Pelvic muscle activity in nulliparous volunteers.

The aim of this study was to describe normal characteristics of spontaneous and voluntary pelvic muscle function in nulliparous healthy continent women and to assess the reaction of the pelvic floor to stress and fatigue. Ten nulliparous volunteers were recruited. Pelvic muscle strength was evaluated by palpation and perineal ultrasound. Kinesiological EMG and perineal ultrasound were performed to test for possible fatigue and to assess bladder neck mobility during coughing with a pre-contraction of the pelvic floor muscles. Bladder neck mobility did not increase after attempts to fatigue the pelvic floor muscles. Bladder neck descent was significantly less when the women were instructed to contract the pelvic floor muscles before coughing. The contraction of the pelvic floor muscles stabilizes the vesical neck in nulliparous women.

Bladder neck mobility in continent nulliparous women.

OBJECTIVE: To evaluate the mobility of the vesical neck during coughing and valsalva in healthy nulliparous volunteers and to test the reliability of the technique applied. DESIGN: Clinical observational study. SETTING: Department of Obstetrics and Gynaecology, Cantonal Hospital Lucerne, Switzerland. POPULATION: Thirty-nine nulliparous volunteers. METHODS: Vesical neck motion was assessed with perineal ultrasound. Intra-abdominal pressure was controlled for with an intrarectal probe. Intra-rater reliability was evaluated. RESULTS: Vesical neck mobility was significantly lower during coughing (8 mm, SD 4 mm) than during valsalva (15 mm, SD 10 mm) (P < 0.005). Between individuals mobility varied from 4 mm to 32 mm during coughing and from 2 mm to 31 mm during valsalva. Test-retest-studies showed a maximum difference between to tests during coughing of 4 mm and during valsalva of 5 mm. CONCLUSION: The bladder neck is mobile in normal continent women and bladder neck mobility is lower during coughing than during Valsalva.

Sonographic evaluation of the bladder neck in continent and stress-incontinent women.

OBJECTIVE: To evaluate a new sonographic method to measure depth and width of proximal urethral dilation during coughing and Valsalva maneuver and to report its use in a group of stress-incontinent and continent women. METHODS: Fifty-eight women were evaluated, 30 with and 28 without stress incontinence proven urodynamically, with a bladder volume of 300 mL and the subjects upright. Urethral pressure profiles at rest were performed with a 10 French microtip pressure catheter. Bladder neck dilation and descent were assessed by perineal ultrasound (5 MHz curved linear array transducer) with the help of ultrasound contrast medium (galactose suspension-Echovist-300), whereas abdominal pressure was assessed with an intrarectal balloon catheter. Statistical analysis used the nonparametric Mann-Whitney test. RESULTS: The depth and diameter of urethral dilation could be measured in all women. During Valsalva, all 30 incontinent women exhibited urethral dilation. One incontinent woman showed dilation only while performing a Valsalva maneuver, not during coughing. In the continent group, 12 women presented dilation during Valsalva and six during coughing. In continent women, dilation was visible only in those who were parous. Nulliparous women did not have dilation during Valsalva or coughing. Bladder neck descent was visible in continent and incontinent women. CONCLUSION: This method permits quantification of depth and diameter of bladder neck dilation, showing that both incontinent and continent women might have bladder neck dilation and that urinary continence can be established at different locations along the urethra in different women. Parity seems to be a main prerequisite for a proximal urethral defect with bladder neck dilation.

The role of the frequency-volume chart in the differential diagnostic of female urinary incontinence.

OBJECTIVE: To investigate the differential diagnostic capacity of the frequency-volume chart in 132 women with urinary incontinence. MATERIAL AND METHOD: For each patient, the readings of two 24-h frequency-volume charts were compared to the urodynamic diagnosis which was used as the gold standard in 73 genuine stress incontinent women, in 23 urge incontinent women, and in 36 women with mixed incontinence. RESULTS: The total voided volume, the mean voided volume, the largest single voided volume, and the smallest single voided volume were statistically differentiating single parameters among the three groups (p<0.05). Applying logistic regression to the two well-defined groups of patients, the one with urge incontinence and the one with genuine stress incontinence, the frequency of micturition during nighttime revealed the best discriminatory power for these conditions. CONCLUSION: This study shows that in the frequency-volume chart micturition during nighttime discriminates best between urge and stress incontinence.

Intraurethral ultrasound correlated with urethral histology.

OBJECTIVE: To examine the anatomic identity of sonographically visible sphincteric structures of the female urethra. METHODS: The urethra, urinary bladder, and vagina were removed from 11 fresh female cadavers and placed in a water bath. Intraurethral ultrasound was performed with a 360 degrees-rotating 7.5-MHz ultrasound probe. Afterward, the specimens were fixed and cross sections were made transverse to the urethral axis at 5-mm intervals. Corresponding ultrasonograms and histologic images were matched and depicted simultaneously side by side. The anatomic identity of sonographically visible structures was determined by histologic examination and thickness of the longitudinal smooth urethral sphincter measured. RESULTS: Structures visible sonographically were the striated and smooth urethral sphincter muscle layers, vagina, and blood vessels with diameters exceeding 0.2 mm. The longitudinal smooth muscle layer appeared as a well-defined internal hypoechoic ring. The outer circular smooth muscle layers and the striated muscle layers were a more irregular and hyperechoic zone. The circular smooth muscle layers and the striated sphincter muscle layers could not always be differentiated easily. With formalin fixation, tissue shrinkage resulted in a smaller thickness of the longitudinal smooth muscle measured on the histologic specimen. CONCLUSION: With intraurethral ultrasound, the longitudinal smooth muscle layer appears as a well-defined and measurable hypoechoic ring. The region of the circular smooth muscle and the striated muscle emerges as a hyperechoic and less definable outer zone.

Examination of voiding in seated women using a remote-controlled ultrasound probe.

BACKGROUND: A remote-controlled steering arm was developed that allows the ultrasound probe to be held on the perineum under ultrasound image guidance with the woman seated on a commercially available bedside commode. TECHNIQUE: The arm's servomechanism monitors contact pressure between the scanning head and the perineum, keeping constant gentle pressure on the perineum so that the transducer follows perineal movement. EXPERIENCE: Twenty patients with urinary incontinence and ten normal volunteers were examined during two voiding episodes, one without perineal ultrasound and one with ultrasound. Ultrasound images and intrarectal pressure measurements were displayed simultaneously on a video monitor. Bladder and urethral visibility and behavior were analyzed during bladder emptying. Of the 30 women, 28 were able to void, with and without the ultrasound probe applied. Two women were not able to urinate under observation either with or without sonography. The bladder base, bladder neck, and upper two-thirds of the urethra were visible throughout voiding in the 28 women able to void. Bladder neck opening could be observed in all of the 28 women. Bladder neck descent during initiation of voiding occurred in 17 women, whereas 11 voided without bladder neck descent. CONCLUSION: The use of this device facilitates ultrasound evaluation of micturition in the physiologic sitting position and allows bladder neck behavior to be seen during bladder emptying.

Ultrasonography of the lower urinary tract.

Ultrasound evaluation in urogynaecology has evolved. Comparison with the old standard, lateral chain urethrocystography, as well as basic investigations of the sonographic technique and standardizations have created a basis for a new imaging standard and for further developments in urogynaecology. The recent progress indicates that sonography holds the key to the future of imaging in urogynaecology.

Exoanal ultrasound of the anal sphincter: normal anatomy and sphincter defects.

OBJECTIVE: To describe the sonographic appearance of normal anal sphincter anatomy and sphincter defects evaluated with a conventional 5 MHz convex transducer placed on the perineum. DESIGN: Prospective, single-blind study. SETTING: Department of Obstetrics and Gynecology, University of Michigan Medical Center, USA. POPULATION: Twenty-five women with symptoms of faecal incontinence, 11 asymptomatic nulliparous women, and 32 asymptomatic parous women. METHODS: A convex scanner was placed on the perineum with the woman in lithotomy position. Images were taken at three levels of the sphincter canal. Pictures were evaluated by two examiners who were blinded to the case history of the women and to the results of each other for the presence or absence of sphincter defects. MAIN OUTCOME MEASURES: Description of anal sphincter appearance on endoanal ultrasound. Reproducibility of the evaluation of sphincter defects. RESULTS: The internal anal sphincter is visible as a hypoechoic circle; the external anal sphincter shows a hyperechoic pattern. Proximally the sling of the puborectalis muscle is visible. Sphincter defects were detected in 20 women. In all five women who subsequently underwent surgery, the presence and location of the defect was confirmed at the time of surgery. Examiners were in agreement 100% of the time on the presence or absence of internal defects. They disagreed in one patient on the presence of an external defect. CONCLUSION: Exoanal ultrasound provides information on normal anatomy and on defects of the anal sphincter.

Levator ani function before and after childbirth.

OBJECTIVE: To evaluate pelvic floor muscle strength before and after vaginal birth. DESIGN: Prospective repeated measures study. SETTING: Main district hospital. POPULATION: Fifty-five women: 25 primiparae and 20 multiparae following vaginal birth, and 10 women following elective caesarean delivery as a control group. METHODS: Pelvic muscle strength was evaluated by palpation, perineometry and perineal ultrasound before childbirth in the 36th to 42nd week of pregnancy, three to eight days postpartum and six to ten weeks postpartum. MAIN OUTCOME MEASURES: Pelvic floor muscle strength on palpation, intravaginal squeeze pressure and vesical neck elevation during squeeze. RESULTS: Pelvic floor muscle strength is significantly reduced three to eight days postpartum in women following vaginal birth but not in women after caesarean delivery. Six to ten weeks later palpation and vesical neck elevation on perineal ultrasound do not show any significant differences to antepartum values, while intravaginal pressure on perineometry remains significantly lower in primiparae, but not in multiparae. CONCLUSIONS: Pelvic floor muscle strength is impaired shortly after vaginal birth, but for most women returns within two months.

Can simultaneous perineal sonography and urethrocystometry help explain urethral pressure variations?

OBJECTIVE: To correlate urodynamic with perineal sonographic findings in pressure variations. PATIENTS AND METHODS: In 15 women presenting with urethral pressure variations a urodynamic evaluation with water filling cystometry, urethral pressure at rest and during coughing and uroflowmetry were performed. During water filling cystometry, there were simultaneous perineal video-sonography and urethrocystometry. Video ultrasound images and urodynamic curves were simultaneously monitored on a computer screen. RESULTS: Simultaneous ultrasound and urodynamic evaluation in the 15 patients revealed movements in two areas leading to urethral pressure variations: activity of the pelvic floor muscles and of the urethral sphincter muscles. For the pelvic floor, we found either slow or fast contractions with, respectively, slow (15-30 cm H2O for 3-10 sec) or fast (30-130 cm H2O for 1-3 sec) urethral pressure changes. Urethral sphincter contractions were always fast, resulting in fast pressure changes of 30-170 cm H2O for 1-3 sec. CONCLUSION: Evaluation of simultaneous perineal sonography and urethrocystometry shows the association of urethral pressure variations and muscle activity. Urethral pressure variations are caused by the activity of urethral sphincter or pelvic floor muscles. With ultrasound the activity of the urethral sphincter muscle can directly be seen whereas pelvic floor muscle activity is indirectly visible. Pelvic floor muscle contractions are either fast or slow, whereas the urethral sphincter muscle contractions are always fast contractions.

Perineal ultrasound: determination of reliable examination procedures.

This is a report on the fundamentals of perineal ultrasound examination for female incontinence. The measurement method described here enabled us to determine the position of the bladder neck, the size of the retrovesical angle beta and the occurrence of funnelling. In four different investigations, each involving at least 30 patients, we investigated the influence of examination position, bladder filling volume and pressure of the ultrasound probe against the perineum on these measurements and analyzed the difference between coughing and the Valsalva maneuver. The results showed that when the patient is standing, the bladder neck is lower than when the patient is supine. We also observed that excessive pressure on the ultrasound probe displaces the bladder neck cranially and can squeeze the urethra. Increasing the bladder filling volume does not affect the measurement values, but funnelling can be seen better with higher bladder volumes. The best overall image quality was obtained at 300 ml. A comparison between coughing and the Valsalva maneuver showed that during coughing, the bladder neck descends less and remains closer to the symphysis than with the Valsalva maneuver.

Usefulness of ultrasound contrast medium in perineal sonography for visualization of bladder neck funneling--first observations.

OBJECTIVES: To assess the efficacy of ultrasound medium when imaging bladder neck anatomy with perineal ultrasound. METHODS: In 10 female patients with urinary stress or stress-urge incontinence, a new echogenic contrast medium (Echovist) was intravesically administered and perineal ultrasound performed. The examination was done with the women in the upright position both without and with ultrasound contrast medium at rest and during pressing, and the pictures of the bladder base, bladder neck, and urethra were compared. RESULTS: With the patient in the upright position, the ultrasound contrast medium enters the urethra during pressing and bladder neck funneling is identified more accurately than without contrast medium. With Echovist, bladder neck funneling was detected in 9 of the 10 cases but without it in only 4 cases. CONCLUSIONS: The use of ultrasound contrast medium results in a better visualization of the bladder neck anatomy. Bladder neck funneling and urinary leakage are seen more distinctly, and this improves the diagnostic reliability in female urinary stress incontinence. This pilot study supports the necessity for further investigations in the use of ultrasound contrast medium as a diagnostic improvement of perineal ultrasound.

[The VIVA urethral plug: a sensible expansion of the spectrum for conservative therapy of urinary stress incontinence?]. / Der VIVA-Urethrastöpsel: Eine sinnvolle Erweiterung des Spektrums zur konservativen Therapie der Stressharninkontinenz?

OBJECTIVE: To evaluate applicability, acceptance, side effects and complications and the possible curative effect on female stress urinary incontinence of the treatment with the urethral plug VIVA (Braun Melsungen, Germany). DESIGN: Part I: Prospective clinical study. Part II: Ongoing prospective-longitudinal study. Additionally two case reports. SUBJECTS: Part II: 156 consecutive patients of the urodynamic out patient clinic. Part II: 21 patients with urinary stress incontinence (SUI). MAIN OUTCOME MEASURES: Part I: Ability to hold the plug while walking and standing, acceptance rate of plug therapy. Part II: Subjective improvement of SUI, pad-weighing test, cough test, urinary tract infections, other complications during four months of plug treatment. RESULTS: Part I: 62% of 156 patients were able to hold the plug. 40% of 53 patients with SUI accepted the plug treatment. Part II: 14 patients completed the study. 4 pat. were subjectively and objectively cured, 3 were improved, 7 unchanged. The cured patients all had a low grade SUI with a urine loss of 3 g in the pad-weighing test before treatment. 12/21 pat, showed 1-2 urinary tract infections and 1 patient dropped out from the study because of recurrent urinary tract infections. In one patient a plug migrated into the bladder and was removed cystoscopically. In two case reports the possibility of symptomatic plug treatment for patients with severe stress incontinence after surgical and radiological treatment of cervical cancer is demonstrated. CONCLUSIONS: Plug treatment is a broadening of the spectrum of conservative treatment of SUI as a symptomatic treatment in pat. with contraindications to anti-incontinence surgery and as a curative treatment in low grade SUI.

Single-use versus reusable laparoscopic surgical instruments: a comparative cost analysis.

OBJECTIVE: Our purpose was to determine and compare the total annual costs for reusable and single-use laparoscopic instruments. STUDY DESIGN: Records were kept over a 12-month period of all laparoscopic operations (performed only with reusable instrumentation), the surgical instruments used, depreciation costs, and all associated expenses (repairs, maintenance, replacements, cleaning, sterilization, wages). The total cost was then calculated and compared with the total cost (purchase price plus disposal fees) that single-use instruments would have caused for the same operations. RESULTS: The total cost for single-use instruments would have been more than seven times that for reusable instruments. CONCLUSION: We have decided to continue using reusable instruments for most of our laparoscopic operations. However, single-use instruments are used in situations in which they present a definite advantage. A proper balance is thus sought between the importance of cost factors, on the one hand, and the recognition of the need for the best instrument available for certain procedures, on the other.

Improvement of perineal sonographic bladder neck imaging with ultrasound contrast medium.

OBJECTIVE: To assess the efficacy of ultrasound contrast medium when imaging bladder neck anatomy in perineal ultrasound. METHODS: In 39 women with clinically and urodynamically proven urinary stress or stress-urge incontinence, a new echogenic contrast medium (Echovist) was administered transurethrally and perineal ultrasound was performed. Women were examined in the upright position both without and with ultrasound contrast medium at rest and during Valsalva maneuver, and the pictures of the bladder base, bladder neck, and urethra were compared. RESULTS: With the subject in the upright position, the contrast medium lay at the lowest point of the bladder and resulted in a reverse picture of the bladder base and bladder neck and clear visualization of these structures. In women with urinary stress incontinence, the ultrasound contrast medium entered the urethra during Valsalva, and bladder neck funneling was identified more accurately than without contrast medium. With Echovist, bladder neck funneling was detected in 38 of the 39 cases, compared with only 19 when it was not used. Furthermore, when the bladder neck, urethra, or bladder base were not visible with plain perineal ultrasound, they were seen when ultrasound contrast medium was used. The contrast agent was well tolerated, and there were no adverse side effects. CONCLUSION: The use of ultrasound contrast medium improves visualization of the bladder neck anatomy. Bladder neck funneling and urinary leakage are seen more distinctly, and this improves the diagnostic reliability in female urinary stress incontinence.

Perineal ultrasound for evaluating the bladder neck in urinary stress incontinence.

OBJECTIVE: To assess the reproducibility of a new method for evaluation of the bladder neck with perineal ultrasound and to compare it with lateral chain urethrocystography. METHODS: In the first phase, two investigators examined 40 patients using perineal ultrasound to assess the reproducibility of a new measurement method for the determination of the bladder neck position. In the second phase, 60 patients were evaluated by perineal ultrasound and lateral chain urethrocystography. RESULTS: With perineal ultrasound, there was good interexaminer agreement for determining bladder neck position, funneling, and bladder neck descent at rest and during the Valsalva maneuver, but not for the posterior angle beta during straining. Comparison of sonographic and x-ray assessments showed good agreement for the bladder neck position at rest, but not during Valsalva, whereas the posterior angle, funneling, and bladder base descent differed between the two techniques at rest as well as during Valsalva. CONCLUSION: With our new method for determining the position of the bladder neck, perineal ultrasound is a reliable technique that allows reproducible static and dynamic evaluation. Lateral chain urethrocystography is superior to perineal ultrasound only if bladder neck funneling is the aim of the evaluation; it is inferior if bladder neck mobility during maximal Valsalva is being investigated.

In vitro chemosensitivity of paclitaxel and other chemotherapeutic agents in malignant gestational trophoblastic neoplasms.

This is the first report on the ATP cell viability assay as a chemosensitivity test system for gestational trophoblastic neoplasms (GTN). We obtained chemosensitivity profiles in two established trophoblastic cell lines and four fresh tumors. Ten drugs were tested in vitro in the two cell lines JAR and JEG-3. The IC50 values of the 10 chemotherapeutic agents tested were very similar for both cell lines. The three most active drugs in these cell lines were VP-16, paclitaxel and vincristine. This is the first report on the activity of paclitaxel in trophoblastic cell lines. We furthermore evaluated this assay for chemosensitivity testing in four fresh malignant GTN tumors: one placental site trophoblastic tumor, one chorocarcinoma and two invasive moles. The placental site trophoblastic tumor specimen revealed to be rather chemoresistant in vitro whereas the other three tumors were chemosensitive. From our cell line data we conclude that the ATP cell viability assay is a practicable assay for chemosensitivity testing of GTN cell lines and gives repeatable results. However, the value of this assay for fresh GTN chemosensitivity testing needs to be defined.

Assessment of effect of photosensitizers on cytotoxicity of photodynamic therapy in human breast cancer cell cultures.

BACKGROUND: Photodynamic therapy (PDT) might be of clinical value for patients with breast cancer with local recurrences or metastasis. However, there is a need for improved photosensitizers that are effective in combination with laser light and have few, if any, side-effects. We evaluated in vitro the effectiveness of a second generation photosensitizer by testing the influence of laser light on cell cultures of a human breast carcinoma cell line, incubated with meta-tetrahydroxyphenylchlorin (m-THPC) (= Temoporfin). EXPERIMENTAL DESIGN: Five thousand MCF-7 cells were plated in 96-well plates. Forty-eight hours before laser treatment, the cells were plated to achieve a monolayer configuration. Twenty-four hours after plating, they were incubated with m-THPC. On day 6 after treatment with m-THPC we lysed the cells to extract the intracellular ATP that correlates with the number of living cells. The ATP-CVA was used to assess the cytotoxicity of the tested photosensitizer m-THPC at various concentrations and the relevant laser light alone prior to their combination after six days of culture. RESULTS: We found a dose-response for m-THPC alone ranging from 2 to 16 micrograms/ml. The calculated inhibition concentration to produce 50% cell kill (IC50) was 4.55 micrograms/ml. We also observed a very low cytotoxicity for laser irradiation alone but a very strong cell kill for the combination of m-THPC together with laser light. CONCLUSIONS: PDT gave almost total cell kill at m-THPC concentrations that are not toxic in vitro.