Incontinence

Incontinence

 

• V
  Khullar et al (King’s College, London).
  
  Prevalence of Faecal
  Incontinence Among women with Urinary Incontinence.
  Br J Obstet Gynaecol 105: 1211-1213, 1998
  
      
  
  Authors
  studied particular problem and came to the conclusion
  that denervation and myogenic injuries occurring in
  childbirth may be the common cause for genuine stress
  and fecal incontinence. 
  The occurrence of detrusor instability and
  fecal incontinence may be attributed to a different
  mechanism.
  
      
  
  Khullar
  et al have reported 30% and 21% incidence of fecal
  incontinence among women with detrusor instability and
  stress incontinence respectively.
  
       
  

• Wright
  EJ, lselin CE, Cart LK, et al [ Duke Univ Med Ctr
  Durham, NC; Univ of Toronto]
  
  Pubovaginal Sling Using Cadaveric Allograft Fascia for
  the Treatment of Intrinsic Sphincter Deficiency
  
  J Urol 160: 759-762, 1998
  
  
  
  Introduction – For female patients with SUI (
  Stress Urinary Incontinence ] caused by intrinsic
  sphincter deficiency, the pubovaginal sling is the
  Gold standard for treatment.
  
  
  
  Autologous fascia harvest causes local discomfort and
  synthetic materials are associated with infection and
  erosion.
  
  
  
  Methods – Over a 28 month period, the allograft
  fascia technique was used in 59 patients and autograft
  fascia in 33.
  
  
  
  Preoperative video urodynamics were done in all
  patients. Consitence outcomes were assessed with the
  SEAPI score.
  
  
  
  Results — According to postoperative SEAP1
  score, both groups showed significant and similar improvement
  in consitence. 
  
  98% of allograft and 94% of autograft group were free
  of stress incontinence.
  
  
  
  Average operative time was 87 minutes in allograft
  group and 111 minutes in autograft group. Mean
  hospital stay was 1.67 days Versus 2.48 days
  respectively.
  
  
  
  Neither group had any problems with infection or
  erosion and both slings were well tolerated.
  
  
  
  Conclusion – The use of allograft fasci [
  fresh-frozen or freeze-dried] seems to be associated
  with similar success rates as  autogenous graft
  materials resulted in shorter operative time and
  hospital stay.
  
  
  
  There was no infection or transmissible diseases
  reported by this method.
  
  
  
  A longer follow-up is needed to assess the durability
  of this method.
  
  

• Chaikin
  DC, Rosenthal J, Blaivas JG [ New York Hosp/Cornell
  Med Ctr ]
  
  Pubovaginal Fascial Sling for All types of stress
  Urinary Incontinence : Long-term Analysis
  
  J Urol 160: 1312-1316, 1998
  
  
  
  Introduction – In the past, surgical treatment
  of stress urinary incontinence depended on the type of
  incontinence.
  
  
  
  Experience with 251 patients who underwent pubovaginal
  sling for all types of SUI is discussed.
  
  
  
  Results – There were 63 patients with simple
  incontinence and 188 with complex incontinence. There
  was one postoperative death. Of the 231 women followed
  up for a median fo 3.1 years 183[73%] were cured and
  48[19%] were improved. Surgical complications included
  persistent urge incontinence [23%] or de novo urge
  incontinence [3%]. Prolonged and unexpected urinary
  retention occurred in 4 patients.
  
  

• Wang
  AC, Lo TS [Chang Jung Univ, Tauvan, Taiwan]
  
  Tension-free Vaginal Tape – A Minimally Invasive
  Solution to Stress Uninary Incontinence in Women
  
  J Reprod Med 43 : 429-434, 1998
  
  
  
  *  A meshed polypropylene tape is used as a
  sub-urethral sling. The use of an introducing trocer
  facilitates placement in the 
  
     retropubic space on either side.
  
  
  
  * The tape is held in space at the retropubic space by
  barbs on the tape.
  
  
  
  * The potential advantage of the procedure include
  short operative time, minimal or no dissection in the
  retropubic space and
  
    the possibility that the TVT procedure can be
  performed with local or minimal anesthesia.
  
  
  
  * Potential disadvantage related to this procedure
  includes the presence of foreign body with
  possibilities of erosion, infection
  
    and rejcetion.
  
  

• Pycha
  A, Kingler CH, Haitel A, et al [ Univ of Vienna ]
  
  Implantable Microballons : An attractive
  alternative in the management of intrinsic sphincter
  Deficiency
  
  Eur Urol 33: 469-475, 1998
  
  
  
  In an innovative, minimally invasive approch to the
  treatment of stress urinary incontinence in females,
  these authors placed, “microballons” in a
  periurethral location in 19 patients.
  
  
  
  8 to 19 patients were dry at a mean follow-up of 14.4
  months.
  
  
  
  7 patients were improved
  
  
  
  Biocompatability was excellent with only 1 patient
  having extrusion of the ballons.
  
  
  
  Patients with urethral hypermobility and detrusor
  instability did not fare as well as those with ISD
  with parallels the clinical experience with other
  injectable bulking  agents such as collagen.
  
  
  
  The material is not degraded with time like collagen.
  
  

• Elsergany
  R, Ghoniem GM [ Tulane Univ, New Orleans, La ]
  
  Collagen Injection for Intrinsic Sphincteric
  Deficiency in Men : A reasonable Option in selected
  patients
  
  J Urol 159 : 1504-1506, 1998
  
  
  
  Introduction – Most cases of persistent incontinence
  after prostatic surgery are the result of intinsic
  sphincteric deficiency.
  
  
  
  The FDA has approved the use of transurethral collagen
  of patients with intrinsic sphincteric deficiency.
  
  
  
  Methods – Mean age of patient was 68-64 years ; 22 had
  grade III and 13 had grade II incontinence.
  
  
  
  Additional injection were done between 1 to 3 months
  after procedure. Follow-up was at 1,3 & 6 months.
  
  
  
  Result – At a mean follow-up of 17.6 months 20% were
  cured, 31.4% improved and 48.6% were considered
  failures.
  
  
  
  Dry patients needed a mean of 2 treatment sessions and
  a mean of 10 cc of injected collagen.
  
  
  
  Conclusion – Men less likely to benefit from the
  procedure are those with a history of pelvic
  irradiation, urethral stricture disease or involuntary
  bladder contractions.
  
  

• Elliott
  DS, Barrett DM [ Mayo Clinic, Rochester, Minn ]
  
  Mayo Clinic Long-term Analysis of the functional
  Durability of the AMS 800 Artificial Urinary Sphincter
  : A Review of 323 Cases
  
  J Urol 159 : 1206-1208, 1998
  
  
  
  The narrow backed cuff design introduced in 1987 had
  led to a decreased incidence of mechanical failure and
  non mechanical failure of this devices.
  
  
  
  Since introduction of the narrow backed off cuff, more
  than 83% of patients have not required reoperation
  over a mean follow-up of 5 and a half years. It is
  marked improvement over the reoperation rate of the
  original device.
  
  
  
  Unfortunately, the author did not define “
  Continence” [ i.e. in the absence of the use of
  pads ] in this study as it is well known that many
  patients who are quite satisfied with the functional
  result from artificial sphincter may nontheless have
  small degress of stress urinary incontinence with
  sudden increases intraabdomional pressure.
  
  

• Cross
  CA, Cespedes RD, English SF, et al [ Univ. of Texas,
  Houston: Wilford Hall Med Ctr, Lackland Airforce Base,
  Tex ]
  
  Transvaginal Urethrolysis for Urethral obstruction
  After Anti-incontinence Surgery
  
  J Urol 159 : 1199-1201, 1998 
  
  
  
  Introduction – With patients undergoing a stress
  urinary incontinence procedure, 5% to 20% subsequently
  have urethral obstruction
  
  
  
  Conclusion – Postoperative urethral obstruction in the
  female should considered in patients with rersistent
  irritative lower urinary tract symptoms, high postvoid
  residuals or frank urinary retention after
  anti-incontinence surgery.
  
  
  
  Classic findings of urodynamic  obstruction are
  not seen in obstructed females [ i.e. high pressure,
  low flow ] . Persistent stress incontinence may be
  present despite apparent urethral obstruction.
  
  
  
  Transvaginal urethrolysis was associated with
  symptomatic cure rate of 72% and improvement rate 85%
  
  
  
  Majority of patients did not undergo a suspension
  procedure at the time of urethrolysis. Only patients
  complaining of SUI with obstruction were resuspended
  at the time of urethrolysis. Whether to resuspend all
  patients undergoing uretrholysis for obstruction
  remains somewhat controversial.
  
  

• Denys
  P, Chartier-Kastler E, Azouvi P, et al [ Reymond
  Poincare Hosp. Garches, France ]
  
  Intrathecal Clonidine for Refactory Detrusor
  Hyperreflexia in Spinal Cord Injured Patients : A
  Preliminary Report
  
  J Urol 160 : 2137-2138
  
  
  
  Conclusion – Reduction in bladder hyperactivity was
  dose dependent beginning 5 minutes after injection and
  continuing at least 3 hrs. Urodynamic measure and
  clionidine dosage was significantly correlated.
  
  
  
  Intrathecal clonidine appears to claim bladder
  hyperactivity in a dose dependent fashion in-patients
  with chronic spinal cord lesions.

Urinary Incontinence

     

• MP Leonard, A Decter, K Hills et al [ Univ of Manitoba, Winnipeg, Canada; Univ of Alberta, Edmonton, Canada]
  
  
  Endoscopic Subureteral Collagen Injection : Are immunological Concerns Justified ?
  
  
  J Urol 160 : 1012-1016, 1998
  
     
  
  
  Conclusions- In 30% of adults treated with collagen for urinary incontinence, antibovine collagen antibodies develop. These patients are usually treated with large volumes of collagen, and there are no known clinical sequelae of this seroconversion.
  
     
  
  
  When collagen is injected for the treatment of reflux, smaller volumes are used, but the rate of seroconversion is the same.
  
     
  
  
  With short follow-up, antibodies cross-reacting with human collagen do not develop, and there are no known autoimmune outcomes in adults or children.
  
      
  
  
  Repeat skin testing between treatments may be appropriate, and urologists should watch for potential immune reactions.
  
  

• KL
  Burgio, et al (Univ of Alabama, Birmingham; Univ of
  Pittsburgh, Pa: Allegheny Gen Hosp, Pittsburgh, Pa; et
  al)
  
  Behavioral vs Drug treatment
  for Urge Urinary Incontinence in Older Women: 
  A Randomized Controlled Trial.
  
  Jama 280: 1995-2000, 1998.
  
      
  
  About 38% of older community-dwelling women, age
  60 years and older have urinary incontinence, which
  contributes to depression and social isolation.
  
       
  
  They
  have studied women divided into 3 groups, there was a
  group with 197 women aged 55-92 yrs who had urge
  urinary incontinence or mixed incontinence with urge
  as the predominant pattern were studied.
  Patients were randomized to receive 8 weeks of
  biofeedback assisted behavior treatment, drug
  treatment with oxybutynin chloride, possible range of
  doses, 2.5mg daily to 5mg 3 times daily or a placebo
  control condition.
  
       
  
  Results
  ; Reduction of incontinence was most pronounced early
  in treatment and progressed more gradually thereafter
  in all 3 treatment groups.
  There was an 80.75 reduction of incontinence
  episodes with behavior treatment, a 68.5% reduction
  with drug treatment, and a 39.4% reduction with
  placebo control.
  
       
  
  It
  was concluded that as a first line treatment for urge
  and mixed incontinence, behavioral treatment is a safe
  and effective conservative intervention that should be
  more readily available.
  
       
  
  Editorial
  comments: 
  The only problem with behavioral treatments is
  that they are time-consuming and require dedicated
  professional teams.
  
        

• F
  Zivkovic, et al (Univ of Graz, Austria)
  
  Body Mass Index and Outcome of
  Incontinence Surgery.
  
  Obstet Gynecol 
  93: 753-756, 1999
  
       
  
  The authors feel that the continence rate for
  anterior colporrhaphy at 5 years was 58%.
  The rate for anterior colporrhaphy with needle
  suspension of bladder neck was 51% at 5 years.
  The rate for Burch colposuspension at 5 years
  was 86%. There
  were no significant differences in the preoperative
  and postoperative body mass indexes of continent and
  incontinent women for each procedure.
  
        
  
  Conclusion
  : For failure of incontinence surgery, preoperative
  obesity was not a risk factor, but the power of this
  study was limited.
  
       
  
  Editor
  A Bergmann comments that Zivkovic et al indicate that,
  at least for the Burch operation, this is not the
  case.  These
  women need a “fixed anchor” when their
  stress incontinence is corrected, and the Burch
  procedure offers that type of correction, i.e.
  attaching the endopelvic fascia to a fixed bony
  structure.
  
       
  
     

Stress
Urianry Incontinence

     

• A Pelvic Muscle Precontraction
  can Reduce Cough-related Urine Loss in Selected Women
  with Mild SUI.
  
   
  J
  Am Geriartr Soc. 46:870-874, 1998.
  
         
  
  Conservative treatment of stress urinary incontinence
  in women typically begins with repetitive
  strengthening, or Kegel exercises, for pelvic floor
  muscles.  Some
  women have reported decreased stress-related urine
  loss as early as 1 to 2 days after beginning these
  exercises.  Because
  pelvic floor hypertrophy cannot occur in such a short
  time span, these women have probably taught themselves
  a new skill – that of intentionally contracting the
  pelvic floor muscles just before and during an
  activity, which causes a rise in intra-abdominal
  pressure.  This
  exercise is called “the Knack”.
  
        
  
  The
  effect of the Knack was assessed at 1 week in 27 older
  women with mild-to-moderate SUI in a prospective,
  randomized, single-blind interventional trial to
  determine its effect on cough-related urine loss.
  
        
  
  It
  was concluded that selected older women with
  mild-to-moderate SUI can learn to effectively use a
  properly timed pelvic floor muscle contraction to
  significantly diminish urine leakage during a cough. 
  The Knack is a  simple and effective method for reducing stress-related urine
  loss in selected older women with mild SUI who are
  capable of performing pelvic floor muscle
  contractions.
  
       
  
  The
  Knack technique is simple and easy to learn. 
  In fact the 2 techniques (i.e. Kegel and the
  Knack) work differently. 
  While Kegel exercise is aimed toward
  strengthening the pelvic floor muscle and providing
  better support for the bladder, the current technique
  is aimed toward “self protection” by
  contracting the muscle before stress, rather than by
  permanently strengthening it.
  
          
  

• An open
  study of
  the Bladder Neck support
  Prosthesis in Genuine Stress Incontinence.
  
  KH
  Moore et al (Univ of New South Wales, Sydney,
  Australia; Royal North Shore Hosp, Sydney, Australia)   Br
  J Obstet Gynaecol 106:42-49, 1999.
  
        
  
  It
  was found that the bladder support prosthesis
  (incontinence ring) maybe a good non-surgical option
  for some women with stress urinary incontinence
  However women with a scarred vagina after a previous
  operation or prolapse of more than one wall may find
  the device difficult to fit or keep in place.
  
          

• Surgical Correction of Stress
  Incontinence in Morbidly Obese Women.
  
  JM
  Cummings, et al (Univ of south Alabam, Mobile; St.
  Louis Univ)  J.
  Urol 160:754-755, 1998.
  
       
  
  Authors
  conclude that Morbidly obese women with stress urinary
  incontinence can be successfully treated with surgery.  
  Sling operations appear to be the procedure of
  choice for this population.