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
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.
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.
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.