British Journal of Urology (1911), 49, 31-42

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Recurrent Stress Urinary Incontinence in the Female J. EDWIN MORGAN

and

GRANT ANGUS FARROW

Deparfnzent of Obstetrics and Gynaecology, and Department of Siirgery, University of Toronto, and Toronto General Hospital

(Received 20 September 1976; accepted for publication 4 October 1976)

Although incontinence is an uncommon problem in the male, it is one of the commonest urological complaints in the female. For the urologist recurrent stress incontinence is more common than primary stress incontinence. In those patients who have had one or more previous vaginal or suprapubic operations a repair is best accomplished by a 2-team abdominal-vaginal approach using a wide band of inert polypropylene mesh (Mar1ex)l (Fig. I). The safety and success of the procedure depends on the wide mobilisation of the bladder and urethra with release from dense pelvic scar followed by suspension of the bladder neck in a high retropubic position. Patients

From 1st January, 1968 to 31st December, 1975, 1,500 females presenting with recurrent urinary incontinence were reviewed by one of us (J. E. M.) at the Urological-Gynaecology Clinic at the Toronto General Hospital. 25 eventually required surgical correction and 8 p/, of the total (127 patients) were treated with the 2-team Marlex sling repair. This group had an average of 2.4 previous unsuccessful procedures for incontinence, not including hysterectomy. Methods The precise technique of the operation has been previously described (Morgan, 1970). The complete mobilisation of the urethrovesical junction suprapubically and vaginally prior to placement of the sling is best accomplished by a 2-team, abdominal-vaginal approach with a gynaecologist below and a urologist above. Marlex mesh is attached to Cooper's ligaments and this provides a broad flat hammock supporting the bladder neck in a high retropubic position (Fig. 2). Results 118 patients had no further anatomical stress urinary incontinence. 9 patients were classed as failures because of persistent symptoms. 4 of these patients have a significant degree of urgency incontinence associated with persistent urinary infection. 3 are incontinent due to a failure of technique with improperly placed slings. 1 patient developed multiple sclerosis and 1 hysterical patient continued to complain of incontinence even after an ileal conduit diversion. Complications have been infrequent. 4 patients had persistent poor bladder emptying, all were cured with an anterior transurethral resection of bladder neck. 1 of these patients had a urethral Read a t the 32nd Annual Meeting of the British Association of Urological Surgeons in London, June 1976. 1

Marlex is manufactured by Usher's Marlex Mesh, Davol Rubber Company, Providence, Rhode Island.

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Fig. 1. Marlex mesh.

Fig. 2. Marlex sling.

stone. 2 patients with prolonged cystitis are now free of infection and off medication. 3 patients had a postoperative wound infection, There were no significant cardiopulmonary or thromboembolic phenomena, no fistulae, and no slings have had to be removed.

Discussion A complete history with pelvic examination, cough test, and urinalysis is usually done by all examiners ; however, to complete the investigation a cystoscopy and cysto-urethrogram should always be performed. Stress incontinence and urgency incontinence are frequently seen in combination. For this reason each patient must be cystoscoped, a procedure seldom carried out by the gynaecologist. The patient with urethral, bladder neck or trigonal irritation will be improperly diagnosed and perhaps subjected to unnecessary surgery. One must also assess the degree of

RECURRENT STRESS URINARY INCONTINENCE IN THE FEMALE

Fig. 3. Normal cysto-urethrogram.

Fig. 4. Dependent urethrovesical junction.

Fig. 5. Incompetent urethrovesical junction with vaginal prolapse.

Fig. 6. “Drain pipe” urethra.

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incontinence. 50% of normal nulliparous females have some degree of urine loss with a sudden coughing or laughing and this must be considered within the range of physiologic normal. Traditionally, the patient with incontinence is seen and treated by the gynaecologist with a vaginal repair. If this procedure fails the patient is referred to the urologist who then performs a suprapubic Marshall Marchetti operation. In assessing long-term (5 years) results of treatment of stress incontinence the generally accepted figures reveal : the vaginal approach yields slightly above 50 % cure rate, while the suprapubic approach yields slightly above 80 % cure rate. With such a difference, why is the vaginal approach still used so frequently? If one assesses the woman presenting with stress incontinence vaginal prolapse syndrome, one-third present with pure stress incontinence with little or no prolapse, one-third present with simple vaginal prolapse without incontinence, and one-third present with a combination of both. It is clear that two-thirds of patients initially present with some degree of vaginal prolapse. Associated factors in this presentation that must be considered are multiparity with stretching of tissues, the older patient with loss of oestrogen and thinning of tissues, chronic chest disease, strenuous activity, and obesity. If the gynaecologist is lax in having cystoscopies performed on these patients, the urologist is frequently as lax in not radiologically demonstrating the defect. The key to treatment is the precise demonstration of the anatomical defect in the urethra. The anatomy of the base of the bladder and urethra is best seen on the lateral view of a barium paste, hypaque static cysto-urethrogram (Low, 1967). Fig. 3 shows a tracing of the normal cysto-urethrogram demonstrating a high retropubic position, the urethrovesical junction is not dependent, and the urethra has a normal Sshaped curve with the upper third of urethra closed. With straining there is a slight normal descent, slight posterior rotation and the upper third of the urethra remains closed. It becomes obvious that this must not be a voiding study, i.e. we want to see this junction in resting and stress conditions while not voiding. During voiding the junction normally opens and becomes incompetent. If this junction (and the term “junction” rather than “angle” is stressed) is the dependent

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portion of the bladder at the base of a funnel, with abdominal pressure directed here, the patient will probably have stress incontinence. This is demonstrated in Figure 4. Another advantage of this X-ray is the ability to document what has been accomplished postoperatively. As noted previously, two-thirds of these patients present with some degree of prolapse and some of these quite correctly should be treated by a vaginal repair. This is particularly so if there is significant descent which can be elevated by vaginal sutures. This is shown in Figure 5 in a patient presenting with severe stress incontinence. Her X-ray shows the urethrovesical junction and upper third of the urethra to be grossly incompetent and dependent, presenting in the perineum. Clinically, she had marked ureterovaginal prolapse. This patient was treated and cured with a vaginal repair. The reason, however, that there are generally such poor results with vaginal repair is that one is able to elevate the junction just so far, and in 50% of cases this is not far enough. The Marshall test is not particularly reliable in this regard. Vaginal sutures are frequently not as effective as the finger or forceps in the vagina. The second danger of the vaginal repair occurs in patients with vaginal prolapse and minimal stress incontinence. Repair of the cystocoele may produce severe incontinence by placing the urethrovesical junction at the most dependent portion of the bladder. The suprapubic approach, on the other hand, yields a success rate of over 80%. One can elevate the junction much higher and it is therefore the procedure of choice in patients with stress incontinence with little retropubic descent and without symptomatic vaginal prolapse. A factor worth noting in the primary suprapubic operation is that by lifting the anterior wall of the vagina, one may make a mild enterocoele progressively symptomatic requiring a subsequent vaginal repair. Although the Marshall-Marchetti procedure is the most frequently employed suprapubic operation, the Burch sling (Burch, 1961 ; Morgan, 1973) employing the vagina as a hammock to Cooper’s ligaments is a very effective procedure in cases not having had previous vaginal surgery. For the urologist the problem of recurrent stress incontinence is more common than primary stress incontinence. In this situation one must be careful to rule out other underlying causes of incontinence. Occasionally, one will find a previously unrecognised neuropathic element or underlying urinary infection. The success rate of treatment is poorer in all procedures following one o r more previous vaginal or suprapubic operations. The poor results in the treatment of recurrent stress incontinence are primarily for one reason only-pelvic scar. Figure 6 shows a fixed, “drain-pipe’’ urethra in the dependent position of the bladder in a patient who had 2 previous vaginal operations and 2 previous suprapubic operations. The suprapubic procedure alone does not release the posterior aspect of the urethra in the dense scar of the vagina following repeated colporrhaphy. As shown in Figure 7, a Marshall procedure in this situation has further opened the urethra creating an anterior funnel, aggravating the stress incontinence. This patient has had 2 vaginal repairs and 1 previous Marshall Marchetti procedure. It is therefore important that the procedurechosen to correct the defect in patients with recurrent stress incontinence after one or more vaginal and/or suprapubic operations must: 1, release the anterior scar in the space of Retzius; 2, release posterior scar in the vagina; 3, adequately elevate the junction so it is n o t the dependent position at the base of the funnel. This is effectively accomplished by the 2-team Marlex sling as seen in Figure 8. Summary 1,500 females presenting with recurrent urinary incontinence were investigated in depth. 27 ”/, required further surgery, 127 of whom were treated with a 2-team Marlex sling. Careful assessment is the key to treatment including cystoscopy and good radiological documentation. One must be aware of the capabilities and limitations of the various procedures employed for stress incontinence and select the correct procedure for the given problem.

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When dealing with recurrent stress incontinence the surgical procedure must take down all periurethral scar, anteriorly and posteriorly and adequately elevate the urethrovesical junction so it is not the dependent point at the base of the funnel. The Marlex sling procedure fulfills the above criteria, has been singularly effective, and remarkably free of complications. References BURCH, J. C. (1961). Urethrovaginal fixation to Cooper’s ligament for correction of stress incontinence, cystocele and prolapse. American Journal of Obstetrics and Gynecology, 81, 281-290. Low, J. A. (1967). Management of anatomic urinary incontinence by vaginal repair. American Journal ofObstetrics and Gynecology, 91, 308-315. MORGAN, J. E. (1970). A sling operation, using Marlex polypropylene mesh, for treatment of recurrent stress incontinence. American Journal of Obstetrics and Gynecology, 106,369-317. J. E. (1973). The suprapubic approach to primary stress urinary incontinence. American Jorrrnal of MORGAN, Obstetrics and Gynecology, 115, 316-320.

The Authors J. Edwin Morgan, MD, FRCS(C), FACOG, Associate Professor, Department of Obstetrics and Gynaecology. Grant Angus Farrow, MD, FRCS(C), FACS, Assistant Professor, Department of Surgery.

Recurrent stress urinary incontinence in the female.

British Journal of Urology (1911), 49, 31-42 0 Recurrent Stress Urinary Incontinence in the Female J. EDWIN MORGAN and GRANT ANGUS FARROW Deparfn...
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