3

STRESS INCONTINENCE OF URINE INTHE FEMALE

By TERENCE MILLIN, M.CH., F.R.C.S.,and

CHARLES D. READ, M.B. F.R.C.S.(E), F.R.A.C.S., F.R.C.O.G.London

PART I

The distressing condition for which Sir EardleyHolland coined the term stress incontinence isvariously known as orthostatic, exertional ordiurnal incontinence.The diagnosis presents little difficulty as a rule.

The history varies according to the severity of thecondition. In its mildest form the patient isconscious of an escape of a small quantity of urinein any movement which entails a rise of intra-abdominal pressure when in the upright position-sneezing, coughing, walking up or down stairs.In its most severe form it may be evidenced byalmost complete incontinence while in the up-right position. Almost invariably there is adequatecontrol while in the recumbent position, thoughwe have observed a few advanced cases in whichcontrol has been inadequate even in this positionif the coughing or sneezing has been violent.

It is important to differentiate between extremeprecipitancy of micturition, i.e., urge incontinence,and the stress variety. Precipitancy may be theresult of urinary infection giving rise to a basalcystitis. Such, of course, calls for appropriateantiseptic therapy, usually with sulpha drugs orthe mandelates, according to the type of infection.Another troublesome cause of urge incontinenceis a urethro-trigonitis unassociated with infection.These cases are frequently attributable to sexualmisfits and other causes of pelvic congestion, andlocal therapy seldom avails, despite claims bysome authors as to the advantages of urethraldilatation, diathermic coagulation, etc. The causefor the pelvic congestion should be sought andremedied, if possible. Operative procedures, tobe discussed later, have no place in the treatmentof such types of incontinence. It is equallyessential to exclude neuropathies, e.g., tabes dor-salis and spina bifida, which may cause a somewhatsimilar syndrome. Surgical intervention in theseis only too often followed by relapse, if notimmediate failure.True stress incontinence in the majority of cases

is found in multiparae with a variable degree of

genital prolapse, but the condition is encounterednot infrequently in nulliparae about the meno-pausal age. It has long been recognized that littlerelationship exists between the degree of genitalprolapse and the severity of the urinary incon-tinence. In fact, many women with an extremedegree of descensus.have no stress incontinence,and conversely, patients exhibiting marked urinaryloss may reveal little or no evidence of urethrocoeleor cystocoele. On several occasions we haveencountered stress incontinence which hasdeveloped after the successful repair of a prolapsein patients who previously had been completelycontinent of urine.Many years ago Victor Bonney showed that by

supporting the bladder neck on either side of theurethra by means of intravaginal digital pressurethe involuntary escape of urine from a full bladdercould be prevented. He deduced that the urinaryloss resulted from a sagging of the bladder neck,due to stretching of the pubocervical fascia, andhe concluded that the cure of the symptoms wasdependent on the restoration of this fascial struc-ture. In cases in which he failed to effect a cureby means of his buttress operation from below, headvocated a cystopexy by the abdominal approach.We have found Bonney's test difficult to apply, asit is hard to convince oneself that the digitalpressure is not being exerted on the upper urethrawhen endeavouring to support the bladder neckby the intra-vaginal fingers. We have found that,by the use of long, rubber-covered forceps in placeof the fingers, it is possible to support the bladderneck without exerting compression of the urethra,and by this means Bonney's contention can beeasily verified.Having established this point it appeared to one

of us (T.M.) that radiological confirmation shouldnot be difficult, and the technique about to bedescribed was evolved. Many previous workershad essayed radiological studies, but little progresshad been made and in I946, Muellner, in an articleon this subject, affirmed that neither endoscopic

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4 POST GRADUATE MEDICAL JOURNAL January 1948

nor radiological studies had offered conclusiveevidence as to the precise mechanism of the lesion.In this connection we must mention the pains-taking studies of Kennedy of New York, who useddistensible rubber bags which could be filled withradio-opaque media. By placing these in theurethra he claimed to demonstrate the presence ofseveral urethral sphincters which he believed toplay an important part in urinary control. Heheld that stress incontinence was the result ofdysfunction of these sphincters, and stressed theimportance of the sphincter surrounding the mid-urethra. The fact, however, that two-thirds ofthe urethra may be excised for malignant involve-ment without the subsequent development ofincontinence would appear to disprove the im-portance of this structure. Moreover, the forma-tion of a completely new urethra by either thetrocarization method of Marion or by the vaginalflap method recently described by Couvelaire ofParis, in both of which complete continence iseventually obtained by the sole use of the bladdermusculature, would appear to present strongconfirmatory evidence that these so-called urethralsphincters play little part in urinary control. Wehave satisfied ourselves that in the interlacingfibres ofthe detrusor at the vesical outlet resides thechief mechanism of urinary control in the female.

Technique of Cystography in StressIncontinenceA No. 20F Malecot catheter is passed on a stilet

into the bladder. The bladder is emptied, andby means of a syringe, 6-Io ozs. of io per cent.solution of sodium iodide is introduced, and thecatheter is spigotted. The patient then standsagainst a vertical X-ray screen with the tubecentred on the upper border of the symphysispubis. She is requested to take a short breath,and to remain immobile while the first exposureis made. The patient, still in the identical position,is then requested to strain down as in the act ofdefaecation, and a second exposure is made onthe same film, i.e., a double exposure. Thesecond exposure reveals the bladder neck in itsposition when the intra-abdominal pressure israised, i.e., as in coughing, sneezing or straining.As an alternative method two separate films maybe used-one exposure being made in the relaxedupright position and the other whilst straining.The films are superimposed for reading purposes.A study of many scores of these skiagrams reveals,as anticipated from the clinical studies, that in thenormal woman not exhibiting stress incontinencethere is no demonstrable descent of the bladderbase, but in those suffering from such a urinaryloss, there is a very appreciable lowering of thevesical .outlet, and in advanced cases there is a

funnelling of the exitus. Moreover, from a studyof the extent of this descent one can estimate theseverity of the condition. In short, it is possibleto assess the degree of the incontinence from aperusal of the. skiagrams.

It can be appreciated that the presence of acystocoele without stress incontinence may givethe radiographic appearance of apparent loweringof the bladder neck in an antero-posterior filmowing to the fact that the cystocoele descendswith its radio-opaque contents. By taking filmsin the lateral or oblique positions the level of thecystocoele can be differentiated from that of thebladder neck. Lateral radiograms, owing to thedensity of the femora and pelvic bones, are lesssatisfactory in their definition than oblique pic-tures, with the tube directed through the obturatorforamen. In these oblique films non-descent ofthe vesical outlet can be demonstrated where stressincontinence is absent. Figs. 1-22 illustrate sometypical cystograms.

Having established to our satisfaction bothclinically and radiographically that a descent ofthe bladder neck is present in those patients whoexhibit stress incontinence, it became obvious thatany operative intervention to cure the condition,must aim at elevation of the bladder neck. Itmust be remembered that we are not here con-cerned with those patients who develop incon-tinence immediately after parturition and whosecure can usually be effected by appropriateremedial exercises, and combined if necessary withfaradic stimulation; neither are we consideringthose minimal degrees of the condition whichbenefit often by fulguration of the bladder neck.We have under review those more advanced casesfor which surgical intervention is sought, or inwhich the simpler remedies have failed. Wewould stress that in all cases in which there is anassociated uterine or vaginal prolapse or both, thefirsi procedure to be embarked upon is one which willcure the prolapse, but at the same time steps shouldbe taken to elevate the bladder neck from below atthe time of the vaginal repair.Operative Treatment of StressIncontinenceThree methods of approach for the cure of the

condition have been described and each method ofapproach exhibits many alternative procedures:

(a) Vaginal approach.(b) Abdominal approach.(c) Combined abdomino-vaginal approach.

Vaginal Operations(i) Colporrhaphy with special sub-urethral

repair of various types as described byBonney, Marion, Kelly, Kennedy, Davies,and Wilfred Shaw.

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January I948 MILLIN : Stress Incontinence of Urine in the Female 5

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FIG. i.-Superimposed cystograms in patient withmarked stress incontinence. Note marked lowering ofbladder base in the position of strain (cf. Fig. 2).FIG. 3.-Superimposed cystograms in patient withmoderate genital prolapse without stress incontinence.Note the descent of the upper level of the bladdershadow on raising the intra-abdominal pressure butfixed position of the bladder base.FIG. 5.-Superimposed cystograms in case of stressincontinence only partially relieved by vaginal repair.(Cure by Millin sling 14 months ago.)

FIG. 2.-Tracing of Fig. i. a, a' indicate upper andlower levels of bladder in the vertical relaxed position;b, b' indicate the same in the position of stiain. Thedescent from a' to b' in the original skiagram was2.5 cm.

FIG. 4.-Superimposed cystograms in case still ex-hibiting marked stress incontinence despite two vaginalrepairs. (Cure by Millin sling 20 months ago.)FIG. 6.-Tracing of superimposed cystograms of casestill exhibiting severe stress incontinence despite pre-vious Fothergill repair and subsequent Gersuny ure-thral rotation. [Skiagrams too indistinct for reproduc-tion.] (Immediate cure by Millin sling-recent case.)

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6 POST GRADUATE MEDICAL JOURNAL January 194g

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FIGS. 7, 8.-Cystograms on separate films of case exhibiting marked stress incontinence despite previousvaginal repair. Compare level of bladder base relative to pubis in the relaxed and straining positions. (Six

months' cure by Millin sling.)FIGS. 9, io.-Cystograms on separate films of case of extreme stress incontinence despite five previous surgical

attempts at cure.

FIGS. I I, 2.-Cystograms on separate films of case ofvery severe stress incontinence despite Gracilis operation.Following latter procedure there was relief for three months, but the condition relapsed.

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January 1948 MILLIN : Stress Incontinence of Urine in the Female 7

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FIGS. 13, i4.-Cystograms of case shown in Figs. i , 12 after Millin sling.FIG. 15.-Tracing of Figs. 13, 14 superimposed.Note fixity of bladder base.FIG. I7.-Superimposed cystogram showing normalappearance after cure by Millin sling of marked stressincontinence. (Three previous failed vaginal inter-ventions.)

FIG. I6.-Oblique cystogram of same case aftersling.

FIG. I8.-Superimposed cystogram after cure byMillin sling.

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8 POST GRADUATE MEDICAL JOURNAL January I94:8

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FIGS. 19, 20.-Oblique cystograms in case of marked stress incontinence (two unsuccessful surgical interventions).Note movement of bladder neck downwards and backwards (three cms. on skiagram) on straining.

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FIG. 2I.-A-P shift cystogram in case of marked pro-cidentia without incontinence. (Foley catheter used here,bag being partially distended with Neo-hydriol). Note nodownward movement of bladder neck.

FIG. 22.-Oblique view of same case showing no move-ment either downwards or backwards on straining.(Cf. Figs. 19 and 20).

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January 1948 MILLIN : Stress Incontinence of Urine in the Female 9

(2) Gracilis transplant of Giordano.(3) Anterior plication of Lowsley.(4) Urethral rotation of Gersuny.(5) Urethral angulation of Thomsen.(6) Urethral angulation and elongation of

Bonney.Abdominal Operations

(I) Cystopexy of Bonney.(2) Cervico-cystopexy of Perrin and Williams.(3) Aponeurotic suspension of Goebel, Stoeckel.(4) Intravesical tautening of bladder neck

(Millin, Macky).(5) Millin sling operation (to be described in

detail later).Combined Abdomino- Vaginal Operations

(I) Frankenheim, Michon.(2) Aldridge, Studdiford.(3) Delinotte.Undoubtedly the commonest operation em-

ployed today is some type of colporrhaphy inassociation with a buttressing of the tissues belowthe bladder neck by some form of suture-mattressor otherwise- suitably placed in the sub-urethraltissues. Experience shows that the long-termresults are on the whole not so satisfactory as wasoriginally thought. It was commonly stated thatthe cure rate was over 90 per cent., but in ourexperience it is certainly much lower than this,and Counsellor has estimated that even in thethe best hands the cure rate is not above 70 percent. We can confirm this. The late recurrence rateis seldom appreciated, and we have seen manypatients in whom the immediate result has beencompletely satisfactory, but with the passage ofa few months the symptoms have returned to theiroriginal degree of severity. Such patients seldombenefit from a repeat vaginal repair.The Kelly operation, so ardently supported by

the Baltimore School, is, we believe, in somerespects based on false premises. Its exponentsbelieve that there is an intrinsic laxity of thesphincter mechanism about the bladder neck, andthey ' take a tuck' in the sphincter by means ofa silk mattress suture during the performance ofthe colporrhaphy. One of us (T.M.) has in thepast operated upon more than forty of these casesby an intra-vesical technique, and has found, incontradistinction to the cases of congenital incon-tinence, only rarely, a marked relaxation of thevesical outlet. (This observation would appear todisprove the contention of Macky, and to makehis proposed intra-vesical tautening of the ' torn'sphincter unnecessary.)The operations of Kennedy and Davies are

based on the belief that the urethral sphincters areof prime importance. They aim at restoring

these structures, but in the course of their opera-tions a wide freeing of the bladder neck and urethrais effected. In Davies' operation the base of thebladder is freed extensively in addition. In boththese operations the loss of blood can be consider-able. We believe that the good results of theseworkers and their adherents, notably Counsellor,are due more to the excellence of the buttressingobtainable after the wide freeing of the bladderneck, and only serve to corroborate our view thatthe essential lesion is a descent of the bladder neck.The Gracilis transplant proposed by Giordano

and advocated by others, notably Loughnane inthis country, is based, in our submission, on afalse conception of the pathology. Attention ishere directed not against the faulty bladder neck,but against the urethra, which it aims at com-pressing. When the muscle transplant does notslough early, a good immediate result may beobtained, but later the muscle becomes convertedinto fibrous tissue and the incontinence recurs.The urethral rotation operation of Gersuny

seldom gives satisfactory results and there is areal risk of sloughing of the urethra. We haveseen two such cases and the results were disastrous.Recently Thomsen has described a method ofacutely angulating the urethra and has shown someurethrograms illustrating both the pre- and post-operative findings. We feel that the good resultsobtained by him are again due more to the eleva-tion of the bladder neck than to the urethralangulation in his procedure.The Lowsley ribbon-gut anterior plication has,

in our opinion, little to recommend it.Recently Wilfred Shaw has advocated the sutur-

ing of what he terms the ' post-urethral ligament'to the cervix, thus forming a shelf upon which thebladder rests. This undoubtedly elevates thethe bladder neck, but we feel that it tends toapproximate the cervix to the symphysis withresulting tendency to retroversion and shorteningof the anterior vaginal wall.

Abdominal OperationsOf the abdominal operations, cystopexy and

cervico-cystopexy have been performed by manyworkers, notably Bonney, Perrin and Everard-Williams. The operation involves a ventro-fixation of the bladder, with or without the bladderneck, to the posterior periosteum of the symphysisand to the anterior abdominal wall. Both catgutand silk have been used and it would appear thatcervico-cystopexy, using silk, offers the best chanceof a cure. We feel that time will eventually showa relaxation of the cervical and bladder musculaturewith recurrence of the incontinence. Moreover,the use of silk may be followed by a perforationof the mucous membrane with exposure of the

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Io POST GRADUATE MEDICAL JOURNAL January 1948

silk to the urine and subsequent formation ofphosphatic encrustations.The original 'sling' operation proposed by

Goebel undoubtedly led to some cures, withimprovement in many others, but suspension ofthe bladder neck from a fixed bony point allowsfor little margin of error-an unduly tight slingwill give rise to a bar formation at the vesicaloutlet with dysuria or even retention, whilst afailure to elevate sufficiently will not realize acomplete relief from symptoms.One of us (T.M.) for some time practised an

intra-vesical operation in which the.bladder wasopened suprapubically and, after a wedge of thebladder neck had been excised, the outlet wasnarrowed and buttressed with chromic catgutmattress sutures. The immediate results wereon the whole good, but relapses occurred, and theoperation was abandoned.The sling operation (to be discussed in detail

in a subsequent article) proposed by Millin morethan three years ago, and now carried out by usin more than 130 cases, has been found singularlyeffective.

Combined ApproachFrankenheim, Michon, Delinotte, Studdiford and

Aldridge have all worked on a combined abdomino-vaginal approach to the problem and the procedureof Aldridge is perhaps the best known and the mostwidely practised. This operation in this countryhas been endorsed by Chassar Moir and it un-doubtedly produces good results. It combines

an anterior vaginal repair with the applicationof a fascial sling of external oblique aponeurosisbelow the urethra. Its performance necessitatesboth an abdominal and a vaginal incision and it isrelatively time-consuming. It involves alterationof the position of the patient during the operationand has the theoretical risk of sepsis ascendingfrom the vaginal incision.

It will be seen from the above considerationthat many procedures have been proposed andapplied to cure this distressing complaint. Themultiplicity of operations suggests that in the pastno single method has been completely successful.We would reiterate that while we consider thata sling operation of the Aldridge or Millin typewill cure most cases, we feel that the performanceof these sling operations is rarely justified until anadequate attempt has been made at repair fromthe vagina. In our view, in the case of a failedurethroplasty, the ' Millin sling' operation is thatof choice.

BIBLIOGRAPHY

ALDRIDGE, A. H. (1942), Amer. J. Obst. & Gyn., 44, 398.DAVIES, J. W. (1942), J. Uroi., 48, 536.DELINOTTE, R. (1947), J. Beige d'Urol., 6,76r.KENNEDY, W. T. (1937), Amer. J. Obst. & Gyn., 34, 576.LOWSLEY, O. S. (1936), J. Urol., 36, 400.MACKY, F. (I944), J. Urol. 52, 27.MICHON, LOUIS (1946), 39me. Congres franc. d'Urol., p. 340.MILLER, J. D. (1938), J. Urol., 40, 6I2.MILLIN, TERENCE (1939), Proc. Roy. Soc Med., xxxii, 777.MILLIN, TERENCE (1947), Proc. Roy. Soc. AMed., 40, 361.MOIR, J. CHASSER (I947), Edin. Med. J., LIV, 368.MUELLNER, S. R. (1946), New Eng. J. Med., 12, 400.PERRIN, E. (1946), 39me. Congresfranc. d'Urol., p. 334.STUDDIFORD, W. E. (1944), Amer. J. Obst. & Gyn., 47, 764.STUDDIFORD, W. E. (1945), Ibid., 50, 119.THOMSEN, EINAR (1940), Acta Radiologica XI, 5, 63.THOMSEN, EINAR (x94I), Acta Radiologica XII, 3, 4, 73, 74.

'Stress Incontinence of Urine in the Female '-Part zwill be published in the February number of this Journal.

In Great Britain there is strong opposition to the whole concept of a universityhospital, an opposition rarely if ever based on first-hand experience of theworking of the system in other countries. Nevertheless I remain convinced thatthe transformation of the teaching hospitals of Great Britain into true universityhospitals would do more than any other single act of reform in medical educationto ensure that our successors will indeed be members of a liberal scientific andlearned profession.

PROFESSOR HARRY PLATT. 1947.

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