Principal and Corresponding author
Professor PEP Petros DSc DS (UWA) Dr Med Sc (Uppsala) MB BS MD (Syd) FRCOG (Lond) FRANZCOG CU.
Affiliation Retired pelvic surgeon
Email pp@kvinno.com
Tel+61 411 181 731
Running title. Urodynamic test for SUI causation by pubourethral ligament weakness
No of words 600
Key words Interventional Urodynamics; pubourethral ligament; stress incontinence.
Dear Editors
The ICS definition for Urodynamic stress urinary incontinence (SUI), is “the finding of involuntary leakage during filling cystometry, associated with increased intra-abdominal pressure, in the absence of a detrusor contraction”( 1)
Though this objective urodynamic test for SUI causation by a weak pubourethral ligament (PUL) was presented in 2003 (2), since that time, more detailed ultrasound evidence has emerged to further validate it as an objective test, figure1.
Figure 2 demonstrates dramatically altered urethral closure pressures from negative to positive (2). The test was objectively validated by an “interventional” transperineal ultrasound and urethral pressure study in 34 women, as in. VIDEO1. I quote parts from the original paper (2).
From Methods (2) : “Thirty-four patients, mean age 53 years (range, 41-69 yrs) mean parity 3 (range, 1-5), presented with a naturally full bladder (mean volume, 462 mL). The tests were performed with the patient in the semirecumbent position. All patients had transperineal ultrasound examination with and without unilateral application of a hemostat at midurethra both during coughing and straining (2).”
From Results (2): “Thirty-four patients had a history of SI: 8 SI only, and 26 mixed SI and urge. Of the 34 patients, 15 had undergone hysterectomy and 17 a total of 26 incontinence operations. After midurethral anchoring, maximal urethral pressure increased from a mean of 33.25 cm H2O to a mean of 58.06 cm H2O. The changes were significant (P < 0.0001Student’s t-test [two tailed])” (2).
The 2003 study was based on a clinical test for SUI developed by the author, VIDEO1, which was seminal in the conceptualization of SUI cure by the midurethral sling (3).
SUI control by hemostat support of PUL as in VIDEO 1, and the sequence of ultrasound videos, figure 1, anatomically validate the urodynamic test figure 2: left frame, normal anatomy at rest; middle frame, lengthening of PUL and stretching open of the posterior urethral wall on straining with urine loss; right frame, instant restoration of normal anatomy at bladder neck and distal urethra by hemostat support of PUL.
Application of mechanical support to the pubourethral ligaments (PUL) in Figure 2, (“interventional urodynamics”) instantaneously restores anatomy and records the pressure changes in real time; this simple intervention converts standard urodynamics to an accurate, anatomically-based diagnostic tool applicable to an individual patient .
VIDEO1 is an original video on which the urodynamic cough test was based. The VIDEO aims to show that though 90% of the urine loss on coughing was controlled by the hemostat test, distal urethral closure is also important. The 2nd part of the video shows the importance of an adequately tight suburethral vaginal hammock in urethral closure. In a small group of 20 women tested in this way under ultrasound control, in 70%, the urine loss was totally controlled, but 30% (6 women) needed an additional fold for total control, as in the video (4).