Urodynamics, the supine empty bladder stress test, and incontinence severity

Trial Design for Mixed Urinary Incontinence: Midurethral Sling Versus Botulinum Toxin A

IMPORTANCE

Mixed urinary incontinence (MUI) is common and can be challenging to manage.

OBJECTIVES

We present the protocol design and rationale of a trial comparing the efficacy of 2 procedures for the treatment of women with MUI refractory to oral treatment. The Midurethral sling versus Botulinum toxin A ( MUSA) trial compares the efficacy of intradetrusor injection of 100 U of onabotulinimtoxinA (an office-based procedure directed at the urgency component) versus midurethral sling (MUS) placement (a surgical procedure directed at the stress component).

STUDY DESIGN

The MUSA is a multicenter, randomized trial of women with MUI electing to undergo procedural treatment for MUI at 7 clinical centers in the NICHD Pelvic Floor Disorders Network. Participants are randomized to either onabotulinumtoxinA 100 U or MUS. OnabotulinimtoxinA recipients may receive an additional injection between 3 and 6 months. Participants may receive additional treatment (including crossover to the alternative study intervention) between 6 and 12 months. The primary outcome is change from baseline in Urogenital Distress Inventory (UDI) at 6 months. Secondary outcomes include change in UDI at 3 and 12 months, irritative and stress subscores of the UDI, urinary incontinence episodes, predictors of poor treatment response, quality of life and global impression outcomes, adverse events, use of additional treatments, and cost effectiveness.

RESULTS

Recruitment and randomization of 150 participants is complete and participants are currently in the follow-up phase.

CONCLUSIONS

This trial will provide information to guide care for women with MUI refractory to oral treatment who seek surgical treatment with either onabotulinumtoxinA or MUS.

The Role of the Supine Empty Stress Test in the Evaluation of Women with Stress Urinary Incontinence: A Retrospective Cohort Study

The International Continence Society recommends the supine empty stress test (SEST) as an accessory test in the evaluation of women with urinary incontinence, especially for the presence of intrinsic sphincter deficiency (ISD). The aim of this study was to investigate the relationship between the SEST and clinical findings in women diagnosed with stress urinary incontinence with single voiding cycle ambulatory urodynamics (AUM). AUM tracings of patients with lower urinary tract symptoms (LUTS = Lower urinary tract symptoms) (n = 513) were retrospectively reviewed, and 364 charts with urodynamic SUI were analyzed. Demographics, examination findings, scores of the Sandvik Incontinence Severity Index and validated questionnaires, and AUM findings were compared between SEST-positive and -negative groups. Additionally, the diagnostic accuracy of the SEST in the diagnosis of low abdominal leak point pressure (ALPP ≤ 60 cm H2O) in women with pure urodynamic SUI was calculated. The SEST was positive in 41.8% (n = 152) of the cohort. Women with a positive SEST had higher scores on the Sandvik severity index (9.2 ± 3.6 vs. 7.5 ± 3.8, p = 0.003) and lower ALPP (79.6 ± 29.3 vs. 98.4 ± 31.3, p < 0.001). The negative predictive value of the SEST for ISD was found to be 92.4%. Thus, the SEST seems to be an objective clinical test reflecting urinary incontinence severity while excluding the presence of ISD.

Home Biofeedback Versus Physical Therapy for Stress Urinary Incontinence: A Randomized Trial

OBJECTIVE

The aim of the study was to assess whether home biofeedback is noninferior to supervised pelvic floor physical therapy (PFPT) for the treatment of stress urinary incontinence (SUI) in women.

METHODS

The study used a randomized controlled noninferiority trial to compare a home biofeedback device with PFPT. Women older than 18 years with SUI and no history of a prior incontinence surgery or PFPT were eligible. Forty-two participants were required to determine noninferiority for the primary outcome, improvement in quality of life as measured by the International Consultation on Incontinence Questionnaire Short Form. The noninferiority margin was 4 points. Secondary outcomes included sexual function, overactive bladder symptoms, and patient impression of improvement.

RESULTS

From June 2018 to October 2019, 54 women with SUI were recruited (27 biofeedback, 27 PFPT) and 43 (21 biofeedback, 22 PFPT) completed follow-up. The groups had comparable baseline characteristics. For the primary outcome of change in mean International Consultation on Incontinence Questionnaire-Short Form scores (where lower scores indicate less incontinence), home biofeedback was found to be noninferior to PFPT with a mean decrease from baseline of -3.95 (95% confidence interval [CI] = -2.21 to -5.70) in the home biofeedback group versus -4.73 (95% CI = -3.21 to -6.25) and -3.95 (95% CI = -2.21 to -5.70) in the PFPT group (P = 0.009). The PFPT group showed more improvement in overactive bladder symptoms, but not in incontinence severity without difference in sexual function.

CONCLUSIONS

Home biofeedback was noninferior to PFPT for the primary treatment of SUI in women at 3 months. These results support the use of personal biofeedback devices for the treatment of SUI.Clinical Trial Registration: ClinicalTrials.gov, http://www.clinicaltrials.gov, NCT03443687.

Relationship of heart rate, perceived exertion, and intra-abdominal pressure in women

Background

Exercise increases intra-abdominal pressure (IAP) acutely, which may impact the pelvic floor of women. IAP during exercise demonstrates high variability among women but is not routinely assessed. Assessing less invasive measures related to IAP during exercise may facilitate study of how IAP impacts the pelvic floor.

Methods

The objective of this study was to investigate the relationship of heart rate and rating of perceived exertion (RPE) with IAP during a standard treadmill test. We describe the trend of IAP by predicted aerobic fitness during incremental exercise. IAP was measured using a validated transducer placed in the upper vagina. Heart rate and RPE were collected during the first 3 stages of the standard Bruce treadmill protocol. Relationships of heart rate and RPE with IAP were determined by Pearson correlation coefficients. Predicted aerobic fitness values for each participant were ranked in tertiles with IAP by treadmill stage.

Results

Twenty-four women participated in this study (mean age: 24.7 (5.4) years; body mass index: 22.5 (2.2) kg/m²). There were significant relationships between heart rate and IAP (r= 0.67, p < 0.001) and RPE and IAP (r= 0.60, p < 0.001) across treadmill stages. Tertiles of predicted aerobic fitness and IAP displayed similar trends as other exercise measures during incremental exercise, such as, heart rate and ventilation.

Conclusion

Heart rate and RPE could be used as proxy measures of IAP during incremental exercise. Aerobic fitness may help explain IAP variability in women and provide context for future research on IAP and pelvic floor health.

The role of urodynamics in the management of female stress urinary incontinence

AIM

The role of urodynamic study (UDS) in the management of female stress urinary incontinence (SUI) is one of the most controversial and debated topic in urogynecology. Here, we aimed to systematically assess the most relevant available evidence on urodynamics' value in the management of women with stress urinary incontinence.

METHODS

A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was performed in May 2018. Only randomized clinical trials, prospective studies, or retrospective studies articles evaluating the use of urodynamic studies in women with stress urinary incontinence were included.

RESULTS

After screening a total of 3055 records, 39 studies published from 1996 to 2018 were included.

CONCLUSIONS

In an uncomplicated population of women with SUI, it is not demonstrated that preoperative urodynamic evaluation can improve the outcome of continence surgery; however, UDS provides additional information regarding lower urinary tract function that could guide the physician to make the right therapeutic choice. UDS should be considered mandatory before surgery in complicated patients, but its use should also be evaluated in index patients when the results may help counseling and management of these women.

Urethral length and bladder neck behavior: can dynamic magnetic resonance imaging give the same results as introital ultrasound?

PURPOSE

To compare dynamic magnetic resonance imaging (dMRI) and introital ultrasound results with regard to urethral length measurements and the evaluation of bladder neck changes.

METHODS

Retrospective analyses of urethral length measurements and detection of bladder neck changes (rotated/vertical bladder neck descent, urethral funneling) were conducted in women-scheduled for surgical treatment with alloplastic material-who had undergone introital ultrasound and dMRI presurgery and 3 months postsurgery. Measurement differences between both imaging modalities were evaluated by assessing the confidence interval for the difference in means between the datasets using bootstrap analysis.

RESULTS

Based on data from 40 patients (320 image series), the urethra could be clearly measured on every pre- and postsurgical dMRI dataset but not on preoperative ultrasound images in nine women during Valsalva maneuver due to a large cystocele. The estimation of the mean difference distribution based on 500,000 bootstrap resamples indicated that the urethral length was measured shorter by dMRI pre- and postsurgery at rest and postsurgery during Valsalva maneuver (median 1.6-3.1 mm) but longer by dMRI (median 0.2 mm) during Valsalva maneuver presurgery. Rotated/vertical bladder neck descent and urethral funneling diagnoses showed concordance of 67-74% in the direct comparison of patients; the estimation of the concordance indicated poorer outcomes with 50-72%.

CONCLUSIONS

Metric information on urethral length from dMRI is comparable to that from introital ultrasound. dMRI is more advantageous in cases with an extended organ prolapse. At present, dMRI does not give the same diagnosis on bladder neck changes as introital ultrasound does.

Demographic features of female urethra length

AIMS

To determine cohort urethral length, identify epidemiological factors influencing the parameter and to establish the percentage of cases with clinically relevant outsized urethras.

METHODS

Prospective cohort study conducted in two tertiary clinical centers between 2013 and 2017. Nine hundred and twenty seven consecutive adult, Caucasian females attending outpatients' clinics were included. The urethral length has been measured in pelvic floor ultrasound examination. The exclusion criteria were inadequate bladder filling (<200 mL; >400 mL), previous history of pelvic floor surgery, and no consent.

RESULTS

Urethral length varied from 19 to 45 mm. The distribution of the examined parameter was normal. Obese patients had significantly longer urethras as compared to non-obese subjects. Number of vaginal deliveries was connected with shorter urethral length. The limitations of the study are: analysis only of Caucasian patients and subjects without previous pelvic floor surgeries.

CONCLUSIONS

Differences in urethral length in the female population were demonstrated. Thirty percent of patients have atypical urethras that may be a risk factor for sling surgery failure. We therefore postulate introduction of urethral measurement before the procedure.

Methods for a multicenter randomized trial for mixed urinary incontinence: rationale and patient-centeredness of the ESTEEM trial

INTRODUCTION AND HYPOTHESIS

Mixed urinary incontinence (MUI) can be a challenging condition to manage. We describe the protocol design and rationale for the Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence (ESTEEM) trial, designed to compare a combined conservative and surgical treatment approach versus surgery alone for improving patient-centered MUI outcomes at 12 months.

METHODS

ESTEEM is a multisite, prospective, randomized trial of female participants with MUI randomized to a standardized perioperative behavioral/pelvic floor exercise intervention plus midurethral sling versus midurethral sling alone. We describe our methods and four challenges encountered during the design phase: defining the study population, selecting relevant patient-centered outcomes, determining sample size estimates using a patient-reported outcome measure, and designing an analysis plan that accommodates MUI failure rates. A central theme in the design was patient centeredness, which guided many key decisions. Our primary outcome is patient-reported MUI symptoms measured using the Urogenital Distress Inventory (UDI) score at 12 months. Secondary outcomes include quality of life, sexual function, cost-effectiveness, time to failure, and need for additional treatment.

RESULTS

The final study design was implemented in November 2013 across eight clinical sites in the Pelvic Floor Disorders Network. As of 27 February 2016, 433 total/472 targeted participants had been randomized.

CONCLUSIONS

We describe the ESTEEM protocol and our methods for reaching consensus for methodological challenges in designing a trial for MUI by maintaining the patient perspective at the core of key decisions. This trial will provide information that can directly impact patient care and clinical decision making.

The "1-3-5 cough test": comparing the severity of urodynamic stress incontinence with severity measures of subjective perception of stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

The purpose of the study was to examine whether a test performed during urodynamics, the "1-3-5 cough test", could determine the severity of urodynamic stress incontinence (USI).

METHODS

We included women referred for urodynamics who were diagnosed with USI. The "1-3-5 cough test" was performed to grade the severity of USI at the completion of filling cystometry. A diagnosis of "severe", "moderate" or "mild" USI was given if urine leakage was observed after one, three or five consecutive coughs respectively. We examined the associations between grades of USI severity and measures of subjective perception of stress urinary incontinence (SUI): International Consultation of Incontinence Modular Questionnaire-Female Lower Urinary Tract Symptom (ICIQ-FLUTS), King's Health Questionnaire (KHQ), Urinary Distress Inventory-6 (UDI-6), Urinary Impact Questionnaire-7 (UIQ-7).

RESULTS

A total of 1,181 patients completed the ICIQ-FLUTS and KHQ and 612 completed the UDI-6 and UIQ-7 questionnaires. There was a statistically significant association of higher grades of USI severity with higher scores of the incontinence domain of the ICIQ-FLUTS. The scores of the UDI-6, UIQ-7 and of all KHQ domains (with the exception of general health perception and personal relationships) had statistically significant larger mean values for higher USI severity grade. Groups of higher USI severity had statistically significant associations with higher scores of most of the subjective measures of SUI.

CONCLUSIONS

Severity of USI, as defined by the "1-3-5 cough test", was associated with the severity of subjective measures of SUI. This test may be a useful tool for the objective interpretation of patients with SUI who undergo urodynamics.

Valsalva leak point pressure-associated Q-tip angle and simple female stress urinary incontinence symptoms

PURPOSE

To clarify the association between clinically defined simple stress urinary incontinence (SUI) symptoms and urodynamic SUI, we examined the relationship between Valsalva leak point pressure (VLPP) as measured by the Q-tip test and Stamey grade in simple female SUI.

METHODS

Two hundred grade I or II female SUI patients with SUI symptom were examined by reviewing medical history; physical examination; urethral mobility as assessed by Q-tip test; stress test; and cystometry, including VLPP measurement. On the basis of the VLPP, patients were classified into urethral hypermobility [UH, subdivided into anatomical incontinence (AI) and equivocal incontinence (EI)] or intrinsic sphincter deficiency groups for analysis of the relationship between VLPP and Stamey grade and Q-tip angle.

RESULTS

Seventy-eight patients were included, and the mean patient age was 54 ± 7.5 years, mean SUI symptom duration 2.8 years (range 0.5-6 years), mean VLPP 103.6 ± 18.4 cm H2O, and mean Q-tip angle 28.6° ± 7.2°. Fifty-three patients were categorized as Stamey grade I, 25 as Stamey grade II, 51 as AI, and 27 as EI. VLPP was found to be negatively correlated with Q-tip angle (Rs = -0.798, Y = -0.313X + 60.95, P < 0.001), and classifications of VLPP and Stamey grade have positive correlation (χ (2) = 4.9130, P = 0.0267).

CONCLUSIONS

In simple female SUI, VLPP is associated with the Q-tip angle and Stamey grade, which may help to reduce some of urodynamic items.

Electroacupuncture at points Baliao and Huiyang (BL35) for post-stroke detrusor overactivity

Acupuncture is used extensively in China for the treatment of stroke and other neurological disorders. The National Institutes of Health recommends acupuncture as an adjunctive therapy for stroke recovery. This study included patients with post-stroke detrusor overactivity who were treated in the Department of Neurology, Fourth Hospital of Harbin Medical University, China. Subjects received either electroacupuncture or sham electroacupuncture at points Baliao [including bilateral Shangliao (BL31), bilateral Ciliao (BL32), bilateral Zhongliao (BL33), and bilateral Xialiao (BL34)] and Huiyang (BL35). Our results showed that electroacupuncture significantly improved cystometric capacity and bladder compliance, decreased detrusor leak point pressure, ameliorated lower urinary tract symptoms, and decreased the risk of upper urinary tract damage. These findings indicate that electroacupuncture at points Baliao and Huiyang is an effective treatment for post-stroke detrusor overactivity.

Neuromuscular characterization of the urethra in continent women

OBJECTIVES

: The study's objective was to describe quantitative urethral function parameters in a racially diverse group of continent women.

MATERIALS AND METHODS

: After institutional review board approval, we recruited women without urinary incontinence from the community. To be considered continent, participants answered "never" to the first 6 questions on the stress subscale of the Medical, Epidemiologic, and Social Aspects of Aging urinary incontinence questionnaire. Participants all underwent quantitative concentric urethral electromyography (EMG) and urodynamic testing.

RESULTS

: Thirty-one women with a mean (SD) age of 39 (14) years underwent EMG and urodynamic testing. The cohort was racially diverse with 13 (43%) white women, 13 (43%) African American women, and 4 (14%) Hispanic women. Body mass index (P = 0.12, 0.06), age (P = 0.40, 0.64), and vaginal parity (P = 0.53, 0.76) did not differ by race or ethnicity. We did not detect differences in any EMG parameter by race, ethnicity, or vaginally parity. A mean (range) of 30 (10-55) motor unit action potential (MUP) analyses was identified and analyzed in multiple MUP analysis, and 14 (8-21) were identified and analyzed in interference pattern (IP) analysis. On average, 37% (20%) (mean [SD]) MUPs were polyphasic.Age significantly correlated with several measures of urethral sphincter function. Increasing age was inversely correlated with IP turns (r = -0.57, P = 0.001), IP amplitude (r = -0.43, P = 0.02), IP turns-amplitude ratio (r = -0.54, P = 0.003), and maximum urethral closure pressures (r = -0.41, P = 0.04). Similarly, maximum urethral closure pressures correlated with IP amplitude (r = 0.38, P = 0.04).

CONCLUSIONS

: These urethral neuromuscular function data on the largest cohort of continent women fully characterized with quantitative urethral EMG demonstrate significant neuropathic MUP changes with advancing age.

What is an evidence-based appropriate workup?

At the present time, there is no evidence-based guidance available for workup of stress urinary incontinence (SUI). In the absence of such evidence, we must rely on expert consensus, which dictates that a workup should typically include documentation of SUI, assessment of impact on the patient, and information on voiding function. Typical assessment may need to be adjusted for more complicated populations (e.g., those with mixed incontinence, those who have failed previous treatment).

When are urodynamics indicated in patients with stress urinary incontinence?

Despite technical and procedural advances in urodynamics over the past decade, the role of urodynamics in women with stress urinary incontinence (SUI) remains controversial. Many of these advancements have been the result of multicentric studies in the United States, such as the UITN and PFDN, which will be highlighted in this article. It appears to be the consensus that urodynamics may not be needed in pure stress incontinence. Urodynamics can be valuable in unmasking stress urinary incontinence in prolapse, although its impact on the ultimate management of occult incontinence remains debated. This article reviews the indications for urodynamic testing in women with SUI but will exclude more complex conditions such as mixed or recurrent incontinence which are outside the scope of this review.

Reproduction of Female Lower Urinary Tract Symptoms on Urodynamics

OBJECTIVES

Urodynamic testing (UDS) can be a valuable tool in the assessment of urinary incontinence and voiding dysfunction. The success of UDS in reproducing patients' symptoms has not been well defined. We sought to determine the ability of UDS to reliably reproduce various lower urinary tract symptoms and secondarily the ability of UDS to produce disparate findings not associated with patients presenting symptoms.

METHODS

Following Institutional Review Board approval, patient data was accumulated prospectively over 10 months. Notation was made of primary and secondary symptoms as well as if these stated symptoms were reproduced during the urodynamic procedure. Presenting lower urinary tract symptoms included for analysis were stress, mixed and urge incontinence, urgency, and obstructive symptoms. We also reviewed the number of disparate urodynamic observations that did not correlate with patient history.

RESULTS

Over a 10-month period, 127 women had interpretable data with respect to whether their presenting symptoms were reproduced during UDS. Presenting symptoms were successfully reproduced on 83% of UDS studies. Disparate urodynamic observations were noted in 60% of patients.

CONCLUSIONS

Reproduction of patient symptoms during UDS occurred in the majority of cases if the patient was queried regarding this association. Additional disparate urodynamic observations were also noted in a majority of patients undergoing UDS. It remains unclear whether reproduction of symptoms during UDS in females ultimately results in improved interventional outcomes. The implications of new or unexpected UDS findings during UDS are unknown.

Can preoperative urodynamic investigation be omitted in women with stress urinary incontinence? A non-inferiority randomized controlled trial

AIMS

To assess in women with stress urinary incontinence (SUI) the value of urodynamics prior to treatment.

METHODS

We performed a multicenter non-inferiority randomized controlled trial. Women with SUI were randomly allocated to management based on a workup with or without urodynamics. The primary outcome was clinical reduction of complaints as measured with the Urogenital Distress Inventory urinary incontinence subscale (UDI-UI) at 12 months after the onset of treatment. A mean difference in improvement of less than 8 was considered non-inferior. The study was analyzed according to intention-to-treat.

RESULTS

The trial was stopped prematurely because of slow recruitment. We randomly allocated 59 women to a strategy with (N = 31) or without (N = 28) urodynamics. The mean difference in improvement on the UDI-UI was 14 in favor of the group without urodynamics (48 SD ± 22 vs. 34 SD ± 22, 95% CI: -28 to -0.26), confirming non-inferiority. Addition of urodynamics did not result in a lower occurrence of de novo overactive bladder complaints compared to a workup without urodynamics (6/31 vs. 1/28; RR 5.4, 95% CI: 0.70-42). In the group allocated to urodynamics, initial surgical management was more often abandoned compared to the group not allocated to urodynamics (5/31 vs. 1/28; RR 4.5, 95% CI: 0.56-36).

CONCLUSIONS

In this relatively small study, the omission of urodynamics was not inferior to the use of urodynamics in the preoperative workup of women with SUI. Women with SUI undergoing urodynamics had the risk of a choice for more prudent treatment, which seemed to result in a delay until effective treatment.

Association of baseline urodynamic measures of urethral function with clinical, demographic, and other urodynamic variables in women prior to undergoing midurethral sling surgery

AIMS

To explore how baseline demographic, clinical, and urodynamic (UDS) variables correlate with measures of urethral function in women planning midurethral sling surgery.

METHODS

Women with predominant stress urinary incontinence (SUI) as part of the trial of mid-urethral slings (TOMUS) were characterized preoperatively including: demographics, body mass index (BMI), responses to the Medical and Epidemiologic Social Aspects of Aging (MESA) and Urogenital Distress Inventory (UDI) questionnaires, pad weight (PW), incontinence duration, prior SUI surgery, prolapse, strength of pelvic contraction, Q-tip test, uroflow, cystometrogram, and detrusor pressures at maximum flow (Pdet at Qmax). Multivariate regression analysis and modeling confirmed variables with significant correlations with maximal urethral closure pressure (MUCP), functional urethral length (FUL), and Valsalva leak point pressure (VLPP).

RESULTS

Five-hundred thirty-nine women were included in the analysis. In multivariable analyses, PW (P =  0.045) and age (P < 0.0001) were negatively correlated with MUCP (as PW and age increased, MUCP decreased); BMI (P = 0.02) and Pdet at Qmax (P < 0.0001) were positively correlated with MUCP (as BMI and Pdet at Qmax increased, MUCP increased). Age (P = 0.002) was negatively correlated with FUL; Qtip delta (P = 0.006), pelvic organ prolapse quantification examination (POPQ) stage (P = 0.002) and strength of pelvic contraction (P = 0.03) were positively correlated with FUL. Duration of incontinence (P = 0.01) was negatively correlated with VLPP; Qtip delta (P = 0.02), BMI (P = 0.0005) and Pdet at Qmax (P = 0.0005) were positively correlated with VLPP.

CONCLUSIONS

Age, BMI, Qtip delta, and Pdet at Qmax were variables that correlated with two or more measures of urethral function. These correlations may help direct future research in female urethral function.

Are multichannel urodynamics required prior to surgery in a woman with stress urinary incontinence?

The National Institute for Clinical Excellence recommends that cystometry need not be performed before conservative therapy for incontinence in women, nor is cystometry routinely recommended in the small group of women with a clearly defined diagnosis of pure stress incontinence. Nonetheless, it is frequently utilized in the assessment of women with stress urinary incontinence in the hope that results will shed light on preoperative risk factors for failure or postoperative voiding dysfunction. The ability of urodynamic studies to characterize these parameters reliably remains under investigation. Because urodynamic studies are invasive, costly, and not always available, it is imperative that its benefit be carefully explored. This review highlights the recent arguments for and against this recommendation.