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 urethrocele 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: enuresis, 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 menopause 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 ·::··: ·:·I*::· ".i :::::·:·-,r. :::i·· :···;I ··: : :.·1.;· r?:·r.:. 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 urethra 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 pessary 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 vagina 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.
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