Pudendal evoked responses.

The dorsal nerve of the penis or clitoris, a branch of the pudendal nerve, was stimulated while averaged evoked responses over the spinal cord, sensory cortex, and bulbocavernosus muscle were recorded in a series of normal subjects. The morphologic features, peak latencies, and peripheral and central conduction times were compared with spinal and cortical evoked responses from the posterior tibial nerve. These tests are of potential clinical importance in the evaluation of sacral nerve root or plexus injuries and bowel, bladder, or sexual dysfunction.

Colonometry, cystometry, and evoked potentials in multiple sclerosis.

The conditions of three patients with advanced-stage multiple sclerosis and symptoms related to bowel and bladder function were evaluated using colonometry, cystometry, and somatosensory evoked responses from the posterior tibial nerve. The colonometrograms and cystometrograms showed notable hyperreflexia and reduced filling capacity when compared with neurologically intact patients. The neurological lesions were localized to above the conus medullaris by recording normal somatosensory responses at L-1 and abnormal responses over the scalp. This combination of tests are important in the documentation of bowel and bladder dysfunction, the localization of the neurological lesion causing the symptoms, and the determination of treatment of bowel and bladder symptoms in patients with multiple sclerosis.

Urodynamic predictability of voiding following incontinence surgery.

To predict the duration of postoperative bladder drainage required after incontinence surgery, 30 patients were studied preoperatively using voiding-simultaneous urethrocystometry. Based on changes in bladder, urethral, and abdominal pressures, patients were divided into three groups. Patients who demonstrated adequate bladder contraction during voiding did not need prolonged catheterization (P less than .005). Patients who did not demonstrate adequate detrusor contraction and used Valsalva maneuver during voiding were at 12 times greater risk of requiring prolonged postoperative catheterization (P less than .05). Changes observed in urethral and abdominal pressures individually during voiding were not significant predictors of the need for prolonged catheterization. Preoperative knowledge of voiding mechanisms can predict postoperative catheterization need.

The Q-tip test: standardization of the technique and its interpretation in women with urinary incontinence.

Q-tip tests were carried out on 63 women to determine optimal placement and the effects of bladder fullness and significant anterior vaginal wall relaxation. Significantly higher maximum straining angles were observed when the tip of the Q-tip was placed at the urethrovesical junction or the proximal urethra, compared with placement in the bladder (P less than .05), midurethra (P less than .01), or distal urethra (P less than .01). Bladder fullness did not alter the results significantly. There were no significant differences in resting or maximum straining angles when patients with significant anterior vaginal wall relaxation and genuine stress incontinence were compared with continent women who had significant anterior vaginal wall relaxation. However, in the absence of significant anterior vaginal wall relaxation, women with genuine stress incontinence had significantly higher maximum straining angles than those with bladder instability (P less than .05) or control subjects (P less than .05). The Q-tip test, if performed correctly, is an easy, inexpensive, and reliable method of quantifying mobility of the bladder neck and proximal urethra in continent or incontinent women with or without pelvic relaxation.

Management of coexistent stress and urge urinary incontinence.

Fifty-two patients with objective evidence of pressure equalization incontinence and detrusor instability were evaluated retrospectively to compare nonsurgical modes of therapy with retropubic surgery. Based on the patient's desire for surgery and her overall medical condition, 27 women were treated primarily with retropubic urethropexy (modified Burch procedure) and 25 with various combinations of oxybutynin, imipramine, and estrogen. Thirty-two percent of the patients treated medically were cured and 28% were markedly improved, whereas 59% of patients treated surgically were cured and 22% improved. There was no statistically significant difference in the results between medical and surgical therapy. All failures in the surgically treated group were due to persistent detrusor instability after surgery. We identified no preoperative urodynamic criteria that consistently and accurately predicted surgical outcome in patients with combined stress and urge incontinence. Patients with combined stress incontinence and detrusor instability should initially be managed medically, as this will reduce the incidence of surgical intervention.

Transvaginal needle bladder neck suspension procedures for stress urinary incontinence: a comprehensive review.

Transvaginal needle bladder neck suspension procedures for surgical correction of stress incontinence are increasing in popularity among genitourinary surgeons. Since 1959, three main modifications of the originally described procedure have emerged as representing various needle suspension procedures, ie, the modified Pereyra procedure among gynecologic surgeons and the Stamey and the Raz procedures among urologic surgeons. The overall success rate of 85% (range 40-100%) among a total of 1967 surgical procedures reported in the published literature may be misleading; the majority of reported studies relied upon subjective clinical cures rather than objectively demonstrable cures of urinary incontinence. The majority of studies lacked long-term follow-up of successfully treated patients. Few studies reported urodynamic changes after needle suspension procedures in terms of increased functional urethral length and improved pressure transmission to the proximal urethra. A 20-50% incidence of postoperative voiding difficulties has been reported in various studies. This publication reviews the controversies in the nomenclature of various needle suspension procedures, indication, suture materials, procedural details, and results of previously published needle suspension procedures and their modifications. Differences among commonly performed procedures are pointed out and analyzed for their role in the correction of stress urinary incontinence.

Modified Burch versus Pereyra retropubic urethropexy for stress urinary incontinence.

Sixty-four women underwent either the modified Burch retropubic urethropexy or the modified Pereyra procedure for surgical correction of stress urinary incontinence. All were evaluated clinically and urodynamically before and one year after surgery. The Burch procedure proved to be superior to the Pereyra procedure in terms of improving pressure transmission to the proximal two-thirds of the urethra (P less than .001), correcting the anatomic defect (P less than .001), avoiding postoperative voiding difficulties (20 versus 30%), and presenting an objective cure rate of 98 versus 85%. The age, parity, and degree of mobility of the urethra and urethrovesical junction did not influence the ability of the Burch and Pereyra procedures to produce efficient postoperative pressure transmission capacity ratio. Both types of surgical procedures were closely comparable in terms of curing stress urinary incontinence, operative time and blood loss, and total hospital stay.

Urodynamics: effect of urinary tract infection on urethral and bladder function.

To determine the accuracy and reliability of urodynamic studies performed during the course of unsuspected but significant lower urinary tract infection (greater than or equal to 10(5) organisms per mL), all the studies were repeated two and four weeks after successful treatment of urinary tract infection. Among 45% of patients (nine of 20) found to have unstable bladder before treatment of urinary infection, 60% of them (six of nine) regained bladder stability after appropriate treatment. Similarly, 30% of stress incontinent patients became continent after treatment of urinary infection and did not need surgery for correction of stress incontinence. Because of the high incidence of false-positive results of urodynamic studies when performed during infection (P less than .05), definite treatment of urinary incontinence should not be undertaken before successful treatment of urinary tract infection and repeating urodynamic studies in patients with persistent lower urinary tract symptoms.

Pessary test in women with urinary incontinence.

Thirty women with urinary incontinence underwent detailed preoperative and postoperative clinical and urodynamic evaluation before and after the pessary test. The urodynamic changes observed with the pessary test (P less than .01) were very similar to those seen after corrective incontinence surgery. The pessary test differentiated patients with bladder instability from those complaining of stress urinary incontinence with a correctable anatomic defect. Pre- and postpessary test voiding urethrocystometry and uroflometry demonstrated absence of urethral obstruction to the free flow of urine. The pessary test is a simple, inexpensive, reliable diagnostic and prognostic tool. It simulates the results of anticipated incontinence surgery and restores continence without causing compression of the urethra as does the Bonney test.

Patch procedure: modified transvaginal fascia lata sling for recurrent or severe stress urinary incontinence.

Ten patients with either recurrent or severe stress urinary incontinence were treated with a new procedure, using a patch of fascia lata to support the bladder base and the urethra. Nine of the ten patients are objectively continent of urine 1-2 years postoperatively. When pre- and postoperative urodynamics were compared, we noted significant increases in urethral closure pressure, functional urethral length, and abdominal pressure transmission to the proximal urethra. Intraoperative and postoperative morbidity was minimal. The procedure is easily performed and requires no more expertise than does a transvaginal needle bladder neck suspension.

Urodynamic appraisal of the Bonney test in women with stress urinary incontinence.

To determine the validity of the Bonney test as a prognostic screening test for urinary incontinence, the urethral and urethrovesical functions were studied under resting and stressful conditions. The characteristic similarity of changes was evident in the functional profile length, closure pressure, and cough pressure profile of the urethra during performance of the Bonney test and intentional urethral occlusion. This study clearly invalidated the Bonney test by objectively demonstrating that the Bonney test restored continence under stress of coughing by obstructing the urethra and urethrovesical junction.

Urodynamics in women with stress urinary incontinence.

Characteristic alterations of urethral pressure and length occur in patients with stress urinary incontinence. Urodynamics in this group of 50 patients revealed a significant decrease in urethral functional length under the stress of bladder filling and change of position from supine to sitting. A decrease in urethral closure pressure was present in individual patients and was significant. All patients with stress urinary incontinence demonstrated a decreased ability to voluntarily increase urethral pressure and also had evidence of pressure equalization on Valsalva maneuver and coughing. Cough pressure profiles also demonstrated equalization of urethral and bladder pressures. These profiles also were performed in a subgroup of 12 patients with genuine stress incontinence after treatment of incontinence by retropubic urethropexy. These profiles became normal after surgery and correlated with the clinical cure of stress urinary incontinence.

Uterine osseous metaplasia.

A rare case of osseous metaplasia of the endocervix and endometrium is discussed with both macroscopic and microscopic evidence of new bone formation in the uterus. History of menstrual irregularities, repeated abortions, infertility with histopathologic evidence of chronic inflammation, and bone formation may be evident in these cases. Various theories of the pathogenesis of benign uterine bone formation are discussed.

An in-line suturing device to simplify sacrospinous vaginal vault suspension.

A disposable suturing instrument is used in our surgical method for sacrospinous vault suspension to facilitate suture placement and retrieval. The pararectal space is dissected and the suturing device is placed just medial to the lateral third of the sacrospinous ligament-coccygeus muscle complex. Depression of the device's firing button advances a standard needle in a controlled circular path through the sacrospinous ligament-coccygeus muscle complex. The needle is retrieved with a straight-needle holder at a consistent location, 3 mm from the shaft of the instrument. A second suture is placed 0.5-1 cm medial to the first suture. If the holding strength for either suture is considered inadequate, the device is reloaded with the same suture and subsequent bites are taken. The procedure is completed using standard methods. In ten women treated for vaginal vault eversion, lateral dissection was completed in less than 10 minutes, and passage of two sutures through the sacrospinous ligament was accomplished in less than 2 minutes. There were no complications. One patient described mild buttock pain that resolved in 1 week. At 4-6 months' follow-up, vaginal examination with maximal straining demonstrated direct apposition of the vaginal wall to the sacrospinous ligament.

Role of antibiotic prophylaxis in retropubic surgery for stress urinary incontinence.

The effectiveness of prophylactic antibiotics was studied prospectively in 26 women undergoing retropubic urethropexy for genuine stress incontinence. Each of the 14 patients in the antibiotic prophylaxis group received three 1-g doses of intravenous cefazolin administered before, during, and 6-8 hours after surgery. Twelve women served as a control group and did not receive prophylactic antibiotics. Postoperative febrile morbidity and hospital stay were significantly less (P less than .01 and P less than .05, respectively) in patients who received prophylactic antibiotics.

Cervical cryotherapy for condylomata acuminata during pregnancy.

Twenty-eight patients were treated by cryotherapy for cervical condylomata acuminata during the second and third trimesters of pregnancy. Most required two treatment sessions before the condylomata resolved. All women responded favorably and none had residual disease at six weeks' postpartum. No neonate was affected. Cryotherapy for cervical condylomata acuminata had no identifiable adverse effect on pregnancy. There were no cases of rupture of membranes or labor starting as a consequence of treatment. There was no scarring to the cervix and deliveries were normal. We conclude that cryotherapy for cervical condylomata acuminata is an effective and safe procedure during the last two-thirds of pregnancy.

Nonfluorescent erythrasma of the vulva.

BACKGROUND: Erythrasma is an uncommon vulvar infection, best diagnosed by its fluorescence under the Wood lamp. This report shows that despite a negative Wood lamp examination, the diagnosis can be made histologically. CASE: A 42-year-old woman was referred to our clinic with a persistent candidal infection. Evaluation included a Wood lamp examination, wet mount, and potassium hydroxide test of the affected skin, all of which were negative. A biopsy of the area demonstrated rods and filamentous organisms in the keratotic layer consistent with a Corynebacterium minutissimum infection. The patient was diagnosed as having erythrasma, and she responded to oral erythromycin. CONCLUSION: Persistent vulvar diseases may be caused by erythrasma despite a negative Wood lamp examination. The diagnosis can be made by biopsy of the lesion.

Survey of voiding dysfunction and urinary retention after anti-incontinence procedures.

OBJECTIVE: To describe trends in the management of prolonged voiding dysfunction and urinary retention after anti-incontinence procedures. METHODS: Physician members of the American Urogynecologic Society were queried by means of a two-page questionnaire regarding the management of prolonged voiding dysfunction and urinary retention after anti-incontinence procedures. RESULTS: A total of 344 (42%) of 825 questionnaires were completed and returned. Of the 344 respondents, 61% identified themselves as urogynecologists, 50% worked in a university-affiliated practice, and 26% had been in practice for 11-20 years. Respondents rarely encountered prolonged urinary retention after anti-incontinence procedures. Among the respondents, 30% allowed 3-6 months for resumption of spontaneous voiding before performing surgical revision, and 90% performed multichannel urodynamic studies before surgical revision. However, 66% performed surgical revision transabdominally when urinary retention occurred after retropubic urethropexy, and 61-81% of respondents performed surgical revision transvaginally when urinary retention followed needle suspension, pubovaginal sling, or tension-free vaginal tape procedures. A total of 90-96% did not perform an anti-incontinence procedure concomitantly with surgical revision. The majority of respondents reported spontaneous voiding in greater than 80% of patients, and recurrent stress urinary incontinence in less than 10% of patients after surgical revision. CONCLUSION: Although certain trends in the management of prolonged urinary retention after anti-incontinence procedures were identified, there was no clear consensus on the method of surgical revision used, nor the management of recurrent stress urinary incontinence after surgical revision. Randomized clinical trials are required to determine the optimal management of prolonged urinary retention after anti-incontinence procedures.

Prevalence of abnormal urodynamic test results in continent women with severe genitourinary prolapse.

Twenty-two clinically continent women with severe genitourinary prolapse were evaluated urodynamically to determine the prevalence of urodynamic abnormalities that could lead to potential urinary incontinence. Urodynamic testing found an occult incontinence disorder in 13 women (59%), of whom four had urine loss during cough pressure profiles after pessary placement, four had uninhibited detrusor contractions during retrograde medium-fill water cystometry, and five had both stress urinary incontinence and an unstable bladder. Therefore, nine of the 22 patients (41%) had uninhibited detrusor contractions during urodynamic testing. However, uroflowmetry did not reveal voiding dysfunction in this group, although peak flow rates appeared to be lower in the subgroup of women manifesting uninhibited detrusor contractions. Associated symptoms of frequency, nocturia, and urgency occurred in 41% of the women in this study; four of nine (44%) who had normal urodynamic test results, five of 13 (38%) who had abnormal test results, and five of nine (56%) who had an unstable bladder. Therefore, associated symptoms could not be used to determine which women would have abnormal urodynamic test results. These preliminary results suggest that women with genitourinary prolapse may be at risk for an occult incontinence disorder that is masked by the prolapse and that could manifest after corrective surgery for prolapse. Urodynamic testing is suggested for women with genitourinary prolapse who present with or without symptoms of incontinence, so that more data can be obtained to determine the importance of abnormal test results.

Urodynamic changes in urethrovesical function after radical hysterectomy.

Twelve patients undergoing radical hysterectomy were comprehensively evaluated urodynamically pre- and postoperatively using sensitive instrumentation, including microtip transducers. Five patients developed genuine stress incontinence, four developed loss of bladder compliance, three developed motor deficits consisting of either inability to relax the urethra or inability to initiate or maintain a vesical contraction, two developed impaired urinary flow, three had persistent excessive residual urine volumes, and two developed bladder sensory loss. These changes persisted beyond the one-year follow-up period. The degree of urethrovesical dysfunction bore no significant relationship to the radicality of the hysterectomy.