**7. References**

214 Urinary Incontinence

or improvement in urge symptoms occurred in 24 (58.5%) patients with urodynamically demonstrated motor urge incontinence, and an additional 7 (17.1%) patients were improved. In those patients with sensory urgency, only 11 (39.3%) patients were cured, and 9 (32.1%) patients were improved. Additionally, in those patients with urodynamic motor urge overactivity, 21 of 23 (91.3%) patients were cured, and 2 (8.7%) patients were improved if low pressure overactivity was present. High-pressure instability was associated with a cure in only 5 (27.8%) patients, and improvement in another 5 (27.8%) patients. The investigators used 15 cm of water as a cutoff for low-pressure versus high-pressure motor overactivity of the bladder. They suggested that patients with low-pressure motor urgency are more likely to experience resolution than those with high-pressure. Despite the fact that the International Continence Society no longer utilizes motor versus sensory urgency, the application of this trial is limited; however, these findings are interesting and provocative for potential subsequent clinical trials. Finally, on the basis of the symptoms present, Scotti et al. reported that high-pressure detrusor overactivity presented commonly with stress symptoms is a significantly poor prognostic indicator with pressures of 25cmH2O or greater

Recently, Paick et al. evaluated factors that might predict persistency of urge incontinence in patients after undergoing tension-free vaginal tape (TVT) procedures. (Paick et al., 2007) They evaluated 274 patients of which 73 had mixed urinary symptoms. They found cure rates for stress incontinence to be different (78.1% for the mixed symptom group versus 95.5% for the pure group). Their analysis revealed that maximal urethral pressure was associated with a greater risk of persistent urge symptoms, suggesting that profound urethral dysfunction may be contributory to persistent symptoms after TVT. These findings are again intriguing and suggest the possibility that urethral dysfunction and resultant effects upon the severity of SUI may affect detrusor function. This paper gives further support to the fact that correction of the low-pressure outlet may benefit at least some individuals with detrusor overactivity although the overall benefit may be less than that

Other studies have failed to find significant predictive value for successful treatment of MUI in urodynamic studies. Houwert et al. retrospectively reviewed 437 patients who received MUS, in which the diagnosis of MUI itself was also used as a factor in analysis. (Houwert et al., 2009) Results showed that a diagnosis of MUI, a history of previous incontinence surgery and the presence of detrusor overactivity was predictive, while urodynamic parameters failed to suggest insight to outcomes in multivariate analyses. However, relative symptom components are most frequently reported as predominant and nonpredominant (assuming a rough estimate of percentage contribution). As noted previously, this method can be inaccurate and begs the need for better methods of symptom quantification. Given the confusing terminology for both patients and surgeons of what constitutes MUI, as well as the higher failure rate of surgical outcomes, treatment should be individualized based on

Recent advances in surgical treatment for stress urinary incontinence have provided effective resolution with limited morbidity. However, preoperative components of urgency complicate the treatment outcomes in a significant number of patients. Detrusor overactivity

being consistent with poor surgical results. (Scotti et al., 1998)

experienced by patients with only SUI.

clinical scenario along with urodynamic findings.

**6. Conclusion** 


Preoperative Factors as Predictors of Outcome

ISSN 0090-4295

660), ISSN 1520-6777

(1049-1054), ISSN 0002-8614

(757-760), ISSN 0029-7844

No.5, pp. (1628-1631), ISSN 0022-5347

*Gynecology*, Vol. 91, No.1, pp. (30-34), ISSN 0029-7844

*Urology*, Vol. 163, No.3, pp. (884-887), ISSN 0022-5347

*Gynecology*, Vol. 51, No.5, pp. (515), ISSN 0029-7844

19, No.10, pp. (1429-1440), ISSN 0937-3462

0090-4295

of Midurethral Sling in Women with Mixed Urinary Incontinence 217

Lemack, G. E. & Zimmern, P. E. (1999). Predictability of urodynamic findings based on the

Lin, L. Y., Yeh, N. H., Lin, C. Y., Sheu, B. C. & Lin, H. H. (2004). Comparisons of urodynamic

Major, H., Culligan, P. & Heit, M. (2002). Urethral sphincter morphology in women with

McLennan, M. T., Melick, C. & Bent, A. E. (2001). Urethral instability: Clinical and

Minassian, V. A., Stewart, W. F. & Hirsch, A. G. (2008). Why do stress and urge incontinence

Nygaard, I. E. & Lemke, J. H. (1996). Urinary incontinence in rural older women: prevalence,

Paick, J. S., Cho, M. C., Oh, S. J., Kim, S. W. & Ku, J. H. (2007). Factors influencing the

Panayi, D. C., Duckett, J., Digesu, G. A., Camarata, M., Basu, M. & Khullar, V. (2009). Pre-

*Neurourology and Urodynamics*, Vol. 28, No.1, pp. (82-85), ISSN 1520-6777 Sand, P. K. (1996). Pelvic floor stimulation in the treatment of mixed incontinence

Schrepferman, C. G., Griebling, T. L., Nygaard, I. E. & Kreder, K. J. (2000). Resolution of

Scotti, R. J., Angell, G., Flora, R. & Greston, W. M. (1998). Antecedent history as a predictor

Segal, J. L., Vassallo, B., Kleeman, S., Silva, W. A. & Karram, M. M. (2004). Prevalence of

Stanton, S. L., Cardozo, L., Williams, J. E., Ritchie, D. & Allan, V. (1978). Clinical and

Stewart, W., Van Rooyen, J., Cundiff, G., Abrams, P., Herzog, A., Corey, R., Hunt, T. &

*World Journal of Urology*, Vol. 20, No.6, pp. (327-336), ISSN 0724-4983

*Journal of Urology*, Vol. 178, No.3, pp. (985-989), ISSN 0022-5347

Urogenital Distress Inventory-6 questionnaire. *Urology*, Vol. 54, No.3, pp. (461-466),

characteristics between female patients with overactive bladder and overactive bladder plus stress urinary incontinence. *Urology*, Vol. 64, No.5, pp. (945-949), ISSN

detrusor instability. *Obstetrics & Gynecology*, Vol. 99, No.1, pp. (63), ISSN 0029-7844

urodynamic characteristics\*. *Neurourology and Urodynamics*, Vol. 20, No.6, pp. (653-

co-occur much more often than expected? *International Urogynecology Journal*, Vol.

incidence and remission. *Journal of the American Geriatrics Society*, Vol. 44, No.9, pp.

outcome of mid urethral sling procedures for female urinary incontinence. *The* 

operative opening detrusor pressure is predictive of detrusor overactivity following TVT in patients with pre-operative mixed urinary incontinence.

complicated by a low-pressure urethra. *Obstetrics and Gynecology*, Vol. 88, No.5, pp.

urge symptoms following sling cystourethropexy. *The Journal of Urology*, Vol. 164,

of surgical cure of urgency symptoms in mixed incontinence. *Obstetrics and* 

persistent and de novo overactive bladder symptoms after the tension-free vaginal tape. *Obstetrics & Gynecology*, Vol. 104, No.6, pp. (1263-1269), ISSN 0029-7844 Serels, S. R., Rackley, R. R. & Appell, R. A. (2000). Surgical treatment for stress urinary

incontinence associated with Valsalva induced detrusor instability. *The Journal of* 

urodynamic features of failed incontinence surgery in the female. *Obstetrics and* 

Wein, A. (2003). Prevalence and burden of overactive bladder in the United States.


Dmochowski, R. & Staskin, D. (2005). Mixed incontinence: definitions, outcomes, and

Dooley, Y., Lowenstein, L., Kenton, K., FitzGerald, M. P. & Brubaker, L. (2008). Mixed

Haylen, B. T., De Ridder, D., Freeman, R. M., Swift, S. E., Berghmans, B., Lee, J., Monga, A.,

Holmgren, C., Nilsson, S., Lanner, L. & Hellberg, D. (2005). Long-term results with tension-

Houwert, R. M., Venema, P. L., Aquarius, A. E., Bruinse, H. W., Kil, P. J. M. & Vervest, H. A.

Karram, M. M. & Bhatia, N. N. (1989). Management of coexistent stress and urge urinary incontinence. *Obstetrics and Gynecology*, Vol. 73, No.1, pp. (4-7), ISSN 0029-7844 Khullar, V., Cardozo, L. & Dmochowski, R. (2010). Mixed incontinence: Current evidence

Kim, H. M., Oh, M. M., Lee, J. G. (2010). Does the incidence of urgency symptoms increase

Kim, J. J., Bae, J. H. & Lee, J. G. (2008). Preoperative factors predicting the outcome of a

Koonings, P., Bergman, A. & Ballard, C. (1988). Combined detrusor instability and stress

Kulseng Hanssen, S., Husby, H. & Schiotz, H. A. (2007). The tension free vaginal tape

Langer, R. (1988). Colposuspension in patients with combined stress incontinence and detrusor instability. *European Urology*, Vol. 14, No.6, pp. (437), ISSN 0302-2838

*Journal of Urology*, Vol. 49, No.12, pp. (1112-1118), ISSN 0494-4747

*Investigation*, Vol. 26, No.3, pp. (250-256), ISSN 0378-7346

*Gynecology*, Vol. 200, No.6, pp. (649. e641-649. e612), ISSN 0002-9378 Jeffry, L., Deval, B., Birsan, A., Soriano, D. & Dara , E. (2001). Objective and subjective cure

*Urogynecology Journal*, Vol. 19, No.10, pp. (1359-1362), ISSN 0937-3462 Fulford, S., Flynn, R., Barrington, J., Appanna, T. & Stephenson, T. (1999). An assessment of

No.1, pp. (135-137), ISSN 0022-5347

Vol. 21, No.1, pp. (5-26), ISSN 0937-3462

Vol. 58, No.5, pp. (702-706), ISSN 0090-4295

Vol. 51, No. 11, pp. (772-776), ISSN 2005-6737

ISSN 1520-6777

6777

*Gynecology*, Vol. 106, No.1, pp. (38-43), ISSN 0029-7844

0643

interventions. *Current Opinion in Urology*, Vol. 15, No.6, pp. (374-379), ISSN 0963-

incontinence is more bothersome than pure incontinence subtypes. *International* 

the surgical outcome and urodynamic effects of the pubovaginal sling for stress incontinence and the associated urge syndrome. *The Journal of Urology*, Vol. 162,

Petri, E., Rizk, D. E. & Sand, P. K. (2010). An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. *International Urogynecology Journal*,

free vaginal tape on mixed and stress urinary incontinence. *Obstetrics and* 

M. (2009). Predictive value of urodynamics on outcome after midurethral sling surgery for female stress urinary incontinence. *American Journal of Obstetrics and* 

rates after tension-free vaginal tape for treatment of urinary incontinence. *Urology*,

and future perspectives. *Neurourology and Urodynamics*, Vol. 29, No.4, pp. (618-622),

along with the severity of stress urinary incontinence? *Korean Journal of Urology*,

midurethal sling operation for treating women with mixed incontinence. *Korean* 

urinary incontinence: where is the primary pathology? *Gynecologic and Obstetric* 

operation for women with mixed incontinence: Do preoperative variables predict the outcome? *Neurourology and Urodynamics*, Vol. 26, No.1, pp. (115-121), ISSN 1520-


**13** 

*Taiwan* 

**Suburethral Slingplasty Using a Self-Fashioned** 

The pelvic floor is a highly complex structure and plays a dual role in supporting the pelvic viscera (bladder, bowel, and uterus) and maintaining the functional integrity of these organs. Pelvic organ support is maintained by complex interactions between the levator ani muscles of the pelvic floor and connective tissues along with the urethra, vaginal wall, rectum, and normal innervation (Boreham et al., 2002; Wei and DeLancey, 2004). The pelvic floor and pelvic cavity is an integral structure and can be functionally divided into three compartments. Each compartment is not discrete and is comprised of different pelvic organs. The anterior compartment contains the urethra and bladder, the middle compartment holds the vagina and uterus, and the posterior compartment consists of the

Conventionally, the pathophysiology of stress urinary incontinence at the bladder neck is caused by proximal urethral hypermobility and/or intrinsic sphincter deficiency (Schick et al., 2004). The urethra and bladder lie on the supportive or suspension layers which are composed of the pubourethral ligament, endopelvic fascia, pubucoccygeal muscle, and the anterior vaginal wall. The breakdown of these layers can attenuate the urethra and/or cause

**2. Pelvic organ prolapse and stress urinary incontinence share similar risk** 

It has been noted that better pelvic-floor muscle function is associated with less severe prolapse and urinary symptoms. Poor pelvic floor muscle function is one of the inciting or contributory factors in the development of prolapse (Borello-France et al., 2007). Consistent tension from increased intra-abdominal pressure, loss of muscular support for pelvic organs, wideness of genital hiatus, and stretched or torn connective tissue might lead to prolapse (Wei and DeLancey, 2004). Furthermore, intermittent mechanical forces imposed on the prolapsed vaginal tissues or denervation of the vaginal tissues during vaginal delivery might cause decreased content of differentiated smooth muscle in the vaginal wall

asymptomatic or symptomatic anterior vaginal wall prolapse.

**1. Introduction** 

anus and rectum.

**factors** 

**Mesh for Treating Urinary Incontinence** 

Chi-Feng Su, Soo-Cheen Ng, Horng-Jyh Tsai and Gin-Den Chen *Kuang Tien General Hospital, Chung Shan Medical University/Hospital,* 

**and Anterior Vaginal Wall Prolapse** 

*Department of Obstetrics and Gynecology* 

