Which women with stress incontinence require urodynamic evaluation?

Significance of 4D US parameters for the clinical treatment of female patients with stress urinary incontinence

Background

Stress urinary incontinence (SUI) that has been associated with abnormal pelvic floor muscle function or morphology is a common condition. This research aimed to study the impact of the four-dimensional (4D) pelvic floor ultrasound on the treatment of female patients with clinical diagnosis of SUI and to evaluate its clinical significance on SUI.

Methods

We enrolled 51 women with SUI. Before transobturator suburethral tape procedures, the patients underwent 4D pelvic floor ultrasonography. The measurements include residual urine volume, bladder detrusor thickness in resting state, the vertical distance from the bladder neck to the posterior inferior edge of pubic symphysis at rest and Valsalva movement, posterior angle of bladder urethra, and urethral rotation angle. The degree of movement of the bladder neck (the difference between the vertical distance from the bladder neck to the posterior inferior edge of the pubic symphysis under the resting state and the maximum Valsalva movement) and the formation of a funnel at the internal orifice of the urethra were calculated.

Results

The mean bladder detrusor thickness was 2.6 ± 0.9 mm, the vertical distance from the bladder neck to the posterior inferior edge of pubic symphysis was 27.7 ± 4.5 mm, the posterior angle of the bladder was 122.7 ± 18.9°, the vertical distance from the rectal ampulla to the posterior inferior edge of pubic symphysis was 18.5 ± 4.6 mm, and the mean area of hiatus of the levator ani muscle was 22.1 ± 6.0 cm2. The mean posterior angle of the bladder on Valsalva was 159.3 ± 23.1°, and the mean urethral rotation angle was 67.2 ± 21.4°.

Conclusions

The 4D pelvic floor ultrasound is a reliable method in evaluating preoperational morphological characteristics of patients with SUI. With the help of the 4D pelvic floor ultrasound, the individualized treatment regimen can be developed and, more importantly, the inappropriate surgical decision can be avoided.

The role of maximal urethral closure pressure in predicting the outcomes of trans-obturator tape operation

OBJECTIVE

To investigate the role of preoperative maximal urethral closure pressure (MUCP) in predicting postoperative outcomes of trans-obturator tape (TOT) operation.

STUDY DESIGN

82 patients who underwent TOT surgery due to urodynamically proven stress urinary incontinence were retrospectively analyzed. Preoperative and 6th month postoperative results of cough stress tests (CST), Turkish validated Incontinence Impact Questionnaire-7 (IIQ-7) and Urogenital Distress Inventory-6 (UDI-6) quality of life (QOL) questionnaires were recorded. Patients who had negative CST and more than 50% improvement in the QOL questionnaires in the postoperative evaluation were classified as cured.

RESULTS

14 (17.1 %) patients had MUCP ≤ 20 cmH2O, 68 (83 %) patients had MUCP > 20 cmH2O. The postoperative IIQ-7 and UDI-6 QOL scores were significantly improved compared to preoperative values in both MUCP ≤ 20 cmH2O and MUCP > 20 cmH2O groups. However, cure rate was lower in the MUCP ≤ 20 cmH2O group than in MUCP > 20 cmH2O group (35.7 % vs 83.8 %, respectively). Preoperative MUCP measurement and urethral mobility assessment were found to be independent factors associated with surgical outcome. A preoperative MUCP ≥ 28.5 cmH2O could predict surgical success after TOT with 92.6 % sensitivity and 85.7 % specificity.

CONCLUSIONS

TOT is a reliable method that has a high efficacy in the surgical treatment of stress urinary incontinence in short-term. Patients with low MUCP can also benefit from TOT. However, the success rate of TOT surgery decreases in the presence of low MUCP and absence of hypermobile urethra.

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.

Urinary Incontinence

Urinary incontinence is a common, often undertreated, condition that impacts millions of Americans. Primary care physicians are well equipped to diagnose and treat urinary incontinence. Key to successful treatment is accurately determining the type of incontinence that ails the patient and using patient-reported quality-of-life indicators to guide stepwise treatment.

An Approach to Urinary Incontinence for Dermatologists

Incontinence-associated dermatitis (IAD) is a condition often encountered by dermatologists. IAD is an inflammatory skin condition secondary to prolonged urine exposure-it is a dermatologic sequela of urinary incontinence. Incontinence should not be dismissed simply as an age-related disorder; rather, it is due to a number of pathologic conditions that can be either reversible or manageable. It is thus critical to identify and treat the underlying causes of urinary incontinence. Clinical management of this common medical issue restores normality to patients' lives while also preventing future dermatologic complications. In this article, we aim to provide dermatologists with an overview of IAD and an approach to the diagnosis and initial management of urinary incontinence.

Diagnosis, Evaluation, and Treatment of Mixed Urinary Incontinence in Women

Mixed urinary incontinence (MUI) is a common clinical problem in the community and hospital setting. The broad definition of the term makes it difficult to diagnose, as well as determine effective treatment strategies. There are no current guidelines recommended for physicians. The estimated prevalence of this condition is approximately 30% in all women with incontinence. It has also been suggested that patients with MUI report more bothersome symptoms than either stress or urge incontinence; approximately 32% of 40- to 64-year-olds with MUI report symptoms of depression. The authors examine the diagnosis, evaluation, and treatment of patients with MUI.

Negative urodynamic testing in women with stress incontinence

INTRODUCTION

A minority of women with a subjective complaint of stress urinary incontinence will have negative urodynamic stress incontinence (USI) findings.

AIM

To test clinical and ultrasound measures as predictors of an unexpected absence of USI. We hypothesised that unexpectedly negative USI would be more common in young women with good pelvic floor and urethral function.

METHODS

A retrospective study analysing 398 data sets from women attending a urogynaecology clinic for evaluation of lower urinary tract and pelvic floor dysfunction. Clinical, urodynamic and translabial ultrasound data were tested as possible predictors of negative USI findings.

RESULTS

Women with unexpectedly negative USI findings were younger, had less anterior compartment prolapse and had a higher maximum urethral pressure. Measures of pelvic floor muscle function were not predictive.

CONCLUSIONS

Women with unexpectedly negative USI are younger and have better urethral function, but voluntary pelvic floor muscle function seems unrelated to this phenomenon.

Is It Possible to Predict Urodynamic Stress Urinary Incontinence in Women with Minimal Diagnostic Evaluation?

<b><i>Objectives:</i></b> To determine whether it is possible to predict urodynamic stress urinary incontinence (uSUI) in women with minimal diagnostic evaluation. <b><i>Materials and Methods:</i></b> Medical records of 2,643 female incontinent patients were reviewed and 301 women were eligible for this study. The positive predictive values (PPV), sensitivity, specificity and negative predictive values (NPV) for uSUI and uSUI with or without detrusor overactivity (DO), and DO patients of pure SUI symptom (group 1), combination of pure SUI symptom and positive provocative stress test (+PST; group 2) and combination of pure SUI symptom, +PST and absence of overactive bladder symptoms (group 3) were calculated for each group. <b><i>Results:</i></b> Mean age was 51.03 years (22-88). PPV, sensitivity and specificity values for uSUI with or without DO of group 3 were 100, 7.4, and 100%, while these values for pure uSUI were 93.3, 9.3, and 99.3%, respectively. Interestingly, none of the patients in groups 2 and 3 had DO. <b><i>Conclusions:</i></b> Our results show that it was possible to predict uSUI with high accuracy using minimal diagnostic evaluation in a group of female patients with pure stress incontinence symptoms +PST while it was also possible to eliminate DO accurately in this group of patients.

The role of preoperative urodynamics in urogynecologic procedures

Urodynamic studies refer to any tests that provide objective information about lower urinary tract function with the goal of evaluating bladder and urethral function. Pre-operative urodynamic testing is commonly performed prior to urogynecologic procedures for urinary incontinence and pelvic organ prolapse. Although the utility of preoperative urodynamics testing before urogynecologic procedures have been challenged in the literature, the preoperative utilization of urodynamic testing in women with complex voiding dysfunction or associated conditions such as prolapse or urethral diverticulum is still considered important for surgical planning and pre-operative counseling.

Psychometric validation of the Italian version of the I-QoL questionnaire: clinical and urodynamic findings

INTRODUCTION AND HYPOTHESIS

The aim was to validate the Italian version of the Incontinence-Quality of Life questionnaire (I-QoL) in women with clinical and urodynamic urinary incontinence (UI). A secondary end point was to compare the results of women with reported UI, but negative urodynamic findings.

METHODS

The Italian translation of the I-QoL was administered to 267 Italian women with pelvic organ prolapse < stage III, and who had undergone previous surgical or medical therapy for UI. Cronbach's alpha was calculated to assess internal consistency of the I-QoL items. Reproducibility was assessed using the intraclass correlation coefficient (ICC). Convergent validity involved comparison of I-QoL scores and the Short Form-36 Health questionnaire.

RESULTS

One hundred and sixty-seven patients were considered for the primary end point: 47 had a negative history of UI and a normal urodynamic test, 120 complained of UI confirmed by a urodynamic test, 59 had a positive history for UI and a urodynamic test negative for UI, and 35 patients not reporting UI had a positive urodynamic test. The I-QoL score revealed that the QoL was lower in patients with reported UI, irrespective of urodynamic findings. The overall I-QoL summary score and subscales showed high internal consistency (alpha ranges from 0.88 to 0.96). ICC ranged from 0.98 to 0.99, demonstrating the stability of the scores. The physical domain of the I-QoL showed a 0.27 correlation with the physical functioning subscale of the SF-36. No significant difference in I-QoL scores was found among various types of UI.

CONCLUSION

The Italian translated version of the I-QoL is reliable, consistent and a valid instrument for assessing impact on quality of life in Italian speaking women with UI.

Can urodynamic stress incontinence be diagnosed by ultrasound?

INTRODUCTION AND HYPOTHESIS

Multichannel urodynamic testing is commonly used to diagnose urodynamic stress incontinence (USI). It has been claimed that USI may be diagnosed by imaging. In this study we determined the predictive value of ultrasound findings for USI.

METHODS

This is an observational study utilising data obtained during urodynamic testing. Data sets were analysed in 209 patients in order to determine the predictive value of sonographic findings for the diagnosis of USI.

RESULTS

Bladder neck descent and maximal urethral pressure were the only independent predictors of USI identified by multivariate logistic regression. The finding of a cystourethrocele with funnelling increased the odds of a diagnosis of USI by 2.5 (95 % confidence interval 1.17-5.4, p = 0.018).

CONCLUSIONS

Translabial ultrasound can identify an anatomical configuration that is associated with USI. However, sonographic findings are insufficient to predict USI and can not replace urodynamic testing.

Outcome of midurethral tape continence surgery in patients with and without urodynamically confirmed stress incontinence

OBJECTIVE

To compare the outcomes of midurethral tape continence surgery in patients with urodynamically confirmed stress incontinence (USI) and patients with symptoms of stress urinary incontinence but normal urodynamic studies (NUDS) and a positive 1-h pad test.

STUDY DESIGN

Analysis of data collected prospectively from 356 women who underwent tension-free vaginal tape (TVT) surgery from June 1998 to September 2009. There were 25 women with NUDS but a positive pad test. Outcome measures in these 25 women were compared with 65 women with urodynamically confirmed stress incontinence. These 65 women were chosen as suitable controls from the group of 331 potential controls. All the women underwent TVT surgery under local or spinal anaesthesia.

RESULTS

The outcome measures were: (1) absence of stress urinary incontinence symptoms, (2) new occurrence of lower urinary tract irritative symptoms (LUTS), (3) persistent voiding dysfunction (VD), and (4) recurrent urinary tract infections (UTIs). Following TVT, stress incontinence was absent in 100% and 97% of patients in the NUDS and USI groups respectively. The occurrence of LUTS was 4% and 4.6% in the NUDS and USI groups, while VD was found in 4% and 4.6% and recurrent UTIs in 8% and 6.1% of the groups respectively.

CONCLUSION

There were no significant differences in outcomes following TVT in patients with and without urodynamically confirmed stress urinary incontinence.

Preoperative clinical, demographic, and urodynamic measures associated with failure to demonstrate urodynamic stress incontinence in women enrolled in two randomized clinical trials of surgery for stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

The unexpected absence of urodynamic stress incontinence (USI) in women planning surgery for stress urinary incontinence (SUI) is a challenge to surgeons. We examined the prevalence and clinical and demographic factors associated at baseline (preoperatively) with the unexpected absence of USI among study participants of two multicenter randomized clinical trials of surgery for treating SUI.

METHODS

Women with SUI symptoms and positive stress tests on physical examination enrolled in two separate clinical trials-one comparing the autologous fascial sling with the Burch colposuspension [Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr), and the other comparing the retropubic mid-urethral sling with the transobturator midurethral sling [Trial of Mid-Urethral Slings (TOMUS)]-were evaluated for USI preoperatively. The association of clinical, demographic, and urodynamic parameters was examined in women without USI in univariate and multivariate analyses.

RESULTS

Overall, 144 of 1,233 women (11.7 %) enrolled in the two studies showed no USI. These women had a significantly lower mean volume at maximum cystometric capacity than those with USI (347.5 vs. 395.8 in SISTEr, p = 0.012), (315.2 vs. 358.2 in TOMUS, p = 0.003) and a lower mean number of daily accidents reported on a 3-day diary (2.2 vs 2.7 in SISTEr, p = 0.030) (1.7 vs 2.7 in TOMUS, p < 0.001). Additionally, those without demonstrable USI were more likely to have Pelvic Organ Prolapse Quantification (POP-Q) stage III/IV (31.7 % vs 14.4 % in SISTEr, p = 0.002), (15.5 % vs 6.9 % in TOMUS, p = 0.025). SUI severity as recorded on the Urogenital Distress Inventory (UDI) correlated strongly with the presence of USI in both studies.

CONCLUSIONS

We observed that about one of eight women planning surgery for SUI does not show USI. Stage 3/4 POP was strongly associated with the unexpected absence of USI. A diminished urodynamic bladder capacity among women who did not display USI may reflect an inability to reach the limits of capacity during urodynamics, at which these women normally leak.

Do urodynamic parameters predict persistent postoperative stress incontinence after midurethral sling? A systematic review

INTRODUCTION AND HYPOTHESIS

It is unclear whether preoperative urodynamic study (UDS) values are predictive of outcomes after midurethral sling.

MATERIALS AND METHODS

We systematically reviewed multiple databases from January 1989 to October 2011 for English-language studies correlating UDS data with postoperative outcomes after midurethral slings. We performed random effects model meta-analyses, as indicated. Relative risk (RR) ratios for the outcome of stress urinary incontinence (SUI) cure were calculated using high maximum urethral closure pressure (MUCP) and Valsalva leak point pressure (VLPP) values as the reference group.

RESULTS

High preoperative MUCP was associated with cure after retropubic [RR 0.67; 95% confidence interval (CI) 0.47-0.97)] and transobturator slings (RR 0.65; 95% CI 0.49-0.90). High preoperative VLPP was also associated with cure after retropubic sling (RR 0.89; 95% CI 0.82-0.96), but this relationship did not achieve statistical significance for cure after transobturator sling (RR 0.86; 95% CI 0.74-1.00).

CONCLUSIONS

Preoperative MUCP and VLPP values may add insight into postoperative outcomes after surgical treatment for SUI.

Effect of acupressure in treating urodynamic stress incontinence: a randomized controlled trial

The efficacy of acupressure therapy in managing urodynamic stress incontinence has not been fully investigated. This study evaluates the effects of a validated acupressure protocol for treating women with urodynamic stress incontinence. A randomized, single-blinded, placebo-controlled trial with a before-and-after study design was conducted. Eighty-one women aged between 18 and 60 were recruited at a urogynecology clinic in an acute hospital in Hong Kong. Participants were randomly assigned to an intervention (acupressure) group, a sham group, or a usual care (control) group. A validated acupressure protocol was employed in the intervention group. The intervention comprised three weekly sessions of 30 minutes each for a total of thirty sessions. Outcome measures included pelvic floor muscle strength, number of episodes of urine leakage over four days, self-reported severity of urine leakage, and responses on the Chinese version of the King's Health Questionnaire. No adverse effects were reported. Five percent of the participants dropped out of the study. Intention-to-treat analysis was conducted, the results indicated significant differences in pelvic floor muscle strength across the three groups (H =7.05, p =0.03) and in self-reported severity of urine leakage between the intervention and control groups (Z = -2.48, p = 0.01). Significant improvement in all domains of the Chinese version of the King's Health Questionnaire was evident in the intervention group. Acupressure is a simple and non-invasive intervention that appears to have positive physiological and psychological effects on women with urodynamic stress incontinence. The findings support acupressure as an intervention option for managing urodynamic stress incontinence in women.

[Urodynamic aspects of feminine urinary incontinence treated with slings]

OBJECTIVES

Treatment of feminine stress urinary incontinence (SUI) with slings aims to supplement the function of the damaged ligaments, favoring the correct transmission of the tensions. Our objective is to determine which preoperative variables could predict the outcome of surgical treatment of SUI and to study the urodynamic changes produced by the surgery.

MATERIAL AND METHODS

139 women (age X =61.7; σ=10.88) operated on due to SUI were studied retrospectively. In 118 cases (84.8%), sling techniques (TVT, TOT, TVT-Safyre, REEMEX) were used. Clinical evaluation and complete preoperative video -urodynamics were made pre-operatively and at 3 months of surgery. A statistical study (Fisher's test, Wilcoxon, Friedman, Student's T and Pearson's χ(2)) and analysis of multivariant logistic regression analysis by step elimination method were performed.

RESULTS

Post-operatively, the SUI (p=0.000) and bladder hyperactivity syndrome decreased. The success percentages (urodynamic absence of SUI) for each technique were: TVT-Safyre (75%), TOT (73%), TVT (60%) and REEMEX (57%), without significant differences. Age (ROC cut-off: 61 years) was a prognostic factor of success (p=0.024). Preoperative maximum flow (Qmax) (16 ml/s) constituted the only urodynamic parameter with a predictive value for success (p=0.026). An open bladder neck was a risk factor for persistence of postoperative SUI (RR=2.78). A significant decrease of the postsurgical Qmax (p=0.017) was verified, without increase of the post micturation residue or of the Wmax. An increase of the postsurgical urethral resistance (UR) was also observed (p=0.004).

CONCLUSIONS

The pre-operative Qmax is the most important urodynamic prognostic parameter in feminine SUI surgery, its normality being associated to a greater probability of cure of the incontinence. In the cases of decreased preoperative flow, use of slings that increase urethral resistance more (REEMEX) is not recommended. Hyperactivity of the preoperative detrusor does not significantly modify the results of surgery of the SUI.

Evaluation of transvaginal slings using different materials in the management of female stress urinary incontinence

PURPOSE

To evaluate tailored polypropylene (prolene) mesh, anterior rectus sheath, and vaginal wall slings positioned under the mid-urethra, to treat stress urinary incontinence (SUI) in women, as SUI is a common pathological condition causing considerable distress and compromising social, physical, psychological, and sexual health, and for which surgical treatment remains controversial.

PATIENTS AND METHODS

This prospective randomised study included 32 patients with SUI, evaluated by SEAPI (Stress, Emptying, Anatomy, Protection, and Instability) symptom score and urodynamics. According to sling material, 12 patients had tailored prolene mesh, 12 had anterior rectus sheath and eight had anterior vaginal wall slings. Operative variables (intraoperative bleeding, duration, complications and hospital stay) were documented, and postoperative complications and continence status were assessed. The follow-up was 12-18 months.

RESULTS

Patients who received tailored prolene mesh slings had a lower operative duration and hospital stay, and less intraoperative bleeding. Postoperative complications, e.g. urinary retention and urgency, were <12%, with no significant differences. There was no significant difference among the three studied groups in the success rate (75%, 67% and 75%).

CONCLUSIONS

Tailored prolene mesh, anterior rectus sheath and the vaginal wall sling are good alternatives to treat SUI in women, with comparable results in a short-term follow up. The surgeon's experience and the patient's clinical circumstances should be considered when choosing a sling material, as success rates are comparable, being slightly better for the prolene sling in operative duration, bleeding and hospital stay.

Epidemiology of mixed urinary incontinence in China

OBJECTIVES

To determine the prevalence and risk factors for mixed urinary incontinence (MUI) among Chinese women.

METHOD

In this cross-sectional survey study we analyzed the answers to a modified Bristol Female Lower Urinary Tract Symptoms questionnaire provided by 19024 women older than 20 years and from 6 regions in China.

RESULTS

The overall prevalence of MUI was 9.4%. The prevalence of MUI increased with age and reached 24.1% among women older than 70 years. Multivariable logistic regression analysis revealed that age, vaginal delivery, chronic constipation, pelvic organ prolapse, chronic pelvic pain, respiratory system disease, menstrual disorder, urinary system disease, alcohol consumption, pelvic surgery, obesity, and a low educational level were independent risk factors for MUI.

CONCLUSION

We found age, vaginal delivery, and chronic constipation to be the main risk factors for MUI among adult women in China.

Neurobiology of stress urinary incontinence: New insights and implications for treatment

Stress urinary incontinence (SUI) is a significant problem for millions of women, many of whom remain untreated for years, sometimes for life. One reason for this is the lack of effective pharmacologic therapy. The drugs used for urge incontinence have little or no effect on leakage occurring without detrusor contraction under conditions of increased intra-abdominal pressure. Recent studies suggest that extrinsic urethral sphincter closure may be controlled by enhancing neurotransmission in pudendal pathways. A new agent, duloxetine, which inhibits serotonin-norepinephrine re-uptake in these pathways, is now in clinical trials and appears to be the first effective pharmacologic therapy for SUI.

Do women with pure stress urinary incontinence need urodynamics?

OBJECTIVES

To evaluate the value of performing urodynamic investigations in the assessment of women with a history of pure stress urinary incontinence (SUI).

METHODS

Consecutive women with lower urinary tract symptoms were studied retrospectively. Urinary symptoms were determined from the frequency-volume chart and symptom section of the King's Health Questionnaire. Only women with pure SUI symptoms were included.

RESULTS

A total of 3428 women aged 24-81 years were studied. Only 308 women (8.9%) could be classified as having pure SUI from the questionnaire. Of these, 241 of women (78.2%) had urodynamic stress incontinence, 23 women (7.5%) had detrusor overactivity, 9 women (2.9%) had mixed urodynamic diagnosis, and 35 women (11.4%) had inconclusive urodynamics. Postvoid residual volumes greater than 100 mL were noted in 24 (7.8%) women.

CONCLUSIONS

Our results show that urodynamic investigations provide useful information in the assessment of women with a history of pure SUI, because as many as 20% of them might not need surgery as the first line of treatment.

Ultrassonografia uretrovesical como método eficaz de avaliação dos parâmetros prognósticos de tratamento cirúrgico da incontinência urinária de esforço

OBJETIVO: Comparar parâmetros ultrassonográficos relacionados à junção uretrovesical e uretra proximal em pacientes curadas e não curadas, tratadas cirurgicamente pela técnica de Burch, com a finalidade de estabelecer se há correspondência com fatores prognósticos. MATERIAIS E MÉTODOS: Trinta pacientes foram selecionadas e divididas em dois grupos: 15 consideradas clinicamente curadas e 15 consideradas não curadas. As pacientes foram submetidas a ultrassonografia transvulvar no pré-operatório e aos 30 e 180 dias do pós-operatório. RESULTADOS: No pré-operatório, o deslocamento da uretra proximal foi maior nas pacientes curadas (15,87 ± 4,55 mm × 12,47 ± 3,52 mm - p < 0,05). No pós-operatório, no esforço, a distância vertical da junção uretrovesical e a uretra proximal foram maiores nas pacientes curadas (12,87 ± 5,80 mm × 5,13 ± 6,55 mm - p < 0,01; e 13,07 ± 6,44 mm × 6,20 ± 6,14 mm - p < 0,01), e o deslocamento vertical da junção uretrovesical e da uretra proximal foi maior nas pacientes não curadas (8,47 ± 3,98 mm × 5,13 ± 2,36 mm - p < 0,001; e 8,33 ± 4,54 mm × 5,20 ± 2,90 mm - p < 0,05). CONCLUSÃO: A ultrassonografia da junção uretrovesical e da uretra proximal pode ser considerada como um método eficaz de avaliação dos parâmetros prognósticos do tratamento cirúrgico de mulheres com incontinência urinária de esforço.

Symptomatic stress urinary incontinence not demonstrated clinically: survey of practice patterns

The aim of this study was to survey obstetrician/gynecologists and urologists regarding management of women undergoing hysterectomy with complaints of stress urinary incontinence (SUI) not demonstrated clinically. A survey was distributed electronically to military healthcare system OB/GYN and urologist physicians. Overall descriptive data and responses analyzed according to respondent demographics and the presence or absence of pelvic organ prolapse are reported. Two-hundred forty-two responses were obtained (44% response rate). Without prolapse, only 32% would perform an anti-incontinence procedure, more often by urologists than OB/GYN physicians. With prolapse, more respondents would perform an anti-incontinence procedure (32% increasing to 59%, p < 0.001). A mid-urethral sling was the most common procedure that was offered. Trainee versus attending status and teaching versus non-teaching responsibilities did not affect responses. There is no consensus among military obstetricians/gynecologists and urologists regarding management of women otherwise undergoing pelvic surgery with subjective SUI. The presence of prolapse influences this decision.

Urodynamics in the management of female stress incontinence--which test and when?

PURPOSE OF REVIEW

This article reviews the literature from the last 12 months in the context of our existing knowledge base and reviews the contentious issue of the role of preoperative urodynamics for stress urinary incontinence, with particular reference to the choice of urodynamic investigations for diagnostic differentiation between intrinsic sphincter deficiency and urethral hypermobility, assessing symptom severity and predicting postoperative prognosis.

RECENT FINDINGS

While there are significant conflicting data regarding the role of urodynamics, particularly in the functional assessment of the urethra, it is clear that these diagnostic techniques can provide clinically useful data. It is in this context that recent guidelines advising on restricted use of invasive urodynamics preoperatively should be carefully reviewed.

SUMMARY

There is a pressing need for randomized controlled trials to be performed to fully assess the role of urodynamics in the preoperative assessment of stress urinary incontinence, especially at this time of rapid change in the surgical treatments available.

[Urodynamic study in the female urinary incontinence evaluation, with the new MoniTorr MR system (non-multichannel urodynamic with urethral retro-resistance pressure measure). Experience with 100 patients]

OBJECTIVE

To compare the clinical diagnosis of the urinary incontinence with the results of LPP and URP obtained by non-multichannel urodynamic. To evaluate the tolerance of the patients to this examination.

PATIENT AND METHOD

Between August and December 2006, 100 urodynamics were made in patients with clinical diagnosis of urinary incontinence, in the Urogynecology Unit of Clinica Las Condes. The clinical diagnosis was compared with the urodynamic results. A subjective tolerance scale was applied (0 was greater tolerance and 10 was maximum discomfort).

RESULTS

In 66 patients with clinical diagnosis of IUS, the urodynamic registered 10 Type 0, 2 (I), 23 (II), 1 (III), 17 (II+III), 1 hyperactive detrusor, 5 (0+ hyperactive detrusor). 3 (II+hyperactive detrusor) and 4 (II+III+hyperactive detrusor). In 15 with Mixed urinary incontinence, the urodynamic showed 6 (Type 0), 2 (II), 2 (II+III), 3 hyperactive detrusor, 1 (II+hyperactive detrusor) and 1 (III+hyperactive detrusor). In 16 patients with urgency incontinence, urodynamic showed 2 normal, 4 (II+III), 7 hyperactive detrusor, 1 (II+hyperactive detrusor) and 2 (II+III+hyperactive detrusor). In 3 patients (two vaginal cuff prolapse and one cistocele, degree IV POP-Q) the urodynamic was indicated in the pre-surgery study considering a great potentially incontinence after correction. Respectively, the patients presented: IUS type III+hyperactive detrusor, IUS type II+III and one normal. All patients expressed 2 and 3 degree tolerance (subjective scale: 1 major tolerance and 10 a minor tolerance).

CONCLUSIONS

The MoniTorr MR urodynamic is a complementary examination very useful in the study of the urinary incontinence. It allows planning the solution adapted for each case and has a high degree of tolerance in the patients.

Mixed incontinence is more bothersome than pure incontinence subtypes

The purpose of the study was to compare incontinence bother in women with mixed incontinence versus pure incontinence subtypes. This is an institutional review board-approved study comparing physical exam findings and responses to the Medical Epidemiologic and Social Aspects of Aging (MESA) questionnaire and the Urinary Distress Inventory (UDI-6). The MESA responses were used to classify women as mixed, pure stress, or pure urge incontinence. This analysis includes 551 women with a mean age of 56 +/- 16 years. Most women were Caucasian (86%) with 7% African American and 5% Hispanic. UDI scores were significantly higher in women with mixed incontinence (61 +/- 23) than those with pure stress incontinence (40 +/- 26) or pure urge incontinence (40 +/- 25; p < 0.0001). Women with mixed incontinence report greater incontinence bother than women with either pure stress or urge incontinence.

Duloxetine compared with placebo for the treatment of women with mixed urinary incontinence

AIMS

Evaluate duloxetine in the treatment of women with mixed urinary incontinence (MUI).

MATERIALS AND METHODS

588 women, 19-85 years old with >or=4 incontinence episodes/week were randomly assigned to duloxetine 80 mg/day (N = 300) or placebo (N = 288). Patients were classified into three symptom subgroups: stress or urge predominant MUI (SPMUI or UPMUI) or balanced MUI (BMUI) based on their responses to the validated Stress/Urge Incontinence Questionnaire. Half the population was randomly assigned to have urodynamics; SPMUI, UPMUI, and BMUI condition diagnoses were based on signs, symptoms, and urodynamic observations. The primary outcome measure was the change in incontinence episode frequency (IEF). Secondary outcome measures included the Incontinence Quality of Life (I-QOL) scores, the ICI Quality of Life (ICIQ-SF) score, and the Patient Global Impression of Improvement (PGI-I) rating.

RESULTS

At baseline, women with SPMUI averaged 15.9 IEF/week (61% stress), those with UPMUI averaged 13.2 (70% urge), and those with BMUI averaged 16.5 (52% urge). Overall IEF decreases were significantly greater with duloxetine than placebo (median percent reduction 60% vs. 47%, P < 0.001); both UUI and SUI episodes were significantly decreased with duloxetine (median SUI IEF reduction 59% vs. 43%, P = 0.001; UUI IEF reduction 58% vs. 40%, P < 0.001). Duloxetine IEF decreases were significantly greater for patients with SPMUI conditions and symptoms and for those with UPMUI conditions but not symptoms. Significant benefits were also demonstrated with duloxetine for improvements in I-QOL total score (11.5 points vs. 8.1 points, P = 0.002), all three I-QOL subscale scores, and for the ICIQ-SF score (-2.6 vs. -1.7, P = 0.002) as well as for PGI-I ratings (much/very much better 44.2% vs. 27.3%, P = 0.001).

CONCLUSION

Duloxetine demonstrated significant efficacy in this population of women with MUI.

Are there differences between women with urge predominant and stress predominant mixed urinary incontinence?

OBJECTIVE

We sought to determine if there are differences in clinical and urodynamic parameters between women with urge predominant and those with stress predominant mixed urinary incontinence (MUI).

METHODS

Charts of 99 female patients with complaints of MUI were reviewed. Patients were divided into two groups based on the subjective predominance of either stress incontinence (MSUI) or urge incontinence (MUUI). All patients completed a subjective evaluation including an AUA Symptom Index, Urogenital Distress Inventory (UDI-6), and Incontinence Impact Questionnaire (IIQ-7). Objective non-invasive measures included physical exam, 48-hr voiding diary, and a 24-hr pad test. Videourodynamics studies (VUDS), performed in all patients, were reviewed and the presence and characteristics of detrusor overactivity (DO) and stress incontinence were noted.

RESULTS

There were no significant differences between groups with respect to symptom scores. MUUI patients had significantly higher pad usage, and lower maximum and average voided volumes than MSUI patients. They were also more likely to have lower urodynamic bladder capacities and demonstrable DO (70% vs. 26%) on VUDS with contractions occurring at lower bladder volumes and with higher amplitude. MSUI patients were more likely to have demonstrable SUI on physical examination (63% vs. 16%) and on VUDS (100% vs. 61%).

CONCLUSIONS

There do appear to be differences in clinical and urodynamic parameters between patients with stress predominant and urge predominant MUI. These may help to determine which component of the mixed incontinence is more problematic.

Reliability and Agreement of Urodynamics Interpretations in a Female Pelvic Medicine Center

OBJECTIVE

To estimate the reliability and interobserver consistency of urodynamic interpretations of female bladder and urethral function.

METHODS

Three urogynecologists and three female urologists at a tertiary care medical center reviewed masked, abstracted clinical and urodynamic information from 100 charts, selected for adequate completeness from a consecutive series of 135 women referred for urodynamic testing. For each of the 100 cases, the reviewers assigned International Continence Society filling and voiding phase diagnoses, and overall clinical diagnoses. Raw agreement proportions and weighted kappa chance-corrected agreement statistics (kappa) were used jointly to describe both reliability and interobserver agreement. Reliability was estimated from duplicate reviews, masked and separated by at least 4 months, of each case by each physician. Interobserver agreement was estimated from comparisons of all pairs of responses from different physicians.

RESULTS

For clinical diagnosis of stress incontinence (present, absent, indeterminate), the within- and across-physician weighted kappa's were, respectively, 0.78 and 0.68. Corresponding results were 0.40 and 0.13 for detrusor overactivity without incontinence, 0.58 and 0.38 for detrusor overactivity with incontinence, and 0.51 and 0.26 for voiding dysfunction. Standard errors of each kappa were between 0.023 and 0.043.

CONCLUSION

In our group, lower urinary tract diagnoses of stress urinary incontinence from both clinical and urodynamic data demonstrated substantial reliability and interobserver agreement. However, by conventional interpretation of kappa-statistics, reliability of diagnoses of detrusor overactivity or voiding dysfunction was only moderate, and interobserver agreement on these diagnoses was no better than fair. Urodynamic interpretations may not be satisfactorily reproducible for these diagnoses.

The puzzle of overactive bladder: controversies, inconsistencies, and insights

Overactive bladder (OAB) affects millions of individuals and may severely impair the quality of life of those affected. The contribution of human behavior to manifestations of this symptom complex remains poorly understood. Continued evolution of our understanding of the pathophysiology of OAB has identified contributory mechanisms, which in turn may open new therapeutic avenues. Recent improvements in drug delivery systems represent advances in the management of OAB. However, more complete symptom control with greater tolerability is desirable; this awaits the development of agents specific for newly emerging and as yet unidentified pathophysiologic pathways. Importantly, as understanding of outcomes assessment in OAB matures, refined assessments of disease severity, response to intervention, and patient preference should be possible.

Pharmacological Management of Women with Mixed Urinary Incontinence

Mixed urinary incontinence (MUI) is a symptomatic diagnosis. It is defined by the International Continence Society as the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing and coughing. A search of medical databases revealed that only a small number of limited studies that assess the prevalence, epidemiology and treatment of MUI have been conducted. Most studies have looked separately at either stress urinary incontinence or urgency urinary incontinence. Thus, management of MUI involves a combination of treatments for both stress and urgency incontinence, but should concentrate initially on the most bothersome and/or predominant symptom. Initial management includes an accurate history and examination, which is supplemented by a bladder diary and quality-of-life questionnaire. Once a preliminary diagnosis is established, first-line therapy includes patient education and lifestyle interventions, such as weight loss. This is supplemented by pelvic floor muscle training and bladder training, which help with both components of MUI. Oral pharmacotherapy often acts synergistically with the previous treatments; however, only very few randomised, placebo-controlled trials have looked at the effects of pharmacotherapy on MUI. The two main classes of drugs are the antimuscarinics, which are effective in urgency incontinence, and the serotonin-norepinephrine re-uptake inhibitors, which are effective in stress incontinence. Combination of these two drug classes is a feasible option but has not been tested in any trials to date. Should these treatments fail, then patients should be referred for cystometry to confirm the diagnosis. Treatment options available following urodynamics include invasive minor and major surgical procedures, which either treat the stress or urgency component of MUI but not both. Surgical procedures carry the risk of infection, haemorrhage and failure.

Secondary-care treatment patterns in the UK for women with urinary incontinence

OBJECTIVES

To describe the treatment trends for women with urinary incontinence (UI) after their referral from primary to secondary care, as despite the high prevalence of UI within the female population, relatively few women actively seek treatment for their UI and fewer reach secondary care.

PATIENTS AND METHODS

We retrospectively reviewed the notes of patients attending in two randomly selected months in five hospital sites in the UK. Records were identified through outpatient clinic lists, surgery lists, nursing and physiotherapy lists. Data were collated and analysed for trends.

RESULTS

In all, 412 women (mean age 54.6 years, SD 12.6) covering 1406 visits to secondary care were covered by the study. Most women had a symptomatic diagnosis of mixed UI and mild to moderate UI, as defined by their physician. Most women had conservative therapies by either continence nurses or physiotherapists, regardless of the severity of their condition; 73% had cystometry and 39% were recommended for surgical intervention.

CONCLUSIONS

Women largely undergo similar procedures in secondary care. Most present with mixed UI. The perceived severity of disease did not preclude a trial of conservative therapies.

Tension-free vaginal tape procedure with manual-tapping method: a potentially useful technique

AIM

Stress urinary incontinence (SUI) is accompanied by pelvic organ prolapse (POP) in many cases. We investigate a procedure to adjust the level of suspension of the mid-urethra using tension-free vaginal tape (TVT) under general anesthesia at the time of POP repair surgery.

METHODS

Preliminary examination carried out prior to this study showed that the pressure stress applied by a surgeon is less than half of that induced using the cough-stress method: the manual-tapping method (MTM) showed an average intravesical urinary leak point pressure (IULPP) of 21.4 mmHg (range 19-23 mmHg), when the cough-stress method demonstrated an average IULPP >52.4 mmHg (range 45-58 mmHg; n = 3). An attempt was made to predict postoperative SUI by packing sponge gauze into the manually replaced vagina preoperatively. If SUI appeared, TVT was added to the repair operation for POP in those patients (n = 11). Lastly, the MTM was used to decide the level of urethral suspension during the TVT procedure following POP repair surgery under general anesthesia (n = 11).

RESULTS

Eleven patients underwent the TVT procedure combined with POP repair surgery. The mean postoperative follow-up period was 23.8 months (range 9-40 months). There was no case of post-surgical ischuria. One patient showed a cystocele during the postoperative course. However, all other patients were relieved from the symptoms of POP, and none complained of SUI following the procedure.

CONCLUSION

The MTM seems to be a more appropriate indicator by which to adjust the level of urethral suspension during the TVT procedure than the conventional method, particularly under general anesthesia. To prevent and cure perioperative SUI, the MTM as a TVT procedure combined with POP repair surgery under general anesthesia is a useful procedure.

Stress urinary incontinence in the gynecological practice

This review discusses the prevalence, risk factors, the impact on the quality of life and healthcare-seeking behavior of women suffering from urinary incontinence (UI) and stress urinary incontinence (SUI) in particular. UI is a common problem, affecting women in all age groups, and has devastating effects on their social, professional and family life. UI may be manifest as stress urinary continence (SUI), i.e. 'the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing'. SUI is the most common form of UI, reported by approximately 50% of the incontinent women. Alternatively, patients may suffer from urge urinary incontinence (UUI), characterized by the 'complaint of involuntary leakage accompanied or immediately preceded by urgency'. This is reported by 10-20% of incontinent women. Patients having symptoms of both disorders may be afflicted by mixed urine incontinence (MUI), being reported by 30-40% of incontinent women. This complaint was recently included in the definitions as: 'Involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing'. Urodynamic studies show that the prevalence of SUI is underestimated when based on symptoms alone, as many patients with mixed symptoms have pure SUI during urodynamics. Although the etiology of SUI is still poorly understood, among the main risk factors are age, pregnancy, childbirth and obesity. Unfortunately, the majority of the patients suffering UI postpones looking for medical help for years, or may even never consult a physician regarding their problem, despite the considerable negative impact on their quality of life. Feelings of shame and embarrassment play an important role in this, in combination with the common belief that UI is a normal and inevitable consequence of the aging process. Clearly, there is still a long way to go in making patients and society aware of the fact that UI is a disorder, which can and should be treated. Consequently, patients must be encouraged to report their problem, while health care providers should raise the issue on routine exams in risk groups.

Stress Urinary Incontinence in Active Elderly Women

Urinary incontinence in the elderly is a significant health problem fraught with isolation, depression, and an increased risk of institutionalization and medical complications. Stress urinary incontinence (SUI), the complaint of involuntary loss of urine during effort or exertion or during sneezing or coughing, is the most common type of urinary incontinence. SUI can seriously degrade the quality of life for many active seniors, and has become an economic challenge for society. With the rapid increase in the active elderly worldwide, SUI is becoming a significant global problem. However, since only a fraction of women with SUI have consulted a physician, the clinical extent and public health impact of SUI are probably underestimated. The mounting social, medical, and economic problem of SUI in active elderly women as a rapidly growing segment of the population worldwide is reviewed. We evaluate the age-related changes of the lower urinary tract, examine risk factors, and suggest different treatment options shown to be effective in reducing SUI in this population.

Relationship between urinary symptoms reported in a postal questionnaire and urodynamic diagnosis

AIMS

To describe the relationship between symptoms reported in a self-completed postal questionnaire and urinary disorders based on urodynamic investigation.

METHODS

The study population was selected from women aged 40 years or over living in the community, who responded to a postal questionnaire. Following assessment and appropriate conservative interventions, those with a pre-defined level of severity of symptoms were offered urodynamic investigation. Logistic regression examined the association between urinary symptoms and the urodynamic diagnoses of detrusor overactivity (DO) and urodynamic stress incontinence (USI).

RESULTS

Four hundred eighty-eight women completed urodynamic investigation; 29.1% (142/488) were found to have DO, 33.6% (164/488) USI, 20.7% (101/488) mixed incontinence, and 16.6% (81/488) no urodynamic abnormality. Stress incontinence (SI) and urge incontinence (UI) were included in the risk model for USI. SI reported monthly or more was associated with increased risk of USI, and UI reported weekly or more with decreased risk (sensitivity 76.9%; specificity 56.3%; positive predictive value (PPV) 67.8%). For DO, strong or overwhelming urgency, UI monthly or more, and nocturia once a night or more were all significantly associated with an increased risk while reporting of SUI monthly or more reduced the risk (sensitivity 63.1%; specificity 65.1%; PPV 63.1%).

CONCLUSIONS

Urinary symptoms reported in a postal questionnaire are able to predict urodynamic diagnoses with moderate accuracy. These models may be useful tools with which to categorize urinary disorders for epidemiological study and, with further development, allocate first line treatment.

Effect of duloxetine on tolterodine pharmacokinetics in healthy volunteers

AIM

To investigate the effect of duloxetine on the pharmacokinetics and tolerability of tolterodine and its active 5-hydroxymethyl metabolite (5-HM).

METHODS

Sixteen healthy subjects received two 5-day treatment regimens in a randomized, double-blinded, crossover fashion: tolterodine (2 mg, BID) + duloxetine (40 mg, BID), tolterodine (2 mg, BID) + duloxetine placebo (BID). Plasma concentrations of tolterodine and 5-HM were measured on day 5. Adverse events, clinical safety laboratory data and vital signs were assessed during the study.

RESULTS

Duloxetine increased the AUC(tau,ss) of tolterodine by 71%[geometric mean, 95% confidence interval (CI) 31, 123], and its C(max,ss) by 64% (CI 30, 106), and prolonged its t(1/2) by 14% (CI 1, 28). Duloxetine did not affect the plasma concentrations or t(1/2) of 5-HM. Laboratory data and vital signs did not reveal any clinically significant changes or abnormalities.

CONCLUSIONS

Duloxetine exhibited minor inhibitory effects on the pharmacokinetics of tolterodine but not 5-HM. Coadministration of these drugs was well tolerated and demonstrated no significant safety findings in the studied population. These findings suggest that there should not be a need for routine adjustment of tolterodine dosage in the presence of duloxetine.