Involuntary detrusor contractions: correlation of urodynamic data to clinical categories.

Data regarding the prevalence and urodynamic characteristics of involuntary detrusor contractions (IDC) in various clinical settings, as well as in neurologically intact vs. neurologically impaired patients, are scarce. The aim of our study was to evaluate whether the urodynamic characteristics of IDC differ in various clinical categories. One hundred eleven consecutive neurologically intact patients and 21 consecutive neurologically impaired patients, referred for evaluation of persistent irritative voiding symptoms, were prospectively enrolled. All patients were presumed by history to have IDC, and underwent detailed clinical and urodynamic evaluation. Based on clinical evaluation, patients were placed into one of four categories according to the main presenting symptoms and the existence of neurological insult: 1) frequency/urgency; 2) urge incontinence; 3) mixed stress incontinence and irritative symptoms; and 4) neurogenic bladder. IDC was defined by detrusor pressure of > or = 15 cm H2O whether or not the patient perceived the contraction; or < 15 cm H2O if perceived by the patient. Eight urodynamic characteristics of IDC were analyzed and compared between the four groups. IDC were observed in all of the neurologically impaired patients, compared with 76% of the neurologically intact patients (P < 0.001). No correlation was found between amplitude of IDC and subjective report of urgency. All clinical categories demonstrated IDC at approximately 80% of cystometric capacity. Eighty-one percent of the neurologically impaired patients, compared with 97% of the neurologically intact patients, were aware of the IDC at the time of urodynamics (P < 0.04). The ability to abort the IDC was significantly higher among continent patients with frequency/urgency (77%) compared with urge incontinent patients (46%) and neurologically impaired patients (38%). In conclusion, when evaluating detrusor overactivity, the characteristics of the IDC are not distinct enough to aid in differential diagnosis. However, the ability to abort IDC and stop incontinent flow may have prognostic implications, especially for the response to behavior modification, biofeedback, and pelvic floor exercise.

Detection of eubacteria in interstitial cystitis by 16S rDNA amplification.

OBJECTIVE: To determine what role non-culturable microorganisms play in the etiology of interstitial cystitis (IC). MATERIALS AND METHODS: Thirty patients fulfilling NIH criteria for the diagnosis of interstitial cystitis and sixteen control patients with culture negative urine gave written informed consent and underwent bladder biopsy. Polymerase chain reaction (PCR) using two sets of universal primers for bacterial 16S rDNA was performed on urine from the cystoscope and on a cold cup bladder biopsy specimen. Of the PCR positive bladder biopsies, three patients with interstitial cystitis and three controls were randomly selected and cloned. Ten clones from each were sequenced and putative taxonomic assignments made. RESULTS: 12/26 (46%) IC and 5/12 (42%) control urine specimens and 16/30 (53%) and 9/15 (60%) bladder biopsies were PCR positive, respectively. The bacterial populations in the two patient groups tested appeared to be different based upon analysis of the 16S rRNA sequences. CONCLUSIONS: Both IC and control patients had non-culturable bacteria in their bladders. A random sampling of the two populations revealed that the bacterial populations are different, suggesting a possible link between one or more bacterial species and IC.

Physiological principles for surgical correction of detrusor dysfunction.

Urinary incontinence may be the result of various forms of detrusor overactivity. Several surgical therapies have been devised, but with the exception of procedures to relieve urethral obstruction, none abolishes the overactivity or restores normal micturition. In general, ablative neurosurgery is considered only in patients with chronic neurologic disease. Bladder augmentation is useful in selected patients. The indications for urinary diversion in patients with detrusor overactivity and urge incontinence are quite limited.

Vaginal flap reconstruction of the urethra and vesical neck in women: a report of 49 cases.

PURPOSE: A retrospective study was done to evaluate the results of a 1-stage urethral reconstruction in women. MATERIALS AND METHODS: Of 49 consecutive women who presented with anatomical damage to the urethra or vesical neck 48 underwent urethral and/or vesical neck reconstruction with vaginal flaps. A Martius labial fat pad flap was used in 47 patients, a gracilis flap in 1 and an anterior bladder tube in 1. In 41 patients the anti-incontinence procedure consisted of a fascial pubovaginal sling placed over the labial fat pad flap without tension. In 5 patients a modified Pereyra operation was done and 1 underwent a Kelly plication. Followup ranged from 1 to 11 years. RESULTS: Postoperatively continence was obtained in 42 of 49 patients (87%). The initial procedure failed in 7 patients and a secondary procedure was successful in 6. Of the 5 initial patients who underwent a modified Pereyra operation 3 had postoperative stress incontinence and all were cured subsequently by a pubovaginal sling. CONCLUSIONS: A 1-stage vaginal flap reconstruction and pubovaginal sling procedure is effective in women with extensive vesical neck and/or urethral damage.

The polypropylene pubovaginal sling for the treatment of recurrent stress urinary incontinence.

PURPOSE: The significance of a 2-team approach to the problems of recurrent incontinence in patients with extensive pelvic scarring from previous surgery is emphasized. MATERIALS AND METHODS: We reviewed 88 consecutive patients who presented between January 1986 and November 1992. The demonstration of a scarred, wide open, proximal urethra or drain pipe urethra was the important selection criterion. Two teams, 1 operating abdominally and 1 vaginally, released the bladder neck from its bed of scar under direct vision and set the sling in place with minimal tension at the bladder neck. RESULTS: Of the women 75 (85.2%) were cured of the stress urinary incontinence and 8 (9.1%) had improvement with mainly urge incontinence, while 5 (5.7%) operations failed. There was a significant association between chronic chest disease and failure. CONCLUSIONS: The 2-team polypropylene (Marlex) mesh approach continues to be an effective treatment for women with complicated stress urinary incontinence.

Preliminary assessment of the incontinent woman.

Assessment of urinary incontinence begins with a thorough history and physical examination. This article reviews the collection of subjective, semi-objective, and objective data that allows for comprehensive evaluation of the incontinent female patient. These results will help direct further evaluation and develop an efficient and effective treatment plan.

Early versus late repair of vesicovaginal fistulas: vaginal and abdominal approaches.

We reviewed retrospectively 24 consecutive women who presented with a vesicovaginal fistula repaired by a single surgeon between 1989 and 1993. All patients underwent preoperative investigation, including cystoscopy, excretory urography and bilateral retrograde pyelography. Followup ranged from 6 months to 5 years. Postoperatively, 96% of the women were cured. Two patients had persistent symptomatic detrusor instability and 1 had mild stress incontinence. In 1 woman a vaginal repair failed and she was subsequently cured after an abdominal repair. Five patients presented 6 to 12 months after fistula formation. Among the other 17 patients the average interval from pelvic surgery to vesicovaginal fistula repair was 10.8 weeks. Indications for abdominal repair were indurated vaginal epithelium approximately 2 cm. in circumference around the fistula, a vault fistula with poor vaginal exposure and fistulas involving the ureters. Surgical timing and route of repair are best tailored to the individual patient.

Extravesical nondismembered ureteroplasty with detrusorrhaphy: a renewed technique to correct vesicoureteral reflux in children.

We performed an extravesical nondismembered reimplant to correct surgically primary vesicoureteral reflux in 45 patients (65 renal units) between April 1989 and September 1990. Of the units 6 had grade I reflux, 16 grade II, 23 grade III, 14 grade IV and 6 grade V. Only patients with primary reflux were included in this study. The success rate was 100% for grades I to III, 92.9% for grade IV and 66.7% for grade V. Overall, the reflux was cured in 62 of the 65 operated renal units (95.4%) or 95.6% of the patients (43 of 45). Postoperative morbidity and complications were minimal. No cases of postoperative obstruction were detected on excretory urography 6 weeks postoperatively. Seven children (16%) suffered from transient inadequate bladder emptying as assessed by post-void ultrasound residual evaluations. This problem resolved spontaneously after a maximum of 4 weeks of clean intermittent catheterization. Compared to conventional transvesical technique, the discomfort related to bladder spasms during the postoperative period was subjectively decreased and patients had no prolonged hematuria.

Intraabdominal hemorrhage as a result of segmental mediolytic arteritis of an omental artery: case report.

This article describes the fifth reported case of segmental mediolytic arteritis and the second in a survivor. The patient had intraabdominal bleeding as a result of a ruptured omental artery. The pathologic and arteriographic findings are described. The pathology is characterized by segmental disruption of the medial smooth muscle cells and the initiation of mediolysis. Mediolysis is associated with marked segmental thinning of the vessel wall, often with only the adventitia intact. Fibrin is deposited at the adventitial and medial surfaces, and hemorrhage into the media may occur. As in this reported case, lysis of the adventitia leads to sudden, often catastrophic intraabdominal hemorrhage. Little associated adventitial inflammation occurred. Segmental mediolytic arteritis seems to involve the intra-abdominal muscular arteries in elderly patients with nonspecific abdominal symptoms. An angiogram showed patchy areas of narrowing involving ileal, gastroduodenal, and renal arteries that correlated with the pathologic findings observed in the excised omental arteries.