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PubMed1999

The significance of the open bladder neck associated with pelvic fracture urethral distraction defects.

PURPOSE: As a result of pelvic fracture urethral distraction defects, urinary continence relies predominantly on intact bladder neck function. Hence, when cystoscopy and/or cystography reveals an open bladder neck before urethroplasty, the probability of postoperative urinary incontinence may be significant. Unresolved issues are the necessity, the timing and the type of bladder neck repair. We report the outcome of various therapeutic options in patients with pelvic fracture urethral distraction defects and open bladder neck. We also attempt to identify prognostic factors of incontinence before urethroplasty. MATERIALS AND METHODS: We retrospectively reviewed the records of 15 patients with a mean age of 30 years in whom an open bladder neck was identified before posterior urethroplasty between January 1981 and October 1997. RESULTS: Of the 15 patients 6 were continent and 8 were incontinent postoperatively. One patient underwent artificial urethral sphincter implantation simultaneously with pelvic fracture urethral distraction defect repair and was dry postoperatively without sphincter activation. Average bladder neck and prostatic urethral opening on the cystourethrogram before urethroplasty was significantly longer in incontinent (1.68 cm.) than in continent (0.9 cm.) patients. Of the 8 patients who were incontinent 6 underwent bladder neck reconstruction, 1 artificial urinary sphincter and 1 periurethral collagen implant. Five patients with bladder neck reconstruction are totally continent and 1 requires 1 pad daily. The patient who underwent collagen implant requires 2 pads daily and the patient who received an artificial urethral sphincter has minor urge leakage. CONCLUSIONS: Open bladder neck before urethroplasty may herald postoperative incontinence which may be predicted by radiographic and cystoscopic features. Evaluation of the risk of postoperative incontinence may be valuable, and eventually guide the necessity and timing of anti-incontinence surgery, although our preference remains to manage the pelvic fracture urethral distraction defects and bladder neck problem sequentially. Bladder neck reconstruction provides good postoperative continence rates and is our technique of choice.

Adolescent↗
PubMed2004

Readjustable transobturator sling: a novel sling procedure for male urinary incontinence.

Post-prostatectomy incontinence remains a significant problem for both patients and urologists. We report a case and the surgical technique of successful sling in the treatment of post-prostatectomy urinary incontinence. Sling surgery was performed on a 69-year-old male patient with severe urinary incontinence (6 pads/day) following radical prostatectomy. The procedure was conducted through the transobturator approach using a sling with a silicone foam pad to protect the urethra. At the 7-month follow-up the patient is using only 1 pad/day. We consider this operation an alternative to artificial urinary sphincter in cases of male sphincter incontinence.

Aged↗
PubMed1995

Harry E. Bacon Oration. Comparison of the functional results of restorative proctocolectomy for ulcerative colitis between the J and W configuration ileal pouches with sutured ileoanal anastomosis.

PURPOSE: This study was designed to compare function of patients who had undergone reconstruction following proctocolectomy for ulcerative colitis using the J or W configuration ileoanal pouch. METHODS: Of 126 patients who underwent restorative proctocolectomy between January 1981 and March 1993, 101 had surgery for ulcerative colitis. Eighty-seven of these patients were available for review by personal or postal interview. All operative procedures were performed by one surgeon. The group comprised 35 W-pouches and 52 J-pouches. RESULTS: More patients with a J-pouch had a stool frequency of greater than 8 per 24 hours (P = 0.044), and they were also more likely to use a perineal pad (P = 0.019). No difference in the rates of nocturnal stool frequency, fecal incontinence, or use of constipating agents between the two pouch designs was found. Significantly more patients with a J-pouch have had episodes of pouchitis (P = 0.001). Of the total patient group 91.9 percent felt that restorative proctocolectomy had improved their quality of life. CONCLUSION: Minor differences in the function of the W configuration ileoanal pouch and the J configuration ileoanal pouch are demonstrated in this study.

Adult↗
PubMed2005

Long-term outcomes of a neo-anus with a pudendal nerve anastomosis contemporaneously reconstructed with an abdominoperineal excision of the rectum.

BACKGROUND: Pudendal nerve innervation can transform a neo-sphincter into an original anal sphincter-like muscle in animal studies. The results led us to clinical trials of a neo-anus with a pudendal nerve anastomosis (NAPNA). No long-term results in a series have been reported. METHODS: From 1995 to 2003, a neo-anus was reconstructed by using an inferior portion of the gluteus maximum muscle with a pudendal nerve anastomosis contemporaneously with an abdominoperineal excision of the rectum (APER) in 19 patients (17 men, 2 women; median age, 62.0 years; range, 46-73) with low-lying malignancy. The long-term (<2 years) clinical results were evaluated. RESULTS: The neo-sphincter began contracting (n = 15) at 6.6 +/- 1.8 months after surgery; then the ileostomy was closed (n = 14) at 9.1 +/- 2.6 months. The long-term results were studied in 10 patients (40.9 +/- 14.1 months after ileostomy closure). All patients (100%) defecated at 4.8 +/- 2.6 times/day without irrigation. Pads were used every day in 9 patients (90%). The Cleveland Clinic Florida incontinence score was 12.2 +/- 3.3 points. No patients lost their occupation. Eight patients (80%) answered that their life with a NAPNA was better than with an ileostomy. The average World Health Organization Quality of Life-BREF in patients with NAPNAs was significantly better than that in those patients who underwent conventional APERs in our hospital (n = 27, 66.4 +/- 0.8 years old) ( P = .0402). Four patients (40%) experiencing the need to defecate got significantly better continence score (mean +/- SD). CONCLUSIONS: The sensitivity to recognize the need to defecate may be a key to success in NAPNAs. A NAPNA can be a practical option for selected patients wishing to avoid a stoma after an APER.

Age Factors↗
PubMed1995

Effect of radical prostatectomy for prostate cancer on patient quality of life: results from a Medicare survey.

OBJECTIVES: To assess patient responses to radical prostatectomy and its effects. METHODS: A national sample was taken of 1072 Medicare patients who underwent radical prostatectomy for prostate cancer (1988 through 1990) by mail, telephone, and personal interviews. The effects of the surgery and its complications on these patients' lives were studied through: (1) patient ratings of the extent to which sexual and urinary dysfunctions were "problems" in their lives; (2) two general measures of quality of life, the Mental Health Index and the General Health Index; (3) patient reports of how they felt about the results of treatment and whether they would choose surgery again. RESULTS: On average, dripping urine, particularly to the point where subjects were wearing pads, had a more significant effect on patients than loss of sexual function; incontinence had significant adverse effects on the measures of quality of life and self-reported results of surgery. Overall, postsurgical patients scored comparatively high on the quality of life measures (similar to a cohort of patients with benigh prostatic hyperplasia who had undergone transurethral resection of the prostate), reported feeling positive about the results (81%), and would choose surgical treatment again (89%). Nonetheless, there was variability in patient response to the effects of surgery. CONCLUSIONS: The results demonstrate the ability of many Medicare patients to adapt to adverse outcomes, such as loss of sexual function and incontinence. They also provide evidence of the variability of individual patients' responses to surgical results and reinforce the importance of individualized decision making for patients facing a decision about radical prostatectomy for prostate cancer.

Aged↗
PubMed1984

Reproducibility and reliability of urinary incontinence assessment with a 60 min test.

Urinary incontinence was objectively assessed in 50 patients. The urine loss was measured as weight gain of perineal pads worn during a 60 min standardized activity period. The test was initiated by drinking 500 ml (not milk and soda water). The patients were instructed not to void before and during the test. After the test, the voided volume was collected. The test proved handy, reproducible and reliable compared to the subjective day-time incontinence. Prior to the actual test, 15 patients participated in a pilot study having an initial voiding and a test period of 3 1/2 hours. This longer test period was not found practical and the gain in positive diagnosis was minimal compared to the disadvantages with a higher number of unscheduled voidings.

Adolescent↗
PubMed2002

Tension-free vaginal tape procedure after previous failure in incontinence surgery.

OBJECTIVES: To study the efficacy of the tension-free vaginal tape (TVT) procedure for patients with recurrent genuine stress incontinence. METHODS: Forty-one women, including 11 with urethral sphincter incompetence (mean age 49.6 years, range 37 to 66), were treated for recurrent genuine stress incontinence with TVT procedure under local or regional anesthesia. Urodynamic studies, a 1-hour pad test, introital ultrasonography on the urethra, a cotton swab test, and subjective symptom analysis were documented before the procedure and at 1 year postoperatively. RESULTS: Of the 41 women, 34 (82.9%) were cured, 2 improved, and 5 (12.2%) had treatment failure. Among the women with failure, three had urethral sphincter incompetence with a fixed urethra. No major surgical complications occurred. Four bladder perforations were noted. The 1-hour pad test reduced from a mean of 27.3 to 1.7 g (P <0.001). The operating time was 22 minutes (range 15 to 44), and the postoperative hospital stay was 22.4 hours (range 12 to 72). Spontaneous voiding with adequate postvoid residual urine volume was noted for all patients by the fourth day postoperatively. The preoperative and postoperative cotton swab result was 40.0 degrees (range 10 degrees to 80 degrees ) and 38.7 degrees (range 10 degrees to 76 degrees ), respectively, without statistically significant changes. Of the 36 cured and improved patients, 31 (86.1%) had a cotton swab test result of 30 degrees or more before and after the TVT procedure. Urodynamic parameters related to the voiding dysfunction showed no significant difference before and after the surgery. Urodynamic assessment showed no significant difference in the filling, voiding, and urethral pressure profile (dynamic and static) variables, except for significant increases in the maximal flow rate, bladder volume at the first desire to void, and cystometric capacity, which were measured preoperatively and postoperatively. No de nova detrusor instability or micturition disturbances were found in the cystometric study. CONCLUSIONS: The TVT procedure for the treatment of recurrent genuine stress incontinence is a safe, effective, and minimally invasive option requiring only a short hospital stay. However, the immobile urethra seems to be a risk factor for failure. Long-term follow-up is needed to determine whether this surgery achieves long-lasting results.

Adult↗
PubMed1984

Urethrovaginal fistula: a review of the surgical management.

Urethrovaginal fistulas may occur after external or surgical trauma and result commonly in urinary incontinence. Various repair procedures have been suggested. However, it appears that the Martius operation with labial fat pad interposition between the repaired urethra and vagina is as satisfactory as any.

Adolescent↗
PubMed2001

Psychometric evaluation of 2 comprehensive condition-specific quality of life instruments for women with pelvic floor disorders.

OBJECTIVE: To evaluate the psychometric properties of the Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ). METHODS: The PFDI and PFIQ are based on the structure and content of two previously validated questionnaires (the Urinary Distress Inventory [UDI] and the Incontinence Impact Questionnaire [IIQ]) and have additional questions regarding pelvic organ prolapse and colorectal dysfunction. The PFDI assesses symptom distress in women with pelvic floor disorders and has 3 scales: UDI (28 items), Colorectal-anal Distress Inventory (17 items), and Pelvic Organ Prolapse Distress Inventory (16 items). The PFIQ assesses life impact and also has 3 scales: IIQ, Colorectal-anal Impact Questionnaire, and the Pelvic Organ Prolapse Impact Questionnaire (31 items each). One hundred women with pelvic floor symptoms were enrolled and completed both the PFDI and PFIQ at baseline and again 1 week later. Patients underwent a comprehensive evaluation that included a structured history, Pelvic Organ Prolapse Quantitation, and a 1-week prospective bowel/bladder diary. Patients with urinary incontinence and stage III or IV pelvic organ prolapse also had a urodynamic evaluation. RESULTS: Each scale of the PFDI and PFIQ proved to be internally consistent (alphas: PFDI.82-.89; PFIQ.96-.97) and reproducible (interclass correlations: PFDI.86-.87; PFIQ.77-.92). Both the UDI and the IIQ significantly correlated with the number of urinary incontinence episodes per week (rho =.26, P <.05; rho =.46, P <.0001, respectively) and the number of pads used per week (rho =.26, P <.05; rho =.40, P <.0001, respectively). The Pelvic Organ Prolapse Distress Inventory and the Pelvic Organ Prolapse Impact Questionnaire significantly correlated with the stage of prolapse (rho =.32 and rho =.33, P <.01 each), and the Colorectal-anal Distress Inventory and Colorectal-anal Impact Questionnaire significantly correlated with the number of fecal incontinence episodes per month (rho =.49, P <.0001 and rho =.30, P <.01) and a diagnosis of defecatory dysfunction (rho =.47, P <.0001 and rho =.29, P <.01). The total time taken to complete both instruments averaged 23 minutes (range, 9-55). CONCLUSION: The PFDI and the PFIQ are reliable, valid, condition-specific quality of life instruments for women with pelvic floor disorders.

Adult↗
PubMed2001

The prevalence of faecal incontinence and constipation in a general New Zealand population; a postal survey.

AIMS: To determine the prevalence of constipation and faecal incontinence in the community. METHODS: A 20-question multi-field postal questionnaire was sent to 1500 adults (over 18 years) randomly selected from the electoral roll in the Canterbury region. Questions detailed frequency of bowel function, time spent at the toilet, incidence and severity of faecal incontinence, constipation, and the effect of disordered bowel function. RESULTS: Of 1500 questionnaires, 717 (48%) were returned (male: female 388:329). The median age was 46 years (range 18-70). 24 (4%) had self-reported gastrointestinal disease. There was a median frequency of seven bowel motions per week (BM/wk) (range 1 to 70) with 89% having between two motions a day and one every two days. Faecal incontinence affected lifestyle in 58 (8.1%). Incontinence of solid stool at least once a month occurred in 70 (9.8%), of liquid stool in 91 (12.7%), of gas in 459 (64%), while 12 (2%) regularly wore a pad. Those with self-reported gastrointestinal disease had a significantly higher (p<0.05) bowel motion frequency (17 vs 7 BM/wk) and median faecal incontinence score (2.5 vs 0). Laxatives were used by 4.9% of the population, while 26.2% increased fibre to avoid constipation. CONCLUSIONS: The normal frequency of bowel motions (+/- 2SD) was 2-17 per week. Faecal incontinence affecting life style affected 8.1%, while constipation requiring regular laxative use affected 4.9% of people. There is acceptance in the community that a moderate degree of bowel dysfunction is normal. Stool frequency and faecal incontinence scores can be used to predict those most likely to have organic gastrointestinal disease.

Adolescent↗
PubMed1999

Effect of a vaginal device on quality of life with urinary stress incontinence.

OBJECTIVE: To assess the effect of a vaginal device (Continence Guard) on urine leakage and quality of life. METHODS: Fifty-five women with stress incontinence participated in a 3-month study. They were assessed by the Incontinence Impact Questionnaire, two incontinence-related quality-of-life questions, a generic quality-of-life questionnaire (Short Form-36), two 24-hour home pad weighing tests, a 2-day voiding diary, uroflowmetry, urine cultures, and a questionnaire about subjective effectiveness of the device. RESULTS: Forty-one (74.5%) women completed the study. Estimated on an intent-to-treat basis, the vaginal device was associated with subjective cure in 11 women (20%) and improvement in 27 (49%). The mean 24-hour pad test leakage and leakage episodes in the voiding diary decreased significantly. Fifty-eight percent of the 55 women enrolled wanted to continue using the device after 3 months. The quality of life measured by the Incontinence Impact Questionnaire showed highly significant improvement, and the results of the two incontinence-related quality of life questions also showed significant improvement. Responses to the Short Form-36 general health questionnaire showed no significant changes. Improvement on the Incontinence Impact Questionnaire correlated with improvements in incontinence, whereas the Short Form-36 scores were unchanged. CONCLUSION: Treatment with the Continence Guard significantly decreases leakage and improves quality of life in women with symptoms of urinary stress incontinence. An incontinence-specific, rather than a generic, quality-of-life questionnaire was important in assessing treatment outcomes.

Adult↗
PubMed2002

A new ultrasonographic method for evaluation of the results of anti-incontinence operations.

BACKGROUND: To evaluate the effectiveness of a new ultrasonographic method for discrimination of successful and failed anti-incontinence operations. METHODS: Ninety-six patients who had undergone anti-incontinence operations for the diagnosis of pure genuine stress incontinence due to bladder neck hypermobility were evaluated by perineal ultrasonography and 1 hr standardized pad test 6, 12 and 24 months after their operations. The distances from the bladder neck to the lower tip (A) and to the posterior midpoint of symphysis pubis (B) were measured at rest and during stress. Bladder neck mobility (Mu) was obtained by two-caliper method. After superimposing the symphysis pubis of the frozen images, the bladder neck positions at rest and during stress were plotted on an x-y coordinate system by using computer programs and the corresponding x and y-values (X and Y) calculated and the second bladder neck mobility (Mc) were measured on the x-y coordinate system by computer. Unpaired and paired-t-tests were used for statistical analysis. RESULTS: Ten (10.4%) patients had recurrent urinary incontinence, while 86 (89.6%) were continent 24 months after the operation. The incontinent patients had significantly longer Mu, Mc and distance B during stress and lower X and Y-values during stress than the continent patients at the last control (P < 0.001). When the previous results were compared, the incontinent patients had significantly lower Y-values during stress and greater Mc values beginning 6 months after the operation, while they were still continent (P < 0.01). Once present, the significant differences between the incontinent versus continent patients persisted from that point onward. CONCLUSIONS: Measurement of the bladder neck mobility on an x-y co-ordinate system could discriminate the failed and successful operations and predict the outcome of the surgery.

Adult↗
PubMed2006

Impact of Parkinson's disease on continence after radical prostatectomy.

OBJECTIVES: It is widely believed that men with idiopathic Parkinson's disease (PD) should not undergo prostate surgery because of the prohibitively high risk of incontinence. However, the data supporting this conclusion were based on cohorts undergoing prostate surgery for voiding dysfunction, not for cancer control. Because both prostate cancer and PD are predominantly diseases of the elderly, it is likely that some men are concurrently diagnosed with both disorders who would otherwise be good candidates for radical prostatectomy (RP). However, the urinary outcomes in men with PD undergoing RP are unknown. Thus, it is possible that men with PD have been denied a potentially curative surgery only on the basis of long-standing assumptions. We addressed this issue by examining a cohort of men with PD who underwent RP at our institution. METHODS: We retrospectively reviewed a cohort of men who had undergone RP at our institution from 1990 to 2000. These men were surveyed 1 year after their surgery to determine their continence status, and their records were reviewed to determine whether any men had been preoperatively diagnosed with PD. RESULTS: Of the 8415 men undergoing RP during the study period, 20 had PD and were included in our study. Their de novo incontinence rate at 1 year was 24%, with no patient requiring more than one to two pads per day. CONCLUSIONS: Most men with PD undergoing RP remained continent 1 year after surgery. Additional studies with longer follow-up are required to determine whether this remains true over time.

Aged↗
PubMed2005

Sacral neuromodulation for intractable urge incontinence: are there factors associated with cure?

OBJECTIVES: To determine the variables that affect the cure rate in patients with urge incontinence treated with sacral neuromodulation. METHODS: This prospective analysis of patients with refractory urinary urge incontinence who underwent placement of a neuromodulator lead and generator was undertaken between October 2000 and December 2003. Quantitative assessment of the severity of their urinary leakage was assessed by preoperative and postoperative 3-day bladder diaries documenting leakage episodes, number of pads used per day, and a 24-hour pad weight assessment. Cure was defined as no daily leakage episodes after permanent implantation. Subjective outcome was assessed using the Incontinence Impact Questionnaire. Two-sample independent t tests, two-way chi-square tests, and tests of two proportions were performed when appropriate, with P < 0.05 considered significant. RESULTS: The mean postimplantation follow-up was 29 months, and the average age was 60 years (range 29 to 83). The cure rate was associated with age, with individuals younger than 55 years having a statistically significant greater cure rate (65% versus 37% for older individuals; P < 0.05). Having three or more chronic conditions was associated with a lower cure rate in both younger and older individuals. Patients with a neurologic condition also had a lower cure rate, but no specific neurologic condition was associated. CONCLUSIONS: Age older than 55 years and more than three chronic conditions were independent factors associated with a lower cure rate in patients implanted with a sacral neuromodulator for refractory urge incontinence. A neurologic condition may be associated with a decrease in the cure rate.

Adult↗
PubMed2005

Incontinence--an aggressive approach to treatment: a case series.

Recent evidence suggests that, for some, leaking urine may be a barrier to physical activity. Although important from a lifestyle point of view, bladder problems and incontinence also affect both men and women socially, psychologically and economically. For example, it can be particularly distressing when incontinence occurs post-prostate surgery, especially if these patients were continent before surgery. This case series outlines an aggressive, innovative, exercise-based approach to the management of stress incontinence post-prostatectomy. The program attempts to enhance neuromuscular and vascular systems associated with continence, with emphasis placed on the abdominal and pelvic floor muscles. The program was undertaken by 14 incontinent post-prostatectomy patients (mean age 63.5 y, using a mean of 3.5 sanitary pads per day). The program was initiated a mean of two months post-op and had a mean duration of six months. Upon completion of the program. 10 patients were found to be completely dry with three retaining a small leakage (a few drops). The 14th could not comply with the program because of illness. The results of this study appear promising in this patient population. There are indications for further research.

Aged↗
PubMed1988

The effect of pelvic floor exercises in the treatment of genuine urinary stress incontinence in women at two hospitals.

The results of the pelvic floor exercises for the treatment of genuine stress incontinence of urine were compared between two different hospitals geographically 50 miles apart. A perineal pad weighing test was used to assess the quantity of urine lost during exercise before and after treatment. A similar percentage of patients in the two studies responded to treatment and became either completely dry or significantly improved at the end of 3 months interval; 69% at LCH and 65% at LGH. Overall, 67% of patients achieved complete continence or a significant improvement as a result of pelvic floor exercises alone.

Adult↗
PubMed2006

Treatment for unsuccessful tension-free vaginal tape operation by shortening pre-implanted tape.

PURPOSE: We studied the efficacy of shortening the pre-implanted suburethral tape in patients with recurrent urodynamic stress incontinence after a TVT operation. MATERIALS AND METHODS: A total of 14 women, including 6 with ISD, were treated for recurrent urodynamic stress incontinence after the initial TVT operation by performing the shortening procedure under local anesthesia. Urodynamics, a 1-hour pad test, introital ultrasonography of the urethra and a cotton swab test were done before the procedure and 1 year postoperatively. RESULTS: All 14 patients completed the shortening procedure. Mean patient age was 47.2 years (range 43 to 66). Mean time between initial TVT and the shortening procedure was 4 months (range 3 to 14). Ten patients (71.4%) were objectively cured and treatment failed in 4 (2 with ISD and 2 with a fixed urethra). Mean operative time was 17 minutes (range 10 to 25). No intraoperative surgical complications were observed. The 1-hour pad test showed a decrease from a median of 9.0 gm to 1.0. Median postoperative hospital stay was 1 day (range 1 to 4). Spontaneous voiding with adequate post-void residual urine was noted in all patients before discharge home. CONCLUSIONS: Shortening a pre-implanted TVT tape for the treatment of recurrent urodynamic stress incontinence is a safe, effective and minimally invasive option requiring only a short hospital stay. However, ISD and an immobile urethra seem to be risk factors for failure. Long-term followup is needed to determine if this surgery achieves long-lasting results.

Adult↗
PubMed2000

[Diagnosis of intrinsic urethral sphincter insufficiency in women].

OBJECTIVE: Evaluation of intrinsic sphincter deficiency (ISD) according to the urethral leak point pressure in female population with stress urinary incontinence. DESIGN: Prospective clinical study. SETTING: Department of Urology, Jessenius School of Medicine Comenius University Martin, Slovak Republic. METHODS: Study population compromise of 204 females with lower urinary tract symptoms. Exclusion criteria were neurogenic bladder and unstable bladder. Valsalva leak point pressures were evaluated (VLPP). ISD was defined if VLPP below 65 cm H2O has been occurred. Pad weighing test (PWT) was positive after leakage of 2 g per hour and more. RESULTS: Stress urinary incontinence was in 134 and continence in 70 cases (control group). The first stage of incontinence was in 83, the second stage in 45 and the third stage in 6 cases of incontinence group. ISD has been occurred in 14 cases (10.5%), 8 cases with the second stage and 6 cases with the third stage. The best correlation was between VLPP and PWT, symptoms of incontinence and age of patients. All ISD cases underwent antiincontinent surgery with urethral suspension, some years ago. CONCLUSION: ISD has been risen in the second stage (6%) and the third stage (4.5%), also, in the female population with stress urinary incontinence.

Adolescent↗