STRESS INCONTINENCE IN WOMEN—Treatment by Retropubic Urethrovesical Suspension

Twenty-four retropubic urethrovesical suspension operations were performed in a five-year period. Twenty-one of the patients were satisfied with the results, although the objective success of the operation did not always correlate with subjective relief of symptoms. The commonest apparent cause for failure was the coincidence of urgency with stress incontinence, and the few true failures, due to secondary relaxation of the paraurethral supports, were often mitigated by compensatory learning on the part of the patients, many of whom remain blissfully unaware of the underlying weakness.The retropubic urethrovesical suspension operation is simple, effective, and free of complications. It is indicated as a primary procedure whenever a vaginal operation has failed to cure (or, worse, has caused) stress incontinence. It is advised as a complementary procedure for women with a secondary complaint of stress incontinence who must undergo laparotomy for other cause.     

The sublingual administration of curare

Urinary continence in women is intimately associated with adequate support of the neck of the bladder. Any increase in tone of the bladder musculature, or in the intravesicular pressure, substantially increases the liability to incontinence. Obstetrical trauma may cause stress incontinence by disrupting supports of the neck of the bladder and by stretching the fascial structures of the posterior portion of the neck of the bladder. Minor injury not grossly demonstrable may occur in this way and upset the very delicate balance existing between the forces of the detrusor muscle and the resistance of the urethrovesical junction.In correcting the defects associated with stress incontinence, there are specific indications for various methods-active exercise, plastic reconstruction of the bladder and urethral supports, and the various operations for suspension of the neck of the bladder.     

STRESS INCONTINENCE OF URINE—A Consideration of Etiologic Factors in Women

Urinary continence in women is intimately associated with adequate support of the neck of the bladder. Any increase in tone of the bladder musculature, or in the intravesicular pressure, substantially increases the liability to incontinence. Obstetrical trauma may cause stress incontinence by disrupting supports of the neck of the bladder and by stretching the fascial structures of the posterior portion of the neck of the bladder. Minor injury not grossly demonstrable may occur in this way and upset the very delicate balance existing between the forces of the detrusor muscle and the resistance of the urethrovesical junction.In correcting the defects associated with stress incontinence, there are specific indications for various methods—active exercise, plastic reconstruction of the bladder and urethral supports, and the various operations for suspension of the neck of the bladder.     

经耻骨上膀胱尿道悬吊术的手术护理

目的:探讨经耻骨上膀胱尿道悬吊术(SPARC)的手术护理方法。方法:对24例女性尿失禁采用SPARC进行手术治疗。结果:21例患者术后尿控满意,3例有轻度尿失禁,无排尿困难及尿路感染。结论:做好术前宣教、心理护理、熟悉手术步骤、对手术所需器械和物品的充分准备是保证手术顺利实施的前提。注意患者体位的护理,预防并发症的发生,熟练准确的技术配合是SPARC手术的护理核心。     

女性压力性尿失禁患者盆底三维超声显像初步研究

目的:通过三维超声对正常未孕妇女及产后压力性尿失禁(SUI)患者的盆底结构显像,研究SUI患者的膀胱颈尿道活动度及肛提肌变化,评估三维超声显像对女性盆底病变的诊断价值.方法:分别对研究组和对照组行盆底结构三维超声检查,测量膀胱尿道连接部的直接移动度(UVJ-M)、张力期膀胱尿道后角、静息期及张力期耻骨直肠肌厚度、耻骨直肠肌夹角,观察肛提肌形态.结果:SUI研究组UVJ-M 15.93± 2.07mm,较对照组7.64± 1.37mm增大(P＜0.01),研究组张力期膀胱尿道后角145.90±22.03°,较对照组106.49±14.32°增大(P＜0.01),研究组静息期耻骨直肠肌厚度6.39±0.48小于对照组6.71±0.69(P＜0.05),研究组张力期耻骨直肠肌厚度6.13±0.49小于对照组6.64± 0.61(P＜0.05),静息期研究组耻骨直肠肌夹角70.08±3.15大于对照组69.45±2.19°,但无统计学意义(P＞0.05),张力期75.49±3.92大于对照组70.35±1.51° (P＜0.01).结论:三雏超声显像能直观有效地观察女性尿道、肛提肌等盆底结构,对诊断压力性尿失禁是一个有意义的辅助手段.     

The Long-Term Influence of Body Mass Index on the Success Rate of Mid-Urethral Sling Surgery among Women with Stress Urinary Incontinence or Stress-Predominant Mixed Incontinence: Comparisons between Retropubic and Transobturator Approaches

Objectives

Mid-urethral sling (MUS) surgery for the treatment of urinary incontinence has been widespread since the introduction of tension-free vaginal tape in the mid-1990s. The majority of studies with short-term follow-up <2 years found no differences in the surgical outcomes according to body mass index (BMI). However, considering the chronic influence of obesity on pelvic floor musculature, it is cautiously speculated that higher BMI could increase stress on pelvic floor and sub-urethral tape, possibly decreasing the long-term success rate in the obese population. We aimed to compare the long-term effects of BMI on the outcomes of MUS between women with retropubic and transobturator approaches.

Methods

We performed a retrospective analysis on 243 consecutive women who received MUS and were followed up for ≥36 months. The influence of BMI on the success rates was separately estimated and the factors for treatment failure were examined using logistic regression in either approach.

Results

The mean follow-up was 58.4 months, and 30.5% were normal weight, 51.0% overweight, and 18.5% obese. Patients received either the retropubic (30.5%) or transobturator (69.5%) approach. The success rates (%) under the transobturator approach differed according to the BMI groups (94.3, 88.6, and 78.6, respectively; P = 0.037) while those under the retropubic approach were not different according to the BMI groups. However, in multivariate models, only the presence of preoperative mixed urinary incontinence (MUI) was proven to be the risk factor for treatment failure in the transobturator approach (OR 6.39, P = 0.003). The percent of subjects with MUI was higher in obese women than in non-obese women with the transobturator approach.

Conclusions

BMI was not independently associated with failures in either approach. Higher success rates in women with lower BMI in the transobturator approach were attributed to the lower percent of preoperative MUI in those with lower BMI.     

Reconstruction of Urethra Totally Destroyed in Labour

Of 50 women who underwent a reconstruction procedure for a totally destroyed urethra, caused by obstructed labour, 35 were clinically cured, eight had serious stress incontinence, and six developed urethral stricture; one operation failed completely, but a repeat reconstruction was completely successful. The procedure consists of repair of the bladder fistula, followed by the construction of a new urethra; the latter is then reinforced by one gracilis muscle detached from its insertion and brought through a tunnel in the fascia of the upper thigh and the labium to be attached to the anterior lip of the cervix. Hence this method combines procedures originally suggested for other purposes by Ingelman-Sundberg and Martius.     

成年女性压力性尿失禁患者心理健康状况调查分析

目的:探讨成年女性压力性尿失禁患者的心理健康状况,提出护理干预方法。方法:采用SCL-90及自编一般资料,对浏阳市市区80名有压力性尿失禁症状的成年女性进行心理健康自评调查,另80名无压力性尿失禁症状的成年女性为对照。结果:有压力性尿失禁症状的成年女性SCL-90总分、阳性项目数、阳性项目均分及躯体化、人际关系、抑郁、焦虑、敌对、恐怖和精神病性等因子评分均明显高于对照组及常模组(P<0.05)。结论:成年女性压力性尿失禁患者心理健康状况不容乐观,应引起重视,并对其进行护理干预,加强对她们的心理疏通,可以提高疾病的防治效果。     

Purse string-formed plication of the SMAS with fixation to the zygomatic bone

The superficial musculoaponeurotic system (SMAS) operation revolutionized face-lift procedures. The idea of having one direction of traction with suturing and fixation of SMAS to a stable structure is gaining popularity. The author's contribution is the fixation of the SMAS and the extension of the supraplatysmal plane to the zygomatic bone periosteum to achieve stable traction and fixation. This procedure has not been described before in medical literature. The purse string-formed plication of the SMAS is a procedure in which the soft tissue (SMAS, parotid fascia, and the extension of the supraplatysmal plane) is plicated and fixed to the periosteum of the zygomatic bone. This superficial operation avoids entering the deeper planes, which could result in severe complications. The procedure fills the cheeks and gives a more natural look than standard face lifts. A total of 250 patients underwent this procedure. The suspension achieved seemed to be more stable than some SMASectomy techniques. Complication rates and recovery times were low. The purse string-formed plication of the SMAS is a safe, quick, and simple procedure with effective results suitable for younger patients with good skin conditions.     

经利用网片的前盆底重建术治疗重度盆腔器官脱垂的临床疗效

目的:探讨经利用网片的前盆底重建术治疗重度盆腔器官脱垂的临床效果。方法:选取2013年1月-2015年3月我院妇科收治的以前中盆腔联合缺陷为主的盆底障碍性疾病患者39例(POP-Q分度III-IV度)。实施经阴道Avaulta前盆腔重建术,24例切除子宫,9例保留子宫,其中6例因中盆腔重度脱垂联合行阴道残端骶棘韧带固定术,2例合并尿失禁同时行经尿道无张力悬吊术。术后随访12-25月,根据盆腔脏器脱垂评分(POP-Q)测量及PFIQ-7评分进行客观评价及主观感受评价进行中短期的临床效果分析。结果:39例患者手术过程顺利,术后无严重并发症,POP-Q评分均较术前显著降低,客观疗效理想。术后阴道前壁及子宫、阴道穹窿脱垂等症状显著改善;到目前为止无一例复发。结论:经阴道前盆腔重建术治疗前盆腔重度盆腔脱垂为主以及合并尿失禁等复杂情况的并发症少,治愈率高,复发率低,临床效果好。     

The structure of the human symphysis pubis with special consideration of parturition and its sequelae

Review of the structure of the symphysis pubis, based on my extensive study of the pelvic joints ('31) shows changes from age, function, pregnancy hormones and stress of parturition. Primary physiologic shearing clefts and secondary traumatic clefts in cartilage are more frequent in females. Inter-digitations in the young osteocartilaginous border secure the vulnerable growth cartilage against increasing shearing forces. The retropubic eminence, ligamentous or cartilaginous, forms earlier in females, later, due to bony lipping in males, secondary to extrusion of disc cartilage. Ovarian and placental hormones in pregnancy cause remodeling and resorption of the posterior margin of the pubic facette and adjacent cortex, making a (variably) deep bony groove for greatly hypertrophied transverse ligaments. Delivery of a mature infant produces traumatic changes leading to extrusion of torn fibrocartilage in any direction, progressively loosening the symphysis, producing cartilage nodules, cysts and reactive bone formation. Older age degenerative arthritis is more frequent in parous females.     

Vesical Dysfunction Due to Prolapsed Disc

Neural disturbance of micturition may occur as a result of a prolapsed intervertebral disc. Single nerve root lesions are unlikely to cause bladder dysfunction; a massive central protrusion producing total blockage of the vertebral canal or multiple disc lesions are more likely to cause disturbance of voiding. High lesions are more prone to cause severe bladder dysfunction. Vesical dysfunction may sometimes be present without the typical back and leg pain.Provided a gynaecological cause is excluded, any young or middle-aged woman developing incontinence and retention with a sterile urine must be fully investigated to exclude a disc lesion. Once the disc has been removed, bladder function will improve, but in some cases recovery will be slow. Rarely some patients have permanent bladder dysfunction following a disc operation.     

悬吊训练疗法联合生物反馈电刺激对产后压力性尿失禁患者盆底功能和尿流动力学的影响

摘要 目的：观察悬吊训练疗法联合生物反馈电刺激对产后压力性尿失禁（PSUI）患者盆底功能和尿流动力学的影响。方法：选择2019年7月~2021年8月期间我院接收的PSUI患者96例,符合要求的患者根据信封抽签法分为对照组（48例）和研究组（48例）。对照组患者接受悬吊训练疗法,研究组患者接受悬吊训练疗法联合生物反馈电刺激,对比两组疗效、盆底功能指标和尿流动力学指标,观察两组尿垫试验漏尿量、国际尿失禁咨询委员会尿失禁问卷简表（ICI-Q-SF）问卷评分。结果：研究组的临床总有效率高于对照组（P<0.05）。治疗1个月后,两组24 h尿垫试验漏尿量和ICI-Q-SF问卷评分降低,且研究组低于对照组（P<0.05）。研究组治疗1个月后盆底肌力改善效果优于对照组（P<0.05）。两组治疗1个月后最大尿道闭合压力（MUCP）、功能尿道长度（LES）、腹压漏尿点压（ALPP）、与最大尿流率（Qmax）升高,且研究组高于对照组（P<0.05）。结论：PSUI患者经悬吊训练疗法联合生物反馈电刺激干预,可有效改善临床症状,促进盆底功能和尿流动力学恢复,效果显著。     

Burch colposuspension for stress urinary incontinence: a 14-year prospective follow-up

We aimed to evaluate the long-term effectiveness and safety of Burch colposuspension(BC) for stress urinary incontinence(SUI). In this prospective cohort study, 84 patients with SUI undergoing BC were enrolled from February 2004 to January 2010.Data on long-term subjective success and postoperative complications were collected at clinic visits and by telephone follow-up.During a mean follow-up period of 14.2 years, 68%(57/84) patients completed the follow-up. A total of 68.4% of patients(39/57) ...     

Impact of surgery for stress incontinence on morbidity: cohort study.

OBJECTIVES: To describe the impact of surgery for stress incontinence on the severity of symptoms, other mental and physical symptoms, and overall health. To describe the incidence of postoperative complications. DESIGN: Prospective cohort study; questionnaires completed by patients before and 3, 6, and 12 months after surgery. Questionnaires completed by surgeons both before and after surgery. SETTING: 18 hospitals in the North Thames region. SUBJECTS: 442 women treated surgically for stress incontinence between January 1993 and June 1994. 367 women returned the 3 month questionnaire; 364 returned the 6 month questionnaire; and 359 returned the 12 month questionnaire. 49 surgeons provided perioperative information on 285 of the 442 women and postoperative information on 278. MAIN OUTCOME MEASURES: Stress incontinence symptom severity index, other urinary symptoms, bowel function, mental health, complications, global measures. RESULTS: Most women (288; 87%) reported an improvement in the severity of their stress incontinence, though only 92 (28%) were cured (continent). These improvements persisted for at least 12 months. The likelihood of improvement was similar regardless of whether urodynamic pressure studies had been conducted before surgery. Following surgery, women were less likely to suffer from urinary frequency, nocturia, postvoid fullness, dysuria, and urgency. While mental health improved for 194 (71%), a quarter of women reported deterioration. Only 37 (10%) were satisfied with postoperative pain control. A third experienced one or more complications while in hospital, most commonly difficulty urinating. This problem affected 1 in 11 women after discharge. A year after surgery two thirds of women reported feeling better (251; 72%), that the outcome met or exceeded their expectations (230; 66%), and that they would recommend the operation to a friend in a similar situation (239; 68%), and that they would recommend the operation to a friend in a similar situation (239; 68%). Surgeons tended to be more optimistic about the effects of surgery; they were satisfied with the outcome in 176 (85%) cases and would again treat 245 (94%) of the women as they had done previously. CONCLUSIONS: Although surgery reduces the severity of stress incontinence it is not as effective as current textbooks suggest. Women considering surgery should be provided with more accurate information on the likelihood of an improvement in symptoms and the occurrence of complications, including postoperative pain. Urgency and urge incontinence should not be considered contraindications to surgery. The need for urodynamic assessment before surgery should be reappraised.     

改良腹腔镜下子宫悬吊术加圆韧带缩短术治疗子宫脱垂的临床观察

目的:研究改良腹腔镜下子宫悬吊术加圆韧带缩短术治疗子宫脱垂的临床效果。方法:将从2014年1月至2015年8月在我院妇科接受手术治疗的子宫脱垂患者60例作为研究对象,其中接受改良腹腔镜辅助下实施子宫悬吊术联合圆韧带缩短术者30例纳入观察组,接受阴式子宫切除术者30例纳入对照组,观察并对比两组治疗前后的盆腔器官脱垂定量(POP-Q)分度情况、手术相关指标及手术并发症。结果:与治疗前比,治疗后两组的POP-Q分度均显著改善(P0.05)。观察组的手术时间、术中出血量以及术后留院时长分别显著少于对照组(P0.05)。观察组的手术并发症总发生率是10.00%,显著低于对照组的33.33%(P0.05)。结论:在改良腹腔镜辅助下实施子宫悬吊术联合圆韧带缩短术对子宫脱垂患者的疗效显著,且有利于患者尽快康复,安全性高,值得临床推广应用。     

Expectations of Stress Urinary Incontinence Surgery in Patients With Mixed Urinary Incontinence

Mixed urinary incontinence is estimated to affect 30% of all women who have urinary incontinence, and it has been shown to be more bothersome to women than pure stress incontinence. Given the degree of bother, many women will undergo surgical correction for incontinence. Patients have high expectations about the success of these interventions. Understanding mixed incontinence and the effects of our interventions can help guide therapeutic choices and manage patients’ expectations.Key words: Urodynamics, Mixed urinary incontinence, Sling, Anti-incontinence surgery, Urgency incontinenceIt has been estimated that approximately 30% of women with urinary incontinence have mixed urinary incontinence (MUI). Degree of bother is higher among women with MUI compared with those who have pure stress urinary incontinence (SUI).¹ MUI can be a very challenging and costly condition to treat.^2,3 Patients with MUI are often offered conservative therapy such as physical therapy, weight-loss strategies, and behavioral modification. Some patients also benefit from treatments aimed directly at urgency, frequency, and urgency incontinence (overactive bladder), which currently include pharmacologic therapy (antimuscarinic or β-3 agonists), chemodenervation (botulinum toxin), or neuromodulation (sacral or posterior tibial nerves).⁴ However, many patients with MUI progress to surgical therapies for treatment of SUI. This article reviews the literature available that can help clinicians manage expectations of SUI surgeries on patients with MUI.     

THE APPLICATION AND EVALUATION OF PERITONEOSCOPY

Peritoneoscopic examination has now been accepted throughout the world as a safe diagnostic procedure in lieu of laparotomy in selected cases.Laparotomies for diagnostic purposes alone should be condemned.Peritoneoscopy should not be done without a definite purpose and the procedure should not be expected to accomplish more than the purpose for which it is done. Indications for the procedure are set forth in detail. Experience has established definite contraindications, which are reviewed.The procedure is especially indicated for patients who are aged, emaciated, anemic, or poor surgical risks for any reason.All patients having ascites of undetermined cause should be examined by peritoneoscopy.The method is especially indicated for examination of patients with liver disease of all types, for pelvic examinations, for use to determine existence of ectopic pregnancy, and for tumor localization.Considerable use was made of the procedure during World War II to determine the extent and site of intra-abdominal injuries caused by crushing, explosions, and falls from high places.The procedure permits early and correct diagnosis, early decision as to the advisability of operation, and determination as to operability in cases of malignant gastric lesions. It is a safe method for obtaining biopsy specimens from intra-abdominal tissue and organs.Accuracy of diagnosis in cases in which the method can be used is considerably greater with peritoneoscopic examination than with clinical information alone.     

Evaluation and surgical management of intrinsic sphincter deficiency after radical prostatectomy

Urinary incontinence following prostatectomy is usually due to intrinsic sphincter deficiency and is often referred to as post-prostatectomy incontinence (PPI). The male sling is an effective minimally invasive procedure for low volume PPI. Although the male sling procedure is becoming increasingly popular, the artificial urinary sphincter (AUS) remains the gold standard. Placement of the AUS cuff using the transcorporal technique salvages patients with urethral atrophy as well as prior AUS erosion or infection. As the surgical options for PPI expand, it is important to analyze the outcomes with contemporary surgical techniques and to develop an algorithm for procedure selection.     

The prevalence of urinary incontinence

Urinary incontinence is a significant health problem with considerable social and economic impact. It is important to distinguish between prevalence and incidence with regard to incontinence, and prevalence-the probability of having incontinence within a defined population at a defined point in time-is the more important when considering its impact and the utilization of healthcare resources. There are large variations in the severity and impact of incontinence, and its severity, frequency, and predictability all need to be considered when evaluating its effects on patients, The degree of bother is particularly significant when determining who will need treatment. Incontinence may be a result of bladder dysfunction, sphincter dysfunction, or a combination of both, but large-scale studies are not designed to determine the etiology. In young women, the prevalence of incontinence is usually low, but prevalence peaks around menopause, with a steady rise there-after into later life. Although the prevalence of stress and mixed (stress and urge) incontinence is higher than urge incontinence, the latter is more likely to require treatment. In women, moderate and severe bother have a prevalence ranging from about 3% to 17%. Severe incontinence has a low prevalence in young women, but rapidly increases at ages 70 through 80. In men, the prevalence of incontinence is much lower than in women, about 3% to 11% overall, with urge incontinence accounting for 40% to 80% of all male patients. Stress incontinence accounts for less than 10% of cases and is attributable to prostate surgery, trauma, or neurological injury. Incontinence in men also increases with age, but severe incontinence in 70- to 80-year-old men is about half of that in women. The most effective therapy for incontinence will rely on targeting the correct populations to be treated, which depends on how data is collected on prevalence and severity.