side effects, and the relapse rate is high. Bladder re- ... neurectomy (Warrell, 1977) and bladder distension ... on each side to ensure correct placement, and.
British Journalof Urology (1992). 69,363-365
01992 British Journal of Urology
Subtrigonal Phenol Injections in the Treatment of Idiopathic Detrusor Instability in the Female-a Longterm Urodynamic Follow-up I. N. RAMSAY, S.CLANCY and P. HILTON University Department of Obstetricsand Gynaecology, Princess Mary Maternity Hospital, Newcastle upon Tyne
Summary-A total of 36 subtrigonal phenol injections were performed on 29 patients with detrusor instability. Long-term follow-up (mean 13.7 months) showed a subjective response rate of only 14%, and objectively there was no significant change in any urodynamic parameter in the group as a whole. There was, however, a significant improvement in cystometric capacity and volume at first contraction, in those under 55 years of age. One patient developed a vesicovaginal fistula following repeat injections. This suggests that subtrigonal phenol injections have little place in the treatment of detrusor instability, especially in the over 55s.and repeat injections should be abandoned because of the risk of major complications. Detrusor instability remains a common problem in the management of female urinary incontinence. In our own unit detrusor instability is present in 20% of patients in a pure or mixed form. The treatment of the condition remains less than satisfactory. Drug treatment is successful in a proportion of patients but even the best treatments have a poor response rate, often have significant side effects, and the relapse rate is high. Bladder retraining has been shown to help a considerable number of patients, but again relapse rates tend to be significant. Holmes et af. (1983) showed that 85% of patients were improved after bladder retraining, but that after 3 years this had fallen to 48%. If non-invasive forms of treatment fail, one is left to consider surgical treatment for the patient with troublesome symptoms. Transvaginal sacral neurectomy (Warrell, 1977) and bladder distension (Pengelly er al., 1978) have proved to be less than ideal and have been abandoned from most clinicians’ practice. Subtrigonal phenol injections for the treatment of detrusor instability were described by Ewing er Accepted for publication 29 May 1991
af. in 1982. Their good results (overall 76% cure
rate) were confirmed by others (Blackford er af., 1984; Cameron-Strange and Millard, 1988), but recently other workers have suggested that the procedure is considerably less successful and not without considerable risks (Rosenbaum et af.,1988 ; Wall and Stanton, 1989). All of these studies have relied upon symptomatic assessment of cure or failure and none has looked at the long-term cystometric change produced by the procedure. In this study we determine the urodynamic changes produced by phenolisation of the pelvic plexus and assess the benefits of the procedure in the long term.
Patients and Methods A total of 36 subtrigonal phenol injections were performed on 29 patients with idiopathic detrusor instability between March 1986 and June 1990. All had previously undergone urodynamic investigation by either dual channel subtracted cystometry or videocystourethrography, and had failed to respond to drug therapy and/or bladder re-training. Urodynamic follow-up was obtained in 25 cases and subjective assessment was obtained in 34; 2 patients declined to attend for review.
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The technique of subtrigonal injection used is as described by Ewing et al. (1982). Our practice, however, is to inject 2 ml of normal saline initially on each side to ensure correct placement, and thereafter inject a further 6 m l of 6% aqueous phenol or as much as can be injected without producing excessive indentation of the bladder. A 14-16 F Foley urethral catheter is left in siru overnight and removed the following morning. When the patient is voiding satisfactorily she is allowed home. Statistical analysis was performed using t tests except for the results of residual volumes, which were not normally distributed. These were analysed using the Wilcoxon matched pairs test.
Results Duration of follow-up was between 1 and 40 months (median 11). The age range was 40 to 73 years (median 57). Subjective assessment showed an improvement rate of 14% after both a first or repeat injection. Table 1 shows the results for the filling phase of the cystometrogram, for all patients. There are no statistically significant differences between pre-treatment and post-treatment values. Tables 2 and 3 show the same parameters when subdivided
by age; this demonstrates a better urodynamic outcome in the younger age group. Table 4 gives the results for voiding function. Numbers are smaller because many patients were unable to void either prior to or following, bladder filling. As results of residual volumes were normal, the small volumes voided prior to filling in the post-treatment group must indicate that their bladders were not full when they were asked to void. There were no statistically significant differences between pretreatment and post-treatment values. Four patients developed a complication following phenolisation, 3 of them following a repeat injection. One patient had delayed voiding (4 days), 2 patients had persistently high residual volumes, and 1 patient developed a vesicovaginal fistula. The vesicovaginal fistula developed within a week of subtrigonal phenolisation in a patient undergoing repeat injections. In view of the fistula and her persistent severe detrusor instability she underwent urinary diversion; she is currently well.
Discussion The finding that there is no overall, significant longterm subjective or urodynamic change following subtrigonal phenolisation suggests, as others have
Table 1 Results of Filling Cystometry Before and After Treatment
Pre-treatment Post-treatment Significance
First desire to void (ml)
Volume 1st con. (ml)
Cystometric capacity ( m l )
Maximum filling pressure (cmH,O)
Maximum detrusor pressure ( c m H 2 0 )
171 (k129) 201 (f135) NS
228 ( f 181) 260(f200)
315 ( f 169) 357(?195) NS
36.4 ( f 21.5) 29.4(+15.7) NS
44.3 (f18.1) 38.0(f 14.1) NS
NS
Table 2 Results of Filling Cystometry Before and After Treatment for Patients Aged > 5 5 years
Pre-treatment Post-treatment Significance
First desire to void Iml)
Volume 1st con. Iml)
Cystometric capacity (ml)
Maximum filling pressure c m H 2 0 )
Maximum detrusor pressure (cmH,O)
ISO(f121) 142 ( f 101) NS
190(f176) 158 (f150) NS
284(f159) 273 (f200) NS
39.1 (k23.2) 31.6 ( f 5 . 2 ) NS
42.2 ( f 22.0) 38.7 ( f 11.3) NS
Table 3 Results of Filling Cystometry Before and After Treatment for Patients Aged < 55 Years
Pre-treatment Post-treatment significance
First desire io void (mil
Volume 1st con. (ml)
Cystometric capacity (ml)
Maximum filling pressure (cmH,O)
Maximum detrusor pressure ( c m H 2 0 )
194 ( f 139) 266 ( f 142)
272 ( f 185) 381 (f189) P=O.Ol
347 ( f 179) 449(f149) P=O.O1
33.4( f 20.2) 26.9(+16.6) NS
46.6 ( f 13.1) 37.2 ( f 17.2) NS
NS
SUBTRIGONAL PHENOL INJECTIONS IN IDIOPATHIC DETRUSOR INSTABILITY
Table 4
365
Results of Voiding Function Before and After Treatment Free flow
Voiding cystomerry
Peak flow rate Voided oolume Residual (ml) volume (ml) (ml1.Y) ( n = 12) ( n = 12) ( n = 18)
Peak flow rate (mlls) (n=18)
Pre-treatment 14.3 (k7.2) Post-treatment 14.3 (+6.8) NS Significance
258 ( + 2 1 I ) 161 ( f 112) NS
16.3 ( f 4 2 ) 11.7 (k36) NS
suggested recently (Rosenbaum et al., 1988; Wall and Stanton, 1989), that the procedure has little to offer in the long term as a treatment of detrusor instability. Certainly we found that some patients noted a transient improvement in symptoms, but the vast majority reverted to their pre-treatment condition after a few days or weeks. There was often disparity between subjective and objective response where patients had an improvement in urodynamic parameters (1 patient actually reverted to a stable bladder), but were symptomatically unchanged. Our finding of an improved response in the younger age group contrasts with the report by Blackford et af. (1984), who showed symptomatic success rates of 14 and 66% in the under 55 and over 55 age groups respectively. Cameron-Strange and Millard (1988), however, reported a slightly better subjective response rate in younger women. It is difficult to explain this disparity, and indeed why the younger age group should have a better response to the procedure. Vesicovaginal fistula formation following the treament has been reported previously (Nordling et al., 1986; Wall and Stanton, 1989), as has rectovaginal fistula formation (Cameron-Strange and Millard, 1988). We can say therefore that fistula formation is a recognised complication of the procedure, and given that all 3 vesicovaginal fistulae reported developed following repeat injections, we would suggest that the practice of repeating subtrigonal phenol injections be abandoned. It appears therefore that phenolisation of the pelvic plexus, like many of the more minor surgical procedures employed, cannot be looked upon as the answer in the treatment of refractory detrusor instability. Transvaginal sacral neurectomy, bladder overdistension and bladder transection have all been introduced with enthusiasm only to be abandoned by many because of poor response or high relapse rates (Warrell, 1977; Pengelly et al., 1978; Mundy, 1983). It may be that the time has
Voided volume Maximum voiding Residual oolume (ml) pressure (mil (n=18) (cmH,Ol (n=18) ( n = 18)
12.0 ( k 4 . 2 ) 332 (f192) 14.0 ( k 6 3 ) 319 (f188) NS NS
35.2 ( k 2 1 . 1 ) 30.0 ( & 16.6) NS
27.5 ( k 6 6 ) 54.7 ( k 8 6 ) NS
come for us to consider earlier use of augmentation cystoplasty. The success rate is high (Mundy and Stephenson, 1985)and most patients sorely troubled by urge incontinence will accept the risks of major surgery, and the likelihood of requiring to selfcatheterise, if there is a real chance of their being rendered continent. References Blackford, H. N., Murray, K., Stephenson, T. P. ef al. (1984). Results of transvesical infiltration of the pelvic nerve plexuses with phenol in 116 patients. Br. J . Urol., 56,647-649. Cameron-Strange, A. and Millard, R. J. (1988). Management of refractory detrusor instability by transvesical phenol injection. Br. J . Urol.,62, 323-325. Ewing, R., Bultitude, M. I. and Shuttleworth, K. E. D. (1982). Subtrigonal phenol injection for urge incontinence secondary to detrusor instability in females. Br. J . Urol.,54,689-692. Holmes, D. M., Stone, A. R., Barry, P. R. etal. (1983). Bladder retraining 3 years on. Br. J . Urol., 55,660-664. Mundy, A. R. (1983). Long-term results of bladder transection for urge incontinence. Br. J . Urol., 55,642-644. Mundy, A. R. and Stephenson, T. P. (1985). “Clam” ileocystoplasty for the treatment of refractory urge incontinence. Br. J . C’rol., 51,641 -646. Nordling, J., Steven, K., Meyhoff H. H. etal. (1986). Subtrigonal phenol injection: lack of effect in the treatment of detrusor instability. Neurourol. Urod.vnam., 5,449-451. Pengelly, A. W. Stephenson, T. P., Milroy, E. J. G . ef al. (1978). Results of prolonged bladder distension as a treatment for detrusor instability. Br. J . Urol., 50,243-245. Rosenbaum, T. P., Shah, P. J. R. and Worth, P. H. L. (1988). Trans-trigonal phenol-the end of an era. Neurourol. Urodynam., I , 294-295. Wall, L. L. and Stanton, S. L. (1989). Transvesical phenol injection of pelvic nerve plexuses in females with refractory urge incontinence. Br. J . Urol.,63,465-468. Warrell, D. W. (1977). Vaginal denervation of the bladder nerve supply. Urol. Inr.. 32, 114-1 16.
The Authors I. N . Ramsay, MRCOG, Clinical Research Associate. S. Clancy, Registrar. P. Hilton, MD, MRCOG, Senior Lecturer. Requestsfor reprints to: I. N. Ramsay, DepartmentofObstetrics and Gynaecology, Southern General Hospital, 1345 Govan Road, Glasgow.
