Vaginal Lawsuit:  Many women complain of persistent urinary problems after pregnancy and childbirth. On closer questioning irritative bladder symptoms may have been present for several years prior to the pregnancy in those women found to have DO. However, both stress and urge incontinence may arise de novo at any time, especially after delivery. Abdominal and pelvic examination form an essential part of the assessment of any woman who presents with urinary incontinence. If there are any symptoms that point to a possibLe neurological cause, it is important to perform a screening neuroLogical examination. examination as they will influence management. Similarly, an assessment of motivation and manual dexterity is important in determining the treatment most likely to prove effective.

Because of the close proximity of the Lower urinary and genital tracts in the female, the presence of pelvic organ prolapse can have an important bearing on urinary symptoms and their management. The grade of proLapse can be classified subjectively as mild, moderate or severe or graded according to the International Continence Society (ICS) pelvic organ prolapse quantification score (POP-Q).

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A cystocele, which drags on the trigone of the bladder, may give rise to urgency and frequency as the trigone stretches and afferent fibres convey a sense of bladder fullness to the brain. Excursion of the bladder neck during coughing may lead to stress incontinence. This is often (but not exclusively) associated with anterior vaginal wall prolapse when a deficiency or abnormality in tissue collagen may be a common aetiological factor. In addition, pelvic masses, such as ovarian cysts or uterine enlargement, can cause urinary symptoms, and these conditions need to be excluded by bimanual examination. If this cannot be done with confidence, for example in the obese patient, then a transvaginal ultrasound scan should be considered.

The impairment of quality of life (QoL) caused by urinary incontinence is difficult to predict using symptoms and urodynamic studies alone. In addition, individuals vary greatly in their perception of the significance of their lower urinary tract symptoms and how severely these restrict their normal psychosocial function. QoL questionnaires are therefore a useful adjunct in assessing the impact of urinary incontinence and bladder dysfunction.

This helps to emphasize the multidimensional nature of QoL and the importance of considering the patient’s own perception of her situation regarding non-health-related aspects of her life. There are many validated questionnaires available to assess QoL impairment [eg King's Health Questionnaire, Bristol Female Lower Urinary Tract Symptom Questionnaire (BFLUTS), Incontinence Impact Questionnaire (IIQ), Urogenital Distress Inventory (UDI)] due to urinary disorders. Most of these have a similar structure, consisting of a series of sections (domains) designed to gather information regarding particular aspects of health. They are particularly helpful for monitoring response to treatment.

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Urinary symptom analysis alone is not sufficient to gain an accurate impression of the underlying pathology, as this may lead to inappropriate treatment being given. Even simple office investigations (Table 3.1) may be invaluable in identifying associated causal factors not immediately apparent. The presence of UTI will worsen irritative bladder symptoms and invalidate the results of urodynamic investigations. A pure growth of more than 100 000 organisms/ml of urine is taken to signify infection that should be treated with appropriate antibiotics.⁸ Recurrent UTI requires investigation to ensure that the bladder is completely emptied after each void. Investigations will also exclude the presence of any focus for infection, such as ureteric or intravesical calculi, or neoplasm.

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Vaginal Lawsuit : Catheters are widely used for effective bladder drainage, either temporarily or permanently, when physiological and anatomical defects or obstruction of the lower urinary tract are present. When dealing with incontinence, all other possibilities for treatment or management must be explored following appropriate investigation. The urethral catheter is the most frequently used catheter as it can be quickly and easily inserted. Urethral catheterization is an accepted aseptic procedure and should be undertaken under the guidance of strict local hospital or community infection-control policies.

All catheters in the UK must now conform to British Standards following reports that some catheters were associated with cytotoxicity.⁸ Plastic or PVC and latex rubber are for short­term use only. They tend to attract surface deposits, causing encrustation and fractures within the catheter. Plastic catheters are also rigid and uncomfortable, causing bladder spasm and bypassing.⁹ Improvements on the latex catheter include ‘siliconizing’ the surface of the catheter producing a lubricant effect to facilitate insertion. Latex has also been coated in Teflon (polytetrafluoroethylene, PTFE) to make it more inert and to give it a smoother surface to reduce urethritis and encrustation.

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For long-term use, silicone elastomer- encapsulated (coated) latex catheters are recommended. Silicone reduces the incidence of trauma, urethritis and encrustation. Hydrogel catheters (eg Biocath, Bard) are similar to silicone catheters but they become smoother when hydrated. Catheters are measured in ‘French’ gauge (Fg) or ‘Charriere’ (Ch) units. This is the measurement of the external circumference in millimetres, which is approximately equal to three times the external diameter, depending on the catheter material. Catheters used in women should range from size 12Ch to 16Ch, with a small balloon.

Urinary tract infection is the most frequent complication with long-term indwelling catheters. Most catheter users wilL have bacteria in the urine within three days.¹¹ Infections can be difficult to eradicate due to the growth of bacterial populations as an adherent biofilm on the catheter surface. Common pathogens, such as Escherichia coli, are eliminated from the urine but persist in the biofilm and restart the cycle of infection. The incidence of catheter blockage and bypassing in long-term catheterization is around 48% for blockage and around 37% for bypassing.¹³ Large catheter, detrusor spasm, blockage, debris or bladder calculus are all reasons for catheter failure. The use of a smaller catheter will help reduce the incidence of abnormal bladder contractions.

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One shouLd also enquire about the presence of stress incontinence, urinary tract infections and voiding difficulty. Nocturnal enuresis as a child is often associated with DO as an adult. A history of previous urological investigations, their result and any ensuing treatment, especially of incontinence surgery, is very important to note. If women complain of incontinence it is important to check for coexistent medical conditions and optimize their treatment. For example, the onset of diabetes significantly increases urine output and many pharmaceutical agents can alter bladder function. In order to gain an accurate impression of the psychosocial morbidity associated with the patient’s condition, it is important to elucidate the restrictions it brings to everyday Life and the coping strategies adopted to deal with these restrictions.

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Vaginal Lawsuit :  Early work wouLd suggest that some SERMs in development, eg levormeloxifene and idoxifene, might increase the risk of urogenital prolapse,⁵³although there were some methodological problems noted in the study. However, in another analysis of three randomized, double­blind, placebo-controlled trials investigating raloxifene in 6926 postmenopausal women. Oestrogens are known to have an important physiological effect on the female Lower genital tract throughout adult life, leading to symptomatic, histological and functional changes. Urogenital atrophy is the manifestation of oestrogen withdrawal following the menopause, presenting with vaginal and/or urinary symptoms. The use of oestrogen replacement therapy has been examined in the management of lower urinary tract symptoms as well as in the treatment of urogenital atrophy. Only recently has this treatment been subjected to randomized placebo-controlled trials and meta-analysis.

Oestrogen therapy alone has been shown to have little effect in the management of USI. When considering the irritative symptoms of urinary urgency, frequency and urge incontinence, oestrogen therapy may be of benefit, although this may simply represent reversal of urogenital atrophy rather than a direct effect on the lower urinary tract. drugs appeared to have a protective effect – fewer treated women had surgery for urogenital prolapse. Finally, low-dose vaginal oestrogens have been shown to have a role in the treatment of urogenital atrophy in postmenopausal women and would appear to be as effective as systemic preparations.

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Incontinence can be cured or significantly improved in most women providing they are appropriately investigated and treated. However, some women may not wish to undergo medical or surgical intervention. There are also a number of women for whom a cure may be impossible. For this group, containment with pads, devices or even catheters may be the most appropriate therapy. Reported figures¹ estimate the overall cost of incontinence to the NHS at £354 million, with the cost continuing to rise.² Continence products are one of the biggest expenditures for the NHS today.

Products available are numerous, but it is important to match the product to the individual’s personal needs, wishes and social circumstances. It is difficult even for a specialist continence nurse to keep up with the choice available. Companies are constantly changing and developing their products, endeavouring to ensure that their products suit the requirements of the users. The pad is the most common and the most readily available form of containment. The market of reusable and disposable products has grown tremendously. In 1974 Bill Kylie, an Australian, launched an oblong absorbent pad that became the forerunner of the disposable pad industry. There are few quality trials to assess pads, and many products have frequently been replaced before the results are published.

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Pads should not be used as an alternative to effective continence promotion strategies. They should really be a temporary measure while investigations are undertaken or treatment is awaited. Pads should only be used as treatment in the severely incontinent person where containment will be a priority. Pads can either be disposable or reusable. There is no strong evidence that one is more effective than the other. The advantages and limitations of reusable and disposable products are outlined in Table 12.1. The commonest problem with disposable pads is that they can become bulky and the covering can even become separated if they are not replaced when needed.

The decision whether or not to use reusable incontinence products rather than disposables is a complex one that will depend on individual needs and preferences. The availability of suitable laundry facilities is an important factor. Over a thousand items, ranging from special toilet seats to assist toilet training to odour-control products are listed in The United Kingdom Continence Foundation Product Directory.

In recent years there has been a wide variety of new continence devices developed.⁷ Although interest continues with clinicians and patients, many of the devices have never made it onto the market or have been removed from the market shortly after release. Some products are available on the Internet, but until these products become more widely available, they will continue to be limited to specialist units in controlled trials.

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Vaginal Lawsuit : In order to clarify the situation, a meta­analysis from the HUT Committee has been reported.⁴³ Of 166 articles identified that were published in English between 1969-92, only six were controlled trials and 17 were uncontrolled series. Meta-analysis found an overall significant effect of oestrogen therapy on subjective improvement in all women and for women with urodynamic stress incontinence (USI) alone. However, when assessing objective fluid loss there was no significant effect. Maximum urethral closure pressure was found to increase significantly with oestrogen therapy, although this outcome was influenced by a single study showing a Large effect.

A further meta-analysis performed in Italy has analysed the results of randomized controlled clinical trials on the efficacy of oestrogen treatment in postmenopausal women with urinary incontinence.⁴⁵ A search of the literature (1965-96) revealed 72 articles, of which only four were considered to meet the meta-analysis criteria. There was a statistically significant difference in subjective outcome between oestrogen and placebo, although there was no difference in objective or urodynamic outcome. The authors conclude that this difference could be relevant,

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In addition to the studies included in the HUT meta-analysis, several authors have also investigated the role of oestrogen therapy in the management of USI only. Oral oestrogens have been reported to increase the maximum urethral pressures and to lead to symptomatic improvement in 65-70% of women/’⁶’⁴⁷although other work has not confirmed this. A recently reported meta-analysis has helped determine the role of oestrogen replacement in women with USI.⁴⁹ Of the papers reviewed, 14 were non-randomized studies, six were randomized trials (of which four were placebo­controlled), and two were meta-anaLyses. Interestingly, symptomatic or clinical improvement was only noted in the non­randomized studies. There was no such effect noted in the randomized trials. The authors conclude that currently the evidence would not support the use of oestrogen replacement alone in the management of USI.

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Oestrogens have been used in the treatment of urinary urgency and urge incontinence for many years, although there have been few controlled trials to confirm their efficacy. To try to clarify the role of oestrogen therapy in the management of women with urge incontinence, a meta-analysis of the use of oestrogen in women with symptoms of’overactive bladder’ has been reported by the HUT Committee.⁵⁰ In a review of 10 randomized placebo-controlled trials, oestrogen was found to be superior to pLacebo (when considering symptoms of urge incontinence, frequency, and nocturia).

A recent development in hormonal therapy has been the development of selective oestrogen receptor modulators (SERMs), see Table 11.1. These drugs have oestrogen-like actions in maintaining bone density and in lowering serum cholesterol, but have anti-oestrogenic effects on the breast⁵¹ and do not cause endometrial stimulation.⁵² In theory, partial oestrogen antagonists may lead to a down- regulation of oestrogen receptors in the urogenital tract and consequently cause an increase in lower urinary tract symptoms and symptomatic urogenital atrophy.

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Vaginal Lawsuit :  Oestrogen receptors have been demonstrated in the squamous epithelium of both the proximal and distal urethra.²⁴ Oestrogen has been shown to improve the maturation index of urethral squamous epitheLium.²⁵It has been suggested that oestrogen increases urethral closure pressure and improves pressure transmission to the proximal urethra, both of which promote continence. Epidemiological studies have implicated oestrogen deficiency in the aetiology of lower urinary tract symptoms. Seventy percent of women relate the onset of urinary incontinence to their final menstrual period.² Lower urinary tract symptoms have been shown to be common in postmenopausal women attending a menopause clinic, with 20% complaining of severe urgency and almost 50% complaining of stress incontinence.

There is, however, conflicting evidence regarding the role of oestrogen withdrawal at the time of the menopause. Some studies have shown a peak incidence in perimenopausal women³⁶‘³⁷ whilst other evidence suggests that many women develop incontinence at least 10 years prior to the cessation of menstruation, with significantly more premenopausal women than postmenopausal women being affected.

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Urinary tract infection is also a common cause of urinary symptoms in women of all ages. This is a particular problem in the elderly with a reported incidence of 20% in the community and over 50% in institutionalized patients.³⁹‘⁴⁰ Pathophysiological changes, such as impairment of bladder emptying, poor perineal hygiene and both faecal and urinary incontinence, may partly account for the high prevalence observed. In addition, as previously described, changes in the vaginal flora due to oestrogen depletion lead to colonization with Gram­negative bacilli, which, as well as causing local irritative symptoms, also act as uropathogens. These microbiological changes may be reversed with oestrogen replacement following the menopause, offering a rationale for treatment and prophylaxis.

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Oestrogen preparations have been used for many years in the treatment of urinary incontinence,⁴¹‘⁴² although their precise role remains controversial. Many of the studies performed have been uncontrolled observational series examining the use of a wide range of different preparations, doses and routes of administration. The inconsistent use of progestogens to provide endometrial protection is a further confounding factor making interpretation of the results difficult.

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Vaginal Lawsuit:  Withdrawal of endogenous oestrogen at the menopause results in well-documented climacteric symptoms, such as hot flushes and night sweats, in addition to the less commonly reported symptoms of urogenital atrophy. Symptoms do not usually develop until several years after the menopause when levels of endogenous oestrogens fall below the level.

Vaginal dryness is commonly the first reported symptom of urogenital atrophy and is caused by a reduction in mucus production within the vaginal glands. Atrophy within the vaginal epithelium leads to thinning and an increased susceptibility to infection and mechanical trauma. Following the menopause, glycogen depletion within the vaginaL mucosa leads to a decrease in lactic acid formation by Doderlein’s lactobacillus and a consequent rise in vaginal pH. The pH increases from around 4, to between 6 and 7. This allows bacterial overgrowth and colonization with Gram­negative bacilli, thus compounding the effects of vaginal atrophy and leading to symptoms of vaginitis,

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Symptoms of urogenital atrophy do not occur until the levels of endogenous oestrogen are lower than that required to promote endometrial proliferation.¹⁶ Consequently, it is possible to use a low dose of oestrogen replacement therapy in order to alleviate urogenital symptoms while also avoiding the risk of endometrial proliferation and removing the need to provide endometrial protection with progestogens.

However, studies investigating the use of oestrogens in the management of urogenital symptoms have shown that 8-10 pg of vaginal oestradiol is effective.¹⁸ Thus, only 10-30% of the dose used to treat vasomotor symptoms may be effective in the management of urogenital symptoms. Since 10-25% of women receiving systemic hormone replacement therapy still experience the symptoms of urogenital atrophy,¹³ Low-dose local preparations may have an additional beneficial effect.

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A recent review of oestrogen therapy in the management of urogenital atrophy has been performed by the Hormones and Urogenital Therapy (HUT) Committee.²⁰ Meta-analysis of 10 placebo-controlled trials confirmed the significant effect of oestrogens in the management of urogenital atrophy. Oestrogen is efficacious in the treatment of urogenital atrophy and low-dose vaginal preparations are as effective as systemic therapy. In addition, exogenous oestrogens have been shown to increase the number of intermediate and superficial cells in the vagina of postmenopausal women.²⁵ These changes have also been demonstrated in the bladder and urethra.

Oestrogen receptors, although absent in the transitional epithelium of the bladder, are present in the areas of the trigone that have undergone squamous metaplasia.²⁴ Oestrogen is known to have a direct effect on detrusor function – oestradiol has been shown to reduce the amplitude and frequency of spontaneous rhythmic detrusor contractions.²⁷ There is also evidence that it may increase the sensory threshold of the bladder in some women.

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Vaginal Lawsuit :  Incontinent nulliparous women have been shown to have a quantitative and qualitative reduction in the collagen content of their tissues¹²where no evidence of neuromuscular damage exists. In the Nuns Study, 50%  postmenopausal) nuns complained of UI; 30% of these complained of stress incontinence, 24% had urge incontinence and 35% had mixed symptoms. Therefore, in the absence of obstetric trauma, UI is more commonly seen to be of a stress rather than an urge type It is possible that neuromuscular damage and connective tissue deficiency are co-contributors in the aetiology of UI. Among primigravid women, those with excessive bladder-neck mobility have the highest risk of postpartum urinary incontinence.¹⁴ It seems likeLy that connective tissue damage is a ‘prerequisite’, and that neuromuscular damage contributes to the aetiology of USI.

Thirty-seven percent of women notice a deterioration in symptoms prior to menstruation.¹⁵ Furthermore, progestogens have been associated with an increase in irritative bladder symptoms¹⁶¹⁷ and urinary incontinence in those women taking combined hormone replacement therapy.¹⁸ The incidence of DO in the luteal phase of the menstrual cycle may be associated with raised plasma progesterone following ovulation – progesterone has been shown to antagonize the inhibitory effect of oestradiol on rat detrusor contractions.¹⁹ This may help to explain the increased prevalence of DO found in pregnancy.

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Intervention may be preventive. Elective caesarean section may prevent neuromuscular damage⁹ but may not prevent postnatal UI.⁴ Rather, antenatal pelvic-floor-muscle training is effective in reducing the incidence of post­partum UI.⁸Postpartum pelvic-floor-muscle training is effective in reducing the incidence of UI at one year. Follow-up of a cohort of women who delivered in 1994 showed that 31.8% of those dry pre­pregnancy are now incontinent.²¹ Women with increased bladder-neck mobility have an increased incidence of stress incontinence at 14 weeks postpartum, even if there is no pre­existing symptomatology.¹⁴ However, onset of UI prior to the initial pregnancy is the best predictor of incontinence 5-7 years later.²¹ Caesarean section remains protective, but less so than at three months postpartum, with a relatively greater effect with increasing parity. The effect is particularly pronounced if the caesarean section is undertaken prelabour.

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‘Routine’ episiotomy was introduced in the UK in the 18th Century and has been advocated to prevent severe perineal tears and preserve sexual function. Review of five randomized controlled trials of the use of routine and selective episiotomy reveals that sexual function is poorer in the routine group, with no difference in the prevalence of UI and no difference in pelvic-floor-muscle strength.²⁴ Ventouse delivery is less traumatic than forceps, but its use has not been shown to be associated with a reduced incidence of UI or neuromuscular damage.

Symptoms of urogenital atrophy are a manifestation of oestrogen withdrawal following the menopause, and may appear many years after the last menstrual period.¹ Oestrogen deficiency following the menopause is known to cause atrophic changes within the urogenital tract²and is associated with urinary symptoms. The role of oestrogen replacement in the treatment of these symptoms of urogenital atrophy has still not been clearly defined despite several randomized trials and widespread clinical use. This chapter presents an overview of the pathogenesis and management of urogenital symptoms and the role of oestrogen replacement therapy.

In addition to oestrogen receptors, both androgen and progesterone receptors are expressed in the lower urinary tract, although their role is Less clear. Progesterone receptors are expressed inconsistently, having been reported in the bladder, trigone and vagina. Their presence may be dependent on oestrogen status. In addition, whilst androgen receptors are present in both the bladder and urethra, their role has not yet been defined.

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Vaginal Lawsuit:  Cytology of the urine should be negative and the urodynamics should be normal. Cystourethroscopy is usually normal, but is undertaken to exclude chronic cystitis, trigonitis or neoplasms. The urethra should be carefully inspected to exclude urethral diverticula or urethritis. Some authors have described outflow obstruction in association with urethral syndrome, and an associated turbulent backflow of bacteria in the urethra. In truth, as Benness describes in his review, there is a paucity of data to support the therapeutic benefits of urethral dilatation or urethrotomy.

Psychogenic factors have been cited in the aetiology of the urethral syndrome, with evidence of a conversion or psychophysiological aetiology in 56 people who were assessed with a personality inventory.¹² However, a longitudinal assessment of community-dwelling women with either acute UTI or urethral syndrome found high levels of anxiety and psychological morbidity associated with symptoms – these resolved in both groups with cessation of symptoms.

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Increasing the fluid intake to ‘flush’ the urinary tract through will serve only to increase urinary frequency. A daily fluid intake of 1.5 litres should be appropriate for metabolic needs, and will maintain a sufficiently dilute urine output to avoid the irritation of concentrated urine. Showering before intercourse and voiding afterwards should help prevent bacterial colonization. In the presence of sterile pyuria, a long course of antibiotic effective against fastidious organisms is appropriate, eg norfloxacin, doxycycline or erythromycin.

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Stress urinary incontinence is a common feature of pregnancy, affecting 59% at 34 weeks gestation and reducing to 31% at 8 weeks postpartum.³ There is no correlation at 12 weeks postpartum between symptoms of urodynamic stress incontinence (USI), diagnosis of USI and vaginal delivery/’ Urodynamic investigation revealed a prevalence of 9% at 34 weeks gestation and 5% at 12 weeks postpartum.

Detrusor overactivity (DO) is also associated with pregnancy,⁶ with 18% suffering urge incontinence.⁷ Around 15% have urge incontinence at three months postpartum⁸ but only 7% have proven detrusor overactivity. Pudendal neuropathy is common following childbirth, and is thought to be caused by a stretching injury. It is also seen in women with urinary incontinence (UI),⁹’¹⁰ and so a causal relationship between childbirth and UI has long been assumed.¹¹ However, pregnancy (rather than childbirth) may be responsible.

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Vaginal Lawsuit :  The treatment with the most evidence to support its use is instillation therapy with dimethyl sulphoxide (DMSO, an industrial solvent). The treatment regimen is easy and inexpensive to perform on an outpatient basis, providing the patient can manage to self- catheterize. A significant improvement can be expected in over 50% of patients with early IC. There is considerable debate as to the relative roles of different components of the muscles both within the wall of the urethra and surrounding it. These muscles help maintain continence. A number of changes occur to the urethra with age. The strength and the amount of urethral connective tissue fall because of oestrogen deficiency. This causes the support of the urethrovesical junction to weaken. In addition, urethraL vascular pulsations in the submucosal plexus gradually decrease with age.

Urethritis is inflammation of the urethra leading to symptoms of frequency, urgency, dysuria and localized urethral pain. It is caused either by an infectious pathogen or by chemical irritation. Evidence of the use of causative chemical agents, such as bubble baths, vaginal deodorants and perfumed cosmetics, should be sought as part of the medical history in women with these symptoms. Responsible infectious agents include many of the microorganisms associated with sexually transmitted infections, such as herpes simplex virus, Neisseria gonorrheae and Chlamydia. The group of organisms that typically cause acute bacterial cystitis, such as Escherichia coli, may also cause urethritis.

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Where urethritis is suspected, appropriate cultures should be taken from the urethra and vagina as well as a midstream urine culture. Urine microscopy typically shows evidence of pyuria and bacteria. Acute urinary retention can occur secondary to urethritis and needs to be considered. Prompt treatment with an indwelling catheter until symptoms have resolved is important in order to prevent overdistension of the bladder. Initiation of treatment with the appropriate antibiotic usually results in rapid recovery, but scarring of the urethra can result in strictures and subsequent voiding difficulties. Referral to a genitourinary medicine clinic for contact tracing and treatment of partners is important if sexually transmitted organisms are responsible.

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Urethral diverticula are usually found in the distal third of the urethra bulging towards the vagina. They are thought to arise from inflammation in the paraurethral glands and are found mainly in parous women. The incidence of this condition is unclear but is probably around 3%. It is an increasingly seen problem, perhaps because of the recent rise in sexually transmitted infections. The term ‘urethral syndrome’ was first used in 1932,⁵ but remains a very misunderstood condition. This is Largely because there is no consensus on the definition or diagnostic criteria. It usually refers to a symptom complex, often consisting of frequency-urgency with dysuria, in the absence of infection. Less commonly, sufferers describe suprapubic or perineal discomfort, or a sense of incomplete voiding.

The aetiology is multifactoriaL and may include infection, atrophy, urethral spasm, psychogenic factors, and there may certainly be some overlap with interstitial cystitis in terms of epithelial dysfunction.¹¹ The diagnosis is one of exclusion, when UTI, DO and local pathology have been eliminated. When culture and sensitivity are repeatedly negative despite ongoing symptoms, especially in young women, it is worth considering culture for fastidious organisms.

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Vaginal Lawsuit:  Bladder retraining is widely used to treat many of the disorders giving rise to symptoms of urinary frequency-urgency, including DO and sensory urgency. The patient is taught to slowly increase the interval between voiding episodes so that frequency can be reduced and the functional cystometric capacity increases.  This technique was used by Oarvis to treat women with sensory urgency. He demonstrated that >50% of these women were symptom-free and objectively dry six months after treatment with bladder retraining.

This chronic inflammatory disorder of the bladder is notoriously difficult to manage and can result in considerable morbidity. Quality-of- life scores in women with IC are consistently low. Women between the ages of 40 and 60 years are most commonly affected. The condition occurs far more frequently in Caucasians and there is a 9:1 female predominance.⁴ Reported prevalence rates for this condition vary widely as there is no universally accepted definition.

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Avoiding often relieves the suprapubic discomfort, and drinking alcohol and caffeine- containing drinks frequently exacerbates the pain. In an attempt to standardize diagnosis, the National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases published consensus criteria in 1988. These consist of a list of exclusion criteria together with some positive cystoscopic features (Table 9.2). There is no universally agreed histological standard for diagnosing IC on bladder biopsy. However, biopsies are useful to exclude other pathology, including malignancy.

Many different treatments have been tried for IC, with little sustained success. Proposed systemic treatments include antihistamines, heparin, amitriptyline and pentosan polysulphate. Pentosan polysulphate is a synthetic glycosaminoglycan analogue and augments the protective mucous layer of the bLadder. Many patients with IC have been shown to have an improvement in symptoms following cystodistension. Unfortunately, any beneficial effects are short-lived. The treatment with the most evidence to support its use is instillation therapy with dimethyl sulphoxide (DMSO, an industrial solvent). The treatment regimen is easy and inexpensive to perform on an outpatient basis, providing the patient can manage to self- catheterize. A significant improvement can be expected in over 50% of patients with early IC.

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In a small Danish follow-up study over three years, monthly instillation of sodium hyaluronate solution (Cystistat, Pliva Pharma) showed benefit in approximately two-thirds of cases, and apparent recovery in 20%.⁶Furthermore, in a study of refractory cases of IC, an initial positive response in 56% at four weeks improved to 71% by week 12. Response then decreased after week 24 of treatment. King’s College Hospital is currently part of an international multicentre study to assess the safety and efficacy of pelvic floor electro­stimulation in the treatment of IC. Although the results are awaited, the initial response appears very encouraging.

Finally, where other treatments fail and symptom severity is such that the patient’s quality-of-life is destroyed, a urological opinion should be sought and reconstructive surgery considered. Sensory urgency is a diagnosis of exclusion made after urodynamic assessment. It consists of the symptom complex of frequency-urgency, and occasionally urge incontinence, but with no evidence of DO on subtracted cystometry or other underlying intravesical pathology.

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Vaginal Lawsuit: The process of toilet training in young children is the learning of corticaL inhibition of detrusor contractions. Many researchers feel that idiopathic DO is either an ‘unlearning’ or poor initial learning of this control. There is also evidence that idiopathic DO is caused by a functional denervation injury of the detrusor muscle. Any neurological lesion or condition that interrupts the cortical inhibition of detrusor contractions can result in neurogenic DO, eg multiple sclerosis or spinaL cord lesions. Urethral outflow obstruction can lead to incomplete bladder emptying, and subsequent symptoms of urgency and frequency.

Treatment consists of a combination of bladder retraining and ‘bladder drill’, with anticholinergic medication to help relearn the cortical inhibition of detrusor contractions. This may be time-consuming and frustrating – correct diagnosis is necessary to ensure maximum patient compliance with this treatment. These injuries can occur because of injudicious and inappropriate care of the bladder after epidural anaesthesia. In the obstetric setting, lack of sensation or awareness in the mother, in combination with a busy postnatal ward, may mean that the mother does not pass urine for many hours after leaving the delivery suite.

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Inappropriate management, combined with a post-partum diuresis, can result in several overdistension injuries, compounding the original problem. Even a single episode of overdistension may result in permanently impaired detrusor function. The female bladder is especially sensitive to overdistension. Functional incontinence includes cases of UI where no organic cause can be found. Several other factors may be responsible for problems with incontinence due to interference with voiding behaviour. These include cognitive factors, such as dementia and learning difficulties, as well as physical factors, such as immobility and disability.

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Symptomatic UTI is a cause of acute incontinence, especially in young women, often because of extreme frequency, urgency and pain. If symptoms persist, despite negative cultures, it is worth considering culture for fastidious organisms, such as Chlamydia trachomatis, Ureaplasma urealyticum or Mycoplasma hominis. Alternatively, empirical treatment might be considered. Atrophic urethritis and/or vaginitis in postmenopausal women are often associated with urinary tract symptoms.

These conditions are due to epithelial and submucosal thinning of the urethra, with consequential irritation and loss of the mucosal seal. Incontinence associated with atrophic urethritis tends to be characterized by urgency and occasionally ‘scalding’ dysuria, and may be underreported.¹² Treatment with local oestrogen cream or hormone replacement therapy is as effective as oral therapy in correcting atrophy.

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Vaginal Lawsuit:  Obstetric fistulae are much commoner in the developing world and are a frequent reason why women are cast out of their homes and communities and abandoned. Urethrovaginal and ureterovaginal fistulae are much less common than vesicovaginal fistulae. In the developed world they are unusual causes of urinary incontinence (UI). Once again, the most common cause of these fistuale in the developing world is obstetric trauma due to ischaemic necrosis; in developed countries the most common cause is surgery. Anterior repair, vaginal hysterectomy and urethral diverticulectomy have all been associated with an increased risk of urethral fistula formation.

USI, as opposed to the patient symptom ‘stress urinary incontinence’ (SUI), is only diagnosed after performing urodynamics and is the involuntary leakage of urine per urethram during periods of raised intraabdominal pressure, in the absence of a detrusor contraction. Normal urethral function maintains a positive urethral closure pressure in the presence of raised intraabdominal pressure, although DO may overcome it. An incompetent urethra allows leakage of urine, even in the absence of a detrusor contraction. Damage to the pubo- urethral ligaments and the levator ani muscles (secondary to pregnancy, childbirth, obesity, radical pelvic surgery, abdominopelvic mass or chronic cough, and possibly exacerbated by inherited weak collagen) may allow bladder- neck hypermobility and descent of the bladder neck and proximal urethra, so that they are no Longer within the intraabdominal pressure zone.

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Symptomatically, these patients are similar to, and often indistinguishable from, patients with DO. Sometimes, however, low compliance may be associated with a fast bladder-filling rate. Low compliance is seen less often at Patients with DO are often indistinguishable from patients with low compliance; however, low compliance may be associated with a fast bladder-filling rate and is seen less often at physiological filling rates.

The incidence of DO increases with age, and urge incontinence is the commonest symptom of incontinence in people aged over 60 years⁸ and the elderly.⁹ Urodynamic assessment is required to make an accurate diagnosis, as women usually present with multiple symptoms, most commonly a syndrome of frequency, urgency and nocturia. The pathophysiology of DO is poorly understood and an underlying cause is rarely found, leading to the term idiopathic DO. Detrusor overactivity and USI can coexist as mixed incontinence and DO can arise de novo after incontinence surgery.

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Vaginal Lawsuit :  Ultrasonography of the urinary tract may be performed. This can be useful to visualize the upper tracts when looking for dilatation secondary to reflux, or to estimate bladder capacity or post-void residual. More recently, bladder wall thickness has been used to assess the probability of DO – a thickened hypertrophied detrusor being associated with abnormal detrusor activity. Ultrasound is a rapid, painless method of examining the pelvis and abdomen, and reveals a high number of incidental ultrasound findings, such as ovarian cysts or uterine fibroids. This is true regardless of the source of referral.²⁸ Such space-occupying lesions may profoundly affect lower urinary tract function. Ultrasound cannot yet, however, replace tests of dynamic function.

In isolation, a micturating cystogram is useful to diagnose fistulae and diverticula (Figure 3.8a,b). It is more useful to combine it with dual-channel subtracted cystometry at video- urodynamics. Magnetic resonance imaging (MRI) has improved the anatomical investigation of incontinence and prolapse because of the highly detailed images now available. Specifically, understanding of the normal pelvic anatomy and comparative studies after childbirth has advanced our knowledge of the mechanisms of incontinence and prolapse.^2g In the UK MRI remains predominantly a research (and tertiary centre) investigative technique because of cost and availability.

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The appropriate investigation of lower urinary tract symptoms is of paramount importance in order to secure an accurate diagnosis. Urinary symptoms alone are not sufficient to gain an accurate impression of the underlying pathology, and this may lead to inappropriate treatment being given and deterioration of the patient’s condition and quality of Life. The International Continence Society (ICS) classifies lower urinary tract dysfunction into disorders of the storage and voiding phases of the micturition cycle.^1,2 Adequate cognitive function, mobility, motivation and manuaL dexterity provide the means to perform the tasks of continence. It follows, therefore, that disruption of any of these functions can lead to incontinence.³Assuming the absence of inflammation, infection or neoplasm, lower urinary tract dysfunction can be caused by disturbances of neurological or psychological control and disorders of muscle function, structural abnormalities.

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Uodynamic stress incontinence (USI), detrusor overactivity (DO), mixed incontinence and overflow incontinence are by far the commonest causes of incontinence in the UK. Urodynamic stress incontinence accounts for approximately 50% of cases, DO for around 40% and overflow for most of the remaining 10%. Many women present with ‘mixed incontinence’, which is usually a combination of stress urinary incontinence with DO. Fistulae are rare in England and are usually secondary to gynaecological surgery, maLignancy or radiotherapy. A fistula is an abnormal connection between two epithelial surfaces.

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Vaginal Lawsuit : Urinary symptom analysis alone is not sufficient to gain an accurate impression of the underlying pathology, as this may lead to inappropriate treatment being given. Even simple office investigations (Table 3.1) may be invaluable in identifying associated causal factors not immediately apparent.  The presence of UTI will worsen irritative bladder symptoms and invalidate the results of urodynamic investigations. A pure growth of more than 100 000 organisms/ml of urine is taken to signify infection that should be treated with appropriate antibiotics.⁸ Recurrent UTI requires investigation to ensure that the bladder is completely emptied after each void. Investigations will also exclude the presence of any focus for infection, such as ureteric or intravesical calculi, or neoplasm.

The frequency-voLume (FV) chart (Figure 3.1) is an important tool in the investigation of patients with lower urinary tract symptoms and voiding dysfunction.¹⁰ The chart is variously known as a FV chart, bladder diary or voiding diary, and is completed daily by the patient over a number of days prior to the visit to the doctor. This facilitates history taking regarding the degree of frequency, nocturia and volumes voided at each episode. Compulsive or excessive fluid consumption, normal consumption at inappropriate times (eg bedtime), or an excessive intake of alcohol or caffeine is easily identified and behavioural modification can be commenced.

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Functional bladder capacity should be consistently around 300-500 ml. Frequent voids of variable amounts throughout the day imply bladder overactivity or behavioural adaptation to symptoms. The pad test is a simple, reliable, non-invasive test that quantifies loss by recording the weight change of the pad after it has been worn by the patient under investigation. More than 10 protocols have been described, which vary according to time and bladder filling.

The original evaluation of a one-hour pad test was published in 1981¹³ and found that pad- weight change of more than 1 g shouLd be regarded as abnormal and worthy of further investigation. In another study comparing continent and incontinent women, the 99% upper confidence limit for urine loss was 1.4 g in continent women with normal urodynamics.

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The ICS has set the upper limit of normal for a one-hour pad test as 2 g.¹⁵ The ICS standardized pad test¹⁶ consists of drinking 500 ml of sodium-free liquid within a 15- minute time frame. A pre-weighed perineal pad is placed into the individual’s underwear, following which a series of set manoeuvres are carried out.

When considering surgical treatment of UI it is important to be clear about the underlying cause. Whereas USI is often successfully treated by surgical intervention, DO is not. Indeed it may be made worse by incontinence surgery. The technique of cystometry is well established. A filling catheter and fluid-filled pressure transducer are inserted into the bladder via the urethra. A fluid-filled pressure transducer is then inserted into the rectum via the anus or the vagina. Subtraction of the intraabdominal pressure from the intravesical pressure (subtraction cystometry) allows assessment of the relationship between pressure and volume during filling and of detrusor function by Tests of urethral function, whilst being of limited value in isolation, do confer some information about surgical success and prognosis. Intrinsic sphincter deficiency (ISD) preoperatively carries an increased risk of surgical failure.

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Vaginal Lawsuit:  If women complain of incontinence it is important to check for coexistent medical conditions and optimize their treatment. For example, the onset of diabetes significantly increases urine output and many pharmaceutical agents can alter bladder function. In order to gain an accurate impression of the psychosocial morbidity associated with the patient’s condition, it is important to elucidate the restrictions it brings to everyday Life and the coping strategies adopted to deal with these restrictions. Many women complain of persistent urinary problems after pregnancy and childbirth. On closer questioning irritative bladder symptoms may have been present for several years prior to the pregnancy in those women found to have DO. However, both stress and urge incontinence may arise de novo at any time, especially after delivery.

Abdominal and pelvic examination form an essential part of the assessment of any woman who presents with urinary incontinence. If there are any symptoms that point to a possibLe neurological cause, it is important to perform a screening neuroLogical examination.  The patient’s mobility and mental state affect her ability to react to her symptoms, and it may be appropriate to formally test these as part of the examination as they will influence management. Similarly, an assessment of motivation and manual dexterity is important in determining the treatment most likely to prove effective.

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Because of the close proximity of the Lower urinary and genital tracts in the female, the presence of pelvic organ prolapse can have an important bearing on urinary symptoms and their management. The grade of proLapse can be classified subjectively as mild, moderate or severe or graded according to the International Continence Society (ICS) pelvic organ prolapse quantification score (POP-Q).

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The impairment of quality of life (QoL) caused by urinary incontinence is difficult to predict using symptoms and urodynamic studies alone. In addition, individuals vary greatly in their perception of the significance of their lower urinary tract symptoms and how severely these restrict their normal psychosocial function. QoL questionnaires are therefore a useful adjunct in assessing the impact of urinary incontinence and bladder dysfunction.

This helps to emphasize the multidimensional nature of QoL and the importance of considering the patient’s own perception of her situation regarding non-health-related aspects of her life. There are many validated questionnaires available to assess QoL impairment [eg King's Health Questionnaire, Bristol Female Lower Urinary Tract Symptom Questionnaire (BFLUTS), Incontinence Impact Questionnaire (IIQ), Urogenital Distress Inventory (UDI)] due to urinary disorders. Most of these have a similar structure, consisting of a series of sections (domains) designed to gather information regarding particular aspects of health. They are particularly helpful for monitoring response to treatment.

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