Abstracts for 2002 ASM of Hong Kong Continence Society

Management of Vaginal Vault Prolapse


Dr. Cecilia Cheon, SMO, Department of Obstetrics & Gynaecology, Queen Elizabeth Hospital


Vaginal vault prolapse occurs in 0.2% to 43% of women after hysterectomy.  It represents a medium or long term failure of the supporting mechanisms.  There are many factors contributing to the problem including deficiency of collagen metabolism, childbirth, estrogen deficiency and trauma etc.

The pelvic floor consists of muscular and fascial structures that support the abdominal cavity and the external openings of the vagina, urethra and rectum.  This support depends on the co-ordinate action of the striated levator ani muscle of the pelvis, the smooth muscle of the pelvic organs and intact connective tissue attachments.  DeLancey described three levels of support in the female pelvis.  Level I support is represented by the endopelvic fascia that support the proximal portion of the vagina from the pelvic sidewall.  Level II support attaches the middle portion of the vagina laterally to the arcus tendinous and fascia of the levator ani muscles.  Level III supports the lower vagina by connections of fibres to levator ani fascia, pubis and perineal body.

Symptoms of the vault prolapse include mass protruding from below, pelvic discomfort, urinary and bowel symptoms etc.  Assessment of the problem should include urodynamics with a ring pessary and anal physiology if there is concommittent anal incontinence.  Classification of prolapse including conventional, ICS POPQ and revised New York classification system.  Each aims at more objective assessment with standardization.

Treatment of vault prolapse aims at preserving sexual function and curing of symptoms.  Treatment can be divided into conservative and surgical approaches.  Conservative treatment using ring pessaries will rely on adequate perineum to support and retain pessary.  It cannot preserve sexual function.  Surgical treatments include vaginal, abdominal, laparoscopic procedures and newly used minimally invasive procedure.  Women undergoing surgical corrections should understand that there is significant morbidity related to operations, small chance of recurrent prolapse and the possibility of revision of hidden concommittent problems such as stress incontinence, voiding dysfunction and anal incontinence.

Perineal Ultrasonography of Bladder Neck Movements and Female Urinary Incontinence


Dr. Shing-Kai Yip, Ass. Professor, Dept of O&G, CUHK

  Genital prolapse, urinary and faecal incontinence are amongst the most prevalent problems in women’s health.  Despite a century of surgical experience, the correct anatomy and mechanics of pelvic support have not been fully elucidated.  Gynaecologists and anatomists traditionally viewed the pelvic floor in mechanically simplistic terms.  Recent advances in imaging technology provide new evidences that change our view and management of pelvic floor dysfunctions.  Magnetic resonance imaging (MRI) provides sufficient resolution to reveal the details of the muscles and ligaments of the pelvic floor.  These information are supplemented by three-dimensional (3D) computer generated models of the pelvis.  This new technology has been employed successfully in the study of female pelvic floor dysfunctions, which included the study of levator ani structure, volume and integrity in women with stress urinary incontinence and genito-urinary prolapse.  Nonetheless, MRI is not universally applied clinically in the assessment of pelvic floor dysfunctions, owing to its cost.  A cheaper and non-invasive alternative is perineal ultrasonography (pUSG).  pUSG uses existing ultrasound technology and techniques, and can be used to visualise the bladder neck and pelvic floor, both in static and dynamic states.  Combining pUSG with the Rectangular Coordinate System, the bladder neck can be accurately located within the pelvis.  This new technology is a useful addition to the clinician’s diagnostic tools, as well as a research tool in the study of pelvic floor dysfunctions.

Primary Nocturnal Enuresis Updates


Prof. C.K.Yeung,  Dept. of Paediatric Surgery, CUHK


Primary nocturnal enuresis (PNE), or bedwetting, is a very common disorder in children in most western countries, with a prevalence ranging from 5% - 10% below the age of ten. Traditionally, it has generally been accepted that PNE is related simply to a delayed maturity of micturition control, and hence an expectant or conservative approach is usually adopted, with a belief that the condition will ultimately resolve spontaneously with age. A recent study of 21,000 school children aged 5 – 19 years in Hong Kong revealed that the actual prevalence of PNE among local children was indeed as high as in other countries, with 10.9% of boys and 9.4%% of girls at 7 years of age still suffering from bed-wetting. Interestingly, although the overall prevalence decreased as children became older, the frequency and severity of wetting episodes progressively increased with age. At age 5 years, only 14 % of enuretic children wet every night, compared to 37% at age 19 years (p<0.05). A further epidemiological study of PNE in adolescents and adults up to the age of 40 years indicated that the prevalence remained rather static with no further significant drop after the age of 10 -12, with over 2% of both male and female adults remaining enuretic. More importantly, over half of the affected adults wets at least 3 or more nights per week, and one quarter experienced symptom every night. This therefore strongly suggested that the previous notion that PNE will get better and spontaneously resolve with growing age probably applies largely only to those with mild enuretic symptoms. As age advances, those with severe symptoms would much more likely have persistent problems into adult life.

Despite extensive clinical research on PNE over the last few decades, a lot of questions still remain unanswered regarding its exact pathogenesis. It can now be envisaged that bedwetting may occur in a child if the volume of urine production after sleep at night is well in excess of the nocturnal functional bladder capacity, and at the same time there is a failure of conscious arousal and waking up to micturate in response to the sensation of a full bladder. Various factors can potentially disturb the balance and result in a mismatch between nocturnal urine production and bladder reservoir function. A deranged circadian rhythm of antidiuretic hormone (ADH) secretion resulting in nocturnal polyuria have been found in many enuretic children. Research data from our centre however also indicated a high proportion of enuretic children with refractory symptoms have underlying bladder and/or brainstem dysfunctions, resulting in a reduction in nocturnal functional bladder capacity with or without additional sleep arousal problems. Furthermore, there is an intricate and dynamic interaction between bladder functional behaviour and the central nervous system, with a significant positive correlation between unstable detrusor contractions and sleep arousal episodes, but a reverse relationship with conscious awakening responses. New concepts of the pathophysiology and management strategy for PNE have been devised.


Continence Clinic – Five Years Experience


Dr. TKK Yu & Dr. CP Wong, Dept. of Integrated Medical Service, Ruttonjee Hospital & Tang Shiu Kin Hospital


Incontinence, both urinary and faecal, is prevalent but a much hidden and neglected health problem. It causes numerous physical, psychological, social and economic consequences. Continence clinic was first established in April 1996 in Ruttonjee Hospital with the aim to provide comprehensive assessment and management for incontinence problem.

A total of 303 new cases were seen in our Continence clinic since 1996 and 296 records could be retrieved. Of the 296 cases, majority of them had urinary incontinence with only 6 cases of faecal incontinence and 5 cases of double incontinence. The mean age was 72.9 years old (range 36 –95) with female predominance (78.7%). Referrals from other departments (apart from geriatrics department), community and self-referrals were increasing and account for about 40% of all referrals. Urodynamics were performed in 76.6% of all urinary incontinence cases. Unstable detrusor being the most frequent urodynamic diagnosis (40.5%), followed by genuine stress incontinence (18.7%), hypocontractile detrusor (18.3%), outflow tract obstruction (10%), sensory urgency (5.5%) and others (7%). Cases without urodynamics investigation were mostly stress incontinence cases. Of those clients with symptoms of stress incontinence, only 39.3% of them could demonstrate genuine stress incontinence during urodynamics study. 43.4% of all cases had more than one diagnosis and 13.1% had transient causes with urinary tract infection being the most common transient cause. Of the 45 clients with typical symptoms of urinary tract infection only 17 of them were proven to have the infection microbiologically. On the other hand, there were 36 cases of culture positive urinary tract infection and only 16 of them had typical symptoms.

Eighty-three clients were given oxybutynin for the treatment of unstable detrusor and within them 25.2% had got mild dry mouth, 15.5% moderate dry mouth and need dosage reduction and 4.8% required drug withdrawal due to severe dry mouth. Cardiac (7.1%) and gastro-intestinal side-effects (3.6%) of oxybutynin were also encountered. Pelvic floor exercise were taught by our continence nurse in nearly half of our clients and among them about a third were also referred to our physiotherapist. Bladder retraining was taught in about one third of our clients but bladder retraining was seldom used as a sole treatment modality. 43 clients (14.5%) were referred to the surgeons or gynecologists for further management. Overall, more than half (54.8%) of the clients had great or total improvement of their incontinence problem.

In these years of working in the Continence clinic, much knowledge has been gained and experience shared among different disciplines. Continence clinic, with comprehensive assessment and treatment, has been successful in the management of incontinence clients.

Extracorporeal Magnetic Innervation Therapy for Stress Incontinence


Tang Siu Fong Anna, C Chen, LS Leung, IC Law, Ivy Yu, AWC Yip, Urology Centre, Kwong Wah Hospital


Extracorporeal Magnetic Innervation (ExMI) is a kind of magnetic flux, which is generated by a machine and is installed in an armchair to generate a contracting wave for muscle stimulation. It aims to stimulate and strengthen the pelvic floor muscle while sitting in the chair.

AIMS AND OBJECTIVES: To investigate how the quality of life affecting Chinese women with stress urinary incontinence in receiving extracorporeal magnetic innervation (ExMI).

PATIENT AND METHOD: Forty subjects of female, with demonstrable stress urinary incontinence and having normal urodynamic studies, were recruited. The Group received 20 minutes treatments twice a week (5 to 10 Hz and 10 to 50 Hz) over 6 weeks (12 treatments) period. The subjects were seated in a chair of a Neocontrol system. The chair contains a magnetic field generator that induces contraction of the pelvic floor muscles. All subjects were required to undergo a pre-study assessment before treatment, which included a gynecology examination, urine test to rule out urinary tract infection, a 3-day bladder diary and a quality of life questionnaire. After treatment completed, a 3-day bladder diary and a post-treatment quality of life evaluation were repeatedly measured at week 2 and week 6.

RESULT: 36 subjects completed the treatment and 6 dropped because of busy schedule. The mean age was 55.2 (range 39 – 72). Duration of symptom was 43 +/- 28.54 months. All presented with demonstrable stress urinary incontinence (SUI). 47% used pads for protection before receiving the treatment.

The score rating for the episode of urine loss, number of pads used and number of nocturia were reduced when comparing the results with the pre and post treatment (p < 0.05). In addition, the score for the number of episode of urine loss, number of pads used and number of nocturia at week 2 post treatment was lower than those at week 6 after treatment.

While rating the quality of life scores in 10 different areas, they were worries about stress urinary incontinence (SUI), easily tiredness, amount of sufficient sleep, fun, level of contact with family / friend, cope of work, satisfaction of life and the average score, the p value between pre and post treatment was < 0.05 showing significant difference, except the items of sexual activity and feeling of rejection. The p value of sexual activity was 0.148, as well as feeling of rejection (p= 0.127).

DISCUSSION: ExMI in the treatment of stress urinary incontinence showed significant reduced in number of episodes of urine loss, number of pads used and number of nocturia while compare the rating with the pre treatment baseline measures and at week 6 post treatment. In addition, the score at week 2 post treatment has relatively reduced in the same areas, while compare with the rating at week 6 post treatment. It showed that magnetic influence for pelvic muscle strengthening would be affected in according with length of time. But how long can the power of the strengthened muscle be lasted, it needs to be further study.

The episode of leakage was reduced during the treatment period. However, the number of pads used between the pre and post treatment was rather subjective. It depends on the subjects’ perceiving of the soaked pads and their usual habit. On the other hands, Chinese women seldom express their concerns on the areas of sexual activity and feeling of rejection hence further investigation on these areas will be needed.

CONCLUSION: At week 2 and week 6 post treatment showed positive changes in affecting subjects after ExMI treatment for pelvic floor muscle training. The power of the strengthened pelvic muscle has been affected for a certain length of time after treatment completed. Extracorporeal magnetic innervations biweekly, with 12 treatments was found to be an effective and acceptance therapy by measuring both bladder diaries and quality of life analysis, especially in reducing subjects' worries about stress urinary incontinence.


Pubovaginal sling operation for stress urinary incontinence using a new biomaterial (small intestine submucosa, sis): two years experience.

  SK Mak, WH Au, YK Szeto, Urology Division, Dept. of Surgery, North District Hospital

Introduction: Pubovaginal sling operations provide the best surgical outcome for stress urinary incontinence. We reviewed our experience in performing pubovaginal sling operation using a new sling biomaterial (SIS) for female patients with genuine stress urinary incontinence.

Material and method: We retrospectively reviewed a case series of our patients who have pubovaginal sling operation performed by a single surgeon (YK Szeto) in our centre. Patients have thorough clinical and urodynamic assessment before the procedure. The 2 x 20 cm SIS urethral sling was prepared by placing a No.1 Prolene suture at either end of the sling. The suture and sling was brought from the vaginal to abdominal incision on either side. The sling was fixed in position behind the urethra at the level of the bladder neck. The suture was tied together on the rectus sheath to tighten the sling. Patients were put on temporary suprapubic or perurethral catheterization post-op. Outcome analysis included a chart review & third party telephone Interview. Surgical outcome was categorized by daily pad use as cured (0), improved (1) or failed (greater than 1 pad.)

Results: Seven female patients, age ranged from 41 to 78 years old (mean 60), underwent pubo-vaginal sling operation using SIS sling from 30 May 2000 to 14 May 2002. Preoperative pad use ranged from 2 to 4 pads per day. Operation time ranged from 80 to 170 minutes (mean 110). Post-operative analgesic use ranged from 0 to 10 days (mean 4). Only short-term post-operative catheterization & hospital stay was required. Median follow-up was 11 months. All patients were satisfied with the surgical outcome, who were either cured (5 patients) or improved (2 patients).

Conclusion: The SIS urethral sling can be used satisfactorily in the pubo-vaginal sling operation. Satisfactory surgical outcome achieved in all of our patients.


Acupunture for Urinary Incontinence?


Ms. Maisie Wong, PT (private), Listed Chinese Medicine Practitioners


Acupunture Therapy has a history of more than 40,000 years and only at the 50s of the 20th century there is increasing studies and research on it.  With the development of medical science and technology, the nature of meridians and acupoints, and the mechanism of acupunture are gradually being better known and understood.

Treatment for urinary problem by acupunture has been found in early Chinese medicine documents.  Different presentation of urinary problems are treated by different acupoints or their combinations with different type of stimulation. Studies have shown that acupunture therapy has a 2-way modulating effect on kidney filtration function, ureter mobility, bladder activity and sphincter contractility.

Needling KI-5 (照海), KI-10 (陰谷) will facilitate the kidney filtration function, whereas needling BL-23 (腎俞), GB-25 (京門) will have an opposite effect.  Recent animal studies also show that needling BL-28 (膀胱俞) will cause detrusor muscle contract and needling BL-23 (腎俞) will relax the bladder.  The effect of acupunture on urinary system seems depend on the specificity of the acupoints, the status of the organs and structures, and the type of stimulation.  Further investigation and controlled studies is needed for the development of acupunture therapy for incontinence.