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The aim of this study was to investigate the difference between sitting and standing passive urethral pressure measurements, and to determine the accuracy of urethral pressure profilometry in each position. Urethral pressure profilometry was performed in the sitting and standing position in 98 women. Stress incontinence due to urethral sphincter incompetence was demonstrated in 59 of whom 6 also had detrusor instability. The others were normal volunteers (7), women with a normal cystometrogram (23), and women with detrusor instability (9). MUCP tended to be higher in the standing than the sitting position but this did not reach statistical significance. Urethral lengthening appeared to occur on standing with a mean increase of FUL of 5 mm on standing. For both FUL and MUCP, there was a wide variation in the difference between sitting and standing values. There was poor reproducibility of measurements of MUCP and FUL in the standing position, limiting its clinical applicability. The difference between sitting and standing MUCP and FUL was not affected by age, parity, weight, height, BMI, or oestrogen status. In women with genuine stress incontinence, there was less difference between sitting and standing MUCP, but this explained only a small part of the variability. The increase in FUL in the standing position was unaffected by diagnosis., (Copyright 2002 Wiley-Liss, Inc.)

The aim of this study was to determine whether water perfusion maximum urethral closure pressure (MUCP) correlates with Valsalva leak-point pressure (LPP), and which of these best correlates with subjective and objective incontinence severity measures. Fifty-two women with previously diagnosed genuine stress incontinence (n = 46), or mixed incontinence with a minor and controlled urge component (n = 6), were assigned an incontinence status grade based on interview and diary review. These women then completed visually observed standing LPPs at 250 ml bladder capacity, supine water perfusion MUCP determinations, pad tests and quality of life questionnaires. The urodynamic and severity measures were compared with correlation analysis or analysis of variance. A modest correlation exists between LPP and MUCP (r = 0.50-0.62, P < 0.001). Both MUCP and LPP demonstrated significant decreases (P < 0.01) with increasing severity of assigned incontinence grade. A very low and insignificant correlation existed for these urodynamic parameters and pad loss or quality of life measures. MUCP and LPP correlate modestly with each other and both are comparable in predicting incontinence severity. Either can be used as the urodynamic measure to assess intrinsic sphincter deficiency.

Objectives: To test the feasibility of using the iontophoretic catheter as a means of delivering local anesthetic (lidocaine hydrochloride) to the urethra for periurethral injection of collagen., Methods: Eight women with urodynamically proven genuine stress incontinence underwent periurethral collagen injections. Local anesthesia was provided by 4% lidocaine with 1 in 100,000 epinephrine administered over 10 minutes using an iontophoretic catheter. Pain was assessed by Likert and visual analogue scales. Cystoscopic appearance of the urethra was noted., Results: The periurethral bulking procedure was completed without further anesthetic in 7 women, 1 of whom had no pain. There was no evidence of urethral damage from the iontophoresis., Conclusions: Iontophoresis shows promise as a method of providing analgesia to the urethra. However, the degree of analgesia is variable, and further research is needed on catheter design to ensure transport of anesthetic agent into the periurethral tissues.

Bladder neck position, as determined by preoperative and postoperative resting and straining lateral bead-chain cystourethrograms, was analyzed by logistic regression analysis in 94 women undergoing 98 operations for genuine stress incontinence. A total of 384 roentgenograms were analyzed in an attempt to build a model that would predict the likelihood of surgical success in a given patient based on the preoperative films and explain a successful surgical outcome based on the characteristics of the postoperative films. The most important predictors of success were the number of previous incontinence operations, a large distance between the bladder neck and the pubic symphysis at rest, and increased mobility of the bladder neck before surgery. Successful surgery appeared to be related most closely to decreasing mobility of a previously hypermobile bladder neck.

Objective: To investigate urethral hypersensitivity as a cause of sensory urgency., Patients and Methods: Twenty women with sensory urgency and 10 normal controls were enrolled in the study. A urethral conductance catheter was designed comprising three pairs of electrodes. These were accurately located in the urethra using the principle of urethral electrical conductance. The urethral sensory threshold was then measured at three sites along the urethral by applying a stimulatory current across each pair of electrodes in turn., Results: The women with sensory urgency had significantly higher thresholds for urethral stimulation along the whole urethra when compared with the control group., Conclusion: Urethral hypersensitivity was not found to be a feature of sensory urgency and in fact the converse was demonstrated. This has not been described before. High sensory thresholds may occur with small fibre peripheral neuropathies. Thus, peripheral neuropathy is potentially a factor in the, as yet unknown, aetiology of sensory urgency.

Measurement of distal urethral electrical conductance (DUEC) has been used to detect the movement of urine along the distal urethra. DUEC was used as a screening test in 100 women attending the urodynamic clinic with incontinence and in the 33 women who voided over 250 ml, the findings correlated well with subsequent urodynamic diagnosis of urethral sphincter incompetence and detrusor instability.

An investigation has been made into the form of the EMG signals from the human bladder and urethral and anal sphincters. A buildup of the low frequency detrusor EMG before micturition occurs in some patients and this is more marked in patients with urgency. A good correlation occurs between the amount of EMG activity and bladder activity as assessed by the cystometrogram. Marked spike activity has been seen in the detrusor EMGs of patients with irritable bladders. The comparison of anal and urethral sphincter EMGs is of interest from the viewpoint of the anatomy of the urethral sphincter and the mechanism of micturition.

Urethral pressure measurements were recorded at rest and during stress by a microtransducer technique in 20 women without urinary symptoms and 120 women with urodynamically proven genuine stress incontinence. In the symptom-free women the resting profile values were largely maintained during stress, as a consequence of 100% transmission of intra-abdominal pressure rises to the proximal three-quarters of the functional urethral length. Whilst the majority maintained continence at the bladder neck level, 25% of these controls showed evidence of bladder neck opening during stress. The stress-incontinent patients showed a deficiency of pressure transmission ratios which appeared to have an 'all or none' character in the determination of symptoms. The amplitude and stability of the maximum urethral closure pressure at rest, the extent of urethral closure pressure lost in response to stress, and the extent of intrabdominal pressure rises interact to determine the severity of symptoms or 'margin to continence'.

To test the postulate that colposuspension cures genuine stress incontinence by repositioning the proximal urethra against the posterosuperior surface of the symphysis pubis, 48 patients cured by colposuspension were studied to note the effects of a barrier placed in the vagina to interrupt the posterior route of force transmission. The barrier reduced peak transmission by 59% (P less than 0.0001). When the barrier was used to block compression by the high cystocoele, stress incontinence recurred transiently in 90% of patients. These results confirm Hilton's postulate (1981) that colposuspension constructs a novel, mechanical urinary sphincter rather than restoring normal sphincter function.

Conventional sling materials have numerous disadvantages. A reinforced Silastic sling is described and its use reported in 30 patients. There was an 83% symptomatic and objective cure of stress incontinence. The advantages of this material include its consistent strength, adjustability and ease of removal.

The Q-Tip test, an inexpensive and widely used clinical investigative tool, was reevaluated as to diagnostic worth. One hundred patients were investigated with cystometergrams or videocystourethrography, and all patients underwent a standardized Q-Tip test. Thirty-two percent of patients with a positive Q-Tip test had either pure detrusor instability or pure sensory urgency as the diagnosis for urinary incontinence. Twenty-nine percent of patients who had a negative Q-Tip test had a diagnosis of pure genuine stress incontinence. The Q-Tip test was more likely to be positive in younger patients with a cystourethrocele who had undergone less bladder neck surgery. This study demonstrates the limitations of the Q-Tip test and reconfirms the need for more sensitive and specific urodynamic investigations of the incontinent woman.

Twenty-seven patients were studied after colposuspension with lateral bead-chain urethrocystography. Successful operation, compared with unsuccessful operation, repositioned the bladder neck significantly closer to the posterosuperior surface of the symphysis pubis, though not significantly higher. After successful colposuspension, the proximal urethra is exposed to compression against the symphysis pubis by the momentary descent of the pelvic viscera during physical effort. Failure of the colposuspension was usually due to an inadequate repositioning of the bladder neck.