Urodynamic Study And Comprehensive Therapy Of The Female Stress Urinary Incontinence

Objective:1. To investigate the clinical role of urodynamic diagnosis on female stress urinaryincontinence (SUI);2. To investigate clinical outcome of treatment of female stress urinary incontinenceby drug and minimally invasive surgical procedure and the prevention ofcomplication.Clinical materials1. 86 female patients presented stress leakage as complaint . Age was 26.5-29 years , mean age 48.6 years . The duration of SUI was from seven months to thirty years . All the patients were multipara . 5 patients underwent uterectomy . Medical examination : 36 patients had anterior vaginal wall bulged , 2 patients posterior vaginal wall bulged , 1 patients uterus prolapsed , exclusion criterion included neurogenic system diseases .2. Between May 2002 and july 2005, 75 consective female patients in qilu hospital of Shandong Univercity were included in this study , the age was from 26.5 to 71 years , mean 45.8 years, duration of incontinence from six monthons to twenty-five years. All patients were proved to be female stress incontinence by pad test, stress test, Bonneg-Marshall test ,cotton swab test and urodynamics . 72 patients underwent pressure-flow test and urethral closure profilometry. Patients can be subdivided into Ⅲ types according to Mcguire methods, type Ⅰ 15 cases , type Ⅱ 27cases and type Ⅲ 30 cases . Exclusion criterion included infection of genitourinarysystem and neurogenic bladder. 35 out of 75 cases were treated with drugs and 41 cases with function practice . 33 patients were treated with tension-free vaginal tape surgical procedure , while 8 cases suprapubic Arch sling .Methods(—) Urodynamic study process : Labore-Bonito urodynamic inspectoscope made in Canade , full urodynamic evaluation were performed according to the standards proposed by the International Continence Society , include uroflow rate , measurement of residual urine , cystometry , pressure-flow test , resting urethral pressure profile and abdominal leak point pressure . Stress incontinence was divided type III according to the Mcquire methods , type I ALPP >100cmH2O, type II ALPP 60-100cmH2O, type III ALPP<60cmH2O (Intrinsic Sphincter Deficiency). The statistical analysis were performed by the T-test of Microsoft Excel , a P value less than 0.05 was consider to indicate statistical significance . (~) Operative technique1. Anaesthesic technique The surgical procedure underwent under spinal anaesthesia in 39 patients and in 2 patients with myoma of uterus were given laparoscopic uterusectomy at the same time under general anaesthesia.2. Surgical incision TVT procedure was performed in lithotomy position.The inferior belly and perineum were conventionally cleansed . Foly catheter was introduced in urethra for bladder empting and measuring the length of urethal. Vagina was exposed by weight dropper retractor . 0.5-lcm longitudinal incision was performed in the anterior midline vaginal wall, starting 1.5cm distal to external urethral orifice. After carefully dissecting with Mayo scissors the vaginal mucosa in order to use the needle-driver and embed the tape . Two small 0.5cm incisions were made at lcm above the pubic symphysis in lower abdominal wall.3. Penetration (1) Tension-Free Vaginal Tape: Subsequently, the steel wire was passed through the foley catheter into the bladder and pushed the bladder to the right side. Arch needle was penetrated in the left paraurethral space , then the needle in close to retropubic bone upwards, penetrated the urogenital diaphragm, the needlewas elicited in the small skin incision made near the superior part of the pubic bone with the guide of finger . At this stage , cystoscopy using a 75° lens was performed to exclude perforation of the bladder and urethral after removing the catheter . If there was damage , the needle needed re-penetrated. The same was performed on the other side. (2) Suprapubic Arch Sling: The arch needle was penetrated through the incision above the symphysis pubic bone , towards the incision of vagina with the needle in close to retropubic bone , penetrated the urogenital diaphragm. The needle came out through the vaginal incision and paraurethral space in the same side , then the bladder was proved no damage by cystoscopy . The tape was elicited from the incision of suprapubic bone after connectting with the arch needle . The same was performed on the other side.4. Tape regulation: we adjusted the TVT tape by placing a pair of scissors in the loop of TVT tape with the urethral after perforation and pulling gradually the ends of TVT tape from the abdomen , while we asked the patients to cough a few times until severas drops of urine leakage . When abdominal pressure could't be added satisfactorily in patients under general anaesthesia , the operator pressed the area of bladder to adjust the position of tape . The plastic sheets was removed and the tape ends were embeded in the subcutaneous layer and abdominal and vaginal incision were closed with 4-0 absorbable surture thread . 16 foley catheter was left . The vagina was ramed with iodophors bandges .5. Postoperative management : Catheter and iodophors pledget were removed after 24 hours postoperation . If there was not dysuria, the patient may go home . Exertional labour and sex were forbidded during postoperative 4 weeks.6. Judgement of effective : All patients underwent symptom assessment by oneself and lh pad test, the criterion of cure was that the weight of lh pad test was less than 2g or the patients had no stress leakage.The criterion of effective was that weight of lh pad test was less than lOg or patients had occasionally stress leakage . The criterion of invalidation was that the symptom wasn't improvement or weight of lh pad test was more than 1 Og .(H) Conservative group : 35 patients got function practice and drug therapy .The drug was a-receptor prolonged action excitomotor—midodrine, po, 2.5mg, tid .The duration of therapy was 1 month . The effective > theside action and the micturation after one month thrapy were observated.Results(—) Urodynamic study: 72 of 86 patients were genuine stress incontinence(GSI), 11 cases were mixed incontinence who accompancy obvious instability bladder , 5 patients complicated with impaired detrusor contractility , 7 patients complicated with low compliance bladder . 72 patients had nomal uroflow , mean maximum uroflow rate were 21.5ml/s(18 to 35ml/s), mean residual urine capacity were llml(0 to 25ml), the ALPP ranged from 30 to 130cmH2O, maximum resting urethral closure pressure (MUPP) ranged from 15 to 60cmH2O , continence zone ranged from 1.5cm to 3.1cm . Of 72 patients with GSI .according to the criterion of Mcquire methods , type I 15 patients , The mean ALPP was 110.5±10.2cmH2O (110 to 130cmH2O), the mean MUCP was 42.5±5.8cmH2O (34 to 54cmH2O);type II 27 patients , the mean ALPP was 85.6±6.5cmH2O (68 to 92cmH2O) , the mean MUCP was 36.8±12.8cmH2O(25 to 60cmH2O);type III 30 patients , the mean ALPP was 45±10.8cmH2O(30 to 60cmH2O), the mean MUCP was 25.4±4.5cmH2O(14-34cmH2O). The was statistical significance in ALPP and MUCP among type I , type II and type III (PO.05).(H) Operation group1. Operation procedure : 33 patients were treated with TVT procedure , 8 patients with SPARC . The duration of operation was 20-50min , mean time was 35.5min , TVT 34.5min, SPARC 36.5min . The blood loss was 10-35ml, mean loss was 25ml, TVT 23.5ml, SPARC 26.5ml . 5 patients happened bladder injury during operation , TVT 3 patients , SPARC 2 patients . Bilateral wall of bladder was damaged in 2 patients, unilateral wall damaged in 3 patients . 2 patients with myoma of uterus were given laparoscopic hysterectomy and TVT procedure in the same time . There wasn't distinctly distinguish in statistics in duration of operation , volume of bleeding and probability of bladder injury between TVT and SPARC . The bulge of vaginal anteriorwall in 26 patients were repaired in the same time .2. Postoperative instance : The duration of indwelling catheter was 24-4 8h in 36 patients , mean time 42 hour , while the duration of indwelling catheter was 4-5 days in 5 patients with bladder trauma . The duration of hospitalization was 2-6 days , mean 3.5 days . Hematoma took place in2 patients in retropubic space , it disappeared completely by antiinfection and physical therapy one month later. After removing the catheter in 40 patients voiding became better, 1 patient happened urine retention because the urethral was trauma when drawing the catheter with the ballon full of water , it became cure with indwelling the catheter for 1 week , until now he mictuirates smoothly for 23 months . Before operation and postoperation mean uroflow , maximum uroflow and residual urine capacity was 10.4ml , 21.5ml and 10.5ml , while follow-up 3 monthes it was 11.5ml, 20.4ml and 11.8ml respectively . There wasn't significant distinguish among these 3 groups . The results objectively proved that tension-free tape midurethral sling procedure has no effect on voiding .3. Results of incontinence treated : The duration of flow-up was 1-29 months , 37 patients could control voiding oneself, the weight of lh pad test was less than 2g , mean l.lg (0-2)g . Mean weight of 1 hour pad test was 5.6g(2-9)g for another 4 patients with less stress leakage. The cure rate was 90.2% , 4 patients with significant improvement.(H) Conservative group :1. Improvement of SUI : The two patients whose age was 26.5 years old and 29 years old emerged SUI after parturition were cured after treatment of drug and pelvic function exercises , the symptom of SUI in 22 patients were improved . The number and volume of incontinence were reduced obviously , the weight of 1 hour pad test was descended from (15±6.5)g to (8.5±6.5)g , the number of urinal pad was reduced from 3/day to 1.5/day,mean (2±1.5)/day, after treatment of SUI. The mean number of pad was reduced 1.5/day , there was obvious clinic signifance (P<0.05) ,the general cure rate was 68.6%(24/35) . Otherwise the symptom of incontinence was not improved in 11 patients ,of them 9 patients were type III of SUI.2.Side effect : The blood pressure(BP) was heightened slightly in 6 patients .theextent of increased BP was from 5mmHg to lOmmHg . Most of these patients appeared hypertention during the first therapic week . The symptom of hypertention in 2 patients was improved obviously after taking hypotensive drug . 3 patients could.well be tolerant without any hypotensive drug taken . 1 patient stopped using the midodrine hydrochloride after three weeks . 3 patients occurred response of gastrointestinal tract , including burning sensation and nausea . while 2 patients appeared the symptom of central nervous system including headache and dizziness . The extent of side effect was from slight to middle , which side effect disappeared quickly after the drug decrement . All the patients could finished the drug therapy with tolerant the side effect.3. Urination : The uroflow rate and postvoid residual in 29 patients were measured before and post drug therapy . The maximum uroflow rate and postvoid residual were (25.5±5.6)ml/s and (8±4.5)ml respectively before drug therapy, , while (22.5±6.5)ml/s and (9±5.6)ml/s respectively post therapy .There wasn't statistical difference (P>0.05). It is confirmed that the drug has no effect on the micturition.Conlcusions1. In all patients with stress urinary incontinence , urodynamic study can distinguish the genuine stress incontinence from SUI complicated with other abnormality .2. There are significant refered value to select the treatment methods and classify3. Tension-free tape mid-urethral sling procedure is an effective and miminallyinvasive surgical procedure in treating female urinary incontinence.4. Drug and pelvic floor exercises have effect on improvement in smptom of incontinence.