Biofeedback in overactive bladder.

Biofeedback is a form of learning or re-education in which the participant is retrained within a closed feedback loop. Information about one or more of the patient's normally unconscious physiologic processes is made available to the patient as a visual, auditory, or tactile signal. Objective responses are recorded on a polygraph trace so that they can be easily observed. Subjective responses are more difficult to monitor and it is often difficult to separate these effects of biofeedback from the placebo effect. Biofeedback has been successfully employed in cases of urinary incontinence due to detrusor instability. Indeed, a recent report has shown that biofeedback-assisted behavioral treatment is more effective than either oxybutynin or placebo in the treatment of urge and mixed urinary incontinence in older, community-dwelling women. Patients embarking on biofeedback need to be well motivated and intelligent enough to understand what is expected of them. The treatment is time consuming for both the patient and the operator, but the benefits of successful treatment include a reduction in morbidity and side effects associated with other therapies. Biofeedback can be employed as an adjunct to other forms of treatment, such as drug therapy, and is particularly useful in children.

Evaluation of female urinary incontinence device.

A new silicone rubber inflatable vaginal pessary has been evaluated in 33 patients with stress incontinence due to urethral sphincter dysfunction (genuine stress incontinence), confirmed by urodynamic assessment. Nine of 20 patients who used the device for one month showed subjective improvement and 2 patients have continued to use the device. Urodynamic changes include a marked increase in maximum urethral closure pressure and elevation of the bladder neck.

Treatment of delayed onset of spontaneous voiding after surgery for incontinence.

A preliminary study on 40 female patients who had undergone colposuspension surgery was carried out using four drugs in an attempt to reduce the time taken to void spontaneously following surgery and to define the cause of delay. Oral diazepam given as night sedation, was found to be the most effective drug.

Urinary urgency in women.

Urinary urgency is a common unpleasant symptom which may result from a variety of different pathologies. Careful patient assessment and appropriate investigation allow the cause to be elucidated and treated effectively in most cases. However, further research is necessary to increase our understanding of these disorders and to improve the quality of life of the women affected by them.

Denervation and re-innervation of the urethral sphincter in the aetiology of genuine stress incontinence: an electromyographic study.

OBJECTIVE: To investigate the role of altered innervation of the urethral sphincter in the genesis of genuine stress incontinence. DESIGN: Prospective observational study. SETTING: Tertiary referral centre urodynamics unit. SUBJECTS: Sixty-eight women, 33 with urodynamically proven pure genuine stress incontinence and 35 controls without urinary symptoms. INTERVENTIONS: Concentric needle electromyography of the urethral striated sphincter. MAIN OUTCOME MEASURES: The means of motor unit potential duration, number of changes in polarity and the amplitude of individual motor unit potentials were compared between the two groups. RESULTS: There was no statistically significant difference in motor unit potential duration (P = 0.87) or in the number of changes in polarity (P = 0.85). There was a trend towards a higher amplitude of motor unit potentials in the control group (P = 0.07). CONCLUSIONS: Our findings suggest that denervation and re-innervation of the striated urethral sphincter following trauma to the pelvic floor, such as that occurring during childbirth, is not a major aetiological factor in the development of genuine stress incontinence.

A comparison of bioelectrical and mechanical activity of the female urethra.

OBJECTIVE: To determine the relationship between mechanical function and innervation of the urethra in order to clarify the effect of denervation and reinnervation on urethral function. DESIGN: Prospective observational study. SETTING: Tertiary referral urodynamics unit. SUBJECTS: Thirty-six women, 21 with urinary symptoms and urodynamically proven genuine stress incontinence and 15 without urinary symptoms. INTERVENTIONS: All women underwent concentric needle electromyography of the urethral sphincter and urethral pressure profilometry at rest and during cough induced stress. RESULTS: Significant correlations were found between variables indicating denervation and reinnervation and improved resting urethral function. No correlation was found between these variables and urethral function under stress. CONCLUSIONS: Our findings contradict current opinion that denervation of the urethral sphincter is associated with a reduction in the sphincteric function of the urethra, at rest or during stress, and suggest that denervation cannot therefore be a major aetiological factor in the development of genuine stress incontinence.

A comparison of vaginal and suprapubic surgery in the correction of incontience due to urethral sphincter incompetence.

A preliminary comparison is presented, with pre-operative and post-operative objective assessment, of 25 women undergoing anterior repair and 25 women undergoing colposuspension for the correction of incontinence due to urethral sphincter incompetence. Colposuspension was found to be effective. The mechanism of successful cure was likely to be a combination of bladder neck and proximal urethral elevation and narrowing.

A comparison between bromocriptine and indomethacin in the treatment of detrusor instability.

Our 32 patients with urinary symptoms owing to detrusor instability (either primary or secondary to an upper motor neuron lesion) have completed a clinical trial of bromocriptine and indomethacin. Each drug was administered for 1 month, using a single blind crossover method. The symptoms and any side effects were assessed by means of a questionnaire before entry into the trial, after administration of the first drug and at the end of the trial. The improvement in diurnal and nocturnal frequency owing to indomethacin was shown by McNemar's test to be statistically highly significant.

Genuine stress incontinence and detrusor instability--a review of 200 patients.

A clinical and urodynamic analysis of 100 women with geniune stress incontinence and 100 women with detrusor instability is presented to compare and contrast the conditions and the results of their treatment. Emphasis is placed on the need to distinguish accurately between these two conditions.

Surgical treatment of incontinence in elderly women.

Careful selection of patients can lead to a modest cure rate in elderly women for incontinence due to urethral sphincter incompetence. This is worth while when considering the few complications encountered during and after the surgical procedure, the independence the patients have achieved and the alternative incomplete cure which would have been afforded by conservative therapy.

Sex hormones, the menopause and urinary problems.

To date, there have been few appropriate placebo-controlled studies using both subjective and objective parameters to assess the efficacy of estrogen therapy for the treatment of urinary incontinence. Further confusion arises from the heterogeneity of different study protocols. Consequently, the best treatment in terms of type and dose of estrogen and route of administration is unknown. From these studies, however, there is clear evidence to suggest that recurrent urinary tract infection can be prevented or even treated by the use of estrogen therapy. Furthermore, systemic estrogen replacement appears to alleviate the symptoms of urgency, urge incontinence, frequency, nocturia and dysuria, and low-dose topical estrogen is effective in the management of atrophic vaginitis. Although the latter example appears to be free from side-effects, even following prolonged administration, it is unclear whether low-dose therapy has a sufficient effect on the lower urinary tract to treat urinary incontinence. There is no conclusive evidence that estrogen replacement alone is sufficient to cure stress incontinence, but in combination with an alpha-adrenergic agonist there may be a role for estrogen therapy in the conservative management of genuine stress incontinence. On the other hand, estrogen supplementation definitely improves the quality of life of many postmenopausal women and, therefore, makes them better able to cope with other disabilities. Perhaps the role of estrogen in the management of postmenopausal urinary disorders is as an adjunct to other methods of treatment such as surgery, physiotherapy and drugs. This is certainly a hypothesis which should be tested.

An objective comparison of the effects of parenterally administered drugs in patients suffering from detrusor instability.

Cystometric changes produced by 3 parenterally administered drugs, flavoxate hydrochloride, emepronium bromide and imipramine hydrochloride, have been evaluated in 15 female patients with detrusor instability. Each patient was given 2 of the 3 drugs and cystometric recordings were done 10 and 30 minutes after the administration of each drug. Emepronium bromide was found to be the only drug to cause a significant improvement in bladder capacity and reduction in detrusor pressure.

Results of the colposuspension operation for incontinence and prolapse.

One hundred and eighty female patients complaining of stress incontinence were treated by a modified Burch colposuspension. Follow-up results were available at six months in 146 patients, at one year in 88 patients and at two years in 43 patients. The overall objective cure for stress incontinence was 87 per cent at six months, 87.5 per cent at one year and 86 per cent at two years. No relationship was found between the cure of incontinence and either the time taken to resume spontaneous voiding after surgery or concomitant hysterectomy. Cystourethrocele was effectively corrected by this procedure.

Perineal pad weighing versus videographic analysis in genuine stress incontinence.

A comparison was made of the sensitivity of perineal pad testing and the videographic diagnosis of genuine stress incontinence (GSI) in postmenopausal women. The 99% upper confidence limit for pad weight gains in 90 normal women was 1.4 g. Ninety-nine women with urodynamically proven GSI were studied and 14 had false negative pad tests. There was no significant correlation between the videographic assessment and the gain in pad weight. We recommend the use of the pad test to confirm incontinence only in the absence of imaging facilities as the latter is more sensitive.

Detrusor instability following surgery for genuine stress incontinence.

Nnety-two female patients with genuine stress incontinence, and with otherwise normal bladder function, were treated by a colposuspension operation. Pre-operative and post-operative clinical and urodynamic assessments were performed on all patients. Following surgery 17 of them were found to have detrusor instability.

Vaginal oestradiol for the treatment of lower urinary tract symptoms in postmenopausal women--a double-blind placebo-controlled study.

A prospective randomised double-blind placebo-controlled trial of 17-beta oestradiol 25-mg vaginal tablets or placebo daily for 12 weeks was undertaken in 110 postmenopausal women with urinary frequency, urgency and/or urge incontinence recruited from a tertiary referral urogynaecology clinic. After 3 months the only statistically significant difference was a greater reduction in urinary urgency in those women with sensory urgency treated with 17-beta oestradiol compared to placebo. This may be due to the effective treatment of local vaginal atrophy by low-dose oestrogen rather than any effect on the lower urinary tract.

Ultrasound: a noninvasive screening test for detrusor instability.

OBJECTIVE: To determine whether transvaginal ultrasound measurement of bladder wall thickness can be used as a screening test for detrusor instability in women with urinary symptoms. DESIGN: A blinded prospective study. SETTING: A London teaching hospital. PARTICIPANTS: One hundred and eight-four symptomatic women presenting to a urodynamic clinic. MAIN OUTCOME MEASURE: The detection of detrusor instability by means of videocystourethrography (VCU) and ambulatory urodynamics in women with a mean bladder wall thickness of greater than 5 mm measured by transvaginal ultrasound. RESULTS: One hundred and eight women had a mean bladder wall thickness of greater than 5 mm. Ninety-four percent (102) of these women had detrusor instability either when undergoing VCU or ambulatory urodynamics. Seventeen women had a bladder wall thickness of less than 3.5 mm of whom three were found to have detrusor instability on VCU. CONCLUSION: The measurement of a mean bladder wall thickness greater than 5 mm with transvaginal ultrasound is a sensitive screening method for diagnosing detrusor instability in symptomatic women without outflow obstruction.

Assessment of urinary symptoms in early pregnancy.

OBJECTIVES: To determine the correlation between lower urinary tract symptoms and urodynamic findings in early pregnancy. SETTING: The termination clinic and gynaecology ward at King's College Hospital. DESIGN: Observational study. SUBJECTS: 47 women before termination of pregnancy at between 6 and 15 weeks. INTERVENTIONS: Women filled in symptom questionnaires and then had urodynamic investigations, consisting of uroflowmetry and subtracted provoked cystometry. MAIN OUTCOME MEASURES: The occurrence of lower urinary tract symptoms and their association with urodynamic findings. RESULTS: Lower urinary tract symptoms were fairly common but there was poor correlation with the urodynamic findings. CONCLUSIONS: The findings suggest that lower urinary tract symptomatology alone is insufficient to study lower urinary tract dysfunction in pregnancy.