Pharmacologic management of urinary incontinence in the female.

Pharmacotherapy combined with behavioral therapy is often used for the initial therapy of urinary incontinence (UI) in the female. Although there are multiple central and peripheral sites and mechanisms that can potentially influence bladder and urethral function, the pharmacological manipulation of only a select few are clinically useful. The problems are: 1) how to affect bladder function without interfering with the function of other organ systems (uroselectivity); and, 2) how to eliminate UI without disturbing normal micturition. Multiple categories of drug therapies are potentially useful to treat UI. It is clear that the ideal agent for this indication has not yet been identified. Although significant improvement can be seen with several different agents for the treatment of various types of incontinence, complete cure is rarely seen with pharmacological therapy of UI. However, several new pharmacologic treatments including some with novel approaches to drug delivery and/or mechanisms of action have emerged in clinical development over the last few years. In initial studies, some of the agents appear to compare favorably to existing therapies. Whether these promising results will hold up when subjected to large scale, well controlled clinical trials is unclear.

Posterior vaginal wall prolapse: transvaginal repair of pelvic floor relaxation, rectocele, and perineal laxity.

PURPOSE: Posterior vaginal wall laxity is one manifestation of pelvic organ prolapse in the female. Recognition and repair of the inherent anatomical defects present in this condition are essential in order to ensure a satisfactory surgical result. METHODS AND MATERIALS: A successful operation for posterior vaginal wall prolapse will often involve repair of three discreet abnormalities in support of the posterior vaginal wall, including the pelvic floor, posterior vaginal wall fascia, and perineal musculature. An overaggressive repair is to be assiduously avoided as this can lead to excessive narrowing of the vaginal canal and considerable postoperative symptoms including dyspareunia. RESULTS: Durable restoration of anatomical support can be achieved in >80% of cases. Functional results in symptomatic patients undergoing posterior vaginal wall prolapse repair do not appear to be as successful in some areas. CONCLUSIONS: Successful surgical repair of posterior vaginal wall prolapse requires a thorough understanding of the anatomy and pathophysiology involved in this condition. A careful anatomical dissection and reconstruction will result in successful anatomical repair in the majority of patients with minimal morbidity.

Simultaneous upper and lower urinary tract obstruction associated with severe genital prolapse: diagnosis and evaluation with magnetic resonance imaging.

Genital prolapse causing both urethral and ureteral obstruction is an infrequent occurrence, especially in the absence of uterine prolapse. We report on a patient with massive genital prolapse causing both urethral and ureteral obstruction in whom magnetic resonance imaging demonstrated the level of obstructive uropathy and, after surgical repair of the prolapse, confirmed restoration of the normal pelvic and upper urinary tract anatomy.

Endoluminal magnetic resonance imaging in the evaluation of urethral diverticula in women.

OBJECTIVES: Accurate determination of the size and extent of urethral diverticula can be important in planning operative reconstruction and repair. Voiding cystourethrography (VCUG) is currently the most commonly used study in the preoperative evaluation of urethral diverticula. We reviewed our experience with the use of endoluminal (endorectal or endovaginal) magnetic resonance imaging (eMRI) in these patients as an adjunctive study to VCUG to evaluate whether the MRI provided anatomically important information that was not apparent on VCUG. METHODS: A retrospective analysis of all patients with a clinical diagnosis of urethral diverticula undergoing MRI at a single institution was performed. Patients were evaluated with history, physical examination, cystoscopy, VCUG, and eMRI. Endoluminal MRI was retrospectively compared to VCUG with respect to size, extent, and location found at operative exploration. RESULTS: Twenty-seven consecutive patients underwent endorectal or endovaginal coil MRI in the evaluation of suspected urethral diverticula. Twenty patients subsequently had attempted transvaginal operative repair of the diverticulum. In 2 patients, eMRI demonstrated a urethral diverticulum, whereas VCUG did not. Operative exploration in these patients revealed a urethral diverticulum. In 14 of 27 patients, the VCUG underestimated the size and complexity of the urethral diverticulum as compared to eMRI and operative exploration. In 13 of 27 patients, the size, location, and extent of the urethral diverticulum on VCUG correlated well with the eMRI and/or operative findings. CONCLUSIONS: We have found endorectal and endovaginal coil MRI to be extremely accurate in determining the size and extent of urethral diverticula as compared to VCUG. This information can be critical when planning the approach, dissection, and reconstruction of these sometimes complex cases.

Significance of hematuria in patients with interstitial cystitis: review of radiographic and endoscopic findings.

OBJECTIVES: Hematuria may be found in up to 30% of patients with interstitial cystitis (IC). However, few studies have described its etiology based on the findings of a complete evaluation. We reviewed the clinical significance of hematuria in the setting of IC. METHODS: We retrospectively reviewed the records of 148 patients fulfilling the National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases inclusion criteria for IC. Patients with gross or microscopic hematuria were identified. Evaluation consisted of urine culture and cytology, cystoscopy, and intravenous urography (or retrograde pyelography plus renal ultrasound). Patients with urinary tract infections were excluded. RESULTS: Of 148 patients, 60 (41%) were found to have had at least one episode of hematuria during a mean follow-up of 18 months. Of 56 patients who agreed to be evaluated, 8 (14%) had positive urologic findings. Of these, none were highly significant; five were simple renal cysts (8.9%), one was a renal stone (1.8%), one was reflux nephropathy (1.8%), and one was medullary sponge kidney (1.8%). Cystoscopy, cytology, and bladder biopsy did not demonstrate malignancy in any patient. No statistically significant differences were found in age (49.9 versus 46.7 years), sex (90% versus 91% female), bladder capacity (792 versus 808 mL), and the presence of Hunner's ulcers (5% versus 2.4%), glomerulations (60% versus 59.9%), or detrusor mastocytosis (55% versus 47.6%) between patients with hematuria and those without (P >0.05). CONCLUSIONS: The incidence of hematuria in patients with IC may be higher than previously reported. Nevertheless, although many of these patients present with pelvic pain and irritative voiding symptoms, the hematuria evaluation is unlikely to reveal a life-threatening urologic condition.

Injected periurethral collagen for postprostatectomy urinary incontinence: MR and CT appearance.

BACKGROUND: Urinary incontinence, a disturbing complication of radical prostatectomy, is often treated with periurethral collagen injections to increase urethral closure and resistance to urinary outflow. METHODS: Using magnetic resonance imaging and computed tomography, we studied the appearance of glutaraldehyde cross-lined bovine collagen endoscopically injected into the periurethral tissues in four men who developed urinary incontinence after radical prostatectomy. Collagen was also scanned in vitro to verify its magnetic resonance appearance. RESULTS: Collagen deposits appear as well-circumscribed nodules of low to intermediate signal intensity on both T1- and T2-weighted images in the periurethral tissues or in the base of the subjacent penile bulb (base of corpus spongiosum). On contrast-enhanced computed tomography, collagen appears as a hypoattenuating nodular-filling defect within the penile bulb. CONCLUSION: These imaging characteristics should allow differentiation of collagen from locally recurrent prostate carcinoma and avoid inappropriate work-up of benign findings.

Erectile function and quality of life after interstitial radiation therapy for prostate cancer.

Few studies have evaluated erectile function after interstitial radiation therapy for localized prostate cancer. Using a validated quality of life questionnaire, we assessed post-treatment erectile function and its relationship to treatment satisfaction and quality of life. We retrospectively reviewed the records of 171 consecutive patients who underwent Pd-103 or I-125 brachytherapy for prostate cancer between December 1992 and June 1998. Seventy percent of patients received neoadjuvant androgen deprivation therapy. All patients were mailed a validated questionnaire assessing sexual function and overall quality of life (UCLA Prostate Cancer Index and SF-36). Sixty-seven percent of all questionnaires were available for evaluation (114/171). The mean age was 69.1 y with a mean follow-up of 23 months (range 4-72, median 24). Seventy-one percent of patients (81/114) had pre-treatment erections sufficient for sustained vaginal penetration. Of these patients, potency was maintained in 49% of men (40/81). An additional 26% had erections firm enough for foreplay but not penetration (21/81). Erectile dysfunction rates were significantly lower in younger patients (48%) vs older patients (55%). There was no difference in post-treatment potency between men who received neoadjuvant hormonal therapy and those who did not (P>0.05). In addition, there were no differences in physical function (86, scale 0-100), general health perception (78), emotional well-being (83), energy/fatigue (74), and overall satisfaction (84) between men with erectile dysfunction and those without. In summary, two years following brachytherapy 25% of patients complained of complete (20/81) or partial (26%, 21/81) erectile dysfunction, for an overall rate of 51% (41/81). Short-term neoadjuvant hormonal therapy (<3-6 months) did not increase the likelihood of post-treatment erectile dysfunction. Interestingly, overall satisfaction rates among brachytherapy patients were high (84/100) and surprisingly did not correlate with post-treatment sexual function.

Treatment of urinary incontinence.

The treatment of urinary incontinence is a dynamic and evolving field. New therapies, techniques, and procedures, as well as some subtle refinements in treatments currently used, offer hope for the millions of people suffering from this condition. Recent attention has been directed toward reevaluating the efficacy and durability of some standard treatments for stress urinary incontinence, including pelvic floor exercise, bladder neck suspensions, and pubovaginal slings. Occlusive or supportive devices have evolved into a suitable alternative in some patients. Extracorporeal magnetic therapy and alternative periurethral injectable agents may offer additional treatment strategies for the relief of symptomatic stress urinary incontinence. New drugs for the treatment of overactive bladder and urge urinary incontinence have been introduced recently and, in combination with neuromodulation, offer the first new treatments for this condition in over 25 years. Yet, as rapidly as new therapies become available for the treatment of urinary incontinence, problems have become evident with some that were introduced just a short time ago. Thus, cautious skepticism regarding these "new and improved" treatments should be maintained until long-term data become available with respect to safety, efficacy, and durability.

Pelvic organ prolapse: a review.

Pelvic organ prolapse is a common medical problem in parous women. This condition usually refers to a combination of deficiencies of the pelvic organs as they relate to support mechanisms of the vaginal wall. Symptoms vary--an accurate diagnosis requires a careful and complete physical examination with attention directed toward the pelvis and perineum. Although many patients will not require surgical treatment for pelvic organ prolapse, a comprehensive approach to repair in which all of the anatomic defects affecting support are addressed is necessary for successful treatment. Patients presenting with pelvic organ prolapse often provide some of the most complex, challenging, and rewarding cases in reconstructive pelvic surgery. This article addresses the definitions and classifications, prevalence and risk factors, and anatomy and pathophysiology relevant to pelvic organ prolapse. Discussion also includes diagnosis and approaches to management (surgical and nonsurgical) of anterior vaginal wall prolapse, cystourethrocele, apical vaginal prolapse, uterine prolapse and enterocele, posterior vaginal wall prolapse, rectocele, and pelvic floor relaxation and perineal laxity, with indications for and approaches to surgery, along with possible complications.

Ventral hernia of the urinary bladder with mixed urinary incontinence: treatment with herniorrhaphy and allograft fascial sling.

Abdominal hernias are not rare in women with urinary incontinence, but incisional bladder hernia is uncommon. The presenting symptoms in the rare cases reported included suprapubic discomfort, irritative voiding symptoms, and urinary incontinence. We present a patient with bladder herniation and severe mixed urinary incontinence. The pathophysiology of the urinary symptoms and the surgical alternatives for the correction of this condition are discussed.

Angiomyolipoma of the renal sinus: diagnosis by percutaneous biopsy.

We report a case of angiomyolipoma of the renal sinus discovered incidentally during an evaluation for microscopic hematuria. Diagnosis was confirmed by percutaneous aspiration biopsy performed with magnetic resonance imaging control allowing differentiation of this entity from other fatty tumors of the renal sinus including liposarcoma, lipoma, and sinus lipomatosis.

Artificial urinary sphincter for post-prostatectomy incontinence: impact of prior collagen injection on cost and clinical outcome.

PURPOSE: We retrospectively reviewed our experience with the artificial urinary sphincter in men with post-prostatectomy incontinence to determine the impact of prior collagen injection therapy on surgical outcome and overall cost of treatment. MATERIALS AND METHODS: The records and preoperative urodynamic studies of 30 men with post-prostatectomy incontinence who underwent artificial urinary sphincter placement were reviewed. Of these patients 23 (76.6%) had undergone prior collagen injection (collagen group) and 7 had not (noncollagen group). Preoperative and postoperative severity of incontinence was assessed with the American Urological Association quality of life index (scale 0 to 6) and number of pads used daily. Using a Valsalva leak point pressure of less than 60 cm. water as a predictor of failure with collagen injection, we calculated the potential savings had these patients foregone collagen injection and chosen artificial urinary sphincter primarily. RESULTS: Of the 30 patients 24 (80%) were incontinent following radical retropubic prostatectomy and 6 (20%) after transurethral resection. Intrinsic sphincter deficiency was the sole etiology of incontinence in most patients (83.3%) and 5 (16.7%) had concomitant detrusor instability. Six patients alternated the use of pads with the use of clamps or a condom catheter to aid in controlling leakage. Mean number of collagen treatment sessions for the injection group was 2.9 (range 1 to 7). There was a significant difference in mean time from prostatectomy to artificial urinary sphincter between the noncollagen (25.3 months) and collagen (35.8 months) groups (p = 0.04). There were no other statistically significant differences between the groups, including mean age (66.2 years, range 45 to 83), mean followup (26.2 months), mean preoperative pads daily (5.8+/-3.4), median preoperative quality of life index (6, range 3 to 6), median preoperative American Urological Association symptom score (13, range 3 to 35) and mean preoperative Valsalva leak point pressure (42.7+/-21.4 cm. water). For all patients in the study the mean postoperative pads daily was 0.8, mean quality of life index 1 and surgical complication rate 13.3%. There were no statistically significant differences between the collagen and noncollagen groups in any of these parameters. Among the collagen group 17 patients (73.9%) had a Valsalva leak point pressure less than 60 cm. water. Considering the mean additional period of incontinence (time between prostatectomy and artificial urinary sphincter) to be 12.9 months and the additional treatment costs (including pads daily and mean number of collagen syringes per patient), the direct costs of treatment for the collagen group were 85.6% higher than those for patients who chose artificial urinary sphincter primarily. CONCLUSIONS: Prior collagen therapy did not adversely influence the surgical complication rate or compromise effectiveness of the artificial urinary sphincter. However, patients with Valsalva leak point pressure less than 60 cm. water have lower rates of success with collagen injection therapy and could benefit from a more successful, timely and cost-effective treatment of incontinence by choosing the artificial urinary sphincter as primary therapy.

The overactive bladder: an overview for primary care health providers.

The overactive bladder, with symptoms of frequency, urgency and urge incontinence, substantially affects the life styles of millions of people throughout the world. The symptoms are associated with significant social, psychological, occupational, domestic, physical, and sexual problems. Despite the considerable impact of the condition on quality of life, sufferers are often reluctant to discuss their problem with family members or health care professionals. This state of affairs is unfortunate, for much can be done to alleviate the symptoms of this distressing condition. It is therefore of utmost importance that medical education about symptoms of the overactive bladder and other related problems be improved, to help health care professionals identify and treat patients who will benefit from therapy. This article reviews current thinking regarding definition, epidemiology, quality of life effects, evaluation and management. Emphasis is placed on knowledge particularly useful in primary care, especially, noninvasive modalities of therapy.

Extraperitoneal laparoscopic urethropexy with Marlex mesh.

OBJECTIVES: Extraperitoneal laparoscopic urethropexy (ELU) has recently been developed as a minimally invasive procedure for the treatment of female stress urinary incontinence (SUI). Use of the laparoscopic stapling device and Marlex mesh in the extraperitoneal space may allow for a technically easier procedure and shorter operative times compared with other laparoscopic techniques without compromising long-term efficacy. We present our initial results and 2.5-year interim analysis with this alternative method of laparoscopic urethropexy. METHODS: Twenty-four consecutive patients with urodynamically demonstrated genuine SUI underwent attempted ELU at a single institution from December 1994 to December 1995. Operative data were collected from the patient chart, and follow-up data were obtained by telephone interview. Treatment was considered successful if, at last follow-up, a patient was using one or fewer pads daily and would recommend the procedure to a friend. RESULTS: ELU was completed in 22 of 24 patients. In 1 patient with a prior history of pelvic surgery, the preperitoneal space was not accessible. Of the 22 patients, 20 were available for follow-up. The mean operative time was 69 minutes. There were no intraoperative complications. At initial follow-up (mean 10.5 months), 18 (90%) of 20 patients reported subjective cure of SUI (one or fewer pads daily). At a mean follow-up of 29 months (range 23 to 34), 16 (80%) of 20 patients had subjective cure of SUI. Six patients would not recommend the procedure to a friend, all of whom had de novo urgency and/or urge incontinence. Thus, using our strict criteria, ELU was successful in 14 (70%) of 20 patients at a mean follow-up of 2.5 years. No patient has had permanent urinary retention. CONCLUSIONS: ELU can be performed rapidly and safely in patients without previous pelvic surgery. De novo urgency incontinence may be problematic. Future analysis of this subset of patients will determine whether this procedure is durable in the long term.

4-Defect repair of grade 4 cystocele.

PURPOSE: The 4-defect repair of grade 4 cystocele corrects discrete and severe deficiencies of vesicourethral support. We describe this technique used during pelvic reconstruction in 130 women. MATERIALS AND METHODS: During a 3-year period 130 patients (age range 35 to 96 years) underwent repair of grade 4 cystocele using the 4-defect repair technique. Cystocele repair had been performed in 60 patients (46%) and hysterectomy had been performed in 85 (65%). A "goalpost incision" is used in the vaginal wall to facilitate separation of the wall from underlying perivesical fascia, entry into the retropubic space, and exposure of the urethropelvic ligament, cardinal ligament and perivesical fascia. The 4 polypropylene sutures are used to provide an anterior vaginal wall sling which is modified to incorporate perivesical fascia and cardinal ligaments. Central defect repair is achieved by approximation of the cardinal ligaments and midline plication of the perivesical fascia over absorbable mesh. RESULTS: A total of 112 patients were available for followup which ranged from 6 to 42 months (mean 21). Repair of grade 4 cystocele was accompanied by other transvaginal repairs in 94 patients (83%), including rectocele repair in 81, hysterectomy in 22 and enterocele repair in 31. Of the patients 92% had excellent objective and subjective results for anatomical cystocele repair. Of the patients with preoperative stress urinary incontinence 90% had excellent or good subjective results. De novo urge incontinence was seen in 7% of patients. CONCLUSIONS: The 4-defect repair technique relies on anatomical restoration of 4 distinct deficiencies of pelvic support and is highly effective for relief of symptoms of grade 4 cystocele.