[Female geriatric patients with urinary incontinence symptoms and their control over pelvic floor muscles]. / Geriatrische Patientinnen mit Harninkontinenz-Symptomen und ihre Kontrolle über den Beckenboden.

UNLABELLED: Not only do anatomy and function of the pelvic floor play an important role as possible causes of female urinary incontinence, they are also crucial for its therapy. The aim of this case control study of female geriatric patients with symptoms of urinary incontinence was to determine the knowledge about their pelvic floor and to assess their ability to contract pelvic floor muscles voluntarily and reflexly. METHODS: A total of 377 female geriatric patients with symptoms of urinary incontinence were investigated in a Basis Assessment for Urinary incontinence. The ability to contract their pelvic floor muscles was examined by a digital vaginal palpation. The extent of the registered muscle strength was graded by the Modified Oxford Grading Scale by Laycock (1994). RESULTS: Of the patients, 65.5% were not aware of their pelvic floor and were not able to contract the pelvic floor muscles (Grade 0 to 1 by Laycock), 22% had an inaccurate knowledge and only performed an insufficient pelvic floor muscle contraction (Grade 2 by Laycock). Only 12.5% could contract their pelvic floor muscles properly (Grade 3 to 4 by Laycock). A subgroup of 83 patients had already absolved pelvic floor exercises in the past, 80 patients with conventional instructions, 3 patients with digital vaginal control. In this subgroup 54.2% of the patients were not able to contract the pelvic floor muscles (Grade 0 to 1 by Laycock) 25.3% only performed an insufficient contraction (Grade 2 by Laycock), while 20% were able to perform a sufficient and powerful contraction (Grade 3 to 4 by Laycock). The three patients in the past controlled by a digital vaginal palpation were part of this group and managed a pelvic floor muscle strength Grade 4 by Laycock. A high percentage of female geriatric patients with symptoms of urinary incontinence have a lack of understanding regarding the position and function of their pelvic floor. These results suggest that conventional pelvic floor muscle exercises without specific control are not an appropriate method to improve geriatric patients' ability to contract their pelvic floor muscles and to prevent urine leakage.

Comparison of Burch and lyodura sling procedures for repair of unsuccessful incontinence surgery.

OBJECTIVE: To assess the effectiveness and late postoperative morbidity of the Burch procedure and the sling procedure for the treatment of recurrent urinary stress incontinence after vaginal hysterectomy and anterior repair. METHODS: Clinical, urodynamic, and sonographic examinations were done on 77 women suffering with recurrent urinary stress incontinence. The women were randomized to two groups, modified Burch colposuspension and lyophilized dura mater sling surgery; 72 women were reexamined 32-48 months after these procedures. RESULTS: The cure rate at 32-48 months' follow-up was 86% for the Burch procedure and 92% for the sling. Women who had had the sling procedure demonstrated a clear decrease in maximal bladder capacity, from 330 to 240 mL (P < .05). In both groups, stress profiles demonstrated a shift of maximal pressure point toward the proximal urethra and a significant improvement in pressure transmission (P < .05). The post-operative patients who had persistent incontinence were found to have insufficient elevation of the bladder neck (less than 10 mm). The uroflow examination showed an increase of urination time in both groups. The incidence of bladder problems was 10% with the Burch procedure and 29% with the sling procedure; however, 13% of the Burch group developed rectoceles. CONCLUSION: Both procedures offer a high rate of success. We believe that the sling surgery should be used only in certain special cases because of its higher rate of complications, but that posterior vaginal repair should be considered after modified Burch colposuspension because of the possibility of rectocele and enterocele.

[Preperitoneal pelviscopic Burch colposuspension using the "Nottingham needle"]. / Präperitoneale pelviskopische Kolposuspension nach Burch mittels "Nottingham-Nadel".

By 40 women with stress incontinence II.-III. degrees we performed a preperitoneal pelviscopic colposuspension (Burch) modified by Gill with the "Nottingham Needle". An urodynamic and sonographic assessment before and 6-9 months after the pelviscopic operation were done. In 38 cases from the 40 women (95%) we saw a good result. The new modification of the pelviscopic colposuspension showed us a low intra- and postoperative morbidity and we consider it a big advantage for obese women.

[A new surgical aid--the "endo-stitch disposable suture device"--for pelviscopic pre-peritoneal Burch incontinence operation. A pilot study]. / Ein neues Hilfsmittel--das "Endo-Stitch-Einwegnahtinstrument"--für die pelviskopische präperitoneale Inkontinenzoperation nach Burch. Eine Pilotstudie.

OBJECTIVE: It is the therapeutical aim of urogynecology to correct urinary incontinence. Which advantages offers the use of the Endo-Stitch needle in Burch's pelviscopic colposuspension? METHODS: When extending the field of pelviscopic surgery, in a prospective study we performed Burch's pelviscopic preperitoneal colposuspension using the disposable Endo-Stitch suture instrument in 12 patients with stress incontinence grades 2 or 3. Clinical and urodynamic evaluations were performed before and 8.5 months after the pelviscopic operation. RESULTS: Clinical and urodynamic follow-up examinations revealed continence in 10 (83%) out of 12 patients. CONCLUSIONS: Our preliminary experience suggests that the pelviscopic incontinence operation by means of the Endo-Stitch needle is a good alternative to abdominal colposuspension. Follow-up results of a large number of patients will have to prove advantages in contrast to conservative surgery.

[Efficacy of various methods for preoperative vaginal antisepsis]. / Zur Effizienz von Verfahren für die präoperative Vaginalantiseptik.

In a prospective clinical study we investigated 115 patients prior to vaginal surgical interventions to determine the antimicrobial efficacy of six different procedures for vaginal antisepsis. To sample the microorganisms we used a cotton swab moistened with a neutralising fluid. Immediately after the time of action of the antiseptic procedures (3 minutes), providone-iodine solution, applied undiluted or diluted 1:10, yielded the strongest median reduction of the vaginal flora (log RF 3.60 and 2.68, respectively). Of three detergents with antiseptic efficacy, octenidine 0.1% was the most efficient formula (log RF 2.32). After 30 minutes the log reduction factors (log RF) of almost all procedures (log RF 2.79-3.25) were in a fairly close range, excepting chlorohexidine 0.05% (log RF 2.07). Overall, the antiseptic detergents showed a marked residual effect, which was less pronounced, if at all, with providone-iodine solutions. A germ-reducing effect of povidone-iodine vaginal suppositories, applied 2 to 3 hrs prior to surgery, was not confirmed, while additional findings indicated that providone-iodine solution applied with the help of a vaginal douche yields a similarly strong germ reduction as the application by means of a ball swabs.

[The prognostic effect of scintigraphy-guided lymphadenectomy in therapy of stage Ib cervix carcinoma]. / Uber den prognostischen Einfluss der Szintigraphie-geleiteten Lymphadenektomie in der Therapie des Zervixkarzinoms im Stadium Ib.

In a retrospective study the survival rates of 161 patients with stage Ib cervical cancer after radical operation (Latzko, Wertheim-Meigs) including complete or incomplete pelvine lymphadenectomy were compared. To increase radicality of lymphadenectomy, preoperative targeting of pelvic lymph nodes was done in all the patients using 99mTc-Sb2S3 radiocolloid. Intraoperatively, a gamma-camera being integral part of an operating table allowed delineation and scintigraphy-guided resection of pelvic lymph nodes. Dependent on the evidence of remaining pelvine foci of radioactivity at the end of the operation, lymphadenectomy was assessed as complete or incomplete. Mean observation time of completely lymphadenectomised patients (n = 117,72.67%) were 80 months (5-169 months) and 42 months (1-149 months) of the incompletely lymphadenectomised patients (n = 44,27.33%). In 28 (23.93%) completely lymphadenectomised patients against only 5 (11.36%) patients with incomplete lymphadenectomy, lymph node metastases were proved histologically. Five year-survival rate of completely lymphadenectomised patients was 85.47% and 88.64% of incompletely lymphadenectomised patients (not significant, Mantel-Test). Also, selective comparison of lymph node-positive patients did not suggest a divergent trend indicated by 13 (46.43%) deaths of completely and 3 (60.0%) deaths of the incompletely lymphadenectomised patients after an observation of five years. The technique of scintigraphy-guided pelvic lymphadenectomy using 99mTc-Sb2S3 radiocolloid cannot be expected to improve prognosis of patients with cervical cancer stage Ib.

[Topical administration of oxybutynin hydrochloride in women with urge incontinence. Results of a prospective randomized double-blind study]. / Zur topischen Anwendung von Oxybutyninhydrochlorid bei Frauen mit Urge-Inkontinenz. Ergebnisse einer prospektiv randomisierten Doppelblindstudie.

Detrusor instability is the second most common cause of femal urinary incontinence. Oxybutynin chloride anticholinergic action with direct muscle-relaxant properties. 39 women with persistent-urgeincontinence participated in a pilot study of intravesical oxybutynin application. Patients received either 20 mg oxybutynin or placebo as 40 ml sterile sodium chloride solution administered intravesically over a period of 10 days. Urodynamic assessment as well as micturition protocols were performed before and after treatment. The intravesical oxybutynin-application was significantly better than the placebo application concerning reduction of pollakisuria and nycturia. Oxybutynin also increased bladder capacity more than in the placebo-treated group (p < 0.01) and provided an improvement of bladder compliance (p < 0.05). No local or systemic side effects were observed which would have immediately terminated the oxybutynin treatment.

[Urethrovesical morphology in continent women in spinal anesthesia]. / Urethrovesikale Morphologie bei kontinenten Frauen in Spinalanästhesie.

OBJECTIVE: To assess the influence of spinal anesthesia on bladder neck position and a clinical stress test in continent women. METHODS: In a prospective investigation, 14 women underwent urodynamic, sonographic and clinical assessment during spinal anesthesia. Results were compared to those obtained immediately preoperatively in the same patient. RESULTS: During spinal anesthesia, the bladder neck was found to be located significantly lower and more posterior, and in 4/7 parous patients (0/7 nullipara) the clinical stress test was positive. CONCLUSION: These data provide additional evidence for the importance of neuromuscular function in the etiology of pelvic floor dysfunction and genuine stress incontinence.

Combined use of 123I-labelled BCD-F9 and 4C4 monoclonal antibody with dissimilar specificity for breast cancer: implication for the detection limit of immunolymphoscintigraphy in the assessment of axillary lymph node metastases.

To determine whether the detection limit of immunolymphoscintigraphy (ILS), reported to be > or = 1 cm, can be improved by comparing imaging after administration of breast cancer-specific monoclonal antibody (MAb) BCD-F9 and breast cancer-nonspecific 4C4, 25 patients with suspected breast cancer were given injections of both 123I-labelled MAbs. The ILS was performed independently for both MAbs, the 4C4 scans serving as an ipsilateral negative control, and was used preoperatively to detect lymph node metastases. Twenty-one patients had breast cancer of whom 11 patients suffered from axillary involvement. Single interpretation of BCD-F9 scans gave true positive results in six of 11 and true negative results in 12 of 14 patients, whereas combined interpretation of BCD-F9 and 4C4 scans gave true positive results in nine of 11 and true negative results in 14 of 14 patients. On the basis of comparison of scintigrams of both MAbs, ILS allowed the detection of lymph node metastases 0.3-0.8 cm in diameter (n = 3). Immunohistochemistry of BCD-F9 and 4C4 MAbs of tumour-free and tumour-bearing lymph nodes correlated with ILS, with the exception of one patient. The study suggests that comparing scans obtained with BCD-F9 and 4C4 MAbs may improve the detection limit of ILS in the preoperative staging of axillae.

[Topical use of oxybutynin hydrochloride in women with urge incontinence]. / Topische Anwendung von Oxybutyninhydrochlorid bei Frauen mit Harndranginkontinenz.

In 36 women with cystometric evidence of bladder instability we investigated the efficacy of intravesical instillation of oxybutynin. The intravesical application of oxybutynin had a significant effect regarding the reduction of pollakiuria and nocturia and an improvement of bladder capacity. No local or systemic side effects were noted.

[Intravesical administration of estriol in sensory urge incontinence--a prospective study]. / Intravesikal appliziertes Ostriol bei sensorischer Urgeinkontinez--eine prospektive Studie.

Local intravaginal application of oestriol is part of the therapeutical programme of sensory urge-incontinence. The effectiveness of a new method--intravesical administration of 1 mg oestriol versus a placebo--has been proved in a prospective randomised study. 21 patients each were treated over a period of three weeks with oestriol or with the placebo-substance intravesically. The effectiveness of the administered therapy was checked with clinical and urodynamic parameters. The intravesical administration of 1 mg oestriol proved to be efficient and free of side effects in respect of the parameters such as imperative micturition, bladder capacity, of the maximum urethral closure pressure as well as the number of micturitions per diem. The intravesical administration of oestriol may be considered as additional method of therapy for treatment of sensory urge-incontinence.

[Surgical treatment of recurrent stress incontinence: Burch versus lyodura sling operation--a prospective study]. / Zur operativen Behandlung der Rezidivstressinkontinenz: Burch-versus Lyoduraschlingenoperation--eine prospektive Studie.

This prospective randomised study involved 52 female patients suffering from recurrent stress urinary incontinence, objectively confirmed by means of clinical incontinence tests and urodynamic examinations. They alternatively underwent colposuspension according to Burch or suburethral sling procedure surgery. Urodynamic and sonographic examinations were carried out before and 2.5 years (i.e. within a range of 2-3) after surgery according to Burch or suburethral sling procedure. There was no significant difference between the two methods with respect to subjective and objective rate of cure, which amounted to 85% of the cases involving colposuspension and 88% of cases involving the suburethral sling procedure. Both methods resulted in a significant improvement of the depression quotient and a significant elevation of the internal urethral meatus (p < 0.05). Apart from an aggravation of urge symptoms in both groups, the patients with surgery according to Burch tended towards enterocele and rectocele in the medium range, whereas urination disorders had to be accepted in the patients operated on according to the sling procedure in the long term.

Genital antisepsis--test methodology and efficacy of povidone-iodine.

Indications for antiseptic prophylaxis include use prior to urinary catheterization and other transurethral instrumentations, diagnostic or therapeutic instrumentation of the cavum uteri, and operations on the external genitalia and the vagina. Indications for antiseptic therapy include treatment of wounds and of infections of the genital tract and also include treatment of the vaginas of pregnant women to prevent infection in the newborn. For prophylactic antisepsis the aim is the optimal reduction of potentially pathogenic microorganisms. In some fields of application, e.g. before urinary catheterization, an immediate effect on the mucous membrane is required, but on other occasions, such as transvaginal operations, an additional sustained effect is desired. Testing the efficacy of mucous membrane antiseptics, especially for the genital tract, necessitates the establishment of standardized test methods. The variability in vaginal flora at various ages makes it reasonable to study women aged 20-50 years. Studies presented in this paper indicate that microorganism sampling using a cotton swab moistened with neutralizing fluid can be favoured compared to using a rinsing technique and that anaerobic culture techniques enable the measurement of the high reduction factors achieved by very efficient antiseptic procedures. Test methods validated for hand disinfectants are used for calculations and statistical evaluation. The antimicrobial efficacy of six vaginal antiseptic procedures were compared in patients prior to vaginal surgery. Three minutes after treatment, the highest mean reduction (log RF) of the normal vaginal flora as well as of potentially pathogenic microorganisms was obtained by povidone-iodine solution undiluted and povidone-iodine solution 1:10 (log RF 3.60 and 2.68, respectively). Out of three detergents with antimicrobial efficacy, octenidine 0.1% was the most effective preparation (log RF 2.32). Chlorhexidine 0.1%, hexetidine 0.1% and chlorhexidine 0.05% led to lower reduction factors (log RF 1.80, 1.62 and 1.02, respectively). After 30 minutes the log reduction factors were approximating each other in nearly all procedures (log RF 2.79-3.25) except the log RF derived from the procedure performed using chlorhexidine 0.05% (log RF 2.07). Povidone-iodine solutions seem to be the method of choice for mucous membrane antisepsis where an immediate effect is required. If a long period of action is needed all procedures examined, except chlorhexidine 0.05%, are acceptable.

[Human papillomavirus (HPV) DNA infections of the uterine cervix]. / Humane Papillomavirus(HPV)-DNA-Infektionen an der Cervix uteri.

411 women who had dysplasia, selected from an ambulatory group as well as 240 women from a random control group were examined, by using cervical smears, which were initially diagnosed as human papilloma viruses-DNA (HPV-DNA) of the type 6/11, or 16/18, or 31/33/35. This was achieved by the in-situ nucleic acid hybridisation technique. The results of the HPV-DNA typing were tabulated with the cytological diagnosis (Munich Papanicolaou (Pap.) group-classification). The control group corresponding to Pap.Gr. I, and was HPV-DNA positive in 6 (2.5%) of the 240 cases. The group of 180 patients with a Pap.Gr. II showed a HPV-DNA positive result for 75 cases (41.7%); 57 of 99 cases (57.6%) occurred in Pap.Gr. IIID; 42 of 54 cases 77.8% (L) were found in Pap.Gr. IV (a/b), and 72 of 78 cases (92.3%) appeared in Pap.Gr. V. The HPV-DNA mixed infections became evident as the cellular dysplasia increased. The results of the HPV-DNA positive diagnosis clearly indicate a close correlation with the Pap.Gr.-classification. The HPV-DNA type 16/18 was most frequent in cervical carcinomas (Pap.Gr. V). The cyto-histological control of the 57 HPV-DNA positive cases of the untreated Pap.Gr. IIID showed a regression in 31.6% of the 18 cases after a period of 3 to 6 months (post HPV-DNA typing). These were histologically normal. In 33 cases (57.9%), there was a persisting Pap.Gr. IIID (CIN I/II) and in 6 cases (10.5%) a progredient correlation in Pap.Gr. IV a/b. The Pap. group IV (a/b) was histologically a CIN grade III.

[Gyneco-urologic problems in climacteric]. / Gynäko-urologische Probleme im Klimakterium.

In climacteric women stress and urge incontinence often occur as a consequence of estrogen deficiency. Urinary incontinence is defined as involuntary discharge of urine associated with psychologic and hygienic problems. Of 3,248 women investigated between 1986 and 1990 at our Clinic for Climacteric Dysfunctions, Vienna, 1,039 women (32%) reported symptoms such as vaginal dryness, incontinence and problems with regard to cohabitation. Indications for estrogen replacement therapy in and/or after the climacteric period are urinary stress incontinence degree I, urge incontinence (pollakisuria, nycturia), atrophic urethritis as well as preoperative estrogen replacement. For therapeutic management both conjugated estrogens and estradiol as well as estriol preparations may be employed, taking the contraindications into account. Postmenopausal estrogen replacement is highly indicated with dysfunctions in the area of urethra and urinary bladder.