Female urinary problems. A gynaecological view.

Urinary incontinence in women is common and it is surprising how many endure it in the erroneous belief that little can be done. Their life is made miserable by a problem which often can be cured or at least significantly alleviated by the judicious use of drugs or surgery.

Urodynamics. Is it useful for the gynaecologist?

The investigation of female incontinence is incomplete without the performance of a urodynamic evaluation. A diagnosis made only on a clinical history and examination is too inaccurate to allow for the proper management of the patient. In a personal series of 100 patients only 56% of those who were ultimately considered to have stress urinary incontinence were correctly diagnosed by clinical means as opposed to 97% correct using urodynamics. A urodynamic evaluation should be performed on most female patients suffering from urinary incontinence and is essential for patients who are being considered for surgery for recurrent stress incontinence. Mention is made of a group of 8 patients whose incontinence was due to a very low urethral closure pressure who responded well to phenylpropanolamine.

Urinary voiding patterns of apparently normal women.

A survey of 886 women who considered themselves to be normal was carried out to determine voiding habits in the population and the prevalence of urinary incontinence of any degree. Eighty-eight percent voided at 3-6 hourly intervals. Increasing age did not affect the frequency of micturition but parturition did. Nocturia was present in 18% but increased with age. Thirty-two percent of the study group admitted to having had one or more episodes of incontinence. Having borne a child increased the prevalence of incontinence but increasing age did not. There was a small but significant occurrence of apparent sphincter weakness in nulliparas.

Bonney's test--fact or fiction?

A prospective urodynamic study in 61 incontinent women assessed the validity of the Bonney test in the diagnosis of true sphincter weakness stress incontinence. The urodynamic findings in all the patients indicated that the Bonney test produced significant increases in the urethral closure pressure and transmission of impulse from the abdomen to the urethra which indicated occlusion of the urethra rather than elevation of the bladder neck. The Bonney test does not differentiate between patients with sphincter weakness and those with bladder instability and therefore should be discarded.

Seven years experience in the evaluation and management of patients with urge incontinence of urine.

In 1970 the authors established a specific clinic at the Royal Women's Hospital in an attempt to evaluate the causes of urinary incontinence, to improve the follow-up of patients treated for this complaint, and to determine areas where treatment was deficient. Of 258 patients seen in the clinic so far 80 (31%) were considered to have had stress incontinence, 84 (33%) urgency, and 82 (32%) both symptoms. Incontinence of urine with exertion was common in patients with urgency and furthermore, the Bonney test of urethral elevation was of no value in distinguishing stress from urge incontinence. Therapy with Probanthine 15 mg t.d.s. and Tofranil 25 mg t.d.s. was effective in 127 patients (90%) in whom urgency was the sole or dominant complaint.

Treatment of the unstable bladder with propantheline and imipramine.

This study shows propantheline and imipramine to be effective in the management of the unstable bladder. It emphasizes the need for urodynamic studies for the accurate diagnosis of urinary incontinence. Comparisons have been made of the efficacy of propantheline and imipramine in various groups of incontinent women and indicates that in appropriately selected groups the 'cure' rate is over 70% but if sphincter weakness is excluded, urodynamics cannot differentiate between those women with unstable bladders who will respond to this medication and those who will not.

Urodynamic investigation in the management of incontinent women.

One hundred and sixty-eight women presenting to a Urinary Incontinence Clinic were studied. Only 52% had a urodynamic diagnosis that supported their clinical signs and symptoms. The response rates to various modalities of treatment for each urinary disorder are described. Fifty-one percent achieved a complete response with the treatment selected, 27% had a partial response, and 10% did not respond or deteriorated. Twelve percent of patients were lost to follow-up.

The sign of stress incontinence--should we believe what we see?

The accuracy of the clinical sign of stress incontinence in the diagnosis of genuine stress incontinence (GSI) was evaluated in 863 (consecutive) women, 779 of whom were referred with the symptom of urinary incontinence. Subjects were assessed clinically and urodynamically by the one clinician (PLD). The positive and negative predictive values of the clinical sign of stress incontinence for a diagnosis of GSI were 91% and 50% respectively. Of the 569 women with GSI, 335 (59%) had GSI as their sole diagnosis and 234 (41%) had an additional urodynamic diagnosis. The clinical sign of stress incontinence when present was a reliable guide to a final diagnosis of GSI. Clinical assessment of incontinent women requires the back-up of urodynamic studies in order to make an accurate diagnosis.

Stamey-Martius procedure for severe genuine stress incontinence.

There are few options now available to treat patients with severe genuine stress incontinence caused by urethral failure. These patients usually have a low maximum urethral closure pressure (less than 20 cm of water) and anterior vaginal wall scarring caused by previous surgery. In 32 such patients we used the Martius fat pad insertion procedure, in addition to the Stamey procedure, and achieved a 91% symptomatic success rate over a mean 13-month follow-up period. Because of its simplicity, reliability and low morbidity, we recommend this procedure in this difficult group of patients before performing a sling procedure or insertion of an artificial urinary sphincter.