Aims of Study
About
a decade ago, Ulf Ulmsten and Peter Papa Petros first proposed their
“Intregral Theory of Pelvic Floor Dysfunction” (1) which has subsequently
been put forward and developed further in a large number of publications.
It has also resulted in the development of surgical procedures designed
to cure stress and urge incontinence (2,3,4), prolapse, voiding dysfunction
(5), symptoms of bowel dysfunction and chronic pelvic pain (6). One
of the main tenets of the Integral Theory is that urgency, frequency,
nocturia and urge incontinence are caused by anterior vaginal wall
relaxation.
So far there has been no systematic attempt
to prove or disprove this hypothesis which, if true, would allow us
to surgically cure a condition that, so far, has been regarded as
virtually incurable (7). This study attempts to correlate symptoms
and urodynamic signs of bladder irritability (frequency, urge incontinence,
nocturia, sensory urgency and detrusor instability) with ultrasonic
evidence of anterior vaginal wall relaxation.
Methods
275 consecutive patients with symptoms of lower
urinary tract dysfunction underwent urodynamic evaluation. After completing
a detailed history, multichannel urodynamics using microtransducer
catheters were performed. Multiple challenge manoeuvres such as fast
fill at 50ml/ min., tilting to the upright position, coughing and
handwashing in cold water, were undertaken to optimise detection of
detrusor instability. Imaging was performed both with fluoroscopy
and with translabial ultrasound, the latter after bladder emptying
and in the supine position. A variety of ultrasound scanners were
used with 3.5- 7 MHz curved array transducers. Findings were documented
on videotape and/or printers and evaluated subsequently by the first
author who was blinded regarding the urodynamic data. 272 datasets
were complete and used for the analysis. Translabial imaging data
was collected as previously described (8) with the addition of quantification
of maximal cystocele descent on Valsalva manoeuvre. Descriptive statistics
were obtained with Microsoft Excel on a PC system. Comparative statistics
were performed using minitab TM (v 12).
Results
Table 1 shows correlations between indices
of anterior vaginal wall descent and lower urinary tract symptoms.
There were the expected positive relationships with stress incontinence
but none of the other symptoms correlated positively. Opening of the
retrovesical angle was negatively associated with nocturia and urge
incontinence. The former was also negatively associated with bladder
neck descent and descent of a cystocele.
|
Symptoms
|
Stress
Incontinence |
Frequency |
Nocturia
|
Urge
Incontinence |
| US parameters |
|
|
|
|
| RVA-S |
p=0.0002* |
p=0.091 |
p=0.005# |
p=0.0036# |
| Rotation |
p=0.0088* |
p=0.96 |
p=0.077 |
p=0.46 |
| BND |
p<0.0001* |
p=0.41 |
p=0.002# |
p=0.17 |
| Cystocele |
p=0.0063* |
p=0.61 |
p=0.0043# |
p=0.26 |
Table 1: Correlations between indices of
anterior vaginal wall descent and symptoms of lower urinary tract
dysfunction (* positive, # negative relationship).
| Urodynamics |
First
Sensation |
Max. Capacity |
Sens
Urgency |
DI |
| US parameters |
|
|
|
|
| RVA-S |
p= 0.370 |
p= 0.160 |
p=0.11 |
p=0.042 |
| Rotation |
p= 0.550 |
p= 0.533 |
p=0.15 |
p=0.10 |
| BND |
p= 0.858 |
p= 0.628 |
p=0.23 |
p=0.014 |
| Cystocele |
p= 0.511 |
p= 0.909 |
p=0.048 |
p=0.0026 |
Table 2: Correlations between indices of
vaginal relaxation and urodynamic findings.
Pearson’s correlation coefficient or t- test. All significant
relationships are negative.
Table 2 demonstrates correlations between descent
parameters and urodynamic signs of bladder irritability. There were
no positive correlations. Sensory urgency was negatively associated
with descent of cystocele, and detrusor instability was negatively
associated with opening of the retrovesical angle, bladder neck descent
and descent of a cystocele.
Conclusion
This retrospective study evaluated imaging
data and urodynamic reports from 272 women suffering from symptoms
of lower urinary tract dysfunction. Opening of the retrovesical angle,
bladder neck descent, urethral rotation and descent of a cystocele
during Valsalva were used to quantify anterior vaginal wall laxity.
None of those parameters were associated with symptoms and signs of
detrusor overactivity. On the contrary, patients with higher grades
of urethral and bladder descent were less likely to suffer from nocturia
and urge incontinence and were less likely to have sensory urgency
and detrusor instability diagnosed on urodynamic testing.
Literature
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4
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