UROLOGICAL SURVEY
Fritsch H, Pinggera GM, Lienemann A, Mitterberger M, Bartsch G, Strasser H
Institute of Anatomy and Histology, University of Innsbruck, Innsbruck, Austria
Neurourol Urodyn. 2006; 25: 128-34
AIMS: Female stress urinary incontinence is thought to result from impairment of the connective tissue “ligaments” of the urethra. Surgical repair of female incontinence mainly involves fixation of the urethra to the pubic bone or other surrounding structures. In the present anatomical-radiological study, the anatomy of the connective tissue structures around the female urethra was investigated to determine the anatomical structures that support the urethra and the rhabdosphincter.
MATERIALS AND METHODS: The topography of the anterior compartment of the female pelvis was studied in serial sections and one anatomical preparation of 30 female fetuses and of six adult females. The pelves of 29 female fetuses were processed according to plastination histology technique. The pelves of the six adult specimens were processed according to sheet plastination technique. In addition, the anatomical findings were compared with MR images of 41 adult female volunteers.
RESULTS: The ventro-lateral aspect of the urethra remains free of fixating ligaments throughout its pelvic course. Ventro-laterally the urethra is enclosed by the ventral parts of the levator ani, its fasciae and a ventral urethral connective tissue bridge connecting both sides. Dorsally, the urethra is intimately connected to the wall of the vagina.
CONCLUSIONS: The female urethra has no direct ligamentous fixation to the pubic bone. Urethral continence after pregnancy and childbirth may be explained by a widening of the hiatus of the levator ani or the anterior vaginal wall, resulting in overstretching of the ventral urethral connective tissue bridge or the disruption of the fixation between urethra and vagina.
Editorial Comment
The authors analyze the anatomy of the female urethra with regards to the support of the urethra and rhabdosphincter. This was accomplished through analysis of the pelves of 30 female fetuses and 6 female adults. The authors find that there is no pubourethral ligament attaching the urethra to the pubic bone; instead the tissues attaching the pubic bone to the bladder neck are mostly tissue containing smooth muscle cells. In addition, the dorsal end of the rhabdosphincter is connected at its dorsal end through a strong connective tissue fixation to the ventral wall of the vagina. The neurovascular bundles are identified in the dorsal lateral pelvic wall in the ventral lateral aspects of the urethra.
This excellent article is extremely well written with beautiful anatomical pictures. That the investigators were not able to find the existence of any true pubourethral ligaments helps explain the ability of a patient to continue with urinary continence after a transvaginal urethrolysis, especially one utilizing the suprameatal transvaginal technique (1). That the authors found that the neurovascular bundles ran in the dorsal lateral pelvic wall on the lateral and ventral aspects of the urethra may explain a potentiality for sexual dysfunction after formal urethrolysis. There is an excellent discussion with regards to 3 supportive structures of the urethra and rhabdosphincter, which were identified, and the pathologic effects on same, which may lead to voiding dysfunction.
Reference
1. Petrou SP, Brown JA, Blaivas JG: Suprameatal transvaginal urethrolysis J Urol. 1999; 161: 1268-71.
Dr. Steven P. Petrou
Associate Professor of Urology
Associate Dean, Mayo Clinic College of Medicine
Jacksonville, Florida, USA
How do the Prevalences of Urogenital Symptoms Change During Pregnancy?
van Brummen HJ, Bruinse HW, van der Bom JG, Heintz AP, van der Vaart CH
Department of Perinatology and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
Neurourol Urodyn. 2006; 25: 135-9
AIM: The aim of this study was to report the changes in prevalences of urogenital symptoms during pregnancy and to evaluate the amount of bother nulliparous pregnant women experience from these symptoms.
METHODS: We have used a prospective longitudinal cohort study design. Five hundred fifteen nulliparous women with a singleton pregnancy were recruited from 10 midwifery practices between January 2002 and July 2003. The women received postal questionnaires. Urogenital symptoms were assessed with the Dutch version of the standardized and validated Urogenital Distress Inventory (UDI). We analyzed our data on item level and on the clustering of items.
RESULTS: The prevalences of the frequency and urgency symptoms are high at 12 weeks (74% and 63%) and remain stable during pregnancy. The prevalences of urinary incontinence and voiding difficulties increase with gestational age. Frequency disappears in 12% in late pregnancy, urgency in 22%, and stress incontinence in 23%. The prevalence of bothersome frequency symptoms is much higher than of urinary incontinence (21% compared to 6%). All UDI subscales increase significantly during pregnancy.
CONCLUSIONS: Urogenital symptoms occur in almost all women during pregnancy. Whereas the prevalence of overactive bladder symptoms is high and remains stable from early pregnancy on, the prevalences of urinary incontinence symptoms increase with gestational age. Despite the high prevalences of symptoms, the majority of women report not to be bothered by it.
Editorial Comment
The authors study a large number of women during their first pregnancy and quantify both the prevalence and level of bother of the voiding symptoms that developed during this period. The investigation found that by twelve weeks of pregnancy, urgency and frequency had been identified and this symptom remained stable during pregnancy. In contrast, the incidence of urinary incontinence increased as the pregnancy matured. The authors concluded that though almost all women in pregnancy have some voiding dysfunction and the prevalence of overactive bladder symptoms is quite high from early on, the majority of women are not bothered by these symptoms.
That nulliparous women have a known rate of voiding dysfunction is well known and quoted by the authors of this manuscript. Perhaps the pregnant women of this study felt almost no bother from their urinary symptoms secondary due to the understanding that this was a self limited phenomena that would cease because of: it was the miracle of childbirth; or, the life changes and challenges associated with a maturing pregnancy reduced voiding dysfunction to a lower priority on the list of physical, mental and situational events that may affect and bother the pregnant female. A clear message from this article is that almost all women who are pregnant will have some kind of voiding dysfunction with urge and frequency starting early and urinary incontinence continuing to worsen as the pregnancy continues; nevertheless, the physician probably will not be challenged to find a solution to this problem for the pregnant woman does not view it as a significant bother.
Dr. Steven P. Petrou
Associate Professor of Urology
Associate Dean, Mayo Clinic College of Medicine
Jacksonville, Florida, USA
Neurourology & Female urology
Publication Dates
-
Publication in this collection
08 June 2006 -
Date of issue
Apr 2006
