The impact of a nationwide hands-on workshop on the diagnostic rates and management of obstetrical anal sphincter Injuries in Israel.

AIM: The aim was to evaluate the influence of a half day, hands-on, workshop on the detection and repair of obstetric anal sphincter injuries (OASIs). METHOD: Starting in February 2011, hands-on workshops for the diagnosis and repair of OASIs were delivered by trained urogynaecologists in departments of tertiary medical centres in Israel. The structure of the hands-on workshop resembles the workshop organized at the International Urogynecological Association annual conferences. Participants included medical staff, midwives and surgical residents from each medical centre. We collected data regarding the rate of OASIs, 1 year before and 1 year following the workshop, in 11 medical centres. The study population was composed of parturients with the following inclusion criteria: singleton pregnancy, vertex presentation and vaginal delivery. Pre-viable preterm gestations (< 24 weeks), birth weight < 500 g, stillborn, and those with major congenital anomalies, multifoetal pregnancies, breech presentations and caesarean deliveries were excluded from the analysis. RESULTS: In the reviewed centres, 70 663 (49.3%) women delivered prior to the workshop (pre-workshop group) and 72 616 (50.7%) women delivered following the workshop (post-workshop group). Third- or fourth-degree perineal tears occurred in 248 women (0.35%) before the workshop, and in 328 (0.45%) following the workshop, a significant increase of 28.7% (P = 0.002). The increase in diagnosis was significant also in women with third-degree tears alone, 226 women (0.32%) before the workshop and 298 (0.41%) following the workshop, an increase of 28.3% (P = 0.005). CONCLUSION: The detection rate of OASIs has significantly increased following the hands-on workshop. The implementation of such programmes is crucial for increasing awareness and detection rates of OASI following vaginal deliveries.

Risk factors for severe perineal injury during childbirth: a case-control study of 60 consecutive cases.

AIM: The study aimed to evaluate the current risk factors for severe perineal tears in a single university-affiliated maternity hospital. METHOD: An obstetric database of 31 784 consecutive women who delivered from January 2007 to December 2009 was screened for cases of third-degree or fourth-degree perineal tears. Four controls, matched by time of delivery, were selected for each case of third- or fourth-degree perineal tear. Maternal and obstetric parameters were analyzed and compared between the study and control groups. RESULTS: Sixty women (0.25% of all vaginal deliveries) had a third-degree (53 women) or a fourth-degree (seven women) perineal tear. The control group comprised 240 matched vaginal deliveries without severe tears. Primiparity, younger maternal age, Asian ethnicity, longer duration of second stage of labour, vacuum-assisted delivery and heavier newborn birth weight were significantly more common among women who had third- or fourth-degree perineal tears. Of the variables that were found to be statistically significant in the univariate analysis, only primiparity (OR = 2.809, 95% CI: 1.336-5.905), vacuum delivery (OR = 10.104, 95% CI: 3.542-28.827) and heavier newborn birth weight (OR = 1.002, 95% CI: 1.001-1.003) were found to be statistically significant independent risk factors for severe perineal trauma. CONCLUSION: Identification of women at risk may facilitate the use, or avoidance, of certain obstetric interventions to minimize the occurrence of childbirth-associated perineal trauma.

Role of urethrocystoscopy in the evaluation of refractory idiopathic detrusor instability.

OBJECTIVES: To assess the role of diagnostic urethrocystoscopy in the evaluation of women with idiopathic detrusor instability (DI) refractory to conventional pharmacologic management. METHODS: One hundred consecutive women (mean age 62.1 +/- 15.1 years) with idiopathic DI refractory to conventional pharmacologic management were prospectively enrolled. All patients underwent a meticulous evaluation, including a detailed history, urogynecologic questionnaire, micturition diary and pad test, urinalysis and culture, physical examination, and urodynamic studies. Refractory DI was defined as the lack of clinical improvement after at least 6 months of conventional drug therapy. These patients underwent additional evaluation with diagnostic urethrocystoscopy. RESULTS: All patients had a normal urinalysis and negative cytologic findings. Diagnostic urethrocystoscopy revealed isolated bladder tuberculosis in one and transitional cell carcinoma in another. Seven other patients had bladder diverticula (only one of which was also diagnosed by sonographic examination) and 22 had mild-to-moderate bladder trabeculations. CONCLUSIONS: The absence of other alarming signs (ie, recurrent urinary tract infection, hematuria, significant residual urinary volume, positive cytologic findings, or suspicious sonographic findings) cannot confirm the lack of significant lower urinary tract abnormalities among patients with refractory DI. Diagnostic urethrocystoscopy, a simple and safe office procedure, facilitates timely diagnosis and appropriate treatment for these patients.

Combined genitourinary prolapse repair and prophylactic tension-free vaginal tape in women with severe prolapse and occult stress urinary incontinence: preliminary results.

OBJECTIVES: Continent patients with a positive stress test demonstrated on repositioning of severe genitourinary prolapse are considered to be at high risk of developing postoperative symptomatic stress urinary incontinence (SUI). Our aim was to evaluate in a prospective study whether a prophylactic, tension-free vaginal tape (TVT) procedure, performed during prolapse repair, may prevent the development of postoperative SUI in these women. METHODS: Thirty consecutive, clinically continent women (mean age 64.5 +/- 9.04 years) with severe genitourinary prolapse and occult SUI were prospectively enrolled. Occult SUI was defined as a positive stress test with repositioning of the prolapse during the preoperative urodynamic studies. All patients had urethral hypermobility; none had intrinsic sphincter deficiency. In addition to genitourinary prolapse repair, these patients underwent concomitant TVT to prevent postoperative SUI. Patients were followed up for at least 1 year. Repeated urodynamic studies were performed at 3 to 6 months postoperatively. The main outcome measures were postoperative SUI, persistent or de novo detrusor instability, and recurrence of prolapse. RESULTS: The mean duration of follow-up was 14.25 +/- 3.08 months (range 12 to 24). None of the patients developed postoperative symptomatic SUI. However, three asymptomatic patients (10%) had a positive stress test during their postoperative urodynamic evaluation. Nine patients (30%) had detrusor instability before surgery, which persisted in six (66%) postoperatively. Postoperative de novo detrusor instability was diagnosed in four other patients (13.33%). None of the patients had recurrent urogenital prolapse, nor did they have clinical evidence of bladder outlet obstruction. CONCLUSIONS: The preliminary results of TVT as a prophylactic procedure in clinically continent women with severe prolapse and occult SUI are encouraging. Long-term follow-up is required to confirm the durability of these results.

Evaluation of female lower urinary tract symptoms: overview and update.

Female lower urinary tract symptoms are nonspecific, and a thorough clinical evaluation is required to establish the correct diagnosis. Such evaluation should consist of a structured micturition history or questionnaire, physical examination with full bladder, micturition diary, pad test and urodynamic evaluation. The urodynamic evaluation should consist at least of cystometry, detrusor pressure/uroflow study, simple ('free') uroflowmetry, assessment of the relative contribution of urethral hypermobility and intrinsic sphincter deficiency, and estimation of postvoid residual urine by ultrasound or catheterization. Recent studies regarding the role of pad tests, micturition diaries and urodynamic studies in the evaluation of female voiding dysfunction are presented. Factors that are associated with the use of transurethral catheter during pressure-flow studies and current controversies regarding the diagnosis of female bladder outlet obstruction are reviewed and discussed. Although the urodynamic study is considered to be the best diagnostic tool in assessment of lower urinary tract function, some practitioners believe that urodynamic evaluation is not routinely warranted and prefer to employ a symptom-based empirical management strategy. Lower urinary tract symptoms are nonspecific, however, and should be used mainly to identify what bothers the patient. Urodynamic studies define the underlying pathophysiology. We believe that treatment of the underlying pathophysiology facilitates better treatment of symptoms.

Use of cadaveric solvent-dehydrated fascia lata for cystocele repair--preliminary results.

OBJECTIVES: To present a surgical technique in which cadaveric fascia lata is used for cystocele repair. METHODS: Twenty-one consecutive women (mean age 67 +/- 10 years) with severe cystocele were prospectively enrolled. All patients underwent meticulous clinical and urodynamic preoperative evaluations. Solvent-dehydrated, Tutoplast-processed, cadaveric fascia lata was used for cystocele repair. The fascia was anchored transversally between the bilateral arcus tendineus and the cardinal and uterosacral ligaments. Standard endopelvic plication was performed thereafter as a second layer. Patients with overt or occult sphincteric incontinence underwent concomitant pubovaginal sling (PVS) surgery as well, using the same material. The main outcome measures included recurrent urogenital prolapse, persistent or de novo urinary incontinence (stress or urge), and dyspareunia. RESULTS: Of the 21 patients, 19 underwent concomitant PVS, 3 concomitant vaginal hysterectomy, and 8 posterior colporrhaphy in addition to their cystocele repair. The mean follow-up was 20.1 +/- 6.7 months (range 12 to 30). No postoperative complications related to the material or technique occurred. None of the patients developed a recurrent cystocele. Two patients (9%), one of whom underwent concomitant posterior colporrhaphy, developed mild recto-enterocele at 4 to 6 months postoperatively. Six patients underwent concomitant PVS for occult sphincteric incontinence. None developed postoperative stress incontinence. Thirteen other patients underwent concomitant PVS for overt sphincteric incontinence. All but two were stress-continent postoperatively. One half of the patients with preoperative urge or mixed incontinence had persistent urge incontinence postoperatively. None of the patients developed postoperative de novo urge incontinence or dyspareunia. CONCLUSIONS: The use of solvent-dehydrated cadaveric fascia lata for cystocele repair, as well as PVS, is associated with encouraging short and medium-term results. Long-term follow-up is needed to evaluate whether these results are durable.

Videourodynamic studies in men with lower urinary tract symptoms: a comparison of community based versus referral urological practices.

PURPOSE: We compared the clinical and urodynamic characteristics of men referred for evaluation of lower urinary tract symptoms in community based versus referral urological practices and examined the various pathophysiological mechanisms of these symptoms. MATERIALS AND METHODS: We reviewed a multicenter urodynamics database of 963 consecutive men referred for the evaluation of persistent lower urinary tract symptoms at 2 community based and 1 urological referral center. Of the 963 patients in the database 422 (44%) were excluded from study due to neurological disorder in 41%, previous urinary or pelvic surgery in 27% and the use of medications known to affect voiding in 24%. A total of 541 patients with a mean age plus or minus standard deviation of 64.4 +/- 13.8 years met study inclusion criteria and were analyzed further. We compared the clinical and urodynamic characteristics of patients at the community and referral centers. RESULTS: Lower urinary tract symptoms were equally common in men presenting to community and referral centers. The most common symptom was difficult voiding, followed by frequency, urgency and nocturia in 58%, 54%, 43% and 40% of the study population, respectively. Urodynamic diagnoses were also similar in the 2 groups. Although bladder outlet obstruction was diagnosed in 69% of patients, it was the only urodynamic finding in a third of the patients with obstruction. The main concomitant urodynamic diagnoses were detrusor overactivity, bladder hyposensitivity, impaired detrusor contractility, low bladder compliance and bladder hypersensitivity in 47%, 10%, 10%, 9% and 3% of obstructed cases, respectively. CONCLUSIONS: The pathophysiology of lower urinary tract symptoms in men is multifactorial, and similar at community practice and tertiary referral centers. The disparity in urodynamic findings and subjective symptoms emphasizes the need for a thorough and early clinical and urodynamic evaluation.

Detrusor instability in men: correlation of lower urinary tract symptoms with urodynamic findings.

PURPOSE: We evaluated the correlation of lower urinary tract symptoms suggestive of detrusor instability with urodynamic findings in men. MATERIALS AND METHODS: Enrolled in our prospective study were 160 consecutive neurologically intact men referred for urodynamic evaluation of persistent lower urinary tract symptoms. All patients had storage symptoms suggestive of detrusor instability. Patients were further clinically categorized according to the chief complaint of urge incontinence, frequency and urgency, nocturia or difficult voiding. The clinical and urodynamic diagnosis in all patients as well as specific urodynamic characteristics of those with detrusor instability were analyzed according to the these 4 clinical categories. RESULTS: Mean patient age was 61 +/- 15 years. The chief complaint was urge incontinence in 28 cases (17%), frequency and urgency in 57 (36%), nocturia in 30 (19%) and difficult voiding in 45 (28%). Detrusor instability was diagnosed in 68 cases (43%). A higher incidence of detrusor instability was associated with urge incontinence than with the other clinical categories (75% versus 36%, p <0.01). Of the patients 109 (68%) had bladder outlet obstruction, including 50 (46%) with concomitant detrusor instability. The prevalence of bladder outlet obstruction was similar in all patients regardless of the chief complaint. All other urodynamic diagnoses were also similar in the 4 clinical categories. The mean bladder volume at which involuntary detrusor contractions occurred were lower in patients with urge incontinence and frequency and urgency than in those with nocturia and difficult voiding (277.1 +/- 149.4 and 267.7 +/- 221.7 versus 346.7 +/- 204.6 and 306.2 +/- 192.1 ml., respectively, not statistically significant, p = 0.07). CONCLUSIONS: Detrusor instability and bladder outlet obstruction are common in men with lower urinary tract symptoms. The symptom of urge incontinence strongly correlated with detrusor instability. Other lower urinary tract symptoms did not correlate well with any urodynamic findings. Therefore, we believe that an accurate urodynamic diagnosis may enable focused and more efficient management of lower urinary tract symptoms in men.

Involuntary detrusor contractions: correlation of urodynamic data to clinical categories.

Data regarding the prevalence and urodynamic characteristics of involuntary detrusor contractions (IDC) in various clinical settings, as well as in neurologically intact vs. neurologically impaired patients, are scarce. The aim of our study was to evaluate whether the urodynamic characteristics of IDC differ in various clinical categories. One hundred eleven consecutive neurologically intact patients and 21 consecutive neurologically impaired patients, referred for evaluation of persistent irritative voiding symptoms, were prospectively enrolled. All patients were presumed by history to have IDC, and underwent detailed clinical and urodynamic evaluation. Based on clinical evaluation, patients were placed into one of four categories according to the main presenting symptoms and the existence of neurological insult: 1) frequency/urgency; 2) urge incontinence; 3) mixed stress incontinence and irritative symptoms; and 4) neurogenic bladder. IDC was defined by detrusor pressure of > or = 15 cm H2O whether or not the patient perceived the contraction; or < 15 cm H2O if perceived by the patient. Eight urodynamic characteristics of IDC were analyzed and compared between the four groups. IDC were observed in all of the neurologically impaired patients, compared with 76% of the neurologically intact patients (P < 0.001). No correlation was found between amplitude of IDC and subjective report of urgency. All clinical categories demonstrated IDC at approximately 80% of cystometric capacity. Eighty-one percent of the neurologically impaired patients, compared with 97% of the neurologically intact patients, were aware of the IDC at the time of urodynamics (P < 0.04). The ability to abort the IDC was significantly higher among continent patients with frequency/urgency (77%) compared with urge incontinent patients (46%) and neurologically impaired patients (38%). In conclusion, when evaluating detrusor overactivity, the characteristics of the IDC are not distinct enough to aid in differential diagnosis. However, the ability to abort IDC and stop incontinent flow may have prognostic implications, especially for the response to behavior modification, biofeedback, and pelvic floor exercise.

Learned voiding dysfunction (non-neurogenic, neurogenic bladder) among adults.

Data concerning learned voiding dysfunction (Hinman syndrome; non-neurogenic, neurogenic bladder) in adults are scarce. The present study was conducted to assess the pre-valence and clinical characteristics of this dysfunction among adults referred for evaluation of lower urinary tract symptoms. Learned voiding dysfunction was suggested by a characteristic clinical history and intermittent "free" uroflow pattern and by the absence of any detectable neurological abnormality or anatomic urethral obstruction. A definitive diagnosis was made by the demonstration of typical external urethral sphincter contractions during micturition by EMG or fluoroscopy. A urodynamic database of 1,015 consecutive adults was reviewed. Twenty-one (2%) patients (age, 24-76 years) met our strict criteria of learned voiding dysfunction. Obstructive symptoms were the most common presenting symptoms, followed by frequency, nocturia, and urgency. Eight (35%) patients had recurrent urinary tract infections, seven of these being women. None of the patients had any clinically significant upper urinary tract damage. First sensation volume was significantly lower in women than in men. Both detrusor pressure at maximum flow and maximum detrusor pressure during voiding were found to be significantly higher in men than in women. Further differentiation between adult women and men failed to reveal any other clinically significant differences. In conclusion, by strict video-urodynamic criteria, 2% of our patients had learned voiding dysfunction. Other patients, with presumed learned voiding dysfunction, who did not undergo video-urodynamics were not included in the present series. Thus, the prevalence of learned voiding dysfunction among adults referred for evaluation of lower urinary tract symptoms is likely to be even higher.

Pubovaginal sling surgery for simple stress urinary incontinence: analysis by an outcome score.

PURPOSE: We assessed the results of pubovaginal sling surgery in women with simple stress urinary incontinence using strict subjective and objective criteria. MATERIALS AND METHODS: Simple incontinence was defined as sphincteric incontinence with no concomitant urge incontinence, pipe stem or fixed scarred urethra, urethral or vesicovaginal fistula, urethral diverticulum, grade 3 or 4 cystocele, or neurogenic bladder. A total of 67 consecutive women with a mean age plus or minus standard deviation of 56 +/- 11 years who underwent pubovaginal sling surgery for simple sphincteric incontinence were prospectively followed for 12 to 60 months (mean 33.9 +/- 22.2). Treatment outcomes were classified according to a new outcome score. Cure was defined as no urinary loss due to urge or stress incontinence, as documented by 24-hour diary and pad test, with the patient considering herself cured. Failure was defined as poor objective results with the patient considering surgery to have failed. Cases that did not fulfill these cure-failure criteria were considered improved and further classified into a good, fair or poor response. RESULTS: Of the 67 patients 46 (69%) had type II and 21 (31%) had type III incontinence. Preoperative diary and pad tests revealed a mean of 5.9 +/- 3.6 stress incontinence episodes and a mean urinary loss of 91.8 +/- 81.9 gm. per 24 hours. There were no major intraoperative, perioperative or postoperative complications. Two patients (3%) had persistent minimal stress incontinence and 7 (10%) had new onset urge incontinence within 1 year after surgery. Overall using the strict criteria of our outcome score 67% of the cases were classified as cured and the remaining 33% were classified as improved. The degree of improvement was defined as a good, fair and poor response in 21%, 9% and 3% of patients, respectively. CONCLUSIONS: Mid-term outcome results defined by strict subjective and objective criteria confirm that the pubovaginal sling is highly effective and safe surgery for simple sphincteric incontinence. A followup of more than 5 years is required to establish the long-term durability of this procedure.

Evaluation of female external genitalia sensitivity to pressure/touch: a preliminary prospective study using Semmes-Weinstein monofilaments.

OBJECTIVES: To assess the use of pressure aesthesiometers (Semmes-Weinstein monofilaments) in the evaluation of female external genitalia. The pressure aesthesiometers are widely used to assess the pressure/touch perceptions of the hand, face, and breast dermatomes. METHODS: Thirty-two consecutive neurologically intact women (mean age 48.7 +/- 13.8 years) and 5 neurologically impaired women referred for a routine gynecologic examination were prospectively enrolled. The monofilaments were applied to the S2-S5 vulvar dermatomes using specific anatomic landmarks. Test-retest reliability studies were performed at the same clinical session. A comparison was made between premenopausal (n = 17) and postmenopausal (n = 15) women; hypoestrogenic (n = 9) and normoestrogenic (n = 23) women; postmenopausal women with (n = 6) and without (n = 9) estrogen replacement therapy; women with normal (n = 18) and abnormal (n = 14) sexual function; and neurologically impaired (n = 5) and neurologically intact (n = 5) women, matched by age, parity, and estrogen status. RESULTS: A clear association was found between reduced vulvar sensitivity to pressure/touch and estrogen deficiency, sexual dysfunction, and neurologic impairment. Postmenopausal women had significantly reduced sensitivity to pressure/touch compared with premenopausal women. Similar decreased sensitivity was found in hypoestrogenic compared with normoestrogenic women, with significantly reduced sensitivity in postmenopausal women not using estrogen replacement therapy. Women with sexual dysfunction and those with neurologic impairment had significantly reduced vulvar sensitivity to pressure/touch. No correlation was found between the sensitivity to pressure/touch and either levator ani muscle bulk or the levator contraction score, but significant differences were found between women with and without vulvovaginal atrophy at the time of the examination. Test-retest analysis confirmed the reliability of the monofilaments in testing vulvar sensation. CONCLUSIONS: The Semmes-Weinstein monofilaments may be used as a valid and reliable diagnostic tool in the evaluation of vulvar sensitivity to pressure/touch. Additional studies with larger series are needed to establish the role of this clinical tool in the evaluation of various treatment outcomes.

Persistent postpartum urinary retention in contemporary obstetric practice. Definition, prevalence and clinical implications.

OBJECTIVE: To prospectively evaluate the prevalence, presumed etiologies and clinical implications of persistent postpartum urinary retention in modern obstetric practice. STUDY DESIGN: The study population comprised 8,402 consecutive, unselected parturients delivered in a university-affiliated maternity hospital over a one-year period. If a woman was unable to void spontaneously until the third postpartum day despite intermittent use of a Foley catheter, a diagnosis of persistent postpartum urinary retention was established. Patients were treated by insertion of a Foley catheter for up to two weeks and subsequently by a suprapubic catheter. Obstetric data were collected from the hospital records. RESULTS: Four patients (0.05% of the study population), aged 29-37 years, developed persistent postpartum urinary retention. Risk factors included vaginal delivery after cesarean section, prolonged second stage of labor, epidural analgesia, and delayed diagnosis and intervention. Urodynamic evaluation, performed on two patients one month after removal of the suprapubic catheter, revealed genuine stress incontinence in one and detrusor instability in another. None had had any lower urinary tract symptoms before pregnancy and delivery. CONCLUSION: Persistent postpartum urinary retention in contemporary obstetric practice is rare but may be associated with long-term bladder dysfunction. Early diagnosis and intervention are required to prevent irreversible bladder damage.

Management of urethral erosion caused by a pubovaginal fascial sling.

Urethral erosion by a fascial sling is a rare postoperative complication, and its repair can become a major surgical endeavor. We present a case of autologous fascial sling erosion into the mid-urethra in a 46-year-old woman that was diagnosed after traumatic urethral catheterization. After 3 months of conservative management failed, we released the sling tension surgically by bilateral excision of the graft, leaving the midline structures undisturbed. This allowed resumption of normal voiding, with complete long-term symptomatic relief.

Does the method of cystometry affect the incidence of involuntary detrusor contractions? A prospective randomized urodynamic study.

The International Continence Society (ICS) defines overactive detrusor as "one that is shown objectively to contract during the filling phase while the patient is attempting to inhibit micturition." The aim of the present study was to assess whether instructing the patient neither to try void nor to inhibit micturition during filling cystometry may improve the detection rate of involuntary detrusor contractions (IDCs). Forty-two consecutive patients (mean age 65 +/- 13.5 years), referred for urodynamic evaluation of persistent irritative lower urinary tract symptoms were prospectively enrolled. All patients were presumed, by history, to have IDCs. Cystometry was performed twice at the same session, each time by using randomly different instructions: Method 1, patients were instructed to try to inhibit micturition during bladder filling; and Method 2, patients were instructed to neither try to void nor try to inhibit micturition, but simply report his or her sensations to the examiner. The occurrence, as well as the urodynamic characteristics of IDCs, were analyzed separately and compared between the two filling methods. Method 1 identified only 20 cases of IDCs, while Method 2 identified 27 cases (48 versus 64 % of the study population, respectively; P = 0.02). Analysis of urodynamic characteristics revealed a clear trend of reduced bladder volume at which IDCs occurred when patients were instructed to neither try to void nor to inhibit micturition during bladder filling; however, statistical significance was not established (189 +/- 122 versus 240 +/- 149 mL, respectively; P = 0.13). All other urodynamic characteristics of IDCs were similar in both methods. In conclusion, better detection rates of IDCs were achieved by instructing the patient to neither try to void nor try to inhibit micturition, but simply report his or her sensations to the examiner, during filling cystometry. If the patient is instructed to inhibit micturition during bladder filling-about 26 % of the IDC cases are misdiagnosed.

The use of prophylactic Stamey bladder neck suspension to prevent post-operative stress urinary incontinence in clinically continent women undergoing genitourinary prolapse repair.

The present study was undertaken to evaluate the efficacy of Stamey bladder neck suspension in preventing post-perative stress urinary incontinence in clinically continent women undergoing surgery for genitourinary prolapse. Thirty clinically continent women with severe genitourinary prolapse were found to have a positive stress test with re-positioning of the prolapse. They all had significant urethrovesical junction hypermobility. In addition to the genitourinary prolapse repair, these patients underwent a prophylactic Stamey procedure to prevent the possible development of post-operative stress urinary incontinence. The mean duration of follow-up was 8+/-4.5 months (range, 3-19 months). Seven (23.30%) patients developed overt post-operative stress urinary incontinence that was confirmed urodynamically. Eleven (36.7%) other patients denied stress incontinence; however, post-operative urodynamics demonstrated sphincteric incontinence. Post-operative complications were uncommon and minor. In conclusion, continent patients with a positive stress test demonstrated on re-positioning of the prolapse during pre-operative urodynamic evaluation are considered to be at high risk of developing post-operative stress urinary incontinence. In these patients, an additional, effective anti-incontinence procedure should be considered during surgical correction of genitourinary prolapse. The Stamey procedure, although simple and safe, does not appear to be the optimal solution to this clinical problem.

Outcome results of transurethral collagen injection for female stress incontinence: assessment by urinary incontinence score.

PURPOSE: We assessed the results of collagen injection for female sphincteric incontinence using strict subjective and objective criteria. MATERIALS AND METHODS: We evaluated 63 consecutive women with sphincteric incontinence who underwent a total of 131 transurethral collagen injections. Sphincteric incontinence was confirmed by urodynamics. All patients were treated with 1 to 5 transurethral collagen injections and treatment outcome was classified according to a new outcome score. Cure was defined as no urinary loss due to urge or stress incontinence documented by a 24-hour diary and pad test, and patient assessment that cure was achieved. Failure was defined as poor objective results and patient assessment that treatment failed. Cases that did not fulfill these cure and failure criteria were considered improved and further classified as a good, fair or poor response. RESULTS: Mean patient age plus or minus standard deviation was 67.7 +/- 12.8 years. All women had a long history of severe stress urinary incontinence, 18 (29%) underwent previous anti-incontinence surgery, and 41% had combined stress and urge incontinence. Preoperatively diary and pad tests revealed a mean of 7.5 +/- 4.6 incontinence episodes and 152 +/- 172 gm. of urine lost per 24 hours. Overall 1 to 5 injections were given in 26, 17, 13, 3 and 4 patients, respectively. Mean interval between injections was 4.4 +/- 5.7 months, mean followup was 12 +/- 9.6 months, and mean interval between the final injection and outcome assessment was 6.4 +/- 4.9 months. There was a statistically significant decrease in the total number of incontinence episodes per 24-hour voiding diary after each injection session. Although there was a clear trend toward decreased urinary loss per 24-hour pad test, statistical significance was not established. Using the strict criteria of our outcome score overall 13% of procedures were classified as cure, 10%, 17% and 42% as good, fair and poor, respectively, and 18% as failure. CONCLUSIONS: As defined by strict subjective and objective criteria, we noted a low short-term cure rate after collagen injection in women with severe sphincteric incontinence. It remains to be determined how patients with less severe incontinence would fare using our outcome assessment instruments.

Bladder outlet obstruction nomogram for women with lower urinary tract symptomatology.

The aim of our study was to construct a bladder outlet obstruction nomogram for women with lower urinary tract symptoms. A urodynamic database of 600 consecutive women was reviewed. Bladder outlet obstruction, utilizing strict diagnostic criteria, was diagnosed in 50 (8.3%) patients. A comparison of patient characteristics, uroflowmetry, and detrusor pressure-uroflow studies was carried out between the obstructed patients (mean age, 64.4 +/- 17.6 years) and 50 age-matched unobstructed controls (mean age, 64.8 +/- 10.7 years). Maximum flow rates were significantly higher in free uroflow studies (free Qmax) than in pressure-flow studies (Qmax), in both obstructed (9.3 +/- 3.7 versus 5.7 +/- 3.6 mL/s, respectively. P = 2. 6 10(-6)) and unobstructed (25.6 +/- 11.2 versus 11.8 +/- 5.9 mL/s, respectively. P = 8.7 10(-12)) patients. Comparison of detrusor pressure at maximum flow (pdet.Qmax) and maximum detrusor pressure during voiding (pdet.max) values did not reveal significant differences, in both obstructed (39.3 +/- 18.4 versus 49.7 +/- 25.5 cm H(2)O, respectively) and unobstructed (16.5 +/- 8.4 versus 20.6 +/- 9.2 cm H(2)O, respectively) patients. Further statistical analysis was carried out to construct bladder outlet obstruction nomogram. The nomogram classifies any pair of values of free Qmax and pdet.max into one of the following four zones: no obstruction, mild obstruction, moderate obstruction, and severe obstruction. Of the 50 obstructed women, 34 (68%) were classified by the nomogram as mildly, 12 (24%) as moderately, and 4 (8%) as severely obstructed. A positive correlation was found between subjective severity of the symptoms (assessed by the AUA Symptom Index score) and the four nomogram zones. In conclusion, the nomogram makes it possible to differentiate between obstructed and unobstructed women and between various degrees of obstruction. We believe the nomogram may also serve as an instrument to assess treatment outcomes.

Is amniotic fluid volume influenced by a 24-hour fast?

OBJECTIVE: To assess the influence of fasting for 24 hours on the amniotic fluid index (AFI). STUDY DESIGN: The AFI of 22 parturients in the second trimester of uncomplicated pregnancy was evaluated on the morning after a 24-hour fast. Patients were prospectively matched to another group of 25 patients who did not fast. Both groups were reevaluated after one week. Two different observers, blind to each other's results, performed the examinations. RESULTS: A statistically significant difference was found in the AFI between the two groups on the day after fasting (11.73 +/- 2.12 versus 15.4 +/- 1.2, respectively; P < .01). After one week there was no difference in AFI between the two groups (15.35 +/- 1.2 and 15.42 +/- 1.2, respectively; P > .01). CONCLUSION: Fasting may reduce the amniotic fluid volume as shown by the AFI, and fluid intake may restore the normal amount of amniotic fluid volume.

Noninvasive outcome measures of urinary incontinence and lower urinary tract symptoms: a multicenter study of micturition diary and pad tests.

PURPOSE: We assessed the test-retest reliability of a 24, 48 and 72-hour micturition diary and pad test in patients referred for the evaluation of urinary incontinence and lower urinary tract symptoms. MATERIALS AND METHODS: We prospectively enrolled 109 patients referred for the evaluation of lower urinary tract symptoms in our multicenter study. Patients were requested to complete a 72-hour micturition diary and pad test, and repeat each test during a 1-week interval. The test-retest reliability of various parameters of the 72-hour micturition diary and pad test was analyzed and compared. Further analysis was done to compare the test-retest reliability of 24, 48 and 72-hour studies performed on the same days after a 1-week interval. Reliability was assessed by Lin's concordance correlation coefficient (CCC) with a cutoff value of 0.7 indicating test-retest reliability. RESULTS: Of the 109 patients 106 (97%) with a median age of 64 years completed the study. The number of pads and total weight gain appeared to be reliable measures of the 24, 48 and 72-hour pad tests. For the 24-hour diary the total number of incontinence episodes was a reliable measure, while the total number of voiding episodes was marginally reliable (mean CCC 0.785 and 0. 689, respectively). For the 48-hour diary the number of incontinence episodes and total number of voiding episodes were reliable measures (mean CCC 0.78 and 0.83, respectively), while for the 72-hour diary each parameter was highly reliable (CCC 0.86 and 0.826, respectively). However, an increased test period was associated with decreased patient compliance. CONCLUSIONS: The 24-hour pad test and micturition diary are reliable instruments for assessing the degree of urinary loss and number of incontinent episodes, respectively. Increasing test duration to 48 and 72 hours increases reliability but is associated with decreased patient compliance.