Evaluation of the Incontinent Female

David Stanford, M.D.

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I. Introduction
A. With a detailed history, physical examination, and neurologic
exam of the lower extremities and perineum (lumbosacral nerve
roots), augmented by a few simple clinical tests, an accurate
diagnosis can usually be established in 90% of patients
C. For the vast majority of women presenting with complaints of
B Failure to do so in two cases that I have already seen has lead to the
urinary incontinence who have not had prior failed anti-inconti-
nence operations nor the history of neurologic injury, this simple
type of evaluation is all that is needed
II. History
A. The details of the general medical, gynecological, and urological
history may be obtained with standard questionnaires
B. History cannot be used alone as a basis for therapy
C. The history provides an error rate of at least 50% in arriving at a
correct diagnosis. The history serves as a guide for emphasis
during the subsequent evaluation process
D. Concomitant drug therapy for medical disease
1. Frequently produces side effects referable to the lower
urinary tract
2. Alterations of drugs or dosages (ie, diuretics, "-blockers)
may diminish the need for further in-depth evaluation and
decrease the patient's symptoms to tolerable levels
3. The menopausal status of the patient is important. If the
patient has any historical or clinical evidence of low estro-
gen, intravaginal estrogens are prescribed, usually on an
every-night basis, until a desired effect is achieved or 6
weeks have passed
4. Gradual tapering of the frequency of usage is generally
possible until a once or twice weekly maintenance schedule
is reached, or the patient is given oral maintenance estrogen
replacement
III. Physical Examination
A. Uroneurogynecologically-oriented physical examination
1. Detection of fistula or neurological disease immediately
directs further evaluation and treatment
2. The clinical evaluation does not allow for accurate assess-
ment of the presence of an anatomical defect
B. Further studies are indicated to confirm the presence of urethral
hypermobility prior to undertaking a surgical procedure to treat
stress incontinence. The "Q-tip"test is very helpful
C. The fluid bridge test may be used to detect funneling
D. A stress test is used to demonstrate urinary leakage with
increased intra-abdominal pressure
E. In some patients, radiologic studies may be necessary to
demonstrate anatomic defects
Urinary incontinence is a condition where there is an involuntary loss
of urine, which is a social and hygienic problem, which is objectively
demonstrable. We want to be sure that we document that someone has
stress incontinence with what we call positive stress test and you have
seen them leak urine which increases intra-abdominal pressure. If you
are going to consider operating on them or even treating them for stress
incontinence in general, you want to document this in your chart.
rapid conclusion and favor of the plaintiff in lawsuits.
Most women who have urinary incontinence will have genuine stress
incontinence as all or part of the problem. In fact about 75% of all
incontinent woman have this as part or their entire problem. There is
an involuntary loss of urine associated with increases in intra-abdomi-
nal pressure from any source whether it be playing golf, tennis,
coughing, intercourse. The bladder pressure exceeds the urethral
pressure in the absence of a bladder contraction. It is usually caused
by an underlying problem with urethral hypermobility but not always.
The second most common condition that we see is called detrusor
overactivity. This is involuntary bladder contractions that result in
urinary leakage. This can occur in the idiopathic condition where
someone is neurologically normal, or they have detrusor instability
where the involuntary bladder contraction seems to occur on a
functional basis. When it is caused by an underlying neurologic lesion,
we call that detrusor hyperreflexia. This is where the bladder
contractions that are occurring are linked not just causally but also
temporarily to an underlying neurologic condition.
There are some other conditions that we seen in adults and pediatric
populations that can cause leakage. They are just not nearly as
common as the three conditions that we have mentioned. Genuine
stress incontinence and detrusor overactivity in general, probably
account for 92-96% of all urinary incontinence that we are going to see
in women. There are subvariants that we will focus on about intrinsic
urethral function in the like, but the other conditions like overflow
incontinence, uninhibited urethral relaxation, these are rare. These are
conditions, which probably affect 1 in 200 incontinent patients or less.
Overflow incontinence, we always think about and diabetics who have
neuropathy, it really outside of the post-surgical iatrogenic condition of
overflow incontinence, this really is probably only seen in about 1 in
750 incontinent people. Sensory urgent continence is a little bit
different. TI is probably more prevalent, but it is so difficult to
characterize. It is a condition where the urge to urinate, increased
afferent sensation overwhelms the patient, and they sort of subcon-
sciously but yet voluntarily urinate. They just let the urine go so bad
bladder infections, interstitial cystitis, and urethral syndrome, all these
things can result in a strong urge. We treat the underlying inflamma-
tory condition, for example an 85-year-old woman with atrophic
urethritis treated with some estrogen cream for two months, she will
come back and tell you the urgency and frequency is gone and I do not
leak urine anymore. We then retrospectively make the diagnosis of
sensory urgent incontinence.
Psychogenic incontinence is important not be fooled by this. That is
why we need to document objectively that there is urinary leakage and
understand what is going on. Congenital causes like diverticula; distal
diverticula will act as a reservoir and collect urine. When the patient
stands up and walks away from the toilet, they will dribble urine as the
urine falls out. Most people have dribbling because of involuntary
bladder contractions and not a diverticulum. Proximal diverticula,
infected pockets of pus, the bladder increases afferent sensation and act
through the pathway of sensory urgent incontinence to cause urinary
leakage.
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 F. No surgical procedure should be undertaken without objectively
documenting the
presence of a significant anatomic defect and urine leakage
during testing
IV. Postvoid Residual Urine
A. Measurement of postvoid residual urine (PVRU), either directly,
with the use of a catheter, or indirectly, by ultrasound (US) or
other radiographic techniques, is an essential part of any
evaluation of urinary incontinence
B. Therapies for stress and urge incontinence will increase urethral
resistance or decrease bladder contractility, which can result in
a worsening of preexisting urinary retention
1. If this occurs, the patient who originally had a problem with
detrusor instability or genuine stress incontinence (GSI)
might then develop a problem with urinary retention associ-
ated with urinary tract infection (UTI) or overflow inconti-
nence as an alternative to their original problem
2. Trading one problem for another is not the desired outcome
C. The measurement of PVRU is important to evaluate whether an
occasional patient is suffering from overflow incontinence, where
the patient's bladder almost always remains fully distended, with
the patient voiding very small amounts and rapidly refilling to her
maximal bladder capacity
1. The patient will often complain of symptoms of stress
incontinence because of intermittent leakage of urine with
any minor activity due to overdistention of the bladder
2. By obtaining a PVRU, one can assess that this is not GSI
causing the symptoms of stress incontinence, but instead
overflow incontinence, possibly due to peripheral neurologic
injury and afferent dysfunction
D. The residual urine should be <30--50 mL
1. On a functional basis, residual urine <100 mL. may even be
acceptable as long as the cause of this mild voiding dysfunc-
tion is well understood
2. 50 mL is a boundary for determining who has urinary
retention
3. Patients who consistently have residual urine >50 mL
undergo more extensive evaluation with voiding pressure
studies or a voiding cystourethrogram
4. If a patient is asked to void in a commode in your office
when she is seeing you for the first tune, she may have an
artificially elevated residual urine due to her discomfort with
the new voiding environment
5. This test should be repeated on multiple occasions before
deciding that the patient has an abnormal residual urine and
Those are sort of the conditions that can represent the patient’s
symptoms. The patient comes into your office, and she wants to know
from you, what can I do about this? To a patient this is sort of an uni-
dimensional problem. I leak urine and, you are a doctor, and you
should be able to tell me why. Give me a pill, and I should be able to
leave here, and a week from now not have this problem. It certainly
isn’t that easy unfortunately, and what we have to do is sort of play
detective and begin to understand exactly what the patient does suffer
from and doesn’t suffer from. We have to determine what is going on.
I see this is kind of complicated because more than 60% of our
patient’s have more than one reason for leaking urine and about 15%
of our patient’s actually have three or more conditions that contribute
to the urine loss and problems. It can get quite tricky in terms of trying
to make the diagnosis.
We always start with a good history. We are going take a history. I
send out a six-page questionnaire to people with a voiding diary, and
we ask them to write down when they urinate, when they leak urine,
whether there is an urge associated and what they are taking in, so we
understand. Especially if you want to use behavioral therapy or
nonsurgical therapy later on, we need to know what their behavior is
currently. It also helps to correlate with the symptoms that they are
telling us and lend some varicosity to the conditions of urgency and
frequency of micturition. Sometimes you will see a patient that will
come in say, I urinate all the time now, and I used to urinate just every
eight hours. Now I am urinating every three to four hours. That
doesn’t seem to be much of a problem. We may want to understand for
the individual, but if that is backed up by their voiding diary that is
helpful. People tend not to urinate also as often on their voiding
diaries as they say they do historically. It helps us understand about the
pattern. It also lets us pick up things like reverse diuresis and
nocturnal diuresis conditions, where someone may have problem with
ADH, and we can treat this quite simply. The other things we want to
know about is what medications they are using. You want to be
careful. A big pearl to take away from this is to understand that alpha
blockers, Hytrin, Minipress, these agents for blood pressure will cause
urinary incontinence by decreasing urethral resistance. You can treat
people quite successfully just by switching them off these medications.
A history is great and very important to outline the underlying
condition. It acts sort of as the outline for what we are going to fill in
and explain. Because no evaluation that you do, whether you do it
simply with no equipment or have a hundred thousand dollar lab that
you are going to do it with and spend hours and hours, it does not
matter if it fails to explain the patients symptoms. On the other hand,
the mistake we make as gynecologists, family practitioners and
urologists is assuming that a history will tell us the underlying
condition. Here we find that history is no more accurate than a good
educated coin toss. When we look at patients symptoms and try to see
if they are pathognomonic for underlying conditions, like stress
incontinence proving that someone has genuine incontinence, urgent
incontinence being indicative detrusor instability. You can see that the
specificity here, especially is quite poor, and in this study of 288
consecutive women with urinary incontinence undergoing multi-
channel urodynamic testing, the sensitivity was 100% but that really
isn’t true in the literature as a whole. In most groups who have shown
sensitivities there that range in 80 to low 90% range. Some people say
that if you have the women who just complains of genuine stress
incontinence, she is under the age of 60, she doesn’t have any other
complaints of frequency urgency or urgent incontinence or nocturia,
that you don’t need to evaluate that patient, that she will always have
genuine stress incontinence.
We start with a physical exam. Obviously we want to augment the
history and understand the anatomic problems. You want to do a good
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 a problem with urinary retention. The patient who has urinary
retention due to significant voiding dysfunction will consis-
tently have elevated residual urine
E. The PVRU in our laboratory is usually obtained immediately
following a spontaneous uroflowmetry study done at the initiation
of the examination
1. This is usually directly removed with a catheter
2. This specimen should be obtained when the patient is in the
supine position, as supine urinary residuals may not fully
reflect the total residual bladder volume
3. Tilting the patient in reverse Trendelenburg or having the
patient stand with the catheter inserted may aid in fully
emptying the bladder
4. This PVRU is then sent for urine culture to rule out preexist-
ing infection which would cause sensory urge incontinence
or detrusor overactivity. It is essential to rule out UTI before
proceeding with a complex urodynamic evaluation
5. On rare occasions, the chronically-infected patient will
respond to antibiotic therapy with total resolution of urinary
incontinence, making further work-ups unnecessary
V. Stress Test
A. Urinary incontinence is defined as a condition where there is
involuntary loss of urine that is objectively demonstrable and
represents a social or hygienic problem
1. Demonstrating the patient's urinary leakage during an
increase in intra-abdominal pressure is essential in the
diagnosis of GSI every patient complaining of urinary
incontinence should undergo a stress test the standing
position has been shown to be far more sensitive, it is the
preferred position
2. A patient who leaks urine when supine with a relatively
empty bladder has a more severe problem with stress
incontinence than the patient who only leaks in the standing
position at maximum cystometric capacity with repetitive
coughing and Valsalva
B. The stress test is performed immediately
following simple cystometry with the patient's bladder fully
distended at maximum cystometric capacity
1. Once the filling catheter is removed, the patient may be
asked to Valsalva and cough repetitively or perform some
other exercises to try to induce urinary leakage under direct
visualization.
2. Patients are initially tested with repetitive coughs, three
times, in the supine position followed by intermittent Valsalva
maneuvers three times in the supine position. Then they are
pelvic exam, neurologic exam and check good lumbosacral nerve roots
because these are the nerves that help control bladder and urethral
function. Of course we want to focus on the pelvic exam but some-
times it can be quite overwhelming. You see somebody who has
complete procidentia and a vaginal wall inversion, and it is hard to
begin to think about this and what really helps I think is to compart-
mentalize it. I think for mere mortals and clinical gynecologists
especially just looking this and thinking about anterior and posterior
compartment defects and atypical prolapse and just these basic
concepts and far come structures out of the vagina or how far they
protrude down into the vagina say using the Beden-Walker 0, 1°, 2°
and 3° prolapsed scale really will help you break things down. To
prove that, it is obvious to all of us that this uterus is now protruding
beyond the vagina, and there is 3rd or 4th degree depending on whose
scale you use. She has an anterior compartment defect and a systole,
but does she have a paravaginal defect? She obviously has a
paravaginal defect because paravaginal defect implies that the
anterolateral vaginal sulcus is detached from the arcus tendentious
fascial pelvis, which is still inside the patient’s body. That is sort of
apart of the defect that we might want to repair when we repair this
prolapse. In addition, she obviously has a cystocele, and we want to get
an idea if that is very small. We want a direct vaginal exam and
understand that. She at least has a traction enterocele because her cul-
de-sac obviously is out of the patient’s body here. We also want to
understand whether this was the propelling property and usual with
uterine prolapse it is a traction enterocele.
You want to do a good neurologic exam. You want to make sure that
the lumbosacral nerve roots are intact. Check for motor strength in the
lower extremities, reflexes and you can check for sensation from L2
–S2 by checking the dermatomes above the knee. Then you augment
this with bulbocavernosus and clitoral reflexes to look at the sacral
nerve roots. When you stroke the labia, you should see contraction of
the levator ani muscles and an anal wink. Likewise when you tap the
clitoris, you should see the same thing. Clitoris is S1 and S2 afferently.
The labia are S2 and S3 and obviously anal wink is S4 and S5. This
helps you cover the ground. We prefer to do this with a Q-tip, so that
we don’t bring up any questions in the patient’s mind as to what is
actually happening.
There are a number of clinical tests that we can do to augment are basic
physical exams. Simple thing that you can do in the office. Be sure she
has urethral hypermobility because around 12% of the population that
has genuine stress incontinence will have it with a well-supported
urethra. We call that subgroup type III incontinence. Those people
won’t have urethral hypermobility, and they won’t benefit from your
MMK. The cure rate is only about 30 to 40%, and I can cure them in
the office with periurethral injections, fat, collagen, Teflon or other
new things that are coming down the road, much more cheaply and
much more simply under a local anesthesia. We can do numerous tests
to look at urethral hypermobility. I prefer the Q-tip test because it is
simple, cheap, and it does not expose people to radiation. There are
standards in the literature that establish that if the straining Q-tip angle
goes more than 30° positive from the horizontal then somebody has
urethral hypermobility. The surgical success will follow expected
outcomes. If the urethral hypermobility is less than a straining angle
positive 30°, and it is the straining angle that is important. It is the
straining angle that matters. You can do this with a Q-tip in. You can
just put a Sims speculum or the back half of a Graves’s speculum and
look at the anterior vaginal wall and see that it moves and say
qualitatively this woman has urethral hypermobility. That is fine.
Next thing we can do is a stress test. This is crucial to making the
diagnosis of genuine stress incontinence, that we objectively demon-
strate the sign of stress incontinence. If someone is coughing and
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 moved to the standing position, where the same maneuvers
are repeated.
3. If they are unable to recreate urinary leakage, the patients
are then asked to cough in series five times or Valsalva five
times to try to induce leakage. If this fails, the patient then is
asked to jump up and down in place three times or to run on
the spot to see if this induces urinary leakage.
4. When this fails, the patient may be asked to do deep knee
bends or lift heavy objects off the floor to try to induce
leakage.
5. Record not only the volume at which the testing was done
and the position of the patient, but also if activities other than
Valsalva or Coughing are used to elicit urinary leakage. This
may help accurately assess the degree of the patient's
problem.
C. The stress test is deemed a positive test when urinary leakage
occurs with increased intra-abdominal pressure
1. In some patients, urinary leakage may be seen to occur not
only at the moment of increased intra-abdominal pressure
but may continue long after the patient has relaxed
2. While such testing is positive because urinary incontinence
occurred, this needs to be qualified because the patient may
be demonstrating stress- induced involuntary detrusor
contractions
3. Up to 5-10% of women with detrusor instability may have
stress-induced detrusor contractions
4. If a patient has a stress test such as this and fails to show
evidence of involuntary detrusor contractions on simple
cystometry, she should be evaluated with multichannel
urethrocystometry
D. Advantages
1. Stress testing is simple and easy to perform. The patient
with a full bladder is asked to increase intra-abdominal
pressure, while the examiner tries to visualize urinary egress
from the urethral meatus
2. It is a reliable test, but the examiner must be cautious about
false-positive results in patients who have
a. Pooled vaginal fluid
b. Increased vaginal discharge
c. Fistulas who may have urinary leakage that is
extraurethral during stress testing
VI. "Q-Tip" Test
A. Assess as urethral hypermobility
1. Measurement of the "Q-tip" angle when resting and during
straining allows for a quantitative analysis of the mobility of
straining and we see them leak urine. The best way to do this, standing
up with a full bladder. It is the most sensitive position. Have the
patient do whatever she needs to do at home to cause leakage. If that
is hitting a tennis ball, have her reduplicate her swing. Have her close
her eyes and pretend she is hitting a backhand as hard as she can or an
overhead. Have her lift suitcases or bend down. Do whatever it takes
in your office to redocument the leakage of urine coincident with
increased intra-abdominal pressure. If she coughs and then starts to
leak urine continuously about three seconds after she coughed, you
want to think about stress provoked involuntary bladder contractions.
One thing we can do is not just do a stress test, but we discovered a
few years back something called the supine empty stress test. Here we
discovered that people who have low urethral closure pressure,
intrinsic sphincteric dysfunction, will leak urine even with a small
amount of urine in their bladder with first or second cough laying
down. There is a difference and you know it. There is a patient you
see who leaks urine when she plays tennis and not at any other time.
In your office you have to have her cough and strain repetitively with
a full bladder before she leaks one drop. There is another patient your
seeing who just emptied her bladder, and she is lying down and you
have her cough and the urine squirts out and hits you in the chest.
What do you know about those two women? You know that the
intrinsic muscular function of one is much stronger than the intrinsic
muscular function of the other or the patient may have what we call
low-pressure urethra. When we correlate this with our work on closure
pressures of 20 or less, we found that there is a positive predicted value
for all patients, even high-risk patients of 90%. In the lowest popula-
tion “out there in the normal world” the positive predicted value should
be about 95%. If you see someone leak urine lying down with not
much in their bladder, you have to assume that they have a low-
pressure urethra and instead of thinking to do an MMK or a Burch, that
patient needs a sling. Burch procedure is only going to work about
45% of the time to objectively cure that patient. She needs not only
support of her urethra but squeeze or compressure. We want to think
about that and maybe refer that patient for multichannel urodynamic
testing to understand not just to close her pressure but avoiding
mechanism and other concurrent problems, which will impact the
patient that we might want to do a sling on.
We do cystoscopy also on people of irritated voiding symptoms, but it
is not apart of the routine work-up of urinary incontinence. It is
important if people have blood in their urine obviously. It is also
important if people have nocturia, dysuria, and suprapubic pain to
evaluate them for various inflammatory conditions as well as neoplasia.
We want to look at the voiding function of patients that we are
evaluating for urinary incontinence to make sure that they don’t have
overflow incontinence from total retention, and also to appreciate that
most things that we do to treat urinary incontinence are going to
increase urethral resistance or decrease detrusor contractility. Both of
the factors tend to promote retention of urine. When we are treating
people for incontinence we are really trying to alter this balance. We
are trying to make them retain a little bit more but not too much that
we cause a pathologic condition where they are retaining urine
completely. Treating involuntary bladder contractions, we like to
decrease detrusor contractility. We have to hit it just right. We want
to understand just a little bit about peoples intrinsic voiding function,
so we can do something called spontaneous uroflowmetry and see how
fast they urinate and what pattern. In boys who have prostatic
hypertrophy, it is very important that we measure the numbers, the
speed.
Because obstruction in woman isn’t due to physical changes. It is due
to functional changes, spasm, irritation and inflammation. We look at
the pattern, and it is just like anything else, a bell-shaped curve, and
that is what defines normal because men and women are different.
5
 the proximal urethra and bladder neck
2. The primary underlying pathology of GSI is relative
hypermobility of the proximal urethra, resulting in decreased
pressure transmission to the urethra when compared to the
bladder
3. While almost all patients with GSI have urethral
hypermobility, many patients with urethral hypermobility are
not found to have urinary incontinence
4. Therefore, this test cannot be used as a predictor of who has
GSI, but instead is of greater significance when it is found to
not demonstrate urethral hypermobility in a patient believed
to have GSI. This patient often is found to have a deficient
"intrinsic sphincteric mechanism" and type III incontinence
5. Different investigators have suggested different cut-off points
to define urethral hypermobility, ranging from a straining
angle of 20-350
a. These angles are good estimates of adequacy of
periurethral support
B. Procedure
1. The "Q-tip" test is performed by placing a sterile cotton tip
applicator, lubricated with 2% lidocaine hydrochloride
(Xylocaine jelly), in to the urethra until resistance abates,
signaling that the cotton tip has reached the bladder neck
2. The cotton tip applicator is snugged back against the bladder
neck, and the resting angle is measured relative to the
horizontal
3. The patient is asked to Valsalva and cough repetitively, and
the maximal straining angle is then recorded
4. A normal resting angle is usually <0E,and a normal straining
angle is < 30-35 E.
5. If the straining "Q-tip" angle is in excess of 30, the "Q-tip"
test is said to be positive, demonstrating urethral
hypermobility.
C. Advantages
1. This test can be done quickly with minimal discomfort to the
patient, and it offers a simple way to assess urethral mobility
without the need for x-ray or US
2. It offers a simple, quantitative, and relative measure of
urethral mobility, which can be compared to postoperative
testing to assess the adequacy of urethral support
VII. Simple Single-Channel Cystometry
A. Cystometry is the measurement of bladder pressure during filling.
If is essential to the evaluation of all incontinent females.
B. It may be performed by numerous methods of varying complexity
1. Multichannel studies using electrical microtransducer
Men are women are different and no where are it more true probably
when one comes to voiding function. We boys can only urinate with
normal flow rates one way by relaxing our urethra and contracting our
bladders. That is because the male urethra is really very long com-
pared the female urethra which usually is about 4 or 5 cm in length.
These leads to changes in voiding function. Women are amazing.
They can urinate not just by urethra relaxation and bladder contraction
but 5 different ways normally. They can urinate by urethra relaxation
with or without a bladder contraction and with or without Valsalva.
We like to see a bell-shaped pattern but here is sort of a roller coaster
pattern or an intermittent interrupted flow. This can be one of two
things. It was that the patient was Valsalva voiding that the woman
had stress incontinence and had learned that she could in and out of the
ladies room quickly by just pushing because her urethra is a push over.
She takes a deep breath in and push, grab a breath-push, grab a breath-
push, etc., rest here for a while and here somebody calling and she
pushes again to get the last little bit out. On the other hand, this could
represent the neurologic condition detrusor sphincter dyssynergy, where
there is intermittent urethral contractions that is autominous and not
coordinated with the bladder contraction where the urethra intermit-
tently spasms and eventually totally extinguishes the bladder contrac-
tion and can lead to retention. We see a pattern like this we need to
evaluate someone with multi-channel urodynamics to understand which
it is.
The last simple test that we should all do in the office to evaluate
incontinent people is the cystometry or the study of storage pressures
in the bladder during bladder filling. I think it is important that we do
this in everyone because if detrusor overactivity is the second most
common condition, we would at least like to rule it in or out. Here we
are measuring urethral single-channel bladder pressure as we fill the
patients bladder retrogrades. This happens to be a filling Foley and a
3-French catheter that we can measure pressure with. One means 100
mL, two means 200 mL. At 225 the patient says I first fell like I can
urinate. Filling with water that is normal. Somewhere between 75 and
250 mL, people should routinely feel the first sensation to void. She
feels full enough to urinate and go out of her way to find a toilet. At
550 she starts to have an involuntary inhibited detrusor contraction
before she reached her maximum systematic capacity. This point
where she couldn’t stand anymore fluid going into her bladder. Before
that happened she has this bladder contraction and urine was leaking
around the catheter onto the floor. This is an objective sign of detrusor
overactivity. This woman was neurologically normal, so we said she
had detrusor instability idiopathic condition. You can do this for
$29.95 or if you are value oriented like me, you can do it almost for
free. Filling 50 mL at a time, stopping to measures the pressure and if
the pressure increases by more than 15 cm of water pressure you say
the patient had an involuntary bladder contraction. If it doesn’t
increase by more than 15 cm, you keep going until you reach your
maximum cystometric capacity where she can’t stand anymore and if
her bladder pressure doesn’t increase by 10-15 cm or more you say that
she has a stable or normal bladder. Using those criteria comparative
to multichannel urodynamic studies we found one CMG is 84%
sensitive as a screening test for detrusor instability and two CMGs on
two different days, which you probably wouldn’t do, are 92% sensitive.
In an older population just took a Foley catheter and did eyeball
cystometry. He took a Foley catheter, put it in the patient’s bladder
lying down, a Toomey syringe on top of it, and he was about 25 cm
above the patient’s pubic symphysis, and he just poured water in. If
the miscus was falling the whole time he poured water in then there
was no bladder pressure increase. When the meniscus starts to rise,
why, because the bladder is contracting and the fluid would overflow
the Toomey syringe and that was indicative of detrusor instability. He
had an 85% sensitivity compared to multichannel urodynamics in a
high-risk population. You can use a very simple test to tell what is
6
 catheters measuring urethral, abdominal, and bladder
pressures with or without electromyelogram (EMG) can be
used with computer-based physiologic recorders to perform
complex urethrocystometry studies.
2. Patients may undergo simple, single-channel "eyeball'
cystometry by slowly filling their bladder through a Foley
catheter and irrigation syringe at the bedside.
3. Multichannel electronic eystometry equipment may cost
anywhere from $10,000-55,000, whereas simple single-
channel cystometry can be performed for under $10. Both
the expensive multichannel systems and the simple single-
channel studies attempt to diagnose bladder pressure
changes during the storage phase of micturition.
C. The bladder should be able to fill to maximum cystometric
capacity (the point where the patient is no longer able to tolerate
any further bladder infusion because of severe discomfort)
without any significant increase in bladder pressure, or urinary
leakage.
D. Simple cystometry may be divided into
1. Those which measure bladder pressure
2. Those, such as "eyeball" cystometry, which merely make a
qualitative assessment as to whether there are involuntary
bladder contractions or not.
E. Simple single--channel quantitative cystometry has been shown
in numerous studies to have a diagnostic sensitivity ranging from
53-93 % when compared with multichannel urodynamic studies.
This sensitivity is largely dependent on the position of the patient
and the provocative maneuvers used during the study
F. "Eyeball" cystometrics
1. The simplest form of cystometric evaluation available
2. Involves minimal equipment
3. Procedure
a. A simple catheter is transurethally placed into the
patient's bladder; this is usually connected to an irriga-
tion syringe
b. The syringe is then held upright above the patient's
pubic symphysis, and sterile water is poured into the
syringe in an intermittent fashion
c. This is done until the patient reaches maximum
cystometric capacity
d. Should the patient have an involuntary unihibited
detrusor contraction during filling, the meniscus within
the syringe will back up and often overflow the open
syringe as a qualitative demonstration of detrusor
overactivity
going on. Go into the operating room and into the anesthesia cart in
the bottom drawer there is a CDP manometer. Rip open the box and
pull out the manometer. The second drawer is the IV extension tubing.
Take a couple of links of IV extension tubing and attach that to the
Foley catheter. The IV tubing is going to go on the other side of the
manometer, which you are going to connect to the saline bags. The
fourth drawer is the bags of saline or sterile water. You can take
either, and they will work well. In the OR their Foley catheters and
Christmas tree adapters, grab a few. You can hook up this cystometer
Foley to Christmas tree adapter to IV extension tubing and back to the
manometer out to the tubing and the bag and then you need an IV pull.
On your way out of the OR just takes one they don’t need it. Bring it
back to your office and hook it up like this and you are ready to go.
We really should be trying to look at cystometry and figure out whom
has detrusor instability. When these simple tests don’t give us an
answer or somebody has had prior surgery or think for some reason
they are high-risk of surgical failure or treatment failure, you want to
know more. They may not void completely or they void in a roller
coaster pattern, in those people you are going want to think about
getting multichannel urodynamic testing to further see that is going on.
What is that compromise? Urethral cystometry is probably the most
crucial part where we measure multiple pressures in the body to look
at what is going on during the storage phase of micturition, as our body
is trying to store urine in a low-pressure reservoir that we call the
bladder. Once you have your subject you can use microtransducer or
water catheters. These are little state microtransducer catheters. One
goes in the urethra to measure urethral and bladder pressure, 6 cm
distally, and the other one in the vagina or rectum. What we do is
measure numerous pressures at the same time. Instead of just
measuring bladder pressure like we did in the other study, we are going
to measure EMG or electrical activity of pelvic floor, rectal pressure,
abdominal pressure, urethral pressure, and then the computer gives is
these two subtractive pressures. True detrusor pressure is the bladder
pressure minus the abdominal pressure. If you bear down or cough,
you are going to see an increase in the bladder pressure, but if it occurs
here in the rectal or abdominal pressure lead, it is going to be sub-
tracted out, and there will be no increase. This tells you what is going
on inside the bladder irrespective of what is going on inside the
abdomen.
Urethral closure pressure is urethra pressure minus bladder pressure.
If this is above 0 everywhere in the urethra then you stay dry. If it is
below 0 everywhere in the urethra then it means the bladder pressure
has exceeded urethral pressure, and you are going to leak urine or your
patient is going to leak urine. This sort of testing not only improves
our specificity to know that this isn’t a bladder contraction and this is
but also our sensitivity in that it lets us see the whole picture of what
is going on in the patients pelvis so we might be tipped off to go a little
bit further or sometimes see a very low pressure bladder contraction
that we might miss in a single-channel study.
Urethral pressure flowmetry, the measuring of the intrinsic function of
the urethra is very important in understanding the patient’s eventual
outcomes with therapies. We can measure what is called urethral
closure pressure profile, pull the transducer out through the urethra and
measure the pressure each step along the way. It generates a curve that
looks like it starts when the catheter moves into the bladder and ends
where the catheter comes out of the urethral meatus. Because of
limitations of time, I don’t want to make you experts on how to do this
or even the concepts behind, but I thought it might just help to show
some differences. This is an incontinent female. Here we have blown
up the bottom line or the urethral closure pressure in this study. We
are going from supine with an empty bladder to supine with a full
bladder and then sitting on the full bladder to sitting with full bladder
and repetitive coughing. The normal patient augments. She increases
7
 4. Following such an evaluation, the catheter may be removed
and stress testing may be done
G. Simple incremental single-channel cystometry
1. Retrograde cystometry may also be accomplished with a
simple mariometric cystometer which allows for the mea-
surement of bladder pressure. This can be accomplished in
a continuous fashion with two transurethral bladder catheters
or in an incremental fashion through a single simple
transurethral catheter
2. Procedure
a. Incremental standing retrograde single-channel
cystometry may be accomplished by transurethrally
placing a simple Foley catheter in the patient's bladder
and distending the balloon to 5 ml.
b. A "Christmas tree"-type adaptor is placed in the Foley
catheter
(1) Two lengths of IV extension tubing are connected to
this and to a simple manometer, taken from either
a cell volume profile or lumbar puncture tray
(2) This is taped to an IV pole so that it is zeroed at the
level of the patient's symphysis
c. The other end of the cystometric manometer is attached
to simple IV tubing, which goes back to a bag of sterile
water
d. The patient's bladder is filled in an incremental fashion
with 50 mL H20 at a time, stopping every minute or so
to measure the baseline resting pressure as well as to
measure the pressure after stabilization following
provocative maneuvers such as:
(1) Coughing
(2) Valsalva
(3) Heel bouncing
(4) Exposing the patient to running water
e. The baseline pressure is taken, and the patient is filled
until she notes the first sensation to void and then until
maximum cystometric capacity. A rise in bladder
pressure > 15 cm H20 from the baseline pressure is
interpreted as a positive test
f. This is especially significant if, when the Foley catheter
is removed, the patient is seen to have involuntary
leakage of urine coincident with this increased bladder
pressure .
3. Continuous monitoring of bladder pressure with a manomet-
ric or electronic cystometer allows for continuous recording
of bladder pressure and the rapid detection of small phasic
her pelvic floor skeletal muscle activity around the urethra, and the
pressure curve gets better as we stress her. The incontinent patient on
the other hand usually starts out in general with lower pressure to begin
with and as we stressed her, she deteriorates. She can’t augment. She
can’t compensate for the increased stress of bladder filling and in a
more upright position and repetitive coughing more pressure gets added
to the bladder, negative pressure transmission, which causes urinary
incontinence. We resupport a proximal urethral in a high retropubic
position. Restore positive pressure transmission even though the
resting pressure may stay low, these cough spikes will be positive, and
the patient won’t leak urine.
We also can do these tests in people who have prolapse to see what is
behind the prolapse. Here is a resting profile without support. There
is a high urethral pressure profile with a big kink in the middle. We
take away the kink and the mechanical obstruction of the urethral
folding on itself, and we see a very low pressure. In this case it is
maintained. The patient doesn’t have stress incontinence, and when
she coughs and strains, there is actually a pressure increase. She didn’t
need to have an anti-incontinence surgery at the time of her pelvic floor
reconstructive surgery, but most people do. 60-70% of the people that
I see who have prolapse in the anterior or posterior compartment that
comes to the introitus or beyond, 60% for posterior compartment and
70% for anterior compartment have potential genuine stress inconti-
nence. Even though they don’t leak urine at home, if you resupport the
prolapse and take away the mechanical obstruction or kink in their
urethra just like unlinking a garden hose, they will leak urine. You
would like to know about that before surgery rather than after surgery.
The last component of multichannel urodynamic testing is instrumented
uroflowmetry with EMG or electromyography. Here this lets us look
behind things. This is a patient I showed you her roller coaster voiding
pattern. This is the same exact patient and what we see is that she
voids by Valsalva and bladder contraction and urethral relaxation
initially. She is doing all of three things at the same time to empty her
bladder completely but in this intermittent interrupted pattern. That is
important for us to understand. In the case of detrusor sphincter
dyssynergia, the other pathologic picture, just graphically shown here,
we fill the patients bladder and we ask her to void when the bladder
contracts and the bladder pressure increases, the urethra and EMG
activity should go silent. If it increases, it is called detrusor sphincter
dyssynergia. That is what is going on with this patient with MS. Here
she has a bladder contraction and she is trying to void, her urethral
pressure goes up and down and the EMG activity increases. This is
detrusor sphincter dyssynergia. There is an underlying neurologic
problem that leads to a lack of coordination between bladder and
urethra.
We have made a diagnosis, and we have a patient who has genuine
stress incontinence with or without detrusor instability. We have
offered her all of the nonsurgical options. Let’s talk about different
types of anti-incontinent surgery. When I think about incontinent
surgeries, I divide them up into 5 classes. Vaginal operations like the
Kelly-Kennedy plication that we are not going to talk about in any
detail today, retropubic urethral plexis; Birches, MMKs, perivaginal
repairs, needle suspension, where we somehow put sutures in the
vagina and suspend them someway abdominally usually upwards or
anteriorly with a needle, and sling procedures. In 1949, Marshall-
Marchetti-Krantz reported on the MMK, and this was sort of the
rebirth of retropubic urethral praxes. I am going to talk about Ton-
nages modification described in 1976, but birch first reported his work
in 1961, and this is the most commonly performed anti-incontinence
operation and its various modifications right now in the world. Some
deserve to be called modified berches and probably some that should
have there own unique names. In the medical literature, there is
8
 changes, which may only last 15-30 seconds and not be
detected with the incremental methodology.
4. Incremental single-channel cystometry has been shown to be
85-93 % sensitive in diagnosing detrusor instability when
compared to multichannel studies. Its sensitivity is aug-
mented by performance of the study on more than one
occasion.
H. Electronic retrograde single-channel cystometry
1. Continuous measurement of bladder pressure with a single-
channel recorder is more accurate than incremental methods
or qualitative assessment with bedside cystometry
2. Procedure
a. Usually a small filling catheter is used to fill the bladder
in a retrograde fashion with water, saline, or CO2 gas.
b. Another smaller catheter (4) is usually connected to an
electronic water or gas manometer to measure the
bladder pressure continuously
3. The addition of an electronic cystometer significantly
increases the cost of such studies, but often an intrauterine
pressure catheter and manometer may be utilized to perform
these studies, thus making the obtainment of additional
equipment unnecessary for many hospital centers
4. These studies may be performed in the supine, sitting, and
standing positions, but are most sensitive in the standing
position
5. Similar to the other cystometric studies, this study is per-
formed by placing both catheters in the bladder and filling
through the filling catheter with either liquid or gas while the
electronic cystometer is zeroed at the level of the pubic
symphysis
6. Bladder pressure
a. Measured continuously throughout filling
b. A small chart strip recorder graphs a continuous
cystometric curve during bladder filling
c. Any bladder pressure increase that results in either
significant symptoms of urgency or urinary leakage are
significant.
7. Care must be taken with all single-channel cystometry
studies that false-positive diagnoses of detrusor overactivity
are not made due to Valsalva
8. Increased intra-abdominal pressure will be recorded in the
bladder as an increase in bladder pressure
9. Without the measurement of coincidental abdominal pres-
sure either through a vaginal or rectal catheter, confusion
can exist as to whether a pressure increase represents an
support for objective cure rates of 80-95% with similar subjective cure
rates slightly higher. There is excellent longevity. This slide is a little
bit old because there is actually ten-year data that came out last year
that showed 86-89% objective cure rates from Italy and Argentina.
Detrusor instability, the surgery creating involuntary bladder contrac-
tions, and this happens with all the surgeries that we do in varying
degrees and you need to understand that, occurs about 7-10% of the
time. The concept is that we want to resupport the proximal urethra,
to stabilize the proximal urethra and restore positive pressure transmis-
sion to the urethra compared to bladder. How do we do it? We suture
the anterior vaginal wall and developing endopelvic connective tissue
posteriorly to some anterior point of support, which is immobile. The
anterior vaginal wall moves when the patient coughs and strain,
pressure is exerted downward in the space of Retzius, if this is
stabilized the pressure will increase within this lumen.
What we fixed here anteriorly, this doesn’t move when someone
coughs and strains. This is why berch procedures and MMKs last so
well, especially if you take away the question of permanent versus
absorbable suture. If you are using premature suture, you stabilize
people and you have them recuperate appropriately and restrict them
for three or four months from strenuous activities and stool softeners,
they will heal well and these people are going to do great. Probably
forever, the majority of these people. Certainly for five or ten years,
these people are going to do very well. It is 1.5-2 cm lateral to the
urethra and then down 1-1.5 cm from there. A figure of 8 stitches that
are then put up in Cooper’s ligament or iliopectineal ligament here.
What this does is stabilizes the posterior wall, the urethra, by stabiliz-
ing the anterior wall of the urethra. We put a backstop here, so that
when pressure is transmitted into this picture A from anterior to
posterior, it is going to cause the urethra to compress on itself against
the anterior vaginal wall. If there is urethral hypermobility, and there
is no support, the pressure is going to largely be transmitted through
and no reflected back. You don’t see nearly the same pressure
increase. That is the short version of the physics of how Copel
suspensions work. Perivaginal repair trys to do the same thing, but it
says lets be anatomic about this. Let’s put the anterolateral vaginal
sulcus back to where it is broken away from the arcus tendentious
fascia with multiple sutures and just in front of the ischial spine all the
way back beyond bladder neck. That is great, but people like me who
really do this where it should be done, at the anterolateral vaginal
sulcus. If you just put this back in the anterior vaginal wall still
sagging in the middle, someone is still going to have urethral
hypermobility. What I think a lot of people do who are successful with
perivaginal repairs, is they probably put there stitches here where I put
my Birch stitches and then sew that out to the arcus tendentious fascia
to the pelvis tensing the anterior vaginal wall. That is fine. Suspend-
ing it going up to the arcus tendentious, long-term it should be stronger
than suspending it directly at a right angle to the arcus tendentious
fascia of the pelvis. Long-term, how well do the perivaginal repairs
compared to Birches. Personally if I want to repair a perivaginal defect
I do this surgery. If I want to repair incontinence, I do a berch
procedure if I am operating abdominally and I have chose to do that.
If I need to both, I do both.
There are numerous needle suspensions in the literature. These
operations and there cure rates in the literature short-term tend to be
79-90%, subjective cure rates above that. Their longevity is poor. A
10-year follow-up in the AUA series showed subjective cure rates
below 30%. Their recommendation was that traditional needle
suspensions should probably not be done and they should look for other
operations. De Nova detrusor instability reported to occur 10-21% of
the time, and there is significant amount of voiding dysfunction, which
ranges with urgency frequency syndromes and retention anywhere from
15-30% of people. When we are operating on this woman and doing
9
 involuntary bladder contraction a vaginal reconstruction which I believe that is a very good thing to do.
Nonetheless, if you are going to operate on this woman vaginally,
10. Such confusion may sometimes be avoided by asking the
wouldn’t it be nice to have a needle suspension that you could do that
patient to deeply inspire during such pressure elevations. adds 15-20 minutes to the operation rather than needing it go above
This should at least momentarily eradicate any increase in and making a separate incision and do a Birch procedure or an MMK
or something like that. It is just logical, but it has to be as good. That
intra-abdominal pressure is what we are going to talk about a little bit on a theoretical basis.
12. Electronic retrograde single-channel cystometry performed Needle suspensions aren’t as good because they resupport the proximal
urethra but trying to do the same thing berch procedures do but the way
with any of these methods may be used to screen for they do it, suture endopelvic connective tissue and anterior vaginal wall
detrusor instability with a diagnostic accuracy in excess of here, but anteriorly to erectus fascia, which is mobile. If you put a
thick loop of suture in between these, the suture you would like to just
75% lift this up anteriorly. The suture doesn’t know to do that. It is not that
a. When suspicious or equivocal studies arise or the smart. It acts circumferentially. What it does is it pulls these two
layers closer together. Instead of lifting the pointer up like this, it justs
results of the studies do not confirm the patient's put the layers together and you tie them under tension. If this comes
symptomatology, more complicated multichannel up halfway, this has to go down halfway. Tension with a permanent
suture in between these two layers like a wafer, what happens when the
studies are indicated patient gets into the delivery room? Coughing and straining and the
b. These studies should be performed with the patient in pressure are being exerted in the space Roexius. It is going to try to
separate these two layers. The fixed suture loop is going to pull
the standing position when possible because of in-
through the tissue like a cheese wire cutting through cheese at some
creased sensitivity point. It is not surprising that we would see the longevity of these
operations is poor. In addition, if we have to compress these two layers
c. Provocative maneuvers may be used to augment the
together, we obviously increase urethral resistance, we will have more
sensitivity of these studies voiding dysfunction, and it is not surprising that we are going to have
(1) Coughing more detrusor overactivity. If we are just doing the operation alone, we
can make incisions on either side of the bladder neck in the
(2) Valsalva anterolateral vaginal sulcus, probably just two 2.0 cm wide, dissect
(3) Heel bouncing underneath the pubic ramous and perforate through either with our
fingers or the scissors, put the finger in and tear the tissue off the pubic
(4) Running water ramous where it inserts in the undersurface of the pubic ramous to open
d. CO2, when placed in the bladder, may form acid and tunnels perivesically on either side. The medial edge of the tissue that
we separate off is a condensation of the endopelvic connective tissue,
directly irritate the bladder wall, resulting in false- which is just fibril fatty, and neurovascular bundle tissue. We call it
positive studies. the posterior pubic urethral ligament. We envelop it in a helical suture
like this with a Ross, and we also incorporate the vaginal tissue here
e. Cold infusions are more likely to elicit bladder contrac- that we reflected off and then we bring it back up into the abdominal
tions than body temperature infusions field with a blunt ligature carrier perforating just through the rectus
fascia. Because we dissected up to the undersurface of the rectus
VIII. Uroflowmetry muscles from below, it improves the safety of these operations by doing
A. A study of voiding velocity with the measurement of the numer- the dissection directly rather than just blindly with our needles like a
Ghedies or a Stamy procedure is done. Then you tie down. The
ous parameters utilized to screen for voiding dysfunction
question is always how tight do you tie. I tie my needle suspension
1. During spontaneous urofiowmetry, without instrumentation, with a Q-tip in the urethra, so it just goes to 0°, and the posterior
urethral wall just starts to lift up or flatten out. That seems to work
one is able to measure the maximum voiding velocity, the
fairly well, but the problem is we have trouble with sutures pulling
mean velocity or flow rate, as well as flow time and the time through. What we have been working on over the last three years is not
to the point of maximum flow anchoring anteriorly to rectus fascia but to some fixed immobile point
trying to make our needle suspensions more like Birch and MMKs.
2. Because voiding flow rates are dependent on bladder volume We can use a titanium anchor anteriorly to fix the suture into the pubic
at the time of voiding (much in the same way as the stroke symphysis and then this picture looks like the diagram for the Birch
procedure or an MMK as opposed to when we try to put rectus fascia
volume of the heart is dependent on the endiastolic volume to anterior vaginal wall, and we have the problem that we talked about
or filling volume of the heart), results obtained vary widely before illustrated by the Stamy procedure where the tissue planes want
to separate and pull apart. If we fix it anteriorly all we do here is sort
depending on bladder volume of stabilize and that is the name percutaneous bladder neck stabiliza-
3. Normal values tion, which is essentially what birches and MMKs are. They are
transcutaneous bladder neck suspensions. Here we make a small
a. It is difficult to assess and define normal values without incision just on the near side of the top of the pubic symphysis over the
the use of a continuous nomogram varying by bladder pubic tubercle about 1.0 cm put a pinpoint bone locator, we take a drill
guide here, and it anchors into the bone. On a flat surface we can drill
volume. in the titanium screw and anchor. We then take the suture and put it
b. Nonetheless, when uroflowmetry is used as a screening on a suture passer and bring it down the back of the pubic bone to
bladder neck and look here as we just perforate through as marked by
test for voiding abnormalities, maximum flow rates <15-

10
 20 ml/second represent some degree of obstruction as
long as the voided volume is >150 mL
c. Most people should be able to void moderate volumes
within 20-30 seconds, usually achieving peak flow rates
within the first 10 seconds of voiding
4. Uroflowmetry is a screening test which looks at the end
result of a complex coordination between the bladder,
urethra, and the voluntary muscles of the pelvic floor to
cause micturition. Evidence of an obstructive or retentive
pattern requires further evaluation with voiding pressure
studies or voiding cystourethrograms.
B. The clinical significance of uroflowmetry is quite different in men
than in women
1. In males, obstructive urofiow patterns (low flow rates)
usually represent some degree of physical obstruction,
usually due to prostatic hypertrophy
2. In women, physical obstruction is quite rare, and most
obstructive uroflowmetry studies in women are from func-
tional obstruction either due to neurologic or nonneurologic
(inflammatory) causes
3. Males normally void by urethral relaxation and detrusor
contraction, whereas women can achieve normal urofiow
patterns by five different mechanisms
a. Thus, the interpretation of uroflowmetry in females is
significantly limited to that of a screening tool
b. In males, on the other hand, the information obtained
about flow rates can often be used as a direct measure
of the degree of prostatic hypertrophy and its response
to treatment
C. Uroflowmetry can be accomplished by two different methods
1. One involves the uses of electronic uroflowmeters, which
take advantage of measuring urine velocity either by translat-
ing the centripetal force of a water wheel into velocity, or by
the use of an instantaneous fluid weight scale to measure
the increasing weight of urine voided over time
2. A simpler method utilizes a stop watch, but allows neither for
calculations of maximum flow rate nor time to peak flow. It
gives the an estimate of the mean flow rate by measuring the
volume of urine voided over a given period of time
D. Perhaps the most important part of uroflowmetry is the assess-
ment of voiding completeness. Catheterization or some other
investigation of the urinary residual will determine who has the
most significant voiding dysfunction
E. Assessment with electronic uroflowmetry
1. Generates a strip chart recording of voiding velocity as well
the Foley catheter through the anterior vaginal wall. It perforates at
1.5-2.0 cm lateral to the bladder. We then drop off the suture, move
the needle over a centimeter and a half, come back through at point two
and pick up the suture. Then move down top three and complete a V-
stitch by moving over to four. What this is a figure of eight suture on
one side that encompasses where I put two sutures of a tonogo Birch of
about two square centimeters of tissue on either side of the bladder
neck staying about 1.5 cm lateral to the proximal urethra. We do this
on both sides. We bring the needle back out and tie down over the
suture space, which puts a ¾ cm gap in each suture, so we stabilize
rather than compress. It automatically forces you to gap this operation
by 1.5 cm of relaxation. It leaves us with 2 square cm area of tissue
being pulled up and stabilized by the bone anchor or stabilizing the
anterior vaginal wall on either side of the urethra.
The sling procedure is the last operation that we have that we routinely
do, and this is where we seek to not only support the urethra but by
using some sort of strap underneath the urethra or a combination of
tissue and suture in some cases, we try to compress the urethra as well
as resupport it. We compress the proximal urethra and resupport it by
suturing either rectus fascia, which is mobile. When we cough or
strain, rectus fascia moves anteriorly out like this even if you are in
great shape and that will pull a moment of force up on the arms of the
sling and tend to compress it. We can anchor it to Cooper’s ligament,
which is immobile, and form a rigid backstop that the urethra can be
pushed down on and likewise compress upon itself. Either way we get
urethral compression against a broad backstop. Cure rates in the
literature are excellent. We see objective cure rates of 80-95%. What
is really neat about slings and those of you that are familiar with these
and do them, is there longevity is nearly 100%. Once a sling works, it
will stay working potentially forever, especially when we use
heterologous materials like Mersilene, Marlex, Gore-Tex, Medx, etc.
These materials are stronger than our body tissues, and they will stay
in place and not move forever. The problem is that while they work
great, there is a big problem with De novo detrusor instability in 10-
30%. They only resolve concurrent detrusor instability about 20-25%
of the time, so they are not good operations when it comes to urge
incontinence and detrusor instability. In addition, there are a lot of
problems with retention. If you make slings just a little bit too tight,
they are very unforgiving.
A primary indication for slings is people who have low-pressure
urethras because we know that those people will fail the prior
operations that we described somewhere between 45-60% of the time.
When you are trying to operate for 10 or 15% failure rate and your
failure rate is really going to be 50 or 60%, it is time to find another
operation. We operate for low-pressure urethras or type III inconti-
nence if they fail periurethral injections. If you fail the MMK you
should always do a sling. I am tempted to that sometimes but really
most of the people in this group actually fall into the low pressure
group. High risk patient like people of COPD, connective tissue
diseases or morbidly obese, then these are other reasons that we see for
doing slings. Fascial lata slings of 88 patients with an 89% cure rate.
Half of them resolved their concurrent detrusor instability, which is
quite high, to only 7% who have de novo detrusor instability, which is
quite low. 1% had permanent retention. Temporary retention beyond
six weeks occurred in ¼ of his patients. UTI and almost all those
people had 1% wound infections and sarcomas even using their own
body tissues. When we use heterologous materials we have to worry
about infection rates that may be even higher. This is a fascia lata sling
here harvesting above the knee. The other alternative is to do a rectus
fascia sling or an Altridge sling where we harvest a strip or two strips
from the rectus fascia anteriorly and then we tape these and bring them
into the vagina and anchor it underneath the urethra at the bladder
neck. Either set the tension abdominally like I like to with rectus
fascia slings because it is easier to set the tension. You want to not
11
 as a printout of think about support or compression. All you want to do is sort of
stabilize the urethra back at around 0 to +10° with a horizontal. You
a. The volume voided
sort of want to put in close to where it was, and it will work fine for
b. Maximum and mean flow rates curing stress incontinence. The problem so much isn’t curing stress
c. Time to peak flow d. EMG activity when measured incontinence, as it is not creating retention in detrusor instability. With
heterologous materials, Morgan’s reported a five-year success rate
2. When the maximum flow rate is in excess of 20 mL/second, some years ago of 77% just suturing Marlex to Cooper’s ligament with
and the patient has no significant retention, uroflowmetry is very little morbidity at 1% official of formation rate and a 3% infection
rate. Nichols used Marlex, but he did an active sling. He put it to
said to be normal in men rectus fascia with a 95% success rate in curing or improving patients.
3. In women, when maximum flow rates are >15-20 mL/second Those were not all cures. Some of the people were improved. We had
a 92% cure rate using Gore-Tex to anterior rectus fascia, which was
and the flow rate is bell-shaped the urofiowmetry study is excellent. Objective cure rate, people didn’t leak a drop of urine four
assessed as normal months after surgery on testing to maximum systematic capacity. The
problem was we only cured 20% of people who had concurrent detrusor
a. Uroflowmetry in women can be used qualitatively instability, and we created concurrent detrusor instability 30% of the
discern who might be Valsalva voiding. Usually Valsalva time. 1/3 of our people while we cured their stress incontinence, we
gave them a new problem, which was urge incontinence. That is not
voiders have an intermittent or roller coaster type very impressive. To get around some of those problems of retention
pattern to the uroflow curve and voiding dysfunction.
b. Identification of women who are largely dependent on
We sue vaginal wall slings in people of low-pressure urethras, weak
the use of Valsalva to void, prior to any surgical inter- bladder contractions and urge incontinence. We feel that this is the
weakest sling that we can use. While Sholmer cures 91% of people, I
vention, is helpful in trying to recognize which group of
was just hoping that I could cure 71% of people. In fact, we reported
patients might be at greater risk of voiding difficulty our one-year cure rate objectively, and it is exactly that. We don’t do
following a surgery that increases urethral resistance as well with our Gore-Tex slings or rectus fascia slings. You know
what, in doing this for five years and we probably do about 40 of these
and prevents urinary leakage during Valsalva a year, we have only had one woman need to self cath for any period of
F. Uroflowmetry serves as a rapid screening method to assess the time. Prior to that, if you look at other literature on others and ours the
retention rate with slings can be anywhere from 3-18%. It is a very
voiding adequacy of patients good operation for nonincreasing urethra resistance very much. We see
1. Care must be taken, especially in women, not to a resolution rate of detrusor instability in about 35-40% of people
instead of 20% with our more aggressive slings. People of both
overinterpret the results. problems we use this operation. If you have a vertical incision, you
2. When abnormalities are found, the testing should be re- stop here and just trace out a trapezoid above. You can make a
blockade dissection where this is the advancement flap. We really
peated don’t do that. We just trace out a trapezoid underneath the proximal
a. Depending on bladder volume, flow rates may vary bladder neck and urethra, dissect away the tissue on either side and
make tunnels just like we did with the Pererra procedure. Put four
widely. sutures in the four corners and bring them up to rectus fascia and sew
b. Initial uroflowmetry studies are often falsely abnormal them down above. The only problem is that while we have a 71% cure
rate of one year, we found that anatomically only 61% of these people
because of the patient's unfamiliarity with such testing
had negative Q-tip tests. 39% of them had already developed urethral
and devices. hypermobility at one year. They said this isn’t very good. This is
going to be like modified Pererra. It looks pretty good in the begin-
c. The patient who consistently shows evidence of obstruc-
ning, and it fades with time. The same concepts involved with the
tion on uroflowmetry should be evaluated more thor- sling you can bone anchor this put a simple mattress suture in the
oughly with multichannel voiding pressure studies with vaginal epithelium and do what is called an in situ sling of vaginal
sling that is bone anchored. What we found now at one year, we’ve
EMG. seen that we have with our fascial patch slings where we harvest a
piece of fascia instead of the vaginal epithelium which is a little more
aggressive, we have a 97% anatomic correction rate at one year. 97%
of people have negative Q-tip tests instead of 61%. We can use this
concept and sort of leverage the concept of bone anchoring and do it
toward in situ slings or harvest the fascial patch sling or a piece of
Mersilene or Gore-Tex and suspend it as you see here to the bone
anchor. Likewise hope to have really improved longevity, and this is
the way we are going.

Laparoscopic retropubic urethropexy. There are numerous techniques

that have been described in the literature, but the point remains that
two and a half years ago Burton, an Australian physician, did a
prospective randomized trial after doing over 200 open Birches and
over 100 scope Birches with traditional laparoscopic suturing. He

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showed that the cure rates were equal at six weeks. One patient out of
30 in each group failed. At one year it was still one patient out of thirty
that failed and had recurrent stress incontinence where as in the scope
Birch group already you saw nine people or 27% failed. At two years
the rate went even higher. The real concern is the strength of the bites
that we take with traditional laparoscopic suturing using small needles
and needle holders that as you know as well as I do don’t always hold
quite as well as we would like delivering them at incident angles that
might not be quite what we do through an open dissection. We have
done a number of things to deal with this. I have tried six different
laparoscopic operations. It is just the pericurtineal balloon, and we use
gasless laparoscopy. What we do is place sutures in at the bladder
neck through Cooper’s ligament. When I am done I get the same Birch
procedure. It is not 30 minutes with staples and Mesh with one suture.
It takes a lot longer. We do Birches through a 4.0 cm incision instead
of the old 15-cm incision I used to use. It takes us a little bit longer.
It takes us about 45-60 minutes instead of 30-45 minutes. Cosmetically
they are a 4.0 cm incisions because it is equal to the three punctures we
used to make for laparoscopy. We can cosmetically do the same thing.
If you think about he needle suspensions and bone anchor suspensions
we were talking about, they are less invasive, more consistent, and give
us good long-term results also. I am not sure that going at it with
laparoscopic, so called birches or staples and Mesh, may be the best
way to treat our patients long-term.

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