The female urethral closure mechanism during physical stress.

The closure of the urethra under the condition of stress is the result of a reflex contraction of the urethral rhabdosphincter and pelvic floor muscles. This is likely induced by activity of the abdominal muscles due to a sudden increase in abdominal pressure. This reflex contraction with an increase of urethral pressure occurs a few milliseconds before an increase in intraabdominal pressure. The urethral pressure increase during stress is only possible with fixation of the urethra by the pubourethral ligaments (PUL), facilitating urethral kinking. The highest and most important increase in pressure and resistance occurs in the distal urethra due to this kinking of the urethra.

The Maximal Urethral Pressure at Rest and during Normal Bladder Filling Is Only Determined by the Activity of the Urethral Smooth Musculature in the Female.

The aim of this opinion paper is to determine the entities that define the maximal urethral pressure (MUP) during rest and during bladder filling that is needed to guarantee continence in females. For the development of this opinion, the literature was searched for via the Pubmed database and historic sources. Animal studies indicate that the maximal urethral pressure is determined by the smooth muscle activity in the mid-urethra. Additionally, during increased smooth muscle tone development, the largest sympathetic responses are found in the middle part of the urethra. This could be confirmed in human studies that are unable to find striated EMG activity in this area. Moreover, the external urethral striated sphincter is situated at the distal urethra, which is not the area with the highest pressure. The external urethral sphincter only provides additional urethral pressure in situations of exertion and physical activity. From a physics point of view, the phasic pressure of the external striated sphincter at the distal urethra cannot be added to the tonic pressure generated by the smooth muscle in the mid-urethra. The assertion that mid-urethral pressure is the result of different pressure forces around the urethra, including that of the external striated sphincter, is not supported by basic research evidence combined with physical calculation and should therefore be considered a misconception in the field of functional urology.

Midurethral support is also necessary for reflex closure of the urethra.

BACKGROUND AND OBJECTIVES: The pathophysiology of female stress urinary incontinence (SUI) is far from unraveled. Capturing all aspects of this bothersome condition in one theory remains challenging. The well-known Hammock and Integral theories, both from the early 90's, were successful in explaining a large proportion of the observations made in clinical practice. Nevertheless, some (pre)clinical observations cannot be explained by the current understanding. One of the issues concerns the pressure transmission. Is this process really a passive mechanical action, or is an additional active mechanism responsible for urethral closure? The finding that an increase in urethral pressure sometimes precedes and exceeds the increase in intravesical pressure suggests the latter. This concept has never been incorporated in one of the existing theories describing SUI. This is remarkable as a lot of evidence has been generated in recent years that proves involvement of active components. This review aims to provide an additional theory in which an active reflex closure mechanism of the urethra is incorporated. METHODS: Recent as well as older publications from clinical and animal studies are included to support the hypothesis. RESULTS: The smooth muscles of the urethra, the vascular bed, and the estrogen-influenced urethral mucosa, combined with striated muscle tone, contribute to the intra-urethral pressure. A passive transmission of force to the urethra exists only in the abdominal proximal third of the urethra. In the distal two thirds of the urethra an active closure mechanism is present, dependent on sufficient urethral support in the proper anatomical position. This active closure mechanism is generated by reflex contraction of striated muscles of the urethra and the pelvic floor. CONCLUSION: Continence is a result of passive as well as active urethral closure mechanisms. The most important factor in female continence seems to be the proper functioning of an active reflex urethral closing mechanism.

Para-Urethral Injections with Urolastic® for Treatment of Female Stress Urinary Incontinence: Subjective Improvement and Safety.

INTRODUCTION: Female stress urinary incontinence (SUI) is often treated surgically. Urethral bulking agents are a minimally invasive alternative, especially in patients suffering from intrinsic sphincter deficiency, but often with limited long-term efficacy. Urolastic® is a non-deformable, non-resorbable silicone elastomer that is used as an injectable. Its properties might result in a more durable response after injection. If this durability factor can be combined with a low complication rate, this can become a useful treatment option. We therefore assessed the subjective improvement and safety after treatment with Urolastic®. MATERIALS AND METHODS: In 2 Dutch hospitals, 65 patients were treated with Urolastic®. The subjective improvement was assessed and the medical charts were reviewed for complications that appeared during the follow-up period. The complications were classified using the Clavien-Dindo classification. RESULTS: We found that 76-88% of the patients showed subjective improvement at 12-25 months follow-up. The rate of improvement experienced was 50-70%. The rate of complications classified as Clavien-Dindo >II was 24-33%. The 12 patients with 75-100% subjective improvement after 2 months, showed 85% improvement after a median of 25 months. CONCLUSIONS: With careful patient selection, Urolastic® seems to be a safe, durable and effective treatment option for female SUI.

A randomized, controlled trial comparing an innovative single incision sling with an established transobturator sling to treat female stress urinary incontinence.

PURPOSE: Mid urethral sling procedures have become the surgical treatment of choice for female stress urinary incontinence. Innovative modifications of mid urethral sling procedures were recently introduced with the claim of offering similar efficacy and decreased morbidity. We compared the efficacy and morbidity of an innovative single incision mid urethral tape and an established transobturator procedure. MATERIALS AND METHODS: We performed a prospective, randomized, controlled trial in 6 teaching hospitals in Belgium and The Netherlands between 2007 and 2009. A total of 96 patients received a TVT Secur™ single incision sling and 98 received a TVT™ Obturator System. We collected data on patient characteristics, surgery related parameters, adverse events, clinical followup, Urogenital Distress Inventory and SF-36® scores, validated questionnaires on daily life activities and visual analog scores objectifying pain. Followup was 1 year. RESULTS: One-year followup was available for 75 single incision sling and 85 obturator system cases. Stress urinary incontinence could be objectified in 16.4% of the patients with a single incision sling and in 2.4% with an obturator system (p <0.05). Stress urinary incontinence was subjectively reported by 24% of single incision sling and 8% of obturator system patients (p <0.05). One year after surgery the mean ± SD UDI incontinence domain score in the single incision sling and obturator system groups was 21 ± 24 and 13 ± 21, respectively (p <0.01). Patients with a single incision sling experienced significantly less pain during the first 2 weeks after surgery (p <0.05) and returned significantly earlier to normal daily activity. The OR of re-intervention for stress urinary incontinence 1 year after receiving a single incision sling vs an obturator system was 2.3 (95% CI 1.9-2.7). CONCLUSIONS: The single incision sling procedure is associated with less postoperative pain and a lower objective cure rate than the obturator system procedure.

Stronger evidence for small fiber sensory neuropathy in restless genital syndrome: two case reports in males.

INTRODUCTION: Restless genital syndrome (ReGS) is characterized by unwanted, unpleasant genital sensations, restless legs, and/or overactive bladder, as well as neuropathy of the dorsal nerve of the clitoris. So far, ReGS has only been reported in females. AIM: To report the occurrence of ReGS in two males. METHODS: Two males with unwanted genital sensations presented in our clinic. In-depth interview, routine and hormonal investigations, electro-encephalography, magnetic resonance imaging of brain and pelvis, manual examination of the pubic bone, and sensory testing of genital dermatomes were performed. In both males, conventional transcutaneous electrical nerve stimulation was applied bilaterally at the pudendal dermatome. MAIN OUTCOME MEASURES: Oral report, questionnaire on frequency and intensity of restless genital feelings, restless legs, overactive bladder, and satisfaction with the transcutaneous electrical nerve stimulation (TENS) treatment. RESULTS: ReGS in a 74-year-old male manifested as unpleasant genital sensations of being on the edge of an orgasm with overactive bladder, in the absence of erection and ejaculation. Genital sensory testing elicited bilateral points of static mechanical hyperesthesia in the pudendal dermatome. Manual examination of the dorsal nerve of the penis (DNP) elicited the genital sensations. TENS application resulted in a 90% reduction of genital sensations and complaints of overactive bladder syndrome (OAB). ReGS in a 38-year-old male manifested as unwanted and unpleasant spontaneous ejaculations and complaints of OAB. Genital sensory testing elicited bilateral points of static mechanical hyperesthesia in the pudendal dermatome. Manual examination of the DNP elicited the genital sensations. TENS application had no effect on genital complaints and complaints of OAB. CONCLUSIONS: ReGS is not a typical female disorder as it also affects males. This notion and the finding of typical sensory abnormalities of the genital end branches of the pudendal nerve in males and females--as previously reported--provides strong evidence for Small Fiber Sensory Neuropathy as a common cause of ReGS.

Outcome and complications of retropubic and transobturator midurethral slings translated into surgical therapeutic indices.

OBJECTIVE: We sought to determine and compare surgical therapeutic indices (STIs) of the retropubic tension-free vaginal tape (TVT) and 2 kinds of transobturator tape (TOT), Monarc (American Medical Systems, Minneapolis, MN), and tension-free vaginal tape obturator. STUDY DESIGN: This was a retrospective cohort study. Patients with predominant stress urinary incontinence who underwent retropubic (TVT, n = 257) or TOT (n = 180) procedures were included. STIs for both groups were calculated by dividing cure by complication rate at, respectively, 2 and 12 months. RESULTS: Two months after surgery the STI was significantly higher after TOT whereas 12 months after surgery results of STIs were equal. The explanation is more durable cure rates and declining long-term side effects after TVT procedures. CONCLUSION: Both surgical approaches seem to have their own benefits. Based on the STI, the balance between cure rate and complications is on the short term in favor of TOT but on the long term similar for TOT and retropubic TVT.

When to perform urodynamics before mid-urethral sling surgery for female stress urinary incontinence?

INTRODUCTION AND HYPOTHESIS: Development of a model that can predict in which group of women pre-operative urodynamics can be safely omitted. METHODS: Three hundred and eighty-one uncomplicated women who underwent pre-operative urodynamics were evaluated. A multivariate logistic regression model was developed based on medical history and physical examination predicting a high probability group of women with detrusor overactivity or a low (<20 cm H2O) mean urethral closure pressure and, therefore, are likely to benefit from urodynamics. RESULTS: Women are likely to benefit from pre-operative urodynamics if they (1) are 53 years of age or older or (2) have a history of prior incontinence surgery and are at least 29 years of age or (3) have nocturia complaints and are at least 36 years of age. CONCLUSION: If urogynaecologists omitted pre-operative urodynamics in women in the low probability group, in our population, pre-operative urodynamics would be reduced by 29%.

Restless genital syndrome before and after clitoridectomy for spontaneous orgasms: a case report.

INTRODUCTION: Females despairing of restless genital syndrome (ReGS) may request clitoridectomy for treatment of unwanted genital sensations. Aim. The aim of this study was to report persistence of ReGS despite clitoridectomy. METHODS: Following a clitoridectomy for spontaneous orgasms, a 77-year-old woman was referred to our clinic for persistent unwanted genital sensations and feelings of imminent orgasm. An in-depth interview, routine and hormonal investigations, electroencephalography (EEG) and magnetic resonance imaging (MRI) of the brain and pelvis were performed. The localizations of genital sensations were investigated by manual examination of the ramus inferior of the pubic bone (RIPB) and by sensory testing of the skin of the genital area with a cotton swab. MAIN OUTCOME MEASURES: The main outcome measures included sensitivity of dorsal nerve of the clitoris in RIPB and MRI-pelvis. RESULTS: Genital dysesthesias, paresthesias, intolerance (allodynia) for tight clothes, aggravation of symptoms during sitting, restless legs, and overactive bladder were diagnosed. Laboratory assessments, and EEG and MRI of the brain were in agreement with aging, but all results were within the normal range. MRI of the pelvis disclosed varices of the uterus and of the left ovarian vein, and a visible scar in the region of the clitoris. Sensory testing of the genital area showed various points of static mechanical hyperesthesia at the left dermatome of the pudendal nerve. Manual examination of the RIPB also elicited the genital sensations at the left side of the vagina at about the 3 o'clock position. CONCLUSIONS: This patient fulfilled all clinical criteria of ReGS that is believed to be caused by neuropathy of the left pudendal nerve. Clitoridectomy abolished spontaneous orgasms for a great part but not completely, and it did not diminish the typical dysesthesias, paresthesias, and feelings of imminent orgasms that typically belong to ReGS. Clitoridectomy is no optional treatment of ReGS. There is a need for publications of ReGS in general medical journals.

Perspectives by patients and physicians on outcomes of mid-urethral sling surgery.

INTRODUCTION AND HYPOTHESIS: The aim of this study is to determine patient expectations regarding wanted and unwanted sequels of mid-urethral sling (MUS) procedures and to identify mismatches during the physician-patient information exchange prior to MUS procedures. METHODS: A patient preference study (40 patients) and a questionnaire study with 20 experts as control group were conducted. Seventeen different sequels, defined by an expert team, were evaluated. RESULTS: Both patients and expert physicians ranked cure and improvement of stress urinary incontinence as the most important goals of treatment. De novo urge urinary incontinence, requiring post-operative intermittent self-catheterisation and dyspareunia were considered to be the most important complications by patients. Time to resume work after the operation and dyspareunia were among the highest rated sequels in the patient group compared to re-operation and intra-operative complications in the expert group. CONCLUSIONS: No differences were found in the five most important outcome parameters. In pre-operative counselling and future clinical trials, time to resume work and dyspareunia should be given more consideration by clinicians.

Successful transcutaneous electrical nerve stimulation in two women with restless genital syndrome: the role of adelta- and C-nerve fibers.

INTRODUCTION: Currently, efficacious treatment of restless genital syndrome (ReGS) is not available. AIM: This study aimed to report the results of transcutaneous electrical nerve stimulation (TENS) for ReGS, being a combination of genital dysesthesias, imminent and/or spontaneous orgasms, and/or restless legs, and/or overactive bladder. METHODS: Two women with ReGS were referred to our clinic. In-depth interview, routine and hormonal investigations, electroencephalography, magnetic resonance imaging (MRI) of the brain and pelvis, manual examination of the ramus inferior of the pubic bone, and sensory testing of genital dermatomes were performed. Conventional TENS (frequency: 110 Hz; pulse width: 80 milliseconds) was applied bilaterally at the region of the pudendal dermatome in which immediate reduction of genital sensations occurred. Patients were instructed for self-application of TENS each day for 2 months. MAIN OUTCOME MEASURES: Oral report, questionnaires on frequency of imminent and/or spontaneous orgasms, combined with questions on intensity of restless genital feelings, restless leg syndrome (RLS), overactive bladder syndrome (OAB), and satisfaction with TENS treatment. RESULTS: ReGS in a 56-year-old woman manifested as multiple spontaneous orgasms, RLS, and OAB. TENS applied to the sacral region resulted in immediate reduction of complaints and a 90% reduction of spontaneous orgasms, RLS, and OAB in 2 months. ReGS in a 61-year-old woman manifested as a continuous restless genital feeling, imminent orgasms, and OAB. TENS applied to the pubic bone resulted in a complete disappearance of restlessness in the genital area as well as OAB complaints in 2 months. Both women reported to be very satisfied and did not want to stop TENS treatment. CONCLUSIONS: Conventional TENS treatment is a promising therapy for ReGS, but further controlled research is warranted. Preorgasmic and orgasmic genital sensations in ReGS are transmitted by Adelta and C fibers and are inhibited by Abeta fibers. A neurological hypothesis on the pathophysiology of ReGS encompassing its clinical symptomatology, TENS, and drug treatment is put forward.

New insights into restless genital syndrome: static mechanical hyperesthesia and neuropathy of the nervus dorsalis clitoridis.

INTRODUCTION: Systematic study of dysesthetic and paresthetic regions contributing to persistent genital arousal in women with restless genital syndrome (ReGS) is needed for its clinical management. AIM: To investigate distinct localizations of ReGS. METHODS: Twenty-three women, fulfilling all five criteria of persistent genital arousal disorder were included into the study. In-depth interviews, routine and hormonal investigations, electroencephalographs, and magnetic resonance imaging (MRI) of brain and pelvis were performed in all women. The localizations of genital sensations were investigated by physical examination of the ramus inferior of the pubic bone (RIPB) and by sensory testing of the skin of the genital area with a cotton swab (genital tactile mapping test or GTM test). MAIN OUTCOME MEASURES: Sensitivity of RIPB, GTM test. RESULTS: Of 23 women included in the study, 18(78%), 16(69%), and 12(52%) reported restless legs syndrome, overactive bladder syndrome, and urethra hypersensitivity. Intolerance of tight clothes and underwear (allodynia or hyperpathia) was reported by 19 (83%) women. All women were diagnosed with ReGS. Sitting aggravated ReGS in 20(87%) women. In all women, MRI showed pelvic varices of different degree in the vagina (91%), labia minora and/or majora (35%), and uterus (30%). Finger touch investigation of the dorsal nerve of the clitoris (DNC) along the RIPB provoked ReGS in all women. Sensory testing showed unilateral and bilateral static mechanical Hyperesthesia on various trigger points in the dermatome of the pudendal nerve, particularly in the part innervated by DNC, including pelvic bone. In three women, sensory testing induced an uninhibited orgasm during physical examination. CONCLUSIONS: ReGS is highly associated with pelvic varices and with sensory neuropathy of the pudendal nerve and DNC, whose symptoms are suggestive for small fiber neuropathy (SFN). Physical examination for static mechanical Hyperesthesia is a diagnostic test for ReGS and is recommended for all individuals with complaints of persistent restless genital arousal in absence of sexual desire.

Risk factors for failure of retropubic and transobturator midurethral slings.

OBJECTIVE: The aim of our study was to identify and compare risk factors for failure of retropubic and transobturator procedures. STUDY DESIGN: This was a retrospective cohort study. Women with predominant stress urinary incontinence who underwent a retropubic (n = 214) or transobturator tape procedure (n = 173) were included. Therapy was considered to have failed in women reporting any amount of urine leakage during stress after 2 and/or 12 months. RESULTS: Risk factors for failure were mixed urinary incontinence (MUI; odds ratio [OR], 3.7; 95% confidence interval [CI], 1.5-9.1) and the observation of detrusor overactivity (DO) at urodynamics (OR, 8.6; 95% CI, 1.9-39.4) in the retropubic group. Reporting a history of previous incontinence surgery (OR, 3.9; 95% CI, 1.3-11.7) and a low mean urethral closure pressure (MUCP) at urodynamics (OR, 14.5; 95% CI, 1.5-139.0) were risk factors for failure in the transobturator group. CONCLUSION: Women with previous incontinence surgery or a low MUCP might benefit more from a retropubic sling, whereas a transobturator procedure might be preferable in women with MUI or DO.

Predictive value of urodynamics on outcome after midurethral sling surgery for female stress urinary incontinence.

OBJECTIVE: The aim of this study was to evaluate the value of urodynamic investigation in the preoperative workup of midurethral sling surgery and to identify risk factors for failure after 3 different midurethral sling procedures. STUDY DESIGN: Retrospective cohort study. 437 women who underwent a tension-free vaginal tape, Monarc, or tension-free vaginal tape-obturator procedure without other simultaneously performed urogynecological surgery were included. Preoperative data were collected from the medical files. Patients who reported any amount of leakage were considered failures. The mean follow-up of the study population was 14 months. RESULTS: After multivariate analysis, mixed urinary incontinence (P = .04), previous incontinence surgery (P = .022), and detrusor overactivity (P = .02) were significantly related to failure of midurethral sling procedures. There were no predictive urodynamic parameters for failure in patients with mixed urinary incontinence or previous incontinence surgery. CONCLUSION: The standard use of urodynamic investigation in the preoperative workup of midurethral sling surgery needs to be revisited.

Female sexual function after surgery for stress urinary incontinence: transobturator suburethral tape vs. tension-free vaginal tape obturator.

INTRODUCTION: The transobturator suburethral tape (TOT) and tension-free vaginal tape obturator (TVT-O) procedures are relatively new incontinence treatment procedures. Studies on the influence on sexual function as a result of these procedures are limited. AIM: The influence of TOT or TVT-O for the surgical treatment of stress urinary incontinence (SUI) on female sexual function. METHODS: We evaluated 77 sexually active patients after TVT-O (N = 34, mean age 53.2 years) and TOT (OB-TAPE, Porges) (N = 44, mean age 52.0 years) placement for SUI based on the responses to a mailed questionnaire 3 months after the operation. MAIN OUTCOME MEASURE: Difference in postoperative sexual complaints related to the TVT-O (inside-out) and TOT (outside-in) procedure. RESULTS: Postoperative TOT and TVT-O: There was almost no difference in frequency of sexual intercourse and an improvement of the continence during intercourse; continence was reported in 33 patients (42.3%) before and 67 patients (78.4%) after operation. The appreciation of sexual intercourse was improved in 15 patients (19.2%) and worsened in eight patients (10.3%). Postoperative TVT-O vs. TOT: No difference was seen in lost of lubrication, clitoral tumescence reduction, and clitoral sensibility reduction between both procedures. Pain because of vaginal narrowing was seen significantly more in the TOT procedure group. CONCLUSION: Overall, in this study, the technique of TOT gave rise to more sexual dysfunction than TVT-O. However, because of the successful outcome on incontinence, both procedures had, overall, a positive effect on sexual function. The cause of significant more pain during intercourse as a result of vaginal narrowing in the TOT procedure requires further investigation. Like other studies, this study demonstrated that incontinence surgery can have a positive and negative outcome on sexual function. It is important to put this issue in the informed consent.

Sexual function after tension-free vaginal tape (TVT) for stress incontinence: results of a mailed questionnaire.

In a retrospective study we evaluated sexual function after tension-free vaginal tape (TVT) placement for urinary stress incontinence based on responses to a mailed questionnaire at least 3 months after the operation, to a maximum of 1 year. From 1999 to 2002, a sexual function questionnaire was mailed to 128 women (and their partners) who had undergone a TVT procedure for genuine urinary stress incontinence, without pelvic organ prolapse or detrusor instability. The questionnaire was returned by 96 women (75%), 69 (72%) of whom reported being sexually active. Mean frequency of intercourse did not change. Overall, 26% described improved intercourse compared to before the operation. Only one patient described worsening of intercourse after the TVT operation because of an increase in her incontinence. Overall, in this study the technique of tension-free vaginal tape as such seems to have no negative impact on sexual function. However, because of its successful outcome on incontinence, it has a positive overall effect on sexual function. The possible causes of postoperative partner discomfort require further investigation.