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Use of standard contraceptivediaphragm in management of stress urinary incontinence
USE OF STANDARD CONTRACEPTIVE DIAPHRAGM IN MANAGEMENT OF STRESS URINARY INCONTINENCE GEORGE M. SUAREZ, M.D. NEIL H. BAUM, M.D. JACK JACOBS, M.D. From the Department of Urology, University of Miami School of Medicine, Miami, Florida, and Departments of Urology and Obstetrics and Gynecology, Touro Infirmary, New Orleans, Louisiana
".he management of stress urinary incontinence (S UI) consists of either surgical interpharmacologic manipulation. Twelve patients with SU1 were evaluated for j the use of a fitted standard contraceptive diaphragm. Complete resolution of SUI 11 of 12 patients (91%). Two of the 12 patients achieved continence but withdrew because of associated discomfort from the diaphragm, therefore, complete resolus achieved in 9 of 12 patients (75 %).
ee is maintained when inres exceed bladder pressure. ~ntinence (SUI) results from hal pressures transmitted to h exceed urethral pressure. for female SUI includes a varoeedures and/or pharmaeo[erein we present our expedard commercially available tginal d i a p h r a g m for the male SUI. 'ial and Methods with signs and symptoms of :ed for management of SUI ;tandard commercially availdiaphragm (Table I). All paa history and physical exalysis, and a u r o d y n a m i e included water eystometry, electromyography, urethral and uroflowmetry. In additderwent eystoseopy and a
Marshall-Marchetti stress test. The diagnosis of SUI was based on a clinical history of involuntary loss of urine with physical strain, and the presence of normal findings on urodynamics tests and cystoseopy, normal urinalysis, and a positive Marshall-Marchetti stress test. TABLE I.
Patient population and prior history
Case No.
Age (Yrs.)
1" 2 3 4 5 6* 7
62 65 43 29 25 68 51
8t 9
39 29
10 11 12
42 48 35
Prior History Marshall-Mar'elaetti-Krantz .. .. Marshall-Marel;etti- Krantz Vaginal hyst./anterior repair . .
Vaginal hyst./anterior repair Anterior repair Vaginal hyst./anterior repair
*Withdrew from study because of associated discomfort from use of diaphragm. ~Unsueeessful with diaphragm use, underwent anterior repair and modified Pereyra procedure.
rAI/Y 1991 / VOLUME XXXVII, NUMBER 2
119
Patients were individually fitted with a vaginal diaphragm and given appropriate instruetions on insertion and removal. Particular emphasis was made on the use of the diaphragm during periods in whieh they would be most susceptible to SUI. Patients were then re-evaluated at two weeks by detailed history and physical examination, urinalysis, and repeat urodynamics. They were then seen on a monthly basis and questioned with regard to any physical discomfort, sensation of urinary obstruction, and incontinenee. Results Twelve patients were evaluated for SUI and fitted with a standard contraceptive diaphragm ranging in size from 60 mm to 70 mm. Eleven of the 12 patients (91%) reported complete resolution of SUI. Two required refitting to a larger size diaphragm before resolution of SUI. One patient whose incontinence did not resolve, described some improvement but yet had occasional incontinence, particularly when her bladder was full. She underwent an anterior repair and modified Pereyra procedure with good results. Two of the 19, patients achieved continence with the vaginal diaphragm but withdrew from the study because of physical discomfort associated with the diaphragm. Otherwise, the remaining 9 patients (75 %) remained continent and experienced no complaints of urinary obstruction, urinary tract infections, or other significant discomfort. Urodynamics evaluation with and without the diaphragm revealed an increase in urethral pressure profiles (UPP) with the diaphragm in place w i t h the m e a n UPP w i t h o u t the diaphragm being 37.5 em H20 pressure and with the diaphragm 81.0 em HzO pressure. These results correlated with a decrease in urine flowmetry in which the mean values without the diaphragm was 29 ec/seeond and with the diaphragm 24 cc/second. There was no change in time to peak flow with the diaphragm in place. Increase in urethral length was variable in each patient and ranged between zero and 1 cm. There was no significant change in bladder capacity and/or postvoid residuals. Urodynamics results with and w i t h o u t the diaphragm are listed in Table II. Comment Stress urinary incontinence (SUI) resulting from increased intra-abdominal pressures is a 120
TABLE II.
Pertinent urodynamics studies on patient population Urodynamics--,Diaphragm~ Without With (UPP/UFS) (UPP/UFS!;
No.
Bladder Capacity
1 2 3 4 5 6 7 8 9 10
320 325 300 350 275 300 250 300 325 250
40/21 30/24 25123 35/28 30/24 40/26 35/22 30/24 25/26
65/20 60/20 70120 'i 70/22 65/20 ~i 70/20 60/18 ~ 65/18 70/20 70/20
11
325
3o/2o
7o/22
12
350
25/28
80/18
C ase
30/22
KEY:UPP = urethral pressure profile, UFS = uroflow studi~
fairly common condition in womer erally the result of an incompetent sure mechanism in association w tomically displaced and/or urethral-vesical anatomy. Standa ment of SUI can consist of either su: pharmacologic manipulation. Sm dures are either retropubie operatl needle suspension operations, ant{ repairs, or pubovaginal sling proe{ The general mechanism by wh surgical procedures correct SUI is of the bladder neck and restoratior vesieal anatomy. In addition, ther( outflow resistance as determined t voiding pressures and peak flow r ments following surgery. Primary pharmacologic manipulation is creasing bladder capacity whil{ bladder outlet resistance. By using a standard eommercia contraceptive vaginal diaphragm, ' to achieve continence in 11 of 12 t SUI (91%). Two of the 12 patie continence but were considered because of the discomfort seeon diaphragm. Therefore, successful SUI was accomplished in 9 of (75%). The proposed theory for a suece~ nal diaphragm in the manageme based on the elevation of the bl thus, restoration of the urethral omy. Furthermore, there is compression o f ~ urethra against the postero-superior aspec~""~
UROLOGY / FEBRUARY1991 / VOLUME XXXVII, N U M D ~
A
\ L
[
/
SUI
Normal
/
U.
FIGURE 1. (A) Vesicourethral angle in normal patient, (B) stress urinary incontinence, and (C) correction with vaginal diaphragm.
Corrected with diaphragm
further increasing max:ure p r e s s u r e s (Fig. 1). 1 d i a p h r a g m accomplishes etive surgery. urodynamies findings are d associates 1 in evaluating ierobiologie factors assod diaphragm. Additional al pessary in w o m e n w i t h urodynamies findings by ary was used in the prel of w o m e n w i t h stress 2 - the m e a n urine flow rate with the d i a p h r a g m t h a n ,~t it r e m a i n e d well within Vurthermore, w e did not ~qe to peak flow w i t h the nor was there a problem ',tion. M a x i m u m urethral 'e noticeably higher w i t h ee. However, the variable .ngth was not consistent in fieult to interpret. h o did not tolerate the rly and most likely reprefunction and associated
g 1991
/
FIGURE 2.
Prototype of anti-incontinence vaginal
ring.
VOLUME XXXVII, NUMBER 2
121
atrophic vaginitis. The 1 unsuccessful ease was a fairly obese woman with a noticeably hypermobile urethra and a eystoeele. This patient subsequently underwent anterior repair and modified Pereyra procedure with satisfactory results. Two other patients who comp l a i n e d of d i s c o m f o r t f r o m t h e v a g i n a l diaphragm also underwent modified Pereyra procedures. Our data suggest that the use of a vaginal diaphragm is a viable alternative in the appropriately selected patient. Furthermore, vaginal diaphragm may be used as a temporizing measure until such time as the patient can be scheduled for surgery. It may also serve as a diagnostic test in predicting the successful outcome of surgical correction. The selection of an appropriate size diaphragm is essential as indicated by 2 of our patients who required a larger size diaphragm before resolution of incontinence. Similarly, too large a size may prove to be uncomfortable.
122
UROLOGY
We have recently used an anti-incontinene~ vaginal ring manufactured by Cook Urologll with excellent results. This device comes in vai iable sizes from 55 m m to 70 m m with 10-rn! girth and a hollow center. We believe that ft variation in sizes, the increased girth, with hollow center provides a more physiologic e61 reetion of SUI (Fig. 2). Indeed, preliminary re sults have been excellent, and we are currentli exclusively using the Cook ring. Miami Urologic InstitUi 7051 SW 62 Ave6~ Miami, Florida 331i (DR. SUARE~ References 1. Fihn SD, Johnson C, Pinkstaff C, and Stature W~ Diaphragm use and urinary tract infections: analysis of u~ dynamic and microbiological factors, J Urol 136. 853 (1986)i!~ 2. Bhatia NN, and Bergman A: Pessary test: simple progno~i test in women with stress incontinence, Urology 24. 109 (1985
/ FEBRUARY
1991
/ VOLUME
XXXVII, NUMBEIIJ
".he management of stress urinary incontinence (S UI) consists of either surgical interpharmacologic manipulation. Twelve patients with SU1 were evaluated for j the use of a fitted standard contraceptive diaphragm. Complete resolution of SUI 11 of 12 patients (91%). Two of the 12 patients achieved continence but withdrew because of associated discomfort from the diaphragm, therefore, complete resolus achieved in 9 of 12 patients (75 %).
ee is maintained when inres exceed bladder pressure. ~ntinence (SUI) results from hal pressures transmitted to h exceed urethral pressure. for female SUI includes a varoeedures and/or pharmaeo[erein we present our expedard commercially available tginal d i a p h r a g m for the male SUI. 'ial and Methods with signs and symptoms of :ed for management of SUI ;tandard commercially availdiaphragm (Table I). All paa history and physical exalysis, and a u r o d y n a m i e included water eystometry, electromyography, urethral and uroflowmetry. In additderwent eystoseopy and a
Marshall-Marchetti stress test. The diagnosis of SUI was based on a clinical history of involuntary loss of urine with physical strain, and the presence of normal findings on urodynamics tests and cystoseopy, normal urinalysis, and a positive Marshall-Marchetti stress test. TABLE I.
Patient population and prior history
Case No.
Age (Yrs.)
1" 2 3 4 5 6* 7
62 65 43 29 25 68 51
8t 9
39 29
10 11 12
42 48 35
Prior History Marshall-Mar'elaetti-Krantz .. .. Marshall-Marel;etti- Krantz Vaginal hyst./anterior repair . .
Vaginal hyst./anterior repair Anterior repair Vaginal hyst./anterior repair
*Withdrew from study because of associated discomfort from use of diaphragm. ~Unsueeessful with diaphragm use, underwent anterior repair and modified Pereyra procedure.
rAI/Y 1991 / VOLUME XXXVII, NUMBER 2
119
Patients were individually fitted with a vaginal diaphragm and given appropriate instruetions on insertion and removal. Particular emphasis was made on the use of the diaphragm during periods in whieh they would be most susceptible to SUI. Patients were then re-evaluated at two weeks by detailed history and physical examination, urinalysis, and repeat urodynamics. They were then seen on a monthly basis and questioned with regard to any physical discomfort, sensation of urinary obstruction, and incontinenee. Results Twelve patients were evaluated for SUI and fitted with a standard contraceptive diaphragm ranging in size from 60 mm to 70 mm. Eleven of the 12 patients (91%) reported complete resolution of SUI. Two required refitting to a larger size diaphragm before resolution of SUI. One patient whose incontinence did not resolve, described some improvement but yet had occasional incontinence, particularly when her bladder was full. She underwent an anterior repair and modified Pereyra procedure with good results. Two of the 19, patients achieved continence with the vaginal diaphragm but withdrew from the study because of physical discomfort associated with the diaphragm. Otherwise, the remaining 9 patients (75 %) remained continent and experienced no complaints of urinary obstruction, urinary tract infections, or other significant discomfort. Urodynamics evaluation with and without the diaphragm revealed an increase in urethral pressure profiles (UPP) with the diaphragm in place w i t h the m e a n UPP w i t h o u t the diaphragm being 37.5 em H20 pressure and with the diaphragm 81.0 em HzO pressure. These results correlated with a decrease in urine flowmetry in which the mean values without the diaphragm was 29 ec/seeond and with the diaphragm 24 cc/second. There was no change in time to peak flow with the diaphragm in place. Increase in urethral length was variable in each patient and ranged between zero and 1 cm. There was no significant change in bladder capacity and/or postvoid residuals. Urodynamics results with and w i t h o u t the diaphragm are listed in Table II. Comment Stress urinary incontinence (SUI) resulting from increased intra-abdominal pressures is a 120
TABLE II.
Pertinent urodynamics studies on patient population Urodynamics--,Diaphragm~ Without With (UPP/UFS) (UPP/UFS!;
No.
Bladder Capacity
1 2 3 4 5 6 7 8 9 10
320 325 300 350 275 300 250 300 325 250
40/21 30/24 25123 35/28 30/24 40/26 35/22 30/24 25/26
65/20 60/20 70120 'i 70/22 65/20 ~i 70/20 60/18 ~ 65/18 70/20 70/20
11
325
3o/2o
7o/22
12
350
25/28
80/18
C ase
30/22
KEY:UPP = urethral pressure profile, UFS = uroflow studi~
fairly common condition in womer erally the result of an incompetent sure mechanism in association w tomically displaced and/or urethral-vesical anatomy. Standa ment of SUI can consist of either su: pharmacologic manipulation. Sm dures are either retropubie operatl needle suspension operations, ant{ repairs, or pubovaginal sling proe{ The general mechanism by wh surgical procedures correct SUI is of the bladder neck and restoratior vesieal anatomy. In addition, ther( outflow resistance as determined t voiding pressures and peak flow r ments following surgery. Primary pharmacologic manipulation is creasing bladder capacity whil{ bladder outlet resistance. By using a standard eommercia contraceptive vaginal diaphragm, ' to achieve continence in 11 of 12 t SUI (91%). Two of the 12 patie continence but were considered because of the discomfort seeon diaphragm. Therefore, successful SUI was accomplished in 9 of (75%). The proposed theory for a suece~ nal diaphragm in the manageme based on the elevation of the bl thus, restoration of the urethral omy. Furthermore, there is compression o f ~ urethra against the postero-superior aspec~""~
UROLOGY / FEBRUARY1991 / VOLUME XXXVII, N U M D ~
A
\ L
[
/
SUI
Normal
/
U.
FIGURE 1. (A) Vesicourethral angle in normal patient, (B) stress urinary incontinence, and (C) correction with vaginal diaphragm.
Corrected with diaphragm
further increasing max:ure p r e s s u r e s (Fig. 1). 1 d i a p h r a g m accomplishes etive surgery. urodynamies findings are d associates 1 in evaluating ierobiologie factors assod diaphragm. Additional al pessary in w o m e n w i t h urodynamies findings by ary was used in the prel of w o m e n w i t h stress 2 - the m e a n urine flow rate with the d i a p h r a g m t h a n ,~t it r e m a i n e d well within Vurthermore, w e did not ~qe to peak flow w i t h the nor was there a problem ',tion. M a x i m u m urethral 'e noticeably higher w i t h ee. However, the variable .ngth was not consistent in fieult to interpret. h o did not tolerate the rly and most likely reprefunction and associated
g 1991
/
FIGURE 2.
Prototype of anti-incontinence vaginal
ring.
VOLUME XXXVII, NUMBER 2
121
atrophic vaginitis. The 1 unsuccessful ease was a fairly obese woman with a noticeably hypermobile urethra and a eystoeele. This patient subsequently underwent anterior repair and modified Pereyra procedure with satisfactory results. Two other patients who comp l a i n e d of d i s c o m f o r t f r o m t h e v a g i n a l diaphragm also underwent modified Pereyra procedures. Our data suggest that the use of a vaginal diaphragm is a viable alternative in the appropriately selected patient. Furthermore, vaginal diaphragm may be used as a temporizing measure until such time as the patient can be scheduled for surgery. It may also serve as a diagnostic test in predicting the successful outcome of surgical correction. The selection of an appropriate size diaphragm is essential as indicated by 2 of our patients who required a larger size diaphragm before resolution of incontinence. Similarly, too large a size may prove to be uncomfortable.
122
UROLOGY
We have recently used an anti-incontinene~ vaginal ring manufactured by Cook Urologll with excellent results. This device comes in vai iable sizes from 55 m m to 70 m m with 10-rn! girth and a hollow center. We believe that ft variation in sizes, the increased girth, with hollow center provides a more physiologic e61 reetion of SUI (Fig. 2). Indeed, preliminary re sults have been excellent, and we are currentli exclusively using the Cook ring. Miami Urologic InstitUi 7051 SW 62 Ave6~ Miami, Florida 331i (DR. SUARE~ References 1. Fihn SD, Johnson C, Pinkstaff C, and Stature W~ Diaphragm use and urinary tract infections: analysis of u~ dynamic and microbiological factors, J Urol 136. 853 (1986)i!~ 2. Bhatia NN, and Bergman A: Pessary test: simple progno~i test in women with stress incontinence, Urology 24. 109 (1985
/ FEBRUARY
1991
/ VOLUME
XXXVII, NUMBEIIJ