title: Symptoms of defective emptying and raised residual urine may arise from ligamentous laxity in the posterior vaginal fornix.
abstract: OBJECTIVE
  To prospectively test the hypothesis that laxity in the posterior ligaments of the vagina may cause raised residual urine and abnormal emptying symptoms.
  
  
  METHODS
  Eighteen patients, 16 multiparous, and 2 nulliparous, were referred with symptoms of abnormal bladder emptying. All were assessed with standard cystometry and standing resting and straining lateral X-ray films, with the bladder containing a Foley balloon catheter containing 10 ml of radio-opaque dye. Three patients were also assessed with videocystourethrograms, and these were compared to 4 normal controls. A posterior fornix repair was performed. A full thickness horizontal vaginal incision was made using a scalpel. The incision was stretched antero-posteriorly, and the utero-sacral and cardinal ligaments tightened by suturing them side to side.
  
  
  RESULTS
  Specific symptoms of defective opening were reduced from a total of 43 pre-operatively to 9 post-operatively. Mean residual urine was reduced from 98.7 to 31.7 ml (p < OR = 0.028). Peak flow increased from 29.7 to 34.2 ml/s, p < OR = 0.08. Mean flow pre-operative was 8.18 ml/s, and post-operative flow 8.6 ml/s (p < OR = 0.88). Mean emptying time decreased from 65.3 to 60.4 s.
  
  
  CONCLUSIONS
  Reference to radiographs in normal patients demonstrates that bladder funnelling is associated with a powerful downward force transmitted to the coccyx via the utero-sacral ligaments. Correction of laxity in the utero-sacral ligaments, the effective insertion points of the downward force, improved bladder emptying. This appears to sustain the hypothesis that abnormal bladder emptying in the female may be at least partly caused by ineffectiveness of the opening muscles, because of laxity in their insertion points.
authors.affiliation: Department of Gynaecology, Royal Perth Hospital, WA, Australia.
authors.forename: P E
authors.initials: PE
authors.lastname: Petros
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008022:Ligaments / Q000601:surgery; D008875:Middle Aged; D010298:Parity; D011859:Radiography; D001745:Urinary Bladder Diseases / Q000000981:diagnostic imaging / Q000209:etiology*; D014550:Urinary Incontinence, Stress / Q000209:etiology; D014563:Urodynamics; D014623:Vaginal Diseases / Q000150:complications* / Q000601:surgery