Figure 1 Restoration of continence by PUL support, VIDEO 1.
UPPER FIGURE
Stress urinary incontinence If PUL is weak, it lengthens to “L”
on effort and cannot support the urethra; PCM cannot stretch the distal
vagina “H” sufficiently to close the distal urethra from behind;
LP/LMA forces stretch the trigone backwards to open “H” and the
posterior urethral wall, from “C” (closed) to “O” (open), broken
lines. The hemostat mimics what a suburethral sling does; it
prevents PUL extension to “L” and restores urethral closure, as seen
in the right ultrasound frame (white arrow).
LOWER FIGURE – transperineal ultrasound in a patient with SUI.
Rest (left image). White circles represent PUL. The organs are in
the correct anatomical position. S=symphysis; U=urethra; a&p=anterior
and posterior vaginal walls.
Strain (middle image) Note elongation of PUL on straining (4
white circles). The funnelling of the bladder neck and expansion of
urethral diameter along the whole urethra exponentially lowers the
urethral resistance to urine flow and urine is lost on coughing.
Hemostat test (right image) The white arrow represents the
hemostat as in VIDEO 1. The hemostat supports a weak PUL, prevents
elongation ”L”, and prevents opening by LP/LMA to cause SUI .