OBJECTIVES: to record the findings frompelvic floor examination in an understandable way thatpermits the indication of a proper treatment.METHODS: We review classic classifications, as wellas genital prolapse stages and degrees. We also record thePOPQ examination system which is the established standardnowadays.RESULTS: Based on different classifications we intendto set up a systematic examination starting at the anteriorsegment, following with central and posteriorcompartments without forgetting pelvic floor descent,anal sphincter and pelvic floor muscles evaluation.CONCLUSIONS: The evaluation of pelvic floor defectsis complex, complicating the pathologic diagnosis inorder to determine the proper treatment. The variousattempts to standardise classifications find problems.Nevertheless, a detailed history, a systematic examinationand multidisciplinary cooperation will be able to correctthis dysfunction.
OBJECTIVES: To review the literature on female bladder outlet obstruction. METHODS: Female lower urinary tract obstruction clinical and urodynamic diagnostic criteria are defined. RESULTS: The main etiologic processes are identified: 1)Obstruction secondary to pelvic organ prolapse; 2)Postsurgical obstruction; 3) Uncoordinated voiding; 4)Detrusor-striated sphincter dyssinergia; 5) Bladder neck primary obstruction. The diagnostic features and various available treatments depending on the etiology (pharmacological, reeducative or surgical) are commented. CONCLUSIONS: Bladder outlet obstruction in the female is an underdiagnosed process frequently, which presents with a clinical picture different than in males, and demands a careful study from the urologist in order to identify the anatomical or functional cause. It will always be important to keep a high level of suspicion, mainly after treatment failures for voiding syndromes or recurrent urinary tract infections.
OBJECTIVES: To perform an update onthe issue of detrusor overactivity, its incidence andtreatment.METHODS: We developed this article combining themost recent publications about current knowledge andconcepts on detrusor overactivity, our own experienceand the database from the Hospital Ramón y CajalUrodynamics Unit.RESULTS/CONCLUSIONS: Detrusor overactivity is ahigh incidence entity resulting from different pathologiesthat alter detrusor muscle function and control mechanisms.Currently, there are various treatment options that permitus to treat this entity with very good results.
OBJECTIVES: To evaluate different methods for clinical evaluation of female urinary incontinence.METHODS: A thorough bibliographic review has been carried out with special attention to the diagnostic tests of greater importance currently. Additionally we present the various female incontinence classifications.RESULTS: There is a growing interest in the use of questionnaires for subjective evaluation of symptoms. Among the objective tests for evaluation and quantification of the urine leaks the frequency/volume charts and the diaper test are very useful. Video-urodynamics and the late contributions from ultrasonography must be highlighted in the field of imaging tests. From the Urodynamics point of view, abdominal leak point pressure plays an interesting role in the diagnosis of female´s urinary incontinence.CONCLUSIONS: After proper clinical evaluation, reasonable use of diagnostic tests and urologists‘ experience will allow to set an exact diagnosis to offer the right treatment to the patients.
OBJECTIVES: To know the results of apelvic floor muscle training program in the treatment offemale stress urinary incontinence.METHODS: Information phase: patient is informedabout the disease, her anatomy, the objectives to bereached and how to perform the exercises. Treatmentphase: 6 weeks of visual and auditory biofeedback assistedpelvic floor exercises to develop the pelvic floor muscles.Follow-up phase: one, 3, 6 month and 1 year visits withcontrol for muscle evolution, motivation reinforcementand improvement of the symptoms.RESULTS: 412 Women underwent pelvic floorrehabilitation in a 4 year period, 45.9% were cured,38.8% improved and 15.3% were treatment failures.CONCLUSIONS: pelvic floor rehabilitation can curefemale urinary stress incontinence and diminishes thenumber of surgical procedures and hospital costs in thetreatment of urinary incontinence.
OBJECTIVES: To analyse the importanceof complete pelvic floor defects correction at the time offemale stress urinary incontinence treatment.METHODS/RESULTS: We review the basic principlesin the treatment of genital prolapse. It is required to treatthe anterior, central and posterior compartments.We describe the various anterior vaginal prolapsecorrection techniques and their basics depending on theassociation or not of urinary incontinence. The techniquesfor central compartment and posterior wall (rectocele)correction are also analysed. The recurrent vaginal domeprolapse and closure procedures are mentioned.CONCLUSIONS: We confront a multidisciplinarypathology in which urologists, gynaecologists,proctologists and pelvic floor physiotherapists can coexistand work together. Due to the variety of problems to besolved, it is necessary to standardise both the terminologyand treatment, either surgical or not.
OBJECTIVES: To evaluate the results of acomprehensive treatment of female stress urinaryincontinence combining prolene mesh sling and propergynaecologic repair depending on the kind of prolapse orpelvic floor dysfunction. To analyse short and long termclinical and urodynamic outcomes, and the effect onquality of life and economics associated with femaleurinary incontinence.METHODS: Prospective study including 102consecutive patients with urinary incontinence; recruitmentstarted in June 1996, ended in March 2002 for thisanalysis but it continues open currently. History of neurourologicdisorders, radiotherapy, oncological diseases,gynaecological diseases and previous surgeries data wererecorded in all subjects. History and physical examinationwere done evaluating urinary symptoms, duration ofurinary incontinence, and urinary symptoms orientedexamination (incontinence, urgency and urgencyincontinence),as well as gynaecological examination evaluating and grading cystocele, rectocele, uterineprolapse, enterocele and dome prolapse. Completeurodynamics were performed before and after surgery.Surgery was indicated as a complete pelvic floordysfunction repair including prolene mesh sling in allcases with urinary stress incontinence, hysterectomy ornot depending on the existence of prolapse, and anterior/posterior colpoperineorrhaphy with or without mesh.Results on urinary continence, complications and theirtreatment were evaluated in the postoperative period, ondischarge, at 6 months and yearly thereafter.RESULTS: Average age was 63.8 years (27 – 82years,SD 11.2). 39.3% of the patients were over age 70. Meanfollow- up was 4.25 years (12-75 months, SD 11.9). Thecost of pads for urinary incontinence was 2741.17 Eurosper patient (456,117 pesetas). 32.3% of the patients hadrisk factors for urinary incontinence surgical treatmentfailure and 18.8% had a leak point pressure below 30 H20cm. 22.3% cases presented with detrusor instability beforesurgery. 102 sling procedures, 20 hysterectomies, 26anterior plasties, 14 posterior plasties, 10 mesh cystocelerepair, 1 posterior mesh, and 2 enterocele sacralpromontory fixation were performed, accounting a total of173 surgical procedures during 102 anaesthesiaprocedures. 9 additional procedures were necessary forthe treatment of complications.Stress continence was achieved in 99.01% cases. Inhalf of the patients with preoperative urgency-incontinenceit continued during the first postoperative year. 11 caseshave postoperative bladder instability, 7 of which had itpreoperatively and 4 were de novo.Complications: 5 cases needed sling section/reconfiguration because of excess tension (non effectivesling). 3 cases needed sling tight stretching /reconfigurationbecause of less than adequate tension. 2 cases of accidentalbladder perforation were treated with primary closureand urinary diversion. One case of infection-abscess in themesh left anchoring stitch was drained under localanaesthesia. There were 6 cases of suprapubic, inguinaland rectal pain (8.1%), in all of them it disappeared within9 months. There were 2 cases of wound infection.CONCLUSIONS: The prolene mesh sling can offerlong term cure for stress urinary incontinence in almost allcases (99.01%), including the complicated ones. 91.1% ofthe patients underwent one surgical procedure only, and8.8% required additional procedures. Results stand thetest of time with a clinical-urodynamic follow up of 4.25years. The voiding urgency referred by 81% of the womenwith large prolapses is associated with demonstratedbladder instability in 63% of the cases. Voiding urgencyas well as bladder instability disappeared in all cases butone, being this fact prolapse-correction dependant, sothat pelvic prolapse correction plays a decisive role. De novo bladder instability is uncommon (3.9%) and appearsrandomly in this series
OBJECTIVES: To evaluate the usefulnessof laparoscopy as a corrective technique for urinary stressincontinence in our experience.METHODS: We review 72 cases of urinary stressincontinence who were treated by laparoscopic bladderneck suspension between April 1996 and December 2001.RESULTS: Average operative time was less than 40minutes and mean hospital stay was 1.6 days. Thecontinence rate was 82% after a mean follow up of 32months.From the 12 patients with incontinence recurrence, 7had the urinary incontinence recurrence within 2 monthsfrom surgery.CONCLUSIONS: The results of laparoscopic correctionin urinary stress incontinence seem to be satisfactory inthe midterm, although it is necessary to have at least 5years of follow up to be able to compare it with consolidatedtechniques considered the gold standard in the treatmentof this disease.
OBJECTIVE: Periurethral injectables areamong the multiple therapeutic options that urologistshave to correct female stress urinary incontinencecurrently.The philosophy of periuretrhal injectables actionmechanism has always been the same, to increase urethralwalls coaptation or pressure, which is pathologicallydiminished.METHOD/RESULTS: New surgical techniques,approaches and instruments have been appearing withtime. Historically various injectable materials have beenused, each one with its advantages and disadvantages.CONCLUSIONS: The role of periurethral injectablesin the treatment of female stress urinary incontinence islimited. The efficacy of the procedure is low and theywould have little room in the treatment of female stressurinary incontinence if it were not because of its minimallyinvasive condition in patients with intrinsic sphincterinsufficiency, whom would require more aggressiveprocedures otherwise also of uncertain results, or toremain untreated.
OBJECTIVES: to review the treatment of female stress urinary incontinence by new systems of tension-free urethral sling TVT type (Tension free vaginal tape) or IVS (intravaginal slingplasty), and the bone anchoring trasvaginal sling procedure Infast.METHODS: We describe the surgical techniques of the various procedures and perform a bibliographic review on the topic.RESULTS/CONCLUSIONS: The pubovaginal sling has become the gold standard in the treatment of female stress urinary incontinence, mainly if there is sphincter intrinsic dysfunction. The concept of tension free medium urethra support has been the most important contribution, that questions the classification of incontinence in types I, II and III, because the pubocervical tension free sling can correct all three. Tension free urethral sling techniques have demonstrated to be effective, minimally invasive with a low complication rate, easily reproducible, and with good continence results in the mid-term.
OBJECTIVES: To report our experience in the diagnosis and treatment of the lower urinary tract obstruction after urinary incontinence corrective surgery, analysing the different techniques performed, retropubic or vaginal urethrolysis.METHODS: We report a series of 14 patients with the diagnosis of obstruction after incontinence corrective surgery. They were classified in 2 groups, those who underwent retropubic procedures (5 cases) and those who underwent prolene mesh sling procedures (9 cases). We detail preoperative clinical-urodynamic parameters, and postoperative bladder outlet obstruction confirmation. Retropubic urethrolysis was performed in all patients after retropubic surgery, with the association of hysterectomy if indicated. The performance of a new sling- urethropexy was individualized. In three cases of retropubic surgery repeated urethropexy was not done. Unilateral section was performed in the sling series for all except one case of double section. A new mesh sling was performed in two cases; two cases did not undergo reoperation. Urethrolysis results were evaluated both subjectively by satisfaction degree scales and objectively by clinical-urodynamic evaluation, comparing clinical data and urodynamic parameters using the proper statistical test.RESULTS: In the retropubic surgery group all patients are continent. Satisfaction degree is: very satisfied 3 patients and 2 quite satisfied. Two presented with voiding urgency not needing anticholinergic drugs, and their urodynamic data returned to normal values without post void residual. The obstructed patients in the sling group reported minimal urgency after urethrolysis in 2 cases. Two patients have stress urinary incontinence: one of them is better than before and refused to undergo a new operation; the other one, who repeated sling, developed a clinical picture of urgency-incontinence again, underwent second section and continues having stress urinary incontinence. Among 7 patients undergoing sling, 4 are very satisfied, 1 quite satisfied, 1 somewhat satisfied and 1 not at all satisfied.Voiding difficulties have disappeared in all cases; comparisons between pre and postoperative urodynamics maximum flow, detrusor pressure at maximum flow and postvoid residual show statistically significant differences. Post-urethrolysis parameters return to preoperative values.CONCLUSIONS: The immediate development of symptoms after surgical correction of urinary stress incontinence is the best diagnostic criteria for obstruction. Detrusor muscle responds to obstruction, but sometimes its response is so minimal that it is difficult to diagnose urodynamically. The knowledge of preoperative values helps to confirm the diagnosis. In any case, urodynamic parameters did not influence the success of urethrolysis.Urethrolysis is an effective operation to cure symptoms secondary to obstruction after incontinence corrective surgery. When a sling has been the procedure performed, probably it is not worth to perform a standard urethrolysis; a simple section of one of the branches seems to be enough to improve symptoms.Currently, there is not scientific evidence about the convenience or not of bladder neck-urethral re-suspension after urethrolysis. The only case-scenario in which it is clearly indicated is that when there is stress incontinence in addition to obstructive symptoms.
OBJECTIVES: to report our experience with a series of 10 patients undergoing radical cystectomy with bladder substitution. We were supported by a better knowledge of the female continence anatomical mechanisms and the demonstration of the oncological viability of the urethral remnant. METHODS: From 1994 to 2002 10 women underwent radical cystectomy with bladder substitution by means of a modified anterior pelvic exanteration; technical modifications to achieve continence preservation are based on: preservation of the distal 2/3 of urethra, pubourethral ligaments and endopelvic fascia, and limitation of lateral vaginal dissection to avoid damage to the striated sphincter innervation. To avoid the neocystocele effect the vagina is fixed to the uterosacral ligaments and to the sacral promontory. RESULTS: Bladder capacity is 332.9 ± 35.6 ml with a flow of 17.7 ml/sec. Complete continence wax achieved in 8 patients, the remainder 2 present grade II urinary stress incontinence. All of them empty their neobladder satisfactorily; only one patient needed a bladder re- education program. One bladder fistula and diarrhoea in one patient are the complications to be highlighted. CONCLUSIONS: The results obtained with orthotopic neobladder in females, achieving a high satisfaction level and quality of life, stimulate us to continue with this technique.
OBJECTIVES: To review the most adequate treatment for female urogenital sinus congenital malformations currently. METHODS: We performed a bibliographic search on this rare disease and review the embryological development of the female urogenital apparatus. RESULTS/CONCLUSIONS: We review the various surgical techniques from a historic point of view pointing at what time should the procedure be done. METHODS: We performed a bibliographic search on this rare disease and review the embryological development of the female urogenital apparatus.RESULTS/CONCLUSIONS: We review the various surgical techniques from a historic point of view pointing at what time should the procedure be done.
OBJECTIVES: To review theetiopathogenic, diagnostic and therapeutic criteria forfemale urethra diverticula.METHODS: Urethral diverticulum was diagnosed infour patients, all of them with recurring urinary tractinfections and irritative voiding symptoms. The finaldiagnosis was established by VCUG (Voidingcystourethrography). Other procedures, more recent andmore in use, are also referred.RESULTS: All patients required surgical treatment,three of them with good results and one without success.The therapeutic procedures most frequently used in theliterature during the last decade are also mentioned.CONCLUSIONS: The milestone in the management offemale urethral diverticula is to think on it in patients withlower urinary tract symptoms. Surgical excision whenamenable obtains optimal results.
OBJECTIVES: to review the etiology,diagnosis and available therapeutic options forvesicovaginal fistula.METHODS: Bibliographic review on diagnosis andtreatment of vesicovaginal fistulas.RESULTS: We review the complete diagnostic protocolfor vesicovaginal fistulae, as well as the various surgicaloptions available, all of them with high success rates.There is an increasing tendency to early repair instead ofdelayed. It is important to follow the principles of fistulaeclosure to achieve success. In cases of complex fistulae theuse of interposed flaps allows to have better results.CONCLUSIONS: There are few vesicovaginal fistulaenot amenable to surgical treatment; to suspect a fistula atthe time of diagnosis and an early treatment with a goodtechnique, regardless of the approach, guarantee a highsuccess rate
OBJECTIVES: Interstitial cystitis is a nosological entity of which many etiological, diagnostic and therapeutic features were unknown until recently, so that we had the objective to review new knowledge acquired during the last decade to offer an update in the disease. METHODS: A bibliographic review on interstitial cystitis is performed with special interest in national and international authors who have experience and large case series. RESULTS: Among the multiple etiopathogenical theories proposed in the past, the hypothesis to be highlighted, that is gaining strength, is the altered bladder urothelium permeability or hemato-urinary barrier alteration, with the aggression of toxic substances contained in urine in high concentrations like potassium. Epidemiologically, some authors think the disease is present in the population in a higher frequency than it is diagnosed, and it may be found in many women with the misdiagnosis of recurrent urinary tract infections. Regarding diagnosis, a new test is proposed to help clinical diagnosis: the potassium test, which consists in the endovesical instillation of this ion at high concentrations reproducing the symptoms. Finally, in the medical treatment it is demonstrated the efficacy of drug associations over monotheraphy (heparinoids, antihistaminic and antidepressant drugs), looking for the correction of the physiopathological abnormalities caused by the disease. Psicologic support and continuous information to the patient about the disease continue to be one of the mainstays of this multimodal therapy. New options like neural stimulation have appeared, although its results are not conclusive so that further studies must be done. CONCLUSIONS: New knowledge about interstitial cystitis allow us to better understand the chain of events happening in it. An early clinical diagnosis, now reinforced with a positive potassium test, is key to start medical treatment (drug combination) targeted to stop the pathogenic process, because it is more effective in the early phases of the disease. For that purpose, the Urologist must have this disease in mind.
OBJECTIVES: To review the topic ofurinary tract infections (UTI) during pregnancy andmenopause. UTI during pregnancy and menopause havegreat relevance in the field of urologic infections; duringpregnancy because of the particularities involved in itsdiagnosis and treatment and potential consequences tothe fetus and mother; menopausal UTI because this groupof women is numerous and represents a growing section ofthe general population pyramid, due to the aging ofpopulation in developed countries associated with longerlife expectancies and grater demand for quality of life.METHODS AND RESULTS: We performed abibliographic review combined with our personalexperience.During pregnancy there are several functional andanatomical changes that condition not only a higher riskof UTI, but also an additional treatment difficulty due toantimicrobial pharmacokinetics alterations and potentialdamage to the fetus. Despite efforts to find an easy, fastand reliable test for bacteriuria detection, urine culturecontinues to be the first diagnostic test for its detection andfollow up during pregnancy. Penicillin derivates andcephalosporins continue to be the first choice becausetheir lack of adverse effects on either fetus or mother.Alternative options like phosphomicin and aztreonamalthough they show low toxicity there is need for morestudies supporting their suitability for the treatment ofpregnancy UTIs.Menopausal female UTI have their different featuresfrom those in younger women. Hormonal alterationsderived from gonadal atrophy associate functional changesin the vaginal ecosystem, making it prone toenterobacteriaceae colonization as a first step up to theurinary tract. This associated with genitourinary tractanatomical alterations inherent t aging make UTIextraordinary prevalent in this growing segment ofpopulation. Treatment lines focus on hormonal alterationcorrection and proper antimicrobial prophylaxis andvaccines in a close future.CONCLUSIONS: UTIs during pregnancy andmenopause have differential features that require differentdiagnostic and treatment approaches.