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Richard C Bump - One of the best experts on this subject based on the ideXlab platform.
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the effect of bladder training pelvic floor muscle training or combination training on urodynamic parameters in women with urinary incontinence
Neurourology and Urodynamics, 1999Co-Authors: J A Fantl, Jean F Wyman, Donna K Mcclish, D M Elser, Deirdre Robinson, Richard C BumpAbstract:The purpose of this study was to compare the effect of three conservative interventions: pelvic floor muscle training, bladder training, or both, on urodynamic parameters in women with urinary incontinence. Two hundred four women with genuine stress incontinence (GSI) or detrusor instability with or without GSI (DI +/- GSI) participated in a two-site trial comparing pelvic floor muscle training, bladder training, or both. Patients were stratified based on severity of urinary incontinence, urodynamic diagnosis, and treatment site, then randomized to a treatment group. All women underwent a comprehensive standardized evaluation including multi-channel urodynamics at the initial assessment and at the end of 12 weeks of therapy. Analysis of covariance was used to detect differences among treatment groups on urodynamic parameters. Post-treatment evaluations were available for 181 women. No differences were found among treatments on the following measurements: maximum urethral Closure Pressure, mean urethral Closure Pressure, maximum Kegel urethral Closure Pressure, mean Kegel urethral Closure Pressure, functional urethral length, Pressure transmission ratios, straining urethral axis, first sensation to void, maximum cystometric capacity, and the MCC minus FSV. The effect of treatment did not differ by urodynamic diagnosis. Behavioral therapy had no effect on commonly measured urodynamic parameters. The mechanism by which clinical improvement occurs remains unknown. Neurourol. Urodynam. 18:427-436, 1999.
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diagnosing intrinsic sphincteric deficiency comparing urethral Closure Pressure urethral axis and valsalva leak point Pressures
American Journal of Obstetrics and Gynecology, 1997Co-Authors: Richard C Bump, Kimberly W Coates, Geoffrey W Cundiff, Robert L Harris, Alison C WeidnerAbstract:Abstract OBJECTIVES: Our purpose was to compare three measures proposed to diagnose intrinsic sphincteric deficiency: maximum urethral Closure Pressure, Valsalva leak point Pressure, and straining urethral axis. STUDY DESIGN: A total of 159 women with pure genuine stress incontinence had the three measures determined in a standardized fashion. Critical cutoff values for the Valsalva leak point Pressure (52 cm) and urethral axis (22 degrees) were established by examining relative frequency distribution curves, using Closure Pressure of 20 as the arbitrary benchmark value for the prevalence of intrinsic sphincteric deficiency. The distribution of cutoff values is described and differences among the measures with respect to risk factors for intrinsic sphincteric deficiency and incontinence severity were determined. RESULTS: Half the subjects fell below at least one cutoff value, but only 10% fell below all three. Sixty-four percent of subjects with either low Closure Pressure or leak point Pressure had low values for the other, whereas 21% had discordance between them. Only 53% of subjects with low Closure Pressure and 40% with low leak point Pressure had an axis ≤22 degrees. Conversely, a substantial portion (36%) of subjects with pure genuine stress incontinence without urethral hypermobility had neither low urethral or leak point Pressures. All three cutoff values were associated with risk factors for intrinsic sphincteric deficiency, but only low Closure and leak point Pressures had significant associations with the severity of incontinence. CONCLUSIONS: Intrinsic sphincteric deficiency should be diagnosed by a composite of historic, urodynamic, anatomic, and clinical severity criteria. We would include a maximum urethral Closure Pressure ≤20, a Valsalva leak point Pressure ≤50, and a stress urethral axis ≤20 in this composite. (Am J Obstet Gynecol 1997;177:10.)
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racial comparisons and contrasts in urinary incontinence and pelvic organ prolapse
Obstetrics & Gynecology, 1993Co-Authors: Richard C BumpAbstract:Objective To compare black and white women with regard to urinary incontinence and prolapse. Methods Two hundred consecutive women referred for evaluation of urinary incontinence or severe prolapse, 54 of whom were black, were evaluated. Each had a comprehensive standardized evaluation. Qualitative and quantitative data were analyzed for significant differences between the groups. Results The symptoms of pure stress, pure urge, and mixed incontinence were described by 7, 56, and 37% of black subjects, respectively, compared to 31, 28, and 41% of white subjects (P = .001). The conditions of pure genuine stress incontinence (GSI), pure motor incontinence, and mixed incontinence were diagnosed in 27, 56, and 17% of black subjects, respectively, compared to 61, 28, and 11% of whites (P = .0008). Black women with mixed symptoms were significantly less likely than white women to have pure GSI (47 versus 74%; P = .05). Blacks with GSI were significantly heavier, had higher parity, more often took a diuretic, were more often diabetic, and had better passive urethral Closure Pressure but greater urethral axis mobility than whites. Blacks with motor incontinence were significantly younger, heavier, less likely to have had prior continence surgery or hysterectomy, and had better passive urethral Closure Pressure but smaller bladder capacities than whites. The prevalence of severe prolapse in this referral population was the same for blacks and whites (24 and 23%), although blacks had significantly more vaginal deliveries. No other significant racial differences were noted in the prolapse group. Conclusions Black women with urinary incontinence have a different distribution of symptoms, different conditions causing their incontinence, and different risk profiles for these conditions than do whites. The significantly lower prevalence of pure GSI in black women compared to white women makes the clinical evaluation for GSI appreciably less accurate in the individual black patient. Until further epidemiologic information regarding incontinence in black women is available, such women should be considered candidates for more accurate, sophisticated urodynamic testing before continence surgery.
John O L Delancey - One of the best experts on this subject based on the ideXlab platform.
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a structured review on the female urethral anatomy and innervation with an emphasis on the role of the urethral longitudinal smooth muscle
International Urogynecology Journal, 2020Co-Authors: Michelle Alexandra Mistry, John O L Delancey, Niels Klarskov, Gunnar LoseAbstract:A damaged sphincteric unit or support system, unstable urethral deformability or damaged sensory innervation are all potential causes of a dysfunctional urethral sphincter. With the current improvement in pharmacological targets and urodynamic understanding, studies have begun quantifying individual structures and their importance in Closure Pressure and consequently urethral continence. However, when it comes to the function of the longitudinal urethral smooth muscle layer, there is currently no consensus. The intent of this structured review is to critically examine literature regarding the female urethral anatomy and Closure mechanism. We hypothesized that the longitudinal smooth muscle is a prerequisite for sufficient urethral Closure and not merely involved during micturition. Overall opinions on a dysfunctional Closure mechanism are controversial. Nonetheless, basic mechanics may be applied to understand simple urodynamics. With the assumption of longitudinal muscles forming a plug when contracted, this could have a substantial effect on the continence mechanism.
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differences in continence system between community dwelling black and white women with and without urinary incontinence in the epi study
American Journal of Obstetrics and Gynecology, 2010Co-Authors: John O L Delancey, Dee E Fenner, Denise Howard, Ken Guire, Divya A Patel, Janis M MillerAbstract:Objective We sought to compare continence system function of black and white women in a population-based sample. Study Design As part of a cross-sectional population-based study, black and white women ages 35-64 years were invited to have pelvic floor testing to achieve prespecified groups of women with and without urinary incontinence. We analyzed data collected from 335 women classified as continent (n = 137) and stress (n = 102) and urge (n = 96) incontinent based on full bladder stress test and symptoms. Continence system functions were compared across racial and continence groups. Results Comparing black to white women, maximal urethral Closure Pressure (MUCP) was 22% higher in blacks than whites (68.0 vs 55.8 cm H 2 O, P Conclusion Black women have higher urethral Closure Pressures than white women. White women with urge incontinence, but not black women, have reduced MUCP.
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stress urinary incontinence relative importance of urethral support and urethral Closure Pressure
The Journal of Urology, 2008Co-Authors: John O L Delancey, Elisa R Trowbridge, Dee E Fenner, Janis M Miller, Daniel M Morgan, Kenneth E Guire, William J Weadock, James A AshtonmillerAbstract:Purpose: Treatment strategies for stress incontinence are based on the concept that urethral mobility is the predominant causal factor with sphincter function a secondary contributor. To our knowledge the relative importance of these 2 factors has not been assessed in properly controlled studies.Materials and Methods: The Research on Stress Incontinence Etiology project is a case-control study that compared 103 women with stress incontinence and 108 asymptomatic controls in groups matched for age, race, parity and hysterectomy. Urethral Closure Pressure, urethral and pelvic organ support, levator ani muscle function and intravesical Pressure were measured and analyzed using logistic regression and multivariable modeling.Results: Mean ± SD maximal urethral Closure Pressure was 42% lower in cases (40.8 ± 17.1 vs 70.2 ± 22.4 cm H2O, d = 1.47). Lesser effect sizes were seen for support parameters, including resting urethral axis and urethrovaginal support (d = 0.41 and 0.50, respectively). Other pelvic floor ...
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effects of aging on lower urinary tract and pelvic floor function in nulliparous women
Obstetrics & Gynecology, 2007Co-Authors: Elisa R Trowbridge, John T Wei, Dee E Fenner, James A Ashtonmiller, John O L DelanceyAbstract:OBJECTIVE: To evaluate the effects of aging, independent of parity, on pelvic organ and urethral support, urethral function, and levator function in a sample of nulliparous women. METHODS: A cohort of 82 nulliparous women, aged 21–70 years, were recruited from the community through advertisements. Subjects underwent pelvic examination using pelvic organ prolapse quantification, urethral angles by cotton-tipped swab, and multichannel urodynamics and uroflow. Vaginal Closure force was quantified using an instrumented vaginal speculum. Subjects were grouped into five age categories and analyses performed using t tests, Fisher exact tests, Kruskal-Wallace, and Pearson correlation coefficients. Multiple linear regression modeling was performed to adjust for factors that might confound the results of our primary outcomes. RESULTS: Increasing age was associated with decreasing maximal urethral Closure Pressure (r–0.758, P<.001) with a 15-cm-H2O decrease in Pressure per decade. Pelvic organ support as measured by pelvic organ prolapse quantification did not differ by age group. Levator function as measured by resting vaginal Closure force and augmentation of vaginal Closure force also did not change with increasing age. CONCLUSION: In a sample of nulliparous women between 21 and 70 years of age maximal urethral Closure Pressure in the senescent urethra was 40% of that in the young urethra; increasing age did not affect clinical measures of pelvic organ support, urethral support, and levator function. (Obstet Gynecol 2007;109:715–20) LEVEL OF EVIDENCE: III
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pathophysiology of adult urinary incontinence
Gastroenterology, 2004Co-Authors: John O L Delancey, James A AshtonmillerAbstract:The anatomic structures that prevent stress incontinence, urinary incontinence during elevations in abdominal Pressure, can be divided into 2 systems: a sphincteric system and a supportive system. The action of the vesical neck and urethral sphincteric mechanisms at rest constrict the urethral lumen and keep urethral Closure Pressure higher than bladder Pressure. The striated urogenital sphincter, the smooth muscle sphincter in the vesical neck, and the circular and longitudinal smooth muscle of the urethra all contribute to Closure Pressure. The mucosal and vascular tissues that surround the lumen provide a hermetic seal, and the connective tissues in the urethral wall also aid coaptation. Decreases in striated muscle sphincter fibers occur with age and parity, but the other tissues are not well understood. The supportive hammock under the urethra and vesical neck provides a firm backstop against which the urethra is compressed during increases in abdominal Pressure to maintain urethral Closure Pressures above rapidly increasing bladder Pressure. The stiffness of this supportive layer is presumed to be important to the degree to which compression occurs. This supporting layer consists of the anterior vaginal wall and the connective tissue that attaches it to the pelvic bones through the pubovaginal portion of the levator ani muscle and also the tendinous arch of the pelvic fascia. Activation of the levator muscle during abdominal pressurization is important to this stabilization process. The integrity of the connection between the vaginal wall and tendinous arch also plays an important role.
May M Wakamatsu - One of the best experts on this subject based on the ideXlab platform.
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the incidence of low Pressure urethra as a function of prolapse reducing technique in patients with massive pelvic organ prolapse maximum descent at all vaginal sites
American Journal of Obstetrics and Gynecology, 1997Co-Authors: Dionysios K Veronikis, David H Nichols, May M WakamatsuAbstract:OBJECTIVE: Our aims were to compare several prolapse-reducing techniques during urodynamic evaluation and prospectively evaluate their usefulness in identifying the incidence of low urethral Closure Pressure in continent patients with massive prolapse. STUDY DESIGN: This preoperative, prospective, repeated-measures urodynamic study evaluated the maximum urethral Closure Pressure with the use of four different techniques in 30 consecutive continent patients with grade 4 prolapse at all vaginal sites. Twenty patients with grade 0 prolapse served as the control group. All patients from the prolapse group underwent surgical treatment and were followed up clinically for a minimum of 1 year. RESULTS: Use of the Scopette (Birchwood Laboratories, Eden Prairie, Minn.) reduction technique to reduce the prolapse in a linear orientation during multichannel urodynamics revealed a 56% incidence of low-Pressure urethra and an overall genuine stress urinary incontinence of 83% in patients with massive pelvic organ prolapse but without clinical urinary incontinence. CONCLUSIONS: There may be an increased indication for sling urethropexy in patients with massive prolapse.
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the incidence of low Pressure urethra as a function of prolapse reducing technique in patients with massive pelvic organ prolapse maximum descent at all vaginal sites
American Journal of Obstetrics and Gynecology, 1997Co-Authors: Dionysios K Veronikis, David H Nichols, May M WakamatsuAbstract:Abstract OBJECTIVE: Our aims were to compare several prolapse-reducing techniques during urodynamic evaluation and prospectively evaluate their usefulness in identifying the incidence of low urethral Closure Pressure in continent patients with massive prolapse. STUDY DESIGN: This preoperative, prospective, repeated-measures urodynamic study evaluated the maximum urethral Closure Pressure with the use of four different techniques in 30 consecutive continent patients with grade 4 prolapse at all vaginal sites. Twenty patients with grade 0 prolapse served as the control group. All patients from the prolapse group underwent surgical treatment and were followed up clinically for a minimum of 1 year. RESULTS: Use of the Scopette (Birchwood Laboratories, Eden Prairie, Minn.) reduction technique to reduce the prolapse in a linear orientation during multichannel urodynamics revealed a 56% incidence of low-Pressure urethra and an overall genuine stress urinary incontinence of 83% in patients with massive pelvic organ prolapse but without clinical urinary incontinence. CONCLUSIONS: There may be an increased indication for sling urethropexy in patients with massive prolapse.(Am J Obstet Gynecol 1997;177:14)
James A Ashtonmiller - One of the best experts on this subject based on the ideXlab platform.
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stress urinary incontinence relative importance of urethral support and urethral Closure Pressure
The Journal of Urology, 2008Co-Authors: John O L Delancey, Elisa R Trowbridge, Dee E Fenner, Janis M Miller, Daniel M Morgan, Kenneth E Guire, William J Weadock, James A AshtonmillerAbstract:Purpose: Treatment strategies for stress incontinence are based on the concept that urethral mobility is the predominant causal factor with sphincter function a secondary contributor. To our knowledge the relative importance of these 2 factors has not been assessed in properly controlled studies.Materials and Methods: The Research on Stress Incontinence Etiology project is a case-control study that compared 103 women with stress incontinence and 108 asymptomatic controls in groups matched for age, race, parity and hysterectomy. Urethral Closure Pressure, urethral and pelvic organ support, levator ani muscle function and intravesical Pressure were measured and analyzed using logistic regression and multivariable modeling.Results: Mean ± SD maximal urethral Closure Pressure was 42% lower in cases (40.8 ± 17.1 vs 70.2 ± 22.4 cm H2O, d = 1.47). Lesser effect sizes were seen for support parameters, including resting urethral axis and urethrovaginal support (d = 0.41 and 0.50, respectively). Other pelvic floor ...
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effects of aging on lower urinary tract and pelvic floor function in nulliparous women
Obstetrics & Gynecology, 2007Co-Authors: Elisa R Trowbridge, John T Wei, Dee E Fenner, James A Ashtonmiller, John O L DelanceyAbstract:OBJECTIVE: To evaluate the effects of aging, independent of parity, on pelvic organ and urethral support, urethral function, and levator function in a sample of nulliparous women. METHODS: A cohort of 82 nulliparous women, aged 21–70 years, were recruited from the community through advertisements. Subjects underwent pelvic examination using pelvic organ prolapse quantification, urethral angles by cotton-tipped swab, and multichannel urodynamics and uroflow. Vaginal Closure force was quantified using an instrumented vaginal speculum. Subjects were grouped into five age categories and analyses performed using t tests, Fisher exact tests, Kruskal-Wallace, and Pearson correlation coefficients. Multiple linear regression modeling was performed to adjust for factors that might confound the results of our primary outcomes. RESULTS: Increasing age was associated with decreasing maximal urethral Closure Pressure (r–0.758, P<.001) with a 15-cm-H2O decrease in Pressure per decade. Pelvic organ support as measured by pelvic organ prolapse quantification did not differ by age group. Levator function as measured by resting vaginal Closure force and augmentation of vaginal Closure force also did not change with increasing age. CONCLUSION: In a sample of nulliparous women between 21 and 70 years of age maximal urethral Closure Pressure in the senescent urethra was 40% of that in the young urethra; increasing age did not affect clinical measures of pelvic organ support, urethral support, and levator function. (Obstet Gynecol 2007;109:715–20) LEVEL OF EVIDENCE: III
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pathophysiology of adult urinary incontinence
Gastroenterology, 2004Co-Authors: John O L Delancey, James A AshtonmillerAbstract:The anatomic structures that prevent stress incontinence, urinary incontinence during elevations in abdominal Pressure, can be divided into 2 systems: a sphincteric system and a supportive system. The action of the vesical neck and urethral sphincteric mechanisms at rest constrict the urethral lumen and keep urethral Closure Pressure higher than bladder Pressure. The striated urogenital sphincter, the smooth muscle sphincter in the vesical neck, and the circular and longitudinal smooth muscle of the urethra all contribute to Closure Pressure. The mucosal and vascular tissues that surround the lumen provide a hermetic seal, and the connective tissues in the urethral wall also aid coaptation. Decreases in striated muscle sphincter fibers occur with age and parity, but the other tissues are not well understood. The supportive hammock under the urethra and vesical neck provides a firm backstop against which the urethra is compressed during increases in abdominal Pressure to maintain urethral Closure Pressures above rapidly increasing bladder Pressure. The stiffness of this supportive layer is presumed to be important to the degree to which compression occurs. This supporting layer consists of the anterior vaginal wall and the connective tissue that attaches it to the pelvic bones through the pubovaginal portion of the levator ani muscle and also the tendinous arch of the pelvic fascia. Activation of the levator muscle during abdominal pressurization is important to this stabilization process. The integrity of the connection between the vaginal wall and tendinous arch also plays an important role.
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racial differences in the structure and function of the stress urinary continence mechanism
Obstetrics & Gynecology, 2000Co-Authors: Denise Howard, John O L Delancey, Ralf Tunn, James A AshtonmillerAbstract:Abstract Objective: To compare the structure and function of the urethral sphincter and the urethral support in nulliparous black and white women. Methods: Eighteen black women (mean age 28.1 years) and 17 white women (mean age 31.3 years) completed this cross-sectional study. The following assessments were made: urethral function using multichannel cystometrics and urethral Pressure profilometry, pelvic muscle strength using an instrumented speculum, urethral mobility using the cotton-swab test and perineal ultrasound, and pelvic muscle bulk using magnetic resonance imaging. Results: Black women demonstrated a 29% higher average urethral Closure Pressure during a maximum pelvic muscle contraction (154 cm H2O versus 119 cm H2O in the white subjects; P = .008). Although not statistically significant, black women had a 14% higher maximum urethral Closure Pressure at rest (108 cm H2O versus 95 cm H2O; P = .23) and a 21% larger urethral volume (4818 mm3 versus 3977 mm3; P = .06). In addition, there was a 36% greater vesical neck mobility measured with the cotton-swab test (blacks 49° versus whites 36°; P = .02) and a 42% difference in ultrasonically measured vesical neck mobility during a maximum Valsalva effort (blacks = −17 mm versus whites −12 mm; P = .08). Conclusion: Functional and morphologic differences exist in the urethral sphincteric and support system of nulliparous black and white women.
Dionysios K Veronikis - One of the best experts on this subject based on the ideXlab platform.
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the incidence of low Pressure urethra as a function of prolapse reducing technique in patients with massive pelvic organ prolapse maximum descent at all vaginal sites
American Journal of Obstetrics and Gynecology, 1997Co-Authors: Dionysios K Veronikis, David H Nichols, May M WakamatsuAbstract:OBJECTIVE: Our aims were to compare several prolapse-reducing techniques during urodynamic evaluation and prospectively evaluate their usefulness in identifying the incidence of low urethral Closure Pressure in continent patients with massive prolapse. STUDY DESIGN: This preoperative, prospective, repeated-measures urodynamic study evaluated the maximum urethral Closure Pressure with the use of four different techniques in 30 consecutive continent patients with grade 4 prolapse at all vaginal sites. Twenty patients with grade 0 prolapse served as the control group. All patients from the prolapse group underwent surgical treatment and were followed up clinically for a minimum of 1 year. RESULTS: Use of the Scopette (Birchwood Laboratories, Eden Prairie, Minn.) reduction technique to reduce the prolapse in a linear orientation during multichannel urodynamics revealed a 56% incidence of low-Pressure urethra and an overall genuine stress urinary incontinence of 83% in patients with massive pelvic organ prolapse but without clinical urinary incontinence. CONCLUSIONS: There may be an increased indication for sling urethropexy in patients with massive prolapse.
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the incidence of low Pressure urethra as a function of prolapse reducing technique in patients with massive pelvic organ prolapse maximum descent at all vaginal sites
American Journal of Obstetrics and Gynecology, 1997Co-Authors: Dionysios K Veronikis, David H Nichols, May M WakamatsuAbstract:Abstract OBJECTIVE: Our aims were to compare several prolapse-reducing techniques during urodynamic evaluation and prospectively evaluate their usefulness in identifying the incidence of low urethral Closure Pressure in continent patients with massive prolapse. STUDY DESIGN: This preoperative, prospective, repeated-measures urodynamic study evaluated the maximum urethral Closure Pressure with the use of four different techniques in 30 consecutive continent patients with grade 4 prolapse at all vaginal sites. Twenty patients with grade 0 prolapse served as the control group. All patients from the prolapse group underwent surgical treatment and were followed up clinically for a minimum of 1 year. RESULTS: Use of the Scopette (Birchwood Laboratories, Eden Prairie, Minn.) reduction technique to reduce the prolapse in a linear orientation during multichannel urodynamics revealed a 56% incidence of low-Pressure urethra and an overall genuine stress urinary incontinence of 83% in patients with massive pelvic organ prolapse but without clinical urinary incontinence. CONCLUSIONS: There may be an increased indication for sling urethropexy in patients with massive prolapse.(Am J Obstet Gynecol 1997;177:14)