Postgrad Med J: first published as 10.1136/pgmj.32.373.527 on 1 November 1956. Downloaded from s27

STRESS INCONTINENCE By JOHN BEATTIE, M.D., F.R.C.S., F.R.C.O.G. Gynaecological Surgeon, St. Bartholomew's Hospital

So far the mist has cleared very little from around obtain such a history, otherwise a patient may be this difficult subject despite the original work operated upon for when the symptoms which has been carried out during the last io are due to something else or if true stress incon- years. Operations for the cure of stress incon- tinence develops after child bearing in such a tinence have been described from time to time patient the results of operation may be dis- during the last 50 years, but until recently most appointing. gynaecologists considered that a modified anterior Other abnormalities of bladder function which colporrhaphy was all that was necessary to achieve must be differentiated from a case of true stress a lasting cure. incontinence are as follows: One of the most important things in dealing with this subject is first to differentiate true stress The Neurogenic Bladder incontinence from inability to control the passage The bladder is often a most sensitive indicator Protected by copyright. of urine from the bladder when the urge to mic- of neurological disease and, of course, there may turate becomes great. There is also the leak which be, and often is, vaginal prolapse present at the occurs in retention with overflow to consider and onset of such a condition. The most often quoted other conditions which cause weakness of the instance of the neurogenic bladder is disseminated bladder sphincterwithout a true stress incontinence sclerosis, and, indeed, it is the commonest neuro- being present. logical disorder found in the British Isles. The Some women suffer from stress incontinence early symptoms may cause a temporary disturbance which is superimposed upon an abnormality of of function only and of short duration. The more bladder function which was present in childhood common type exhibits acute exacerbations at inter- due to a congenital cause. A recent investigation vals with quiescent phases lasting for up to seven of 40 patients operated upon for stress incon- years or more. The gynaecologist should look out tinence at St. Bartholomew's Hospital showed that for the following stigmata of the disease in all cases the following abnormalities of bladder function complaining of defective bladder function, for in had occurred during childhood: , 8 per disseminated sclerosis there may be urgency and cent.; urge incontinence, 12 per cent.; excessive precipitancy with urge incontinence and, less com- http://pmj.bmj.com/ frequency, io per cent. Some of these symptoms monly, retention with overflow. There may be also were combined in a single case and an abnormality defective memory, disturbances of sensation, scan- of function of the bladder in childhood occurred ning speech, dragging of the foot, horizontal in o of the 40 cases (25 per cent.). nystagmus, diplopia or temporary loss or dimness These figures may be compared with those of of vision and emotional disturbances which are Fisher and Forsythe' who found in 135 children often diagnosed as hysteria. There may be pain over the of were 20 cases of abnor- and stiffness with weakness of one or both age 5 (51 girls) legs, on September 30, 2021 by guest. mal bladder, i.e. three neurogenic disorders, 14 especially when tired, an increase in the deep with wide bladder neck anomaly and three with a reflexes, loss of the abdominal reflex and an ex- small capacity bladder. Vesical spasm also may tensor plantar response, a spastic gait and intention occur in children without infection when a small tremor. capacity bladder is present due to a failure of If any case of stress incontinence exhibits one physiological development. This condition can or more of these symptoms and signs, the patient continue into adult life or may develop after the should be referred for an expert neurological due to shrinkage of bladder capacity opinion. with consequent frequency and urgency of Other neurological conditions which may simu- micturition. late a mechanical stress incontinence are neuro- Abnormal bladder symptoms in children may syphilis and compression of the cord or corda persist into adult life and it is most important to equina due to tumours or other lesions. Abnormal 528 POSTGRADUATE MEDICAL JOURNAL November 1956 Postgrad Med J: first published as 10.1136/pgmj.32.373.527 on 1 November 1956. Downloaded from

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Straining cystogram. Posterior urethro-vesical angle Straining cystogram. Posterior urethro-vesical angle present. is absent. bladder function also occur as a stress incontinence occurs on may hysterical only exertion,Protected by copyright. manifestation. The symptoms produced by dia- whether standing or sitting. It is customary to betes insipidus have been diagnosed as due to test for true stress incontinence by placing a finger prolapse owing to the vast quantities of urine to either side of the without direct com- passed, which caused frequency and urge incon- pression upon it. The incontinence on stress tinence in a multipara. The tabetic bladder dys- should then be cured when the urethra is thus function may antedate the Argyll-Robertson pupil supported. A useful test is the application of and absent knee jerks. In these cases there is an a Hodge in the reversed position when the imbalance between the sympathetic and para- narrow end lies above the symphysis pubis and sympathetic nerve supply with retention of urine, this reconstitutes the absent urethro-vesical angle overflow and incontinence. which will produce a temporary cure of the stress incontinence. The Bladder Psychogenic In some patients with stress incontinence, The psychogenic bladder is probably the most particularly in the rather rare case of the nul- interesting of all, for a functional element may it is not to demonstrate the lipara, possible http://pmj.bmj.com/ produce frequency, urgency, urge incontinence or physical signs of urethral prolapse. These are the stress incontinence at any time even after a suc- cases which present considerable difficulty and in cessful operation for the cure of urethrocele has which a straining cystogram is required. It is been performed. remarkable also that a severe degree of vaginal The writer had a recent example of this in a prolapse may be present without stress incon- woman who for I8 months complained of stress tinence and with a well marked urethro-vesical incontinence which was demonstrated during a when Stress in- examination. There was no urethrocele angle which persists straining. vaginal continence may on rare occasions occur when on September 30, 2021 by guest. present and a straining cystogram showed a well urethral funnelling is present and also herniation marked posterior urethro-vesical angle and no of the funnelling of the internal meatus. The urine was trigone. sterile. The symptoms began after an emotional Jeffcoate and Robinson2 have proved con- upset over her daughter. In view of all the clusively in many hundreds of X-ray photographs negative findings the patient was reassured and that in at least 90 per cent. of all cases of true given a bottle of potassium citrate mixture. This stress incontinence the posterior urethro-vesical cured her completely but an operation would also angle is absent when straining, and is also often have been a success! absent when the bladder is at rest (Figs. i and 2). It is important therefore to differentiate the case This investigation therefore in the great majority of of true stress incontinence from those mentioned cases gives a clear indication of the necessity or above. A typical case is easy to diagnose, for the otherwise of operation to cure a case of stress November 1956 BEATTIE: Stress Incontinence 529 Postgrad Med J: first published as 10.1136/pgmj.32.373.527 on 1 November 1956. Downloaded from incontinence. The angle normally varies between these circumstances and all that is necessary is to 90o and I30°. have a mechanism to resist an increase of pressure The anatomy of bladder function has been a which occurs on exertion. When the bladder con- controversial subject for many years but it now tains 250 c.c. of urine there is an urge to micturate, seems clear that the following structures take part which is easily controlled and which then passes in the act of micturition. off while the bladder continues to fill slowly. When I. The inner circular and outer longitudinal about 500 c.c. is present in the bladder a further muscle fibres of the bladder mingle at the urethral and more powerful urge to micturate occurs. orifice to form a double sling. These fibres Superimposed upon this normal bladder mech- continue down the urethral wall towards the anism is the influence of the will and there is triangular ligament. This constitutes the main probably no function in the body which is more sphincter which remains closed except during directly under control in this way. micturition. The act of micturition is initiated by various 2. The membranous sphincter or compressor reflexes and voluntary control is destroyed by urethrae extends above the triangular ligament section of the nervi erigentes, which contain both and embraces the urethra. The muscle fibres afferent and efferent paths. It is the pressure in the pass to the lateral walls of the and up to the bladder and not the volume which starts the act bladder base. This structure produces the main and the normal pressure required varies between voluntary control of micturition. 40 and go c.c. of water. This sudden rise of 3. The Levator Ani muscle. Contrary to pressure relaxes the internal meatus and at the previous statements it now seems to be proven same time there is relaxation of the levator ani and that the pubo-coccygeus does not send fibres to a coincident slight voluntary increase in intra- embrace the urethra but these are inserted abdominal pressure. When the pressure of urine into the wall and when con- in the urethra rises to between and 15 c.c. of

laterally vaginal 3 Protected by copyright. tracted they pull the urethra up and forward to water further contraction of the detrusor of the compress it. bladder occurs. 4. The vesico-vaginal is a muscle sheet During the act of micturition pressure starts at which also contains elastic tissue which spreads 30 to 50 c.c. of water and can rise to 50 or Ioo c.c. round and to either side of the urethra and to the by voluntary expulsive efforts. When coughing vaginal wall. with a full bladder the intravesical pressure can 5. The bulbo cavernosus surrounds the lower rise as high as Ioo c.c. of water with complete con- end of the vagina and connects between the tinence in the normal subject. The voluntary urethra and the clitoris by a dense band of fibrous muscles of urethral control under these circum- tissue. When the bulbo cavernosus contracts it stances play an important role in maintaining con- will draw the urethra towards the anus and thus tinence. It is notable, therefore, that in cases of compress it against the anterior vaginal wall and acquired stress incontinence the single abnor- against the levator ani muscle which contracts at mality, apart from the rare abnormalities such as the same time and compresses the urethra in the funnelling and trigone hernia, is absence of the opposite direction. urethro-vesical angle on straining. In this respect http://pmj.bmj.com/ The last four structures mentioned when put the changes which occur in the bladder during the into action will produce voluntary cessation of first and second stages of labour, as described by micturition when necessary. This second line Malpas and Jeffcote4, are of great interest. The of defence is efficient enough to allow 50 per cent. level of the bladder base in the pelvis is not altered of women with stress incontinence to stop the leak during the first stage of labour. As the presenting with ease if they are conscious of the risk when a part descends in the second stage the urethro- sudden stress is about to occur. Cinematograph vesical junction moves towards the symphysis films taken during the act of micturition show that pubis. The extent of the displacement of the on September 30, 2021 by guest. when this ceases by voluntary effort, the compres- bladder and urethra depends 6n the relative sizes sor urethrae cuts off the flow and the urethra then of the presenting part and the cavity of the pelvis. empties backwards into the bladder (Ardran, If there is delay due to a tight fit in the plane of the Simmons and Stewart)3. mid cavity, the bladder neck may be lifted to the The physiology of bladder function is obscure, top of the symphysis pubis and the bladder is but certain proven facts are now established. When rolled upwards and forwards. In view of this the the bladder fills slowly, as it does normally, there old theory that the urethra is pushed off the sym- is almost no increase in muscle tone and under physis pubis is untenable. The rotation of the these conditions the pressure in the bladder varies bladder must stretch the lower pole and the invest- between zero and io c.c. of water. The involuntary ment surrounding the posterior wall of the bladder sphincter control is an efficient mechanism under neck. In this way obliteration of the urethro-vesical D1l Postgrad Med J: first published as 10.1136/pgmj.32.373.527 on 1 November 1956. Downloaded from 530 POSTGRADUATE MEDICAL JOURNAL . November 1956 angle occurs just as in stress incontinence and it is interesting results of straining cystograms taken common to see involuntary voiding of urine under after the cure of 30 cases of stress incontinence by stress during the descent of the head in the second the ordinary method. Only in four of these was stage of labour. the urethro-vesical angle restored, showing that The obliteration of the posterior urethro-vesical the reconstitution of the angle by this form of angle must be associated with stretching or damage operation is extremely difficult to achieve. In nine to the urethral supports and those of the bladder of the 30 cases stress incontinence subsequently base, but a recent paper by Youssef and Mahfouz5 recurred and the success in the other patients must suggests that in cases of stress incontinence there have been due entirely to a strengthening of the is also an actual acquired weakness of the urethral voluntary supports of the urethra. sphincter. It may be, therefore, that the oblitera- When stress incontinence recurs after a col- tion of the urethro-vesical angle is associated with porrhaphy has been performed it is possible to loss of tone in the intrinsic involuntary musculature repeat the same operation, but with only moderate of the bladder neck. success in curing the symptoms. Most gynae- The successful cure of stress incontinence is cologists will resort to some other form of opera- still hard to achieve. Kegel6 is a great exponent tion, of which the placing of a sling under the of the conservative approach to the subject and he urethra to lift it forwards and upwards and thus has published good results in both the nullipara reconstitute the urethro-vesical angle is the most and the multipara by using the vaginal obturator popular. Giordano in I907 first used the gracilis connected to a perineometer. Constant exercise of muscle for this purpose and Goebell in I9I0 used the levator ani muscle upon the obturator increases the pyramidalis muscle by transplantation. Stoekel the tone and strengthens the vesico-vaginal fascia. in i917 used strips of rectus muscle to place around Until recent years most gynaecologists con- the urethra and did an anterior colporrhaphy as sidered that a modified anterior colporrhaphy for well. Aldridge7 then made the sling operation stress incontinence was all that was required to popular once more by using strips of fascia of theProtected by copyright. produce a permanent cure. Indeed, the operation external oblique muscles to pass round the urethra was often left to the house surgeon, whereas to and be sewn together beneath it through an in- produce a good result requires experience and cision in the anterior vaginal wall. This is still the considerable technical skill. Whatever special safest and most reliable of all modern sling opera- sutures may be employed to bring together and tions, but it is laborious to perform and time con- plicate the vesico- and urethro-vaginal fascia the suming. Millin and Read8 have described two principles remain the same. A wide dissection of sling operations and the second one includes the the urethra and bladder base must be achieved use of fascia lata to place beneath the urethra and without any remaining adhesion to the anterior through the rectus muscles and fascia in the supra- vaginal wall. The attachments of the pubo- pubic region. Some surgeons use wide nylon coccygeus muscles to the sulci lateral to the urethra ribbon, which is introduced around the urethra in and in the anterior vaginal wall must be exposed. the same way. A wide plication of the urethro-vaginal fascia is All sling operations produce an excellent result then carried out by means of Lembert's sutures, if they are performed with great care by a really http://pmj.bmj.com/ using fine chromicized catgut. The bladder itself skilled gynaecologist who is well used to vaginal should not be unduly plicated above the vesico- surgery. In order to achieve a good result the urethral junction, as this may tend to obliterate the following criteria must be satisfied. It is necessary posterior angle. The same complication will occur to find the line of cleavage between bladder fascia if the anterior vaginal wall is shortened by a con- and vaginal skin. After free mobilization of the tinuous suture which is drawn tight. It is a major bladder a modified anterior colporrhaphy, as done disaster to find that a patient who has had a Man- to cure stress incontinence, is first performed and chester repair performed for uterine and vaginal the sling is then adjusted under the urethra at the on September 30, 2021 by guest. prolapse has developed stress incontinence in con- correct tension so that the urethro-vesical angle is sequence because the anterior vaginal wall has reconstituted. It is wise to leave the bladder with been shortened. Modifications of this technique 8 oz. of water in it for a few hours to produce with descriptions of special sutures have been pressure against the dead space on each side of described by Kelly, Pacey, Reddington, Ingleman the bladder base through which the sling has been Sundberg and others. introduced. A permanent cure of stress incontinence cannot The dangers and complications of any sling be assessed until more than two years have elapsed operation may be considerable and are nearly all since operation. In expert hands the success of associated with the sling being tied too tight and local suture of the urethral supports varies between producing an excessive angulation of the urethra. 75 and 90 per cent. Jeffcote has published some In this way it is possible to produce vesical or November 1956 BEATTIE: Stress Incontinence 531 Postgrad Med J: first published as 10.1136/pgmj.32.373.527 on 1 November 1956. Downloaded from A book for the postgraduate PRACTICAL OBSTETRIC PROBLEMS by IAN DONALD M.B.E., M.D. (Lond.), F.R.C.O.G. Regius Professor of Midwifery, University of Glasgow "There is no better concise yet reasonable statement of the modern practice of obstetrics." Brit. Med. J. "... this book is likely to become the standby of the obstetric practitioner and especially xii + 578 pp. of the aspirant for higher degrees, for it presents a well-balanced account of modern obstet- 115 illustrations ric practice." J. Obstet. Gynaec. Brit. Emp. (1955) 47s. 6d. net A new monograph entitled ANAESTHETIC ACCIDENTS by V. KEATING M.B., B.Ch., D.A., F.F.A.R.C.S. Consultant Anaesthetist and Lecturer in Anaesthetics, University College Hospital of the West Indies This work correlates current opinion on the prevention, diagnosis and treatment of the immediate and remote complications of general and regional anaesthesia, with each section of the book illustrated by the author's personal observations. Anaesthetic accidents are relatively uncommon, but when they do occur they may lead to the death or life-long vii + 261 pp. Protected by copyright. invalidism of the patient; thus a knowledge of the experience of others and pertinent 13 illustrations experimental facts are important. (1956) 25s. net Lloyd-Luke (Medical Books) Ltd., 49, Newman Street, W.I urethral fistulae, partial or complete obstruction of Marchetti and Krantz,ll who recommend a freeing the urethra, chronic over-distension of the bladder, of the urethra and bladder base in the same way avulsion of the urethra, loss of the micturition followed by suture of the urethra, bladder base or reflex and persistent infection of the urinary lateral vaginal fornices to the periosteum behind bladder. Haematomata around the bladder and the pubic bones, thus lifting up the urethra and infection in the may also occur. reconstituting the posterior urethro-vesical angle. As a sling operation is done as a rule only after This brief resume of the modern operative a previous operation has failed to cure stress in- treatment of stress incontinence demonstrates http://pmj.bmj.com/ continence, the surgeon tends to pull the sling too clearly that the problem has not yet been solved tight, as he dare not fail to cure the condition by and will not be so until more is known of the dys- allowing it to be too loose. Efforts are being made function of the bladder which occurs in cases of at present to devise some means of measuring the stress incontinence. tensiork required in individual cases, which varies with the resistance produced when the urethra is lifted upwards and forwards. REFERENCES There is little doubt that whatever method of I. FISHER, O. D., and FORSYTHE, W. I. (I954), Archives o on September 30, 2021 by guest. Dis. in Children, Oct., 461. sling operation is performed the final result is pro- 2. JEFFCOTE, T. N. A., and ROBERTS, H. (I952), J. Obstet. duced by fibrosis around the operation area, which Gynaec. Brit. Emp., 59, 685. 3. ARDRAN, G. M., SIMMONS, G. A., and STEWART, J. H. keeps the urethra in its new position. In cases in (I956), Ibid.; 63, 26, which the sling has had to be removed owing to 4. MAIPAS, P., and JEFFCOTE, T. N. A. (I949), Ibid., 56, 949* around it the result is 5. YOUSSEF, A. F., and MAHFOUZ, M. M. (1956), Ibid., suppuration ultimate usually 63, 19. as good as if the sling was still in place. 6. KEGEL, A. H. (1951), .7 Amer. med. Ass., 146, 9. In this respect it is interesting that good results 7. ALDRIDGE, H. (1942), Amer. J. Obstet. & Gynec., 44, 398. are claimed both who frees the 8. MILLIN, T., and READ, C. (1948), Postgrad. med. J., 24, 268. by Mulvaney,9 9. MULVANEY, J. H. (1952), J. Obstet. Gynaec. Brit. Emp., bladder base and urethra through a suprapubic 59, 7I1. incision and does Io. WILLIAMS, E. (1946), Proc. R.S.M., 40, 361. extra-peritoneal nothing else, II. MARSHALL V. F., MARCHETTI, A.A., and KRANTZ. and, by Everard Williams,10 and by Marshall K. E. (x949), Surg. Gynec. Obstet., 88, 509.