Biomedical subjects
Publications and source records attributed to S Walter.
Urinary incontinence arises because of a disproportion between the bladder pressure and the urethral closure pressure. A programme of investigation is proposed. Emphasize is on a careful history taking supplemented with cystometry, colpocysto-urethrography, and urodynamic examination. The treatment is described depending on type and severity of incontinence.
A broad variety of incontinence aids should be available as the needs of the individual patient are different. The various major types of aids are described. The correct choice of aids for any patient depends on a combination of factors: aid, patient factors, and environment. Thorough knowledge of the various aids, their use, advantages, and limitations is needed. A well-organized aid-distribution centre makes an acceptable cost/benefit balance possible.
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Forty-one consecutive female patients were operated on despite the finding of motor urge incontinence; they were reinvestigated six months to two years after operation. Seventeen of the patients had associated symptomatic genital prolapse and were operated without previous pharmacological treatment. The remaining 24 patients were resistant to parasympatholytic treatment. The method of operation was based on vaginal examination and evaluation of bladder suspension defect at voiding-cystourethrography. Cure and improvement rate was 73 per cent. Cystometry was normalized in 30 per cent of all patients and in 45 per cent of patients with preoperative detrusor instability on provocation only. Disappearance of detrusor instability as well as normalization of a bladder suspension defect was associated with a good result. Motor urge incontinence should not contraindicate incontinence surgery on females selected and treated as in the present study.
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Phosphatidylinositol (PI) synthesis and its role in controlling the cell cycle has been investigated using fibroblasts and liver cells in culture. PI synthesis as measured by incorporation of [3H]-myo-inositol into trichloroacetic acid precipitable material during 0--60 min after serum or growth factor stimulation of serum-starved cells is increased in primary fetal rat liver cells, rat embryo fibroblasts, and 3T3 mouse cells. In contrast, growth stimulation of 3T3 cells and hepatocytes rendered quiescent in G1 by amino acid starvation is not accompanied by increased incorporation of [3H[-myo-inositol into trichloroacetic acid precipitable material. This suggests that those cells might be arrested at a different point in G1 than cells arrested by serum depletion. Inhibition of PI synthesis by variation of-hexachlorocyclohexane (HCH), a steric analog of myo-inositol, during early times (e.g., 0--4 hr) after growth stimulation, reversibly blocks initiation of DNA synthesis in 3T3 cells. The results support the idea that increased PI synthesis in response to growth stimulation in the cell types studied here is a prerequisite for progression through G1 and subsequent entry into S phase.
A survey of the innervation of the bladder and urethra is presented. Based on the defects of innervation the main types of neurogenic bladder disorders are classified and described. The principal diagnostic procedures, cystometry and sphincter-electromyography, are reviewed in detail. The findings at voiding cysto-urethrography are depicted. It is important to be able to distinguish between voiding disorders of non-neurogenic and neurogenic origin. The specific treatment of the various types of neurogenic disorders of the lower urinary tract is described.
Colpo-cysto-urethrography, urodynamic and cystometric examinations were performed in 420 patients from the departments of urology and gynecology. One hundred and ninty-eight patients displayed displacement of the urethro-vesical junction in the anterior and inferior direction. Three grades of displacement were established. The mildest form, grade 1, was visible only during a cough. The intermediate form, grade 2, was present even at rest. The severest form, grade 3, involved a displacement of the anterior vaginal wall, resulting in anterior bladder descent during cough and/or micturition. Stress incontinence was a complaint in 82 per cent of the women. The pathology is shown to be laxity of the arcus tendineus fasciae pelvis, which normally exerts a pull on the bladder neck in a postero-cranial direction. In seven cases anatomically corrective operations on this ligament were performed, resulting in a normal bladder base in an anatomically correct position. The operation is complicated and not suited for routine use.
Of 420 female patients examined by means of colpo-cysto-urethrography 51 patients presented posterior bladder suspension defects. Two distinct forms were seen:1. Trigonocele (22 patients)--a downward herniation of the trigone between the postero-inferiorly displaced vagina and the bladder neck, which is retained in a nearly normal position by muscle fibers from the pubococcygeal muscle and the pubovesical ligaments. Symptoms were mostly those associated with prolapse. Stress incontinence was rare, while urge incontinence, cystitis and retention of urine were seen. The morphology varied from cases where the herniation disappeared during detrusor contraction (compensated trigonocele) through typical forms to transitional forms between trigonocele and posterior bladder descent. 2. Posterior bladder descent (29 patients) comprises postero-inferior displacement of the vagina and bladder base together. Two subgroups are discernible: A. Bladder descent even at rest (16 patients). B. Bladder descent only during micturition (13 patients). Symptoms were varied, but stress incontinence was found in 31 per cent in group A, and 62 per cent in group B. Morphological forms varied from two cases that were normalized in position during detrusor contraction (compensated descent) to total prolapse during micturition.
Neurogenic bladder dysfunction can be difficult to manage and is usually impossible to cure. This case report describes neurosurgical treatment of a case of recurrent urinary incontinence in a 56 years old woman who was previously treated on four occasions with vaginal repair operations with no beneficial effect. Cystometry revealed detrusor hyperreflexia (supranuclear bladder paresis). Myelography demonstrated cervical spinal cord compression. She was treated with spondylodesis of the cervical spine with complete relief of incontinence. 18 months postoperative cystometry was normal and after three years she was free of symptoms.
Urinary excretion of metabolites of the tryptophan-nicotinic acid ribonucleotide pathway, urinary excretion of 4-pyridoxic acid and blood concentrations of oestradiol and pyridoxal phosphate were studied in groups of post-menopausal women before or during treatment with natural oestrogens, i.e. oestradiol and oestriol, before and after loading doses of 9800 mumol L-tryptophan or 700 mumol L-kynurenine sulphate. Natural oestrogens induced abnormalities of tryptophan metabolism similar to those induced by synthetic oestrogens, and there was a dose related increase in urinary excretion of metabolites of the tryptophan-nicotinic acid ribonucleotide pathway before the kynureninase step. The increase in urinary excretion of these metabolites also after a loading dose of 700 mumol L-kynurenine indicates an inhibitory effect of oestrogens on kynureninase in vivo. Evidence is presented that this inhibition is an effect mediated through decreased availability of vitamin B6, the coenzyme of kynureninase, although the possibility of a direct effect of oestrogens on kynureninase can not be excluded.
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One hundred consecutive female patients with urinary incontinence were investigated with CO2 cystometry including detrusor reflex activation procedures such as postural change and ability to suppress self-induced detrusor contractions. Detrusor hyperreflexia was seen in 20 patients during bladder filling in the supine position, and in an additional 35 patients after detrusor reflex activation procedures. Four different types of detrusor hyperreflexia are described based on the cystometric findings. In 38 patients treated with parasympatholytics, 66% showed a good result independent of the type of detrusor hyperreflexia.
The bulbocavernosus reflex can be elicited either by penile or urethral stimulation. The mean signal transit time after electrostimulation of the dorsal penile nerve to evoked response in the anal sphincter (35 msec) was only half the signal transit time after stimulation in the posterior urethra (60 msec). Thus, the modified bulbocavernosus reflex elicited either by squeezing the glans penis or by pulling a urethral balloon catheter represents two different reflexes with differenct afferent and probably different intraspinal pathways. In the clinic it is therefore important, when testing the bulbocavernosus reflex, to report how it is elicited.
A case of neurosurgical treatment of recurrent urinary incontinence caused by detrusor hyperreflexia is reported. The importance of cystometry in the diagnosis of recurrent urinary incontinence is stressed.