Cure of childhood urgency incontinence with a midurethral sling
Original article by PETER PETROS
Perth Hospital, Perth, Western Australia
CASE REPORT
Miss "X", a 21 year old nullipara had a major incontinence
problem, since childhood which had failed to respond
to any treatment including a "bladder stretch" at 8 years
of age. Her main complaint was history of severe incontinence,
wetting with urgency, with use of 3-4 menstrual
pads per day. Urinary 24 hour diary confirmed this was a
severe problem: 11 entries of urgency with micurition, with
5 recorded episodes of involuntary wetting. She also gave
a history of stress incontinence, nocturia X 1 per night. She
was objectively assessed with a self-administered questionnaire,
diary, pad tests, urodynamics, ultrasound, and "simulated
operation".
There was no urine loss with 10 coughs
in the upright position with a bladder volume of 155 ml.
24 hour pad loss was 90.4 gm. Rotation and a bladder
base descent of 17.7 mm was measured on straining during
transperineal ultrasound. There was no funnelling or urine
loss even with repeated coughing or straining. Overactive
bladder was diagnosed on urodynamics testing. Residual
urine (catheter) was 2 ml. A "simulated operation", was
performed to test the diagnosis of congenital pubourethral
ligament defect: the patient was examined with a bladder
sufficiently full to provoke urgency in the supine position.
Unilateral digital pressure at midurethra relieved the sensation
of urgency 100%.1
Risks and benefits were explained to the patient and
her mother in detail. A midurethral "tension-free" polypropylene
tape was inserted. Immediately after surgery, the
patient reported 100% disappearance of her urge incontinence
symptoms, and also, her stress incontinence symptoms.
On post-operative ultrasound, bladder base descent
was 9.2 cm, with no rotation. The patient remained cured at
last review 4 years later.
This case is of interest on several counts. The patient had
a congenital defect, confirmation of a lax pubourethral ligament
with a 'simulated operation' (disappearance of urgency
with digital midurethral anchoring), surgical cure in the
presence of "overactive bladder", and decision to operate in
a patient who intended to become pregnant sometime in the
future.
The patient was assessed according to the Integral Theory
System1 which states that stress and urgency are mainly
caused by ligamentous laxity, a results of damaged collagen/
elastin, and this may be congenital.
The diagnosis of congenital pubourethral ligament (PUL)
laxity was confirmed with transperineal ultrasound, and by a
"simulated operation":1 disappearance of urge symptoms on
reinforcing the site of PUL insertion. Total cure of urgency
and stress symptoms appear to validate lax PUL as the cause
of symptoms. One significant concern for the patient, her
mother (and indeed the surgeon), was to assess whether the
proposed surgery would interfere with any future childbearing.
Based on the anatomical knowledge of where the tape
was placed, what happens to bladder base during labour (it
rotates suprapubically), and previous experience,2-4 I was
able to reassure the patient and her mother that problems
during pregnancy or labour were unlikely. Surgical cure
in the presence of urodynamic "overactive bladder"(OAB)
presents a singular validation of the recent Cochrane report,5
that the urodynamics OAB has no predictive value in incontinence
surgery.
- Petros PE. The Female Pelvic Floor. Springer Heidelberg, 2nd edition, Chapter 3, 2006; 51-82.
- Petros PE & Ulmsten U. Pregnancy effects on the intravaginal sling operation. Acta Obstetricia et Gynecologica Scandinavica 1990; 69 (Suppl. 153): 77-78.
- Tsia-Shu Lo, Huei-Jean Huang, Ling-Hong Tseng. Success of Tension-Free Vaginal Tape. Procedure After Pregnancy and Vaginal Delivery. Journal of Gynecologic Surgery 2001; 17: 129-131.
- Vella M, Robinson D, Brown R, Cardozo L. 2007, Pregnancy and delivery following tension-free vaginal tape. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18: 347-8.
- Glazener CMA, Lapidan MC. Urodynamic investigations for the management of urinary incontinence in children and adults (Cochrane Review). In: The Cochrane Library, 2006; Issue 1.
Correspondence to:
Professor PETER PETROS
14A Osborne Pde
Claremont WA 6010 Australia
Phone: 61 8 9384 8064
Fax 61 8 9384 0176
Email: kvinno@highway1.com.au