Postgrad Med J: first published as 10.1136/pgmj.24.267.3 on 1 January 1948. Downloaded from

3

STRESS INCONTINENCE OF URINE IN THE FEMALE By TERENCE MILLIN, M.CH., F.R.C.S., and CHARLES D. READ, M.B. F.R.C.S.(E), F.R.A.C.S., F.R.C.O.G. London PART I The distressing condition for which Sir Eardley genital prolapse, but the condition is encountered Holland coined the term stress incontinence is not infrequently in nulliparae about the meno- variously known as orthostatic, exertional or pausal age. It has long been recognized that little diurnal incontinence. relationship exists between the degree of genital The diagnosis presents little difficulty as a rule. prolapse and the severity of the urinary incon- The history varies according to the severity of the tinence. In fact, many women with an extreme condition. In its mildest form the patient is degree of descensus.have no stress incontinence, conscious of an escape of a small quantity of urine and conversely, patients exhibiting marked urinary in any movement which entails a rise of intra- loss may reveal little or no evidence of urethrocoele abdominal pressure when in the upright position or cystocoele. On several occasions we have -sneezing, coughing, walking up or down stairs. encountered stress incontinence which has by copyright. In its most severe form it may be evidenced by developed after the successful repair of a prolapse almost complete incontinence while in the up- in patients who previously had been completely right position. Almost invariably there is adequate continent of urine. control while in the recumbent position, though Many years ago Victor Bonney showed that by we have observed a few advanced cases in which supporting the bladder neck on either side of the control has been inadequate even in this position by means of intravaginal digital pressure if the coughing or sneezing has been violent. the involuntary escape of urine from a full bladder It is important to differentiate between extreme could be prevented. He deduced that the urinary precipitancy of micturition, i.e., urge incontinence, loss resulted from a sagging of the bladder neck, http://pmj.bmj.com/ and the stress variety. Precipitancy may be the due to stretching of the pubocervical , and result of urinary infection giving rise to a basal he concluded that the cure of the symptoms was cystitis. Such, of course, calls for appropriate dependent on the restoration of this fascial struc- antiseptic therapy, usually with sulpha drugs or ture. In cases in which he failed to effect a cure the mandelates, according to the type of infection. by means of his buttress operation from below, he Another troublesome cause of urge incontinence advocated a cystopexy by the abdominal approach. is a unassociated with infection. We have found test difficult to as

urethro- Bonney's apply, on September 30, 2021 by guest. Protected These cases are frequently attributable to sexual it is hard to convince oneself that the digital misfits and other causes of pelvic congestion, and pressure is not being exerted on the upper urethra local therapy seldom avails, despite claims by when endeavouring to support the bladder neck some authors as to the advantages of urethral by the intra-vaginal fingers. We have found that, dilatation, diathermic coagulation, etc. The cause by the use of long, rubber-covered forceps in place for the pelvic congestion should be sought and of the fingers, it is possible to support the bladder remedied, if possible. Operative procedures, to neck without exerting compression of the urethra, be discussed later, have no place in the treatment and by this means Bonney's contention can be of such types of incontinence. It is equally easily verified. essential to exclude neuropathies, e.g., tabes dor- Having established this point it appeared to one salis and spina bifida, which may cause a somewhat of us (T.M.) that radiological confirmation should similar syndrome. Surgical intervention in these not be difficult, and the technique about to be is only too often followed by relapse, if not described was evolved. Many previous workers immediate failure. had essayed radiological studies, but little progress True stress incontinence in the majority of cases had been made and in I946, Muellner, in an article is found in multiparae with a variable degree of on this subject, affirmed that neither endoscopic Postgrad Med J: first published as 10.1136/pgmj.24.267.3 on 1 January 1948. Downloaded from

4 POST GRADUATE MEDICAL JOURNAL January 1948 nor radiological studies had offered conclusive funnelling of the exitus. Moreover, from a study evidence as to the precise mechanism of the lesion. of the extent of this descent one can estimate the In this connection we must mention the pains- severity of the condition. In short, it is possible taking studies of Kennedy of New York, who used to assess the degree of the incontinence from a distensible rubber bags which could be filled with perusal of the. skiagrams. radio-opaque media. By placing these in the It can be appreciated that the presence of a urethra he claimed to demonstrate the presence of cystocoele without stress incontinence may give several which he believed to the radiographic appearance of apparent lowering play an important part in urinary control. He of the bladder neck in an antero-posterior film held that stress incontinence was the result of owing to the fact that the cystocoele descends dysfunction of these sphincters, and stressed the with its radio-opaque contents. By taking films importance of the sphincter surrounding the mid- in the lateral or oblique positions the level of the urethra. The fact, however, that two-thirds of cystocoele can be differentiated from that of the the urethra may be excised for malignant involve- bladder neck. Lateral radiograms, owing to the ment without the subsequent development of density of the femora and pelvic bones, are less incontinence would appear to disprove the im- satisfactory in their definition than oblique pic- portance of this structure. Moreover, the forma- tures, with the tube directed through the obturator tion of a completely new urethra by either the foramen. In these oblique films non-descent of trocarization method of Marion or by the vaginal the vesical outlet can be demonstrated where stress flap method recently described by Couvelaire of incontinence is absent. Figs. 1-22 illustrate some Paris, in both of which complete continence is typical cystograms. eventually obtained by the sole use of the bladder Having established to our satisfaction both musculature, would appear to present strong clinically and radiographically that a descent of confirmatory evidence that these so-called urethral the bladder neck is present in those patients who little part in urinary control. We exhibit stress incontinence, it became obvious that sphincters play by copyright. have satisfied ourselves that in the interlacing any operative intervention to cure the condition, fibres ofthe detrusor at the vesical outlet resides the must aim at elevation of the bladder neck. It chief mechanism of urinary control in the female. must be remembered that we are not here con- cerned with those patients who develop incon- Technique of Cystography in Stress tinence immediately after parturition and whose Incontinence cure can usually be effected by appropriate A No. 20F Malecot catheter is passed on a stilet remedial exercises, and combined if necessary with into the bladder. The bladder is emptied, and faradic stimulation; neither are we considering by means of a syringe, 6-Io ozs. of io per cent. those minimal degrees of the condition which solution of sodium iodide is introduced, and the benefit often by fulguration of the bladder neck.http://pmj.bmj.com/ catheter is spigotted. The patient then stands We have under review those more advanced cases against a vertical X-ray screen with the tube for which surgical intervention is sought, or in centred on the upper border of the symphysis which the simpler remedies have failed. We pubis. She is requested to take a short breath, would stress that in all cases in which there is an and to remain immobile while the first exposure associated uterine or vaginal prolapse or both, the is made. The patient, still in the identical position, firsi procedure to be embarked upon is one which will is then to strain down as in the act of cure the but at the same time should requested prolapse, steps on September 30, 2021 by guest. Protected defaecation, and a second exposure is made on be taken to elevate the bladder neck from below at the same film, i.e., a double exposure. The the time of the vaginal repair. second exposure reveals the bladder neck in its position when the intra-abdominal pressure is Operative Treatment of Stress raised, i.e., as in coughing, sneezing or straining. Incontinence As an alternative method two separate films may Three methods of approach for the cure of the be used-one exposure being made in the relaxed condition have been described and each method of upright position and the other whilst straining. approach exhibits many alternative procedures: The films are superimposed for reading purposes. (a) Vaginal approach. A study of many scores of these skiagrams reveals, (b) Abdominal approach. as anticipated from the clinical studies, that in the (c) Combined abdomino-vaginal approach. normal woman not exhibiting stress incontinence Vaginal Operations there is no demonstrable descent of the bladder (i) Colporrhaphy with special sub-urethral base, but in those suffering from such a urinary repair of various types as described by loss, there is a very appreciable lowering of the Bonney, Marion, Kelly, Kennedy, Davies, vesical .outlet, and in advanced cases there is a and Wilfred Shaw. January I948 MILLIN : Stress Incontinence of Urine in the Female 5 Postgrad Med J: first published as 10.1136/pgmj.24.267.3 on 1 January 1948. Downloaded from

-:: ·l.·a~ales - .,.,...... @ .:.:.. . a::···· .... - oPU ':::·.:i iii' f=ta;l ......

11..·..I... L.i ''.... o :'vml ll *:::..,;,2&SS-

i~i- :ir::l-

-t:i·:e:: l::·:·:.:.::i--: *iiiiiiiisaii'.'.Riilil *.tl~nr:·:··I·I; ·:·:·:i. --~ri~i eS-I-im-

-:ci: 1E|1-,.....(,:: ~i~li[:I::I~.~*--·;·i~i·:..°j::::.E.·~~i~: ··I· ·- --...;..0. l"· :I:::·:·- lii~;ll·:. 11 --.>;....'..' ~iiii-igigii~i'·i- :'"'' ''''' :::""' 9tiiiii I | -,,- 1119ii~- I. III -ias llllli~l;i-: IW I··· -ii: Wi~~IYi~lYsi:'·:npn~n-el= | m -

*:I-I...:...-.rlre

.: Bl:::::.

'i 'i.. -. .·:.S e -. .·:..: ·rz::i:: ff ;,i·.·::·:k by copyright. - - .·BS-:ozmoiiiiiI!iEc~ ·---

P~.·:.:c:`:.:eleg -····~: :~

rigc

1:r-eees~pi 1~lii:~~iiiiiiiii~~~ii~~~~ii~~ ···: ···· ··· ·i::iit http://pmj.bmj.com/

sap,.2iy;;9,2.e ...,,;o.0 ··.; .s:.-;.,,, -

-;r..i. :'l·:·: ..:.o.ce. BPiiiii·· .:.::·:··:*

:~~ :f:;·.:::.I on September 30, 2021 by guest. Protected

FIG. i.-Superimposed cystograms in patient with FIG. 2.-Tracing of Fig. i. a, a' indicate upper and marked stress incontinence. Note marked lowering of lower levels of bladder in the vertical relaxed position; bladder base in the position of strain (cf. Fig. 2). b, b' indicate the same in the position of stiain. The FIG. 3.-Superimposed cystograms in patient with descent from a' to b' in the original skiagram was moderate genital prolapse without stress incontinence. 2.5 cm. Note the descent of the upper level of the bladder FIG. 4.-Superimposed cystograms in case still ex- shadow on raising the intra-abdominal pressure but hibiting marked stress incontinence despite two vaginal fixed position of the bladder base. repairs. (Cure by Millin sling 20 months ago.) FIG. 5.-Superimposed cystograms in case of stress FIG. 6.-Tracing of superimposed cystograms of case incontinence only partially relieved by vaginal repair. still exhibiting severe stress incontinence despite pre- (Cure by Millin sling 14 months ago.) vious Fothergill repair and subsequent Gersuny ure- thral rotation. [Skiagrams too indistinct for reproduc- tion.] (Immediate cure by Millin sling-recent case.) B1 Postgrad Med J: first published as 10.1136/pgmj.24.267.3 on 1 January 1948. Downloaded from 6 POST GRADUATE MEDICAL JOURNAL January 194g

"''''''i?!!iiiiii :i. ·:: ...:~ ...... I~ii"*'i'iil·?:ail!:"?:':'"'111:*~!~'!~11~i~'e'i:;··;:··:·7 iiii?.'~e:.: ':~:::" ....· ·"::':...i~i~i~i!i~i~ii~ii~Ri~i~:i::"

:':?;...... LI~iLI

i.:':"~. .· B·,::::

idiiiiiil;:::·~~~..'i·:i;,i:iiiilifl:i..~,i~iiii:iii~ii:ii'i·i by copyright. liiil:'·:··'··:·:·iiili?'i~~ii:...... i;lii::!.:·.;'ii·~ ~:.:' '."'... '"'" ".iii'i~~i... http://pmj.bmj.com/ on September 30, 2021 by guest. Protected

FIGS. 7, 8.-Cystograms on separate films of case exhibiting marked stress incontinence despite previous vaginal repair. Compare level of bladder base relative to pubis in the relaxed and straining positions. (Six months' cure by Millin sling.) FIGS. 9, io.-Cystograms on separate films of case of extreme stress incontinence despite five previous surgical attempts at cure. FIGS. I I, 2.-Cystograms on separate films of case ofvery severe stress incontinence despite Gracilis operation. Following latter procedure there was relief for three months, but the condition relapsed. Postgrad Med J: first published as 10.1136/pgmj.24.267.3 on 1 January 1948. Downloaded from January 1948 MILLIN : Stress Incontinence of Urine in the Female 7

%.-.v..~: ..:~ '..',,...¥.'.-. .'.':,,'.

.'..:':...... ";...... -'~: -:...... - i:?~;.~ ii~~~~i::~!~:'::!':1~;':: :(::(:11::il:;'~':~:~~~ ~~~~~.:." iil'ijfi ;'~'-'~~~~~:~~~.'.~_-'~:.",, ,,~~~~? ·~ ~ ~~~~~~ ~ ~ ~ ~~ ~...:. -.~ .-:.. ...:. . :...::.-....b..::.!:~.¢:::

.-..;-;..:_-.-!...,.. :. -· .. .' '.... :! '.., ...... ,,::: ..'.',...... :....

".....''"..... ·:"...... ' ' ...... ?'":~j :~~~ ...... ~~~~~~~~~~~~~~~~~~~~~~~...:%...·'~'~~.;....''.'..' :~.''"..' "."'. ;' '., by copyright.

...... i:Fiilsiiijllill...... 1BIF~lllil:i~i $i:iiilii

~ ~."',, .,:'·..''.,,,'.'~ ~~~~~~~~~~~~~~~~~~~~~.'...'.. .. '.' "-...2· 18:";':.::i;.': ...:&~4..~? .':'.''.".' ".: .';:~'.- .....%..:.':Lii;:l.'.!.: tt,~.! .:.!..-:,.-l::..::L'..,,,~;;'i:;.....:::.i-"'.....;:..... -.'7~'~;{.~"',""--~~~~~'-...:~~~~~-....':'.------..------:.::---, -.--'.-':'----'. http://pmj.bmj.com/

.:..:...:~.::...... on September 30, 2021 by guest. Protected

FIGS. 13, i4.-Cystograms of case shown in Figs. i , 12 after Millin sling. FIG. 15.-Tracing of Figs. 13, 14 superimposed. FIG. I6.-Oblique cystogram of same case after Note fixity of bladder base. sling. FIG. I7.-Superimposed cystogram showing normal appearance after cure by Millin sling of marked stress FIG. I8.-Superimposed cystogram after cure by incontinence. (Three previous failed vaginal inter- Millin sling. ventions.) Postgrad Med J: first published as 10.1136/pgmj.24.267.3 on 1 January 1948. Downloaded from 8 POST GRADUATE MEDICAL JOURNAL January I94:8

··· .·'::':jl·i· ·:;·. i:::'.· ;'·: :"":'·':"·:··· iiii'l'iiiiii'iil "·iYil:: ·i·:

III a.l.·..fgi.ggll.lsfs8.!":-:r"...i.'.:.

ii·:.:· .:jl ·:1:::

lii:i ·I: ii:·"i. i·: ···:·,::.r::i::r::.:i·:iiCai ·:::;·:·:··:i.:..:··:·.·: ·:r· ·····:;··;··;·:··.· ·:··· iFi·:· ::·i:··:··. :i' ;i':'i: ·· ·' ·: .i. ,:.;::::lil.i:.i: ;iiiji.. .i::::.:: :··:;·:':: ·.i. ··'·:'·i

FIGS. 19, 20.-Oblique cystograms in case of marked stress incontinence (two unsuccessful surgical interventions). Note movement of bladder neck downwards and backwards (three cms. on skiagram) on straining. by copyright. http://pmj.bmj.com/

it ·i··:iiiiBi;;i:·· i·:·i·l:::l::$·i·:::.·. sBssas.Bplsaasss..ill.i.,.i.P,···'ii.: !I..i ...: ·'·:'·. ··:.·:: ::::I.: ·.: :..:·.I:;ii.i4i...g...... ge

..ZE.B8..3i;.ik;;iEi$:4 on September 30, 2021 by guest. Protected li:gE$ ;i· ::a··l·

.i-.- .:1..·...... i·i. ··i ::I .:.I :i: :· .-irrplllal. i'·'· .·':,:II:;sd.g.a.sc s.a.s.p!l :::i·:

I' .· ·:;·:·:·:il:i·:·;:·:· FIG. 2I.-A-P shift cystogram in case of marked pro- FIG. 22.-Oblique view of same case showing no move- cidentia without incontinence. (Foley catheter used here, ment either downwards or backwards on straining. bag being partially distended with Neo-hydriol). Note no (Cf. Figs. 19 and 20). downward movement of bladder neck. Postgrad Med J: first published as 10.1136/pgmj.24.267.3 on 1 January 1948. Downloaded from

January 1948 MILLIN : Stress Incontinence of Urine in the Female 9 (2) Gracilis transplant of Giordano. these structures, but in the course of their opera- (3) Anterior plication of Lowsley. tions a wide freeing of the bladder neck and urethra (4) Urethral rotation of Gersuny. is effected. In Davies' operation the base of the (5) Urethral angulation of Thomsen. bladder is freed extensively in addition. In both (6) Urethral angulation and elongation of these operations the loss of blood can be consider- Bonney. able. We believe that the good results of these workers and their adherents, notably Counsellor, Abdominal Operations are due more to the excellence of the buttressing (I) Cystopexy of Bonney. obtainable after the wide freeing of the bladder (2) Cervico-cystopexy of Perrin and Williams. neck, and only serve to corroborate our view that (3) Aponeurotic suspension of Goebel, Stoeckel. the essential lesion is a descent of the bladder neck. (4) Intravesical tautening of bladder neck The Gracilis transplant proposed by Giordano (Millin, Macky). and advocated by others, notably Loughnane in (5) Millin sling operation (to be described in this country, is based, in our submission, on a detail later). false conception of the pathology. Attention is here directed not against the faulty bladder neck, Combined Abdomino- Vaginal Operations but against the urethra, which it aims at com- (I) Frankenheim, Michon. pressing. When the muscle transplant does not (2) Aldridge, Studdiford. slough early, a good immediate result may be (3) Delinotte. obtained, but later the muscle becomes converted Undoubtedly the commonest operation em- into fibrous tissue and the incontinence recurs. ployed today is some type of colporrhaphy in The urethral rotation operation of Gersuny association with a buttressing of the tissues below seldom gives satisfactory results and there is a the bladder neck by some form of suture-mattress real risk of sloughing of the urethra. We have or otherwise- suitably placed in the sub-urethral seen two such cases and the results were disastrous. tissues. Experience shows that the long-term Recently Thomsen has described a method ofby copyright. results are on the whole not so satisfactory as was acutely angulating the urethra and has shown some originally thought. It was commonly stated that urethrograms illustrating both the pre- and post- the cure rate was over 90 per cent., but in our operative findings. We feel that the good results experience it is certainly much lower than this, obtained by him are again due more to the eleva- and Counsellor has estimated that even in the tion of the bladder neck than to the urethral the best hands the cure rate is not above 70 per angulation in his procedure. cent. We can confirm this. The late recurrence rate The Lowsley ribbon-gut anterior plication has, is seldom appreciated, and we have seen many in our opinion, little to recommend it. patients in whom the immediate result has been Recently Wilfred Shaw has advocated the sutur- http://pmj.bmj.com/ completely satisfactory, but with the passage of ing of what he terms the ' post-urethral ligament' a few months the symptoms have returned to their to the cervix, thus forming a shelf upon which the original degree of severity. Such patients seldom bladder rests. This undoubtedly elevates the benefit from a repeat vaginal repair. the bladder neck, but we feel that it tends to The Kelly operation, so ardently supported by approximate the cervix to the symphysis with the Baltimore School, is, we believe, in some resulting tendency to retroversion and shortening respects based on false premises. Its exponents of the anterior vaginal wall. believe that there is an intrinsic laxity of the on September 30, 2021 by guest. Protected sphincter mechanism about the bladder neck, and Abdominal Operations they ' take a tuck' in the sphincter by means of Of the abdominal operations, cystopexy and a silk mattress suture during the performance of cervico-cystopexy have been performed by many the colporrhaphy. One of us (T.M.) has in the workers, notably Bonney, Perrin and Everard- past operated upon more than forty of these cases Williams. The operation involves a ventro- by an intra-vesical technique, and has found, in fixation of the bladder, with or without the bladder contradistinction to the cases of congenital incon- neck, to the posterior periosteum of the symphysis tinence, only rarely, a marked relaxation of the and to the anterior abdominal wall. Both catgut vesical outlet. (This observation would appear to and silk have been used and it would appear that disprove the contention of Macky, and to make cervico-cystopexy, using silk, offers the best chance his proposed intra-vesical tautening of the ' torn' of a cure. We feel that time will eventually show sphincter unnecessary.) a relaxation of the cervical and bladder musculature The operations of Kennedy and Davies are with recurrence of the incontinence. Moreover, based on the belief that the urethral sphincters are the use of silk may be followed by a perforation of prime importance. They aim at restoring of the mucous membrane with exposure of the Postgrad Med J: first published as 10.1136/pgmj.24.267.3 on 1 January 1948. Downloaded from Io POST GRADUATE MEDICAL JOURNAL January 1948 silk to the urine and subsequent formation of an anterior vaginal repair with the application phosphatic encrustations. of a fascial sling of external oblique aponeurosis The original 'sling' operation proposed by below the urethra. Its performance necessitates Goebel undoubtedly led to some cures, with both an abdominal and a vaginal incision and it is improvement in many others, but suspension of relatively time-consuming. It involves alteration the bladder neck from a fixed bony point allows of the position of the patient during the operation for little margin of error-an unduly tight sling and has the theoretical risk of sepsis ascending will give rise to a bar formation at the vesical from the vaginal incision. outlet with or even retention, whilst a It will be seen from the above consideration failure to elevate sufficiently will not realize a that many procedures have been proposed and complete relief from symptoms. applied to cure this distressing complaint. The One of us (T.M.) for some time practised an multiplicity of operations suggests that in the past intra-vesical operation in which the.bladder was no single method has been completely successful. opened suprapubically and, after a wedge of the We would reiterate that while we consider that bladder neck had been excised, the outlet was a sling operation of the Aldridge or Millin type narrowed and buttressed with chromic catgut will cure most cases, we feel that the performance mattress sutures. The immediate results were of these sling operations is rarely justified until an on the whole good, but relapses occurred, and the adequate attempt has been made at repair from operation was abandoned. the . In our view, in the case of a failed The sling operation (to be discussed in detail urethroplasty, the ' Millin sling' operation is that in a subsequent article) proposed by Millin more of choice. than three years ago, and now carried out by us in more than 130 has been found BIBLIOGRAPHY cases, singularly ALDRIDGE, A. H. (1942), Amer. J. Obst. & Gyn., 44, 398. effective. DAVIES, J. W. (1942), J. Uroi., 48, 536. DELINOTTE, R. (1947), J. Beige d'Urol., 6,76r. KENNEDY, W. T. (1937), Amer. J. Obst. & Gyn., 34, 576. Combined Approach LOWSLEY, O. S. (1936), J. Urol., 36, 400. by copyright. MACKY, F. (I944), J. Urol. 52, 27. Frankenheim, Michon, Delinotte, Studdiford and MICHON, LOUIS (1946), 39me. Congres franc. d'Urol., p. 340. MILLER, J. D. (1938), J. Urol., 40, 6I2. Aldridge have all worked on a combined abdomino- MILLIN, TERENCE (1939), Proc. Roy. Soc Med., xxxii, 777. to the and the MILLIN, TERENCE (1947), Proc. Roy. Soc. AMed., 40, 361. vaginal approach problem procedure MOIR, J. CHASSER (I947), Edin. Med. J., LIV, 368. of Aldridge is perhaps the best known and the most MUELLNER, S. R. (1946), New Eng. J. Med., 12, 400. PERRIN, E. (1946), 39me. Congresfranc. d'Urol., p. 334. widely practised. This operation in this country STUDDIFORD, W. E. (1944), Amer. J. Obst. & Gyn., 47, 764. has been endorsed Chassar Moir and it un- STUDDIFORD, W. E. (1945), Ibid., 50, 119. by THOMSEN, EINAR (1940), Acta Radiologica XI, 5, 63. doubtedly produces good results. It combines THOMSEN, EINAR (x94I), Acta Radiologica XII, 3, 4, 73, 74.

'Stress Incontinence of Urine in the Female '-Part z http://pmj.bmj.com/ will be published in the February number of this Journal. on September 30, 2021 by guest. Protected In Great Britain there is strong opposition to the whole concept of a university hospital, an opposition rarely if ever based on first-hand experience of the working of the system in other countries. Nevertheless I remain convinced that the transformation of the teaching hospitals of Great Britain into true university hospitals would do more than any other single act ofreform in medical education to ensure that our successors will indeed be members of a liberal scientific and learned profession. PROFESSOR HARRY PLATT. 1947.