A comparison of urethral profilometry using microtip and fiberoptic catheters.

This paper compares urethral profilometry measurements using two different types of catheter: the Millar microtip transducer and the FST fiberoptic catheter. Outcome variables were functional urethral length (FUL), maximum urethral closure pressure (MUCP), and mean pressure/transmission ratio (PTR). Thirty women presenting to the urodynamics laboratory with symptoms of stress urinary incontinence were evaluated with both catheters. All subjects underwent two passive urethral pressure profiles and two dynamic (cough) urethral pressure profiles with each catheter. For FUL and MUCP, the means of the two passive measurements were compared between catheters. For PTR, the means of the two dynamic measurements were compared between catheters. There was no difference in FUL between the two catheter types. The FST measurements of MUCP and PTR were lower than the microtip measurements. Twenty percent of patients would have been diagnosed with low-pressure urethra with the FST catheter, but not with the microtip catheter. Caution must be used when applying urethral measurements taken with the fiberoptic catheters to standards set with microtip catheters.

A 25-year experience with 519 anterior colporrhaphy procedures.

A 25-year experience with 519 anterior colporrhaphies was reviewed to assess the results in treating genuine and mixed stress urinary incontinence, the incidence of new urinary incontinence following prolapse surgery, the incidence of new detrusor instability after incontinence and prolapse surgery, and the morbidity associated with anterior colporrhaphy. The cure rate in treating genuine stress incontinence in 194 patients was increased from 75 to 94% when a Kelly-Kennedy-type technique was modified to include a vaginal retropubic urethropexy. The surgical cure in treating mixed incontinence was unsatisfactory (64%) in unselected cases but good (84%) in selected cases. Previous incontinence surgery, especially more than one procedure, significantly reduced the cure rate for genuine stress incontinence. The incidence of new incontinence after prolapse surgery in one subgroup of patients was 11%, indicating the need for measures to minimize this possibility at prolapse surgery. The incidence of new detrusor instability after surgery was 6% (higher after incontinence surgery than after prolapse surgery). The incidence of significant morbidity, excluding incontinence, was minimal (1%) among the 519 anterior colporrhaphies.

Neuropharmacology of the lower urinary tract in women.

One of the most common gynecologic complaints is urinary incontinence, which afflicts approximately one third of the female population. In urodynamic units, approximately 80 per cent of women with urinary incontinence have detrusor hyperreflexia as the sole reason for, or as a component of, their incontinence problem. Approximately 80 to 85 per cent of patients with detrusor hyperreflexia have a functional neuromuscular disturbance of their detrusor muscle. One to 2 per cent of the patients seen in our urodynamic unit have detrusor hyperreflexia caused by a neurogenic bladder. As our clinic's population ages, this type of functional neuromuscular disturbance--neurogenic bladder problem--will increase. The neuromuscular control of the lower urinary tract is complex and not fully understood, explaining why we are unable to treat the functional neuromuscular disturbance in some patients effectively and why we may have to try several drugs before finding one that is effective in other patients. Although patients may have the same symptoms and even the same urodynamic findings, the cause of the functional neuromuscular disturbance may be different. One patient may respond to drug A and not to drug B, and another patient with virtually the same symptoms and urodynamic findings responds to drug B and not to drug A. The main neurologic control of the lower urinary tract is through the sacral outflow of somatic and (mainly) parasympathetic nerve fibers. There appears to be an "on-off" control mechanism involving the urethrovesical unit wherein there is parasympathetic inhibition of the detrusor muscle and parasympathetic stimulation of the urethral smooth muscle and stimulation of somatic nerves to the urethral striated muscle at rest. Reverse action occurs when the patient voids. For this reason, cholinergic and anticholinergic drugs exert a powerful influence on the lower urinary tract. Adrenergic control through alpha 1- (and indirectly alpha 2-) and beta 2-receptors (with a preponderance of alpha-receptors in urethral smooth musculature and a preponderance of beta-receptors in the detrusor muscle) appears to modulate and modify parasympathetic action. This explains why adrenergic stimulant and blocker drugs, in most women, do not affect the lower urinary tract as much as parasympathomimetic-lytic drugs. However, adrenergic effect seems to be greater in some women than in others, explaining, for example, why some patients with detrusor hyperreflexia respond to beta 2-stimulatory drugs and not to anticholinergic drugs. Also inter-twined in the neuromuscular control of the lower urinary tract are the roles of prostaglandins and calcium-potassium channel changes.(ABSTRACT TRUNCATED AT 400 WORDS)

The fascia lata sling procedure for treating recurrent genuine stress incontinence of urine.

The fascia lata sling procedure has been used over the past 22 years in our unit for treating recurrent urinary stress incontinence when irreparably poor local support tissues were suspected. Sixty-nine patients had undergone one previous operation to correct urinary stress incontinence. One hundred one patients had two or more previous operations. The cure rate for the condition of genuine stress incontinence has been 100% in the last 148 cases and 98.2% overall. However, the cure rate for the symptom of urinary stress incontinence was 92.4%. There were only three sling failures in the entire series, occurring in the first 22 cases. Ten other patients had urinary incontinence with stress because of motor urge incontinence. The most troublesome postoperative problem has been delayed voiding.

Intraurethral-intravesical cough-pressure spike differences in 267 patients surgically cured of genuine stress incontinence of urine.

Cough-pressure spike differences between the urethra and bladder were compared before and after surgery that cured genuine stress incontinence in 267 women. In 97.4% of 151 patients cured by a fascia lata sling procedure, the urethralvesical cough-pressure transmission ratio was greater than 100%, and in no case was it less than 100%. In 46.6% of 116 patients cured by anterior colporrhaphy, the cough-pressure transmission ratio was greater than 100%, and in 20.7% of the 116 patients, the transmission ratio was less than 100%. The 24 women in the latter group were cured by a sufficient increase in resting intraurethral pressure (to augment the maximal intraurethral closure pressure with stress) to maintain continence with increased intra-abdominal pressure. We believe that urethral kinking at the instant of increased intra-abdominal pressure with stress produced the greater than 100% cough-pressure transmission ratio seen in 201 (75.3%) of the 267 patients cured of genuine stress incontinence.

Treatment of urinary stress incontinence with anterior colporrhaphy.

The results of treating 105 patients with urinary stress incontinence using anterior colporrhaphy have been reviewed. When polyglycolic suture material and a suprapubic catheter were used, the cure rate was 90.9%, which is comparable to other procedures that are associated with greater morbidity. the problem of comparing the results of one procedure with those of another and results from one center with those of another is discussed. The authors maintain that the surgical objective in treating urinary stress incontinence is to create differentially better support to the urethra, or to a portion of the urethra, so that a mechanical kinking effect can occur synchronously with stress in the urethra to offset pressure increase in the bladder, thereby maintaining urinary continence.

Results in treating 88 cases of recurrent urinary stress incontinence with the Oxford fascia lata sling procedure.

Eighty-eight consecutive fascia lata sling procedures were performed for recurrent urinary stress incontinence. The cure rate was 88.6%. Ten patients were not cured (although six of these were improved) and three failures to cure were sling failures occurring in the first 25 cases. The other seven failures to cure were due to detrusor overactivity. The only significant complication was delayed successful voiding.

Urodynamic studies in female patients with multiple sclerosis.

Patients with multiple sclerosis may have two fundamental, related problems in the lower urinary tract, i.e., urinary retention and/or urinary incontinence. Forty-six patients were assessed by urodynamic testing. Evidence of detrusor overactivity was seen in 40 patients (86.9%), elevated resting urethral pressures in 39 patients (84.8%), a positive bethanechol chloride (Urecholine) stress test in 24 patients (63.2%), and a significant residual urine in 26 patients (56.5%). Data were analyzed in an attempt to explain retention and incontinence in these patients.

Urinary stress incontinence.

The clinical management of urinary stress incontinence requires, firstly, careful evaluation, and then careful individualization of treatment. Much more clinical and basic research is required in order to enhance our better understanding of the causes and treatment of detrusor overactivity.

Experience in treating two hundred and eighty-eight patients with endometrial carcinoma from 1968 to 1972.

The results in treatment of 288 patients with endometrial carcinoma (1968 to 1972) were compared to results achieved in a similar series of 236 patients (1962 to 1967) at The University of Alberta, Edmonton, Alberta, Canada. The overall 5 year survival rate for the 524 patients was 76.1% (75.4% when Stage 0 is excluded), with generally better results in the more recent series except in treating Stage II disease. The overall 5 year survival rate for Stage I disease in the more recent series was 89.1%. Parameters for assessing a prognosis and management plan are indicated, with emphasis on the identification of high-risk Stage I cases.

Results in treating 210 patients with detrusor overactivity incontinence of urine.

Eighty (72.7 per cent) of 110 patients with detrusor overactivity (in controlled and uncontrolled series) showed improvement with parasympatholytic drug (propantheline bromide or dycyclomine HC1) therapy. Twenty per cent of patients on placebo therapy showed improvement. When standard surgery improved bladder neck funnelling, detrusor overactivity was improved in 77.3 per cent of cases. Surgery failed to improve detrusor overactivity in 54.5 per cent of patients who showed no significant bladder neck funnelling. Bladder neck funnelling appears to be a cause of detrusor overactivity in some women. Results with medical and surgical therapy were not associated with significant change in bladder capacity.

Electromyographic and pressure studies in the canine bladder.

The dog is unable to void until funnelling of the bladder neck occurs, even when the bladder is stressed with a large volume and with parasympathomimetic drugs. Nil or very little pressure rise occurs just prior to micturition. Well-coordinated voiding is associated with simultaneous electrical activity in either the upper urethra and bladder neck or these two areas plus the fundus, with predominance of electrical activity (frequency and amplitude) in the bladder neck in both circumstances. In cooordinate electrical activity is seen in bladder fundus, bladder neck, and upper urethra with incoordinate voiding.

Characteristics of responses of isolated human fallopian tube to transmural stimulation and to sympathomimetic amines.

The responses of circular and longitudinal muscle of human fallopian tube to transmural stimulation and sympathomimetic amines have been investigated. It was found that tissues from the earlier part of the menstrual cycle (i.e., estrogen dominant) were less responsive to all stimuli than those from the middle or late phase of the cycle. Although excitatory alpha responses of ampulla and isthmus could be observed, the predominant response of ampulla and isthmus, in all phases of the menstrual cycle, to (--)-noradrenaline and transmural stimulation was inhibition of spontaneous activity. The inhibitory response to transmural stimulation, was abolished by tetrodotoxin and guanethidine. The inhibitory responses to transmural stimulation and (--)-noradrenaline were reversed by propranolol. These findings show that the response of tissues to transmural stimulation resulted from release of noradrenaline from adrenergic nerves, and subsequent action on inhibitory beta adrenergic receptors.

Adrenocortical function studies during the normal menstrual cycle and in women receiving norethindrone with and without mestranol.

PIP: Adrenocortical function was studied in 10 women receiving norethindrone 2 mg plus mestranol 100 mcg ("maxi" pill) and in 10 women receiving norethindrone .35 mg ("mini" pill) over a 9-month period; plasma cortisol levels (8 a.m. and 3 p.m.), 24-hour urinary cortisol levels, and cortisol secretion rates were measured on Days 10 and 24 of the menstrual cycle. Prior to therapy, during a normal menstrual cycle, 18 of 20 showed a significant peak of luteinizing hormone (LH) which was considered presumptive evidence of ovulation. The 9th cylce during therapy showed: 1) no significant difference between plasma and urinary cortisol on Days 10 and 24, 2) a significant increase in plasma cortisol concentrations at 8 a.m. and 3 p.m. on Days 10 and 24 with the maxi pill in comparison to pretreatment levels, 3) a significant decrease in plasma cortisol at 3 p.m. on Day 10 with the mini pill but no change at other times, 4)a significant decrease in cortisol secretion rate on Day 24 with the maxi pill but no change with the mini pill, and 5) a significant decrease in urinary cortisol levels with the maxi pill on Days 10 and 24 and with the mini pill on Day 10. The mini pill results suggest that progesterone may be responsible for depression of adrenocortical acitivity during the luteal phase. Rise in plasma cortisol concentration probably occurred because of a corresponding rise in corticosteroid-binding globulin concentration induced by the estrogen. Progesterone is likely responsible for halting cortisol production and/or release.^ieng