Female Stress Urinary Incontinence Due to Intrinsic Sphincteric Deficiency: Recognition and Management

Abstract

No AccessJournal of UrologyClinical Urology: Review Article1 Jul 1996Female Stress Urinary Incontinence Due to Intrinsic Sphincteric Deficiency: Recognition and Management Francois Haab, Philippe E. Zimmern, and Gary E. Leach Francois HaabFrancois Haab , Philippe E. ZimmernPhilippe E. Zimmern , and Gary E. LeachGary E. Leach View All Author Informationhttps://doi.org/10.1016/S0022-5347(01)65925-1AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: The recent literature on intrinsic sphincteric deficiency is reviewed. Materials and Methods: We performed an extensive literature search related to the diagnosis, management and treatment of intrinsic sphincteric deficiency. Results: Stress urinary incontinence results from insufficient urethral resistance and/or support during increases in intra-abdominal pressure. Since treatment of stress urinary incontinence is closely related to the mechanism of urinary leakage, recognition of intrinsic sphincteric deficiency is of the utmost importance in its evaluation. Furthermore, to date there is no consensus on the treatment of intrinsic sphincteric deficiency and various procedures may be considered. Conclusions: The pathophysiology of urinary incontinence in female patients is still controversial. Intrinsic sphincteric deficiency is best recognized by history and clinical examination in conjunction with documentation of severe stress urinary incontinence, a fixed urethra and a low Valsalva leak point pressure. The pubo-vaginal sling procedure still represents the most widely accepted treatment to correct intrinsic sphincteric deficiency. References 1 : Standardization of terminology of lower urinary tract function. First and second reports: International Continence Society. Urology1977; 9: 237. Google Scholar 2 : The value of urodynamic testing in stress urinary incontinence. J. Urol.1980; 124: 256. Link, Google Scholar 3 : Stress incontinence: classification and surgical approach. J. Urol.1988; 139: 727. Link, Google Scholar 4 : Development of a plan for the diagnosis and treatment of urinary stress incontinence. Amer. J. Obst. Gynec.1962; 83: 632. Google Scholar 5 : Observations on stress incontinence of urine. Amer. J. Obst. Gynec.1952; 64: 721. Google Scholar 6 : Pathophysiology of lower urinary tract dysfunction. Urol. Clin. N. Amer.1985; 12: 215. Google Scholar 7 : Pubovesical ligament: a separate structure from the urethral supports ("pubo-urethral ligaments"). Neurourol. Urodynam.1989; 8: 53. Google Scholar 8 : Anatomy and physiology of urinary continence. Clin. Obst. Gynec.1990; 33: 298. Google Scholar 9 : Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Amer. J. Obst. Gynec.1994; 170: 1713. Crossref, Medline, Google Scholar 10 : The pathophysiology of stress incontinence. Urol. Clin. N. Amer.1985; 12: 271. Google Scholar 11 : Factors maintaining the intraurethral pressure in women. Invest. Urol.1980; 17: 343. Google Scholar 12 : Surgical treatment of anatomical stress incontinence. Neurourol. Urodynam.1988; 7: 569. Google Scholar 13 : Role of inner urethral softness in urinary continence. Urology1980; 16: 115. Google Scholar 14 : The vascular component in the production of intraurethral pressure. J. Urol.1972; 108: 93. Link, Google Scholar 15 : Estrogen effects on the urethra: beneficial effects in women with genuine stress incontinence. Obst. Gynec. Surv.1993; 48: 509. Google Scholar 16 : Current concepts of female pelvic anatomy and physiology. Urol. Clin. N. Amer.1991; 18: 175. Google Scholar 17 : Diagnostic advantages of fluoroscopic monitoring during urodynamic evaluation. J. Urol.1981; 125: 830. Link, Google Scholar 18 : The structure of the female lower urinary tract and pelvic floor. Urol. Clin. N. Amer.1985; 12: 207. Google Scholar 19 : Internal urinary sphincter in maintainance of female continence. Brit. Med. J.1986; 292: 166. Google Scholar 20 : Distal urethral compensatory mechanisms in women with an incompetent bladder neck who remain continent, and the effect of menopause. Neurourol. Urodynam.1990; 9: 579. Google Scholar 21 : Asymptomatic bladder neck incompetence in nulliparous females. Brit. J. Urol.1989; 64: 357. Google Scholar 22 : The ileal neobladder in women: 9 years of experience with 18 patients. J. Urol.1996; 155: 76. Link, Google Scholar 23 : Lower urinary tract reconstruction following cystectomy in women using the Kock ileal reservoir with bilateral ureteroileal urethrostomy: initial clinical experience. J. Urol.1994; 152: 1404. Link, Google Scholar 24 : The autonomic innervation of the human male and female bladder neck and proximal urethra. J. Urol.1977; 118: 302. Link, Google Scholar 25 : Spinal cord injury and sacral arc denervation in the female. Probl. Urol.1991; 5: 155. Google Scholar 26 : Neurologic implications of the pathologically open bladder neck. J. Urol.1983; 129: 780. Link, Google Scholar 27 : The incontinent myelodysplastic patient. Urol. Clin. N. Amer.1991; 18: 295. Google Scholar 28 : The striated urogenital sphincter muscle in the female. Anat. Rec.1983; 205: 223. Google Scholar 29 : Some aspects of striated urethral sphincter structure and function. J. Urol., part 21994; 152: 2321. Abstract, Google Scholar 30 : The contribution of magnetic resonance imaging of the pelvic floor to the understanding of urinary incontinence. Brit. J. Urol.1993; 72: 715. Google Scholar 31 : The anatomy of stress incontinence: magnetic resonance imaging of the female bladder neck and urethra. J. Urol.1990; 143: 563. Link, Google Scholar 32 : A comparative study of the human external sphincter and periurethral levator ani muscle. Brit. J. Urol.1981; 53: 35. Google Scholar 33 : Structural aspects of the extrinsic continence mechanism. Obst. Gynec.1988; 72: 296. Google Scholar 34 : Histochemical study of urethral striated musculature in the dog. J. Urol.1982; 128: 406. Link, Google Scholar 35 : The effect of pharmacological stimulation and blockade of autonomic receptors on the urethral pressure and power generation during coughing and squeezing of the pelvic floor in healthy females. Scand. J. Urol. Nephrol.1993; 27: 519. Google Scholar 36 : The effect of bilateral pudendal blockade on the adjunctive urethral closure forces in healthy females. Scand. J. Urol. Nephrol.1994; 28: 249. Google Scholar 37 : Neuroanatomy and clinical significance of the external urethral sphincter. Urol. Int.1987; 42: 132. Google Scholar 38 : Urodynamic findings in patients after failure of stress incontinence operations. Prog. Clin. Biol. Res.1981; 78: 351. Medline, Google Scholar 39 : Colpocystourethropexy: the way we do it. J. Urol.1976; 116: 751. Link, Google Scholar 40 : Operative correction for female urethral incompetence. Sem. Urol.1986; 4: 13. Google Scholar 41 : Treatment of female incontinence secondary to urethral damage or loss. Urol. Clin. N. Amer.1991; 18: 355. Google Scholar 42 : Experience with the management of urethral diverticulum in 63 women. J. Urol.1994; 152: 1445. Link, Google Scholar 43 : Urinary disorders in intervertebral disc prolapse. Neurourol. Urodynam.1987; 6: 11. Google Scholar 44 : Predicting intrinsic urethral sphincter dysfunction in women with stress urinary incontinence. Obst. Gynec.1994; 84: 188. Google Scholar 45 : Complicated stress urinary incontinence. Sem. Urol.1989; 7: 103. Google Scholar 46 : Failure of operations for stress urinary incontinence: evaluation and treatment. In: . Chicago: Year Book Medical Publishers1990: 107. Google Scholar 47 : Standardisation of terminology of lower urinary tract function. Neurourol. Urodynam.1988; 7: 403. Crossref, Google Scholar 48 : Twenty-four hour pad weighing test: reproducibility and dependency of activity level and fluid intake. Neurourol. Urodynam.1994; 13: 261. Google Scholar 49 : Inter and intra departemental variations of the eprineal pad weighing test. Neurourol. Urodynam.1986; 5: 23. Google Scholar 50 : Objective assessment of urinary incontinence: an evaluation of three different pad-weighing tests. Neurourol. Urodynam.1987; 6: 325. Google Scholar 51 : Objective quantification of stress urinary incontinence: a short, reproducible, provocative pad-test. Neurourol. Urodynam.1991; 10: 475. Google Scholar 52 : Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program for Women Research Group. Neurourol. Urodynam.1995; 14: 131. Google Scholar 53 : Health-related quality of life measures for women with urinary incontinence: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program in Women (CPW) Research Group. Quality Life Res.1994; 3: 291. Google Scholar 54 : SEAPI QMM incontinence classification system. Neurourol. Urodynam.1992; 11: 187. Crossref, Google Scholar 55 : The role of patient history in the diagnosis of urinary incontinence. Obst. Gynec., part 21994; 83: 904. Google Scholar 56 : Female incontinence. In: SIU reports. Urinary Incontinence. Edited by . : 1991: 55. Google Scholar 57 : Role of the Q-tip test in evaluating stress urinary incontinence. J. Reprod. Med.1987; 32: 273. Google Scholar 58 : Negative Q-tip test as a risk factor for failed incontinence surgery in women. J. Reprod. Med.1989; 34: 193. Google Scholar 59 : The diagnostic value of history, physical examination, and the Q-tip cotton swab test in women with urinary incontinence. Amer. J. Obst. Gynec.1988; 159: 145. Google Scholar 60 : Evaluation of the causes and severity of geriatric incontinence. A critical approach. Urol. Clin. N. Amer.1991; 18: 243. Google Scholar 61 : Evaluation of methods for assessment of bladder and urethral function. In: Urology in the Elderly. Edited by . New York: Churchill Livingstone1984: 19. Google Scholar 62 : Voiding dysfunction in children: diagnosis and management. In: Neurourology and Urodynamics. Principles and Practice. Edited by . New York: Macmillan Publishing Co.1988: 237. Google Scholar 63 : The effects of sacral denervation on bladder and urethral function. Surg., Gynec. & Obst.1977; 144: 343. Google Scholar 64 : Evaluating symptoms. In: Practical Urogynecology. Baltimore: Williams & Wilkins1993: 41. chapt. 3. Google Scholar 65 : The bulbocavernosus reflex in urology: a prospective study of 299 patients. J. Urol.1981; 126: 197. Link, Google Scholar 66 : Urodynamic appraisal of the Bonney test in women with stress urinary incontinence. Obst. Gynec.1983; 62: 696. Google Scholar 67 : Recurrent stress urinary incontinence. SIU Rep.1991; 5. Google Scholar 68 : On diurnal incontinence of urine in women. J. Obst. Gynaec. Brit. Emp.1923; 30: 358. Google Scholar 69 : Intraurethral and intravesical pressure in normal and stress-incontinent women. Obst. Gynec.1967; 29: 613. Google Scholar 70 : The urethral pressure profile. Brit. J. Urol.1969; 41: 211. Google Scholar 71 : Urodynamics of the female lower urinary tract. Urol. Clin. N. Amer.1985; 12: 231. Google Scholar 72 : Urethral pressure measurement by microtransducer: the results in symptom-free women and in those with genuine stress incontinence. Brit. J. Obst. Gynaec.1983; 90: 919. Google Scholar 73 : Hydrodynamics and mechanics of bladder and urethra. In: Urodynamics. Edited by . Edinburgh: Churchill Livingstone1984: 42. Google Scholar 74 : Resting and stress urethral pressures as a clinical guide to the mechanism of continence in the female patient. Urol. Clin. N. Amer.1985; 12: 247. Google Scholar 75 : Editorial comment. Neurourol. Urodynam.1989; 8: 499. Google Scholar 76 : Simultaneous urethral pressure profilometry using a microtip transducer catheter in the bitch: effects of bitch position and transducer orientation. Neurourol. Urodynam.1990; 9: 281. Google Scholar 77 : Female urethral pressure profile: reproducibility, axial variation and effects of low dose oral contraceptives. J. Urol.1984; 131: 394. Abstract, Google Scholar 78 : Clinical significance of axial variations in female urethral pressure profiles. Neurourol. Urodynam.1989; 8: 491. Google Scholar 79 : Directional differences in urethral pressure recordings: contributions from the stiffness and weight of the recording catheter. Neurourol. Urodynam.1985; 4: 117. Google Scholar 80 : Urethral pressure profile in female stress incontinence. J. Urol.1978; 120: 475. Link, Google Scholar 81 : Office urodynamics. Urol. Clin. N. Amer.1988; 15: 609. Google Scholar 82 : Discriminant analysis of urethral pressure profilometry data for the diagnosis of genuine stress incontinence. Brit. J. Obst. Gynaec.1990; 97: 251. Google Scholar 83 : Urodynamic parameters in patients with slight and severe genuine stress incontinence: is the stress profile useful?. Neurourol. Urodynam.1994; 13: 21. Google Scholar 84 : Urethral pressure profile in continent women from childhood to old age. Acta Obst. Gynec. Scand.1980; 59: 331. Google Scholar 85 : The effects of estrogens and gestagens on the urethral pressure profile in urinary continent and stress incontinent women. Acta Obst. Gynec. Scand.1980; 59: 265. Google Scholar 86 : Urethral pressure and pressure variations in healthy fertile and postmenopausal women with reference to the female sex hormones. J. Urol.1991; 146: 1434. Abstract, Google Scholar 87 : The low pressure urethra as a factor in failed retropubic urethropexy. Obst. Gynec.1987; 69: 399. Google Scholar 88 : Unsuccessful Burch retropubic urethropexy: a case-controlled urodynamic study. Amer. J. Obst. Gynec.1989; 160: 452. Google Scholar 89 : Low urethral pressure and stress urinary incontinence in women: risk factor for failed retropubic surgical procedure. Urology1990; 36: 245. Google Scholar 90 : Surgical management of stress incontinence in patients with low urethral pressure. Gynec. Obst. Invest.1991; 31: 106. Google Scholar 91 : The outcome of transvaginal cystourethropexy in patients with anatomical stress urinary incontinence and outlet weakness. J. Urol.1990; 144: 106. Abstract, Google Scholar 92 : A clinical and urodynamic assessment of the Burch colposuspension for genuine stress incontinence. Brit. J. Obst. Gynaec.1983; 90: 934. Google Scholar 93 : A clinical and urodynamic study comparing the Stamey bladder neck suspension and suburethral sling procedures in the treatment of genuine stress incontinence. Brit. J. Obst. Gynaec.1989; 96: 213. Google Scholar 94 : The impact of bladder neck suspension on the resting and stress urethral pressure profile: a prospective study comparing controls with incontinent patients preoperatively and postoperatively. J. Urol.1981; 125: 55. Link, Google Scholar 95 : Long-term results after Burch colposuspension. Amer. J. Obst. Gynec.1994; 171: 647. Google Scholar 96 : Prognostic value of urodynamic testing in myelodysplastic patients. J. Urol.1981; 126: 205. Link, Google Scholar 97 : Clinical assessment of urethral sphincter function. J. Urol.1993; 150: 1452. Link, Google Scholar 98 : Urodynamic evaluation of stress incontinence. Urol. Clin. N. Amer.1995; 22: 551. Crossref, Medline, Google Scholar 99 : The effects of increasing vesical volume on Valsalva leak point pressure in women with pure genuine stress urinary incontinence. Neurourol. Urodynam.1995; 14: 409. Google Scholar 100 Dmochowski, R., Ganabathi, K., Zimmern, P. E., Wolde-Tsadik, G. and Leach, G. E.: Variability of Valsalva leak point pressure. Submitted for publication. Google Scholar 101 : The Valsalva leak point pressure in the evaluation of stress urinary incontinence: technical aspects of measurement. J. Urol., part 21994; 151: 478A. abstract 1001. Google Scholar 102 : Abdominal leak point pressures in stress incontinence. J. Urol., part 21995; 153: 493A. abstract 1057. Google Scholar 103 : Pitfalls in determination of leak point pressure. J. Urol., part 21992; 148: 588. Abstract, Google Scholar 104 : Reliability & specificity of the leak point pressure. J. Urol., part 21995; 153: 492A. abstract 1055. Google Scholar 105 : Reproducibility of abdominal leak point pressure in the diagnosis of stress urinary incontinence. J. Urol., part 21994; 151: 478A. abstract 1003. Google Scholar 106 : Valsalva leak point pressures in adult women with genuine stress incontinence: reproducibility, effect of catheter caliber, and correlations with passive urethral pressure profilometry. Neurourol. Urodynam.1993; 12: 307. Google Scholar 107 : Stress leak point pressure: a simple and reproducible method utilizing a fiberoptic microtransducer. Urology1995; 46: 81. Google Scholar 108 Flood, H. D. and Liu, J.: The effect of the urethral catheter on leak point pressure in patients being assessed for urethral reconstruction. Read at meeting of Urodynamics Society, Las Vegas, Nevada, April 23-28, 1995. Google Scholar 109 : Correlation of Valsalva leak point pressure with subjective degree of stress urinary incontinence in females. J. Urol., part 21995; 153: 492A. abstract 1054. Google Scholar 110 : Correlation of the cystoscopic appearance and functional integrity of the female urethral sphincteric mechanism. Urology1994; 44: 250. Google Scholar 111 : Sphincter electromyography. Neurourol. Urodynam.1983; 2: 269. Google Scholar 112 : Electromyographic study of striated muscle of male urethra. Brit. J. Urol.1955; 27: 148. Google Scholar 113 : Pitfalls of urodynamic testing. Urol. Clin. N. Amer.1991; 18: 257. Google Scholar 114 : Improved method for needle electromyography of the urethral sphincter in women. Neurourol. Urodynam.1994; 13: 29. Google Scholar 115 : Coaxial needle electromyography (EMG) as an adjunct to clinical neurourologic testing. J. Urol., part 21995; 153: 335A. abstract 428. Google Scholar 116 : The relationship between external anal and external urethral sphincter activity in continent women. Neurourol. Urodynam.1991; 10: 555. Google Scholar 117 : Urethral sphincter electromyography with vaginal surface electrodes: a comparison with sphincter electromyography recorded via periurethral coaxial, anal sphincter needle and perianal surface electrodes. J. Urol.1985; 133: 815. Abstract, Google Scholar 118 : Dissociation of urethral and anal sphincter activity in neurogenic bladder dysfunction. J. Urol.1979; 122: 352. Google Scholar 119 : A new approach to electromyography of the external urethral sphincter. J. Urol.1977; 117: 773. Link, Google Scholar 120 : Premiers renseignements de l'examen electromyographique du sphincter strie de l'urethre humain. Acta Urol. Belg.1964; 32: 425. Google Scholar 121 : Sacral evoked potentials in normal women and in women with stress incontinence. Neurourol. Urodynam.1987; 6: 321. Google Scholar 122 : Evaluating the incompetent outlet. Probl. Urol.1990; 4: 1. Google Scholar 123 : The role of voiding cystourethrography in the evaluation of the female lower urinary tract. Probl. Urol.1991; 5: 23. Google Scholar 124 : Radiography, sonography and magnetic resonance imaging for stress incontinence. Contributions, uses, and Urol. Clin. N. Amer.1995; 22: Google Scholar : of transvaginal in the evaluation of women with stress urinary incontinence. J. Abstract, Google Scholar : neck by vaginal Brit. J. Urol.1993; 166. Google Scholar : evaluation of in women with stress urinary incontinence. J. Clin. 16: 295. Google Scholar : of bladder neck Brit. J. Obst. Google Scholar : of incontinence with intraurethral Google Scholar : of concepts of pelvic floor and urethral using and surface imaging of urethra. J. Urol., part 21994; 151: abstract Google Scholar : for urinary incontinence. J. Link, Google Scholar : for female stress incontinence: and J. Urol., part 21994; 151: abstract Google Scholar : for urethral incompetence. J. Urol.1990; 8: Google Scholar : in stress incontinence. Brit. J. Urol.1985; Google Scholar : of for female urinary incontinence. Urol.1983; 9: Google Scholar : effect of for female stress incontinence. Urol.1991; 197. Google Scholar : Long-term of women with periurethral for stress incontinence. Brit. J. 69: Google Scholar : in female patients with urinary incontinence. J. Urol.1993; 150: Link, Google Scholar : for stress urinary incontinence: Brit. J. Urol.1993; Google Scholar : Long-term of intraurethral for female stress incontinence. J. Urol., part 21995; 153: abstract Google Scholar : of patients with intrinsic sphincter deficiency for treatment with we do J. Urol., part 21995; 153: abstract Google Scholar : in women. J. Urol., part 21995; 153: abstract Google Scholar : of and in the of for incontinence to intrinsic sphincteric deficiency in females. J. Urol., part 21994; 151: abstract Google Scholar : for patients with stress urinary incontinence. J. Urol., part 21994; 151: abstract Google Scholar : for 3 female stress incontinence: the 50 patients. Med. J. Google Scholar : for genuine stress incontinence: a Brit. J. Google Scholar : of in women with or stress incontinence: outcome Brit. J. Google Scholar : of in the treatment of urinary incontinence in the female. J. Google Scholar : for sphincteric incontinence in women. J. Urol., part 21994; 151: abstract Google Scholar : urodynamic and J. Urol., part 21994; 151: abstract Google Scholar : Treatment of urinary stress incontinence using of Urol.1991; 44: Google Scholar : of for the treatment of sphincteric incontinence. J. Urol.1994; 151: Abstract, Google Scholar : Long-term to and in a Brit. J. Google Scholar : a new treatment for female stress incontinence. J. Urol., part 21992; abstract Google Scholar : correction of and stress incontinence with J. Urol., part 21994; 151: abstract Google Scholar : of for stress urinary incontinence. Neurourol. Urodynam.1993; 12: 131. Google Scholar : for the treatment of urinary incontinence. Brit. J. Google Scholar : and after periurethral of Crossref, Medline, Google Scholar : in and following of J. Urol., part 21994; 152: Abstract, Google Scholar : following periurethral for urinary incontinence. J. Urol.1989; Link, Google Scholar : Surgical treatment of intrinsic urethral Urol. Clin. N. Amer.1995; 22: Google Scholar : for urinary incontinence. Urol. Clin. N. Crossref, Medline, Google Scholar : Improved needle in periurethral Urology1995; Google Scholar : resonance imaging of periurethral for stress urinary incontinence. J. Urol., part 21995; 153: abstract Google Scholar : for female stress incontinence: of a analysis and J. Urol., part 21994; 151: abstract Google Scholar : of in the treatment of intrinsic sphincteric deficiency in the female patient. Urol. Clin. N. Amer.1995; 22: Google Scholar : study of of and by different Google Scholar : 2: 187. Google Scholar : for treatment of stress incontinence. 5: Crossref, Google Scholar : The sling for the treatment of stress urinary incontinence: a Amer. J. Obst. 151: Crossref, Medline, Google Scholar : The sling procedure for genuine stress incontinence of urine. Obst. Gynec.1988; 72: Google Scholar : The sling for the treatment of stress urinary incontinence. J. Link, Google Scholar : The sling for stress urinary incontinence, results and J. Urol., part 21994; 151: abstract Google Scholar : for urinary incontinence. Acta Obst. Gynec. 64: 187. Google Scholar : suspension for stress urinary incontinence. Amer. J. Obst. Google Scholar : sling for the treatment of stress urinary incontinence. J. Urol.1991; Link, Google Scholar : The vaginal a suspension procedure for incontinence in patients. Urology1994; Crossref, Medline, Google Scholar : of vaginal for sling J. Urol., part 21995; 153: abstract Google Scholar : of a vaginal for sling J. Urol., part 21995; 153: abstract Google Scholar : in J. Urol., part 21995; 153: abstract Google Scholar : sling for incontinence and intrinsic sphincter and outcome J. Urol., part 21995; 153: abstract Google Scholar : the suburethral sling J. Urol., part 21994; 151: abstract Google Scholar : Experience with for urinary incontinence at the of J. Link, Google Scholar : we patients incontinence following J. Urol., part 21994; 151: abstract Google Scholar : sling for intrinsic sphincteric deficiency. J. Urol.1990; 8: Google Scholar : years Crossref, Medline, Google Scholar : colposuspension de a A de 32 a Prog. Urol.1993; 3: Google Scholar : for the management of urinary incontinence in female J. Urol., part 21994; 152: Abstract, Google Scholar : sling procedure for stress incontinence. J. Urol.1978; Link, Google Scholar : sling procedure for urinary stress incontinence. reference to determination of of suspension from by J. Urol.1990; Google Scholar : surgical approach to bladder outlet following J. Link, Google Scholar : sling for urethral sphincter incompetence in women. Brit. J. Obst. Google Scholar : to suburethral sling for urinary incontinence: clinical and study. Amer. J. Obst. Crossref, Medline, Google Scholar Haab, and Leach, G. E.: Surgical treatment of male incontinence. In: Urinary Incontinence. Edited by J. G. New York: in Google Scholar : Long-term of urinary by an J. Urol., part 21995; 153: abstract Google Scholar : The of the sphincter in the treatment of urinary incontinence in the female patient. Urol. Clin. N. Amer.1985; 12: Google Scholar : The urinary sphincter in the treatment of incontinence in the female patient. 4: 35. Google Scholar : Abdominal approach for of the urinary sphincter in females. Neurourol. Urodynam.1988; 7: Google Scholar : and results in the of the urinary sphincter in women with stress urinary incontinence by a vaginal approach. Neurourol. Urodynam.1988; 7: 613. Google Scholar : urinary sphincter for female urinary incontinence: and J. Link, Google Scholar : is the urinary of in females. J. Urol., part 21995; 153: abstract Google Scholar : Role of the urinary sphincter in the treatment of stress incontinence in women. Brit. J. 69: Google Scholar : of the urinary sphincter in the management of severe incontinence in females. Surg., Gynec. & Google Scholar : Management of stress urinary incontinence using urinary sphincter. 499. Google Scholar : urinary sphincter in and women with incontinence. J. Urol., part 21994; 151: abstract Google Scholar : Management of urinary incontinence in women with the urinary sphincter. J. Urol.1985; Link, Google Scholar : Stress urinary incontinence to intrinsic sphincter experience with urinary sphincter and sling J. Urol., part 21994; 151: abstract Google Scholar : Brit. J. Urol.1991; Google Scholar : The management of to the bladder or during of the urinary sphincter in the female patient. J. 148: Abstract, Google Scholar : A new of urinary Brit. J. Urol.1993; 72: Google Scholar : urinary sphincter in In: Clinical Edited by . chapt. Google Scholar : closure of the bladder neck and of a catheter for urethra after J. Urol.1985; Link, Google Scholar : The management of female incontinence by with or urethral Brit. J. Urol.1983; Google Scholar : reconstruction of the urethra and vesical neck in women: J. Urol., part 21994; 151: abstract Google Scholar : Urethral closure in management of urinary incontinence. 34: Google Scholar : Long-term of transvaginal urethral closure and for urinary incontinence in women with Brit. J. Urol.1994; Google Scholar : abdominal and vaginal approach for bladder neck closure and urinary in the J. Urol.1994; 152: Link, Google Scholar : urethral closure with sling for female urethra after urethral Urology1994; 499. Google Scholar : of incontinence. Urol. Clin. N. Amer.1995; 22: Google Scholar : Estrogen in the management of urinary incontinence in postmenopausal women: a First of the and Urogenital Obst. Gynec.1994; 83: Google Scholar : The role of female in stress incontinence. Google Scholar : Surgical treatment of intrinsic urethral dysfunction. Urol. Clin. N. Amer.1995; 22: Crossref, Medline, Google Scholar of Medical by and of Sphincteric of the by of and A of and of and of and A of and of and A of and of and of Zimmern and Leach Urinary Stress Incontinence Due to Intrinsic Sphincteric Deficiency: Experience and of & by Francois Haab by Philippe E. Zimmern Current of of Medical by Gary E. Leach for by All