Successful management of female stress urinary incontinence

Successful management of female stress urinary incontinence

SUCCESSFUL MANAGEMENT OF FEMALE STRESS URINARY INCONTINENCE ROBERT B. QUATTLEBAUM, JR., M.D. From the Savannah Urological Clinic, P.C., Savannah, G...

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SUCCESSFUL MANAGEMENT OF FEMALE STRESS URINARY INCONTINENCE ROBERT

B. QUATTLEBAUM,

JR., M.D.

From the Savannah Urological Clinic, P.C., Savannah, Georgia

ABSTRACT - The basic defect in most cases of stress incontinence is an abnormally short urethra when the patient assumes the erect position. The treatment is an operative procedure which prevents shortening of the urethra when the patient stands. Results in 74 patients selected for this operative procedure are presented and the procedure is described.

Stress incontinence of urine may be defined as the sudden involuntary loss of urine on exertion caused by a sudden rise of intra-abdominal pressure, usually occurring in the upright position. Much research has been done in an effort to define the defects of the bladder and urethra present in female patients with stress urinary incontinence, and not all investigators agree on its etiology. Abnormalities have been observed radiographically showing loss of the posterior vesicourethral angle, descent of the bladder outlet, and funneling of the bladder outlet. These same radiographic changes, however, have been described in women without obvious stress urinary incontinence. ’ In 1960 Lapides et a1.2 demonstrated that the basic defect in most cases of stress incontinence is an abnormally short urethra when the patient assumes the erect position, and that the appropriate treatment is an operative procedure which prevents the urethra from shortening when the patient gets to her feet. This premise is in accord with the physical law which states that the resistance a tubular structure presents to fluid flow varies directly with the length of the tube. The purpose of this article is to confirm that the basic lesion in stress incontinence is a shortening or telescoping of the urethra on standing. The treatment is to fasten the urethra in such a fashion as to prevent shortening of the urethra when the patient stands. The technique employed in this study represents a minor modification of the Lapides anterior urethropexy.3

UROLOGY

/ MAY 1976 / VOLUME

VII,

NUMBER

5

Material and Methods During the period April, 1970, through May, 1973, 74 patients ranging in age from twentythree to eighty-five years were selected for surgical correction of stress urinary incontinence. Each patient was completely cleared of infection, and all were subjected to voiding cystourethrography, intravenous pyelography, cystoscopy, and measurement of the urethral length. The length of the urethra was considered the most important fact in selecting patients for surgery. The technique described by Lapides et al.* was used to measure the urethral length. In the 74 patients studied, symptoms had been present for one to 120 months (average thirtyfive months). Of these patients 67 were white (90.4 per cent) and 7 black (9.6 per cent). The urethral measurement averaged 1.9 cm. in the supine position and 1.4 cm. in the upright position preoperatively. Technique With the patient under spinal or general anesthesia in the supine position, the table slightly flexed, an 18 F, three-way Foley catheter is inserted and connected to drainage. A transverse or midline incision may be employed. Incision of the tendinous insertion of the rectus muscles often affords better exposure. The urethra and bladder are exposed and the loose periurethral fat is dissected exposing the vesicourethral junction. The visceral aspect of the pubis is scarified using

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FIGURE 1. Sutures (A) placed at miaYine and lateral to vesicourethral junction and (B) attached to suprapubic and Cooper’s ligament.

FIGURE 2. Lateral view showing suture attached to overlying fascia of recti.

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a free 4 by 4-inch gauge sponge over the index finger. Bleeders are fulgurated as they appear. A 1-O chromic catgut suture on a Haney needle holder is passed through the anterior wall of the bladder at the vesicourethral junction (Fig. 1A). This suture includes about 1 cm. of tissue and may enter the wall of the bladder. The suture is placed on traction and secured to the interpubic fibrocartilagenous ligament (suprapubic ligament). Similar sutures are placed on each lateral aspect of the vesicourethral junction and secured to Cooper’s ligament (Fig. 1B). A suture is then taken through the bladder just distal to the peritoneal reflection and secured to the under surface of the rectus fascia (Fig. 2). A Penrose drain is placed in the depths of the wound and brought out through a separate stab-wound incision. The various layers of the abdominal wall are closed using 2-O chromic. The patient is kept at bedrest for four to five days. The catheter is then removed and the patient becomes ambulatory.

UROLOGY

! MAY1976

/ VOLUMEVII,

NUMBER5

Results Of the 74 patients who underwent surgery, 7 have been lost to follow-up and 4 have died. Sixty-three patients have been followed up for an average of forty-four months. The average urethral length postoperatively measured 3.9 cm. in the supine position and 3.5 cm. upright. Sixty-one patients (97 per cent) are considered totally cured of incontinence and 2 (3 per cent) are considered failures. One of these patients did well for two years with no incontinence. However, recently she has had a hysterectomy, gained 69 pounds, and is being seen by a psychiatrist. Her urethra thirty-nine months postoperatively measured 2 cm. in the erect position as compared to I.5 cm. preoperatively. The other patient did well for two and a half years, but became obese; recurrent incontinence developed and recently after dieting, she underwent a repeat urethropexy and is continent eight months postoperatively. The average postoperative hospitalization was 9.2 days. The most common complication was urinary retention after catheter removal and occurred in 10 patients (7.4 per cent). In 1 patient wound infection developed, and in another mild cellulitis occurred; 2 patients

UROLOGY

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MAY 1976

!

VOLUME VII, NUMBER 5

experienced some cardiovascular difficulty requiring digitalization. The catheter was incorporated in a fixation suture in 1 patient and required transurethral excision. There were no cases of ostitis pubis. Comment The data appear to confirm that female stress incontinence is due to an abnormal shortening of the urethra when the patient assumes the upright position and that it can be corrected by fixation of the vesicourethral junction to the overlying ligaments and fascia preventing shortening when the patient gets to her feet or exerts. 2515 Habersham Street P.O. Box 3458 Savannah, Georgia 31403 References ARDRAN, G. M., HAMILL, J., and SIMMONS, C. A.: Further observations of the female urethra and bladder, Proc. R. Sot. Med. 49: 647 (1956). LAPIDES, J., et al. : Physiopathology of stress incontinence, Surg. Gynecol. Obstet. 111: 224 (1960). LAPIDES, J.: Simplified operation for stress incontinence, Trans. Am. Assoc. Genitourin. Surg. 62: 12 (1970).

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