thorax to cease cardiac motion, and 60 mg of MTX was injected into the sac and the surrounding myometrium. This allows a more rapid intemption of the pregnancy than by injection of MTX intramuscularly. This is very important when no surrounding myometrium is seen between the embryo and the bladder and avoids the risk of extensive bleeding’ and rupture due to persistent activity. In our case the hCG level decreased to undetectable levels on day 82 and the embryonic structures completely disappeared without any complementary procedure. Three months after starting her periods, the woman became pregnant and delivered at 37 weeks by caesarean section.