The accuracy of the clinical sign of stress incontinence in the diagnosis of genuine stress incontinence (GSI) was evaluated in 863 (consecutive) women, 779 of whom were referred with the symptom of urinary incontinence. Subjects were assessed clinically and urodynamically by the one clinician (PLD). The positive and negative predictive values of the clinical sign of stress incontinence for a diagnosis of GSI were 91% and 50% respectively. Of the 569 women with GSI, 335 (59%) had GSI as their sole diagnosis and 234 (41%) had an additional urodynamic diagnosis. The clinical sign of stress incontinence when present was a reliable guide to a final diagnosis of GSI. Clinical assessment of incontinent women requires the back-up of urodynamic studies in order to make an accurate diagnosis.

A survey of 886 women who considered themselves to be normal was carried out to determine voiding habits in the population and the prevalence of urinary incontinence of any degree. Eighty-eight percent voided at 3-6 hourly intervals. Increasing age did not affect the frequency of micturition but parturition did. Nocturia was present in 18% but increased with age. Thirty-two percent of the study group admitted to having had one or more episodes of incontinence. Having borne a child increased the prevalence of incontinence but increasing age did not. There was a small but significant occurrence of apparent sphincter weakness in nulliparas.

In 1970 the authors established a specific clinic at the Royal Women's Hospital in an attempt to evaluate the causes of urinary incontinence, to improve the follow-up of patients treated for this complaint, and to determine areas where treatment was deficient. Of 258 patients seen in the clinic so far 80 (31%) were considered to have had stress incontinence, 84 (33%) urgency, and 82 (32%) both symptoms. Incontinence of urine with exertion was common in patients with urgency and furthermore, the Bonney test of urethral elevation was of no value in distinguishing stress from urge incontinence. Therapy with Probanthine 15 mg t.d.s. and Tofranil 25 mg t.d.s. was effective in 127 patients (90%) in whom urgency was the sole or dominant complaint.

This study shows propantheline and imipramine to be effective in the management of the unstable bladder. It emphasizes the need for urodynamic studies for the accurate diagnosis of urinary incontinence. Comparisons have been made of the efficacy of propantheline and imipramine in various groups of incontinent women and indicates that in appropriately selected groups the 'cure' rate is over 70% but if sphincter weakness is excluded, urodynamics cannot differentiate between those women with unstable bladders who will respond to this medication and those who will not.

There are few options now available to treat patients with severe genuine stress incontinence caused by urethral failure. These patients usually have a low maximum urethral closure pressure (less than 20 cm of water) and anterior vaginal wall scarring caused by previous surgery. In 32 such patients we used the Martius fat pad insertion procedure, in addition to the Stamey procedure, and achieved a 91% symptomatic success rate over a mean 13-month follow-up period. Because of its simplicity, reliability and low morbidity, we recommend this procedure in this difficult group of patients before performing a sling procedure or insertion of an artificial urinary sphincter.