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Female stress incontinence
cul-de-sac anywhere in the urinary tract, even if drainage from it is not obstructed, can be a cause of recurrent attacks of urinary tract infection. In the case presented, the infection was found in the bladder urine, and there was no evidence of vesicoureteral reflux. The decision to operate on this patient was taken not “based merely on the basis of flank pain” but for the following reasons which have been alluded to in the article: 1. Repeated attacks of documented urinary tract infection. 2. Each attack of urinary infection was accompanied by left flank pain, and there was no radiologic evidence of chronic pyelonephritis in the left kidney. 3. The patient was followed up for three months after demonstrating the blind-ending bifid ureter, and during this period the patient had two more attacks of infection and left flank pain. I believe these are sufficient criteria for surgical intervention in this condition, and this is in agreement with views expressed by other authors. The cause of pain in the absence of hydronephrosis could be the distention of the blind segment which was certainly present in my patient. K. Gopinatha Rao, M.D. Brandon,
FEMALE
STRESS
Manitoba,
P.O. Box 280 Canada R7A 522
INCONTINENCE
Recently I attended two urologic conTo the Editor: ventions where reports were presented on various surgical techniques for the cure of female stress incontinence. Much was said about the urethrovesical angle and the importance of lengthening the urethra.
342
It seems to me the fundamental accomplishment of these successful surgical procedures is restoration of a normal internal sphincter. The concept of the bladder base plate as a concentric series of muscular rings surrounding the bladder neck and all in the same plane can be compared to a rope coiled and lying on the deck of a boat. With normal muscle tonus, pressure is inwardly transmitted sufficiently to keep the bladder neck closed. If the central part sags, producing a cornucopia, then the rings of muscle are not in the same plane, do not press against each other, and they are ineffectual as an internal sphincter. Restoring the base plate to one plane by elevating the sag is the reason for success of these operations. Restoring the urethrovesical angle is an incidental corollary. And catheter measurements to the contrary, the urethra is not lengthened by urethropexy. When the bladder neck descends, the urethra is pressed downward, not telescoped. It is fixed at the anterior aspect of the external meatus; so it bows or bends vaginally, retaining its length even though the bladder is now closer to the external meatus. The posterior lip of the meatus is pushed down and anteriorly, forcing the meatus to point forward. A voiding cystogram would demonstrate a curved urethra of normal length in lateral view if the contrast media were sufficiently dense to be seen through the bone. A catheter is not pliable enough to follow the posterior contour of the channel and assumes a straight course, giving the impression of a shorter urethra. Surgically elevating the bladder neck straightens but does not lengthen the redundant urethra. If the urethra were incised from the external meatus to the external sphincter, incontinence would not result. And those urethral cephalad lengthening procedures intravesically are not usually successful, I do not believe length is important for urinary control. Louis J. Scheinman,
M.D. 715 Cobb Medical Center Seattle, Washington 98101
UROLOGY
/
MARCH 1976 /
VOLUME VII, NUMBER 3
FEMALE
STRESS
Manitoba,
P.O. Box 280 Canada R7A 522
INCONTINENCE
Recently I attended two urologic conTo the Editor: ventions where reports were presented on various surgical techniques for the cure of female stress incontinence. Much was said about the urethrovesical angle and the importance of lengthening the urethra.
342
It seems to me the fundamental accomplishment of these successful surgical procedures is restoration of a normal internal sphincter. The concept of the bladder base plate as a concentric series of muscular rings surrounding the bladder neck and all in the same plane can be compared to a rope coiled and lying on the deck of a boat. With normal muscle tonus, pressure is inwardly transmitted sufficiently to keep the bladder neck closed. If the central part sags, producing a cornucopia, then the rings of muscle are not in the same plane, do not press against each other, and they are ineffectual as an internal sphincter. Restoring the base plate to one plane by elevating the sag is the reason for success of these operations. Restoring the urethrovesical angle is an incidental corollary. And catheter measurements to the contrary, the urethra is not lengthened by urethropexy. When the bladder neck descends, the urethra is pressed downward, not telescoped. It is fixed at the anterior aspect of the external meatus; so it bows or bends vaginally, retaining its length even though the bladder is now closer to the external meatus. The posterior lip of the meatus is pushed down and anteriorly, forcing the meatus to point forward. A voiding cystogram would demonstrate a curved urethra of normal length in lateral view if the contrast media were sufficiently dense to be seen through the bone. A catheter is not pliable enough to follow the posterior contour of the channel and assumes a straight course, giving the impression of a shorter urethra. Surgically elevating the bladder neck straightens but does not lengthen the redundant urethra. If the urethra were incised from the external meatus to the external sphincter, incontinence would not result. And those urethral cephalad lengthening procedures intravesically are not usually successful, I do not believe length is important for urinary control. Louis J. Scheinman,
M.D. 715 Cobb Medical Center Seattle, Washington 98101
UROLOGY
/
MARCH 1976 /
VOLUME VII, NUMBER 3