|THE PART OF THE URODYNAMIC STUDY
Even when examined conscientiously with a history and a urinary diary excluding
compatible symptoms, a detrusor instability, this entity may be diagnosed in up to 9% of
the patients, be exclusively responsible for incontinence with SUI in 4% of the cases (9). This incidence grows
considerably for the subgroup of patients that have ID symptoms. A considerable part of
patients have small defined symptoms and can not define clearly which symptom is worse, if
the symptoms of urinary loss to stress or those of urgeincontinence. This sub group of
patients benefits clearly with the urodynamic study. This exam allows the confirmation of
the existence of detrusor instability, the vesical compliace, the post urination residue
and the abdominal leak point pressure of loss. (ALPP) and the pressure of vesical
contraction. ( the ALPP is useful for surgeons that do not do pubovaginal sling or the
TVT, the choice of surgery for the treatment of SUI).
Mixed urinary incontinence is not an only entity. In reality there exist several
conditions that may take the patient to these symptoms and signs grouped as "mixed
urinary incontinence". With the complex appearance of existent interrelation between
the sphincterian mechanism and the detrusor activity, you may say that, in one extreme
there are patients with predominance of stress urinary loss (predominant sphincter lesion)
and little or non urgency - urgeincontinence ("normal detrusor activity") ; on
the other extreme, patients with predominance of associated symptoms to detrusor
instability are showing small loss to effort by a discreet deficit of the sphincterian
mechanism. Evidently, the predominant disturbance influences the choice of therapy.
1) Surgery. There is a controversy if the surgical treatment of patients with ID that
lessens the rate of success in the correction of SUI. The colposuspension of Burch cured
only 43% of the patients with MUI and 85% of the patients with an exclusive complaint of
SUI (10). On the
other hand, other authors did not observe any influence of ID about the rates of cure of
In patients that present detrusor instability associated to abdominal pressure
enlargement, the pubovaginal sling allowed the correction of the urgeincontinence in 75%
of the patients (12).
Recently Schrepferman et al evaluated the behavior of the urgency symptoms and
urgeincontinence in patients submitted to pubovaginal sling. Of the group of 84 patients,
69 (82%) presented detrusor instability or sensorial urgency in the pre-operative.
Complete resolution or improvement of the symptoms occurred in 31 (75.8%) of the patients
with ID and 20 (71.4%) of the patients with sensorial urgency. The patients with non
inhibited contractions of a high amplitude had a worse prognostic (55.6%) of resolution or
Eventually, it may be necessary to do a vesical enlargement for patients with a diurease
capacity and low compliace of the bladder.
2) Conservative treatment
2.1 Behavior treatment.
2.1.1 Vesical treatment. The inferior urinary tract physiology may be
modulated, in various aspects, by the cerebral cortex. This way it is possible to inhibit
in voluntary contractions by the detrusor and induce voluntary contractions or reflexes of
some muscular groups. Some patients have as main problems pollakiuria, urgency and
urgeincontinence. With the use of a urinary diary (to write for 3 days, liquid ingestion,
the volume and the hour of each urination and the episodes of urinary loss). Starting from
the obtained data, the treatment is programmed with the intention of increasing and
controlling the urgency episodes. The intervals are increased progressively between one
and another urination. In our personal experience the adherence is low to this
therapeutical proposal. In medical literature favorable results are gotten in 44 to 97% of
2.1.2 Biofeedback. In this behavior technique, visual instruments are used or
hearing to make conscious the functions of the detrusor and the urethra. The patients may
be taught to recognize and enlarge the contractile force of muscular groups that they had
not noticed before. These techniques may be used together with the perineal exercises for
improvement of the final results.
2.2 Medicament treatment.
2.2.1 anticholinergic drugs. The physiological vesical contraction is done mainly by the
humoral stimuli based on the stimulation of cholinergic receptors in the smooth
muscular cells of the bladder (15). Probantine in a dose of 15 to 30 mg of 4/ 4
or 6/ 6 hours, preferably on an empty stomach is the agent that may be used in practical
clinic, but with precarious results. The anticholinergic agents enlarge the functional
vesical capacity and diminish the amplitude of the no-inhibited contractions. The main
collateral effects are: dry mouth, intestinal constipation, blurry vision and tachycardia.
It must not be used on patients with glaucoma or carriers of cardiac arrhythmia (16). In practice there
are few controlled studies and in general, show very little efficient results of this
drug. Additionally, it has a short half life, making it necessary to fraction the drug in
multiple daily taking, it makes it difficult to adhere to the treatment.
2.2.2 Muscle tropic relaxants: these drugs act directly on the smooth muscle
depressing its activity and they have anticholinergic actions and variable local
anesthetics. Oxybutinine is usually used on a daily dosage of 5 to 15 mg divided in 2 to 3
takings. The dosage may be regulated by the patient and adjusted till the maximum level of
efficiency with the number of collateral effects acceptable by the patient (dryness of the
mouth, specially). The collateral effects are related to the anticholinergic effects (
look above). When compared to propanteline, it is a placebo, with good or excellent
results, in relation to symptomatic improvement we obtained in 67% of the patients that
used Oxybutinine and 50% of the propanteline group. The urodynamic parameters
improved, like the volume of the first no inhibited contraction and the maximum
cystometric capacity (17).
2.3 Pelvic floor physiotherapy. The use of the perineal exercises allows the
enlargement of the capacity of voluntary reflex contraction of the muscular group,
improving the sphincterian function. When they are adequately stimulated, with continuous
and repeated exercises, there exists an increase of the amplitude and duration of the
contractions of the muscular fibers. The musculature of the pelvic floor as well as the
tendinous ligations have a fundamental part in the mechanism of urinary incontinence.
Unhappily the published results, in terms of efficiency, are highly variable, and like the
treatment protocols, inclusion criteria and cure are not uniform, it is difficult or
impossible to compare the treatment series. The positive results of improvement or cure
for patients with SUI may arrive at 80% of the cases (18,19).
2.4 Electric stimulation. The electric stimulation may be effective in the
treatment of MUI. The frequency used to increase the tonus of the pelvic floor, varies
from 50 to 100 Hz, while the inhibitor reflexes of the detrusor are obtained with
frequencies between 5 to 20 Hz. So the results can be obtained it is fundamental that
there exist unimpaired nervous fibers or partially viable. In our experience, that
involved electric stimulation and pelvic floor physiotherapy for 14 weeks in 20 patients
with mixed urinary incontinence. We got an accentuated improvement or complete
disappearance of the urgency and urgeincontinence symptoms in all the patients. It is
curious to observe the answer to electric stimulation, it was superior for the symptoms of
ID (100% of accented improvement or cure) than for SUI (59% of accented improvement or
2.5 Acupuncture. In the cases where the loss component to small efforts and
predominate the loss by urgeincontinence, acupuncture may be used as an alternative
method, minimally invasive. Even though there are few published works and suffer with the
lack of an adequate controlled group, the method seems efficient and free from risk with
an index of subjective success of until 77% of the patients. In spite of the cure success
of the symptomatology in only 1 to 17 patients the non inhibited contractions were
abolished in the urodynamic control study (21). On the other hand, Chang did acupuncture in
52 women, urgency and dysuria. He did a urodynamic study before and with pollakiuria after
the treatment and he observed a significant increase in the maximum cystometric capacity,
a decrease of the maximum urinary flux and inhibition of the detrusor contractions after
treatment. The index of success in the decrease of the symptomatology was of 85% (22).