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Incontinent Female

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					Evaluation of the Incontinent Female

            David Stanford, M.D.




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I.     Introduction                                                              Urinary incontinence is a condition where there is an involuntary loss
                                                                                 of urine, which is a social and hygienic problem, which is objectively
       A.   With a detailed history, physical examination, and neurologic
                                                                                 demonstrable. We want to be sure that we document that someone has
            exam of the lower extremities and perineum (lumbosacral nerve        stress incontinence with what we call positive stress test and you have
            roots), augmented by a few simple clinical tests, an accurate        seen them leak urine which increases intra-abdominal pressure. If you
                                                                                 are going to consider operating on them or even treating them for stress
            diagnosis can usually be established in 90% of patients              incontinence in general, you want to document this in your chart.
       B . For the vast majority of women presenting with complaints of
       C                                                                         Failure to do so in two cases that I have already seen has lead to the
                                                                                 rapid conclusion and favor of the plaintiff in lawsuits.
            urinary incontinence who have not had prior failed anti-inconti-
            nence operations nor the history of neurologic injury, this simple   Most women who have urinary incontinence will have genuine stress
                                                                                 incontinence as all or part of the problem. In fact about 75% of all
            type of evaluation is all that is needed                             incontinent woman have this as part or their entire problem. There is
II.    History                                                                   an involuntary loss of urine associated with increases in intra-abdomi-
                                                                                 nal pressure from any source whether it be playing golf, tennis,
       A.   The details of the general medical, gynecological, and urological    coughing, intercourse. The bladder pressure exceeds the urethral
            history may be obtained with standard questionnaires                 pressure in the absence of a bladder contraction. It is usually caused
                                                                                 by an underlying problem with urethral hypermobility but not always.
       B.   History cannot be used alone as a basis for therapy
       C. The history provides an error rate of at least 50% in arriving at a    The second most common condition that we see is called detrusor
                                                                                 overactivity. This is involuntary bladder contractions that result in
            correct diagnosis. The history serves as a guide for emphasis
                                                                                 urinary leakage. This can occur in the idiopathic condition where
            during the subsequent evaluation process                             someone is neurologically normal, or they have detrusor instability
                                                                                 where the involuntary bladder contraction seems to occur on a
       D. Concomitant drug therapy for medical disease
                                                                                 functional basis. When it is caused by an underlying neurologic lesion,
            1.   Frequently produces side effects referable to the lower         we call that detrusor hyperreflexia. This is where the bladder
                 urinary tract                                                   contractions that are occurring are linked not just causally but also
                                                                                 temporarily to an underlying neurologic condition.
            2.   Alterations of drugs or dosages (ie, diuretics, "-blockers)
                 may diminish the need for further in-depth evaluation and       There are some other conditions that we seen in adults and pediatric
                                                                                 populations that can cause leakage. They are just not nearly as
                 decrease the patient's symptoms to tolerable levels             common as the three conditions that we have mentioned. Genuine
            3.   The menopausal status of the patient is important. If the       stress incontinence and detrusor overactivity in general, probably
                                                                                 account for 92-96% of all urinary incontinence that we are going to see
                 patient has any historical or clinical evidence of low estro-   in women. There are subvariants that we will focus on about intrinsic
                 gen, intravaginal estrogens are prescribed, usually on an       urethral function in the like, but the other conditions like overflow
                                                                                 incontinence, uninhibited urethral relaxation, these are rare. These are
                 every-night basis, until a desired effect is achieved or 6      conditions, which probably affect 1 in 200 incontinent patients or less.
                 weeks have passed                                               Overflow incontinence, we always think about and diabetics who have
                                                                                 neuropathy, it really outside of the post-surgical iatrogenic condition of
            4.   Gradual tapering of the frequency of usage is generally         overflow incontinence, this really is probably only seen in about 1 in
                 possible until a once or twice weekly maintenance schedule      750 incontinent people. Sensory urgent continence is a little bit
                                                                                 different. TI is probably more prevalent, but it is so difficult to
                 is reached, or the patient is given oral maintenance estrogen
                                                                                 characterize. It is a condition where the urge to urinate, increased
                 replacement                                                     afferent sensation overwhelms the patient, and they sort of subcon-
                                                                                 sciously but yet voluntarily urinate. They just let the urine go so bad
III.   Physical Examination
                                                                                 bladder infections, interstitial cystitis, and urethral syndrome, all these
       A.   Uroneurogynecologically-oriented physical examination                things can result in a strong urge. We treat the underlying inflamma-
            1.   Detection of fistula or neurological disease immediately        tory condition, for example an 85-year-old woman with atrophic
                                                                                 urethritis treated with some estrogen cream for two months, she will
                 directs further evaluation and treatment                        come back and tell you the urgency and frequency is gone and I do not
            2.   The clinical evaluation does not allow for accurate assess-     leak urine anymore. We then retrospectively make the diagnosis of
                                                                                 sensory urgent incontinence.
                 ment of the presence of an anatomical defect
       B.   Further studies are indicated to confirm the presence of urethral    Psychogenic incontinence is important not be fooled by this. That is
                                                                                 why we need to document objectively that there is urinary leakage and
            hypermobility prior to undertaking a surgical procedure to treat     understand what is going on. Congenital causes like diverticula; distal
            stress incontinence. The "Q-tip"test is very helpful                 diverticula will act as a reservoir and collect urine. When the patient
                                                                                 stands up and walks away from the toilet, they will dribble urine as the
       C. The fluid bridge test may be used to detect funneling                  urine falls out. Most people have dribbling because of involuntary
       D. A stress test is used to demonstrate urinary leakage with              bladder contractions and not a diverticulum. Proximal diverticula,
                                                                                 infected pockets of pus, the bladder increases afferent sensation and act
            increased intra-abdominal pressure                                   through the pathway of sensory urgent incontinence to cause urinary
       E.   In some patients, radiologic studies may be necessary to             leakage.
            demonstrate anatomic defects


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      F.   No surgical procedure should be undertaken without objectively         Those are sort of the conditions that can represent the patient’s
                                                                                  symptoms. The patient comes into your office, and she wants to know
           documenting the
                                                                                  from you, what can I do about this? To a patient this is sort of an uni-
           presence of a significant anatomic defect and urine leakage            dimensional problem. I leak urine and, you are a doctor, and you
           during testing                                                         should be able to tell me why. Give me a pill, and I should be able to
                                                                                  leave here, and a week from now not have this problem. It certainly
IV.   Postvoid Residual Urine                                                     isn’t that easy unfortunately, and what we have to do is sort of play
      A.   Measurement of postvoid residual urine (PVRU), either directly,        detective and begin to understand exactly what the patient does suffer
                                                                                  from and doesn’t suffer from. We have to determine what is going on.
           with the use of a catheter, or indirectly, by ultrasound (US) or       I see this is kind of complicated because more than 60% of our
           other radiographic techniques, is an essential part of any             patient’s have more than one reason for leaking urine and about 15%
                                                                                  of our patient’s actually have three or more conditions that contribute
           evaluation of urinary incontinence                                     to the urine loss and problems. It can get quite tricky in terms of trying
      B.   Therapies for stress and urge incontinence will increase urethral      to make the diagnosis.
           resistance or decrease bladder contractility, which can result in      We always start with a good history. We are going take a history. I
           a worsening of preexisting urinary retention                           send out a six-page questionnaire to people with a voiding diary, and
                                                                                  we ask them to write down when they urinate, when they leak urine,
           1.   If this occurs, the patient who originally had a problem with     whether there is an urge associated and what they are taking in, so we
                detrusor instability or genuine stress incontinence (GSI)         understand. Especially if you want to use behavioral therapy or
                                                                                  nonsurgical therapy later on, we need to know what their behavior is
                might then develop a problem with urinary retention associ-
                                                                                  currently. It also helps to correlate with the symptoms that they are
                ated with urinary tract infection (UTI) or overflow inconti-      telling us and lend some varicosity to the conditions of urgency and
                                                                                  frequency of micturition. Sometimes you will see a patient that will
                nence as an alternative to their original problem
                                                                                  come in say, I urinate all the time now, and I used to urinate just every
           2.   Trading one problem for another is not the desired outcome        eight hours. Now I am urinating every three to four hours. That
      C. The measurement of PVRU is important to evaluate whether an              doesn’t seem to be much of a problem. We may want to understand for
                                                                                  the individual, but if that is backed up by their voiding diary that is
           occasional patient is suffering from overflow incontinence, where      helpful. People tend not to urinate also as often on their voiding
           the patient's bladder almost always remains fully distended, with      diaries as they say they do historically. It helps us understand about the
                                                                                  pattern. It also lets us pick up things like reverse diuresis and
           the patient voiding very small amounts and rapidly refilling to her    nocturnal diuresis conditions, where someone may have problem with
           maximal bladder capacity                                               ADH, and we can treat this quite simply. The other things we want to
                                                                                  know about is what medications they are using. You want to be
           1.   The patient will often complain of symptoms of stress             careful. A big pearl to take away from this is to understand that alpha
                incontinence because of intermittent leakage of urine with        blockers, Hytrin, Minipress, these agents for blood pressure will cause
                                                                                  urinary incontinence by decreasing urethral resistance. You can treat
                any minor activity due to overdistention of the bladder           people quite successfully just by switching them off these medications.
           2.   By obtaining a PVRU, one can assess that this is not GSI
                                                                                  A history is great and very important to outline the underlying
                causing the symptoms of stress incontinence, but instead          condition. It acts sort of as the outline for what we are going to fill in
                overflow incontinence, possibly due to peripheral neurologic      and explain. Because no evaluation that you do, whether you do it
                                                                                  simply with no equipment or have a hundred thousand dollar lab that
                injury and afferent dysfunction
                                                                                  you are going to do it with and spend hours and hours, it does not
      D. The residual urine should be <30--50 mL                                  matter if it fails to explain the patients symptoms. On the other hand,
                                                                                  the mistake we make as gynecologists, family practitioners and
           1.   On a functional basis, residual urine <100 mL. may even be
                                                                                  urologists is assuming that a history will tell us the underlying
                acceptable as long as the cause of this mild voiding dysfunc-     condition. Here we find that history is no more accurate than a good
                tion is well understood                                           educated coin toss. When we look at patients symptoms and try to see
                                                                                  if they are pathognomonic for underlying conditions, like stress
           2.   50 mL is a boundary for determining who has urinary               incontinence proving that someone has genuine incontinence, urgent
                retention                                                         incontinence being indicative detrusor instability. You can see that the
                                                                                  specificity here, especially is quite poor, and in this study of 288
           3.   Patients who consistently have residual urine >50 mL              consecutive women with urinary incontinence undergoing multi-
                undergo more extensive evaluation with voiding pressure           channel urodynamic testing, the sensitivity was 100% but that really
                                                                                  isn’t true in the literature as a whole. In most groups who have shown
                studies or a voiding cystourethrogram                             sensitivities there that range in 80 to low 90% range. Some people say
           4.   If a patient is asked to void in a commode in your office         that if you have the women who just complains of genuine stress
                                                                                  incontinence, she is under the age of 60, she doesn’t have any other
                when she is seeing you for the first tune, she may have an        complaints of frequency urgency or urgent incontinence or nocturia,
                artificially elevated residual urine due to her discomfort with   that you don’t need to evaluate that patient, that she will always have
                                                                                  genuine stress incontinence.
                the new voiding environment
           5.   This test should be repeated on multiple occasions before         We start with a physical exam. Obviously we want to augment the
                                                                                  history and understand the anatomic problems. You want to do a good
                deciding that the patient has an abnormal residual urine and


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               a problem with urinary retention. The patient who has urinary      pelvic exam, neurologic exam and check good lumbosacral nerve roots
                                                                                  because these are the nerves that help control bladder and urethral
               retention due to significant voiding dysfunction will consis-
                                                                                  function. Of course we want to focus on the pelvic exam but some-
               tently have elevated residual urine                                times it can be quite overwhelming. You see somebody who has
     E.   The PVRU in our laboratory is usually obtained immediately              complete procidentia and a vaginal wall inversion, and it is hard to
                                                                                  begin to think about this and what really helps I think is to compart-
          following a spontaneous uroflowmetry study done at the initiation       mentalize it. I think for mere mortals and clinical gynecologists
          of the examination                                                      especially just looking this and thinking about anterior and posterior
                                                                                  compartment defects and atypical prolapse and just these basic
          1.   This is usually directly removed with a catheter                   concepts and far come structures out of the vagina or how far they
          2.   This specimen should be obtained when the patient is in the        protrude down into the vagina say using the Beden-Walker 0, 1°, 2°
                                                                                  and 3° prolapsed scale really will help you break things down. To
               supine position, as supine urinary residuals may not fully         prove that, it is obvious to all of us that this uterus is now protruding
               reflect the total residual bladder volume                          beyond the vagina, and there is 3rd or 4th degree depending on whose
                                                                                  scale you use. She has an anterior compartment defect and a systole,
          3.   Tilting the patient in reverse Trendelenburg or having the         but does she have a paravaginal defect? She obviously has a
               patient stand with the catheter inserted may aid in fully          paravaginal defect because paravaginal defect implies that the
                                                                                  anterolateral vaginal sulcus is detached from the arcus tendentious
               emptying the bladder                                               fascial pelvis, which is still inside the patient’s body. That is sort of
          4.   This PVRU is then sent for urine culture to rule out preexist-     apart of the defect that we might want to repair when we repair this
                                                                                  prolapse. In addition, she obviously has a cystocele, and we want to get
               ing infection which would cause sensory urge incontinence
                                                                                  an idea if that is very small. We want a direct vaginal exam and
               or detrusor overactivity. It is essential to rule out UTI before   understand that. She at least has a traction enterocele because her cul-
                                                                                  de-sac obviously is out of the patient’s body here. We also want to
               proceeding with a complex urodynamic evaluation
                                                                                  understand whether this was the propelling property and usual with
          5.   On rare occasions, the chronically-infected patient will           uterine prolapse it is a traction enterocele.
               respond to antibiotic therapy with total resolution of urinary
                                                                                  You want to do a good neurologic exam. You want to make sure that
               incontinence, making further work-ups unnecessary                  the lumbosacral nerve roots are intact. Check for motor strength in the
V.   Stress Test                                                                  lower extremities, reflexes and you can check for sensation from L2
                                                                                  –S2 by checking the dermatomes above the knee. Then you augment
     A.   Urinary incontinence is defined as a condition where there is           this with bulbocavernosus and clitoral reflexes to look at the sacral
          involuntary loss of urine that is objectively demonstrable and          nerve roots. When you stroke the labia, you should see contraction of
                                                                                  the levator ani muscles and an anal wink. Likewise when you tap the
          represents a social or hygienic problem                                 clitoris, you should see the same thing. Clitoris is S1 and S2 afferently.
          1.   Demonstrating the patient's urinary leakage during an              The labia are S2 and S3 and obviously anal wink is S4 and S5. This
                                                                                  helps you cover the ground. We prefer to do this with a Q-tip, so that
               increase in intra-abdominal pressure is essential in the           we don’t bring up any questions in the patient’s mind as to what is
               diagnosis of GSI every patient complaining of urinary              actually happening.
               incontinence should undergo a stress test the standing             There are a number of clinical tests that we can do to augment are basic
               position has been shown to be far more sensitive, it is the        physical exams. Simple thing that you can do in the office. Be sure she
                                                                                  has urethral hypermobility because around 12% of the population that
               preferred position
                                                                                  has genuine stress incontinence will have it with a well-supported
          2.   A patient who leaks urine when supine with a relatively            urethra. We call that subgroup type III incontinence. Those people
                                                                                  won’t have urethral hypermobility, and they won’t benefit from your
               empty bladder has a more severe problem with stress
                                                                                  MMK. The cure rate is only about 30 to 40%, and I can cure them in
               incontinence than the patient who only leaks in the standing       the office with periurethral injections, fat, collagen, Teflon or other
               position at maximum cystometric capacity with repetitive           new things that are coming down the road, much more cheaply and
                                                                                  much more simply under a local anesthesia. We can do numerous tests
               coughing and Valsalva                                              to look at urethral hypermobility. I prefer the Q-tip test because it is
     B.   The stress test is performed immediately                                simple, cheap, and it does not expose people to radiation. There are
                                                                                  standards in the literature that establish that if the straining Q-tip angle
          following simple cystometry with the patient's bladder fully            goes more than 30° positive from the horizontal then somebody has
          distended at maximum cystometric capacity                               urethral hypermobility. The surgical success will follow expected
                                                                                  outcomes. If the urethral hypermobility is less than a straining angle
          1.   Once the filling catheter is removed, the patient may be           positive 30°, and it is the straining angle that is important. It is the
               asked to Valsalva and cough repetitively or perform some           straining angle that matters. You can do this with a Q-tip in. You can
                                                                                  just put a Sims speculum or the back half of a Graves’s speculum and
               other exercises to try to induce urinary leakage under direct      look at the anterior vaginal wall and see that it moves and say
               visualization.                                                     qualitatively this woman has urethral hypermobility. That is fine.
          2.   Patients are initially tested with repetitive coughs, three        Next thing we can do is a stress test. This is crucial to making the
               times, in the supine position followed by intermittent Valsalva    diagnosis of genuine stress incontinence, that we objectively demon-
                                                                                  strate the sign of stress incontinence. If someone is coughing and
               maneuvers three times in the supine position. Then they are


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                moved to the standing position, where the same maneuvers             straining and we see them leak urine. The best way to do this, standing
                                                                                     up with a full bladder. It is the most sensitive position. Have the
                are repeated.
                                                                                     patient do whatever she needs to do at home to cause leakage. If that
           3.   If they are unable to recreate urinary leakage, the patients         is hitting a tennis ball, have her reduplicate her swing. Have her close
                are then asked to cough in series five times or Valsalva five        her eyes and pretend she is hitting a backhand as hard as she can or an
                                                                                     overhead. Have her lift suitcases or bend down. Do whatever it takes
                times to try to induce leakage. If this fails, the patient then is   in your office to redocument the leakage of urine coincident with
                asked to jump up and down in place three times or to run on          increased intra-abdominal pressure. If she coughs and then starts to
                                                                                     leak urine continuously about three seconds after she coughed, you
                the spot to see if this induces urinary leakage.                     want to think about stress provoked involuntary bladder contractions.
           4.   When this fails, the patient may be asked to do deep knee            One thing we can do is not just do a stress test, but we discovered a
                                                                                     few years back something called the supine empty stress test. Here we
                bends or lift heavy objects off the floor to try to induce           discovered that people who have low urethral closure pressure,
                leakage.                                                             intrinsic sphincteric dysfunction, will leak urine even with a small
                                                                                     amount of urine in their bladder with first or second cough laying
           5.   Record not only the volume at which the testing was done             down. There is a difference and you know it. There is a patient you
                and the position of the patient, but also if activities other than   see who leaks urine when she plays tennis and not at any other time.
                                                                                     In your office you have to have her cough and strain repetitively with
                Valsalva or Coughing are used to elicit urinary leakage. This        a full bladder before she leaks one drop. There is another patient your
                may help accurately assess the degree of the patient's               seeing who just emptied her bladder, and she is lying down and you
                                                                                     have her cough and the urine squirts out and hits you in the chest.
                problem.
                                                                                     What do you know about those two women? You know that the
      C. The stress test is deemed a positive test when urinary leakage              intrinsic muscular function of one is much stronger than the intrinsic
                                                                                     muscular function of the other or the patient may have what we call
           occurs with increased intra-abdominal pressure
                                                                                     low-pressure urethra. When we correlate this with our work on closure
           1.   In some patients, urinary leakage may be seen to occur not           pressures of 20 or less, we found that there is a positive predicted value
                only at the moment of increased intra-abdominal pressure             for all patients, even high-risk patients of 90%. In the lowest popula-
                                                                                     tion “out there in the normal world” the positive predicted value should
                but may continue long after the patient has relaxed                  be about 95%. If you see someone leak urine lying down with not
           2.   While such testing is positive because urinary incontinence          much in their bladder, you have to assume that they have a low-
                                                                                     pressure urethra and instead of thinking to do an MMK or a Burch, that
                occurred, this needs to be qualified because the patient may         patient needs a sling. Burch procedure is only going to work about
                be demonstrating stress- induced involuntary detrusor                45% of the time to objectively cure that patient. She needs not only
                                                                                     support of her urethra but squeeze or compressure. We want to think
                contractions                                                         about that and maybe refer that patient for multichannel urodynamic
           3.   Up to 5-10% of women with detrusor instability may have              testing to understand not just to close her pressure but avoiding
                                                                                     mechanism and other concurrent problems, which will impact the
                stress-induced detrusor contractions                                 patient that we might want to do a sling on.
           4.   If a patient has a stress test such as this and fails to show
                                                                                     We do cystoscopy also on people of irritated voiding symptoms, but it
                evidence of involuntary detrusor contractions on simple              is not apart of the routine work-up of urinary incontinence. It is
                cystometry, she should be evaluated with multichannel                important if people have blood in their urine obviously. It is also
                                                                                     important if people have nocturia, dysuria, and suprapubic pain to
                urethrocystometry
                                                                                     evaluate them for various inflammatory conditions as well as neoplasia.
      D. Advantages                                                                  We want to look at the voiding function of patients that we are
                                                                                     evaluating for urinary incontinence to make sure that they don’t have
           1.   Stress testing is simple and easy to perform. The patient
                                                                                     overflow incontinence from total retention, and also to appreciate that
                with a full bladder is asked to increase intra-abdominal             most things that we do to treat urinary incontinence are going to
                pressure, while the examiner tries to visualize urinary egress       increase urethral resistance or decrease detrusor contractility. Both of
                                                                                     the factors tend to promote retention of urine. When we are treating
                from the urethral meatus                                             people for incontinence we are really trying to alter this balance. We
           2.   It is a reliable test, but the examiner must be cautious about       are trying to make them retain a little bit more but not too much that
                                                                                     we cause a pathologic condition where they are retaining urine
           false-positive results in patients who have                               completely. Treating involuntary bladder contractions, we like to
                a.   Pooled vaginal fluid                                            decrease detrusor contractility. We have to hit it just right. We want
                                                                                     to understand just a little bit about peoples intrinsic voiding function,
                b.   Increased vaginal discharge                                     so we can do something called spontaneous uroflowmetry and see how
                c.   Fistulas who may have urinary leakage that is                   fast they urinate and what pattern. In boys who have prostatic
                                                                                     hypertrophy, it is very important that we measure the numbers, the
                     extraurethral during stress testing                             speed.
VI.   "Q-Tip" Test
                                                                                     Because obstruction in woman isn’t due to physical changes. It is due
      A.   Assess as urethral hypermobility                                          to functional changes, spasm, irritation and inflammation. We look at
           1.   Measurement of the "Q-tip" angle when resting and during             the pattern, and it is just like anything else, a bell-shaped curve, and
                                                                                     that is what defines normal because men and women are different.
                straining allows for a quantitative analysis of the mobility of


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               the proximal urethra and bladder neck                             Men are women are different and no where are it more true probably
                                                                                 when one comes to voiding function. We boys can only urinate with
          2.   The primary underlying pathology of GSI is relative
                                                                                 normal flow rates one way by relaxing our urethra and contracting our
               hypermobility of the proximal urethra, resulting in decreased     bladders. That is because the male urethra is really very long com-
               pressure transmission to the urethra when compared to the         pared the female urethra which usually is about 4 or 5 cm in length.
                                                                                 These leads to changes in voiding function. Women are amazing.
               bladder                                                           They can urinate not just by urethra relaxation and bladder contraction
          3.   While almost all patients with GSI have urethral                  but 5 different ways normally. They can urinate by urethra relaxation
                                                                                 with or without a bladder contraction and with or without Valsalva.
               hypermobility, many patients with urethral hypermobility are      We like to see a bell-shaped pattern but here is sort of a roller coaster
               not found to have urinary incontinence                            pattern or an intermittent interrupted flow. This can be one of two
                                                                                 things. It was that the patient was Valsalva voiding that the woman
          4.   Therefore, this test cannot be used as a predictor of who has     had stress incontinence and had learned that she could in and out of the
               GSI, but instead is of greater significance when it is found to   ladies room quickly by just pushing because her urethra is a push over.
                                                                                 She takes a deep breath in and push, grab a breath-push, grab a breath-
               not demonstrate urethral hypermobility in a patient believed      push, etc., rest here for a while and here somebody calling and she
               to have GSI. This patient often is found to have a deficient      pushes again to get the last little bit out. On the other hand, this could
                                                                                 represent the neurologic condition detrusor sphincter dyssynergy, where
               "intrinsic sphincteric mechanism" and type III incontinence       there is intermittent urethral contractions that is autominous and not
          5.   Different investigators have suggested different cut-off points   coordinated with the bladder contraction where the urethra intermit-
                                                                                 tently spasms and eventually totally extinguishes the bladder contrac-
               to define urethral hypermobility, ranging from a straining
                                                                                 tion and can lead to retention. We see a pattern like this we need to
               angle of 20-350                                                   evaluate someone with multi-channel urodynamics to understand which
                                                                                 it is.
               a.   These angles are good estimates of adequacy of
                    periurethral support                                         The last simple test that we should all do in the office to evaluate
     B.   Procedure                                                              incontinent people is the cystometry or the study of storage pressures
                                                                                 in the bladder during bladder filling. I think it is important that we do
          1.   The "Q-tip" test is performed by placing a sterile cotton tip     this in everyone because if detrusor overactivity is the second most
               applicator, lubricated with 2% lidocaine hydrochloride            common condition, we would at least like to rule it in or out. Here we
                                                                                 are measuring urethral single-channel bladder pressure as we fill the
               (Xylocaine jelly), in to the urethra until resistance abates,     patients bladder retrogrades. This happens to be a filling Foley and a
               signaling that the cotton tip has reached the bladder neck        3-French catheter that we can measure pressure with. One means 100
                                                                                 mL, two means 200 mL. At 225 the patient says I first fell like I can
          2.   The cotton tip applicator is snugged back against the bladder     urinate. Filling with water that is normal. Somewhere between 75 and
               neck, and the resting angle is measured relative to the           250 mL, people should routinely feel the first sensation to void. She
                                                                                 feels full enough to urinate and go out of her way to find a toilet. At
               horizontal                                                        550 she starts to have an involuntary inhibited detrusor contraction
          3.   The patient is asked to Valsalva and cough repetitively, and      before she reached her maximum systematic capacity. This point
                                                                                 where she couldn’t stand anymore fluid going into her bladder. Before
               the maximal straining angle is then recorded                      that happened she has this bladder contraction and urine was leaking
          4.   A normal resting angle is usually <0E,and a normal straining      around the catheter onto the floor. This is an objective sign of detrusor
                                                                                 overactivity. This woman was neurologically normal, so we said she
               angle is < 30-35 E.
                                                                                 had detrusor instability idiopathic condition. You can do this for
          5.   If the straining "Q-tip" angle is in excess of 30, the "Q-tip"    $29.95 or if you are value oriented like me, you can do it almost for
                                                                                 free. Filling 50 mL at a time, stopping to measures the pressure and if
               test is said to be positive, demonstrating            urethral
                                                                                 the pressure increases by more than 15 cm of water pressure you say
               hypermobility.                                                    the patient had an involuntary bladder contraction. If it doesn’t
     C. Advantages                                                               increase by more than 15 cm, you keep going until you reach your
                                                                                 maximum cystometric capacity where she can’t stand anymore and if
          1.   This test can be done quickly with minimal discomfort to the      her bladder pressure doesn’t increase by 10-15 cm or more you say that
               patient, and it offers a simple way to assess urethral mobility   she has a stable or normal bladder. Using those criteria comparative
                                                                                 to multichannel urodynamic studies we found one CMG is 84%
               without the need for x-ray or US                                  sensitive as a screening test for detrusor instability and two CMGs on
          2.   It offers a simple, quantitative, and relative measure of         two different days, which you probably wouldn’t do, are 92% sensitive.
                                                                                 In an older population just took a Foley catheter and did eyeball
               urethral mobility, which can be compared to postoperative         cystometry. He took a Foley catheter, put it in the patient’s bladder
               testing to assess the adequacy of urethral support                lying down, a Toomey syringe on top of it, and he was about 25 cm
                                                                                 above the patient’s pubic symphysis, and he just poured water in. If
VII. Simple Single-Channel Cystometry                                            the miscus was falling the whole time he poured water in then there
     A.   Cystometry is the measurement of bladder pressure during filling.      was no bladder pressure increase. When the meniscus starts to rise,
                                                                                 why, because the bladder is contracting and the fluid would overflow
          If is essential to the evaluation of all incontinent females.          the Toomey syringe and that was indicative of detrusor instability. He
     B.   It may be performed by numerous methods of varying complexity          had an 85% sensitivity compared to multichannel urodynamics in a
                                                                                 high-risk population. You can use a very simple test to tell what is
          1.   Multichannel studies using electrical microtransducer


                                                                                                                                                          6
          catheters measuring urethral, abdominal, and bladder               going on. Go into the operating room and into the anesthesia cart in
                                                                             the bottom drawer there is a CDP manometer. Rip open the box and
          pressures with or without electromyelogram (EMG) can be
                                                                             pull out the manometer. The second drawer is the IV extension tubing.
          used with computer-based physiologic recorders to perform          Take a couple of links of IV extension tubing and attach that to the
          complex urethrocystometry studies.                                 Foley catheter. The IV tubing is going to go on the other side of the
                                                                             manometer, which you are going to connect to the saline bags. The
     2.   Patients may undergo simple, single-channel "eyeball'              fourth drawer is the bags of saline or sterile water. You can take
          cystometry by slowly filling their bladder through a Foley         either, and they will work well. In the OR their Foley catheters and
                                                                             Christmas tree adapters, grab a few. You can hook up this cystometer
          catheter and irrigation syringe at the bedside.                    Foley to Christmas tree adapter to IV extension tubing and back to the
     3.   Multichannel electronic eystometry equipment may cost              manometer out to the tubing and the bag and then you need an IV pull.
                                                                             On your way out of the OR just takes one they don’t need it. Bring it
          anywhere from $10,000-55,000, whereas simple single-               back to your office and hook it up like this and you are ready to go.
          channel cystometry can be performed for under $10. Both
                                                                             We really should be trying to look at cystometry and figure out whom
          the expensive multichannel systems and the simple single-          has detrusor instability. When these simple tests don’t give us an
          channel studies attempt to diagnose bladder pressure               answer or somebody has had prior surgery or think for some reason
                                                                             they are high-risk of surgical failure or treatment failure, you want to
          changes during the storage phase of micturition.                   know more. They may not void completely or they void in a roller
C. The bladder should be able to fill to maximum cystometric                 coaster pattern, in those people you are going want to think about
                                                                             getting multichannel urodynamic testing to further see that is going on.
     capacity (the point where the patient is no longer able to tolerate
                                                                             What is that compromise? Urethral cystometry is probably the most
     any further bladder infusion because of severe discomfort)              crucial part where we measure multiple pressures in the body to look
                                                                             at what is going on during the storage phase of micturition, as our body
     without any significant increase in bladder pressure, or urinary
                                                                             is trying to store urine in a low-pressure reservoir that we call the
     leakage.                                                                bladder. Once you have your subject you can use microtransducer or
D. Simple cystometry may be divided into                                     water catheters. These are little state microtransducer catheters. One
                                                                             goes in the urethra to measure urethral and bladder pressure, 6 cm
     1.   Those which measure bladder pressure                               distally, and the other one in the vagina or rectum. What we do is
     2.   Those, such as "eyeball" cystometry, which merely make a           measure numerous pressures at the same time. Instead of just
                                                                             measuring bladder pressure like we did in the other study, we are going
          qualitative assessment as to whether there are involuntary         to measure EMG or electrical activity of pelvic floor, rectal pressure,
          bladder contractions or not.                                       abdominal pressure, urethral pressure, and then the computer gives is
                                                                             these two subtractive pressures. True detrusor pressure is the bladder
E.   Simple single--channel quantitative cystometry has been shown           pressure minus the abdominal pressure. If you bear down or cough,
     in numerous studies to have a diagnostic sensitivity ranging from       you are going to see an increase in the bladder pressure, but if it occurs
                                                                             here in the rectal or abdominal pressure lead, it is going to be sub-
     53-93 % when compared with multichannel urodynamic studies.             tracted out, and there will be no increase. This tells you what is going
     This sensitivity is largely dependent on the position of the patient    on inside the bladder irrespective of what is going on inside the
                                                                             abdomen.
     and the provocative maneuvers used during the study
F.   "Eyeball" cystometrics                                                  Urethral closure pressure is urethra pressure minus bladder pressure.
                                                                             If this is above 0 everywhere in the urethra then you stay dry. If it is
     1.   The simplest form of cystometric evaluation available
                                                                             below 0 everywhere in the urethra then it means the bladder pressure
     2.   Involves minimal equipment                                         has exceeded urethral pressure, and you are going to leak urine or your
                                                                             patient is going to leak urine. This sort of testing not only improves
     3.   Procedure
                                                                             our specificity to know that this isn’t a bladder contraction and this is
          a.    A simple catheter is transurethally placed into the          but also our sensitivity in that it lets us see the whole picture of what
                patient's bladder; this is usually connected to an irriga-   is going on in the patients pelvis so we might be tipped off to go a little
                                                                             bit further or sometimes see a very low pressure bladder contraction
                tion syringe                                                 that we might miss in a single-channel study.
          b.    The syringe is then held upright above the patient's         Urethral pressure flowmetry, the measuring of the intrinsic function of
                                                                             the urethra is very important in understanding the patient’s eventual
                pubic symphysis, and sterile water is poured into the        outcomes with therapies. We can measure what is called urethral
                syringe in an intermittent fashion                           closure pressure profile, pull the transducer out through the urethra and
                                                                             measure the pressure each step along the way. It generates a curve that
          c.    This is done until the patient reaches maximum               looks like it starts when the catheter moves into the bladder and ends
                cystometric capacity                                         where the catheter comes out of the urethral meatus. Because of
                                                                             limitations of time, I don’t want to make you experts on how to do this
          d.    Should the patient have an involuntary unihibited            or even the concepts behind, but I thought it might just help to show
                detrusor contraction during filling, the meniscus within     some differences. This is an incontinent female. Here we have blown
                                                                             up the bottom line or the urethral closure pressure in this study. We
                the syringe will back up and often overflow the open         are going from supine with an empty bladder to supine with a full
                syringe as a qualitative demonstration of detrusor           bladder and then sitting on the full bladder to sitting with full bladder
                                                                             and repetitive coughing. The normal patient augments. She increases
                overactivity


                                                                                                                                                       7
    4.   Following such an evaluation, the catheter may be removed          her pelvic floor skeletal muscle activity around the urethra, and the
                                                                            pressure curve gets better as we stress her. The incontinent patient on
         and stress testing may be done
                                                                            the other hand usually starts out in general with lower pressure to begin
G. Simple incremental single-channel cystometry                             with and as we stressed her, she deteriorates. She can’t augment. She
    1.   Retrograde cystometry may also be accomplished with a              can’t compensate for the increased stress of bladder filling and in a
                                                                            more upright position and repetitive coughing more pressure gets added
         simple mariometric cystometer which allows for the mea-            to the bladder, negative pressure transmission, which causes urinary
         surement of bladder pressure. This can be accomplished in          incontinence. We resupport a proximal urethral in a high retropubic
                                                                            position. Restore positive pressure transmission even though the
         a continuous fashion with two transurethral bladder catheters      resting pressure may stay low, these cough spikes will be positive, and
         or in an incremental fashion through a single simple               the patient won’t leak urine.

         transurethral catheter                                             We also can do these tests in people who have prolapse to see what is
    2.   Procedure                                                          behind the prolapse. Here is a resting profile without support. There
                                                                            is a high urethral pressure profile with a big kink in the middle. We
         a.   Incremental     standing    retrograde     single-channel     take away the kink and the mechanical obstruction of the urethral
              cystometry may be accomplished by transurethrally             folding on itself, and we see a very low pressure. In this case it is
                                                                            maintained. The patient doesn’t have stress incontinence, and when
              placing a simple Foley catheter in the patient's bladder      she coughs and strains, there is actually a pressure increase. She didn’t
              and distending the balloon to 5 ml.                           need to have an anti-incontinence surgery at the time of her pelvic floor
                                                                            reconstructive surgery, but most people do. 60-70% of the people that
         b.   A "Christmas tree"-type adaptor is placed in the Foley
                                                                            I see who have prolapse in the anterior or posterior compartment that
              catheter                                                      comes to the introitus or beyond, 60% for posterior compartment and
                                                                            70% for anterior compartment have potential genuine stress inconti-
              (1) Two lengths of IV extension tubing are connected to
                                                                            nence. Even though they don’t leak urine at home, if you resupport the
                  this and to a simple manometer, taken from either         prolapse and take away the mechanical obstruction or kink in their
                  a cell volume profile or lumbar puncture tray             urethra just like unlinking a garden hose, they will leak urine. You
                                                                            would like to know about that before surgery rather than after surgery.
              (2) This is taped to an IV pole so that it is zeroed at the
                  level of the patient's symphysis                          The last component of multichannel urodynamic testing is instrumented
                                                                            uroflowmetry with EMG or electromyography. Here this lets us look
         c.   The other end of the cystometric manometer is attached        behind things. This is a patient I showed you her roller coaster voiding
              to simple IV tubing, which goes back to a bag of sterile      pattern. This is the same exact patient and what we see is that she
                                                                            voids by Valsalva and bladder contraction and urethral relaxation
              water                                                         initially. She is doing all of three things at the same time to empty her
         d.   The patient's bladder is filled in an incremental fashion     bladder completely but in this intermittent interrupted pattern. That is
                                                                            important for us to understand. In the case of detrusor sphincter
              with 50 mL H20 at a time, stopping every minute or so         dyssynergia, the other pathologic picture, just graphically shown here,
              to measure the baseline resting pressure as well as to        we fill the patients bladder and we ask her to void when the bladder
                                                                            contracts and the bladder pressure increases, the urethra and EMG
              measure the pressure after stabilization following            activity should go silent. If it increases, it is called detrusor sphincter
              provocative maneuvers such as:                                dyssynergia. That is what is going on with this patient with MS. Here
                                                                            she has a bladder contraction and she is trying to void, her urethral
              (1) Coughing
                                                                            pressure goes up and down and the EMG activity increases. This is
              (2) Valsalva                                                  detrusor sphincter dyssynergia. There is an underlying neurologic
                                                                            problem that leads to a lack of coordination between bladder and
              (3) Heel bouncing
                                                                            urethra.
              (4) Exposing the patient to running water
         e.   The baseline pressure is taken, and the patient is filled     We have made a diagnosis, and we have a patient who has genuine
                                                                            stress incontinence with or without detrusor instability. We have
              until she notes the first sensation to void and then until    offered her all of the nonsurgical options. Let’s talk about different
              maximum cystometric capacity. A rise in bladder               types of anti-incontinent surgery. When I think about incontinent
                                                                            surgeries, I divide them up into 5 classes. Vaginal operations like the
              pressure > 15 cm H20 from the baseline pressure is            Kelly-Kennedy plication that we are not going to talk about in any
              interpreted as a positive test                                detail today, retropubic urethral plexis; Birches, MMKs, perivaginal
                                                                            repairs, needle suspension, where we somehow put sutures in the
         f.   This is especially significant if, when the Foley catheter    vagina and suspend them someway abdominally usually upwards or
              is removed, the patient is seen to have involuntary           anteriorly with a needle, and sling procedures. In 1949, Marshall-
                                                                            Marchetti-Krantz reported on the MMK, and this was sort of the
              leakage of urine coincident with this increased bladder       rebirth of retropubic urethral praxes. I am going to talk about Ton-
              pressure .                                                    nages modification described in 1976, but birch first reported his work
                                                                            in 1961, and this is the most commonly performed anti-incontinence
    3.   Continuous monitoring of bladder pressure with a manomet-          operation and its various modifications right now in the world. Some
         ric or electronic cystometer allows for continuous recording       deserve to be called modified berches and probably some that should
                                                                            have there own unique names. In the medical literature, there is
         of bladder pressure and the rapid detection of small phasic


                                                                                                                                                      8
         changes, which may only last 15-30 seconds and not be               support for objective cure rates of 80-95% with similar subjective cure
                                                                             rates slightly higher. There is excellent longevity. This slide is a little
         detected with the incremental methodology.
                                                                             bit old because there is actually ten-year data that came out last year
    4.   Incremental single-channel cystometry has been shown to be          that showed 86-89% objective cure rates from Italy and Argentina.
         85-93 % sensitive in diagnosing detrusor instability when           Detrusor instability, the surgery creating involuntary bladder contrac-
                                                                             tions, and this happens with all the surgeries that we do in varying
         compared to multichannel studies. Its sensitivity is aug-           degrees and you need to understand that, occurs about 7-10% of the
         mented by performance of the study on more than one                 time. The concept is that we want to resupport the proximal urethra,
                                                                             to stabilize the proximal urethra and restore positive pressure transmis-
         occasion.                                                           sion to the urethra compared to bladder. How do we do it? We suture
H. Electronic retrograde single-channel cystometry                           the anterior vaginal wall and developing endopelvic connective tissue
                                                                             posteriorly to some anterior point of support, which is immobile. The
    1.   Continuous measurement of bladder pressure with a single-           anterior vaginal wall moves when the patient coughs and strain,
         channel recorder is more accurate than incremental methods          pressure is exerted downward in the space of Retzius, if this is
                                                                             stabilized the pressure will increase within this lumen.
         or qualitative assessment with bedside cystometry
    2.   Procedure                                                           What we fixed here anteriorly, this doesn’t move when someone
                                                                             coughs and strains. This is why berch procedures and MMKs last so
         a.   Usually a small filling catheter is used to fill the bladder   well, especially if you take away the question of permanent versus
              in a retrograde fashion with water, saline, or CO2 gas.        absorbable suture. If you are using premature suture, you stabilize
                                                                             people and you have them recuperate appropriately and restrict them
         b.   Another smaller catheter (4) is usually connected to an
                                                                             for three or four months from strenuous activities and stool softeners,
              electronic water or gas manometer to measure the               they will heal well and these people are going to do great. Probably
                                                                             forever, the majority of these people. Certainly for five or ten years,
              bladder pressure continuously
                                                                             these people are going to do very well. It is 1.5-2 cm lateral to the
    3.   The addition of an electronic cystometer significantly              urethra and then down 1-1.5 cm from there. A figure of 8 stitches that
         increases the cost of such studies, but often an intrauterine       are then put up in Cooper’s ligament or iliopectineal ligament here.
                                                                             What this does is stabilizes the posterior wall, the urethra, by stabiliz-
         pressure catheter and manometer may be utilized to perform          ing the anterior wall of the urethra. We put a backstop here, so that
         these studies, thus making the obtainment of additional             when pressure is transmitted into this picture A from anterior to
                                                                             posterior, it is going to cause the urethra to compress on itself against
         equipment unnecessary for many hospital centers                     the anterior vaginal wall. If there is urethral hypermobility, and there
    4.   These studies may be performed in the supine, sitting, and          is no support, the pressure is going to largely be transmitted through
                                                                             and no reflected back. You don’t see nearly the same pressure
         standing positions, but are most sensitive in the standing          increase. That is the short version of the physics of how Copel
         position                                                            suspensions work. Perivaginal repair trys to do the same thing, but it
                                                                             says lets be anatomic about this. Let’s put the anterolateral vaginal
    5.   Similar to the other cystometric studies, this study is per-        sulcus back to where it is broken away from the arcus tendentious
         formed by placing both catheters in the bladder and filling         fascia with multiple sutures and just in front of the ischial spine all the
                                                                             way back beyond bladder neck. That is great, but people like me who
         through the filling catheter with either liquid or gas while the    really do this where it should be done, at the anterolateral vaginal
         electronic cystometer is zeroed at the level of the pubic           sulcus. If you just put this back in the anterior vaginal wall still
                                                                             sagging in the middle, someone is still going to have urethral
         symphysis
                                                                             hypermobility. What I think a lot of people do who are successful with
    6.   Bladder pressure                                                    perivaginal repairs, is they probably put there stitches here where I put
                                                                             my Birch stitches and then sew that out to the arcus tendentious fascia
         a.   Measured continuously throughout filling
                                                                             to the pelvis tensing the anterior vaginal wall. That is fine. Suspend-
         b.   A small chart strip recorder graphs a continuous               ing it going up to the arcus tendentious, long-term it should be stronger
              cystometric curve during bladder filling                       than suspending it directly at a right angle to the arcus tendentious
                                                                             fascia of the pelvis. Long-term, how well do the perivaginal repairs
         c.   Any bladder pressure increase that results in either           compared to Birches. Personally if I want to repair a perivaginal defect
              significant symptoms of urgency or urinary leakage are         I do this surgery. If I want to repair incontinence, I do a berch
                                                                             procedure if I am operating abdominally and I have chose to do that.
              significant.                                                   If I need to both, I do both.
    7.   Care must be taken with all single-channel cystometry
                                                                             There are numerous needle suspensions in the literature. These
         studies that false-positive diagnoses of detrusor overactivity      operations and there cure rates in the literature short-term tend to be
         are not made due to Valsalva                                        79-90%, subjective cure rates above that. Their longevity is poor. A
                                                                             10-year follow-up in the AUA series showed subjective cure rates
    8.   Increased intra-abdominal pressure will be recorded in the          below 30%. Their recommendation was that traditional needle
         bladder as an increase in bladder pressure                          suspensions should probably not be done and they should look for other
                                                                             operations. De Nova detrusor instability reported to occur 10-21% of
    9.   Without the measurement of coincidental abdominal pres-             the time, and there is significant amount of voiding dysfunction, which
         sure either through a vaginal or rectal catheter, confusion         ranges with urgency frequency syndromes and retention anywhere from
                                                                             15-30% of people. When we are operating on this woman and doing
         can exist as to whether a pressure increase represents an


                                                                                                                                                       9
               involuntary bladder contraction                                    a vaginal reconstruction which I believe that is a very good thing to do.
                                                                                  Nonetheless, if you are going to operate on this woman vaginally,
          10. Such confusion may sometimes be avoided by asking the
                                                                                  wouldn’t it be nice to have a needle suspension that you could do that
               patient to deeply inspire during such pressure elevations.         adds 15-20 minutes to the operation rather than needing it go above
               This should at least momentarily eradicate any increase in         and making a separate incision and do a Birch procedure or an MMK
                                                                                  or something like that. It is just logical, but it has to be as good. That
               intra-abdominal pressure                                           is what we are going to talk about a little bit on a theoretical basis.
          12. Electronic retrograde single-channel cystometry performed           Needle suspensions aren’t as good because they resupport the proximal
                                                                                  urethra but trying to do the same thing berch procedures do but the way
               with any of these methods may be used to screen for                they do it, suture endopelvic connective tissue and anterior vaginal wall
               detrusor instability with a diagnostic accuracy in excess of       here, but anteriorly to erectus fascia, which is mobile. If you put a
                                                                                  thick loop of suture in between these, the suture you would like to just
               75%                                                                lift this up anteriorly. The suture doesn’t know to do that. It is not that
               a.    When suspicious or equivocal studies arise or the            smart. It acts circumferentially. What it does is it pulls these two
                                                                                  layers closer together. Instead of lifting the pointer up like this, it justs
                     results of the studies do not confirm the patient's          put the layers together and you tie them under tension. If this comes
                     symptomatology,       more     complicated   multichannel    up halfway, this has to go down halfway. Tension with a permanent
                                                                                  suture in between these two layers like a wafer, what happens when the
                     studies are indicated                                        patient gets into the delivery room? Coughing and straining and the
               b.    These studies should be performed with the patient in        pressure are being exerted in the space Roexius. It is going to try to
                                                                                  separate these two layers. The fixed suture loop is going to pull
                     the standing position when possible because of in-
                                                                                  through the tissue like a cheese wire cutting through cheese at some
                     creased sensitivity                                          point. It is not surprising that we would see the longevity of these
                                                                                  operations is poor. In addition, if we have to compress these two layers
               c.    Provocative maneuvers may be used to augment the
                                                                                  together, we obviously increase urethral resistance, we will have more
                     sensitivity of these studies                                 voiding dysfunction, and it is not surprising that we are going to have
                     (1) Coughing                                                 more detrusor overactivity. If we are just doing the operation alone, we
                                                                                  can make incisions on either side of the bladder neck in the
                     (2) Valsalva                                                 anterolateral vaginal sulcus, probably just two 2.0 cm wide, dissect
                     (3) Heel bouncing                                            underneath the pubic ramous and perforate through either with our
                                                                                  fingers or the scissors, put the finger in and tear the tissue off the pubic
                     (4) Running water                                            ramous where it inserts in the undersurface of the pubic ramous to open
               d.    CO2, when placed in the bladder, may form acid and           tunnels perivesically on either side. The medial edge of the tissue that
                                                                                  we separate off is a condensation of the endopelvic connective tissue,
                     directly irritate the bladder wall, resulting in false-      which is just fibril fatty, and neurovascular bundle tissue. We call it
                     positive studies.                                            the posterior pubic urethral ligament. We envelop it in a helical suture
                                                                                  like this with a Ross, and we also incorporate the vaginal tissue here
               e.    Cold infusions are more likely to elicit bladder contrac-    that we reflected off and then we bring it back up into the abdominal
                     tions than body temperature infusions                        field with a blunt ligature carrier perforating just through the rectus
                                                                                  fascia. Because we dissected up to the undersurface of the rectus
VIII. Uroflowmetry                                                                muscles from below, it improves the safety of these operations by doing
     A.   A study of voiding velocity with the measurement of the numer-          the dissection directly rather than just blindly with our needles like a
                                                                                  Ghedies or a Stamy procedure is done. Then you tie down. The
          ous parameters utilized to screen for voiding dysfunction
                                                                                  question is always how tight do you tie. I tie my needle suspension
          1.   During spontaneous urofiowmetry, without instrumentation,          with a Q-tip in the urethra, so it just goes to 0°, and the posterior
                                                                                  urethral wall just starts to lift up or flatten out. That seems to work
               one is able to measure the maximum voiding velocity, the
                                                                                  fairly well, but the problem is we have trouble with sutures pulling
               mean velocity or flow rate, as well as flow time and the time      through. What we have been working on over the last three years is not
               to the point of maximum flow                                       anchoring anteriorly to rectus fascia but to some fixed immobile point
                                                                                  trying to make our needle suspensions more like Birch and MMKs.
          2.   Because voiding flow rates are dependent on bladder volume         We can use a titanium anchor anteriorly to fix the suture into the pubic
               at the time of voiding (much in the same way as the stroke         symphysis and then this picture looks like the diagram for the Birch
                                                                                  procedure or an MMK as opposed to when we try to put rectus fascia
               volume of the heart is dependent on the endiastolic volume         to anterior vaginal wall, and we have the problem that we talked about
               or filling volume of the heart), results obtained vary widely      before illustrated by the Stamy procedure where the tissue planes want
                                                                                  to separate and pull apart. If we fix it anteriorly all we do here is sort
               depending on bladder volume                                        of stabilize and that is the name percutaneous bladder neck stabiliza-
          3.   Normal values                                                      tion, which is essentially what birches and MMKs are. They are
                                                                                  transcutaneous bladder neck suspensions. Here we make a small
               a.    It is difficult to assess and define normal values without   incision just on the near side of the top of the pubic symphysis over the
                     the use of a continuous nomogram varying by bladder          pubic tubercle about 1.0 cm put a pinpoint bone locator, we take a drill
                                                                                  guide here, and it anchors into the bone. On a flat surface we can drill
                     volume.                                                      in the titanium screw and anchor. We then take the suture and put it
               b.    Nonetheless, when uroflowmetry is used as a screening        on a suture passer and bring it down the back of the pubic bone to
                                                                                  bladder neck and look here as we just perforate through as marked by
                     test for voiding abnormalities, maximum flow rates <15-


                                                                                                                                                            10
               20 ml/second represent some degree of obstruction as         the Foley catheter through the anterior vaginal wall. It perforates at
                                                                            1.5-2.0 cm lateral to the bladder. We then drop off the suture, move
               long as the voided volume is >150 mL
                                                                            the needle over a centimeter and a half, come back through at point two
          c.   Most people should be able to void moderate volumes          and pick up the suture. Then move down top three and complete a V-
               within 20-30 seconds, usually achieving peak flow rates      stitch by moving over to four. What this is a figure of eight suture on
                                                                            one side that encompasses where I put two sutures of a tonogo Birch of
               within the first 10 seconds of voiding                       about two square centimeters of tissue on either side of the bladder
     4.   Uroflowmetry is a screening test which looks at the end           neck staying about 1.5 cm lateral to the proximal urethra. We do this
                                                                            on both sides. We bring the needle back out and tie down over the
          result of a complex coordination between the bladder,             suture space, which puts a ¾ cm gap in each suture, so we stabilize
          urethra, and the voluntary muscles of the pelvic floor to         rather than compress. It automatically forces you to gap this operation
                                                                            by 1.5 cm of relaxation. It leaves us with 2 square cm area of tissue
          cause micturition. Evidence of an obstructive or retentive        being pulled up and stabilized by the bone anchor or stabilizing the
          pattern requires further evaluation with voiding pressure         anterior vaginal wall on either side of the urethra.
          studies or voiding cystourethrograms.                             The sling procedure is the last operation that we have that we routinely
B.   The clinical significance of uroflowmetry is quite different in men    do, and this is where we seek to not only support the urethra but by
                                                                            using some sort of strap underneath the urethra or a combination of
     than in women                                                          tissue and suture in some cases, we try to compress the urethra as well
     1.   In males, obstructive urofiow patterns (low flow rates)           as resupport it. We compress the proximal urethra and resupport it by
                                                                            suturing either rectus fascia, which is mobile. When we cough or
          usually represent some degree of physical obstruction,
                                                                            strain, rectus fascia moves anteriorly out like this even if you are in
          usually due to prostatic hypertrophy                              great shape and that will pull a moment of force up on the arms of the
                                                                            sling and tend to compress it. We can anchor it to Cooper’s ligament,
     2.   In women, physical obstruction is quite rare, and most
                                                                            which is immobile, and form a rigid backstop that the urethra can be
          obstructive uroflowmetry studies in women are from func-          pushed down on and likewise compress upon itself. Either way we get
          tional obstruction either due to neurologic or nonneurologic      urethral compression against a broad backstop. Cure rates in the
                                                                            literature are excellent. We see objective cure rates of 80-95%. What
          (inflammatory) causes                                             is really neat about slings and those of you that are familiar with these
     3.   Males normally void by urethral relaxation and detrusor           and do them, is there longevity is nearly 100%. Once a sling works, it
                                                                            will stay working potentially forever, especially when we use
          contraction, whereas women can achieve normal urofiow             heterologous materials like Mersilene, Marlex, Gore-Tex, Medx, etc.
          patterns by five different mechanisms                             These materials are stronger than our body tissues, and they will stay
                                                                            in place and not move forever. The problem is that while they work
          a.   Thus, the interpretation of uroflowmetry in females is       great, there is a big problem with De novo detrusor instability in 10-
               significantly limited to that of a screening tool            30%. They only resolve concurrent detrusor instability about 20-25%
                                                                            of the time, so they are not good operations when it comes to urge
          b.   In males, on the other hand, the information obtained        incontinence and detrusor instability. In addition, there are a lot of
               about flow rates can often be used as a direct measure       problems with retention. If you make slings just a little bit too tight,
                                                                            they are very unforgiving.
               of the degree of prostatic hypertrophy and its response      A primary indication for slings is people who have low-pressure
               to treatment                                                 urethras because we know that those people will fail the prior
                                                                            operations that we described somewhere between 45-60% of the time.
C. Uroflowmetry can be accomplished by two different methods
                                                                            When you are trying to operate for 10 or 15% failure rate and your
     1.   One involves the uses of electronic uroflowmeters, which          failure rate is really going to be 50 or 60%, it is time to find another
                                                                            operation. We operate for low-pressure urethras or type III inconti-
          take advantage of measuring urine velocity either by translat-
                                                                            nence if they fail periurethral injections. If you fail the MMK you
          ing the centripetal force of a water wheel into velocity, or by   should always do a sling. I am tempted to that sometimes but really
          the use of an instantaneous fluid weight scale to measure         most of the people in this group actually fall into the low pressure
                                                                            group. High risk patient like people of COPD, connective tissue
          the increasing weight of urine voided over time                   diseases or morbidly obese, then these are other reasons that we see for
     2.   A simpler method utilizes a stop watch, but allows neither for    doing slings. Fascial lata slings of 88 patients with an 89% cure rate.
                                                                            Half of them resolved their concurrent detrusor instability, which is
          calculations of maximum flow rate nor time to peak flow. It       quite high, to only 7% who have de novo detrusor instability, which is
          gives the an estimate of the mean flow rate by measuring the      quite low. 1% had permanent retention. Temporary retention beyond
                                                                            six weeks occurred in ¼ of his patients. UTI and almost all those
          volume of urine voided over a given period of time                people had 1% wound infections and sarcomas even using their own
D. Perhaps the most important part of uroflowmetry is the assess-           body tissues. When we use heterologous materials we have to worry
                                                                            about infection rates that may be even higher. This is a fascia lata sling
     ment of voiding completeness. Catheterization or some other            here harvesting above the knee. The other alternative is to do a rectus
     investigation of the urinary residual will determine who has the       fascia sling or an Altridge sling where we harvest a strip or two strips
                                                                            from the rectus fascia anteriorly and then we tape these and bring them
     most significant voiding dysfunction                                   into the vagina and anchor it underneath the urethra at the bladder
E.   Assessment with electronic uroflowmetry                                neck. Either set the tension abdominally like I like to with rectus
                                                                            fascia slings because it is easier to set the tension. You want to not
     1.   Generates a strip chart recording of voiding velocity as well


                                                                                                                                                   11
          as a printout of                                                 think about support or compression. All you want to do is sort of
                                                                           stabilize the urethra back at around 0 to +10° with a horizontal. You
          a.   The volume voided
                                                                           sort of want to put in close to where it was, and it will work fine for
          b.   Maximum and mean flow rates                                 curing stress incontinence. The problem so much isn’t curing stress
          c. Time to peak flow d. EMG activity when measured               incontinence, as it is not creating retention in detrusor instability. With
                                                                           heterologous materials, Morgan’s reported a five-year success rate
     2.   When the maximum flow rate is in excess of 20 mL/second,         some years ago of 77% just suturing Marlex to Cooper’s ligament with
          and the patient has no significant retention, uroflowmetry is    very little morbidity at 1% official of formation rate and a 3% infection
                                                                           rate. Nichols used Marlex, but he did an active sling. He put it to
          said to be normal in men                                         rectus fascia with a 95% success rate in curing or improving patients.
     3.   In women, when maximum flow rates are >15-20 mL/second           Those were not all cures. Some of the people were improved. We had
                                                                           a 92% cure rate using Gore-Tex to anterior rectus fascia, which was
          and the flow rate is bell-shaped the urofiowmetry study is       excellent. Objective cure rate, people didn’t leak a drop of urine four
          assessed as normal                                               months after surgery on testing to maximum systematic capacity. The
                                                                           problem was we only cured 20% of people who had concurrent detrusor
          a.   Uroflowmetry in women can be used qualitatively             instability, and we created concurrent detrusor instability 30% of the
               discern who might be Valsalva voiding. Usually Valsalva     time. 1/3 of our people while we cured their stress incontinence, we
                                                                           gave them a new problem, which was urge incontinence. That is not
               voiders have an intermittent or roller coaster type         very impressive. To get around some of those problems of retention
               pattern to the uroflow curve                                and voiding dysfunction.
          b.   Identification of women who are largely dependent on
                                                                           We sue vaginal wall slings in people of low-pressure urethras, weak
               the use of Valsalva to void, prior to any surgical inter-   bladder contractions and urge incontinence. We feel that this is the
                                                                           weakest sling that we can use. While Sholmer cures 91% of people, I
               vention, is helpful in trying to recognize which group of
                                                                           was just hoping that I could cure 71% of people. In fact, we reported
               patients might be at greater risk of voiding difficulty     our one-year cure rate objectively, and it is exactly that. We don’t do
               following a surgery that increases urethral resistance      as well with our Gore-Tex slings or rectus fascia slings. You know
                                                                           what, in doing this for five years and we probably do about 40 of these
               and prevents urinary leakage during Valsalva                a year, we have only had one woman need to self cath for any period of
F.   Uroflowmetry serves as a rapid screening method to assess the         time. Prior to that, if you look at other literature on others and ours the
                                                                           retention rate with slings can be anywhere from 3-18%. It is a very
voiding adequacy of patients                                               good operation for nonincreasing urethra resistance very much. We see
     1.   Care must be taken, especially in women, not to                  a resolution rate of detrusor instability in about 35-40% of people
                                                                           instead of 20% with our more aggressive slings. People of both
          overinterpret the results.                                       problems we use this operation. If you have a vertical incision, you
     2.   When abnormalities are found, the testing should be re-          stop here and just trace out a trapezoid above. You can make a
                                                                           blockade dissection where this is the advancement flap. We really
          peated                                                           don’t do that. We just trace out a trapezoid underneath the proximal
          a.   Depending on bladder volume, flow rates may vary            bladder neck and urethra, dissect away the tissue on either side and
                                                                           make tunnels just like we did with the Pererra procedure. Put four
               widely.                                                     sutures in the four corners and bring them up to rectus fascia and sew
          b.   Initial uroflowmetry studies are often falsely abnormal     them down above. The only problem is that while we have a 71% cure
                                                                           rate of one year, we found that anatomically only 61% of these people
               because of the patient's unfamiliarity with such testing
                                                                           had negative Q-tip tests. 39% of them had already developed urethral
               and devices.                                                hypermobility at one year. They said this isn’t very good. This is
                                                                           going to be like modified Pererra. It looks pretty good in the begin-
          c.   The patient who consistently shows evidence of obstruc-
                                                                           ning, and it fades with time. The same concepts involved with the
               tion on uroflowmetry should be evaluated more thor-         sling you can bone anchor this put a simple mattress suture in the
               oughly with multichannel voiding pressure studies with      vaginal epithelium and do what is called an in situ sling of vaginal
                                                                           sling that is bone anchored. What we found now at one year, we’ve
               EMG.                                                        seen that we have with our fascial patch slings where we harvest a
                                                                           piece of fascia instead of the vaginal epithelium which is a little more
                                                                           aggressive, we have a 97% anatomic correction rate at one year. 97%
                                                                           of people have negative Q-tip tests instead of 61%. We can use this
                                                                           concept and sort of leverage the concept of bone anchoring and do it
                                                                           toward in situ slings or harvest the fascial patch sling or a piece of
                                                                           Mersilene or Gore-Tex and suspend it as you see here to the bone
                                                                           anchor. Likewise hope to have really improved longevity, and this is
                                                                           the way we are going.

                                                                           Laparoscopic retropubic urethropexy. There are numerous techniques
                                                                           that have been described in the literature, but the point remains that
                                                                           two and a half years ago Burton, an Australian physician, did a
                                                                           prospective randomized trial after doing over 200 open Birches and
                                                                           over 100 scope Birches with traditional laparoscopic suturing. He


                                                                                                                                                   12
showed that the cure rates were equal at six weeks. One patient out of
30 in each group failed. At one year it was still one patient out of thirty
that failed and had recurrent stress incontinence where as in the scope
Birch group already you saw nine people or 27% failed. At two years
the rate went even higher. The real concern is the strength of the bites
that we take with traditional laparoscopic suturing using small needles
and needle holders that as you know as well as I do don’t always hold
quite as well as we would like delivering them at incident angles that
might not be quite what we do through an open dissection. We have
done a number of things to deal with this. I have tried six different
laparoscopic operations. It is just the pericurtineal balloon, and we use
gasless laparoscopy. What we do is place sutures in at the bladder
neck through Cooper’s ligament. When I am done I get the same Birch
procedure. It is not 30 minutes with staples and Mesh with one suture.
It takes a lot longer. We do Birches through a 4.0 cm incision instead
of the old 15-cm incision I used to use. It takes us a little bit longer.
It takes us about 45-60 minutes instead of 30-45 minutes. Cosmetically
they are a 4.0 cm incisions because it is equal to the three punctures we
used to make for laparoscopy. We can cosmetically do the same thing.
If you think about he needle suspensions and bone anchor suspensions
we were talking about, they are less invasive, more consistent, and give
us good long-term results also. I am not sure that going at it with
laparoscopic, so called birches or staples and Mesh, may be the best
way to treat our patients long-term.




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mike shinoda mike shinoda MR
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