Mohammad Akram Khalid  ( Department of Urology, General Hospital, Kettering, Northants NN16 8VZ, U.K. )

Endoscopic Pen-urethral Teflon injection offers a simple form of treatment with a low morbidity rate for some patients with urinary incontinence. It is particularly useful in patients with stress inconti­nence, post-prostatectomy incontinence and in some cases of neuropathic incontinence. Findings in a group of ten patients who underwent this technique are presented. Seventy percent of patients improved by this procedure (JPMA 38: 231 , 1988).

Teflon (Polytetrafluoroethylene) has been in clinical use for a long time. It was first used to bulk out the vocal cords in Paralytic Dysphonia. ¹. Later on, it was introduced into Urological prac­tice for the management of urinary incontinence due to sphincter insufficiency. In the first large series Poiltano reported a success rate of 75% in 165 patients with stress incontinence using Pen-urethral Teflon injection². Since then many more series have been published reporting reasonable success following Periurethral Teflon injection particularly in women with stress incontinence^3-4.

Diagnostic Work-up
Ten patients with urinary incontinence were selected for endoscopic peri.urethral Teflon injection either because they were unfit for major surgery for stress incontinence due to obesity, heart disease, cerebro vascular accident or advanced rheurnatod arthritis or it was considered the treat­ment of choice particularly for post.prostatectomy and neuropathic incontinence. Five male and five female patients, mean age 58.6 years (Range 27-75 years) underwent this procedure. They had stress incontinence (5 patients), post-prostat tomy incontinence (4 patients) and neuropathic incontinence (1 patient).
Pre-operative evaluation consisted of renal function tests, urinalysis, urine culture, intra­venous urogram and urodynamic studies (Table I).

All patients underwent the same technique des­cribed below and repeat injections were also performed by the same technique.
Technique of Injection
A purpose made Endoscopic Needle and a high pressure metal gun (STORZ; Figure)

were used. The procedure was covered by pen-operative parenteral antibiotics. The patient was placed in lithotomy position under general or epi­dural anaesthesia. Preliminary cystoscopy was performed to exclude any intravesical pathology. An 8 Ch endoscopic needle was passed through the operating channel of the cystoscope. A plastic syringe filled with Teflon paste was then loaded onto the metal gun and Teflon injected.
In male patients, the needle was pushed into the submucosal tissue at end distal to the distal sphincter and Teflon paste injected. Three large cushions of Teflon were thus raised at 3°, 6° and 9° clock positions. A total of 10—15 ml of Teflon paste was injected.
In female patients, three similar cushions of Teflon were raised extending from the bladder neck upto approximately one cm proximal to the external urethral meatus so that the bladder neck appeared to be almost closed. The bladder was not drained with a catheter postoperatively.

Mean follow up period was 9.7 months (range 2-18 months). The success of the proce­dure as judged subjectively by the patients was graded as cured when it was completely dry, improved when there was good control of con­tinence with minimal leakage, and failed when no change was found.
Five out of 10 patients (50%) were cured, 2 (20%) improved and 3 (30%) failed to respond. All patients experienced some discomfort on voiding postoperatively. Three patients developed urinary tract infection which responded to appro­priate antibiotic therapy. One patient went into urinary retention. She voided satisfactorily follow­ing urethral dilatation. In one patient Teflon in­jection was repeated three times but he failed to improve and ten days after the last injection he passed the Teflon per-urethrum. Another patient who failed to improve declined repeat injection and underwent colposuspension. None of the patients went into chronic urinary retention as assessed by follow-up bladder ultrasonography. There was no death in this series.

Female patients with stress incontinence would normally be treated with colposuspension but to undertake open pelvic surgery in the presence of multiple medical problems could be risky. Insertion of an artificial urinary sphincter would be indicated to treat male urinary incontin­ence due to sphincter weakness. But this device is not free from problems. Endoscopic Peri-ure­thral Teflon injection, because of its simplicity, low morbidity and minimal complications, seemed a reasonable alternative form of treatment in this group of patients. Prior to undertakin
Endoscopic Teflon injection, different pharma­cological agents were tried to augment bladder outflow resistance but the response was disappoin­ting.
All patients tolerated Endoscopic Teflon injection very well and an improvement rate of 70% in this small series compared favourably with 53.6—71% reported in other studies.^4-5 Teflon had also been used to treat urinary incontinence in children with poor external sphincters and 50-85% success rate was achieved⁶. Six female patients with neurogenic bladder disease were incontinent inspite of intermittent catheterization and drugs for detrusor hyper-reflexia. Teflon was injected peri-urethrally and all these patients became dry in between catheterization⁷. Vicente achieved 65% cure rate by treating 26 women with stress incontinence using this technique.^8-
Three patients in this series failed to im­prove following Teflon injection. One patient had poorly compliant bladder as a result of previous radiotherapy for bladder tumour. Moreover previous prostate and urethral stricture surgery markedly compromized his outflow tract. The second patient with marked degree of cystocele failed to improve and later underwent colposus­pension. The third patient also had marked degree of cystocele and after initial improvement her incontinence recurred within a month.
Repeat injections of Teflon can achieve better results². If partial improvement occurs, Teflon injection can be repeated without difficulty after six to eight weeks once inflammation has resolved4 but repeat injections failed to imprOve the outcome in one of my patients.
Detrusor instability seems to mitigate the success­ful outcome of this procedure³ and good results are also associated with high preoperative cysto­metric capacity and lower maximal urethral pre s­sure. ³
Endoscopic Teflon injection carries mini­mal complications. Patients usually experience some discomfort on voiding. The main risk of this procedure is to induce bladder outflow obstruc­tion, but in Schulman’s series of 56 patients, only one patient went into persistent urinary retention who was successfully managed with internal urethrotomy ⁴.
One patient in this study voided satisfac­torily after urethral dilatation and none of them developed chronic urinary retention. Sarramon evaluated his 12 female patients with stress incon­tinence following Endoscopic Teflon injection using urodynamic studies and voiding cystoure­thrography. He noticed an increase in urethral length and bladder capacity, improved abdomino­urethral transmission and reduction in posterior vesico-urethral angle associated with elevation of the bladder neck⁹
Spontaneous extrusion of Teflon paste does occur postoperatively. One patient passed the Teflon paste perurethrum ten days after the injection. In another series of 26 patients, 6 passed the Teflon paste perurethrum at variable intervals after the injection. ⁸
Distal embblization of Teflon particles has been demonstrated in experimental animals¹⁰  and Teflon embolization from Teflon pledgets used in repairing ventricular septal defects has occurred¹¹. Widespread interstitial pulmonary granulomas have been seen in a case who had periurethral Teflon injection few years prior to committing suicide; however this was an incidental finding unrelated to the cause of death¹² Never­theless after having used Teflon injection in more than one thousand patients in twenty years, Politano has not encountered any case of malign­ancy attributable to Teflon¹³.
Teflon particles have been found to be carcino­genic in 0; therefore a caution has been ex­pressed against the use of Teflon injection in long term effects are young children until its fully known¹⁴

I wish to thank Mr. J.T. Hill F.R. CS., the consultant urological surgeon, for his in­valuable help and guidance in preparing this manuscript.

1. Arnold, G.E. Vocal rehabilitation of paralytic dysphonia. Arch. Otolaryngol., 1963; 78: 179.
2. Politano, VA., Small, M.P., Harper, .J.M. and Lynne, C.M. Periurethral teflon injection for urinary incontinence. J. Urol., 1974; 111 : 180.
3. Urn, KS., Ball, A. J. and Feneley, R.C.L. Periure­thral teflon injection; a simple treatment for urinary incontinence. Br. J. Urol., 1983;55:208.
4. Schulrman, C.C., Simon, J., wespes, E. and Germeau, F. Endoscopic injections of teflon to treat urinary incontinence in women. Br. Med. J. (Clin. Res. ).1984; 288:192.
5. Kaufman, M., Lockhart, J.L., Silverstein, MJ. and Politano, V. A. Transurethral polytetrafluo­roethylene injection for post-pro statectomy urinary incontinence. J. Urol., 1984; 132 : 463.
6. Vorstman, B., Lockhart, J., Kaufman, M.R. and Politano, V. Polytetrafluoroethylene injection forurinary incontinence in children. J. Urol., 1985; 133 : 248.
7. Lewis, R.I., Lockhart, J.L. and Politano, VA. Periurethxal polytetrafluoroethylene injections in incontinent female subjects with neurogenic bladder disease. J. Urol., 1984; 131 : 459.
8. Vicente, J., Arano, P. Endoscopic injection of teflon in urinary incontinence in women. J. Urol. (Paris), 1984;90:35.
9. Sarramon, J.P. Value of teflon in recurrent stress incontinence in elderly women with urodynamic control. Ann. Urol. (Paris), 1987; 21:23. EngI. Abst.
10. Malizia, AS., Reiman, H.M., Dewanjee, M.K.,Barham, S.S. and Meyers, R.R. Migration of penurethrally injected teflon. Read at Annual meetingof the American Urological Association, Las Vegas, U.SA., 1983 (Abst. 222).
11. Weingarten, J. and Kaufman, SI. Teflon emboliza­lion to pulmonary arteries. Ann. Thorac. Surg., 1977; 23 : 371.
12. Mittleman, R.E. and Marraccini, J.V. Pulmonaryteflon granulomas following periurethral teflon injection for urinary incontinence. Arch, Pathol.Lab.Med.,1983; 107 :611.
13. Politano,VA. Migration of polytetrafluoroethylenepolylef (Letter).JAMA., 1985; 254:1902.
14. Malizia, AS. Migration of polytetrafluoroethylenepolylef (Letter). JAMA., 1985; 254: 1903.