British Journal of Obstetrics and Gynaecology February 1978. Vol85. pp 149-152
SPONTANEOUS VOIDING AFTER SURGERY FOR URINARY INCONTINENCE BY
S. L. STANTON, Senior Lecturer and Honorary Consultant, Urodynamic Unit Department of Obstetrics and Gynaecology, St George’s Hospital and Consultant Gynaecologist, St Helier Hospital LINDACARDOZO, Clinical Research Fellow AND
NASREEN CHAUDHURY, Registrar Department of Obstetrics and Gynaecology, St George’s Hospital, London Summary Eighty patients with urinary incontinence were treated by colposuspension and bladder neck plication. Fourteen patients had difficulty in establishing normal micturition postoperatively. Of these, 10 patients took longer than 21 days to void and had reduced peak urine flow rates after surgery; the other four patients voided within ten days of surgery but had reduced peak urine flow rates before and after surgery and all had residual urines in excess of 100 ml following surgery. The value of the preoperative diagnosis of pre-existent bladder dysfunction by symptomatology and the peak urine flow rate is discussed.
assessment followed by a videocystourethrography with bladder pressure and urine flow measurements, and cystoscopy. After the colposuspension operation the bladder was drained by a suprapubic catheter which was removed once spontaneous voiding had been established and the residual urine was less than 100 ml on two consecutive occasions (Stanton et al, 1976). Postoperative clinical assessment was made at two months and videocystourethrography was repeated at three months. Measurements were made of residual urine volume, intrinsic bladder pressure rise at the end of supine bladder filling (Pl) and on standing (P2), the maximum voiding pressure and the peak flow rate (Table I).
RETENTION of urine and difficulty in voiding are known complications of surgery for urinary incontinence. The explanations given include bladder atony, undue elevation of the bladder neck, excessive narrowing of the urethra and anxiety. We have studied the preoperative and postoperative clinical and urodynamic data of patients undergoing a Burch colposuspension operation and bladder neck plication (Stanton et al, 1976). Three groups of patients are compared. Group 1 contained ten patients who voided spontaneously within ten days of surgery and without residual urine. Group 2 contained ten patients who took longer than 21 days to void spontaneously and five of them had postoperative residual urine volumes which were greater than 100 ml. Group 3 contained four patients who voided within ten days of surgery and all of whom had postoperative residual urine volumes which were greater than 100 ml.
RESULTS There were no abnormal neurological findings. In Group 1, all patients voided within ten days of surgery. The average age of patients was 52.4 years, with a range of 37 to 59 years.
METHOD All patients had a preoperative clinical 149
150
STANTON, CARDOZO AND CHAUDHURY
TABLE I Preoperative and postoperative data of the patients in the three groups Group 2 Mean $SD
Group 1 Mean & SD
Group 3 Mean* SD
Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative 3.9f2.92 4 . 4& 3 . 5 0
6.2f5.22 2 . 9 k3.28
3.0h2.58 2.5 f 3 . 0 0
6.0A8.49 3.0 $4.76
P1 (cm of water) P2 (cm of water) Maximum voiding pressure (MVP) (cm of water) Peak flow rate (PFR) (ml/second) Residual urine volume (ml)
29.51- 9.37 26.5f11.16 0 6.5+14
20.2& 6.99 11.2* 7.31 14.7 f 2.05 11.7% 3.95 10 $28 131.6f97 15 f30 152.5zk-33 (range 0-300) (range 131x200)
Outlet resistance (M VP/PFR2)
0.07+0.07
0.08f0.12
P1 P2
= =
4.8f3.12 3.7 & 5.08 36.3*17.09
6.3+3.97 1.4f 1 . 5 5
34.7f11.74 25.3f18.15
0.081-0.07
33.Oi-24.92 31.50f9.85
0.53$0.61
0.15+0.05
3 4 . 5 3 ~6.40
0.354~0.32
Bladder pressure at end of filling with patient supine. Bladder pressure at end of filling with patient standing.
All clinical and urodynamic parameters were normal before and after operation. In Group 2, the patients took on average 26.6 days to void spontaneously, with a range of 21 to 37 days. Their average age was 5 8 . 8 years with a range of 41 to 77 years. After surgery two patients complained of incomplete bladder emptying and one patient complained of a slow urinary stream. Urodynamic data showed the mean maximum voiding pressure to be normal, although two patients had maximum voiding pressures in excess of 70 cm of water after surgery and one of these had an abnormally low peak flow rate of 14 ml/second (the normal peak flow rate is above 20 ml/second for more than 200 ml voided). The average peak flow rate was significantly low. Five patients had a postoperative residual urine greater than 100 ml; the mean residual urine volume for the group was 131.6 ml. The four Group 3 patients took on average 9 . 7 days to void spontaneously with a range of 7 to 12 days. Their average age was 47.2 years with a range of 35 to 66 years. One patient complained of incomplete bladder emptying before surgery. After surgery two patients complained of incomplete bladder emptying. Urodynamic data showed the maximum voiding pressures to be normal, however, the peak flow rates were reduced both preoperatively and postoperatively. In addition, all four patients had a postoperative residual urine
volume which was greater than 100 ml, with an average of 152.5 ml. None of these patients had ureteric reflux. Statistical evaluation was carried out using Student’s ‘t’ test. The difference in the preoperative peak flow rate was significant (P t0.05) in Groups 1 and 2 and highly significant ( P t 0 . 0 2 ) between Groups 1 and 3. The difference between Groups 2 and 3 was not significant. The difference in the postoperative peak flow rate was highly significant (Pt0.01) between Groups 1 and 2 and significant (P
SPONTANEOUS VOIDING AFTER SURGERY FOR URINARY INCONTINENCE BY
S. L. STANTON, Senior Lecturer and Honorary Consultant, Urodynamic Unit Department of Obstetrics and Gynaecology, St George’s Hospital and Consultant Gynaecologist, St Helier Hospital LINDACARDOZO, Clinical Research Fellow AND
NASREEN CHAUDHURY, Registrar Department of Obstetrics and Gynaecology, St George’s Hospital, London Summary Eighty patients with urinary incontinence were treated by colposuspension and bladder neck plication. Fourteen patients had difficulty in establishing normal micturition postoperatively. Of these, 10 patients took longer than 21 days to void and had reduced peak urine flow rates after surgery; the other four patients voided within ten days of surgery but had reduced peak urine flow rates before and after surgery and all had residual urines in excess of 100 ml following surgery. The value of the preoperative diagnosis of pre-existent bladder dysfunction by symptomatology and the peak urine flow rate is discussed.
assessment followed by a videocystourethrography with bladder pressure and urine flow measurements, and cystoscopy. After the colposuspension operation the bladder was drained by a suprapubic catheter which was removed once spontaneous voiding had been established and the residual urine was less than 100 ml on two consecutive occasions (Stanton et al, 1976). Postoperative clinical assessment was made at two months and videocystourethrography was repeated at three months. Measurements were made of residual urine volume, intrinsic bladder pressure rise at the end of supine bladder filling (Pl) and on standing (P2), the maximum voiding pressure and the peak flow rate (Table I).
RETENTION of urine and difficulty in voiding are known complications of surgery for urinary incontinence. The explanations given include bladder atony, undue elevation of the bladder neck, excessive narrowing of the urethra and anxiety. We have studied the preoperative and postoperative clinical and urodynamic data of patients undergoing a Burch colposuspension operation and bladder neck plication (Stanton et al, 1976). Three groups of patients are compared. Group 1 contained ten patients who voided spontaneously within ten days of surgery and without residual urine. Group 2 contained ten patients who took longer than 21 days to void spontaneously and five of them had postoperative residual urine volumes which were greater than 100 ml. Group 3 contained four patients who voided within ten days of surgery and all of whom had postoperative residual urine volumes which were greater than 100 ml.
RESULTS There were no abnormal neurological findings. In Group 1, all patients voided within ten days of surgery. The average age of patients was 52.4 years, with a range of 37 to 59 years.
METHOD All patients had a preoperative clinical 149
150
STANTON, CARDOZO AND CHAUDHURY
TABLE I Preoperative and postoperative data of the patients in the three groups Group 2 Mean $SD
Group 1 Mean & SD
Group 3 Mean* SD
Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative 3.9f2.92 4 . 4& 3 . 5 0
6.2f5.22 2 . 9 k3.28
3.0h2.58 2.5 f 3 . 0 0
6.0A8.49 3.0 $4.76
P1 (cm of water) P2 (cm of water) Maximum voiding pressure (MVP) (cm of water) Peak flow rate (PFR) (ml/second) Residual urine volume (ml)
29.51- 9.37 26.5f11.16 0 6.5+14
20.2& 6.99 11.2* 7.31 14.7 f 2.05 11.7% 3.95 10 $28 131.6f97 15 f30 152.5zk-33 (range 0-300) (range 131x200)
Outlet resistance (M VP/PFR2)
0.07+0.07
0.08f0.12
P1 P2
= =
4.8f3.12 3.7 & 5.08 36.3*17.09
6.3+3.97 1.4f 1 . 5 5
34.7f11.74 25.3f18.15
0.081-0.07
33.Oi-24.92 31.50f9.85
0.53$0.61
0.15+0.05
3 4 . 5 3 ~6.40
0.354~0.32
Bladder pressure at end of filling with patient supine. Bladder pressure at end of filling with patient standing.
All clinical and urodynamic parameters were normal before and after operation. In Group 2, the patients took on average 26.6 days to void spontaneously, with a range of 21 to 37 days. Their average age was 5 8 . 8 years with a range of 41 to 77 years. After surgery two patients complained of incomplete bladder emptying and one patient complained of a slow urinary stream. Urodynamic data showed the mean maximum voiding pressure to be normal, although two patients had maximum voiding pressures in excess of 70 cm of water after surgery and one of these had an abnormally low peak flow rate of 14 ml/second (the normal peak flow rate is above 20 ml/second for more than 200 ml voided). The average peak flow rate was significantly low. Five patients had a postoperative residual urine greater than 100 ml; the mean residual urine volume for the group was 131.6 ml. The four Group 3 patients took on average 9 . 7 days to void spontaneously with a range of 7 to 12 days. Their average age was 47.2 years with a range of 35 to 66 years. One patient complained of incomplete bladder emptying before surgery. After surgery two patients complained of incomplete bladder emptying. Urodynamic data showed the maximum voiding pressures to be normal, however, the peak flow rates were reduced both preoperatively and postoperatively. In addition, all four patients had a postoperative residual urine
volume which was greater than 100 ml, with an average of 152.5 ml. None of these patients had ureteric reflux. Statistical evaluation was carried out using Student’s ‘t’ test. The difference in the preoperative peak flow rate was significant (P t0.05) in Groups 1 and 2 and highly significant ( P t 0 . 0 2 ) between Groups 1 and 3. The difference between Groups 2 and 3 was not significant. The difference in the postoperative peak flow rate was highly significant (Pt0.01) between Groups 1 and 2 and significant (P
