[Gynecology: urinary incontinence - mini-review and case reports]. / Gynäkologie: Fälle aus der Harninkontinenz-Sprechstunde.

Although urinary incontinence affects one in three women, it is still a taboo topic. Today, effective conservative and surgical treatment options are available. When conservative therapies fail, minimally invasive surgical methods can be offered. The tension-free vaginal tape TVT is gold standard in the treatment of female stress urinary incontinence. In case of immobile urethra or in multi-morbid patients, the minimally invasive technique of periurethral injection of bulking agents may be useful. In patients with refractory overactive bladder, the intravesical injection of botulinum neurotoxin is available.

Histomorphological analysis of the urogenital diaphragm in elderly women: a cadaver study.

The objective of this study was to describe the histomorphological structure of the urogenital diaphragm in elderly women using a modern morphometric procedure. Biopsies were taken from the posterior margin of the urogenital diaphragm of 22 female cadavers (mean age, 87 years) using a 60-mm punch. Hematoxylin/eosin and Goldner sections were analyzed with the Cavalieri estimator. The mean thickness of the urogenital diaphragm was 5.5 mm. The main component was connective tissue. All biopsies contained smooth muscle. Eighteen biopsies contained more smooth muscle than striated muscle. In six of 22 biopsies, no striated muscle was found. The ratio of striated to smooth muscle to connective tissue was 1:2.3:13.3. Muscle fibers were dispersed in all parts of the urogenital diaphragm. The urogenital diaphragm of elderly women mainly consists of connective tissue. Smooth muscle was also found but to a lesser extent. The frequently used English term "perineal membrane" for the urogenital diaphragm is justified and well describes our findings in elderly women.

[Urinary incontinence and descensus genitalis--the silent sickness]. / Harninkontinenz und Descensus Genitalis--Das stille Leiden.

In the last few years, urogynaecology has become a very innovative gynaecological subspecialty. New findings have led to a multitude of different medicinal and operative therapy options. Stress incontinence can be improved by sling procedures in more than 80% of patients. Likewise, new drugs to treat stress incontinence have been available for some time. Injections of botulinum toxin A into the detrusor muscle are a promising treatment strategy in cases of therapy-resistant overactive bladder.

[Overactive bladder: prospects and limitations of botulinum toxin]. / Uberaktive Blase: Möglichkeiten und Grenzen der Botoxtherapie.

Botulinum toxin is the most potent poison known to man. It is produced by Clostridium botulinum and consists of a heavy chain which is responsible for the internalization of the toxin into the cytosol and a light chain that has the ability to cleave proteins within the nerve terminal. As those proteins are essential for normal vesicular transport and fusion of acetylcholine, botulinum toxins are able to prevent its release at the presynaptic membrane, resulting in a chemodenervation of the detrusor muscle after intravesical injection of the toxin and an impressive reduction of symptoms of overactive bladder. Clinical studies show success rates between 60 and 96% for neurogenic and non-neurogenic detrusor overactivity. Thus, application of botulinum toxin to the lower urinary tract appears to be an efficient, safe and minimally invasive procedure.

Experience with 100 cases treated with botulinum-A toxin injections in the detrusor muscle for idiopathic overactive bladder syndrome refractory to anticholinergics.

PURPOSE: In this prospective, nonrandomized, ongoing study we evaluated the efficacy and safety of botulinum-A toxin injections in the detrusor muscle to treat patients with idiopathic overactive bladder resistant to conventional treatment, such as anticholinergic drugs. MATERIALS AND METHODS: A total of 23 men and 77 women with a mean age of 63 years (range 24 to 89) with nonneurogenic overactive bladder, including urgency-frequency syndrome, and incontinence despite the administration of maximal doses of anticholinergics were consecutively treated with injections of 100 U botulinum-A toxin in the detrusor muscle at 30 sites under cystoscopic guidance. Micturition diary, full urodynamics, neurological status and urine probes were performed in all participants before treatment. Bladder biopsies were done only in cases of suspected bladder fibrosis or unclear findings. Special attention was given to reflex volume, maximal bladder capacity, detrusor compliance, post-void residual urine, urgency and frequency/nocturia. Clinical, urodynamic and quality of life assessments were performed at baseline, and 4, 12 and 36 weeks after botulinum-A toxin treatment. RESULTS: Overall after 4 and 12 weeks 88% of our patients showed significant improvement in bladder function in regard to subjective symptoms, quality of life and urodynamic parameters (p <0.001). Urgency disappeared in 82% of the patients and incontinence resolved in 86% within 1 to 2 weeks after botulinum-A toxin injections. Mean frequency decreased from 14 to 7 micturitions daily (-50%) and nocturia decreased from 4 to 1.5 micturitions. Mean maximal bladder capacity increased 56% from 246 to 381 ml, mean detrusor compliance increased from 24 to 41 ml/cm H(2)O and pretreatment detrusor instability (mean reflex volume 169 ml) resolved in 74% of patients. Mean volume at first desire to void increased from 126 to 212 ml and mean urge volume increased from 214 to 309 ml. There were no severe side effects except temporary urine retention in 4 cases. Only in 8 patients was the clinical benefit poor and analysis revealed preoperative low detrusor compliance. Mean efficacy duration +/- SD was at least approximately 6 +/- 2 months and then symptoms began to increase. CONCLUSIONS: Our results show that intradetrusor botulinum-A toxin injections may be an efficient and safe treatment option in patients with severe overactive bladder resistant to all conventional treatments.

Updated recommendations on ultrasonography in urogynecology.

Ultrasound is a supplementary, indispensable diagnostic procedure in urogynecology; perineal, introital, and endoanal ultrasound are the most recommended techniques. The position and mobility of the bladder neck can be demonstrated. In patients undergoing diagnostic work-up for urge symptoms, ultrasound occasionally demonstrates urethral diverticula, leiomyomas, and cysts in the vaginal wall. These findings will lead to further diagnostic assessment. The same applies to the demonstration of bladder diverticula, foreign bodies in the bladder, and bullous edema. With endoanal ultrasound, different parts of the sphincter ani muscle can be evaluated. Recommendations for the standardized use of urogenital ultrasound are given.

[Urinary stress incontinence in the female: comparison of incontinence theories and new tension-free surgical procedures]. / Stressinkontinenz der Frau: Theorien und moderne Operationstechniken in Vergleich.

Urethral sphincter competence involves a complicated inter action of many factors which act in concert. Stress incontinence occurs due to damage to the urethral support and loss or deterioration of urethral sphincter function as a consequence of delivery or aging. Recent research indicates that a more integrated, comprehensive view regarding the different structures, both inside and outside the urethra, is needed to explain the mechanism of incontinence. According to the theories of de Lancey, urinary stress incontinence is caused by defects in the supporting tissues that both actively and passively stabilize the urethra in its correct anatomical position. The integral theory of Petros and Ulmstein explains how laxity in the vagina or its supporting ligaments may cause stress incontinence favored by laxity in the ligamentous insertion points of the vagina. Colposuspension procedures have dominated incontinence surgery for the last 50 years. The introduction of the tension-free vaginal tape procedure was a real innovation that has challenged our understanding of the continence mechanism and taught us the importance of the midurethra. Different modifications of the tension-free procedures have been introduced recently and are discussed in this paper.

Ultrafast MR imaging of the pelvic floor.

OBJECTIVE: The aim of this study was to compare pelvic floor anatomy and laxity at rest and on straining (Valsalva's maneuver) using dynamic ultrafast MR imaging in women who were continent versus those with stress incontinence differing in obstetric history. MATERIALS AND METHODS: Thirty continent women were divided into three equal groups (nulliparous, previous cesarean delivery, previous vaginal delivery) and compared with 10 women with stress-incontinence with a history of at least one vaginal delivery. MR imaging of the pelvic floor at rest and on maximal strain was performed, using axial T2-weighted fast spin-echo images followed by sagittal ultrafast T2-weighted single-shot fast spin-echo sequences. Mean population age (age range, 22-45 years; mean +/- SD, 36 +/- 5.4 years), was similar in the four groups, as was parity in the three parous groups. RESULTS: Mean distances between the bladder floor and pubococcygeal line at rest did not differ between the four groups. On straining, bladder floor descent was 1.1 +/- 0.9, 1.0 +/- 1.1, and 1.9 +/- 0.9 cm in continent nulliparous, cesarean delivery, and vaginal delivery women, respectively, versus 3.2 +/- 1.0 cm in incontinent women (p = 0.0005). Cervical descent was greater in incontinent versus nulliparous women (p = 0.0019). Bladder floor descent was greater in the continent vaginal delivery group than in continent cesarean delivery control patients (p = 0.04). In patients with stress incontinence, symptoms did not correlate with amplitude of descent. The right levator muscle was thinner overall than the left, regardless of frequency direction (p = 0.001). CONCLUSION: Ultrafast MR imaging using the T2-weighted single-shot fast spin-echo sequence allows dynamic evaluation of the pelvic compartments at maximal strain with no need for contrast medium. Pelvic floor laxity and supporting fascia abnormalities were most common in patients with stress incontinence followed by continent women with a history of vaginal delivery. The results are therefore compatible with the hypothesis of vaginal delivery as a contributory factor to stress incontinence in older parous women.

Pelvic floor muscle contraction during a cough and decreased vesical neck mobility.

OBJECTIVE: To test the hypothesis that a voluntary pelvic muscle contraction initiated in preparation for a cough, a maneuver we call the Knack, significantly reduces vesical neck displacement. METHODS: A convenience sample of 22 women consisted of 11 young, continent nulliparas (mean age [+/- standard deviation] 24.8 +/- 7.0 years) and 11 older, incontinent paras (mean age [+/-SD] 66.9 +/- 3.9 years). With the use of perineal ultrasound, we quantified vesical neck displacement at rest and during coughs using caliper tracing and a coordinate system. The subjects coughed with and without voluntary pelvic floor muscle contraction. RESULTS: Vesical neck mobility during coughs was significantly decreased when voluntary contraction was used: from a median (range) of 5.4 (20.0) mm without volitional contraction to 2.9 (18.3) mm with volitional contraction (P <.001). The younger women demonstrated a median (range) decrease in excursion from 4.6 (19.5) to 0.0 (17.0) mm (P =.007), and the older incontinent women demonstrated a median (range) decrease from 6.2 (10.0) to 3.5 (15.4) mm (P =.003). At rest, the median vesical neck position in the group of older incontinent women was significantly further dorsocaudal (P =.001) than in the younger women. CONCLUSION: A pelvic floor muscle contraction in preparation for, and throughout, a cough can augment proximal urethra support during stress, thereby reducing the amount of dorsocaudal displacement.

[Morphologic assessment for diagnosing urogynaecologic disorders]. / Morphologische Diagnostik in der Urogynäkologie.

Morphologic assessment for diagnosing urogynecologic disorders is done as part of the gynecologic examination and urogenital ultrasound with the equipment available in the gynecologist's office. Evaluation of the pelvic floor by separate palpation of both sides, assessment of contractility, testing of speculum elevation, and ultrasound examination of voluntary motor function by elevation of the bladder neck during muscle contraction provide adequate information on the pelvic floor status for initiating pelvic floor re-education and/or conditioning. In assessing prolapse, differentiation of a lateral defect from a central defect of the anterior compartment is an important prerequisite for surgical decision-making in stress urinary incontinence (colposuspension versus TVT-plasty) and urogenital prolapse (abdominal versus vaginal access). Introitus or perineal ultrasound allow for reliable assessment of the topography of the bladder neck and will also demonstrate morphologic changes of the urethra, the periurethral tissue, and the bladder. - Radiographic examinations (e. g., excretory urography, double-balloon urethrography, micturition cystourethrography, retro- and antegrade depiction of fistulae) are not part of the basic diagnostic work-up and should only be performed in the framework of specific urogynecologic assessment. These procedures are indicated for assessing the upper urinary tract, for confirming the diagnosis of urethral diverticulae, and for clarifying extraurethral urinary incontinence. - Magnetic resonance imaging allows for the detailed morphologic assessment of the levator ani muscle, the endopelvic fascia, and the urethra. However, since normal values for comparison have not yet been established and the examination is complicated and expensive, the use of MRI is still restricted to scientific investigations.

[Pathophysiology of female incontinence]. / Pathophysiologische Vorstellungen zur Harninkontinenz.

In the last 100 years many different theories have tried to explain the symptoms and causes of urinary incontinence in the female. Urinary incontinence is a debilitating condition and not only leads to medical problems and costs, but is associated with embarrassment that can lead to isolation and loss of independence. Women with stress urinary incontinence can have both urethral support loss and decreased urethral function. Aging and delivery can lead to multiple damages which can be manifest either as loss of support with symptoms of prolaps or incontinence. This paper provides an overview of the functional anatomy of the structures responsible for controlling urinary continence under stress and discusses some of the theories on incontinence.

Quantification of intramuscular nerves within the female striated urogenital sphincter muscle.

OBJECTIVE: To analyze the quantity and distribution of intramuscular nerves within the striated urogenital sphincter and test the hypothesis that decreased nerve density is associated with decreased striated sphincter muscle and cadaver age. METHODS: Thirteen cadaveric urethras (mean age 47 years, range 15-78 years) were selected for study. A sagittal histologic section was stained with S100 stain to identify intramuscular nerves. The number of times that a nerve was seen within the striated urogenital sphincter (nerve number) was counted. The number of axons within each nerve fascicle was also counted. Regression analysis of nerve density against muscle cell number and age was performed. RESULTS: Remarkable variation was found in the quantity of intramuscular nerves in the striated urogenital sphincter of the 13 urethras studied. The number of nerves ranged from 72 to 543, a sevenfold variation (mean 247.1 +/- standard deviation 123.2), and the range of number of axons was 431 to 3523 (2201 +/- 1152.6). The larger nerve fascicles were seen predominantly in the distal (13.1 +/- 5.7 axons per nerve) compared with the proximal part of the striated urogenital sphincter (1.2 +/- 2). Reduced nerve density throughout the striated urogenital sphincter correlated with fewer muscle cells (P =.02). Nerve density also decreased with advancing age (P =.004). CONCLUSION: Remarkable variation in the quantity of intramuscular nerves was found. Women with sparse intramuscular nerves had fewer striated muscle cells. Intramuscular nerve density declined with age.

[Neurofibromatosis of the breast in a patient with Morbus von Recklinghausen]. / Neurofibromatose der Brust bei Morbus von Recklinghausen.

Neurofibromatosis is a rare autosomal dominant disorder with several subtypes. Common is the appearance of specific skin alterations. Neurofibromas occurring in the breast are very rare, and in such cases they are most common in the areolar area. A case of a 46-year-old woman with von Recklinghausen's disease of the breast is reported, and the literature will be discussed.

Primary carcinoma of the fallopian tube. A report of 19 cases with literature review.

Primary carcinoma of the fallopian tube is the rarest cancer of the female genital tract with an incidence of 0.5% of all gynecologic tumors. Since the first report in 1847 about 1,500 cases have been published. Due to similarity of the clinical presentation the staging and therapeutic management have been adapted to that of ovarian cancer. We retrospectively evaluated all the 19 patients who had been diagnosed with primary carcinoma of the fallopian tube at the Department of Obstetrics and Gynecology of the University of Zurich between 1977 and 1998. All lesions were staged according to the rules of FIGO adopted in 1991. At the time of diagnosis the median age was 62 (46-87) years. Twelve (63%) women revealed FIGO stage III-IV, whereas four (21%) and three (16%) patients were diagnosed in stage I and stage II, respectively. Eight (42%) women were nullipara. Histology showed serous-papillary carcinoma, in ten (53%) cases. The 5-year survival rate was 22% for all FIGO stages and 80% for stage I. None of the patients with stage III and IV survived 5 years. Ovarian cancer and primary carcinoma of the fallopian tube are similar in many aspects. Both carcinomas have a similar age distribution, show an increase among nulliparous women, are often of serous papillary histology, have a poor prognosis with stage and residual tumor size as important prognostic factors, and respond initially well to platinum-based chemotherapy. Nevertheless, there appears to be a difference between the two diseases: primary carcinoma of the fallopian tube is more often diagnosed in an earlier stage. This many be due to lower abdominal pain resulting from tubal dilatation and to abnormal bloody-watery discharge.

Using fasting plasma glucose concentrations to screen for gestational diabetes mellitus: prospective population based study.

OBJECTIVE: To evaluate whether measuring fasting plasma glucose concentration is an easier screening procedure for gestational diabetes mellitus than the 1 hour 50 g glucose challenge test. DESIGN: Prospective population based study. SETTING: Outpatient clinic in a university hospital. PARTICIPANTS: 520 pregnant women (328 (63%) white, 99 (19%) Asian, 31 (6%) African, 62 (12%) others) with mean age 28.4 (SD 0.2; range 17-45) years. All underwent a glucose challenge test between the 24th and 28th gestational week, followed by a diagnostic 3 hour 100 g oral glucose tolerance test within one week. This was done irrespective of the result of the challenge test. MAIN OUTCOME MEASURE: Receiver operating curves were used to determine the best cut off values for screening with fasting plasma glucose concentrations. RESULTS: Fasting plasma glucose concentration at a threshold value of 4.8 mmol/l and the glucose challenge test with a threshold value of 7.8 mmol/l yielded sensitivities of 81% and 59% respectively and specificities of 76% and 91% respectively. Measuring fasting plasma glucose concentration as a screening procedure required a diagnostic test in 30%, compared with 14% when the challenge test was used. CONCLUSIONS: Measuring fasting plasma glucose concentrations using a cut off value of >/=4. 8 mmol/l is an easier screening procedure for gestational diabetes than the 50 g glucose challenge test and allows 70% of women to avoid the challenge test.

Sonographic evaluation of the bladder neck in continent and stress-incontinent women.

OBJECTIVE: To evaluate a new sonographic method to measure depth and width of proximal urethral dilation during coughing and Valsalva maneuver and to report its use in a group of stress-incontinent and continent women. METHODS: Fifty-eight women were evaluated, 30 with and 28 without stress incontinence proven urodynamically, with a bladder volume of 300 mL and the subjects upright. Urethral pressure profiles at rest were performed with a 10 French microtip pressure catheter. Bladder neck dilation and descent were assessed by perineal ultrasound (5 MHz curved linear array transducer) with the help of ultrasound contrast medium (galactose suspension-Echovist-300), whereas abdominal pressure was assessed with an intrarectal balloon catheter. Statistical analysis used the nonparametric Mann-Whitney test. RESULTS: The depth and diameter of urethral dilation could be measured in all women. During Valsalva, all 30 incontinent women exhibited urethral dilation. One incontinent woman showed dilation only while performing a Valsalva maneuver, not during coughing. In the continent group, 12 women presented dilation during Valsalva and six during coughing. In continent women, dilation was visible only in those who were parous. Nulliparous women did not have dilation during Valsalva or coughing. Bladder neck descent was visible in continent and incontinent women. CONCLUSION: This method permits quantification of depth and diameter of bladder neck dilation, showing that both incontinent and continent women might have bladder neck dilation and that urinary continence can be established at different locations along the urethra in different women. Parity seems to be a main prerequisite for a proximal urethral defect with bladder neck dilation.

The role of the frequency-volume chart in the differential diagnostic of female urinary incontinence.

OBJECTIVE: To investigate the differential diagnostic capacity of the frequency-volume chart in 132 women with urinary incontinence. MATERIAL AND METHOD: For each patient, the readings of two 24-h frequency-volume charts were compared to the urodynamic diagnosis which was used as the gold standard in 73 genuine stress incontinent women, in 23 urge incontinent women, and in 36 women with mixed incontinence. RESULTS: The total voided volume, the mean voided volume, the largest single voided volume, and the smallest single voided volume were statistically differentiating single parameters among the three groups (p<0.05). Applying logistic regression to the two well-defined groups of patients, the one with urge incontinence and the one with genuine stress incontinence, the frequency of micturition during nighttime revealed the best discriminatory power for these conditions. CONCLUSION: This study shows that in the frequency-volume chart micturition during nighttime discriminates best between urge and stress incontinence.

Examination of voiding in seated women using a remote-controlled ultrasound probe.

BACKGROUND: A remote-controlled steering arm was developed that allows the ultrasound probe to be held on the perineum under ultrasound image guidance with the woman seated on a commercially available bedside commode. TECHNIQUE: The arm's servomechanism monitors contact pressure between the scanning head and the perineum, keeping constant gentle pressure on the perineum so that the transducer follows perineal movement. EXPERIENCE: Twenty patients with urinary incontinence and ten normal volunteers were examined during two voiding episodes, one without perineal ultrasound and one with ultrasound. Ultrasound images and intrarectal pressure measurements were displayed simultaneously on a video monitor. Bladder and urethral visibility and behavior were analyzed during bladder emptying. Of the 30 women, 28 were able to void, with and without the ultrasound probe applied. Two women were not able to urinate under observation either with or without sonography. The bladder base, bladder neck, and upper two-thirds of the urethra were visible throughout voiding in the 28 women able to void. Bladder neck opening could be observed in all of the 28 women. Bladder neck descent during initiation of voiding occurred in 17 women, whereas 11 voided without bladder neck descent. CONCLUSION: The use of this device facilitates ultrasound evaluation of micturition in the physiologic sitting position and allows bladder neck behavior to be seen during bladder emptying.