Outcome measures and surgery for stress urinary incontinence

A large number of surgical procedures to correct urinary stress incontinence in the female have been described. There has been wide variablility in reported success rates. This variablility is due to a number of factors. Papers published in 1997 that assess outcomes in the treatment of female stress urinary incontinence illustrate many of the current problems that exist with examining outcomes, including patient selection, modifications in technique, the definition of success, how success is measured and when the outcome is assessed.

Collagen implant for treating stress urinary incontinence in women with urethral hypermobility

PURPOSE

We evaluated the use of collagen in women with stress urinary incontinence and urethral hypermobility.

MATERIALS AND METHODS

We treated 90 patients with stress urinary incontinence and urethral hypermobility with 1 to 3 injections of Contigen implant (C. R. Bard, Inc., Covington, Georgia) between June 1996 and October 1998. Observations at 3, 6 and 12 months included continence grade, 7-day voiding diaries and quality of life questionnaires. Abdominal leak point pressure was determined at baseline and 12 months.

RESULTS

At the 6-month followup 68 patients remained in the study, of whom 30 (44%) were dry and 24 (35%) were improved. Of the 58 patients who reached the 12-month followup 19 (33%) were dry and 19 (33%) were improved. Considering all patients entered into the study at 6 months 30 (33%) were dry and 24 (27%) were improved. Of the original 90 patients 19 (21%) were dry and 19 (21%) were improved at 12 months. The probability of maintaining initial improvement for 12 months was 44%. The success of bulking agent therapy was not predicted by the initial incontinence grade. Improved continence grade correlated with improved leak point pressure.

CONCLUSIONS

This therapy is appropriate in women with urethral hypermobility who wish to avoid surgical risks and in those in whom surgery is ill advised.

1999 American Urological Association Gallup Survey: changes in physician practice patterns, treatment of incontinence and bladder cancer, and impact of managed care

PURPOSE

The Health Policy Survey and Research Committee of the American Urological Association and the Gallup Organization have performed a yearly survey of American urologists since 1992 to assess practice patterns. The results of the 1999 survey are presented.

MATERIALS AND METHODS

A random sample of 503 urologists was interviewed in February and March 1999. Major content areas were physician practice patterns, the impact of managed care, and the treatment of pediatric patients, prostate cancer and benign prostatic hyperplasia, female incontinence and bladder cancer.

RESULTS

The average urologist is 46.8 years old, certified by the American Board of Urology, sees 78 patients and performs 3.1 major surgical procedures weekly, refers moderate and complex pediatric procedures to specialists, and receives 40.6% of practice income from managed care.

CONCLUSIONS

In an era when large group practices seem to be the norm remarkably 32% of urologists remain in solo practice. There has been a shift in where urologists spend their time, that is more in the office and less in the operating room. Minor and major open surgical procedures increased from 12.4 weekly to 16.4 and 2.9 to 3.1 in 1995 and 1999, respectively. Most urologists are comfortable treating straightforward pediatric problems such as cryptorchidism but refer more complex problems to pediatric urologists. Managed care represents an ever increasing proportion of urologist practice income, while office expenses continue to increase.

Irritative voiding symptoms: identifying the cause

Most cases of irritative voiding are caused by urinary tract infections associated with common, community-acquired pathogens such as Escherichia coli. But when symptoms persist in the absence of infection, less common diagnoses must be considered. Appropriate cultures and urodynamic studies will rule out obstruction and identify detrusor hyperactivity. Definitive diagnosis of interstitial cystitis requires cystoscopy and hydrodistention.

Prospective development of a cost-efficient program for the pubovaginal sling

OBJECTIVES

We designed and implemented a cost-containment program for patients undergoing a pubovaginal sling procedure. We sought to test the hypothesis that preoperative patient education could reduce the length of hospital stay in these patients. Our goal was to decrease hospital charges while maintaining quality of care.

METHODS

A multidisciplinary group of clinic and hospital staff identified factors that contribute to a patient's hospital charges for a pubovaginal sling procedure. A program of preoperative patient education to teach intermittent self-catheterization was combined with the elimination or control of items considered unnecessary to the delivery of safe, efficient care. Patient care was standardized from the preoperative visit to discharge planning. The difference in the mean values of 38 prestudy patients was compared with 15 study patients with a Wilcoxon rank sum test.

RESULTS

Length of hospital stay was reduced from a mean of 2.8 to 1.1 days after implementation of the program (P < 0.0001). This decreased length of stay, combined with a reduction in routine laboratory studies (97% decrease; P < 0.0001), operating room charges (11% decrease; P < 0.01), and medications (35% decrease; P < 0.01), led to significantly reduced hospital charges. Total hospital charges decreased by 35%, from a mean of $4862 to a mean of $3153 (P < 0.0001). There was no increase in morbidity. Patient satisfaction with length of hospital stay did not change significantly following implementation of the program.

CONCLUSIONS

With a program of preoperative patient education combined with a critical review of the factors contributing to a patient's hospital charges, it is possible to implement a cost-efficient program for a pubovaginal sling, leading to a 35% reduction in mean total hospital charges. This approach directed toward other incontinence procedures could be expected to yield comparative results.

Urodynamic assessment of urethral sphincter function in post-prostatectomy incontinence

PURPOSE

Direct measurement of maximum urethral pressure by urethral profilometry has been used widely to assess urethral sphincter function. We attempted to determine if there was any relationship between maximum urethral pressure, which is measured at the level of the membranous urethra, or extrinsic urethral sphincter function, and the amount of abdominal pressure needed to cause leakage (abdominal leak point pressure) in men with post-prostatectomy incontinence. We also examined the relationship between external sphincter function and continence or incontinence.

MATERIALS AND METHODS

We retrospectively evaluated fluoro-urodynamics performed in 37 men with post-prostatectomy incontinence. Urodynamic study consisted of measurement of maximum urethral and abdominal leak point pressures, and assessment of extrinsic sphincter function by pressure measurements and radiographically.

RESULTS

Data were analyzed on 27 patients for whom abdominal leak point and maximum urethral pressures were available. Mean maximum urethral pressure was 52.5 cm. water (range 20 to 165) and mean abdominal leak point pressure was 77.8 cm. water (range 27 to 132). Regression analysis was performed between maximum urethral and abdominal leak point pressures. A Pearson correlation coefficient of 0.13834 was calculated (p = 0.4914) indicating virtually no correlation between the 2 measurements in our sample. Extrinsic urethral sphincter was normal in all patients. Only 1 of 37 patients had no evidence of intrinsic sphincter deficiency, that is there was no urine leakage with increases in abdominal pressure and the patient was incontinent solely based on bladder dysfunction (detrusor instability).

CONCLUSIONS

Our study indicates that incontinence after prostatectomy due to an increase in abdominal pressure (stress incontinence) does not depend on extrinsic sphincter function and is not related to maximal urethral pressure. We conclude that post-prostatectomy incontinence due to sphincter dysfunction results from intrinsic sphincter deficiency. In our experience bladder dysfunction is rarely the sole cause of post-prostatectomy incontinence.

Florid xanthomatous pelvic lymph node reaction to metastatic prostatic adenocarcinoma. A sequela of preoperative androgen deprivation therapy

We describe a florid xanthomatous histiocytic reaction in the pelvic lymph nodes of a patient treated with androgen deprivation therapy prior to radical prostatectomy. The xanthomatous reaction was so marked that it nearly obscured the presence of metastatic carcinoma in the same lymph nodes. A similar histiocytic reaction was also present in association with carcinoma in the prostatectomy specimen, a finding that was not identified in pretreatment biopsy specimens. No other known cause of pronounced histiocytic lymph node proliferation was present in this patient. Only one brief description of a xanthomatous reaction in lymph nodes associated with this treatment has been previously recorded in the literature to our knowledge. Other patients from our institution who were treated similarly preoperatively all had lymph nodes negative for tumor, and none demonstrated a xanthomatous tissue reaction, suggesting that this reaction may be a marker for metastatic tumor in the same lymph node.

Pubovaginal slings for the management of urinary incontinence in female adolescents

A pubovaginal sling is an effective treatment for type III incontinence secondary to poor proximal urethral sphincter function. We used a pubovaginal sling to treat incontinence in 15 female adolescents. The etiology of incontinence was spinal dysraphism in 10 patients and prior trauma in 3. Simultaneous bladder augmentation was performed in the remaining 2 patients for poor bladder compliance. Three patients required additional procedures including repeat slings in 2 and repeat augmentation in 1. Of 13 patients followed for more than 6 months 11 remain dry, 1 leaks small amounts and wears 1 pad per day, and 1 did not achieve acceptable continence and was subsequently managed with bladder augmentation and a Mitrofanoff procedure. The upper urinary tracts have remained normal in all 13 patients. The pubovaginal sling has proved to be safe and successful in these children. The overall continence rate of 92% compares favorably to other available modalities.

Early clinical experience with adult bladder auto-augmentation

Five patients 18 to 73 years old underwent auto-augmentation for a small capacity, poorly compliant bladder. The mean operative time and hospital stay were 106 minutes and 6 days, respectively. No postoperative complications occurred. Followup ranged from 12 to 82 weeks. Bladder capacity increased from 75 to 310 cc or 40 to 310%. Compliance also improved in all patients. Three patients had reflux preoperatively, which resolved in 1 and improved in 2. Of 4 patients who were incontinent preoperatively 3 became continent postoperatively and extended the interval between catheterizations. Upper tract function has remained stable. No patient required enterocystoplasty to control bladder pressures.

Cerebral aetiology of urinary urge incontinence in elderly people

We have examined 73 elderly incontinent patients (mean age 79 years) and 27 continent subjects (mean age 78 years) of similar cognitive status. Among the incontinent patients, 20 were shown objectively to have urge incontinence with normal bladder filling sensation, 14 had objectively demonstrated urge incontinence with reduced bladder sensation, and 39 had other types of incontinence. We compared cognitive function (by Mini-mental State Examination: MMSE) and regional brain perfusion (by SPECT scanning) in these four groups. Patients with objectively demonstrated urge incontinence and reduced bladder sensation stood out as being different from the rest: their mean MMSE score was significantly lower than that of any of the other three groups; perfusion of the frontal cortex was significantly poorer than that in the continent and other incontinent groups; global cortical perfusion was significantly poorer than in the other incontinence groups. This was not found in patients with urge incontinence and normal bladder sensation. The observations support the hypothesis that in elderly people urge incontinence with reduced bladder sensation can be a consequence of cortical neuropathy, especially in the frontal lobes.

The effect of terazosin on bladder function in the spinal cord injured patient

We prospectively studied the effect of terazosin on bladder compliance in 12 spinal cord injured patients. All study patients had demonstrated previously poor compliance despite clean intermittent catheterization and maximum anticholinergic therapy. Patients were started on 5 mg. terazosin nightly for 4 weeks. They were evaluated with a history, physical examination, symptom score, and synchronous cystoscopy and cystometry before, during and after terazosin therapy. Detrusor compliance improved in all patients during the treatment phase. The change in bladder pressure and the safe bladder volume were statistically and clinically significant. Patients also reported fewer episodes of incontinence and dysreflexia. The improvement in compliance and continence suggests that in the spinal cord injured patient terazosin may have an effect on alpha receptors in the detrusor muscle or central effects and that improved compliance is not due to decreased outlet resistance.

Clinical assessment of urethral sphincter function

Measurements of urethral pressures, such as maximum urethral pressure, are widely believed to have relevance in the management of urinary incontinence despite evidence to the contrary. In this study maximum urethral pressure and the abdominal pressure required to cause stress incontinence were measured in 125 women with stress incontinence. In women the abdominal pressure required to cause stress incontinence was unrelated to maximum urethral pressure. These findings indicate that maximum urethral pressure has little relationship to urethral resistance to abdominal pressure. In the 9 children with myelodysplasia we compared the detrusor pressure with the abdominal pressure required to induce urethral leakage. These values also were quite different, indicating that as far as the urethra is concerned abdominal pressure and detrusor pressure are not equivalent forces.

Polypharmacy and its effect on urinary incontinence in a geriatric population

The relationship between medication and incontinence was studied retrospectively in 128 elderly patients enrolled in an incontinence study. Patients were taking up to 18 non-topical medications but most of these were unlikely to have a significant urological effect. Nevertheless, 62% of patients were receiving, for other medical problems, up to 4 drugs which could potentially affect the lower urinary tract. These were classified by their mode of action. The most common types of urologically active medication, apart from diuretics, were calcium channel blockers, used by 21% of patients, and tricyclic antidepressants, used by 12%. The urodynamic findings in patients on different types of medication were compared. Patients with urodynamically proven urge incontinence who were on calcium channel blockers had significantly less urine loss than those not on the drug. Tricyclic antidepressants have been used in the treatment of urge incontinence; in this study urine loss was less severe among those receiving tricyclics, although the differences were not significant. A few patients on beta-blockers apparently had more severe urge incontinence. Drugs prescribed to the elderly for non-urological medical problems can affect the lower urinary tract and may have some effect, either beneficial or adverse, on incontinence.

Effect of transurethral resection of the prostate on detrusor instability and urge incontinence in elderly males

Detrusor instability is common in men with evidence of outflow obstruction due to benign prostatic hypertrophy and typically reverses in about two thirds of patients after transurethral resection of the prostate (TURP). It is also common among the elderly without outflow obstruction and may lead to urge incontinence. To determine whether TURP has an effect on detrusor instability and urge incontinence in elderly men, or whether these abnormalities are due to other age-associated changes, 12 males (mean age 80 years) with urge incontinence or frequency and urgency of micturition, and symptomatic benign prostatic hypertrophy, were studied by 24-hour monitoring of incontinence and videourodynamic examination, before and after TURP; 7/12 patients were significantly cognitively impaired. Preoperatively, all patients showed detrusor instability, which reversed postoperatively in only one patient, a significantly smaller proportion than that consistently reported in younger patients. Preoperatively, 11/12 patients were incontinent. After TURP, 8/11 patients had an improvement in the amount of incontinence, by up to 458 g in 24 hours. Those who improved had been urodynamically more severely obstructed preoperatively. Those with the most improvement were also cognitively impaired. We conclude that, in the geriatric population, detrusor instability and urge incontinence may be the result of age-associated changes and not secondary to obstruction. Detrusor instability is likely to persist following TURP. Preoperative urodynamic assessment of obstruction in the incontinent male with benign prostatic hypertrophy may be useful since the severity of incontinence responds well to TURP if there is marked obstruction. Cognitive impairment should not be a deterrent to operation.

Relationship of fluid intake to voluntary micturition and urinary incontinence in geriatric patients

The aim of this study was to investigate, in a group of geriatric inpatients with established incontinence, the relationships among urine loss, voided volumes, frequency of voiding, and fluid intake. The investigated included 128 patients: 76 women and 52 men, with a median age of 79 years. One-half had significant cognitive impairment. Patients underwent 24-hr monitoring of fluid intake, urine loss, and voiding, as well as conventional videourodynamic testing. Diurnal and nocturnal voiding frequencies were significantly but relatively weakly related to fluid intake. Diurnal and nocturnal voided volumes were more closely related, however, to the fluid intake. There was a strong and easily interpretable relationship among nocturnal voided volume, nocturia, cystometric bladder capacity, and evening fluid intake. Sixty of 128 patients had urodynamically proven urge incontinence, and this group was studied separately. They were more cognitively impaired and had significantly greater urine loss and smaller fluid intake than was true of the other incontinent patients. Urine loss was significantly related to fluid intake in this group. Nocturnal urine loss increased by an average of 28 ml/dl of evening fluid intake and decreased by 17 ml/dl voided at night. These results suggest that nocturnal toileting and evening fluid restriction may reduce nocturnal urine loss by a small but useful amount in carefully selected older patients with severe urge incontinence.

Characteristics of urinary incontinence in elderly patients studied by 24-hour monitoring and urodynamic testing

Characteristics of urinary incontinence have been studied in 100 elderly incontinent patients using invasive video-urodynamics and noninvasive 24-h monitoring of incontinence, fluid intake, voiding and residual urine. Incontinence was of the urge type in 51 patients, including 24 with reduced bladder sensation. Noninvasive 24-h monitoring showed satisfactory reproducibility and high sensitivity (88%) for detecting urine loss. Urodynamically proven urge incontinence, especially in combination with reduced sensation, and recent bacteriuria were associated with severe urine loss on 24-h monitoring. On 24-h monitoring, urine output was significantly larger at night and nocturia was common. In urge incontinence urine loss was predominantly nocturnal and the amount depended significantly on the previous evening's fluid intake and on nocturia. Noninvasive 24-h monitoring showed that post-void residual was common and was often largest in the early morning. It also yielded many free-voiding flow curves. Normal flow curves with small residual urine make dysfunction of voiding itself unlikely. Thus noninvasive monitoring provides information about incontinence and voiding that is suitable for designing intervention and management strategies. Invasive testing may be necessary however to confirm the urodynamic type of incontinence or suspected voiding dysfunction.