Incontinent women have altered pelvic floor muscle contraction patterns.

PURPOSE: Pelvic floor exercises are invaluable for regaining continence but mechanisms are not fully understood. To contribute to the understanding of these mechanisms we investigated the contraction sequence of superficial vs deep pelvic floor muscles in 6 positions in continent and incontinent women. MATERIALS AND METHODS: The onset of contraction of the superficial and deep pelvic floor muscles was recorded by perineal and intravaginal surface electromyography in 32 continent and 50 incontinent women. The agreement between perineal and intravaginal recordings was calculated with the kappa statistic and the percent of agreement. Differences in onset between superficial and deep pelvic floor muscle contractions are reported as the median and IQR. RESULTS: Perineal and intravaginal electromyography recordings used to define the onset of muscle activity showed a high level of agreement. In the continent group the superficial muscles almost always contracted before the deep muscles in all 6 positions. In the incontinent group the reverse sequence was observed in 3 of 6 positions. Higher and less consistent time differences in the onset of contraction of the 2 muscle layers were found in incontinent vs continent women. CONCLUSIONS: Contractions of the superficial and deep pelvic floor muscles can be recorded by intravaginal or perineal electrodes. A consistent contraction sequence can be found in continent women but it is lacking in incontinent women. This might be a possible explanation for incontinence. Including differentiated muscle contraction exercises in pelvic floor muscle exercise programs may further optimize treatment outcomes.

Cadaver fascia lata sling in the treatment of intrinsic sphincter weakness.

Eight older women with stress incontinence caused by intrinsic urethral weakness underwent sling surgery with allogenic fascia lata. The tolerance of the material was excellent. In 1 case a secondary release of the fixation on the pecten was necessary because of too much tension; in the other cases the evolution was uneventful and resulted in perfect continence lasting for at least 2 years of follow-up.

Surgical correction of vesicoureteral reflux: 5-year follow-up with 99Tcm-DMSA scintigraphy.

AIM: To evaluate kidney function before and after surgical correction of vesicoureteral reflux. The long-term effect was measured with quantitative nephro-scintigraphy using 99Tcm labelled dimercaptosuccinic acid (99Tcm-DMSA). METHODS: Forty-five children with a history of urinary tract infections due to vesicoureteral reflux (VUR) were studied. VUR grade was determined with contrast voiding cystourethrography. Planar scintigraphy was performed with 99Tcm-DMSA and uptake measured as a percentage of injected dose. Kidney function was evaluated at baseline and 5 years after corrective surgery. RESULTS: Three months after surgery, persistent mild reflux was found in eight of 76 treated renal units. Kidney uptake at 5-year follow-up was unchanged in the majority of children, indicating preservation of renal function found at baseline. The split renal function showed an excellent correlation (r = 0.99) between baseline and follow-up studies (regression slope 1.01). Percentage uptake had a regression slope of 0.89 significantly different from unity (P<0.05). Empirical kidney-depth correction techniques were compared. The scintigraphic pattern worsened in six kidneys, indicative of increased scarring in a minority of children. CONCLUSION: Planar nephro-scintigraphy with 99Tcm-DMSA was well tolerated in our paediatric population, and appeared appropriate to evaluate kidney function in time. After surgical correction of VUR, the baseline function was maintained in 94% of kidneys.

Extensive surgery on the trigone for complete ureteral duplication does not cause incontinence or voiding problems.

OBJECTIVES: To evaluate whether extensive trigonal surgery for duplicated kidneys is harmful for later bladder and urethral function. METHODS: Of 201 surgically treated children with kidney and ureteral duplication, 145 were followed up for at least 1 year. The mean follow-up was 5 years (range 1 to 15), and all patients were at least 7 years old at the date of their last follow-up visit. Trigone surgery was performed in 105 children; bilateral trigonal surgery in 26, unroofing in 25, and total excision in 5. On all later consultations, the presence of infection, voiding habits, continence pattern, and ultrasound findings for residual urine volume and kidney function were noted. Children with recurrent urinary tract infection or dysfunctional voiding for more than 2 years underwent a urodynamic examination. RESULTS: Nine children, of whom five were boys, had nocturnal enuresis only. Eight patients had day and nighttime wetting. Seven of the 8 patients had recurrent urinary infections; urodynamic evaluation revealed a high compliance (with residual urine) in three of these children and four had detrusor instability. One girl had an irregular bladder neck, with stress incontinence. All reflux, whether surgically or conservatively treated and also three of four occurring de novo, disappeared within 1 year after surgery. In the group without voiding dysfunctions, seven cystitis and five pyelonephritis attacks occurred. CONCLUSIONS: Neither extensive trigonal surgery nor pre-existing trigonal deformation by ureteroceles provokes later bladder dysfunction.

The after-contraction: a true detrusor contraction or a late dyssynergic urethral sphincter contraction?

OBJECTIVE: To evaluate the mechanism and significance of the after-contraction, recorded in bladder pressure by urodynamics, at the end of micturition. PATIENTS AND METHODS: The urodynamic recordings showing an after-contraction of the detrusor in 65 patients of all ages and with a variety of pathologies were re-examined. Special attention was directed to the anal or urethral sphincter needle electromyographic activity and to the monitored urethral pressure, to determine any relationships with the patterns of detrusor pressure. RESULTS: An after-contraction was noted in 61 patients with detrusor instability and in 11 with urethral instability. In 59 patients it was evident that the after-contraction, i.e. a renewed increase in detrusor pressure during the declining contraction, correlated with a sphincter contraction preceding it by a fraction of a second. Similar increases in detrusor pressure were apparent in patients with detrusor-sphincter dyssynergia throughout voiding. In six patients the relationship was less clear mainly because there were artefacts in the curves. CONCLUSION: The after-contraction arises by a sudden stopping of the outflow of urine, provoked by a sphincter contraction. This may occur by involuntary dyssynergia or by an early voluntary interruption of the voiding stream. The 'milk back' of urine from the proximal urethra to the bladder and the inhibited detrusor contraction (if the perineal contraction is prolonged) may cause some postvoid residual urine. It occurs mainly in the presence of detrusor and/or urethral instability.

Urethral instability as an important element of dysfunctional voiding.

PURPOSE: We monitored detrusor and urethral behavior during bladder filling in girls with dysfunctional voiding (incomplete perineal relaxation) to determine the causes of this pathological condition. MATERIALS AND METHODS: In 15 girls without neuropathy but with a staccato voiding pattern in whom symptoms of urinary tract infection and urge incontinence were refractory to treatment we recorded urethral and bladder pressure, and anal sphincter needle electromyography throughout slow bladder filling. RESULTS: Urethral instability was observed in 8 of the 15 girls as urethral pressure decreases with short periods of electromyography silence (6) or as intermittent urethral pressure increases with short perineal spasms (2). Detrusor instability was noted in 12 girls, while bladder pressure was normal in 1 and hypoactive in 2. In 6 cases of an unstable bladder urethral pressure decreases with silent electromyography periods were also noted. In 1 case low basic urethral pressure had short periods of increased pressure with electromyography bursts. In another case high compliance bladder uninhibited sphincter contractions were noted throughout filling. CONCLUSIONS: Dysfunctional voiding is a misleading term since a pathological condition is also present during the bladder filling phase. Frequently observed detrusor and urethral instability may explain the urge sensation during filling and the staccato voiding phase.

A critical view on the value of urodynamics in non-neurogenic incontinence in women.

The requirements for reliable urodynamics are standardized techniques, including uniform pressure sensors, filling rates, position and posture during the investigation, and uniform diuresis. Physiological variations in flow and urethral pressure profile (UPP) (menstrual cycle, intensity of coughing, circadian variations) must be considered. Parameters of the UPP (maximum (closure) urethral pressure, pressure-transmission ratio and leak-point pressure) are useful if interpreted with caution. Uninhibited detrusor contractions are more frequently recorded in ambulatory urodynamics, and range from 'subthreshold' to very strong. No quantification formulae correlate with subjective symptoms or degree of urge (incontinence). Mixed incontinence can make the results of surgery worse, but do not so necessarily. Postoperative dysuria cannot be predicted from urodynamics, as surgical factors are more important. Electromyography is not useful in non-neurogenic female incontinence. For routine nonneurogenic incontinence extensive urodynamic testing can be reduced to one pressure measurement; more complicated cases must be tested by a physician with large practical experience and a theoretical background.

Do posture and straining influence urinary-flow parameters in normal women?

The influence of posture of the pelvis and straining on urinary flow was investigated in 21 normal women, mainly physiotherapists, who were asked to urinate on an uro-flow chair at their usual time and frequency. Subjects were at random instructed to urinate in five different test situations: anteversion, anteversion with straining, retroversion, retroversion with straining, and forward bending without straining. The urinary-flow parameters investigated were volume, peak flow, time to peak, peak-to-end time, total time, and mean flow. The analysis was done by means of analysis of variance but only for micturition volumes >150 mL. The morphology of the urinary-flow curves was examined for the presence of irregularities and increasing (after top) or decreasing (for top) curve tops and after-dribbling. Results demonstrated no significant differences for peak flow, total time, and mean flow in the anteversion, retroversion, and the forward-bending position. This holds for test situations and re-test controls. However, straining increased the peak flow and mean flow rates in all positions and in all women, whereas it reduced the total voiding time. The voided volumes were lowest in anteversion. Irregularities were less frequent in the forward-bending position. It can be concluded that the forward-bending position is the most preferable urinating position to relax the pelvic floor muscles. Neurourol. Urodynam. 19:3-8, 2000.

A review of ninety-two obstructive megaureters in children.

OBJECTIVES: The evolution of clinical presentation, age of surgery and therapeutic approach of obstructive nonrefluxing megaureters (OMU) in children throughout the years has been retrospectively evaluated. METHODS: 78 children with 92 stenotic ureterovesical junctions (UVJ) were reviewed. 66 underwent surgery at a median age of 20 months, after a median of 10.5 months of conservative treatment with prophylactic antibiotics. 21 OMU were diagnosed prenatally, 71 because of symptoms at later age. 15 ureters (12 children) (24% in the prenatal, 14% in the second group) were treated in a conservative way for 2 years with antibiotics. In the prenatal group 33% needed a reimplantation with tailoring and 10% without tailoring while in the other group the figures are reversed: 39% without and 21% with tailoring. 28% in the prenatal group and 17% of the second group were reimplanted at a mean of 15 months after a primary cutaneous ureterostomy. Three of 5 ureteroceles were treated by endoscopic incision; 4 had an immediate nephroureterectomy. The mean follow-up is >70 months. RESULTS: By prenatal diagnosis the number of conservatively treated cases increased from 14 to 24%. Indications for surgery remained unchanged: recurrent infection and poor kidney function. Both approaches resulted in stabilization of pretreatment renal function; nearly half of the DMSA scans showed a R:L difference of >20% at follow-up. Ureterostomy for infected deteriorating kidneys rapidly ameliorated the function and resulted in shrinking of the ureteral diameter making tailoring at reimplantation unnecessary. One of the 3 endoscopically incised ureteroceles required later reintervention. CONCLUSIONS: Male:female (3:1), left:right (2:1) prevalence and high associated urological (30%) and nonurological (19%) pathology is found. Unsatisfactory reliability of tests for obstruction diagnosis and a referral bias explains the larger number of conservatively treated ureters in the prenatal group. Despite prenatal diagnosis, the age for surgery was not altered since the indications remained identical. Most OMU can be treated by a simple or tailored reimplantation of the ureter after resection of the stenotic segment. A temporary ureterostomy in small children with refractory infections restores function and avoids the necessity for tailoring at final reconstruction. One of 3 endoscopically incised ureteroceles needed surgery at a later stage. DMSA shows stable function after reimplantation.

Intravesical application of a stable oxybutynin solution improves therapeutic compliance and acceptance in children with neurogenic bladder dysfunction.

PURPOSE: To improve patient compliance with and acceptance of intravesical oxybutynin therapy for neurogenic bladder dysfunction we developed a stable oxybutynin solution that eliminates the complicated crushing procedure. MATERIALS AND METHODS: From January 1995 to January 1997 we prospectively evaluated 15 children with a mean age of 6.1 years with persistent detrusor hyperactivity or significant side effects on oral oxybutynin therapy who received intravesically 0.2 mg./kg. (maximum 5 mg.) of a stable oxybutynin solution (5 mg./5 ml., pH 5.85) twice daily. RESULTS: The oxybutynin solution remained stable up to 24 months. In 13 of the 15 children therapeutic compliance was excellent. Detrusor hyperactivity decreased and systemic side effects were absent or minimal. After 4 and 24 months mean cystometric bladder capacity plus or minus standard error of mean increased from 114+/-15.2 to 161+/-26.6 and 214+/-21.7 ml. (p <0.01), mean ratio of cystometric-to-expected bladder capacity increased from 0.88+/-0.12 to 1.18+/-0.14 and 1.24+/-0.16 (p <0.01), and end filling bladder pressure decreased from 57.0+/-7.1 to 25.6+/-4.4 and 30.8+/-4.4 cm. water (p <0.01), respectively. CONCLUSIONS: Intravesical instillation of a specially prepared oxybutynin solution is safe and reliable in children with persistent detrusor hyperactivity or side effects on oral oxybutynin therapy. Eliminating the complex crushing preparation of the solution by the child or parent has made this therapy easy to use and acceptable in the long term.

Tethered cord syndrome in occult spinal dysraphism: timing and outcome of surgical release.

OBJECTIVE: To investigate the influence of neurosurgical intervention on the appearance of upper motor neuron (UMN) signs in newborns diagnosed with occult spinal dysraphism and tethered cord (TC) during the first month of life. METHODS: A prospective study (1990 to 1996) of 22 consecutive newborns with occult spinal dysraphism monitored for the appearance of UMN signs. Untethering was performed when neurologic or urodynamic investigation indicated the presence of UMN dysfunction. RESULTS: Of 22 patients, 10 remained free of UMN symptoms during follow-up (mean, 67+/-22 months). Untethering was performed in 12 of 22 patients because of the presence of UMN symptoms. In 7 of these 12 patients, there was a documented asymptomatic period of 13+/-11 months before the onset of UMN symptoms. Untethering at a mean age of 18+/-17 months restored normal neurologic and urinary function in all patients (mean postoperative follow-up, 25+/-16 months). Of the 12 children, 5 presented with UMN signs at birth. In these children, untethering was performed at a mean age of 9+/-5 months. In two of these five patients, UMN symptoms did not resolve after surgery, and ongoing conservative bladder treatment was required (mean follow-up, 37+/-14 months). In none of the 12 operated children did signs of retethering occur. CONCLUSIONS: A significant number (10/22) of children born with occult spinal dysraphism and TC did not develop UMN symptoms during follow-up; neurosurgical correction after the appearance of an UMN sign restored normal neurologic and urinary function in all children; and untethering in children presenting at birth with UMN symptoms resulted in poorer outcome.

Detrusor pressure in ambulatory versus standard urodynamics.

An ambulatory urodynamic examination was performed on 28 non-neurogenic incontinent patients in whom classical cystometry could not confirm objectively the history and clinical diagnosis of urinary incontinence. In 12 of 13 stress-incontinent patients, real leakage could be demonstrated. Of 15 patients with mixed incontinence, bladder instability was found in 8 and urethral instability in 2. Voiding detrusor pressures in ambulatory measurements were approximately 10 cm H2O higher than in classical cystometry, although the voided volumes were lower. Advantages and pitfalls of ambulatory detrusor pressure monitoring are discussed.

Microsurgery for intra-abdominal testicular retention.

OBJECTIVES: In cases of high intra-abdominal retention of the testis a standard technique of cryptorchidy treatment will not be able to bring down the testis into the scrotum. In this study we wanted to evaluate the feasibility and reliability of the technical aspects of testicular autotransplantations in children under the age of 5 years. STUDY DESIGN: A series of 25 microsurgical autotranslantations of testes performed on 17 boys since July 1984 are reviewed. Emphasis was placed on the microvascular transplantation technique, the age of the patient and the long term viability of the autotransplants. An end-to-end microvascular anastomosis between the deep inferior epigastric artery and the testicular artery was performed in an end-to-end way using mattress stitches to accommodate the difference in diameter between the donor and recipient vessels. Also the testicular veins were anastomosed to the deep inferior epigastric veins. RESULTS: Of the 25 transplantations (96%) were successful after a mean follow up of 24 months, the one failure was ascribed arterial thrombosis. CONCLUSION: Our results show a 96% survival of the transplanted testes using the end-to-end vascular anastomosis as described here.

Physiological and pathological urethral pressure variations.

From an analysis of 202 patients and a careful literature analysis we conclude that pathological urethral instability should be differentiated from physiological urethral pressure variations by the following criteria: a pronounced amplitude of at least one third of the maximum urethral pressure variations by the following criteria: a pronounced amplitude of at least one third of the maximum urethral closure pressure (usually > 25 cm H2O), a short duration (1-5 s), a simultaneous inhibition of the electromyographic activity in urethral and (or) anal sphincter, and the occurrence of the phenomena starting at the beginning of bladder filling (100 ml).

Treatment of neurogenic bladder dysfunction in infants and children with neurospinal dysraphism with clean intermittent (self)catheterisation and optimized intravesical oxybutynin hydrochloride therapy.

Clean intermittent (self)catheterisation (CIC) in combination with oral anticholinergic drugs (oxybutynin hydrochloride [OH] is the present standard therapy for neurogenic bladder dysfunction (NBD) with detrusor hyperactivity. However, complete suppression of detrusor contractions and complete urinary continence is not always obtained despite maximal dosage, and the high incidence of severe systemic anticholinergic side-effects often impairs therapeutic compliance, resulting in dose reduction or even discontinuation of therapy. The intravesical administration of OH has been shown recently to be an effective alternative for treating persistent detrusor hyperactivity, and occurrence and severity of systemic side-effects appeared to be significantly decreased. However, available data are limited from a paediatric view. Furthermore, it is our belief that the use of crushed OH tablets with consequent problems of impracticability accounts for the variable long-term patient compliance reported to be the only disadvantage to intravesical OH. Using an optimized drug preparation we demonstrate the superiority of intravesical OH for treatment of NBD in 15 children (range 0.6-13.75 years, mean 6.1) with incomplete detrusor activity suppression and/or intolerable systemic side-effects on oral OH therapy. Since the previous reported problems of impracticability and variable long-term patient compliance can be resolved by optimized drug preparation, we therefore conclude that the era of crushing OH tablets should be over in order to allow the intravesical OH therapy on a long-lasting and large-scale basis.

Results of endoscopic treatment for vesico-ureteric reflux.

The 1.5- to 8-year results of endoscopic injection of polytetrafluoroethylene for reflux are described. We obtained a 70% complete and long-lasting success rate after a single injection. More than the degree of reflux, the configuration of the ostium determines the results. Implications of the product in the later life of the children are discussed.

Cough-induced electrostimulation in incontinence.

A new method for treatment of urinary stress incontinence is described. Through a vaginal plug the pelvic floor muscles receive a series of electric stimulations which are triggered by an increase of abdominal pressure, detected by an inbuilt pressure sensor. In this study the best parameters for the stimuli are determined during three successive coughs, which are the most common course of urine loss.

Bladder pressure and kidney function in children with myelomeningocoele: review article.

Therapy of children with myelomeningocoele should achieve a double goal: on the one hand, obtain continence and, on the other hand, preserve kidney function without complications. The first goal is a social and psychological one, the latter is a vital one.