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STRESS INCONTINENCE of URINE in the FEMALE by TERENCE MILLIN, M.CH., F.R.C.S., and CHARLES D

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STRESS INCONTINENCE of URINE in the FEMALE by TERENCE MILLIN, M.CH., F.R.C.S., and CHARLES D 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 urethra 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 fascia, 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-trigonitis 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 urethral sphincters 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.
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