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
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1 Karger
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- Author contributions Single author
- Acknowledgements NA
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).