Urethrovesicopubic relationships and urinary stress incontinence

URETHROVESICOPUBIC STRESS INCONTINENCE*

RELATIONSHIPS

AND URINARY

IV. The Uterine Suspension Syndrome C. PAUL HODGKINSON, M.D., AND WILLIAM T. KELLY, M.D., DETROIT, (From

the Department

of Gynecology

and Obstetrics,

Hewy

Ford

MICH.

Hospital)

NTERIOR displacement of the bladder, imprint of the uterus upon the posterosuperior surface, and partial elimination of the segment of bladder posterior to the urethrovesical junction, are three abnormal alterations in urethrovesicopubic relationships. They occur as the result of extravesical pressure. First observed after uterine suspension, these relationships have been noted to occur also in association with pelvic tumors. They stand out in contrast to the usual downward and backward rotatory changes incident to parturition. Urinary stress incontinence may accompany either type of change. It is the purpose of this report to evaluate the importance of the anatomic changes which occur as the result of posterosuperior extravesical pressure.

A

Material Since 1949 the metallic bead chain technique1 has been employed as part of the preoperative routine for patients with three types of clinical conditions: urinary stress incontinence, relaxation of support of the pelvic floor, and large intrapelvic tumors; over 500 easeshave been investigated. For this presentation two groups of patients have been selected: Group I, 44 patients whose histories included uterine suspension; Group II, 42 patients who had not had uterine suspension, but whose radiograms showed anatomic relationships similar to those observed after this operation.

Normal

Urethrovesicopubic

Relationships

(Fig. 1)

Previously established variations of normal urethrovesicopubic relationships served as the standards of reference.” In the normal nonparous patient the bladder was observed to be ovoid, centrally located, with the lowermost level midpubic. The urethra joined the base of the bladder at an oblique angle posterior to the midcoronal plane. The anterior third of the bladder occupied a suprapubic position. The first changes effected by parturition were observed to result from inferior and posterior weaknesses; the suprapubic portion of the bladder tended to recede and the base of the bladder tended to sag. With uterovaginal prolapse the bladder rotated downward and backward; with urinary stress incontinence, vertical downward thrust without rotation occurred. The smooth bladder sil*Presented at the Eighty-flrst Asheville, N. C., May 19-21. 1958.

Annual

Meeting 1114

of the American

Gynecological

Society,

houette was replaced by one of irregular contour; the bladder wall flabby. These urethrovesieopubic relationships were in agreement Stevens and Smith” first findings in similar studies reported by others.” on the metallic bead chain technique, and noted they had never found bladder which extended anterior to the symphysis.

Relationships

After

Uterine

Suspension

appeared with thl: report,eti a normal

(Figs. Z-5)

After uterine suspension the bladder is displaced anterior to the symlmysis. This action involves chiefly the dome of the bladder, and any change in position of the base is more apparent than real. The segment of the bladder posterior to the urethrovesical junction is sharply reduced in size. Because of extravesicnl pressure on the posterosuperior surface, the normal shape of the bladder s:ilhouett,e is altered to a rigid, somewhat angular shalje showing t,he imprint of thaw constrained uterus. Mobility of the bladder is minimal and that lovvc>r bordt~r is ~suall~~ ~~ppcl~Lc{ f to a level of high normal. Initially, the capacity is reduced. Gradually the bladder compensates 133 ballooning peripherally around the centrally impressed uterus. Radiographltally these changes can be distinguished by variations in radiopacity. Group I. History of Utenhe SuspewGoa.-2. ClirLicaZ Appraisal.-By means of these anatomic changes, in (+roup I were divided into 3 classes: (‘1~s -4 (typicul suspension ~Plationships) : 27 patients vesical relationships conformed in all respert.s to follow uterine suspension; Class IC (a.bsent suspension relationships) : 11 pat,ients ships showed no influence from uterine suspension;

the -I1 patients whose urethrothose known to whose and,

relation-

Class C’ (pwrtia,l suspension rebutionships): 6 patients who showed at least one dist,inct characteristic of uterine suspension. One additional patient on whom preoperative studies were not done is in eluded because of relationships observed at the time of operation; she probahl;\ could have been included in Class B. This intragroup classification provided mcaans whereby symptoms could bt compared with anatomic relationships. 2. Vital Statistics (Table I).-Distinct differences were evident for age, age at the time of the menopause, age at the t.ime of the uterine suspension, and the number of patients who were delivered of infants after uterine suspcnsiotr was performed. TABLE

I.

VITAL

-.

---i--:

MENOPAUSE CLASS --I__~~

A B C

j

AYERAGE AGE

44 60 48

-

BEFORE (70)

78 18 50

AFTER (%)

6,NO “5 30

(~IUP r

STATISTNT.

I-

----

.4VICRAGE AGK UTERIKE SIJSPENSION

29 44 (3ij 36

) !

POSTSIJSPENSIOK I~ELIVERIES (%

I

37 30 (60) SO

The average age of patients in Class A was -11 years; 22 per cent had involutional changes of the menopause; t,he age at whrch uterine suspension was performed averaged 29 years; and 63 per cent had all their children before thta uterine suspension operation.

The average age of Class B patients (absent suspension relationships) was 60 years, 82 per cent were beyond the menopause; the average age at. which uterine suspension was performed was $4 years; and only 30 per cent wt’rt’ delivered of an infant after utcrinc s~wpc~~sio~~. Critic21 review of thr rc~rds of these patient.s suggested that the figures were distorted. Five patirnt,s of this class had ill-advised uterine suspension with the intention o-t correcting uterine prolapse at the respective ages of 41, 45, 61, 68, and 46 years. If these patients are excluded from statistical analysis 01’ this class, the average age at which uterine suspension was performed was 37 yrars, and 60 per cent were delivcrecl of an infant vaginally after that t,ime. These factors suggested t,hat the effects of extravesical pressure caused 1~~ uterine suspension were mitigated bq’ advancing age, involutional changes of the menopause, and vaginal delivery after uterine suspension.

44 yrs., Married, Fig.

l.-Comparison with

Ncrmal Para stress

52 yrs., Stress Para 4.

0. of

urethrocystograms incontinence (middle),

of

the and

47 yrs., Married, Pora 2 Gilliam -Daleris. Uterine Suspension ot age 37.

Incontinence

following types of patients: after uterine suspension

(right).

normal

(left),

3. Symptoms (Table IZ).-Frequency, urgency, and stress incontinence were appraised according to the item count of incidence and the degree of severity. Multiple symptoms were usually present in an individual patient. Urgency and frequency occurred in nearly all patients in Class A (typical suspension relationships) ; in several it was sufficiently severe as to bc graded as “urge incontinence. ” TABLE

CLASS

0

A 3

2 3

c

ovaginal

*Four

FREQUENCY DEGREE 1 B+

0

patients prolapse.

of Class

II.

SYMPTOMS,

-j

24 x

6

B were

4+

0

2 0”

10 5

0

unable

GROUP URGENCY DEGREE I

2+

void

STRESS 1

4+

17

unless

0

INCONTINENCE DEGREE I 3+ / 4+

9

6 4

2

to

I

0 they

manually

17

8 1

1

3 5 replaced

0 0 their

uter-

Vdun1e ii,

I’TEBLNE

SUSPENSION

AND

UR1NAR.Y

STRESS

LNCOBTINENCE

.Nurn her 5

II Ii

Stress incontinence was present in 18 (69 per cent ‘i of thr 26 patients (Ii In 17 patients it was considered lo Irtb (‘lass A. The degree of severity varied. of mild-to-moderate degrees, and in one patient it was extremely severe. In contrast the patients in Class B (absent suspension relationships ) hail both a reduced incidence and a lessened severity of symptoms. Frequency. urgency, and stress incontinence were absent in 3, 5, and 8 patients, respectively. Four patients were unable to void unless they first manually replaced their uttrovaginal prolapse. Three patients complained of mild stress incont,inenccl. 4. Ph~sicnl Pindings (Table III).-(‘ysi.ocelr, urethroccle. rectocek. am1 ntcrovaginal prolapse were graded from 0 to 4 plus. Tn general, the patients irl

Fig. Z.-I’hotograph the fundus of the uterus. tracings h&ve been used.

of anteroposterior Because details

were

radiogram difficult

showing the to demonstraW

radiolucent shadow ,#I by photowaphir rnwn?-

(‘lass A had comparatively little loss of support while those in Class II (a\: Jkenced extensive degrees of relaxation. Respcctivcly, c!atocele, urethroctclc. rectocelc, and uterovaginal prolapse was absent in 6, 11, 13, and 21 patients in (‘lass A; for patients in Class B (absent suspension relationships) the similar figures were I, 1, 1, and 0. Cystometric studies were performed upon 32 patients. The capacity of thtB bladder is shown in Table IV. While the number is too small to permit accurate’ induction, an important trend is indicated from the fact that 47 per cent of thtl patients in Class A had capacities of less than 350 C.C. On the other hand, whill: small capacity may have been detected as a trend, the abilit,y of the bladder tr) compensate for the constraining pressure of the uterus is well demonstrated fl!, the capa.citg in excess of 850 cc. regist.ered for 6 patients.

TABLE

CLASS

I

CYSTOCELE DEGREE 0 I 2+ /

6

A B C

22 8 6 TABLE

III.

PHYSICAL FINDINQS, ___-_ ____. URETHROOELE DEGREE

GROUP

I

4+ 0

11

2 0

1:

1 0

IV.

0

H 6

BLADDER

2 0 CAPACITY,

13 1 3

15

8 ?I

GROUP -__---

A B c

I

350 C.C. 9 1

I

550 C.C. 4 2 1

0

2 n

I -___ --

CAPACITY CLASS

~~~PROLAPSE DEGREE

RECTCCELR DEGREE

850 C.C. 5 3 2

-___~-

-~-

I

0

6

.i

1

5

0

____~--~

1,200 C.C. 1 2 -- 2~..___

In this study the mitigation of urinary symptoms in patients of Class B (absent suspension relationships) as compared to those of Class A (*typical suspension relationships) was striking. Stress incontinence was not observed in any patient of Class B once full downward and backward rotation of the bladder developed. As bhe fixation of uterine suspension decreased, symptoms abated. 5. Operatims.-In appraising the results of the operative procedures employed for the patients in the three classes, it was apparent that objectives varied. For patients in Class B (absent suspension relationships) the chief purpose of the operations was to correct uterovaginal prolapse; procedures for treatment of stress incontinence were employed only three times. For patients in Class A (typical suspension relationships), the intent of the operative procedure was to improve or restore the physiologic function of the bladder. Twenty of the 29 patients in Classes A and C were operated upon Usually the procedures were comprimarily to relieve urinary symptoms. pounded to release the constraining influence of the suspended uterus, and to improve the retaining function of the sphincter mechanism. Most practically these were attained by combining abdominal hysterectomy and retropubic urethropexy, with either the technique of Marshall-Marchett? or the round ligament procedure of Barn@ and Hodgkinson and Kelly.” With vaginal hysterectomy, the procedures of Kelly or Kennedy wcrc most, advantageously employed. Because the pressure influences of the suspended uterus could not be detected accurately by clinical examination, urethrocystograms were found to be essential for selection of the proper operative procedure. Vaginal plastic operations for the treat,ment of stress incontinence were ill chosen if urethrocystograms showed the urethra and bladder to be snpportcd at a level of high normal. 6. Results.-Because patients in Class A (typical suspension relationships) were operated upon to restore or improve physiologic function, those of Class B (absent suspension relationships) to correct anatomic deficiency, and those of Class C (partially typical relationships) for both reasons, appraisal of results is complicated. If alterations of the anatomy toward normal are used as objective evidence of success, the results for patients in Class B included one failure and 10 acceptably improved. By subjective standards, no failure was recorded for the patients in Class B. Different objective and subjective standards were necessary for evaluation of results in patients in Classes A and C. If one accepts the thesis that the constraining pressure by the suspended uterus is an inimical influence, then

UTERINE

\~‘~,lUnx 7f’

Vmber

r’ig-.

by

i

SUSPENSION

3.-llrlpr’eusionisti(~ Mr. Tom Stcbbins

observed surface

Fig. of

Fig.

bladder, posterior

tracing to sho\v

I.-Impressionistic in some patients. the bladder and

B.-Impressionistic

@ving a “saddle” radiogram.

ANI)

of radiopram the distortion

UR1NAR.Y

STHHSS

shown in Wig. 2. of the antrrmpostcrior

tracing to show the The uterine fundus displaced laterally.

excellent is partially

tracing showing complete configuration to the superior

LNCOXTINENCE

Thv

uterus surfape

support of the sumrimposed

1 I I!$

has been (tra\vrl of the hltlrldrr.

base of the over the

superimposition of the su&%Ce of the bladder

ill

bladder superior

uterus over the in the antero-

evidence t,hat this influence has been lessened or removed as the result of operation is essential for evaluating postoperative improvement, To test full) this thesis, objective and subjective evidence must bc correlated. Consecluentl>T. the rationale, in addition to the operative technique, needs to bc t,est,ed. Of the 27 patients in Class A (typical suspension relationships) and 6 in Class C (partial suspension relationships) all but 4 were operated upon. C’ounting 4 patients operated upon twice, 33 operations were performed lipon ?!I patients. A.J., 770224 Feb. 24,1955 Preoperative - Abdominal Retropubic Voginol

suspension wall

Hysterectomy of urethro

Ott I I,1955 Postoperotwe

Feb. 14,1956 Postoperative

,

suspension

technique

Vaginal

- Repair

Retropubic

of urethra. wall

technique

NON STRAINING

H

STRAINING

Fig. 6.-Operative failure. The urethrocystograms on the left show urethrovesicopubic relationships prior to abdominal total hysterectomy and retropubic urethropexy (Marshall-Marchetti technique). The urethrograms in the center show technical failure of the urethropexy. Reoperation to correct persistent urinary stress incontinence was performed one year later and the radiograms on the right show the relationships following successful execution of the operative technique. These radiograms show that the bladder may be slow to recede after being disposed anteriorly by uterine suspension.

By the use of subjective standards, patients were declared cured if stress incontinence was relieved completely and if urinary urgency and frequency were intermittent and mild. If stress incontinence was completely relieved but if urinary urgency and frequency persisted to the degree that antispasmodics were required, the patient was declared improved. Failure was recorded if urinary stress incontinence persisted. The patients in Classes A and C were considered collectively. With these standards, 14 (48 per cent) of the patients were cured, 10 (35 per cent) were improved, and 5 (17 per cent) were failures. The pre- and postoperative urethrocystograms of the patients recorded as initial failures were compared. In each instance an anatomic reason for failure was detected. When this was corrected by reoperation, 4 of the 5 patients were cured; 1 has not submitted to reoperation.

Vululne 76

Uumberi

UTER.INE

SUSPENSION

AND

TJRINARY

HTREW

lS(‘<)h-TTNF:N(-‘E:

1l.“l_

Patient H. L. (Class C) suffered recurrence of stress incontinence 8 months after vaginal hysterectomy and cystourethroplasty (Kennedy technique). Thr preoperative urethrocystograms showed anterior displacement of the bladder, slight diminution in size of the posterior bladder segment and minimal descensus. E.G., 13 03 04

STRAINING I.

3.

Oct. I I,1951 Post operative Voginol Plastic Kelly-Kennedy technique

6 Mar. 31,1953 Post operative Totol Abdominal

2.

4.

Hysterectomy

May 3,1952 Pre operative Total Abdominal

Hysterectomy

Jan. 24,1954 Post opefotive Totol Abdominal

Hysterectomy

Fig. 7.-Operative failure. Radiograms 1 and B show urethrovesicopubic relationships after vaginoplasty with the Kennedy technique. Although restoration of bladder support was acceptable, stress incontinence persisted. After abdominal hysterectomy. expansion of the Posterosuperior bladder segment is evident. Comparison of radiograms 3 and 4 shows the POStrrosuperior expansion to be progressive.

The relationships were typical of urinary stress incontinence in that the urethrovesical junction was displaced to the lowermost level of the bladder during straining. Although the bladder was supported to the normal level after operation, the relationships of stress incontinence persisted. After retropuhic urethropexy (Marshall-Marchetti technique) she had full control of her urine and was declared cured. Failure in this patient was considered to have been the result of improper selection of the initial operative procedure. Her experience serves as an example as to why, in patients with minimal cystourethrocele, vaginal plastic procedures frequently fail. Patient A. J. (Class A) failed to obtain relief from urinary stress incontinence following hysterectomy and retropubic urethropexy ( Marshall-Marchetti technique). Postoperative urethrocystograms showed no elevation of the urethrovesical junction, indicating that failure was caused from faulty technique. She submitted to the same operation one year later and was cured (Fig. 6).

Patient E. C. (Class A) was the victim of intractable urinary stress in continence of 4 years’ duration. The onset of her affliction was incident to suspension of the uterus by the Gilliam-Doleris technique. Urethroplasty (Kennedy technique) resulted in slight improvement. Postoperative urethrocyst ograms disclosed relationships typical of uterine suspension. Her bladder capacity was 300 C.C. Abdominal hysterectomy, performed to permit retrocession of the bladder and expansion of the posterosuperior segment, was followed hy cornplctc

NON

STRAINING

STRAINING L.W., 518641 Fig. 8.-The postoperative radiograms show changes in urethrovesicopubic relationships effected by different operative procedures. On the left, the changes following retropubic WC?thropexy are shown. k previously placed tantalum bar inferior to the urethrovesical junction is shown. The center radiogram shows the changes following abdominal total hysterectomy. Because it was necessary to remove the tantalum bar. additional vaginal plastic operative work was required, and the subsequent urethrovesicopubic relationships are shown on the right. The patient is compIetely free of urinary stress incontinence.

cure. Because the significance of uterine suspension in the etiology of urinary stress incontinence was not initially appreciated, failure resulted. When these factors were recognized and, as the result of hysterectomy, dissipated, the patient, was cured (Fig. ‘7). Patient L. W. (Class A) was substantially improved following retropubic urethropexy (Marshall-Marchetti technique). Her bladder capacity was 150 C.C. Complete urinary control and normal bladder capacity were obtained by The latter opabdominal hysterectomy and subsequent vaginal urethroplasty. eration was made necessary as the result of removing a tantalum bar, previously The effects of hysterectomy were striking in placed for suburethral support. this patient. Subsequently performed urethrocystograms showed the salutary changes in the position of the bladder to be progressive (Fig. 8). B. K. (Class C), the fifth patient in whom failure was recorded, has not resubmitted to operation. Urethrocystograms performed following vaginal hysterectomy and cystourethroplasty show the relationships of stress incontinence.

\ illume Xumbe,

76 .i

L-FERINE

8UHI’ENSION

AND

URINARY

STRESS

LNCON1’.TNEN(!E

Il2:I

NON STRAINING

STRAINING ,

._

Fig. 9.-This patient, aged 31, para i, had numerous pelvic operations, including anterior suspension. Symptoms of urgency. frequency. and stress incontinence were severe. Bladder capacity was 200 C.C. The hatched bladder shadow and the black beads show the urethrovesical relationships prior to hysterectomy and release of intra-abdominal adhesions. The postoperative relationships are shown by the solid black line. Retrocession of bladder position awl rnlarged bladder capacity are shown.

NON STRAINING

\

Fig. 10.-The relatively normal these abnormal bladder relationships from the vaginal approach, and, to tionships by retropubic urethropexy. throvesical junction but unsatisfactory

STRAINING

position of the bladder base makes clinical detection of difficult. This position militates against successful repair some extent, prevents the establishment of optimum relaThese radiograms show adequate elevation of the weposterior bladder rotation.

1124

HODGKINSON

SND

KELLY

Because the degree of cystourethrocele was minimal, the operative procedure was ill chosen; better results probably would have been obtained with abdominal hysterectomy and retropubic urethropexy. Objective evidence of improvement was evaluated with the aid of urethrocystograms. Full technical improvement was accorded when the radiograms showed the constraining influence to have been removed; thereby the bladder was permitted to retrocede and the posterosuperior segment to expand. In addition, the urethrocystograms permitted evaluation of the efficiency of the operation. Elevation of the urethrovesical junction above the lowermost, level of the bladder is an essential feature of urethropexy; a sharp posterior angle is thereby created. In the vaginal plastic operations, the essential features are : (1) reconstitution of the vesical sphincter, (2) full support to the urethra, and (3) rational, but not excessive, correction of t,he cystocele. Fig. 9 shows relationships considered to be favorable which resulted from hysterectomy alone. Simple release from the constraining influence of the suspended uterus did not immediately effect ultimate improvement. Follow-up urethrocystograms several months later showed improved changes in anatomy which were paralled by improvement in subjective symptoms. The changes in urethrovesical relationships effected by combining retropubic suspension of the urethra with hysterectomy are depicted in Fig. 10. The high position of the bladder after uterine suspension tends to neutralize the effectiveness of elevation of the urethrovesical junction and posterior rotation of the bladder incident to retropubic urethropesy. Group II.

Extravesical

Pressure

Simulating

Uterine

Xuspension.-

1. Clinical Appr&saZ.-When the urethrocystograms of 42 patients were scrutinized, relationships were discerned which simulated those of uterine suspension. The etiological factors were utrrine myomas 34, adhesions from previous surgery 3, retrodisplacement of the uterus 3, congenital bands from the anterior cervix 1, and ovarian fibroma 1 (Fig. 11). The average weight of the uteri and myomas was 250 grams. More important than weight was the position of the tumor. When located low on the anterior or posterior surface of the uterus, inimical pressure influences were likely. Third-degree retrodisplacement of the uterus when combined with adenomyosis, pelvic adhesions, and subinvolution was the mechanism in 3 cases. 2, &ymptoms.-The symptoms resembled those observed in patients in Group I, Class A (typical suspension relationships) ; urinary urgency a.nd frrquency predominated. Only 16 patients complained of urinary stress incontinence. In all patients the degree of intensity of symptoms was mild. The capacity of the bladder, as revealed by cystometric studies, was as follows: less than 350 cc. 4 patients (1’7 per cent) ; less than 550 c.c., 8 patients (33 per cent) ; less than 850 CC., 9 patients (38 per cent) ; and less than 1200 cc., 3 patients (12 per cent). 3. Operations.-The following operations were performed : ( 1) hysterectomy total abdominal, 9; (2) hysterectomy, total abdominal, combined with retropubic urethropexy (Marshall-Marchetti technique), 10; (3) hysterectomy, total abdominal, combined with retropubic urethropexy (round ligament technique) , 3 ; (4) vaginal hysterectomy, 2; and, (5) vaginal hysterectomy combined with urethroplasty (Kelly or Kennedy technique), 10. 4. Results.--If failure to cure urinary stress incontinence and subsequent occurrence of stress incontinence are used as indices of results, then failure occurred three times, twice after total abdominal hysterectomy, and once after vaginal hysterectomy combined with urethroplasty.

\
I’I’EKINE

SU8PENBION

AND

UR1NAR.Y

STRESS

IN~‘ON’l’IN~:N(‘l’:

IlZl

If failure to obtain immediate relief from the symptoms of frequency and urgency is used to gauge the operative results for the patients of Group El, t.1~ (lur(: rat,e is still less. Many patients showed gradual improvement over tlu subsequent 4 to 6 months, and, if given no additional treatment, were dcclartkd (‘11 rd.

Wg.

Il.-This

impressionistic

drawing duced

by

shows uterine suspension a uterine flbromyoma.

syndrome

relationships

rlro-

If substantial alteration of urethrovesicopubic relationships toward normal is used as objective evidence of immediate operative success, the results were disappointing, because immediate shift of the position of the bladder frequentl) failed to develop. Comment The initiation or aggravation of urinary symptoms following uterine suspension, and their dissipation following hysterolytic procedures are cogent factors to support a direct cause-and-effect relationship for the “uterine suspension syndrome. ’ ’ How these changes of anterior displacement following uterine suspension compare with retrocessive changes following parturition is a clinical problem for contemplation. Harris, Mengert, and Plassl” confirmed the observation of Halban and Tandler that the uterus was normally a mobile organ. and was subject to the dictates of gravity and contiguous pressure. Also, the bladder is highly mobile. Lynchll stated that the bladder is rarely disturbed by pressure and that it is able to distend in all directions. So long as the capacity is not curtailed, the organ is extremely tolerant to displacement. The support for the base of the bladder in normal nonparous patients was shown to be afforded by the superior surface of the symphysis, the pubococcygeus,

1126 muscles and the central pubocervical fascia.” With retrocession following parturition more responsibility for support came from the laterally placed pubococcygeus muscles and the pubocervical fascia of the lcvator hiatus. After uterine suspension, support appear’s to come mainly from tho supclrior surface of the symphysis. The lowest level of the bladder frcqucntly is clcva.ted to a position of high normal. These two factors--ant.c>rior displacement and high position-lessen the importance of the support usually afforclcd by the mnscnlature of the pelvic floor; likewise, this operat,ion adds to the rigidity of mcchanical fixation. Reference to extravesical pressure and urinary stress incontinence has been vague and relatively infrequent. Ullery’” and FrosP mentioned inflammatory and neoplastic diseases of the uterus and rectum as possible etiological factors. Te Linde1*3 I5 has repeatedly urged the gynecologist to broaden his professional purview to recognize secondary damage to the urinary system, possibly resulting from expanding pelvic masses. He cited the work of Everett and Sturgis in which thry showed dilatat.ion of the upper urinary tract, in 50 per cent of patientas with benign pelvic disease. Hundley and IXehlG rcportcd similar results. The evaluation and assignment of bladder symptoms in the female are extremely hazardous. Studies by Ncmir and Midclleton16 and Kellar17 showed that a high percentage of normal subjects admit, having urinary stress incontinence. Nemir and Middleton questioned 1,327 young nulliparas. Urinary stress incontinence to some degree was admitted by 53.4 per cent. Laughing was the chief provocative factor. Kellar’s study yielded similar results : of 134 healthy nulliparas, 87 admitted stress incontinence; 17 stated that it occurred frequently; less than half of the subjects admitted having urinary urgency. Although the degree of stress incontinence admitted by the subjects of these two groups probably should be considered to be of subclinical intensity, these studies suggested a natural propensity of a large percentage of human females to clt~rlop this annoying symptom. Several patients of Class A stated categorically that their urinary symptoms were initiated by uterine suspension. For patient L. W., previously mentioned, the procedure started a chain of unsuccessful operations for stress ~ncontinenec which finally ended in uretcrosigmoidostomy and, later colostomy because of chronic pyelonephritis. Chronic azotemia developed. Discouragement over her ill health contributed to marital discord and she was divorced. This stimulated the performance of another series of operative procedures which included rctropubic urethropexy, excision of a previously placed suburcthral tantalum bar, hysterectomy, and re-establishment of the continuity of the bowel and urinary systems. Now the patient is completely continent,, and she has remarried. In the patients of Class A (typical suspension relationships) frequency and urgency appeared to be more directly related to the anatomic changes induced by uterine suspension than did urinary stress incontinrnce. It appeared highIT improbable that extravesical pressure per se could cause urinary stress incontlnence. On the other hand, it appeared likely that potential stress incontinencn would become overt in a patient subjected to uterine suspension should prior weakness of the sphincter-retaining mechanism be present. BarneP stated that since urinary incontinence, regardless of tht exact etiology, represented a momentary increase in the forces of urinary expulsion over the powers of urethral resistance, it appears probable that incontinence could result from (a) an increase in intravesical pressure, (b) a weakening of the powers of resistance, or (c) a combination of the two. Until the means of the voluntary control of urine are better understood, placing the prime responsibility in a phantom, physioanatomic sphincter-retaining mechanism appears the least objectionable. While the cinefluorographic studies of Ardran, Simmons, and StewartI and Lund and associateP

\olume ic; Number 5

W.‘EMNE

SUSPENSION

AND

URINARY

STRESS

INCONTINENCE

ll”7 _

have been most informative, certain facets of information are still not known. It is difficult to reconcile, on an anatomic basis, the return to the bladder of the urine in the proximal two thirds of the urethra upon voluntary inhibition of urination. Complete urinary continence has been observed many times folThis indicates the presence of sorrw lowing amput,ation of the female urethra. 111 sort of a retaining mechanism above the level of traumatic amputation. addition, the part played by reversal of intra-abdominal pressure needs nluc4dation. Berglas and Rubinzl showed that the pelvic cavity was subject to a II the regulating changes of intra-abdominal pressure by the abdominal malls, and that the musculature of the floor of the pelvis was an’intrinsic part of the pltysiologic complex of muscles. LamZ2 claimed that the intra-abdominal presisurc’ was a relative figure. He showed that pressure measured at t.he uppermost levcll When measured at the lowest I~~vel, ill{, was registered as a negative quantity. pressure was positive. While the interserous pressure was probably negative, under all circumstances, the weight of the intra-abdominal contents negated t hih reading in the lowest levels. For these reasons it is probable that uterine suspension and pelvic twuors play no more than ancillary roles in the development of urinary stress incontinence. Te Linde*” warned against subjec&g t.he patient with congenital rctroversion t 0 ut,crine suspension. He also stated that operative failure seldom occurred when t#he patient had a well-developed cystourethrocele. Failure was most frequent,ly observed in patients without cystocele and in t,hose with exc?essivc, scarring around the urethra as a result of previous operations. These warnings :IY(’ c~sp&~lly applicable to patients with the ltterine suspension syrldromp.

Treatment From experience with these two groups of’ patients, it, is evident tll;tt, great cart= must be used in selecting the proper operative procedure. Frank” warned “in t,hc absence of cystocele and presence of stress incontinence, not. to sul)ject pa,tients to operative procedures unless every psychical and neurogenic cause for the condition can be excluded.” Because the anatomic relationships cannot. 1~1’ evaluated by clinical means alone, anteroposterior and lateral urethrocystograms should be employed. The high location of the bladder may be deceiving in the It also militat,es anatomic diagnosis of this type of urinary stress incontinence. against success if vaginal plastic operations of the Kelly or Kennedy t,yge are employed. Not only is it difficult to accomplish t,echnically a successful vaginal plastic operation under these circumstances, but nothing is done to alter the eslravesical pressure of the uterus on the bladder. The admonition “. . . do a vaginal plastic procedure first . . .” does not, hold for stress incontinence of this type. In our experience, the best operative pro(aedures are those which eomhin(~ Il.vstrrol~sis and retropubic urethropexy.

Summary

and Conclusions

Two groups of patient,s have been presented whose urethrocystopubic I’+ lationships showed anterior displacement of the bladder. reduction in the size of the posterior bladder segment, and evidence of postrrosuperior extraveGa pressure. Urinary frequency, urgency, and stress incontinence were the associat,ed subjective complaints. It appeared probable that these anatomic changes played no more than ancillary roles in the etiology of urinary stress incontinence. Yet, unless the) wcr(’ corrclrted. successful establishment of urinary control was in jeopardy.

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Am. I. Obst. B Gym. i%vemher. 1958

Moreover, because of these peculiar urethrovesicopubic relationships, the surgical treatment must be carefully contemplated. Vaginal plastic operations Abdominal procedures which invol vc hysare least likely to be successful. terolysis and retropubic urethropexy are best. Because the anatomic relationships are opposite to those usually observed in urinary stress incontinence, because they cannot be properly evaluated by clinical means alone, and because combined operative procedures must be employed if success is to be obtained, it has been found convenient to designate these objective signs and subjective symptoms, when occurring concomitantly, as the uterine suspension syndrome.

References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 3 7. 18. 19.

Hodgkinson, C. P.: AM. J. OBST.& GYNEC.~~: 560,1953. Hodgkinson, C. P.: AM.J.OBST.& GYNEC.~~: 5X$1957. Muellner, S. R.: Surg., Gynec. & Obst. 88: 237, 1949. Stevens, W., and Smith, S. P.: J. Urol. 37: 194, 1937. Frank, R. T.: AM. J. OBST. & GYNEC. 24: 574, 1932. J. A. M. A. 127: 572, 1945. Hundley, J. M., Jr., and Diehl, W. K.: Surg., Gynec. & Obst. 88: 509, 1949. Marshall, V. F., Marchetti, A. A., and Krantz, K. E.: J. Obst. & Gynaec. Brit. Emp. 57: 404, 1950. Barns,*H. H. F.: Hodgkmson, C. P., and Kelly, W. T.: Obst. & Gynee. 10: 493, 1957. Harris, L. J., Mengert, W. F., and Plass, E. D.: AM. J. OBST. & GYNEC. 31: 1009, 1936. Lynch, F. S.: In Davis, C. H., and Carter, B.: Gynecology and Obstetrics, Hagerst,own, Md., 1953, W. F. Prior Co., vol. 2, chap. 12, pp. 45-47. Ullery, J. Cl.: Stress Incontinence in the Female, New York, 1953, Grune & Stratton. Frost, I. F.: In Carter, B. N., editor: Monographs on Surgery, Baltimore, 1952, Williams & Wilkins Company, pp. 82-98. Te Linde, R. W.: Aa6. J. OBST. & GYNEC. 60: 273,195O. Gynecology and Te Linde, R. W., and Braek, C. B.: In Davis, C. H., and Carter, B.: Obstetrics, Hagerstown, Md., 1953, W. F. Prior Co., vol. 3, chap. 10. AM. J. OBST. $ GYNEC. 68: 1166, 1954. Nemir, A., and Middleton, R. P.: Kellar, R. J.: Proc. Roy. Soe. Med. 49: 657, 1956. AM. J. OBST. & GYNEC. 40: 381, 1940. Barnes, A. C.: .J. Obst. & Gynaec. Brit. Emp. 63: Ardran, G. M., Simmons, C. A., and Stewart, J. H.:

26, 1956.

20. Lund,

d. J., Benjamin, J. A., Tristan, T. A., Fullerton, J. S.: AM. J. OBST. & GYNEC. 74: 896, 1957. 21. Berglas, B., and Rubin, I. C.: Surg., Gynec. & Obst. 22. Lam, C. R.: Arch. Surg. 39: 1006, 1939.

R. E., Ramsey, 97:

677,

Cr. H., and

Watson,

1953.

Discussion DR. RICHARD W. TE LINDE, Baltimore, M/Id.-Several points have been made by Dr. Hodgkinson which I believe should be emphasized: (1) the importance of a thorough examination of patients with incontinence before deciding on the proper therapeutic approach; (2) the conclusion that vaginal plastic procedures for stress incontinence are ill chosen if the urethra and bladder base are supported at a high level; and (3) the fact that failure to demonstrate elevation of the urethrovesical junction following the Marshall-Marchetti operation indicates deficiency of technique and clinical failure. I might add that the same is true of the sling type of operation with which I have had more personal experience. So much for our points of agreement, but I must confess that I have not been completely convinced by the evidence presented of the “uterine suspension syndrome.” I must admit, however, that we do not see in our area today many patients who have had uterine Fifty years ago Dr. Kelly often suspended two or three uteri in a morning. Tosuspensions. day, that is approximately the number of operations which are done primarily for uterine suspension in a year in our clinic where we do over 3,000 operations. Over the past years, however, I have seen many patients after uterine suspension and have not been impressed with the association of urge or stress incontinence in these patients. A properly done suspension should put the uterus in the position in which it normally was meant to be. This

\
UTERINE

SUSPENSION

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URINARY

STRESS

INCONTINENCE

1129

being the case, it is difficult for me to visualize the mechanics of urge or stress incontinence On the other hand, many uteri have when the uterus has been restored to its normal position. I can find nothing in in t,he past been erroneously suspended for these bladder symptoms. the present study to indicate what symptoms these patients had before the suspension was done. Since many of the suspension operations were done many years before, it would he al. most impossible to get this information. Is it not possible that in some of these patients tile Also included symptoms preceded the suspension and were persistent after the operation? after among the patients with the ( ‘uterine suspension syndrome ’ ’ are some who had children the suspension and developed cystourethroceles which, in my opinion, would be more apt i (1 account for the urinary symptoms than the suspension operation. Although postsuspension patients are not very frequent in our area, Negro \vom(lr( with large fibroids are. Stress incontinence and urgency depend not only upon the strength of the vesieal sphincter, but also upon the intravesical pressure. The latter may be increased 1ly excessive obesity and intra-abdominal tumors. Such large space-occupying tumors may he R factor in frequency and stress incontinence. On the other hand, moderate-sized fibroids seldom give rise to these symptoms and it seems that they should, if the replacement, of the rlormal-sized uterus to its proper position is capable of causing such symptoms. I mention these objections to emphasize how cautious one must be in evaluating caust* I honestly believe that much morr work and effect when considering a clinical syndrome. must he done before we can accept the “uterine suspension syndrome” as a clinical entity. [ do appreciate, however, the great amount of work such a study entails and this presentation has alerted me so that, in the future I shall be watchful for evidence of this spndromtl. I prrf(Jr at this time to retain an open mind. DR. LAWRENCE R. WHARTON, Raltimore, &M.-I find it rather difficult, Iti (lid cuss t,his paper today because we see so few uterine suspensions and we do so many less than formerly. I do not believe I could assemble a group of 50 pa&&s after suspension in many years of practice, so that I feel this is a condition we do not see enough of in Baltimore to evaluate from this viewpoint. I think we are indebted to Dr. Hodgkinson for one thing, however. We have always felt that Merino suspension was an operation that should not 1~ done without great colmidt’ration and as he adds one more reason why we should no do it we arc grateful to him. I would like to discuss, as Dr. Te Linde did, the interpretation of one feature of tht* syndrome on which is based the indication for hysterectomy in women who have stress incontinence. I refer to what Dr. Hodgkinson calls the imprint of the uterus on thlb hladder. We do a great many cystograms and intravenous pyelograms in our studier a1111 we very frequently see a concavity in the cystogram caused by t,he pressure of the uterus lying above the bladder. So far as I know, our x-ray depart,ment has not paid much att+*n tion to this picture and I myself do not lay much stress on the fact that the normal uterus lying above the bladder can produce this change in the outline of the bladder. T do not remember any case in my own practice in which I thought t.he pressure of the normal uterus 1111 the bladder was producing bladder symptoms. We have, however, seen patients who have had hysterectomy for various urinary symptoms and always without henefit. I do not want to criticize Dr. Hodgkinson’s conclusions on this but in discussing his conclusions I feel that we should know more about these individual cases in which hysterectomy was done because of pressure by a normal uterus. I feel that it would be unfortunate if the general surgeon were allowed to get the impression that a cystogram which showed pressure of :t, uterus on top of the bladder in a woman with stress incontinence was justification for hysterectomy. The members of this Society have long tried to bring to the attention of doctors the fact that hysterectomy should be done only for definite pathological indications, After we know more about Dr. Hodgkinson’s work and the cases he has studied we may 1~. able to modify what I have said, but I would be slow in doing hysterectomy in t,hese eases, tinence vesical

Finally, I would like to discuss one of Dr. Hodgkineon’s comments, that stress incon is due to either (1) weakness of t.he sphincter muscle or (2) increase in the intra. pressure caused by one of many ancillary factors. With this, I am completely ill

accord. !Vhen viewed in this general light, we may divitle the 1~~oblrms of stress iuc~)ntinenee into three parts. E’irst, cases in which tho urinary sphincter is normally strong :tull efficient. These women never have stress incontinence no matter what ancillary factors they may develop, uterine fibroids, prolapse of the uterus, pregnancy, psychomurotic instatbility, or any one of many other conditions. Then, at the opposite extreme, are found those in whom the sphincter mechanism has been severely damaged, perhaps by a transnrrthral resection. These women are incontinent and do not need any ancillary factor 11, 11roclm:t~ it.

Then, finally, there is the large group of women whose sphincter mechanisms are not quite perfect but who have stress iucontinence only when some ancillary factor adds SOL+ thing to the intravesical pressure or lessens the <+liciency of the sphincter which is already below par. The great majority of our cases of stress incontinence belong to this group), and as we can see at a glance, most of these ancillarv factors are basically medical problems. Likewise, we have found that the strengthening of the sphincter mechanism often can also 1~~ accomplished without surgical intervention. This is therefore a situation in which it is extremely important to study the patient as a whole hcfore embarking on surgery. In some of these women there is present a simple thing like meustruation or a psychoneurotic disturbance or the fact that she is too fat or has a urologic condition which makes it impossible for the urinary system to work properly-all these things must be investigated in studying a case of stress incontinence. Most of them are medical situatious requiring careful I would also suggest that in mau,v of these CRSPS, excepting medical and sympathetic care. medical care will eliminate the one with prolapse or a large fibroid or injury to the urethra, many factors which influence and precipitate stress incontinence, through the use of exercise. This sort of treatment, carefully done, will in the long run procluce a great many ,ures and will eliminate many people who will never need operation and tinally will SCl’~“t’ll out, CRSI’S I do not know whether Dr. Hodgkinin which it is perfectly clear that operation is necessary. son has used this method of screening. I know his paper was strictly a surgiral discussion, but I think it is a good thing, even in presenting such a paper, lo indicate to the general reader, who may not be as well versed as t,his group, that it is necessary in these cases to find some reason for operation and to eliminate the cases in whirh the operation is not necessary. DR. JOSHUA WILLIAM DAVIES, New York, N. Y.-Dr. J. Wesley Boveet, of George Washington University, was interested in the cervical supports of the uterus, so he devised several operations which were destined to restore the cervix to its normal position in the midpelvis. He believed that the tonicity of the uterosacral ligaments assisted in maintaining a flattened bladder trigone. It may seem curious that a full bladder does not rt is the compress the walls of the vagina and bulge into the concavity of the sa(rum. tough fibrous capsule of the trigonal area which prevents such displacement. The trigoue is attached to the lateral pelvic wall through connective tissue and inferior vcsiisal bloo~l vessels. Its proximodistal flattening is duo to the tonicity of the utrrosacral ligaments. In the erect posture the plane of the trigone is practically vertical. As the bladder fills with urine that portion of the muscularis which extends from the urethra to the urachus rests against the urethra and tends to compress it as intra-abdominal pressure is increased. lf the fundus of the uterus is attached to the anterior abdominal wall the cervix is displaced The uterine suspension synand the bladder trigonal area relaxes and becomes congested. drome referred to by Dr. Hodgkinson may be the result of trigonal relaxation and urethral congestion. The treatment for such urirmry complaints is preventive. The uterus should not be fixed to the anterior abdominal wall. Occasionally it is necessary to replace a rctroverted uterus because of symptoms; but before the attempt to restore the uterus to an anterior position, it is necessary to separate adnexal adhesions which are responsihle for holding the fundus posteriorly. The Journal of the American Medical Associatio~n, vol. 154, pp. 749-751, describes an additional adhesion between the sigmoid colon and the left round ligament which may be responsible for a torsion and a retroversion of the fundus of the uterus. If such an adhesion is divided, the smooth muscle in the round ligaments will be observed to contract and by so doing to

\‘durne

ih

Number 5

l:‘l’ER.lNE

SUSPENSION

AND

UR1NAR.Y

draw the uterus away from the raw adhesion area. uterus away from divided adhesions, it is advisable region of t,he internal abdominal ring.

STRESS

INCONTINENCE

11:1i

Should it he necessary to draw to attach the round ligament ill

1.11, +I~~

DR. JOHN B. MONTGOMERY, Philadelphia, Pa.-1 am in agreement with Dr. ‘1’~~12in(lrX that hladdcr symptoms and certainly stress incontinence following uterine suspension are most unusual. This operation is not frequently done nowadays. In 1942 we investigate
distreiising a s~*lpctell It woulcl know alsli assclrixtcd

DR. HODGKINSON (Closing).-The discussants have rightfully emphasized the CECIL lroversial place these anatomic changes have in gynecologic surgery for urinary s:trPss ill continence. This paper, however, was not intended to be :t criticism or an evaluat,icrn (11 the operation of uterine suspension. It was intended to bc an appraisal of the importanr*, of the changes in the anatomy of the bladder incident to uterine suspension and pelvic tumors. Cert,ain types of patients have a propensity for developing three anatomic changes. For instance, the patient with the congenital retroversion of the uterus, in whom the anterior vaginal wall is short and in whom the cervix IS located forward on the anterior vaginal wall is prone to develop these relationships with suspension of the uterus by the Gilliam Doleris technique. In reoperating upon these patients, we observed that the ones most likely t.o sho\v these relationships were those in whom the operation had been technically successful. Frequently, the uterine fundus was found to be densely adherent to the anterior at)dominal wall. That not all patients who have had suspension of the uterus develop urinary symptomwas illustrated by the patients in Group I, Class B; nrithtr did they show the typical r111r1 tionships in anatomy known to follow suspension of the uterus. Dr. Wharton emphasized the importance of employing, preoperatively, constbrvativi means for management of the patient with urinary stress incontinence. We routinely employ perineal exercises and also find them to be of value in the postoperative period. The patients included in this report represent but a small percentagr of t.he over 500 patirlnt. ohserved and it, was not our intention to detail the over-all treatment of urinary stress jn(,(,n tinencc. It appeared to us that this type of urinary st,rPss incontinenccx was on a diff~~tr,~l~ anatomic basis from t,hat usually observed. 1 would like to reaffirm one impression implied by Dr. Davies conrerning RI’ made in the position of the pubic bone. We have not changed the position hone. Thrsr slides arc unaltered tracings of x-ra.ps olltainrxd with the patient position. The comments by Dr. Montgomery Anspach and Montgomery on suspension it ww the last paper on suspension of

any &angc’ of the pubi~~ in the (~~~~,~I

were most apt. 1 l~are read the paper of t,he uterus t)y the Simpson technique. the uterus presllnted before this society.

lly 1 )ri. [ }l,?licsv,