Role of 3D ultrasound in the treatment of stress urinary incontinence with polyacrylamide hydrogel (Bulkamid®) – a pilot study

Role of 3D ultrasound in the treatment of stress urinary incontinence with polyacrylamide hydrogel (Bulkamid®) – a pilot study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Role of 3D ultrasound in the treatment of stress urinary incontinence with polyacrylamide hydrogel (Bulkamid®) – a pilot study Aiste Ugianskiene, Caroline Sollberger Juhl, Karin Glavind This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4352930/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction and Hypothesis Polyacrylamide hydrogel (PAHG) is a bulking agent used in treatment of stress urinary incontinence (SUI) in women. Some women experience an improvement or cure in stress urinary incontinence (SUI) symptoms lasting only a few weeks after the injection of the bulking agent. The aim of this study was to use three-dimensional ultrasound (3DUS) to describe the changes in volume, number of deposits and echogenicity of the bulking agent 3 months after PAHG injection. Methods Prospective cohort study of fourteen women with SUI or mixed primarily SUI, who underwent an injection of PAHG. The subjective outcome was evaluated with Patient Global Impression of Improvement questionnaire. 3DUS was performed in all patients immediately after injection of PAHG and again at 3 months follow-up. Results The study found a mean 36.5% loss in bulking agent volume during the study period. A total of 53 PAHG deposits were found by ultrasound immediately after injection. At 3 months follow-up 41 PAHG deposits were left. All deposits were hypoechogenic immediately after injection and only 24% of demonstrated PAHG collections had a hypoechoic echogenicity at 3 months follow-up. Conclusions More than 1/3 of volume of injected PAHG and 23% of deposits could not be found by 3DUS at 3 months follow-up. Only 24% of PAHG injections in our patients had hypo-echoic echogenicity at 3 months follow-up. Larger 3DUS studies with longer follow-up and focus on exact location of the PAHG injections are important future studies. Polyacrylamide hydrogel Bulkamid bulking agent three-dimensional ultrasound stress urinary incontinence Figures Figure 1 Figure 2 Brief summary Volume of injected polyacrylamide hydrogel decreases over time. Introduction Periurethral injection of a bulking agent polyacrylamide hydrogel (PAHG, Bulkamid®) is a minimally invasive surgical procedure used as one of the surgical treatments of stress or mixed urinary incontinence in women. It is easily administered under local anesthesia and can be performed in an ambulatory setting [ 1 ]. In a recent review, mean follow-up duration of studies ranged from 3 to 96 months. Only two studies reported on longer-term outcomes of 38 and 96 months. Definitions of treatment “success” varied between studies. As a result, there was a wide variability in reported success rates, ranging from 29.8–89.7% in the short-term, and 42% to approximately 70% in the long-term [ 2 ]. The mechanism of action of these agents however is not fully understood. One theory is that the injection of PAHG into the urethral submucosa creates artificial urethral cushions that can improve urethral coaptation and restore continence. Another theory was put forward by Klarskov et al. suggesting that the bulking material may function as additional central filler volume which increases the length of the muscle fibers and thereby the power of the urethral sphincter [ 3 ]. PAHG can be visualized ultrasonographically. Two- dimensional ultrasound (2DUS) and three-dimensional ultrasound (3DUS) imaging are objective tools for the assessment of the lower urinary tract and pelvic floor. 2DUS is the most widely applied technique, primarily because of its availability and significantly lower cost. 3DUS technique allows more accurate characterization of periurethral bulking agent volume, configuration, and location in relation to the urethra and bladder neck [ 4 ]. The optimal site for injection and the amount to be injected is still unknown. Some women experience an improvement or cure in stress urinary incontinence (SUI) symptoms lasting only a few weeks after the injection of the bulking agent. Our theory is that one of the reasons might be that the amount of PAHG diminishes over time perhaps because of rupture or leakage from the injection site. The primary aim of this study was to describe the changes in volume, number of deposits and echogenicity of the bulking agent 3 months after PAHG injection. The secondary aim was to determine whether there was an association between degree of improvement and sonographic findings. Material and methods This study was performed as a prospective cohort study. A total of fourteen patients with SUI or mixed primarily SUI were recruited. Patients with previous bulking operations were not included. Preoperative evaluation included medical history, a physical and pelvic examination including genital prolapse score, uroflowmetry and a post-void residual urine volume (PVR). All patients completed the International Consultation on Incontinence-Urinary Incontinence Short Form (ICIQ-UI SF) [ 5 ] before surgery and three months postoperatively. The subjective outcome was evaluated with Patient Global Impression of Improvement questionnaire (PGI -I) [ 6 ]. Demographic data including age, body mass index, number of births, previous caesarean sections and previous prolapse and incontinence operations were obtained before the bulking procedure. All data extracted were entered into The Research Electronic Data Capture (RedCap), which is browser-based, metadata-driven electronic data capture software and workflow methodology for designing clinical and translational research databases. The study was registered and approved at The Health Department (ID number K2022-044). After providing written informed consent, between October and December 2022, patients underwent an injection of PAHG. All injections were performed in an office setting under local anesthesia, 2 ampullas of Citanest/Octapressin®30 mg/ml/0.54 µg/ml, 1.8 ml, and catheter gel containing 2% lidocaine and 0.025% chlorhexidine. Before injections a clean urine dipstick was required. Hydrogel was injected into the submucosa under endoscopic control 1.5 cm from the vesicourethral junction in locations “2, 5, 7 and 10” o’clock, 0.5 ml at each site. The needle was re-sited if the injection appeared to be too superficial or too deep. After the bulking procedure, about 150 ml of NaCl was left as a residual urine. Patients were discharged after a successful voiding, PVR < 150 ml. All procedures were performed by the same three surgeons using a standardized technique. Endovaginal 3DUS was performed in all patients immediately after injection of PAHG and again at 3 months follow-up. 3DUS was performed using the Voluson530D ultrasound machine with 7.5-MHz transvaginal 3D probe that was placed beneath the urethral meatus. Bulking agent deposits were measured in three dimensions and the volume calculated from this. Results Of the 14 patients who underwent an injection of PAHG during the study period, 11 patients (79%) reported mixed urinary incontinence and 3 patients (21%) stress urinary incontinence. Demographic data of the study population are shown in Table 1. Eleven patients (78.6%) experienced some degree of improvement according to the PGI-I questionnaire at 3 months: 26.8% were minimally improved, 26.8 % much improved and 21.4% very much improved (Table 2). No patients had worsening in incontinence. Mean score ISIQ UI-SF before surgery was 15 and declined to 9.8 at 3 months follow-up (Table 2). A total of 53 PAHG deposits were found by ultrasound immediately after injection. At 3 months follow-up 41 PAHG deposits (77%) were left. The bulking agent exhibited various levels of echogenicity 3 months after surgery. All deposits were hypoechogenic immediately after injection (Figure 1) and only 24% of demonstrated PAHG collections had a hypoechoic echogenicity at 3 months follow-up (Figure 2). The PAHG collections varied from single spherical to oblong collections. PAHG collection in two patients appeared as exophytic masses projecting into the bladder at the bladder base at 3 months follow-up. One of these patients experienced very much improvement in continence and another one had no improvement in continence at all. The mean volume of PAHG injection at baseline was 1.168 cm³and the mean change in volume of injection was 0.451 cm³, which was a mean 36.5% loss in volume during the study period (Table 3). We found no correlation between the clinical outcome and amount of bulking agent left at 3 months follow-up (Table 2). Discussion This study found that the volume of injected PAHG was reduced significantly 3 months after surgery. In contrast to some previous histological studies [ 7 , 8 ], which stated that PAHG injections remain stable in volume for years, we found a mean 36.5% loss in bulking agent volume during the study period. The only study by Mouritsen et al. [ 9 ] described volume of injected PAHG in eleven women at eight years follow-up. The deposits had a volume of 0.14–2.44 cm³. In our study, the volume range of PAHG at 3 months follow-up was 0.217–1.365 cm³. The amount of PAHG injected per treatment was 2 ml (= 2 cm³), but the median amount of bulking agent found by ultrasound immediately after the injection was only 1.2105 cm³ In a previous paper by Lose et al [ 10 ], the authors speculated that too much material injected per site might increase the risk of material leakage, either via the injection hole, or due to rupture of the covering mucosa. This might explain our findings. Because of the limited potential volume in the submucosal space, it is necessary to be aware about the amount of bulking agent injected. The optimal relationship between amount of injected material and cure rate has not been defined. All the patients underwent imaging with 3DUS immediately after the surgery. Because of abundance of water in PAHG, all the deposits were seen as hypoechoic mass collections. In eleven patients (79%) four PAHG deposits were visualized and in three patients (21%) only three deposits. At 3 months follow-up, only 41 (77%) out of 53 deposits of bulking agent were left. Presence of fewer deposits than injected may represent loss of material through the urethra but might also be caused by confluence of deposits. Mouritsen et al [ 9 ] found that PAHG deposits were still visible on vaginal ultrasound as hypoechoic collections even eight years post injection. In contrast to this previous study [ 9 ], only 24% of PAHG collections in our patients had hypo-echoic echogenicity at 3 months follow-up. Most bulking agent deposits had hyperechoic appearance. Even though, we found a reduction in volume of PAHG 3 months after surgery, 78.6% of patients experienced improvement in their continence. Our results are comparable to reports in the literature on bulking agents [ 2 , 10 – 12 ]. A subjective evaluation of continence status could overestimate the results. Sometimes even a minor objective leak decrease could be seen as a major continence improvement. We believe that PAHG has a place in a treatment of urinary incontinence with improvement of patients´ quality of life even with suboptimal treatment results. The role of using 2D and/or 3DUS in the treatment of stress/mixed urinary incontinence with various urethral bulking agents as collagen, Coaptite, Macroplastique is well-described in previous studies [ 4 , 13 – 18 ], but there is lack of studies using PAHG as bulking agent. Mouritsen et al [ 9 ] described volume and placement of the injected PAHG deposits at eight years follow-up. Unfortunately, the number and volume of the deposits around the urethra were not recorded with ultrasonography at the time of injection and hence a change in number and size of deposits over time could not be determined. To the best of our knowledge, our study is the first one to describe sonographic findings using urethral bulking agent PAHG immediately after treatment and at follow-up. Limitations of the present study are a small cohort and a short follow-up. Using of 3DUS is an operator-dependent technology, which has the potential to skew results. In this study no correlation between the clinical outcome and amount of bulking agent left at 3 months follow-up was found (Table 2 ). Our study population was too small to show a clinically significant difference and included a large percentage of patients with mixed urinary incontinence which makes conclusion on incontinence difficult. Furthermore, our study did not investigate the exact location of the bulking material. We are not able to explain the echogenicity changes in some patients and not in others. The strength of our study is that all procedures were performed at a high-volume specialty center of well-trained surgeons. The same validated questionnaires were used both pre- and postoperatively giving a more exact information about changes in urinary incontinence and no patients were lost to follow-up. In conclusion, more than 1/3 of volume of injected PAHG and 23% of deposits could not be found by 3DUS at 3 months follow-up Only 24% of PAHG injections in our patients had hypo-echoic echogenicity at 3 months follow-up. Three-dimensional ultrasound examination can be easily applied in a clinical setting. Larger 3DUS studies with longer follow-up and focus on exact location of the PAHG injections are important future studies. Abbreviations PAHG polyacrylamide hydrogel SUI stress urinary incontinence 3DUS three-dimensional ultrasound PGI I-Patient Global Impression of Improvement ICIQ UI SF-International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form Declarations Each authors' contribution to the Manuscript: A UGIANSKIENE: Project development, Data collection and analysis, Manuscript writing C SOLLBERGER JUHL: Data collection and analysis, Manuscript editing K GLAVIND: Project development, Data analysis, Manuscript editing Ethical/Institutional Review Board Approval. The study was registered and approved at The Health Department, The Region of Northern Denmark (ID number K2022-044). Funding Declaration – none Competing interests – none Conflict of interest - none References Juhl CS, Bjørk J, Glavind K. Treatment of stress urinary incontinence with polyacrylamide hydrogel in an office setting: patient perspectives. Int Urogynecol J. 2022;33(8):2169–2176. doi: 10.1007/s00192-022-05135-3 . Epub 2022 Mar 14. Hoe V, Haller B, Yao HH, O'Connell HE. Urethral bulking agents for the treatment of stress urinary incontinence in women: A systematic review. Neurourol Urodyn. 2021;40(6):1349–1388. doi: 10.1002/nau.24696 . Epub 2021 May 20. Klarskov N, Lose G. Urethral injection therapy: what is the mechanism of action? Neurourol Urodyn. 2008;27(8):789–92. doi: 10.1002/nau.20602 . Poon CI, Zimmern PE. Role of three-dimensional ultrasound in assessment of women undergoing urethral bulking agent therapy. Curr Opin Obstet Gynecol. 2004;16(5):411–7. Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P (2004) ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn 23:322–30. Yalcin I, Bump RC. Validation of two global impression questionnaires for incontinence. Am J Obstet Gynecol. 2003;189:98–101. Christensen LH, Breiting VB, Aasted A, Jorgensen A, Kebuladze I (2003) Long-term effects of polyacrylamide hydrogel on human breast tissue. Plast Reconstr Surg 111:1883–1890 Christensen LH, Nielsen JB, Mouritsen L, Sorensen M, Lose G (2008) Tissue integration of polyacrylamide hydrogel: an experimental study 1476 Int Urogynecol J (2010) 21:1471–1477 of periurethral, perivesical, and mammary gland tissue in the pig. Dermatol Surg 34(Suppl 1):S68–S77 Mouritsen L, Lose G, Møller-Bek K. Long-term follow-up after urethral injection with polyacrylamide hydrogel for female stress incontinence. Acta Obstet Gynecol Scand. 2014;93(2):209–12. doi: 10.1111/aogs.12283 . Epub 2013 Dec 24. Lose G, Sørensen HC, Axelsen SM, Falconer C, Lobodasch K, Safwat T. An open multicenter study of polyacrylamide hydrogel (Bulkamid®) for female stress and mixed urinary incontinence. Int Urogynecol J. 2010;21(12):1471–7. doi: 10.1007/s00192-010-1214-1 . Epub 2010 Jul 20. Sokol ER, Karram MM, Dmochowski R. Efficacy and safety of polyacrylamide hydrogel for the treatment of female stress incontinence: a randomized, prospective, multicenter North American study. J Urol. 2014;192(3):843–9. doi: 10.1016/j.juro.2014.03.109 . Epub 2014 Apr 2. Leone Roberti Maggiore U, Alessandri F, Medica M, Gabelli M, Venturini PL, Ferrero S (2013) Outpatient periurethral injections of polyacrylamide hydrogel for the treatment of female stress urinary incontinence: effectiveness and safety. Arch Gynecol Obstet 288(1):131–137 Leonhardt C, Krysl J, Arenson AM, et al. Periurethral injection of collagen in the treatment of urinary stress incontinence: ultrasonographic appearance. Can Assoc Radiol J 1995; 46: 189–193. Elia G, Bergman A. Periurethral collagen implant: ultrasound assessment and prediction of outcome. Int Urogynecol J Pelvic Floor Dysfunct 1996; 7: 335–338. Defreitas GA, Wilson TS, Zimmern PE, et al. Three-dimensional ultrasonography: an objective outcome tool to assess collagen distribution in women with stress urinary incontinence. Urology 2003; 62: 232–236 Cecile A Unger, Matthew D Barber, Mark D Walters. Ultrasound Evaluation of the Urethra and Bladder Neck Before and After Transurethral Bulking. Female Pelvic Med Reconstr Surg. 2016 Mar-Apr;22(2):118–22. Yune JJ, Quiroz L, Nihira MA, Siddighi S, O'Leary DE, Santiago A, Shobeiri SA. The Location and Distribution of Transurethral Bulking Agent: 3-Dimensional Ultrasound Study. Female Pelvic Med Reconstr Surg. 2016 Mar-Apr;22(2):98–102. Hegde A, Smith AL, Aguilar VC, et al. Three-dimensional endovaginal ultrasound examination following injection of Macroplastique for stress urinary incontinence: outcomes based on location and periurethral distribution of the bulking agent. Int Urogynecol J 2013; 24(7): 1151–1159. Tables Table 1. Demographics of the study population Study population N=14 Age, median (range), years 51 (43-85) Parity, median (range) 2 (0-3) Body mass index, kg/m²: mean (range) 27.9 (20.9-32.8) Cesarean section: n (%) 1 (7%) Previous hysterectomy: n (%) 0 (%) Previous prolapse surgery: n (%) 1 (7%) Previous anti-incontinence surgery: n (%) 0 (0%) Table 2. Data on scores of ICIQ-UI short form before and 3 months after surgery and PGI-I results 3 months after surgery Patients ICIQ-UI SF before surgery ICIQ-UI SF 3 months after surgery Subjective results 1. 15 8 Much improved 2. 17 15 Minimally improved 3. 20 10 Much improved 4. 16 8 Much improved 5. 19 14 Not improved 6. 7 3 Very much improved 7. 16 7 Very much improved 8. 14 6 Very much improved 9. 14 10 Minimally improved 10. 15 19 Minimally improved 11. 19 6 Much improved 12. 10 8 Not improved 13. 12 8 Minimally improved 14. 16 16 Not improved Table 3. Changes in volume of injected Bulkamid ® and subjective success rates Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4352930","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":301220036,"identity":"04e424e3-9522-4c00-a8ab-410c92ef8236","order_by":0,"name":"Aiste Ugianskiene","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAdUlEQVRIiWNgGAWjYFAC5gMgwoAULWwJJGvhMSBRC/+MnG+fCxisjYnXInEjd/PsGQzpZiS4C6iFmYfhsA3xOuRv5DwmUYvBjRxmkBYSHGZ45pkxM49BOgnelzueDHRYhbVhA/F6IM4jUf0oGAWjYBSMAgIAAFl7GU+9mGscAAAAAElFTkSuQmCC","orcid":"","institution":"Aalborg University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Aiste","middleName":"","lastName":"Ugianskiene","suffix":""},{"id":301220037,"identity":"dd86ad6f-9bac-49eb-8b80-aec970ad8905","order_by":1,"name":"Caroline Sollberger Juhl","email":"","orcid":"","institution":"Aalborg University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Caroline","middleName":"Sollberger","lastName":"Juhl","suffix":""},{"id":301220038,"identity":"1bbd8c50-d08c-4457-b4f3-d97dfc61c975","order_by":2,"name":"Karin Glavind","email":"","orcid":"","institution":"Aalborg University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Karin","middleName":"","lastName":"Glavind","suffix":""}],"badges":[],"createdAt":"2024-05-01 07:25:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4352930/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4352930/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":56478295,"identity":"31ca4e0d-b466-4d8c-8546-cf78ceca4520","added_by":"auto","created_at":"2024-05-14 17:51:19","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":41171,"visible":true,"origin":"","legend":"\u003cp\u003eSagittal endovaginal ultrasonography demostrating the hypoechoic polyacrylamide hydrogel deposits\u003cstrong\u003e \u003c/strong\u003eimmediately after injection\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4352930/v1/9b7ecf9794489c623698371f.jpg"},{"id":56478284,"identity":"5cd62527-1a54-4d70-92f2-95e0d4f63a4b","added_by":"auto","created_at":"2024-05-14 17:51:17","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":34988,"visible":true,"origin":"","legend":"\u003cp\u003eSagittal endovaginal ultrasonography demostrating the hyperechoic polyacrylamide hydrogel deposits\u003cstrong\u003e \u003c/strong\u003eat 3 months follow-up\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4352930/v1/de5b27021d282841f953bad2.jpg"},{"id":57003376,"identity":"fa6bc286-3d5a-46a0-b674-9d29a3c280d7","added_by":"auto","created_at":"2024-05-23 09:25:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":429941,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4352930/v1/3ca66e19-120f-4fb5-b284-fcfa8a8de9b4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Role of 3D ultrasound in the treatment of stress urinary incontinence with polyacrylamide hydrogel (Bulkamid®) – a pilot study","fulltext":[{"header":"Brief summary","content":"\u003cp\u003eVolume of injected polyacrylamide hydrogel decreases over time.\u003c/p\u003e\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003ePeriurethral injection of a bulking agent polyacrylamide hydrogel (PAHG, Bulkamid\u0026reg;) is a minimally invasive surgical procedure used as one of the surgical treatments of stress or mixed urinary incontinence in women. It is easily administered under local anesthesia and can be performed in an ambulatory setting [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In a recent review, mean follow-up duration of studies ranged from 3 to 96 months. Only two studies reported on longer-term outcomes of 38 and 96 months. Definitions of treatment \u0026ldquo;success\u0026rdquo; varied between studies. As a result, there was a wide variability in reported success rates, ranging from 29.8\u0026ndash;89.7% in the short-term, and 42% to approximately 70% in the long-term [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe mechanism of action of these agents however is not fully understood. One theory is that the injection of PAHG into the urethral submucosa creates artificial urethral cushions that can improve urethral coaptation and restore continence. Another theory was put forward by Klarskov et al. suggesting that the bulking material may function as additional central filler volume which increases the length of the muscle fibers and thereby the power of the urethral sphincter [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePAHG can be visualized ultrasonographically. Two- dimensional ultrasound (2DUS) and three-dimensional ultrasound (3DUS) imaging are objective tools for the assessment of the lower urinary tract and pelvic floor. 2DUS is the most widely applied technique, primarily because of its availability and significantly lower cost. 3DUS technique allows more accurate characterization of periurethral bulking agent volume, configuration, and location in relation to the urethra and bladder neck [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The optimal site for injection and the amount to be injected is still unknown.\u003c/p\u003e \u003cp\u003eSome women experience an improvement or cure in stress urinary incontinence (SUI) symptoms lasting only a few weeks after the injection of the bulking agent. Our theory is that one of the reasons might be that the amount of PAHG diminishes over time perhaps because of rupture or leakage from the injection site.\u003c/p\u003e \u003cp\u003eThe primary aim of this study was to describe the changes in volume, number of deposits and echogenicity of the bulking agent 3 months after PAHG injection. The secondary aim was to determine whether there was an association between degree of improvement and sonographic findings.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eThis study was performed as a prospective cohort study. A total of fourteen patients with SUI or mixed primarily SUI were recruited. Patients with previous bulking operations were not included.\u003c/p\u003e \u003cp\u003ePreoperative evaluation included medical history, a physical and pelvic examination including genital prolapse score, uroflowmetry and a post-void residual urine volume (PVR). All patients completed the International Consultation on Incontinence-Urinary Incontinence Short Form (ICIQ-UI SF) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] before surgery and three months postoperatively. The subjective outcome was evaluated with Patient Global Impression of Improvement questionnaire (PGI -I) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Demographic data including age, body mass index, number of births, previous caesarean sections and previous prolapse and incontinence operations were obtained before the bulking procedure.\u003c/p\u003e \u003cp\u003eAll data extracted were entered into The Research Electronic Data Capture (RedCap), which is browser-based, metadata-driven electronic data capture software and workflow methodology for designing clinical and translational research databases.\u003c/p\u003e \u003cp\u003eThe study was registered and approved at The Health Department (ID number K2022-044).\u003c/p\u003e \u003cp\u003eAfter providing written informed consent, between October and December 2022, patients underwent an injection of PAHG. All injections were performed in an office setting under local anesthesia, 2 ampullas of Citanest/Octapressin\u0026reg;30 mg/ml/0.54 \u0026micro;g/ml, 1.8 ml, and catheter gel containing 2% lidocaine and 0.025% chlorhexidine. Before injections a clean urine dipstick was required. Hydrogel was injected into the submucosa under endoscopic control 1.5 cm from the vesicourethral junction in locations \u0026ldquo;2, 5, 7 and 10\u0026rdquo; o\u0026rsquo;clock, 0.5 ml at each site. The needle was re-sited if the injection appeared to be too superficial or too deep. After the bulking procedure, about 150 ml of NaCl was left as a residual urine. Patients were discharged after a successful voiding, PVR\u0026thinsp;\u0026lt;\u0026thinsp;150 ml.\u003c/p\u003e \u003cp\u003eAll procedures were performed by the same three surgeons using a standardized technique.\u003c/p\u003e \u003cp\u003eEndovaginal 3DUS was performed in all patients immediately after injection of PAHG and again at 3 months follow-up. 3DUS was performed using the Voluson530D ultrasound machine with 7.5-MHz transvaginal 3D probe that was placed beneath the urethral meatus. Bulking agent deposits were measured in three dimensions and the volume calculated from this.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 14 patients who underwent an injection of PAHG during the study period, 11 patients (79%) reported mixed urinary incontinence and 3 patients (21%) stress urinary incontinence.\u003c/p\u003e\n\u003cp\u003eDemographic data of the study population are shown in Table 1.\u003c/p\u003e\n\u003cp\u003eEleven patients (78.6%) experienced some degree of improvement according to the PGI-I questionnaire at 3 months: 26.8% were minimally improved, 26.8 % much improved and 21.4% very much improved (Table 2). No patients had worsening in incontinence.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMean score ISIQ UI-SF before surgery was 15 and declined to 9.8 at 3 months follow-up (Table 2).\u003c/p\u003e\n\u003cp\u003eA total of 53 PAHG deposits were found by ultrasound immediately after injection. At 3 months follow-up 41 PAHG deposits (77%) were left.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe bulking agent exhibited various levels of echogenicity 3 months after surgery. All deposits were hypoechogenic immediately after injection (Figure 1) and only 24% of demonstrated PAHG collections had a hypoechoic echogenicity at 3 months follow-up (Figure 2).\u003c/p\u003e\n\u003cp\u003eThe PAHG collections varied from single spherical to oblong collections. PAHG collection in two patients appeared as exophytic masses projecting into the bladder at the bladder base at 3 months follow-up. One of these patients experienced very much improvement in continence and another one had no improvement in continence at all.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe mean volume of PAHG injection at baseline was 1.168 cm\u0026sup3;and the mean change in volume of injection was 0.451 cm\u0026sup3;, which was a mean 36.5% loss in volume during the study period (Table 3).\u003c/p\u003e\n\u003cp\u003eWe found no correlation between the clinical outcome and amount of bulking agent left at 3 months follow-up (Table 2).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study found that the volume of injected PAHG was reduced significantly 3 months after surgery. In contrast to some previous histological studies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], which stated that PAHG injections remain stable in volume for years, we found a mean 36.5% loss in bulking agent volume during the study period. The only study by Mouritsen et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] described volume of injected PAHG in eleven women at eight years follow-up. The deposits had a volume of 0.14\u0026ndash;2.44 cm\u0026sup3;. In our study, the volume range of PAHG at 3 months follow-up was 0.217\u0026ndash;1.365 cm\u0026sup3;.\u003c/p\u003e \u003cp\u003eThe amount of PAHG injected per treatment was 2 ml (=\u0026thinsp;2 cm\u0026sup3;), but the median amount of bulking agent found by ultrasound immediately after the injection was only 1.2105 cm\u0026sup3;\u003c/p\u003e \u003cp\u003eIn a previous paper by Lose et al [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], the authors speculated that too much material injected per site might increase the risk of material leakage, either via the injection hole, or due to rupture of the covering mucosa. This might explain our findings. Because of the limited potential volume in the submucosal space, it is necessary to be aware about the amount of bulking agent injected. The optimal relationship between amount of injected material and cure rate has not been defined.\u003c/p\u003e \u003cp\u003eAll the patients underwent imaging with 3DUS immediately after the surgery. Because of abundance of water in PAHG, all the deposits were seen as hypoechoic mass collections. In eleven patients (79%) four PAHG deposits were visualized and in three patients (21%) only three deposits. At 3 months follow-up, only 41 (77%) out of 53 deposits of bulking agent were left. Presence of fewer deposits than injected may represent loss of material through the urethra but might also be caused by confluence of deposits.\u003c/p\u003e \u003cp\u003eMouritsen et al [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] found that PAHG deposits were still visible on vaginal ultrasound as hypoechoic collections even eight years post injection. In contrast to this previous study [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], only 24% of PAHG collections in our patients had hypo-echoic echogenicity at 3 months follow-up. Most bulking agent deposits had hyperechoic appearance.\u003c/p\u003e \u003cp\u003eEven though, we found a reduction in volume of PAHG 3 months after surgery, 78.6% of patients experienced improvement in their continence. Our results are comparable to reports in the literature on bulking agents [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. A subjective evaluation of continence status could overestimate the results. Sometimes even a minor objective leak decrease could be seen as a major continence improvement. We believe that PAHG has a place in a treatment of urinary incontinence with improvement of patients\u0026acute; quality of life even with suboptimal treatment results.\u003c/p\u003e \u003cp\u003eThe role of using 2D and/or 3DUS in the treatment of stress/mixed urinary incontinence with various urethral bulking agents as collagen, Coaptite, Macroplastique is well-described in previous studies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], but there is lack of studies using PAHG as bulking agent. Mouritsen et al [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] described volume and placement of the injected PAHG deposits at eight years follow-up. Unfortunately, the number and volume of the deposits around the urethra were not recorded with ultrasonography at the time of injection and hence a change in number and size of deposits over time could not be determined. To the best of our knowledge, our study is the first one to describe sonographic findings using urethral bulking agent PAHG immediately after treatment and at follow-up.\u003c/p\u003e \u003cp\u003eLimitations of the present study are a small cohort and a short follow-up. Using of 3DUS is an operator-dependent technology, which has the potential to skew results.\u003c/p\u003e \u003cp\u003eIn this study no correlation between the clinical outcome and amount of bulking agent left at 3 months follow-up was found (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Our study population was too small to show a clinically significant difference and included a large percentage of patients with mixed urinary incontinence which makes conclusion on incontinence difficult. Furthermore, our study did not investigate the exact location of the bulking material.\u003c/p\u003e \u003cp\u003eWe are not able to explain the echogenicity changes in some patients and not in others.\u003c/p\u003e \u003cp\u003eThe strength of our study is that all procedures were performed at a high-volume specialty center of well-trained surgeons. The same validated questionnaires were used both pre- and postoperatively giving a more exact information about changes in urinary incontinence and no patients were lost to follow-up.\u003c/p\u003e \u003cp\u003eIn conclusion, more than 1/3 of volume of injected PAHG and 23% of deposits could not be found by 3DUS at 3 months follow-up Only 24% of PAHG injections in our patients had hypo-echoic echogenicity at 3 months follow-up. Three-dimensional ultrasound examination can be easily applied in a clinical setting. Larger 3DUS studies with longer follow-up and focus on exact location of the PAHG injections are important future studies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePAHG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epolyacrylamide hydrogel\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSUI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003estress urinary incontinence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e3DUS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ethree-dimensional ultrasound\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePGI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eI-Patient Global Impression of Improvement\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICIQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUI SF-International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEach authors\u0026apos; contribution to the Manuscript:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA UGIANSKIENE: Project development, Data collection and analysis, Manuscript writing\u003c/p\u003e\n\u003cp\u003eC SOLLBERGER JUHL: Data collection and analysis, Manuscript editing\u003c/p\u003e\n\u003cp\u003eK GLAVIND: Project development, Data analysis, Manuscript editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical/Institutional Review Board Approval.\u003c/strong\u003e The study was registered and approved at The Health Department, The Region of Northern Denmark (ID number K2022-044).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration \u0026ndash; none\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests \u0026ndash; none\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest - none\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJuhl CS, Bj\u0026oslash;rk J, Glavind K. Treatment of stress urinary incontinence with polyacrylamide hydrogel in an office setting: patient perspectives. Int Urogynecol J. 2022;33(8):2169\u0026ndash;2176. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00192-022-05135-3\u003c/span\u003e\u003cspan address=\"10.1007/s00192-022-05135-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2022 Mar 14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoe V, Haller B, Yao HH, O'Connell HE. Urethral bulking agents for the treatment of stress urinary incontinence in women: A systematic review. Neurourol Urodyn. 2021;40(6):1349\u0026ndash;1388. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/nau.24696\u003c/span\u003e\u003cspan address=\"10.1002/nau.24696\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2021 May 20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKlarskov N, Lose G. Urethral injection therapy: what is the mechanism of action? Neurourol Urodyn. 2008;27(8):789\u0026ndash;92. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/nau.20602\u003c/span\u003e\u003cspan address=\"10.1002/nau.20602\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePoon CI, Zimmern PE. Role of three-dimensional ultrasound in assessment of women undergoing urethral bulking agent therapy. Curr Opin Obstet Gynecol. 2004;16(5):411\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAvery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P (2004) ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn 23:322\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYalcin I, Bump RC. Validation of two global impression questionnaires for incontinence. Am J Obstet Gynecol. 2003;189:98\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristensen LH, Breiting VB, Aasted A, Jorgensen A, Kebuladze I (2003) Long-term effects of polyacrylamide hydrogel on human breast tissue. Plast Reconstr Surg 111:1883\u0026ndash;1890\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristensen LH, Nielsen JB, Mouritsen L, Sorensen M, Lose G (2008) Tissue integration of polyacrylamide hydrogel: an experimental study 1476 Int Urogynecol J (2010) 21:1471\u0026ndash;1477 of periurethral, perivesical, and mammary gland tissue in the pig. Dermatol Surg 34(Suppl 1):S68\u0026ndash;S77\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMouritsen L, Lose G, M\u0026oslash;ller-Bek K. Long-term follow-up after urethral injection with polyacrylamide hydrogel for female stress incontinence. Acta Obstet Gynecol Scand. 2014;93(2):209\u0026ndash;12. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/aogs.12283\u003c/span\u003e\u003cspan address=\"10.1111/aogs.12283\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2013 Dec 24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLose G, S\u0026oslash;rensen HC, Axelsen SM, Falconer C, Lobodasch K, Safwat T. An open multicenter study of polyacrylamide hydrogel (Bulkamid\u0026reg;) for female stress and mixed urinary incontinence. Int Urogynecol J. 2010;21(12):1471\u0026ndash;7. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00192-010-1214-1\u003c/span\u003e\u003cspan address=\"10.1007/s00192-010-1214-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2010 Jul 20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSokol ER, Karram MM, Dmochowski R. Efficacy and safety of polyacrylamide hydrogel for the treatment of female stress incontinence: a randomized, prospective, multicenter North American study. J Urol. 2014;192(3):843\u0026ndash;9. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.juro.2014.03.109\u003c/span\u003e\u003cspan address=\"10.1016/j.juro.2014.03.109\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2014 Apr 2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeone Roberti Maggiore U, Alessandri F, Medica M, Gabelli M, Venturini PL, Ferrero S (2013) Outpatient periurethral injections of polyacrylamide hydrogel for the treatment of female stress urinary incontinence: effectiveness and safety. Arch Gynecol Obstet 288(1):131\u0026ndash;137\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeonhardt C, Krysl J, Arenson AM, et al. Periurethral injection of collagen in the treatment of urinary stress incontinence: ultrasonographic appearance. Can Assoc Radiol J 1995; 46: 189\u0026ndash;193.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElia G, Bergman A. Periurethral collagen implant: ultrasound assessment and prediction of outcome. Int Urogynecol J Pelvic Floor Dysfunct 1996; 7: 335\u0026ndash;338.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDefreitas GA, Wilson TS, Zimmern PE, et al. Three-dimensional ultrasonography: an objective outcome tool to assess collagen distribution in women with stress urinary incontinence. Urology 2003; 62: 232\u0026ndash;236\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCecile A Unger, Matthew D Barber, Mark D Walters. Ultrasound Evaluation of the Urethra and Bladder Neck Before and After Transurethral Bulking. Female Pelvic Med Reconstr Surg. 2016 Mar-Apr;22(2):118\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYune JJ, Quiroz L, Nihira MA, Siddighi S, O'Leary DE, Santiago A, Shobeiri SA. The Location and Distribution of Transurethral Bulking Agent: 3-Dimensional Ultrasound Study. Female Pelvic Med Reconstr Surg. 2016 Mar-Apr;22(2):98\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHegde A, Smith AL, Aguilar VC, et al. Three-dimensional endovaginal ultrasound examination following injection of Macroplastique for stress urinary incontinence: outcomes based on location and periurethral distribution of the bulking agent. Int Urogynecol J 2013; 24(7): 1151\u0026ndash;1159.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Demographics of the study population\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.6822429906542%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.3177570093458%\" valign=\"top\"\u003e\n \u003cp\u003eStudy population N=14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.6822429906542%\" valign=\"top\"\u003e\n \u003cp\u003eAge, median (range), years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.3177570093458%\" valign=\"top\"\u003e\n \u003cp\u003e51 (43-85)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.6822429906542%\" valign=\"top\"\u003e\n \u003cp\u003eParity, median (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.3177570093458%\" valign=\"top\"\u003e\n \u003cp\u003e2 (0-3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.6822429906542%\" valign=\"top\"\u003e\n \u003cp\u003eBody mass index, kg/m\u0026sup2;: mean (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.3177570093458%\" valign=\"top\"\u003e\n \u003cp\u003e27.9 (20.9-32.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.6822429906542%\" valign=\"top\"\u003e\n \u003cp\u003eCesarean section: n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.3177570093458%\" valign=\"top\"\u003e\n \u003cp\u003e1 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.6822429906542%\" valign=\"top\"\u003e\n \u003cp\u003ePrevious hysterectomy: n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.3177570093458%\" valign=\"top\"\u003e\n \u003cp\u003e0 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.6822429906542%\" valign=\"top\"\u003e\n \u003cp\u003ePrevious prolapse surgery: n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.3177570093458%\" valign=\"top\"\u003e\n \u003cp\u003e1 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.6822429906542%\" valign=\"top\"\u003e\n \u003cp\u003ePrevious anti-incontinence surgery: n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.3177570093458%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. Data on scores of ICIQ-UI short form before and 3 months after surgery and PGI-I results 3 months after surgery\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.157684630738522%\" valign=\"top\"\u003e\n \u003cp\u003ePatients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.151696606786427%\" valign=\"top\"\u003e\n \u003cp\u003eICIQ-UI SF before surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.35129740518962%\" valign=\"top\"\u003e\n \u003cp\u003eICIQ-UI SF 3 months after surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.339321357285428%\" valign=\"top\"\u003e\n \u003cp\u003eSubjective results\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.157684630738522%\" valign=\"top\"\u003e\n \u003cp\u003e1.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.151696606786427%\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.35129740518962%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.339321357285428%\" valign=\"top\"\u003e\n \u003cp\u003eMuch improved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.157684630738522%\" valign=\"top\"\u003e\n \u003cp\u003e2.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.151696606786427%\" valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.35129740518962%\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.339321357285428%\" valign=\"top\"\u003e\n \u003cp\u003eMinimally improved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.157684630738522%\" valign=\"top\"\u003e\n \u003cp\u003e3.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.151696606786427%\" valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.35129740518962%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.339321357285428%\" valign=\"top\"\u003e\n \u003cp\u003eMuch improved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.157684630738522%\" valign=\"top\"\u003e\n \u003cp\u003e4.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.151696606786427%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.35129740518962%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.339321357285428%\" valign=\"top\"\u003e\n \u003cp\u003eMuch improved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.157684630738522%\" valign=\"top\"\u003e\n \u003cp\u003e5.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.151696606786427%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.35129740518962%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.339321357285428%\" valign=\"top\"\u003e\n \u003cp\u003eNot improved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.157684630738522%\" valign=\"top\"\u003e\n \u003cp\u003e6.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.151696606786427%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.35129740518962%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.339321357285428%\" valign=\"top\"\u003e\n \u003cp\u003eVery much improved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.157684630738522%\" valign=\"top\"\u003e\n \u003cp\u003e7.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.151696606786427%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.35129740518962%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.339321357285428%\" valign=\"top\"\u003e\n \u003cp\u003eVery much improved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.157684630738522%\" valign=\"top\"\u003e\n \u003cp\u003e8.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.151696606786427%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.35129740518962%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.339321357285428%\" valign=\"top\"\u003e\n \u003cp\u003eVery much improved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.157684630738522%\" valign=\"top\"\u003e\n \u003cp\u003e9.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.151696606786427%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.35129740518962%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.339321357285428%\" valign=\"top\"\u003e\n \u003cp\u003eMinimally improved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.157684630738522%\" valign=\"top\"\u003e\n \u003cp\u003e10.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.151696606786427%\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.35129740518962%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.339321357285428%\" valign=\"top\"\u003e\n \u003cp\u003eMinimally improved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.157684630738522%\" valign=\"top\"\u003e\n \u003cp\u003e11.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.151696606786427%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.35129740518962%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.339321357285428%\" valign=\"top\"\u003e\n \u003cp\u003eMuch improved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.157684630738522%\" valign=\"top\"\u003e\n \u003cp\u003e12.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.151696606786427%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.35129740518962%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.339321357285428%\" valign=\"top\"\u003e\n \u003cp\u003eNot improved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.157684630738522%\" valign=\"top\"\u003e\n \u003cp\u003e13.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.151696606786427%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.35129740518962%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.339321357285428%\" valign=\"top\"\u003e\n \u003cp\u003eMinimally improved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.157684630738522%\" valign=\"top\"\u003e\n \u003cp\u003e14.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.151696606786427%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.35129740518962%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.339321357285428%\" valign=\"top\"\u003e\n \u003cp\u003eNot improved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3. Changes in volume of injected Bulkamid\u003cstrong\u003e\u0026reg;\u003c/strong\u003e and subjective success rates\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\" 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ultrasound, stress urinary incontinence","lastPublishedDoi":"10.21203/rs.3.rs-4352930/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4352930/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction and Hypothesis\u003c/h2\u003e \u003cp\u003ePolyacrylamide hydrogel (PAHG) is a bulking agent used in treatment of stress urinary incontinence (SUI) in women. Some women experience an improvement or cure in stress urinary incontinence (SUI) symptoms lasting only a few weeks after the injection of the bulking agent. The aim of this study was to use three-dimensional ultrasound (3DUS) to describe the changes in volume, number of deposits and echogenicity of the bulking agent 3 months after PAHG injection.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eProspective cohort study of fourteen women with SUI or mixed primarily SUI, who underwent an injection of PAHG. The subjective outcome was evaluated with Patient Global Impression of Improvement questionnaire. 3DUS was performed in all patients immediately after injection of PAHG and again at 3 months follow-up.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study found a mean 36.5% loss in bulking agent volume during the study period. A total of 53 PAHG deposits were found by ultrasound immediately after injection. At 3 months follow-up 41 PAHG deposits were left. All deposits were hypoechogenic immediately after injection and only 24% of demonstrated PAHG collections had a hypoechoic echogenicity at 3 months follow-up.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eMore than 1/3 of volume of injected PAHG and 23% of deposits could not be found by 3DUS at 3 months follow-up. Only 24% of PAHG injections in our patients had hypo-echoic echogenicity at 3 months follow-up. Larger 3DUS studies with longer follow-up and focus on exact location of the PAHG injections are important future studies.\u003c/p\u003e","manuscriptTitle":"Role of 3D ultrasound in the treatment of stress urinary incontinence with polyacrylamide hydrogel (Bulkamid®) – a pilot study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-14 17:50:54","doi":"10.21203/rs.3.rs-4352930/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"da4625a7-2034-4a64-91c9-408c76aadec9","owner":[],"postedDate":"May 14th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-23T09:17:39+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-14 17:50:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4352930","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4352930","identity":"rs-4352930","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}