Stress Incontinence

STRESS INCONTINENCE ERNEST HOCK

The causes and mechanism of stress incontinence in women are still poorly understood. A review of the literature shows a divergence of opinions. Most authors accuse tears in the sphincters or injury to the supportive structures of the bladder neck acquired during childbirth. Other causes listed are: cystocele, urethrocele, idiopathic weakness of the sphincter, inbalance of the nervous mechanism of the internal sphincter, spina bifida, fine bands fixing the sphincter to the rami of the os pubis, etc. It is difficult to understand how these conditions can explain all cases or all the symptoms frequently encountered in stress incontinence. For a clear understanding of stress incontinence a discussion of the mechanism producing normal urinary continence will be helpful. According to older textbooks of urology, an intact external sphincter is essential for continence. This seems to be borne out by the fact that operations on the bladder neck such as prostatectomy do not produce incontinence. On the other hand, newer experiences show that the external sphincter may be destroyed without incontinence developing. Hinman in his Principles and Practice of Urology (1935) states: "At the present writing we do not know the exact nature of this (sphincter) mechanism." Much of the confusion is due to the idea that one or both sphincters must actively contract to produce normal closure of the urethra. The description of the external sphincter in many textbooks seems to imply that urinary continence is primarily achieved by constant voluntary contraction of the external sphincter. In reality this muscle does no more than, by its inherent tonus, to contribute to the resistance of the urethra. It contracts actively only if a desire to void has to be suppressed. Continence is not achieved by active, spbjncteric contraction, but by the resistance of the urethra to the intravesical pressure. If the l_!rethral resistance is strong enough to withstand a sudden increase of the intravesical pressure, no urine will be forced through the urethra. If the urethral resistance is diminished, incontinence will result, its severity depending on the decrease of the urethral resistance. For the achievement of continence it is immaterial whether the internal sphincter or the external sphincter functions well; the only important criterion is whether the sum total of all factors contributing to the urethral resistance is great enough to withstand a sudden increase of the intravesical pressure. Let us now examine the factors affecting urethral resistance: According to the laws of physics the resistance of the urethra is determined by its length and width. Whereas the length can be considered a constant factor, the width is subjected to the elasticity of the urethra and its supportive structures and to the tonus of the involuntary and voluntary sphincters. Apart from neurological disorders which are not considered here, the resistance of the urethra can be diminished by: 1. Injury or tears of the supportive structures of the urethra 1069

1070

ERNEST HOCK

2. Injury or tears of the involuntary and/ or voluntary sphincter 3. Relaxation of the urethra due to other causes. That injury to the supportive structures of the urethra diminishes urethral resistance has been shown by Langworthy, Drew, and Vest who, experimenting with cats, dissected the urethra and bladder neck away from the vagina and observed that the urethral resistance fell to less than half the previous level. That tears of the sphincters will reduce urethral resistance is self evident. However, these mechanical causes alone can account for only a limited number of cases in clinical practice. We have to assume other factors in order to explain the following facts: 1. Many women with pronounced urethrocele and cystocele are perfectly continent. 2. Stress incontinence is found in young girls and women who never had children and in whom no trace of urethral relaxation can be detected. 3. Some women acquire stress incontinence during pregnancy without sign of mechanical relaxation of the urethra. 4. Stress incontinence develops frequently after the menopause, sometimes 10, 20, and more years after childbirth. 5. Urinary frequency, nocturia, and other signs of bladder irritation are exceedingly frequent in incontinent women. 6. The degree of stress incontinence varies often in the same individual. 7. Many women state that they are incontinent during the cold season and improve in summer. 8. In some cases incontinence and difficulty to void alternate. 9. Catheterization with a soft catheter often improves the incontinence for a few days. Dilatation of the urethra with metal sounds is still more effective. Logically one would expect increase of incontinence after dilatation of an already relaxed sphincter. In points 3 and 4 hormonal influences could be considered. However, all other points listed can be explained only by the assumption of a reflex or reflexes keeping the sphincters relaxed. That such reflexes exist has been shown by Barrington who found that: 1) Active contraction of the bladder wall produces relaxation of the urethra and 2) distention of the urethra causes contraction of the detrusor. Or, applied to our problem: Irritation of the urethra may cause relaxation of the internal sphincter by reflex contraction of the detrusor. Langworthy, Drew, and Vest found a reflex mechanism producing relaxation of the external sphincter. The afferent fibers of the reflex arc run through the pelvic and pudic nerves, the efferent fibers through the pudic nerve. The existence of these reflexes permits the conclusion that any disease en the urethra which causes continuous irritation may be able to produce reflex relaxation of the sphincters. It is also to be expected that the same reflex may increase the tonus of the detrusor with the effect that the bladder will empty more frequently and at a lesser filling. Thus the often observed combination of urinary frequency and stress incontinence could be explained. Predominance of the reflex causing an increase of the detrusor tonus would then lead to urinary

STRESS INCONTINENCE

1071

frequen:cy as the prominent symptom. Predominance of the reflex causing sphincteric relaxation would produce incontinence, especially in cases with additional mechanical relaxation of the urethra. On the same basis also the coexistence or alternation of incontinence and obstructive symptoms could be understood. Seasonal changes in the degree of incontinence are to be explained by a reflex originating in the cold perceptors of the skin. It is a common experience that cold increases urinary frequency. As pointed out above, a reflex causing contraction of the detrusor also relaxes the internal sphincter. If the urethra is already relaxed for other reasons, but not enough to produce clinical incontinence, additional relaxation of the urethra by the cold reflex may be sufficient to cause incontinence to become manifest. Because stimulation of the pelvic nerves produces urethral relaxation, any organ in nervous connection with the pelvic nerves or with the medullary bladder centers has to be considered a potential cause of stress incontinence. This would explain urinary frequency and incontinence in women with pelvic disease. Incontinence on laughing in otherwise normal women is probably due to the combined effects of reflex sphincter relaxation and sudden rise of the intravesical pressure. From clinical experience it appears that, in the majority of cases, the reflex causing urethral relaxation has its origin in changes of the urethra itself. Also menopausal incontinence cannot be explained simply by some hormonal inbalance. It seems more likely that deficiency of estrogens predisposes to senile "urethritis" in a similar way as it causes senile vaginitis and other regressive changes of the genital tract. Treatment with estrogens would then improve this type of incontinence indirectly by correction of the urethral disease. This conception is supported by the fact that many cases do not respond satisfactorily to estrogens but are benefited by local treatment of the urethra. The favorable effect of urethral dilatation on stress incontinence cannot be explained without a discussion of how urethral dilatation in general affects bladder neck disease. In men suffering from chronic prostatitis urethral dilatation is a very effective means of alleviating urinary frequency and backache. The usual explanation given is that by the dilatation secretion is mechanically expressed from the prostate, and that consequently the decreased intraprostatic tension produces less irritation of the bladder. However, good results are frequently observed after simply passing a soft rubber catheter (e.g. 16 F.) into the bladder. Such a catheter could hardly have any mechanical effect on the prostate. The clue was a patient with chronic, nonspecific prostatovesiculitis who complained of pain in his left inguinal, iliac, and lumbar regions. Whenever, during catheterization, the catheter tip reached the prostatic urethra, copious, whitish secretion appeared in the urethral orifice around the catheter and, at the same time, the patient felt suddenly relieved. I have observed the same reflex repeatedly in other patients. Usually, when the catheter tip reaches the region of the verumontanum, there is a sudden, sharp, sometimes cramplike pain of short duration which is followed by relief. If the posterior urethra is viewed with a cystoscope, secretion can often be

1072

ERNEST HOCK

seen escaping in intermittent spurts from the prostatic and ejaculatory ducts. This observation suggests active contraction of the seminal vesicles and prostatic muscle as a response to the irritation produced by the cystoscope. The author has consistently observed that cystoscopy relieves patients with chronic prostatitis better than prostatic massages and urethral dilatations. This is probably due to the combined effects of dilatation, protracted instrumentation, and irrigation. Light fulguration of the bladder neck or prostatic fossa gives still better results because the stimulus of the fulguration produces a stronger contraction of the prostatic muscle. However, the improvement does not last very long and, with a few exceptions, fulguration of the prostatic urethra is not indicated in chronic prostatitis. These observations lead to the conclusion that urethral dilatation causes emptying of the prostate mainly by a reflectory contraction of the prostatic muscle, partly it may be due to mechanical expression of secretion. Incidentally, it seems that also the effect of prostatic massage is not due to purely mechanical emptying of the gland. The frequently observed erection after massage suggests that reflexes play a part. The female urethra contains glands that are the homologue of the male prostate. These glands are frequently the seat of infection and then produce symptoms identical with those caused by prostatitis in men. Relaxation of the sphincters due to the irritation of such chronically inflamed glands is a very frequent and important factor in the causation of stress incontinence. The favorable effect of urethral dilatations then has to be explained exactly in the same way as in male patients with chronic prostatitis, i.e., by emptying of the urethral glands. The author has repeatedly observed clouds of secretion emerge from the female bladder neck while watching the posterior urethra through the cystoscope with the inflow shut off. Here the question could be asked: If reflex relaxation of the urethra can cause stress incontinence in women, why is it not observed in men? Chronic prostatitis is a frequent disease and, if the above theory is correct, we should expect to find at least some cases with stress incontinence. The answer is that stress incontinence in the male exists. It is not frequent because prostatic disease tends more to produce urinary obstruction. Also, the male urethra is longer than the female and its supportive structures much more strongly developed, factors that increase its resistance to the flow of urine. As a matter of fact, stress incontinence is occasionally observed after prostatectomy of any type. Only, it is usually mistaken for incontinence due to injury to the external sphincter. If, however, such a patient is asked to empty his bladder and then suddenly to interrupt the urinary stream, he can usually do it perfectly well, proving that his voluntary sphincter is not severely damaged. Stress incontinence is observed particularly in cases of transurethral prostatectomy in whom not all prostatic tissue had been removed. The removal of more tissue then results, paradoxically, in restoration of urinary continence. TREATMENT

A rational treatment of stress incontinence consists of the elimination of the cause of the urethral relaxation. If the relaxation is due to mechanical injury

STRESS INCONTINENCE

1073

of the sphincters or supportive structures of the urethra, one of the accepted incontinence operations is indicated. If a reflex from some pelvic organ is responsible, correction of the disease will cure the incontinence. A very frequent cause, however, seems to be chronic inflammation of the urethral glands, and then cure is to be expected from treatment of the urethritis. In most cases a combination of several factors is at work. Usually there is some degree of mechanical relaxation of the urethra which in itself, however, is insufficient to produce incontinence. If reflex urethral relaxation is added, the combination of both may lead to incontinence, and then clinical cure will follow the efunination of only one factor. Because in the individual case it is often difficult to determine whether incontinence is due more to mechanical or reflectory relaxation of the urethra, it is advisable to begin with the simpler and less risky treatment of the urethritis. It should be pointed out that, on cystoscopy, the bladder neck and urethra may appear entirely normal, and yet there may be an infection in the depth of the bladder neck glands. The treatment of the urethritis consists of urethral dilatations and fulguration, the latter being especially effective. Excessive dilatation of the urethra is unnecessary and not desirable; on the contrary, it may aggravate the condition. Improvement does not depend on the degree of dilatation of the urethra, but on the emptying of the urethral glands. Fulguration should be done with low power current and cover the entire circumference of the bladder neck and all other inflamed areas of the urethra. Any polypoid formations should be thoroughly destroyed. As a rule the patient is continent the minute she leaves the cystoscopic table. However, after-treatment with urethral dilatations, and sometimes repeated fulgurations are necessary if relapses are to be prevented. Estrogenics are of definite value in post-menopausal incontinence and, in light cases, may be sufficient to bring relief without any local treatment of the urethra. This effect is presumably due to the improvement of senile regressive changes in the urethra itself. Antispasmodics such as belladonna or Trasentin are valuable adjuvants. Glingar of Vienna (1924) seems to have been the first to cauterize the bladder neck for stress incontinence. His patient was improved for only a short time. In later years this method was employed by many urologists and gynecologists, especially in Europe, and the results claimed were 70 to 80 per cent cures and marked improvements. The original idea was to produce scar formation which would lead to narrowing of the relaxed bladder neck. That this explanation must be incorrect, at least in the majority of the cases, is suggested by the fact that the patients are continent the minute they leave the cystoscopic table, and if incontinence recurs, it happens after days or weeks. If scar formation were responsible, one would expect gradual disappearance of the incontinence. The most likely explanation is that the stimulus of the fulguration empties the urethral glands thoroughly, thus reducing the irritation of the nerve endings originating the reflex relaxation of the sphincters. As the glands fill up again with secretion the symptoms recur. Only if all the infected glands are completely destroyed by the fulguration, can a lasting cure be expected.

1074

ERNEST HOCK REPORT OF CASES

The case histories of 20 women suffering from moderate to severe stress incontinence were analyzed. The age ranged between 25 and 76 years with an average of 48.6 years. Fifteen women belonged in the age group of 41 to 60. Nineteen women showed some symptoms suggesting irritation of the bladder neck region. These were: frequency, 16; nocturia, 13; dysuria, 9; urgency, 5; backache, 13. Fifteen women gave a history of deliveries, miscarriages, or previous pelvic operations while in five no definite pelvic disease could be detected. On cystoscopic examination inflammatory changes of the bladder neck and the urethra were found in 12 women. The urethra and bladder neck appeared normal in 7 women. Cystoscopy was not done in 1 case. The results of conservative treatment were: cured, 8; considerably improved, 4; slightly or not improved, 8. In order to correlate the mechanical factors favoring incontinence with the prognosis of conservative treatment, the state of relaxation of the urethra and the urethral supports was noted in each case. As no exact objective tests TABLE mIBmRA

Not relaxed Stricture Not relaxed Relaxed Relaxed

URETHRAL SUPPORTS

not relaxed not relaxed relaxed not relaxed relaxed

I

NO. OF CASES

5 2 1 7 5

CURED

4 2 1 1 0

IMPROVED

1 0 0 2 1

NOT DlPROVED

0 0 0 4 4

are available, the resistance of the urethra was judged by the resistance felt on passing a 22 F. catheter. If on straining a definite urethrocele was visible, the woman was classified as having relaxed urethral supports. Results are shown in table 1. Details are given in table 2. Case 1. Mrs. M. K., aged 37, was first seen May 16, 1945. History: Rheumatic fever in childhood; at age of 6, kidney and bladder infection, was unable to void for 2 days. 1927, Injury to back; ever since, backaches. 1938, Appendectomy and partial hysterectomy; several months later, cholecystectomy. 1940, Head injury from automobile accident; ever since, headaches and dizziness. 1941, Pneumonia. Two miscarriages; no children. For the past 10 years the patient had had urinary frequency, backaches, abdominal pain and "pressure" in the groins, nocturia constantly 1 to 3 times. If she held her urine for a longer period, the following micturition was very painful. She had had shooting pains in the thighs and legs, mucous colitis for about 6 years, had had 6 to 8 bowel movements daily, no improvement in spite of treatment by several physicians. She was incontinent on coughing, lifting, getting up in a hurry, or when excited. She was very nervous, and had hot flashes. The menses were scanty, irregular every 3 to 6 weeks. The patient was well developed and moderately obese. Psoriasis of trunk

TABLE 2 CASE NO,

--

--

NOCT-

URIA

DYS· URIA

URGENCY

+ ++

3

++

3-4

0

0

4 5

++

1 2

+

0 0

0

BACK· ACHE

-- -- -- -1-3 + + + 3-6 + 0 +

1 2

0

URETHRA

URETHRAL SUPPORTS

DELIV· E1l.IES

PELVIC

MISCAll• PATROL• JI.IAGES OGY

CYSTOSCOPY

TYPE 01!'

TREATMENT

ll.ESULT OP TREATMENT

normal normal

0 1

2 1

+ +

Urethritis Urethritis

Dil. Fulg. Dil. Fulg.

cured improved

0

relaxed

relaxed

7

0

+

negative

Dil. Fulg.

failure

+ +

relaxed relaxed

relaxed normal

4 5

3 0

+ +

Urethritis negative

Dil. Fulg. Dil. Fulg.

failure failure

+

3

0

0

0

relaxed

normal

4

0

+

Urethritis

Dil. Fulg.

failure

7

+ + +

0 0 0 0 2-3 0

0 0

+

0

0 0 0 0

+

+

normal normal normal normal relaxed relaxed

1 0 0 2 1 3

0 0 0 3 0 0

0 0 0 0

+

normal normal relaxed stenosed normal relaxed

Urethritis negative negative negative negative not done

Fulg. Fulg. Fulg. Dil. Dil. Fulg. Dil.

cured cured improved cured cured improved

0 0 0

0 0 0 0

+ + + +

normal relaxed relaxed stenosed relaxed relaxed normal relaxed

normal norm.al relaxed normal relaxed normal normal normal

0 0 2 0 0

2

0

Urethritis Urethritis Urethritis Urethritis Urethritis negative Urethritis Urethritis

Dil. Fulg.

1

0 0 0 0 0 0

Dil. Dil. Dil. Dil. Dil. Dil. Dil.

cured improved failure cured failure failure cured failure

12

13 14 15

16 17 18

19 20

0

+ + + 0

+ + + + 0

+

1 0 2 4

1-2 3 0 2-3

+ 0

0

+ + ++ 0

0

+ +

+ +

0 0 0 0

0

+ + +

NOTE

-- -- -normal normal

6

8 9 10 11

'--

DAY PRE· QUENCY

+ + 0 0 0

+ 0

+ + +

Fulg. Fulg. Fulg. Fulg. Fulg. Fulg. Fulg.

Improved after cauterization of cervical erosion Cured-perfectly continent for 5 months; after recurrence fall; cured by operation Had had unsuccessful incontinence operation Had had unsuccessful incontinence operation

I

&l

~

I t;j

Cystocele and rectocele, operation advised

Operation advised

......

~

O"t

1076

ERNEST HOCK

and extremities was present. The heart and lungs were normal; the abdomen was soft, diffusely tender to the touch, and the right lumbar region and costovertebral angle were very tender. The kidneys were not felt. The cervix was irregular; no erosion, moderate fl.uor, body of uterus could not be felt, adnexal regions tender, palpation of the bladder neck region painful. The urine cont.'1ined occasional pus cells, was otherwise negative. Cystoscopy: The bladder was normal except for hyperplasia of the epithelium of the distal 1/3 of the trigone. The bladder neck was irregular, but no definite papillary formations were seen. The urethral mucosa was chronically inflamed. Ureteral catheters passed easily into both kidney pelves. Urine from the kidneys was negative; pyelogram was negative. The patient was treated with estrogens, and dilatations of the urethra followed by swabbing the urethra with 25 per cent argyrol twice weekly. After 1 month she was considerably improved, less nervous, less hot fl.ashes, less abdominal discomfort, but backaches and incontinence were not much better. On June 28, 1945 fulguration of the diseased areas of urethra and bladder neck was done. Two weeks later the abdominal pain and dysuria had disappeared, she had no backache, and could hold her urine for several hours during the day, nocturia 1. Seven weeks after the fulguration the patient was continent. She had no nocturia, and the day frequency was every 3 to 5 hours. She was much less nervous, and had occasional hot fl.ashes. The colitis had cleared up, and the patient said that she felt "normal." Case 2. Mrs. L. J., aged 25, had had mild urinary frequency since childhood. Seven years ago she had a miscarriage, complicated with phlebitis; since then, urinary frequency had increased. Two years ago the patient had dilatation and curettage followed by pelvioperitonitis, which was treated conservatively; since then she has had a copious vaginal discharge. In May 1944 both tubes, one ovary, and the appendix were removed; the operation was complicated by intra-abdominal abscesses; then ileus from adhesions, for which she was operated on in October 1944. Severe urinary frequency and burning on urination, backaches, and pain in the abdomen have been present since that operation. For the past 2 months she had been unable to hold her urine on coughing, lifting, sneezing, or carrying objects as light as 5 pounds. The menses were fairly regular. ·w hen first seen, on July 18, 1945, she complained of urinary frequency every 15 minutes, nocturia 3 to 6 t imes, considerable burning on urination, incontinence, but also difficulty in starting the urinary stream, headaches, nervous exhaustion, dizziness and backache. The abdomen was soft; the epigastrium and left lumbar region were tender to touch. No relaxation of the vaginal walls was present, the bladder neck was t ender to touch, cervical erosion was present with a moderate amount of whitish mscharge. T he body of the uterus was small, retrofl.ected, and moving the uterus produced "pulling" pain. The region of the adnexa was t ender. The urine contain'ed 1 to 3 red blood cells per high power field, occasional pus cells, otherwise negative.

STRESS INCONTINENCE

1077

Cystoscopy showed a normal bladder. Ureteral orifices were normal in shape and position. Indigo carmine injected intravenously appeared in good concentration, on the left after 5 minutes, on the right after 6 minutes. The bladder neck appeared normal, but clouds of secretion from the bladder neck glands could be observed when the water inflow to the cystoscope was shut off. The anterior wall of the urethra appeared somewhat granular and hyperemic, but no papillary formations were seen. The whole circumference of the bladder neck was fulgurated with low power current. After the procedure, the patient felt considerable relief in her back, and could stoop down or arch her back without pain, which she had been unable to do before cystoscopy. The patient felt better for about 1 day, then she had a "reaction," pains and aches all over the body, although the backache was somewhat less. The incontinence did not improve. One week after the fulguration the urethra was dilated to 29 F., after which the patient felt better generally, and the incontinence improved somewhat. Two days later the cervical erosion was cauterized. Since then she has been constantly improving. Three weeks after the cauterization of the cervix she reported that she was continent except when lifting heavy objects and then only a few drops. She had no abdominal pain and no backache. She voided every 3 to 4 hours during the day, nocturia 1 to 2. Case 3. Mrs. M. H., aged 49, had had 7 deliveries. She had had painful micturition 20 years ago. For the past 6 years she was unable to hold her urine when laughing, sneezing, lifting, or walking fast. She underwent an operation through the vagina for incontinence 3 years ago without any improvement. Diurnal frequency occurred every 15 minutes, nocturia 3 to 4. An old cervical laceration with cervicitis was present. The body of the uterus and adnexa were negative. There was moderate relaxation of the anterior vaginal wall; the bladder neck was definitely tender to touch. An urinalysis was negative. Cystoscopy on June 26, 1945 showed a normal bladder. The urethra was somewhat hyperemic, the bladder neck appeared relaxed, but was otherwise normal. After the cystoscopy the urethra was swabbed with 10 per cent silver nitrate. On June 29 the patient reported that she had been continent since the cystoscopy, that she was able to hold her urine for 2 to 3 hours during the day, and to get up at night once. She complained only of slight burning on urination. On July 9, the whole circumference of the bladder neck was fulgurated with low power current. Four days later she was continent, had no nocutria, day frequency every 3 to 4 hours, had no burning on urination, and had a general feeling of well being. Three weeks after the fulguration there was a recurrence of urinary frequency, moderate burning on urination, and incontinence, though the latter was much less than before treatment. Treatment was resumed with bi-weekly urethral dilatations and the incontinence was promptly relieved. The treatment was continued for 6 weeks to insure a permanent cure. The patient was continent until December 20 when she slipped on ice and fell.

1078

ERNEST HOCK

Soon afterwards she noticed that the incontinence had recurred. On examination the urethra seemed more relaxed than before the injury. Urethral dilatations and fulguration of the bladder neck were tried for 4 weeks, but without effect. In February 1946 a transvesical sphincterorhaphy, according to Macky, was done. Since then the patient has been continent. However, the time has been too short for a critical evaluation of the result. Case 4. Mrs. L. W., aged 54, had had 4 deliveries and 3 miscarriages, the last of which occurred 12 years ago, and was followed by some febrile complication. Since then the patient has had urinary frequency, burning on urination, and stress incontinence. During the winter the incontinence always got worse; the patient took daily hot baths. which reduced the incontinence somewhat. Eighteen months ago the patient underwent an operation for left inguinal hernia; 1 month later operation was repeated for recurrence of the hernia. Eight months ago the uterus was removed for fibroids, following which her incontinence had been worse. At the end of the first examination (August 8, 1945) her complaints were continuous sacroiliac backache, increasing with every movement; always tired, nervous; incontinent on standing, walking, coughing; urinary frequency every 15 minutes while sitting, less when lying down; nocturia 1, burning on urination. Sometimes when urinating she felt a sudden interruption of the urinary stream. The patient had moderate relaxation of the urethral supports. There was no urethral secretion, the urethra was not tender to touch, but the bladder neck region was very tender. A small cervical stump was felt; the rest of the uterus was absent. The urine was clear, contained occasional pus cells, but otherwise was negative. A 20 F. catheter was passed into the bladder, nothing else done. On the following day, the patient reported that the backache had almost completely disappeared, that she felt relaxed and much less nervous, and that she could cough, sneeze, or lift without losing a drop of urine. On cystoscopy the bladder was normal. The urethra showed chronic, granular inflammation without any polypoid formations. The urethra was thoroughly fulgurated. Eight days later she reported that she was continent, but suffered more from severe burning on urination and from severe backache. A month following the cystoscopy her backache was much improved, but the incontinence had recurred. She could hold her urine somewhat better after taking a hot bath. Cystoscopy was repeated on September 11, 1945. Beforehand the patient stated that she had incontinence on standing or walking, and moderate backache. Cystoscopy showed a normal bladder. The internal sphincter was seen to project into the urethral lumen in its entire circumference; there seemed to be no real urethral relaxation or atonia. The urethra was diffusely red, and there were several small papillary projections. Fulguration of all inflamed areas of the urethra was done. Immediately the patient stated that her backache had entirely disappeared, and that she felt considerably relaxed. Three days

STRESS INCONTINENCE

1079

later she reported no nocturia, day frequency every 3 hours, almost perfect continence, no backache. The patient was given a course of urethral dilatations twice weekly. On October 5, 1945 she reported to be completely continent even on lifting, no nocturia, day frequency every 1 to 2 hours, no backache, "feeling better than for many years." On October 10 the patient lifted a heavy object. Immediately she felt a severe pain in her back and her incontinence recurred, almost as bad as before treatment was begun. Bi-weekly dilatation of the urethra was continued for another month, but there was no lasting improvement of the incontinence though the backache was completely relieved. Operation was advised, but the patient refused. Case 5. Mrs. E. V., aged 57, had had 5 deliveries, the last in 1914. In 1918 both tubes, the right ovary, the appendix, and the uterus were removed for pyosalpinx, and a Webster Baldy suspension done. The patient felt well until 1940 when she began to lose urine on lifting and coughing. The incontinence became worse and in 1941 she was completely incontinent when walking, partially when standing. In November 1941 an anterior colporrhaphy with KellyO'Connor incontinence operation and posterior colporrhaphy were done; the incontinence did not improve. When first seen, in July 1945, the patient complained of being constantly wet, sometimes even when lying down; nocturia 2 times, but during the day no real frequency because of complete incontinence; no dysuria, but some indefinite hypogastric sensations. The vagina was very narrow, no relaxation of the vaginal walls, on straining questionable descensus of the urethra. The urethra was slightly tender to touch, and uterus absent. An urinalysis was negative. Cystoscopy on July 13, 1945 showed a normal bladder. The urethra was wide; there was little resistance to introduction of the cystoscope. The bladder neck was relaxed, almost smooth; the posterior urethra appeared normal. Circular fulguration of the entire bladder neck was done with low power current. Three days later the patient reported to be perfectly continent, hypogastric "pressure" gone, less tired, felt fine. On July 27 the patient returned with the news that 5 days after the cystoscopy the incontinence had recurred, though not to the same degree as before. She was given a course of urethral dilatations twice a week. After each dilatation she was continent for about 1 day, but then the old condition recurred. On August 13 the bladder neck was again fulgurated. The patient remained continent for 3 days after the fulguration, then she began to lose her urine, and on September 10 her condition was the same as before treatment was begun. To test the strength of the sphincter mechanism, her bladder was filled with water, then the patient was asked to urinate and stop the urinary stream on command repeatedly. She could hold her urine as long as she actively contracted her voluntary sphincter, but on walking a few steps urine leaked again. On September 11 another fulguration of the bladder neck was done, this time

1080

ERNEST HOCK

without any result. The patient was subsequently cured by a transvesical sphincterorhaphy, according to Macky. Case 6. Mrs. L. B., aged 52, had had 4 deliveries. She underwent uterine suspension 25 years ago. She had had urinary frequency since childhood, but had had symptom-free intervals of months and years. During pregnancies she repeatedly had burning on urination. For the past 3 years the patient had been unable to hold her urine when coughing, lifting, or walking. She was continent when sitting. In January 1944 she had a dilatation and curettage, perinea! repair, and an operation for incontinence. For 12 days after the operation she could not void and had to be catheterized. However, shortly after her discharge from the hospital incontinence recurred. When first seen, in June 1945, she complained of incontinence while in an upright position, urinary frequency, nocturia 3 times, and hypogastric discomfort. The vagina was narrow as a result of previous surgery. No bulging of the vaginal walls was noted on straining. The urethra was definitely relaxed, and there was very little resistance to the passing of a catheter. Palpation of urethra, bladder neck, and trigonal regions from the vagina was moderately painful; palpation near the cervix gave the impression of a thinned out scar. The uterus appeared normal, the right parametria thickened and tender, right adnexal region tender to touch. Urinalysis: negative. Cystoscopy on June 28 showed moderate hyperplasia of the trigonal epithelium and the urethra was chronically inflamed. The bladder was normal. Fulguration of the bladder neck was done. From the day of fulguration on the patient was continent, had no nocturia, but still complained of pain in the right adnexal region. She neglected to come for further treatments, and after 6 weeks she returned complaining of recurrence of the incontinence. A second fulguration of the bladder neck was done on August 13. After that she was continent for 6 days, but then incontinence gradually recurred and, in spite of continued local treatment of the urethra, the condition grew worse. By September 12 she had lost practically all control and complained of a constant urge to urinate. The bladder was filled with water and the patient asked to "(Irinate and interrupt the urination repeatedly on command. She had no voluntary control whatsoever. An operation was advised, but the patient refused. Case 7. Mrs. B. M., aged 60, for the past 5 years had had incontinence on coughing, straining, or sneezing, itching of the vulva and anal region, moderate backache for about 12 years, moderate day frequency, no nocturia. She had 1 delivery over 30 years ago. Examination revealed a moderate sized rectocele, no relaxation of the anterior vaginal wall, slight prolapse of the urethral mucosa; the urethra and bladder neck were tender to touch. The uterus was small, essentially negative. The urine contained 2 to 3 white blood cells per high power field. Cystoscopy on April 23, 1945 showed a normal bladder. The ureteral orifices were slitlike in normal position. The posterior third of the bladder neck was relaxed; granular urethritis was present. Fulguration of the bladder

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neck was done. A day later the patient reported that she was continent, and that she could cough and sneeze without losing a single drop. She has remained continent. (The patient was seen last in June 1945.) Case 8. Mrs. G. G., aged 54, had an appendectomy 30 years ago. She had no deliveries, and had never been seriously ill. One year ago, for a period of about 3 months, she was incontinent on laughing, lifting, or coughing, then became continent spontaneously. For the past 3 weeks she could not hold her urine when lifting or coughing. She had moderate day frequency, no dysuria, nocturia 1. The uterus was atrophic. No relaxation of the vaginal walls was noted. There was moderate tenderness of the bladder neck. The urine was negative. Cystoscopy on April 18, 1945 showed a normal bladder and ureteral orifices. On the bladder base, right side, crossing the bladder neck, a submucous varicose vein was present. Fulguration of the bladder neck was done. From the day of fulguration the patient has been perfectly continent. Case 9. Mrs. V. S., aged 78, complained of moderate dysuria and day frequency for many years. She had had stress incontinence for at least 10 years, and frequent spontaneous remissions. For the past 2 months she had been incontinent on lifting, coughing, and at times, even on walking. Pelvic examination was essentially negative; there was no vaginal relaxation. The urine was normal. Cystoscopy on April 20, 1945 showed normal bladder and ureters. Moderate relaxation of the bladder neck was present. Immediately following fulguration of the bladder neck the patient was continent. Six weeks later she had a very mild recurrence of the incontinence with slight urinary frequency and nocturia l to 2 times. However, she was satisfied with the :result and refused further treatment. Case 10. Mrs. M. W., aged 51, was first seen on January 23, 1946. For the past 10 years she had complete urinary incontinence when on her feet or even when sitting. She was continent while in the horizontal position. She had no frequency, nocturia, or backache. She underwent appendectomy in 1928. She had had 2 children, and 3 miscarriages. The urethra was narrow; a 22 F. cathether could not be passed; an 18 F. catheter passed with ease, but caused slight bleeding. On pelvic examination the bladder neck was tender to touch, but otherwise negative The urine was negative. On January 25, the patient reported that, since the first examination, she had been perfectly continent and could even lift comparatively heavy objects without losing a drop of urine. The patient had subsequently 3 more dilatations of the urethra with soft catheters and on February 13, cystoscopy showed a normal bladder and urethra. Up to the present time the patient has not had a recurrence of her incontinence. The following 2 case histories of men have been included in order to emphasize the similarities between stress incontinence in the female and incontinence in the male. Case 11. Mr. J. K., aged 58, complained of urinary frequency, and nocturia

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3 to 4 times for the past 2 years. On May 8, 1945, he had complete urinary retention, which necessitated catheterization for 2 days. The patient was hospitalized on May 11, 1945. He had been short of breath on exertion for many years; he was hospitalized in 1943 for chronic emphysema with asthmatic bronchitis. The patient had emphysema of the lungs, diffuse dry rales and wheezes. Heart: Left ventricular hypertrophy. Blood pressure, 170/90. On rectal examination the prostate was enlarged 1 to 2+, nodular, hard, a.n d tender. Urinalysis: Albumin 2+, 6 to 8 pus cells per high power field, 30 to 35 red blood cells per high power field. The blood non-protein nitrogen was 30 mg. per cent, acid serum phosphatase 0, 2 Bodansky units. The residual urine was 400 cc. A catheter was passed into the bladder and anchored. Cystoscopy (May 18, 1945): The prostatic urethra was irregular and rigid, and the instrument passed with some difficulty. There was moderate bleeding. The bladder mucosa and ureteral orifices were normal, and the trigone hypertrophied. The bladder neck showed a bar-like elevation, and the left lateral lobe projected moderately into the urethral lumen. The distance between the verumontanum and the bladder neck was estimated at about 2.5 cm. On May 24, 1945, under spinal anesthesia, about 6 gm. prostatic tissue was removed by transurethral resection. Microscopic examination was unsatisfactory because of burning of tissues. On May 28 the Foley catheter was removed. There was no residual urine. Ever since the patient was incontinent while sitting or standing up, but had urinary control in the horizontal position. He was discharged from the hospital on June 2, then treated ambulatory with instillations into the bladder and urethral dilatations. There was no marked improvement of the incontinence. In order to test the condition of his external sphincter the bladder was filled with water and the patient asked to urinate and interrupt the stream repeatedly on command. He could hold his urine perfectly as long ash~ actively contracted his voluntary sphincter. On July 12 he was continent while lying down, incontinent while sitting or standing, nocturia 2 to 3 times, continuous burning sensation of moderate intensity in the bladder region. On cystoscopy the bladder was entirely normal. The posterior urethra was smooth. On the left side, near the bladder neck, there were several (4 to 5) small cystic formations in the mucosa. There was moderate oozing from the left anterior wall of the prostatic ureth\ra. The cystic formations near the bladder neck and the bleeding spots were fulgurated. Immediately the patient stated that the burning sensation in the region of the bladder had completely disappeared; and that a constant feeling as if he had to urinate, of which he had not been quite conscious before, was gone. Ever since the fulguration the patient's ability to hold his urine improved. The burning sensation did not recur. On August 8, 1945 he reported that he had slight dribbling after urination, but otherwise perfectly continent, and could hold urine for 3 to 4 hours. Case 12. Mr. J. S., aged 28, was seen on November 9, 1945, complaining of swelling of the left testicle for 5 days, and incontinence of varying severity for

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about 1 year. The patient had gonorrhea at the age of 20; otherwise never ill. About l year ago left epididymitis developed and was treated with prostatic diathermy. Soon after he began to lose a few drops of urine when sneezing, coughing, or lifting. The incontinence grew worse and for the past 2 months his condition had been very embarassing because he got wet on the slightest exertion. On detailed questioning the patient reported the following additional symptoms: Moderate lumbar backache, pain in the left inguinal region, exhaustion, frequently hot flashes, frequent profuse perspiration without apparent cause, burning on urination, day frequency 3 to 4, nocturia none to once, considerable dribbling after micturition. The left epididymis was nodular, hard, and moderately enlarged and tender; the prostate of normal size and consistency, fairly smooth, moderately tender, and the left seminal vesicle was thickened and hard. The urine contained 3 to 4 pus cells per high power field, was otherwise negative. The prostatic secretion contained a marked decrease of lecithin bodies, numerous pus cells, partly in clumps. All other findings were normal. Cystoscopy showed a normal bladder and posterior urethra. The patient was given sulfathiazole 30 gr. daily and prostatic massages once a week for 1 month. On December 7 he reported no backaches, general improvement, incontinence much less than before and insignificant in quantity. Patient's own estimate was that he was at least 80 per cent improved, occasionally lost a few drops of urine, but could hardly notice it because of the small amount. SUMMARY

Urinary continence is achieved by the sum total of all factors increasing the urethral resistance. Urinary incontinence develops if the sum total of these factors is decreased to such a degree that the urethral resistance is insufficient to withstand a sudden increase of the intravesical pressure. Reflex relaxation of the urethra is often a major factor in the causation of incontinence. The treatment of incontinence should be directed against its cause. If reflex relaxation of the urethra is an important factor, elimination of the irritating focus alone may effect a clinical cure. Chronic inflammation of the urethral glands is the most common cause of relaxation of the urethra in women. The treatment of these inflamed urethral glands consists of urethral dilatations and fulgurations. The effect of urethral dilatations on stress incontinence has been discussed and its mechanism explained. Twenty cases of stress incontinence in women and 2 cases of a similar condition in men have been reported.

105 Murray St., Binghamton, N. Y.

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REFERENCES .ABESHOUSE, B . s.: J. Urol., 33: 28, 1935. BARRINGTON, F. J . F. : Quoted by Langworthy and others, J . Urol., 43: 123, 1940. BARNES, A. C .: J. Urol., 47: 694, 1942. BITSCHAI : Ztschr. f. Urol., 22: 973, 1928. CHWALLA, R.: Wien. klin. Wchnschr., 48: 1210, 1935. DAVIS, J. W. : J . Urol., 48: 536, 1942. FOLSOM, A. I. AND O'BRIEN, H. A.: J . A. M. A., 128: 408, 1945. GLINGAR, A.: Die Endoskopie der Harnrohre. Berlin: J . Springer, 1924. JACOBSON, C. E .: J. Urol., 63: 670, 1945. LANGWORTHY, 0. R ., DREW, J . E. AND VEST, S. A.: J . Urol. 43: 123, 1940. MACKY, F . : J. Urol. 62: 27, 1944. MICKULICZ, RADECKY: Ztschr. f. Urol., 22: 957, 1928. NovAK, J .: Urol. and Cut. Rev., 49: 425, 1945. PATTISON, D . H. AND THOMPSON, G. J .: Proc. Staff Meet. Mayo Clinic, 18: 377, 1943. PHANEUF, E. AND OTHERS: New Eng. J. Med., 229: 743, 1943. PICARD, E . : Ztschr. f. Urol., 23: 654, 1929. SPENCE, H . M.: J. Urol. 43: 199, 1940. STUDDIFORD, E. W. : Am. J. Obst. & Gyn., 47: 764, 1944: SuBOTZKY, B .: Ztschr. f. Urol., 26: 819, 1932.