The prevalence of detrusor overactivity amongst patients with symptoms of overactive bladder: a retrospective cohort study.

INTRODUCTION AND HYPOTHESIS: Overactive bladder (OAB) is a symptom-based condition consisting of urgency, with or without incontinence, usually with frequency and nocturia. There are many potential causes of OAB, yet many patients are prescribed anticholinergic medications empirically. This study aimed to determine what proportion of patients presenting for urogynecologic assessment with symptoms of OAB had urodynamic detrusor overactivity (DO). METHODS: Retrospective chart review was performed for 220 consecutive patient referrals. Demographic data, physical exam information, and urodynamic results were collected. The t test and Fisher's exact test were used for statistical analyses. RESULTS: The prevalence of DO was 11.8 % in this population. Urogenital atrophy and incomplete emptying were more common. Patients with DO were older and more often menopausal than those without DO. Significant prolapse was a common finding amongst patients with OAB symptoms. CONCLUSIONS: Patients with symptoms of OAB should undergo pelvic examination and assessment of post-void residuals before being initiated on anticholinergic medication.

Vaginal delivery and pelvic floor dysfunction: current evidence and implications for future research.

Vaginal delivery is the major risk factor for the development of pelvic organ prolapse and urinary and fecal incontinence, resulting from damage to the pelvic floor muscles, nerves and connective tissue. This article reviews the perineal trauma mechanism during vaginal delivery and discusses implications of current and future research projects.

The Marshall-Marchetti-Krantz procedure: a critical review.

The success of the Marshall-Marchetti-Krantz procedure is reviewed in 56 articles that were predominantly retrospective analyses. The overall success rate was 86.1 per cent in 2712 cases, with 92.1 per cent in primary and 84.5 per cent in repeat procedures. An overall complication rate of 21.1 per cent was calculated. The frequency of osteitis pubis was 2.5 per cent. Lack of pre- or postoperative urodynamic evaluation in the selection of cases, loss of patients to follow-up in reported series, and the lack of long-term follow-up cases must be considered in appraising this retrospective review.

Urethral diverticula.

Urethral diverticula are more common than heretofore thought, and the suspicion must always be high in the clinician's mind. Specifically aided by urethroscopy, positive pressure urethrography, and urodynamics, the physician can determine the number of diverticula and their role in underlying continence mechanisms. This should lead to more objective surgical decisions with better results.

Urinary fistulas.

Urinary fistulas, although relatively uncommon, present a formidable challenge to the urogynecologist, general urologist, and general obstetrician-gynecologist. Current diagnostic modalities are reviewed and conservative and surgical therapies are outlined.

Urinary incontinence as a worldwide problem.

OBJECTIVES: This paper reviews the literature on the prevalence of urinary incontinence (UI) and demonstrates its impact as a worldwide problem. METHODS: A MEDLINE search was performed to review population-based studies in English. Studies were grouped according to demographic variables and type of incontinence. Risk factors, help-seeking behavior, and quality of life measures were analyzed. RESULTS: The median prevalence of female UI was 27.6% (range: 4.8-58.4%) and prevalence of significant incontinence increased with age. The commonest cause of UI was stress (50%), then mixed (32%) and finally urge (14%). Risk factors included parity, obesity, chronic cough, depression, poor health, lower urinary tract symptoms, previous hysterectomy, and stroke. Although quality of life was affected, most patients did not seek help. CONCLUSION: UI is a prevalent cross-cultural condition. Future studies should rely on universally accepted standardized definitions to produce meaningful evidence-based conclusions, as well as project the costs of this global healthcare problem.

The role of estrogen in female urinary incontinence and urogenital aging: a review.

Urogenital aging is a complex of urogenital symptoms involving the lower urinary tract, the genital tract and the pelvic floor. These symptoms involve hypoestrogenism in the menopausal woman. This review concludes that irritative urinary and local vaginal symptoms are quite amenable to estrogen therapy. Urinary incontinence is thought to be benefited by treatment with estrogen, although controversy exists. There is a limited role for estrogen in problems of urogenital prolapse, rectal symptoms, and sexuality in menopause.

Pharmacology of the lower urinary tract.

Recent advances in our understanding of the neurophysiology and neuropharmacology of the lower urinary tract have improved our ability to treat disorders of bladder and urethral function. Similarly, many classes of drugs used in treating various medical conditions can cause lower urinary-tract symptoms and dysfunction. Based on objective urodynamic evaluation, the clinician is able to sort out bladder and urethral abnormalities and scientifically choose appropriate pharmacologic regimes to treat these conditions. This article reviews lower urinary-tract physiology and provides the clinician with a rational, objective, neuro-pharmacologic approach to lower urinary-tract disorders.

Massive genital and vaginal vault prolapse treated by abdominal-vaginal sacropexy with use of Marlex mesh: review of the literature.

Two patients with massive procidentia and 13 patients with posthysterectomy vaginal vault prolapse underwent surgical procedures at Mount Sinai Hospital, Toronto, between May 1978 and February 1986. The standard procedure consisted of an abdominal sacropexy, with use of Marlex mesh to anchor the vaginal vault to the sacral promontory and retroperitonealization of the mesh. In 11 of the 15 patients, one or more concurrent procedures were performed at the same time. There were no intraoperative complications. One serious postoperative complication occurred, and one patient developed recurrent vault prolapse. Follow-up has been from 3 to 93 months with an average of 28 months. In 14 patients (93.3%) subjective and objective improvement was achieved. A review of the literature is presented.

Unrecognized small vesicovaginal fistula as a cause of persistent urinary incontinence.

Three cases of persistent urinary incontinence from unrecognized small vesicovaginal fistula after abdominal hysterectomy for benign gynecologic disease are presented. Visualization of urine in the posterior fornix was suggestive; diagnosis was confirmed by methylene blue test and cystoscopy. Two patients had undergone interval Marshall-Marchetti-Krantz operations for suspected stress-related urinary incontinence. An extensive literature survey confirms that the vesicovaginal fistula were an unlikely complication of the Marshall-Marchetti-Krantz procedure.

The role of intraoperative cystoscopy in prolapse and incontinence surgery.

OBJECTIVE: Unrecognized ureteral and bladder injury are a known source of morbidity and mortality in gynecologic surgery. The objective of this study was to determine the frequency that intraoperative cystoscopy during prolapse and incontinence procedures produced a change in intraoperative management to prevent ureteric and bladder injury. STUDY DESIGN: This study reviewed the charts and operative reports of 235 cases of routine intraoperative cystoscopy during prolapse and incontinence surgery during a 2-year period in a tertiary care urogynecology unit. Demographic data and potential risk factors for intraoperative urinary tract injury were recorded. Cases that involved a change in management brought about by intraoperative cystoscopy with intravenous indigo carmine were compared with cases in which intraoperative cystoscopy was normal. Variables were compared with use of the Student t test and the chi(2) test. RESULTS: Of 235 cases, 11 were excluded. Of the 224 remaining cases, 12 (5.3%) underwent changes in intraoperative management as a result of cystoscopic findings. Eight cases involved ureteric blockage. Patients with abnormal cystoscopies did not differ from patients with normal intraoperative findings with regard to age, weight, parity, maximum grade of prolapse, estimated blood loss, or previous surgery. In 58% of patients with abnormal cystoscopies, there was no suspicion of technical difficulty on the basis of previous surgical history. Preoperative renal imaging did not predict cases with abnormal cystoscopy. There were no cases of complications caused by the intraoperative cystoscopy. CONCLUSION: Intraoperative cystoscopy with intravenous injection of indigo carmine is a safe technique that can detect otherwise undetected intraoperative compromise of the urinary tract during prolapse and incontinence surgery. It is recommended that cystoscopy be used liberally to reduced the frequency of serious sequelae from urinary tract injury.

Age as a risk factor in major genitourinary surgery.

Surgery for urinary incontinence is often not considered in elderly persons (older than 65 years) because of their age. In this paper the authors examine the effect of age on the success rate and complications of abdominal correction (modified retropubic colpourethropexy with or without other major gynecologic surgery) for genuine stress incontinence. Other than age, length of hospital stay and some urodynamic values there were no statistically significant differences in success and complication rates between the elderly and younger patients. The authors conclude that in properly selected elderly patients with genuine stress incontinence, retropubic colpourethropexy is as safe and effective as in younger patients.

Prophylactic use of antibiotics in combined abdominovaginal Marlex sling procedures for correction of recurrent urinary stress incontinence.

The charts of 75 patients who underwent a combined abdominovaginal Marlex sling procedure to correct urinary incontinence were analysed to assess the value of antibiotic prophylaxis. Six patients who received antibiotics preoperatively for underlying medical problems were excluded from the study. Eighteen patients operated on before 1980 did not receive antibiotic prophylaxis and of these only 1 suffered a superficial abdominal wound infection. Fifty-one consecutive patients received antibiotics prophylactically; of this group again only 1 had a superficial abdominal wound infection. These findings suggest that antibiotic prophylaxis may not be necessary with this operation. Nevertheless, the authors believe a prospective, randomized, double-blind study to include a placebo is warranted, and such a study will be undertaken in their unit.

Accuracy of total bladder volume and residual urine measurements: comparison between real-time ultrasonography and catheterization.

The practical value of ultrasonography as a rapid means to accurately determine total bladder volumes and residual urine volume was assessed. Transverse and sagittal bladder diameters were measured with real-time ultrasonography in 50 women: (1) before uroflowmetry, (2) before supine-postvoiding catheterization, (3) before standing catheterization, and (4) after standing catheterization. Calculated bladder volumes, by use of the measured diameters, for each of eight formulas from the literature were compared with their corresponding measured total urine volume, total residual volume, and standing residual volume. The lower limit of ultrasonographic visualization of urine in the bladder was approximately 42 ml. No correlation existed between calculated ultrasound bladder volumes and measured urine volumes for any of the eight formulas. Standing residual volumes were measured in 96% of cases. Ultrasonography cannot as yet rapidly measure bladder volumes accurately. Catheterization remains the best method of assessing postvoid residuals: supine measurements, the gold standard, should be augmented by standing measurements when more accurate volumes are required.

Surgical management of pelvic organ prolapse and stress urinary incontinence.

There is no single operative approach to correct pelvic organ prolapse in conjunction with urinary and/or fecal incontinence or rectal prolapse. Each case needs to be individualized and dealt with surgically following the principles outlined in Table 1. In postmenopausal women, it is not only important to pretreat patients with estrogen prior to reconstructive pelvic surgery, but also maintain patients on long-term treatment after surgery. The genitourinary and reconstructive pelvic surgeon should have the skills to offer patients alternative approaches tailored to their individual symptomatology, and anatomic and pelvic pathology. Long-term follow-up of all patients is imperative to ascertain the clinical and cost effectiveness of these procedures.

The accuracy of portable abdominal ultrasound equipment in measuring postvoid residual volume.

This study examines the accuracy of a new portable abdominal ultrasound machine (Bladder Scan, BVI 2500) used to measure postvoid urine residual (PVR). Using this machine, we started prospectively measuring residual urine in the first 80 women undergoing uroflowmetry in our urodynamic unit. Ultrasound PVR measurements were done immediately prior to catheterization while the patient was in the supine position. The catheterized postvoid residual was used as the gold standard. Eighty paired measurements were done on 78 women. Compared to catheterized PVR, ultrasound PVR measurements tend to underestimate and correlated poorly with the actual residual volume. The reading was considered accurate if it was within 25% of the catheterized PVR. The ultrasound PVR measurements were most accurate (60.6%) when the readings were below 50 ml and least accurate (10%) when readings were higher than 150 ml. Readings between 50 and 150 ml were 27% accurate. A measurement of zero '000' was common (44%), usually reflecting volumes of less than 50 ml (84% of cases). However, it could indicate that the bladder had been missed altogether. Partial measurement of the bladder volume, where the lateral bladder borders are missing, produces readings much below the actual volume: a 'tip of the iceberg' phenomenon. We therefore advocate caution when interpreting PVR measurements from portable abdominal ultrasound machines, and if an accurate measurement of PVR is necessary, catheterization remains a more reliable method.

Sacrospinous vault suspension and abdominal colposacropexy: success rates and complications.

OBJECTIVE: Our purpose was to compare success rates and complications of sacrospinous vault suspension and abdominal colposacropexy. STUDY DESIGN: A case series is presented of 130 attempted sacrospinous vault suspensions with the Miya hook and 80 cases of abdominal colposacropexy, done in conjunction with other procedures. Patients were assessed 6 weeks and 6 and 12 months after surgery and yearly thereafter. RESULTS: Sacrospinous vault suspension was completed in 125 women (5 abandoned because of technical difficulty). Abdominal colposacropexy was completed in all 80 women. There was only one intraoperative complication-hemorrhage from the presacral veins during abdominal colposacroplexy. The incidence of postoperative febrile morbidity was 10% after sacrospinous vault suspension and 6% after abdominal colposacropexy. Follow-up ranged from 6 months to 5 years. The incidence of recurrent vault prolapse was 2.4% with sacrospinous vault suspension and 1.3% with abdominal colposacropexy. Demonstrable stress urinary incontinence occurred in one woman after abdominal colposacropexy and in none after sacrospinous vault suspension. CONCLUSION: Sacrospinous vault suspension and abdominal colposacropexy are associated with a low incidence of intraoperative and postoperative complications and recurrent vault prolapse. Latent stress urinary incontinence may be unmasked, particularly with abdominal colposacropexy, and preoperative urodynamic evaluation is therefore recommended.

Bacterial vaginosis increases in pessary users.

The purpose of this study was to examine the association between pessary use, smoking and changes in the vaginal flora. Patients using pessaries were age matched with non-pessary using controls. All candidates examined were women attending the Mount Sinai Hospital, Toronto, for genitourinary problems. Vaginal cultures were routinely performed on all women attending the unit, irrespective of symptoms. Forty-four pessary users were age matched with 176 controls (4 controls per case). The mean age was 60.1 +/- 12.6 years, and 15% of these were premenopausal. The duration of pessary use ranged from 0.5 to 8 years (mean 3.3 +/- 1.7). Weight, parity, smoking status, diabetes mellitus, thyroid disease, UTI and postvoid residual urine volume were not significantly different between pessary users and controls. Bacterial vaginosis (BV) was noted in 32% of pessary users, versus 10% of controls. The relative risk of developing BV in pessary users was 3.3 (OR, 4.37; 95% CI, 2.15-9.32), P = 0.0002. Smoking independently affected the vaginal flora, increasing the relative risk of developing BV to 2.9 (OR, 3.78; 95% CI, 2.05-8.25), P = 0.0013. It was concluded that pessary use is a very effective and conservative method for the treatment of genital prolapse. However, we found that the presence of a foreign body was associated with changes in the vaginal flora, thereby increasing the odds of developing bacterial vaginosis to 4.37; this was further compounded by smoking.