title: Changes in bladder neck geometry and closure pressure after midurethral anchoring suggest a musculoelastic mechanism activates closure.
abstract: OBJECTIVE
  The aim of this study was to investigate the anatomical origins and clinical significance of cough pressure transmission ratio (CTR) by using virtual-operation (VO) techniques.
  
  
  METHODS
  Thirty-four patients underwent perineal ultrasound examination, standard urethral pressure cough testing both with and without unilateral midurethral anchoring (VO), all tests being performed without urethral elevation. In eight patients where there was no change in CTR, a one-sided fold of suburethral vagina (VO) was taken (pinch test) and the CTR repeated.
  
  
  RESULTS
  After midurethral anchoring, maximal urethral pressure increased from a mean of 33.25 cm H2O to a mean of 58.06 cm H2O (P < 0.0001) and restoration of anatomy was noted in all 11 patients who had obvious funneling on straining. Conversion of a <100% CTR to >100% CTR in the proximal urethra was observed in 14 of 22 patients (P < 0.005), with no significant change noted in the distal urethra. Further conversion of CTR was noted in six of the remaining eight patients with unilateral plication of suburethral vagina (pinch test).
  
  
  CONCLUSIONS
  A musculoelastic closure mechanism most likely activates urethral closure. CTR is most likely an index of changed intraurethral area, not necessarily closure, and may be a more sensitive objective test than perineal ultrasound for diagnosing urethral narrowing, especially when used with virtual-operation techniques.
authors.affiliation: Department of Gynaecology, Royal Perth Hospital, Perth, Western Australia. kvinno@highway1.com.au
authors.forename: Peter
authors.initials: P
authors.lastname: Petros
mesh_terms: D000328:Adult; D000368:Aged; D003371:Cough; D004548:Elasticity; D005260:Female; D006801:Humans; D008875:Middle Aged; D011312:Pressure; D014463:Ultrasonography; D014521:Urethra / Q000000981:diagnostic imaging / Q000502:physiology*; D001743:Urinary Bladder / Q000000981:diagnostic imaging / Q000473:pathology* / Q000503:physiopathology*; D014550:Urinary Incontinence, Stress / Q000000981:diagnostic imaging* / Q000503:physiopathology* / Q000601:surgery; D014621:Vagina