Effects of pelvic floor muscle training on strength and predictors of response in the treatment of urinary incontinence.

AIMS: The objectives of this study were (1) to determine the effect of training on pelvic floor muscle strength; (2) to determine whether changes in pelvic floor muscle strength correlate with changes in continence; and (3) to determine whether demographic characteristics, clinical incontinence severity indices, or urodynamic measures predict response to pelvic floor muscle training. METHODS: One hundred thirty-four women with urinary incontinence (95=genuine stress incontinence [GSI]; 19=detrusor instability [DI]; 20=mixed incontinence [GSI+DI]) were randomized to pelvic floor muscle training (n=67) or bladder training (n=67). Urinary diaries, urodynamic evaluation, and vaginal pressure measurements by using balloon manometry were performed at baseline and after 12 weeks of therapy. Primary outcome measures consisted of incontinent episodes per week and vaginal pressure measurements. RESULTS: Both treatment groups had a reduction in incontinent episodes (P

Urinary retention and intravesical hemorrhage following urethral collagen injections in women using warfarin.

Two women on warfarin anticoagulation experienced urinary retention following urethral collagen bulk injections. Both women developed implant site hematomas, with urinary retention and intravesical hemorrhage. One woman was supratherapeutic and the other was therapeutic on warfarin therapy. Both women required transfusion and prolonged catheterization.

Postpartum depression: a comparison of screening and routine clinical evaluation.

OBJECTIVE: This study compared the efficacy of routine clinical evaluation with that of screening with the Edinburgh Postnatal Depression Scale for the detection of postpartum depression in a residency training program practice. STUDY DESIGN: Three hundred ninety-one patients during a period of 1 year were assigned according to delivery date to screening for postpartum depression with the Edinburgh Postnatal Depression Scale or to a control group who had only spontaneous detection during routine clinical evaluation. The incidences of postpartum depression detection and demographic characteristics were compared between 79 patients in the Edinburgh Postnatal Depression Scale group and 96 patients in the clinical evaluation group by means of chi(2) analyses. RESULTS: The incidence of postpartum depression detection with the Edinburgh Postnatal Depression Scale was significantly higher than the incidence of spontaneous detection during routine clinical evaluation (35.4% and 6.3%, respectively; P =.001). CONCLUSIONS: The Edinburgh Postnatal Depression Scale is an effective adjunct to clinical interview for diagnosis of postpartum depression and should be considered in residency training.

Understanding lower urinary tract function in women soon after bladder neck surgery. Continence Program for Women Research Group.

The aim of this work was to correlate anatomic and urodynamic measures with function following bladder neck surgery. Eighty-seven women who underwent bladder neck surgery at two tertiary academic medical centers in the southeastern U.S. were studied in this prospective outcomes analysis. Preoperative and 6-week and 6-month postoperative status was assessed with urodynamic testing, physical examination, and condition-specific quality of life instruments. Correlations of dynamic urethral obstruction (quantified by pressure transmission ratio, PTR, determinations) and urethral support (quantified by urethral axis measurements) with functional status were determined. At 6 weeks, 50% of the subjects with inadequate dynamic obstruction (PTR < 90%) had genuine stress incontinence (GSI) compared to 5% of those with PTR >/= 90% (P = .00002). Of those with excessive obstruction (PTR > 110%), 32% had detrusor instability (DI) and 47% had emptying phase dysfunction (EPD) compared to 6% and 24%, respectively, of those with PTR /= 90% but

The clinical evaluation of pelvic floor dysfunction.

Although Baden concluded that "the pelvic exam is just the pelvic exam," the history and examination are tools of no less merit than the cystometrogram or scalpel for clinicians treating patients with symptomatic pelvic floor dysfunction. An effective history and physical examination provide the basis for effective management of the patient's symptoms.

Pressure transmission ratio reproducibility in stress continent and stress incontinent women.

Our objective was to determine the effect of cough strength on pressure transmission ratios and establish quantitative and qualitative intra-observer test-retest reproducibility of pressure transmission ratios calculated from dynamic urethral pressure profilometry. The study included 242 consecutive urodynamic evaluations on women without pelvic organ prolapse. Dynamic urethral pressure profiles were performed in duplicate with coughs of different intensities. The analysis included pressure transmission ratios from the proximal 3 urethral quartiles (Q1 through Q3) and the mean pressure transmission ratio calculated from these quartiles. The final diagnoses were stratified into genuine stress incontinence, 135 (56%), and stress continence, 107 (44%). Correlations were strong for pressure transmission ratios from the first versus the second dynamic urethral pressure profile (K = 0.712 for mean). While the variation in cough intensity between hard and soft coughs averaged 30 cm H2O (P < 0.001), correlation's were equally strong between hard and soft cough pressure transmission ratios (K = 0.712 for mean). When mean pressure transmission ratios were stratified into below 90% and at least 90% categories, 83.5% of subjects had test-retest concordance (K = 0.671). Concordance rates were less for stress continent subjects (80.0%; K = 0.527) than for genuine stress incontinence subjects (86.4%; K = 0.679). Pressure transmission ratios appear to have reasonable quantitative and qualitative reproducibility which is unaffected by cough strength. The degree of individual variability limits the utility of pressure transmission ratios to diagnose genuine stress incontinence independent of other, equally variable clinical and urodynamic parameters, but this measure is sufficiently reproducible to be useful in characterizing stress sphincteric function in population studies.

Relationship between urethral and vaginal pressures during pelvic muscle contraction. The Continence Program for Women Research Group.

Condensation is the performance of an effective pelvic muscle contraction increases urethral and vaginal pressures and is independent of demographic, clinical, and urodynamic factors. Our objective was to examine the relationship between urethral closure pressure and vaginal pressure during a pelvic muscle contraction in minimally trained women. Our secondary aim was to determine whether demographic, clinical, or urodynamic factors predict pelvic muscle contraction performance. Two hundred two women with urinary incontinence underwent multichannel urodynamic evaluation, including urethral profilometry and measurement of vaginal pressure during pelvic muscle contraction. One hundred forty-four women were diagnosed with genuine stress incontinence, 28 with detrusor instability, and 30 with mixed incontinence. Urethral and vaginal pressures correlated significantly during pelvic muscle contraction (P < or = 0.006). The ability to perform an adequate pelvic muscle contraction was independent of subject age, parity, hormonal or hysterectomy status, clinical severity, urethral support, and urethral profilometry measures (P > or = 0.42).

The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery.

OBJECTIVE: Our goal was to evaluate the role of intraoperative cystoscopy during surgery for pelvic organ prolapse and urinary incontinence. STUDY DESIGN: Charts of 224 consecutive patients who had intraoperative cystoscopy performed after urogynecologic surgery were reviewed. RESULTS: Nine injuries occurred that were unsuspected before cystoscopy, for an incidence of 4%. Six ureteral ligations occurred, four after Burch cystourethropexy and two after vaginal culdoplasty. Intravesical sutures were noted after two Burch procedures, and another injury occurred with passage of fascia lata through the bladder during a pubovaginal sling procedure. Eight injuries were managed by removal and replacement of the suture or sling with only one requiring ureteroneocystotomy. When patients with injuries were compared with those without, there were no statistical differences in demographic or surgical parameters. CONCLUSIONS: The potential for damage to the lower urinary tract is significant with complex urogynecologic surgery. Because of the increased and delayed morbidity associated with unrecognized injury, intraoperative surveillance cystoscopy should be considered a part of all such procedures.

Voiding function following prolapse surgery. Impact of estrogen replacement.

OBJECTIVE: To identify factors that would predict postoperative bladder function in postmenopausal women undergoing pelvic reconstructive surgery for pelvic organ prolapse. STUDY DESIGN: Demographic variables and urodynamic measures were analyzed in respect to the length of postoperative bladder catheterization. RESULTS: Patient age, the presence of abnormal preoperative voiding patterns or elevated postvoid residuals, the route of surgical approach and the performance of urethropexy did not correlate significantly with the length of postoperative catheterization; only hormonal status did. Postmenopausal women using estrogen replacement therapy required significantly fewer days of catheterization than those who were not receiving estrogen replacement therapy. CONCLUSION: The use of preoperative estrogen replacement therapy is associated with a reduction in the length of postoperative bladder catheterization in women undergoing pelvic reconstructive surgery for pelvic organ prolapse.

Interobserver and intraobserver reliability of the proposed International Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society pelvic organ prolapse classification system.

OBJECTIVE: Our purpose was to determine the intraobserver and interobserver reliability of site-specific measurements and stages with the proposed international Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society 1994 draft prolapse terminology document. STUDY DESIGN: Women who completed informed consent procedures underwent pelvic examinations by two investigators, each blinded to the results of the other's examination. The reproducibility of the nine site-specific measurements and the summary stage and substage were analyzed with Spearman's correlation coefficient (rs) and Kendel tau B Correlation Coefficient (tau b), respectively. Similar analyses were performed on supine and upright examinations performed at two different times by one examiner. RESULTS: Experienced examiners averaged 2.05 minutes per examination and new examiners averaged 3.73 minutes. In the study of interobserver reliability, 48, subjects, mean age 61 +/- 14 years, parity 3 +/- 2, weight 74 +/- 31 kg, comprised the study population. Correlations for each of the nine measurements were substantial and highly significant (rs 0.817, 0.895, 0.522, 0.767, 0.746, 0.747, 0.913, 0.514, and 0.488, p = 0.0008 to < 0.0001). Staging and substaging were highly reproducible (tau b 0.702 and 0.652). In no subject did the stage vary by more than one; in 69% stages were identical. In the study of intraobserver reliability, for 25 subjects correlations for each of the nine measurements were equally strong (rs 0.780, 0.934, 0.765, 0.759, 0.859, 0.826, 0.812, 0.659, 0.431). Measurements from the upright examinations reflected greater prolapse. Staging and substaging were highly reproducible (tau b 0.712 and 0.712). In no subject did the stage vary by more than one; in 64% stages were identical. All stage discrepancies represented an increase in the upright position. CONCLUSIONS: There is good reproducibility of measures with the proposed system. The data suggest that the reliability is independent of examiner experience. Patient position is likely important in maximizing the severity of the prolapse.

Randomized prospective comparison of needle colposuspension versus endopelvic fascia plication for potential stress incontinence prophylaxis in women undergoing vaginal reconstruction for stage III or IV pelvic organ prolapse. The Continence Program for Women Research Group.

OBJECTIVE: Severe prolapse may mask potential genuine stress urinary incontinence in women. Some have suggested that a suspending urethropexy be performed in women who have potential genuine stress incontinence demonstrated by barrier reduction of the prolapse preoperatively. Our aim was to compare outcomes after prolapse surgery that included a formal bladder neck suspension with those operations that did not. STUDY DESIGN: This prospective randomized clinical trial assigned 32 women with bladder neck hypermobility and stage III or IV pelvic organ prolapse to receive either a needle colposuspension or bladder neck endopelvic fascia plication as part of the vaginal reconstructive surgery. Twenty-nine subjects underwent detailed clinical, anatomic, urodynamic, and quality-of-life evaluations before and 6 weeks and 6 months after surgery; 23 completed urinary diary and quality-of-life evaluations after a mean of 2.9 years. RESULTS: Needle colposuspension increased short-term complications without providing additional protection from de novo stress incontinence. Barrier testing before surgery predicted urethral sphincteric resistance after surgery; however, such testing neither predicted a patient's function after surgery nor indicated the need for a suspending urethropexy. The combination of a needle colposuspension with a sacrospinous ligament suspension predisposed to the early development of support defects of the upper anterior vaginal segment and to failure of bladder neck support. CONCLUSIONS: Preoperative barrier testing in women with severe prolapse is not useful in identifying individuals who require a suspending urethropexy. Needle colposuspension increases short-term complications, lacks durability, and may predispose to early and severe recurrent anterior prolapse when performed with a sacrospinous ligament vault suspension.

The effect of vesical volume on Valsalva leak-point pressures in women with genuine stress urinary incontinence.

OBJECTIVE: To determine the effect of increasing vesical volume on the Valsalva leak-point pressure, examine the relationship between leakage at a given volume and clinical incontinence severity, and evaluate the relationships between leakage at a given volume and other measures of urethral resistance. METHODS: One hundred twenty women with genuine stress urinary incontinence (GSI) underwent serial Valsalva leak-point pressure determinations at vesical volumes of 100, 200, and 300 mL, and at maximum cystometric capacity. Urinary diary data, quantitative pad testing, and passive and dynamic urethral profilometry were also performed. RESULTS: Thirty-three women had leakage starting at a vesical volume of 100 mL, 18 at 200 mL, and 19 at 300 mL, and 17 had leakage only at maximum cystometric capacity. The mean first positive Valsalva leak-point pressures were significantly higher than Valsalva leak-point pressures at maximum capacity in all groups: in women who began to leak at 100 mL, 57 versus 36 cm H2O (P < .001); at 200 mL, 59 versus 45 cm H2O (P < .001); and at 300mL, 61 versus 47 cm H2O (P = .01). Women who had leakage at lower vesical volumes had worse measures of clinical incontinence severity and lower maximum urethral closure pressure less than or equal to 20 cm H2O) and pure intrinsic sphincteric deficiency (low urethral pressure and the lack of urethral hypermobility), but the specificities were 63 and 50%, respectively. CONCLUSIONS: Women with GSI are more likely to leak during Valsalva with increasing vesical volume. Valsalva leak-point pressures decrease significantly with bladder filling. The volume at which leakage occurs correlates inversely with clinical severity and directly with maximum urethral closure pressure. A negative Valsalva leak-point pressure at 300 mL excludes the presence of low urethral pressure and pure intrinsic sphincteric deficiency; however, the specificity and positive predictive value are inadequate for making a clinical diagnosis of either condition.

Bladder compliance in neurologically intact women.

No data currently exist to define normal bladder compliance (C) in women. This study was undertaken to establish normative data for C in neurologically intact women and to determine if detrusor instability (DI) is associated with changes in C. The multichannel urodynamic tracings of 270 patients (195 stable, 75 unstable) were reviewed according to a standard written protocol. Vesical and abdominal pressures (Pves, Pabd) were measured during retrograde filling after a stable baseline was established (< 50 ml) and just prior to cessation of infusion. If a detrusor contraction occurred, measurements were taken during a 5-sec window preceding onset of contraction. The vesical volume used to calculate C was the total bladder volume determined by completely emptying the bladder at the end of cystometry. Compliance was calculated by dividing this volume by the change in detrusor pressure (Pdet). For the purpose of some analyses, infinite C, i.e., no observed rise in Pdet, was arbitrarily assigned a value of 1,000. Overall, 47.6% of women had no increase in Pdet with filling to maximum cystometric capacity (MCC) and had infinite C. Women with instability were significantly less likely to have infinite C than those with stable bladders (32% vs. 53%; P = 0.003). In 75% of women, C was > 130 ml/cm; in 90%, C was > 60 ml/cm; and in 95%, C was > 40 ml/cm. There were significant differences between the distribution of stable and unstable bladders above and below each of these percentile cutoffs. Only 2 women, both of whom had unstable bladders, had C < 20 ml/cm water. Ninety-five percent of neurologically intact women have C > 40 ml/cm, and nearly half have no increase in Pdet during filling to MCC. Patients with DI have significantly less compliant bladders than do those with stable bladders. If C is < 40 ml/cm, a woman is 16 times more likely to have DI. Decreased C may suggest the diagnosis of DI in patients with urge incontinence whose symptoms are not reproduced in the laboratory.

Correlation of urodynamic measures of urethral resistance with clinical measures of incontinence severity in women with pure genuine stress incontinence. The Continence Program for Women Research Group.

OBJECTIVE: Our aim was to correlate multiple measures of urethral resistance with five clinical measures of incontinence severity in women with pure genuine stress incontinence. STUDY DESIGN: Seventy-five women with pure genuine stress incontinence underwent passive and dynamic urethral pressure profilometry and Valsalva leak point pressure determinations. The standardized and validated measures of incontinence severity included (1) the number of incontinent episodes, (2) the number of continence pads used recorded in a prospective 1-week urinary dairy, (3) grams of fluid loss on a pad quantitation test, and (4) two condition-specific quality-of-life scales, the urogenital distress inventory and the incontinence impact questionnaire. The urodynamic and severity measures were compared with Pearson product-moment correlation analysis. RESULTS: There were no significant correlations between dynamic urethral pressure profile pressure transmission ratios and any measure of incontinence severity. Passive urethral pressure profile variables correlated significantly with incontinence episodes and pad use. Valsalva leak point pressures correlated significantly with pad use and quantitation testing. None of the urodynamic measurements was significantly correlated with either of the quality-of-life scales, but our power to demonstrate a correlation was limited. CONCLUSIONS: Both passive urethral pressure profile measures and Valsalva leak point pressures correlate with some severity measures of genuine stress incontinence. Although inefficient pressure transmission during stress is critical to the pathogenesis of genuine stress incontinence, the severity of the pressure transmission defect is not related to clinical severity. Conversely, impairment of intrinsic urethral resistance is not essential to the pathogenesis of genuine stress incontinence, but the degree of sphincteric impairment is related to severity once the condition exists.

Valsalva leak point pressures in women with genuine stress incontinence: reproducibility, effect of catheter caliber, and correlations with other measures of urethral resistance. Continence Program for Women Research Group.

OBJECTIVES: The Valsalva leak point pressure has been promoted as an alternative to urethral pressure profilometry as a measure of urethral resistance in women with genuine stress incontinence. Our aims were to evaluate the reproducibility of the Valsalva leak point pressure, to assess the effect of catheter caliber on the Valsalva leak point pressure, and to compare vesical Valsalva leak point pressure to other measures of urethral resistance. STUDY DESIGN: Sixty consecutive women with genuine stress incontinence underwent duplicate Valsalva leak point pressure determinations by use of 8F and 3F vesical and 8F vaginal catheters. Subjects also underwent a standard resting urethral pressure profilometry, cough leak point pressure determinations, and pressure-flow micturition studies. RESULTS: Leakage was demonstrated on both Valsalva maneuvers in approximately 80% of subjects with both catheters. In subjects who leaked with both strains there was an extremely high correlation between the test-retest Valsalva leak point pressure within both catheters. The intercatheter correlation between the 8F and 3F Valsalva leak point pressures was significant but much weaker than the intracatheter correlations; 8F Valsalva leak point pressures were significantly higher than 3F Valsalva leak point pressures, although there were individual exceptions to this observation. Urethral pressure profilometry measures and micturition opening pressures were poorly correlated with Valsalva leak point pressure. Cough and vaginal Valsalva leak point pressures were significantly correlated with vesical Valsalva leak point pressure, but cough leak point pressures were significantly higher and vaginal Valsalva leak point pressures were significantly lower than the vesical Valsalva leak point pressure. CONCLUSIONS: Valsalva leak point pressure is a simple and reproducible technique for evaluating urethral resistance in women with genuine stress incontinence. However, variations in Valsalva leak point pressure measurement must be precisely described, standardized, and validated before a technique can be advocated for clinical use.

Inhibition of erythrocyte plasma membrane NADH dehydrogenase by nucleotides and uncouplers.

Erythrocyte ghost NADH dehydrogenase is inhibited in a competitive fashion by ATP and ADP whereas other nucleoside di- and triphosphates, cyclic nucleosides, as well as non-phosphorylating ATP analogs are relatively ineffective. In addition, this enzyme, measured with ferricyanide as electron acceptor, is inhibited by uncouplers of oxidative phosphorylation (proton-conducting reagents), the inhibition being competitive in character (i.e., the uncouplers were without influence upon maximum velocity). The effectiveness of the uncouplers was in the order of their hydrophobic character with the presence of the alkyl side chain rendering nonyl-dinitrophenol much more active than 2,6-dinitrophenol itself. Hydrophobic compounds that are not protonophores (e.g., eosin, proflavin or valinomycin) were not inhibitory. Whereas adenine nucleotides probably inhibit NADH oxidation competitively through structural similarity with the substrate, it appears unlikely that uncouplers compete at the NADH site directly. Rather, the apparently-competitive inhibition in the latter case may reflect competition for proton transfer to an acceptor residing in a hydrophobic region of the enzyme complex.