Discriminant analysis of urethral pressure profilometry data for the diagnosis of genuine stress incontinence

Questionnaire-based somatosensory profiling in breast cancer survivors: are we there yet? Associations between questionnaires and quantitative sensory testing

PURPOSE

Pain and sensory disturbances are common side effects of breast cancer treatment. Differential somatosensory functioning may reflect distinct pathophysiological backgrounds and therapeutic needs. Aim was to examine whether questionnaires evaluating signs and symptoms related to somatosensory functioning correlate sufficiently with quantitative sensory testing (QST) in breast cancer survivors to warrant consideration for somatosensory profiling in clinical practice.

METHODS

One year after breast cancer surgery, 147 women underwent QST and completed following questionnaires: Douleur Neuropathique en 4 questions (DN4), Central Sensitization Inventory, Margolis Pain Diagram and Visual Analog Scales (VAS). Associations between the questionnaires and QST were evaluated using Spearman correlation coefficients (rs).

RESULTS

Significant but weak (rs < 0.30) correlations were found between total DN4 score and QST results at the inner upper arm for detection of sharp stimuli (rs = 0.227), cold stimuli (rs = -0.186), and painful heat stimuli (rs = 0.179), as well as between QST evaluating conditioned pain modulation and the Margolis Pain Diagram on one hand (rs = 0.176) and minimum-maximum pain intensity differences (VAS) on the other (rs = -0.170).

CONCLUSION

Questionnaires evaluating signs and symptoms related to somatosensory functioning are insufficient for somatosensory profiling. Although somatosensory profiling may be valuable in a mechanism-based management, more research on the most appropriate clinical tools is needed.IMPLICATIONS FOR REHABILITATIONClinicians should be able to recognize that patients with persistent pain or sensory disturbances following breast cancer surgery may have a component of altered somatosensory processing as a significant contributor to their complaint in order to address it appropriately.Somatosensory profiling has yet to be implemented into clinical practice.No evidence-based recommendations can be made on the use of self-reported questionnaires to assess somatosensory processing in a breast cancer population based on the findings of this study.It is suggested to combine information on how individuals process and experience somatosensory stimulation with information from the patient interview or questionnaires to consider which biological, psychological and/or social factors may drive or sustain these neurophysiological processes.

Differences between water-filled and air-charged urodynamic catheters for determining the urethral pressure profile in neurogenic lower urinary tract dysfunction patients

AIM

The maximum urethral closure pressure (MUCPs) and functional urethral length (FUL) obtained with water-filled and air-charged catheters during urethral pressure profile (UPP) determination was compared in a single, blind, randomized, and prospective trial.

METHODS

Thirty-three males with spinal cord injuries and neurogenic lower urinary tract dysfunction underwent UPP determinations using water-filled and air-charged catheters in random order; the patients were unaware of the catheter sequence. The variability of the same type of catheter and the agreement between the different types of catheters were compared. The Pearson correlation coefficient was used to check the correlation between the catheters and the Bland-Altman method was used to verify the agreement.

RESULT

The intraclass correlation coefficients for MUCPs and FULs determined using water-filled and air-charged catheters were 0.89, 0.75, 0.94, and 0.78, respectively. The interclass correlation coefficients for MUCPs and FULs between the two catheters were 0.43 and 0.28, respectively. Bland-Altman plots suggested that the values measured by air-charged catheters were significantly higher than water-filled catheters (mean difference, 26.0 and 2.4 cmH₂ O, respectively). There were wide 95% limits of agreement (-54.0 to 106.0 and -0.3 to 5.1 cmH ₂ O, respectively) that exceeded the clinical range for differences in MUCP and FUL.

CONCLUSION

Air-charged catheters usually give higher readings than water-filled catheters for UPP. Agreement between water-filled and air-charged catheters was not good. Nevertheless, the catheter type which is more relevant to the disease requires further study.

Investigating the validity of the DN4 in a consecutive population of patients with chronic pain

Neuropathic pain is clinically described as pain caused by a lesion or disease of the somatosensory nervous system. The aim of this study was to assess the validity of the Dutch version of the DN4, in a cross-sectional multicentre design, as a screening tool for detecting a neuropathic pain component in a large consecutive, not pre-stratified on basis of the target outcome, population of patients with chronic pain. Patients' pain was classified by two independent (pain-)physicians as the gold standard. The analysis was initially performed on the outcomes of those patients (n = 228 out of 291) in whom both physicians agreed in their pain classification. Compared to the gold standard the DN4 had a sensitivity of 75% and specificity of 76%. The DN4-symptoms (seven interview items) solely resulted in a sensitivity of 70% and a specificity of 67%. For the DN4-signs (three examination items) it was respectively 75% and 75%. In conclusion, because it seems that the DN4 helps to identify a neuropathic pain component in a consecutive population of patients with chronic pain in a moderate way, a comprehensive (physical-) examination by the physician is still obligate.

Trans-abdominal ultrasound shear wave elastographyfor quantitative assessment of female bladder neck elasticity

INTRODUCTION AND HYPOTHESIS

Disorders of micturition result from a wide variety of conditions and evaluation often involves multiple diagnostic modalities. However, the sensitivity and specificity of these techniques are highly variable and may not always yield a diagnosis. Novel imaging techniques such as ultrasound shear wave elastography may help to improve diagnostic accuracy.

METHODS

Continent women were recruited from outpatient gynecology offices from a tertiary medical system. Participants underwent ultrasound evaluation with measurement of the shear wave velocity (SWV) of the bladder neck (BN). SWV was used to determine the Young's modulus of the bladder neck. The median bladder neck stiffness was calculated and univariate and step-wise and backward multivariate logistic regression analyses were used to identify significant patient characteristics associated with bladder neck stiffness above or below the median.

RESULTS

Fifty-seven women underwent SWE of the bladder; 12 were excluded, and 45 were included in the analysis. The median bladder neck stiffness of the study population was 22 (17.1-28.2) kPa. Age greater than 45 years was associated with a bladder neck stiffness above the median, OR 8.39, p < 0.001. Having no vaginal deliveries was also associated with a bladder neck stiffness greater than 22 kPa, unadjusted OR 4.76 (95 % CI 1.41-20.0, p = 0.012). Bladder volume and bladder neck thickness were not significantly associated with bladder neck stiffness above or below the median.

CONCLUSION

Trans-abdominal shear wave elastography can be used to quantitatively assess bladder neck stiffness. This technique may potentially be useful for evaluating chronic urinary retention.

Comparison of Perineal Sonographically Measured and Functional Urodynamic Urethral Length in Female Urinary Incontinence

Objectives. To detect the anatomical insufficiency of the urethra and to propose perineal ultrasound as a useful, noninvasive tool for the evaluation of incontinence, we compared the anatomical length of the urethra with the urodynamic functional urethral length. We also compared the urethral length between continent and incontinent females. Methods. 149 female patients were enrolled and divided into four groups (stress, urge, or mixed incontinence; control). Sonographically measured urethral length (SUL) and urodynamic functional urethral length (FUL) were analyzed statistically. Standardized and internationally validated incontinence questionnaire ICIQ-SF results were compared between each patient group. Results. Perineal SUL was significantly longer in incontinent compared to continent patients (p < 0.0001). Pairwise comparison of each incontinent type (stress, urge, or mixed incontinence) with the control group showed also a significant difference (p < 0.05). FUL was significantly shorter in incontinent patients than in the control group (p = 0.0112). But pairwise comparison showed only a significant difference for the stress incontinence group compared with the control group (p = 0.0084) and not for the urge or mixed incontinent group. No clear correlation between SUL, FUL, and ICIQ-SF score was found. Conclusions. SUL measured by noninvasive perineal ultrasound is a suitable parameter in the assessment of female incontinence, since incontinent women show a significantly elongated urethra as a sign of tissue insufficiency, independent of the type of incontinence.

Signal processing in urodynamics: towards high definition urethral pressure profilometry

BACKGROUND

Urethral pressure profilometry (UPP) is used in the diagnosis of stress urinary incontinence (SUI) which is a significant medical, social, and economic problem. Low spatial pressure resolution, common occurrence of artifacts, and uncertainties in data location limit the diagnostic value of UPP. To overcome these limitations, high definition urethral pressure profilometry (HD-UPP) combining enhanced UPP hardware and signal processing algorithms has been developed. In this work, we present the different signal processing steps in HD-UPP and show experimental results from female minipigs.

METHODS

We use a special microtip catheter with high angular pressure resolution and an integrated inclination sensor. Signals from the catheter are filtered and time-correlated artifacts removed. A signal reconstruction algorithm processes pressure data into a detailed pressure image on the urethra's inside. Finally, the pressure distribution on the urethra's outside is calculated through deconvolution. A mathematical model of the urethra is contained in a point-spread-function (PSF) which is identified depending on geometric and material properties of the urethra. We additionally investigate the PSF's frequency response to determine the relevant frequency band for pressure information on the urinary sphincter.

RESULTS

Experimental pressure data are spatially located and processed into high resolution pressure images. Artifacts are successfully removed from data without blurring other details. The pressure distribution on the urethra's outside is reconstructed and compared to the one on the inside. Finally, the pressure images are mapped onto the urethral geometry calculated from inclination and position data to provide an integrated image of pressure distribution, anatomical shape, and location.

CONCLUSIONS

With its advanced sensing capabilities, the novel microtip catheter collects an unprecedented amount of urethral pressure data. Through sequential signal processing steps, physicians are provided with detailed information on the pressure distribution in and around the urethra. Therefore, HD-UPP overcomes many current limitations of conventional UPP and offers the opportunity to evaluate urethral structures, especially the sphincter, in context of the correct anatomical location. This could enable the development of focal therapy approaches in the treatment of SUI.

A novel automated detection system for swallowing sounds during eating and speech under everyday conditions

The wave analysis of swallowing sounds has been receiving attention because the recording process is easy and non-invasive. However, up until now, an expert has been needed to visually examine the entire recorded wave to distinguish swallowing from other sounds. The purpose of this study was to establish a methodology to automatically distinguish the sound of swallowing from sound data recorded during a meal in the presence of everyday ambient sound. Seven healthy participants (mean age: 26·7 ± 1·3 years) participated in this study. A laryngeal microphone and a condenser microphone attached to the nostril were used for simultaneous recording. Recoding took place while participants were taking a meal and talking with a conversational partner. Participants were instructed to step on a foot pedal trigger switch when they swallowed, representing self-enumeration of swallowing, and also to achieve six additional noise-making tasks during the meal in a randomised manner. The automated analysis system correctly detected 342 out of the 352 self-enumerated swallowing events (sensitivity: 97·2%) and 479 out of the 503 semblable wave periods of swallowing (specificity: 95·2%). In this study, the automated detection system for swallowing sounds using a nostril microphone was able to detect the swallowing event with high sensitivity and specificity even under the conditions of daily life, thus showing potential utility in the diagnosis or screening of dysphagic patients in future studies.

Urethral retro-resistance pressure: association with established measures of incontinence severity and change after midurethral tape insertion

AIMS

Our study explored the relationship between URP and established measures of incontinence severity. We also report on change in URP after insertion of midurethral tape (MUT).

METHODS

All participants had incontinence secondary to urodynamic stress incontinence only. URP was measured using the Monitorr (Gynecare) device prior to and 3 months after MUT insertion. The following measures of incontinence severity were completed before and 3 months after insertion of MUT: 24-hour pad test; International Consultation on Incontinence Questionnaire for evaluating symptoms and impact of urinary incontinence; King's Health Questionnaire for evaluating disease-specific quality of life and a 3-day urinary dairy with episodes of incontinence recorded.

RESULTS

Preoperative URP and measures of incontinence severity were available for 100 women. Mean URP bore no relationship to the severity of urine loss assessed by 24-hour pad loss. There was no correlation between URP and other measures of incontinence severity. Pre and postoperative URP was available in 73 women. Although 84.9% were objectively cure (24-hour pad test of <5 g) after surgery, pre and postoperative URP was not significantly different [62.7 (+/-19.4) cmH(2)O vs. 61.2 (+/-204) cmH(2)O; p = 0.57].

CONCLUSIONS

Urethral retro-resistance pressure is not a useful measure of urethral function.

Urethral pressure measurement in stress incontinence: does it help?

INTRODUCTION AND OBJECTIVES

The resting urethral pressure profile (UPP), used for the assessment of women with stress incontinence, is routine in many urodynamic units. It is time- and effort-consuming, and its diagnostic value is controversial, as well as its value in the prediction of outcome of anti-incontinence surgery. Herein, we assessed its value in the prediction of the outcome of surgery.

PATIENTS AND METHODS

Sixty women were randomized to fascial sling or TVT. Urodynamics were performed preoperatively, 6 months and annually thereafter. After filling and voiding cystometry, resting UPP was performed while sitting. Automated catheter pulling, at a rate of 1 mm/s, was adopted. Averaged readings were obtained. Comparison of maximum urethral closure pressure (MUCP) in success and failure, as well as in sling and TVT, was performed, utilizing ANOVA.

RESULTS

Preoperative MUCP and functional urethral length (FUL) were 72.9 +/- 27.9 cmH2O and 2.4 +/- 0.7 cm. At last follow-up, they were 71.1 +/- 20.7 cmH2O and 2.7 +/- 0.7 cm, respectively. The differences between sling and TVT as regards value of MUCP and FUL were not significant. The relationship of the outcome of surgery and UPP parameters showed no statistical difference. No significant effect was shown for the success of surgery, duration of follow-up, and interaction of outcome and time over MUCP (P = 0.82, 0.56 and 0.69, respectively) or FUL (P = 0.82, 0.11 and 0.67, respectively).

CONCLUSION

The routine use of resting UPP has no added value in terms of the prediction of success of incontinence surgery. It does not help with follow-up and adds to the time and cost of the examination.

The correlation of urethral resistance pressure with maximum urethral closure pressure and stress incontinence

OBJECTIVE

Aim of the study was to correlate urethral retro resistance pressure with the maximum urethral closure pressure (MUCP) and functional urethral length (FUL) in patients with urinary incontinence and healthy individuals.

STUDY DESIGN

Two hundred and twenty patients with the complaint of urinary incontinence had a urodynamic examination including urethral pressure profiles and URP. Additionally, 15 healthy individuals without the complaint of any incontinence had their URP and urethral pressure profiles measured. The correlation of MUCP, FUL and URP were calculated using Graph Pad Instat 4.0 for windows.

RESULTS

URP correlates well with the diagnosis of urodynamic stress incontinence. Correlation coefficient between URP and MUCP is 0.9262. Healthy individuals have significantly higher values for URP and MUCP.

CONCLUSION

URP is a valuable less invasive test than conventional urethral function tests for the diagnosis of urodynamic incontinence with an excellent correlation of MUCP and URP.

Dynamic transurethral sonography and 3-dimensional reconstruction of the rhabdosphincter and urethra: initial experience in continent and incontinent women

OBJECTIVE

The purpose of this study was to evaluate the female urethra and the striated urinary sphincter, the rhabdosphincter (RS), by means of dynamic transurethral sonography and sonographic 3-dimensional (3D) reconstructions.

METHODS

In 15 female patients with urinary stress incontinence (mean age, 67.5 years) and 5 continent women (mean age, 48.3 years), morphologic characteristics and function of the RS and urethra were examined with a 10-MHz transurethral ultrasound transducer. With the help of a mechanical pullback system, the transducer was slowly retracted to scan the whole urethra and the RS from the bladder neck to the urethral orifice. Subsequently, 3D reconstructions of the urethra using an integrated computer system were performed. The RS as well as the length of the urethra were investigated under contracted and noncontracted conditions to measure contractility of the RS and dynamic changes of the lower urinary tract.

RESULTS

Partial or complete loss of RS function was detected in patients with stress incontinence. The findings on sonography were found to correlate well with the grade of incontinence. Furthermore, under contraction of the RS, a median increase in urethral length was observed. In incontinent patients, the increase in the urethral length was statistically significantly less (P = .04), which was related to the reduced contractility of the RS.

CONCLUSIONS

Dynamic transurethral sonography with subsequent 3D reconstructions allows for assessment of function and morphologic characteristics of the RS and urethra. Normal contraction of the RS results in an elongation of the urethra.

Systematic review and meta-analysis of methods of diagnostic assessment for urinary incontinence

AIMS

To evaluate the performance of all tests proposed for the diagnosis of urinary incontinence.

METHODS

A systematic review and meta-analyses of the published literature of methods for diagnostic assessment of urinary incontinence.

RESULTS

One hundred twenty-one papers were included in the full review [Martin et al., 2006]. The quality of reporting in the primary studies was poor which reduced the number of studies that could be included in the data analysis. The literature suggests that women with urodynamic stress incontinence (USI) can be correctly identified in primary care from clinical history alone with a sensitivity of 0.92 (95% C.I.: 0.91-0.93) and specificity of 0.56 (0.53-0.60). A clinical history for the diagnosis of detrusor overactivity (DO) was found to be 0.61 (0.57-0.65) sensitive and 0.87 (0.85-0.89) specific. Within secondary care imaging of leakage by ultrasound was found to be effective in the diagnosis of USI in women with a sensitivity of 0.89 (0.84-0.93) and specificity of 0.82 (0.73-0.89).

CONCLUSIONS

Clinical interpretation of the results of the review is difficult because few studies could be synthesized and conclusions made. The published evidence suggests that a large proportion of women with USI can be correctly identified in primary care from history alone. Ultrasound offers a useful diagnostic tool which could be used prior to, and possibly instead of, multi-channel urodynamics in some circumstances. If a patient is to undergo urodynamic testing, multi-channel urodynamics is likely to give the most accurate result. Further primary studies adhering to STARD guidelines are required on commonly used tests.

Urogynaecology: Urethral retro-resistance pressure and urodynamic diagnoses in women with lower urinary tract symptoms

OBJECTIVE

This study determines whether the retrograde urethral retro-resistance pressure (URP) measurement discriminates between urodynamic diagnoses in a group of women.

DESIGN

A prospective observational study.

SETTING

Urogynaecology units of three tertiary referral teaching hospitals.

POPULATION

Women with lower urinary tract symptoms.

METHODS

Consecutive women attending the urodynamic clinics of three tertiary referral teaching hospitals were studied using a validated urinary symptom questionnaire, URP measurement and urodynamic evaluation between February and July 2004. The URP mean values were compared with urinary symptoms and urodynamic diagnoses, using the independent t test correction for multiple measurements.

MAIN OUTCOME MEASURES

Retrograde URP, urodynamic diagnoses and urinary symptoms.

RESULTS

One hundred and eighty-five women were recruited. Women with urodynamic stress incontinence (USI) have significantly lower URP than women with competent urethral sphincters (P < 0.05, independent t test). Women with mixed urodynamic incontinence had values of URP intermediate between women with detrusor overactivity (DOA) and those with USI. In the mixed group, URP mean values were not significantly different from those with DOA and competent sphincters or USI (P > 0.05, independent t test). There was no significant difference between mean URP values and different urinary symptoms (P > 0.05, independent t test).

CONCLUSIONS

There are significantly different URP measurements between women with DOA and those with USI. However, the URP is not a diagnostic tool.

Primer: questionnaires versus urodynamics in the evaluation of lower urinary tract dysfunction—one, both or none?

What is the role of urodynamic assessments and have we made too much use of them? Is there a correlation between symptoms and underlying pathophysiology? These questions are addressed in this article. There are disparities in the assessment of lower urinary tract dysfunction between the accuracy of symptomatic assessment and the underlying pathophysiology. This is particularly evident with voiding symptoms, in contrast to storage symptoms, and has fuelled the debates that have resulted in the abandonment of the term 'prostatism' in favor of 'lower urinary tract symptoms', whereas the term 'overactive bladder syndrome' has been embraced as a storage symptom complex. Clearly, voiding disorders principally affect men, whilst storage disorders are more common in women. Much has been written and spoken about regarding the use of symptomatic assessment versus urodynamics in the assessment of lower urinary tract symptoms in men, whilst there has been a clearer consensus on the potential usefulness of urodynamics in the assessment of storage disorders, and so this article focuses principally on the latter topic.

Preoperative pressure-flow studies: useful variables to predict the outcome of continence surgery

OBJECTIVE

To determine whether the acceleration of flow rate (AFR), pressure flow variables and urethral pressure profilometry (UPP) measurements might have a role in evaluating women with urodynamic stress incontinence (USI), to predict the surgical outcome and de novo detrusor overactivity after Burch colposuspension.

PATIENTS AND METHODS

Women with a urodynamic diagnosis of USI (209) who had a modified Burch colposuspension were assessed retrospectively. The AFR, the opening (ODP) and closing detrusor pressure (CDP), DP at maximum flow rate and UPP values were calculated for each woman before surgery.

RESULTS

The preoperative AFR was significantly higher in women who developed de novo detrusor overactivity after surgery. The women who had persistent USI after colposuspension had significantly lower preoperative ODP and CDP than women who were continent after colposuspension. Other variables were not significantly different between the groups of women.

CONCLUSIONS

The AFR and ODP appear to be useful preoperative measures to predict the outcome of continence surgery and the emergence of de novo detrusor overactivity.

A critical review of diagnostic criteria for evaluating patients with symptomatic stress urinary incontinence

The first paper in this section is a review by several highly respected authors of diagnostic criteria for evaluating patients with symptomatic stress urinary incontinence, and is followed by a review of the role of urgency and its measurement in the overactive bladder symptom syndrome, with emphasis on current concepts and future prospects. These are two important papers, which point the reader in the direction of a greater understanding of these conditions. The concept of alpha-blockade before a trial without catheter after acute urinary retention is revisited by authors from the UK, who used tamsulosin in a randomized controlled trial. They found that it is appropriate to recommend tamsulosin for such use in this condition.

Air-charged and microtransducer urodynamic catheters in the evaluation of urethral function

This study aimed to compare measurements of urethral pressure profile and Valsalva leak point pressure (VLPP) obtained with air-charged and microtransducer catheters. Forty-five women with urogynecologic dysfunction underwent multichannel urodynamic evaluation including maximum urethral closure pressure (MUCP), functional urethral length (FUL), and VLPP with air-charged balloon catheters as well as microtransducer catheters. Lin's concordance coefficient was used to examine the agreement of MUCP, VLPP, and FUL measurements with the two catheters. The MUCPs measured with the two catheters had a high concordance coefficient of 0.69 (95% CI 0.50, 0.82). The VLPP measurements obtained with the catheters also agreed well, with a concordance coefficient of 0.71 (95% CI 0.43, 0.87). The measurements of mean FUL had a low concordance of 0.35 (95% CI 0.085, 0.57). Overall, air-charged and microtransducer catheters yield similar information when evaluating VLPP and MUCP. There were differences in FUL and these were likely due to different catheter diameters.

Urethral retro-resistance pressure: A new clinical measure of urethral function

AIMS

The urethral retro-resistance pressure (URP) is a new retrograde measurement of urethral function. URP is the pressure required to achieve and maintain an open sphincter. The assessment of any potential diagnostic measure must include an evaluation in individuals both with and without disease. In this study, we examined URP values in women without urinary incontinence.

METHODS

Four centers enrolled 61 women who did not report symptoms of urinary incontinence, and who had negative standing stress tests (SST). Each center was to perform three consecutive URP measurements on each subject. At two centers, 32 subjects returned in 3-7 days for three additional URP measurements. We compared the average URP in this asymptomatic population to the average URP from women symptomatic of stress urinary incontinence (SUI) derived from a previous study. We evaluated the within-subject variation of the URP measurement at a single visit and the within-subject change in URP over time using test and retest values.

RESULTS

The mean age was 33 +/- 9 years and the mean body mass index (BMI) was 24 +/- 6. URP values were normally distributed. The mean URP at visit 1 was 112.6 +/- 39.2 cm H2O (n = 60). This was statistically significantly different from the mean URP of symptomatic women (69.9 cm H2O, P < 0.0001). The within-subject standard deviation of URP at visit 1 was 12.6 +/- 12.6 cm H2O (n = 60) and at retest visit was 9.3 +/- 6.2 cm H2O (n = 32). For the retest cases, the mean URP at visit 1 was 113.9 +/- 39.9 cm H2O (n = 32) and at retest visit was 125.5 +/- 33.9 cm H2O (n = 32) (Wilcoxon Signed Rank test, P = 0.145).

CONCLUSIONS

The mean URP measurement obtained in this study of asymptomatic women showed significantly higher values when compared to our study in women with SUI. The URP measurements were consistent within the same subject. Furthermore, there was no statistically significant difference in the URP measurement from visit 1 to retest visit. The data suggest that URP shows promise as a physiological urethral pressure measurement.

Intrinsic urethral sphincteric deficiency: critical analysis of various diagnostic modalities

PURPOSE OF REVIEW

The proper diagnosis of intrinsic urethral sphincteric deficiency among women with urinary incontinence carries important implications for determining the most effective medical or surgical therapy. Numerous diagnostic tests have been described attempting to make an accurate and comprehensive assessment of urethral function, but all suffer from a lack of standardization or inconsistently quoted reference values. This paper will review the literature on the positive aspects and limitations of commonly employed procedures to diagnose intrinsic urethral sphincteric deficiency.

RECENT FINDINGS

Specific urodynamic studies, including the 'active' valsalva leak-point pressure and the 'static' urethral pressure profile are commonly used to determine urethral competence. However, these tests measure specific aspects of the continence mechanism under different clinical conditions, which limits the direct comparison between them. More complex techniques such as Doppler ultrasound, video-urodynamics and both static and dynamic magnetic resonance imaging are attempting to validate the urodynamic findings for urethral function. This approach may encourage the standardization of these procedures and parameters for diagnosing intrinsic urethral sphincteric deficiency.

SUMMARY

A single definitive test for the diagnosis of intrinsic urethral sphincteric deficiency does not exist. Instead, multiple tests should be employed to reach a consensus for the diagnosis. This should include a complete voiding history, simple office examinations, and advanced studies such as urethrocystoscopy, urodynamics and possibly radiological evaluations. Understanding the limitations and variabilities of their equipment and the specific studies utilized should enable practitioners to standardize the approach for determining the extent of urethral dysfunction.

Is urethral pressure profilometry a useful diagnostic test for stress urinary incontinence?

Urethral pressure profilometry is commonly used as a diagnostic test for stress urinary incontinence. The objective of this article is to review the published literature on urethral pressure profilometry to summarize its usefulness. MEDLINE was used to search the published English literature from 1966 to October 2000 for full-length original research articles on urethral pressure profilometry and stress urinary incontinence in women. Terms related to urethral pressure profilometry are defined consistently but techniques are not standardized, introducing variation in test results. Reproducibility of urethral pressure profilometry parameters is poor, both because of biological variation and variation within the test procedure itself (related in part to lack of standardization). Parameters of urethral pressure profilometry do not distinguish between continent and incontinent women and do not characterize the severity of incontinence or urethral incompetence. It is, therefore, concluded that urethral pressure profilometry is not a useful diagnostic test for stress urinary incontinence in women. Its use in clinical management is not supported by current evidence.

Evaluation of colposuspension for treatment of incontinence in spayed female dogs

OBJECTIVE

To determine the long-term effects of colposuspension in spayed female dogs with urinary incontinence and identify preoperative anatomic or urodynamic measurements associated with a successful outcome.

DESIGN

Prospective study.

ANIMALS

23 client-owned spayed female dogs with urinary incontinence.

PROCEDURE

Prior to surgery, a history was obtained, and a physical examination, CBC, serum biochemical analyses, urinalysis, bacterial culture of a urine sample, vaginourethrocystography, urethral pressure profilometry, and leak point pressure test were performed. Colposuspension was performed, and preoperative tests were repeated 2 months after surgery. Clients were interviewed 2 weeks, 1 month, and 1 year after surgery.

RESULTS

22 dogs were followed up for 1 year. Twelve had complete urinary control 2 months after surgery, and 3 had complete urinary control 1 year after surgery. Dogs with normal urinary control at 2 months had an increased leak point pressure (LPP), compared with preoperative measurements, and their LPP was the same as normal dogs. Eight dogs had complete urinary control, and 9 were considered greatly improved 1 year after surgery when medical treatment was added to the effect of colposuspension. Client satisfaction was high, with 19 of 22 (86%) owners being pleased with their decision to have surgery performed. The only predictors of complete urinary control 2 months after surgery were a more caudal position of the external urethral opening in relation to the pubis on preoperative radiographs and a longer overall urethral length.

CONCLUSIONS AND CLINICAL RELEVANCE

Colposuspension alone will result in complete urinary control in few dogs with urinary incontinence but may improve urinary control sufficiently that owners will be pleased. Preoperative vaginourethrocystography may be helpful in predicting response to surgery, and the LPP test correlates with improved urinary control.

Validation of cough-induced leak point pressure measurement in the evaluation of pharmacological treatment of stress incontinence

To improve routines in clinical practice and research, it is important that new tests are thoroughly evaluated before they gain widespread application. This includes establishing the reliability and validity of the new test. The purpose of this study was to establish the construct and criterion validity of cough-induced leak point pressure (CILPP) measurement. Data on CILPP, maximum urethral pressure (MUP), and a short-term pad test from a phase-I trial of a new pharmacological agent (LS 4416), developed for the treatment of stress incontinence, was used to test the validity of CILPP. Fifteen post-menopausal women with stress incontinence were studied. Phenylpropanolamine (PPA) was used as a positive control. Administration of PPA produced a statistically significant increase in MUP and CILPP. There was a significantly better effect of treatment, expressed as an increase in MUP at 1.5 hr, when PPA was used than with placebo or LS 4416. When CILPP was used to detect change after therapy, PPA produced a significantly greater increase in CILPP than did placebo (least square mean of difference 17.25, P = 0.0202). There was a moderate but statistically significant correlation between CILPP and the short-term Pad Test. Construct validity was demonstrated by the ability of CILPP to detect limited improvement in patients with stress incontinence. Criterion validity was established by the correlation of CILPP to a short-term Pad Test. We propose that, thanks to its greater methodological qualities, leak point pressure measurement should be adopted as a standard method to ascertain the effect of treatment in patients with stress incontinence. Neurourol. Urodynam. 18:591-602, 1999.

Efficacy of an external urethral device in women with genuine stress urinary incontinence

The efficacy of a new external anti-incontinence device in patients with a videourodynamic diagnosis of genuine stress incontinence (GSI) in an open longitudinal study is reported. Fourteen women with GSI underwent assessment before and after 3-4 weeks of device use. Assessment consisted of visual analog scores (VAS), quality of life (QOL) questionnaires, urine for culture and a 1 hour pad test. VAS scores showed a significant improvement for the symptom of stress incontinence (P<0.05). QOL scores improved significantly by 38% (P<0.05) and 29% (P<0.01) for the Incontinence Impact Questionnaire and Urogenital Distress Inventory, respectively. The mean pad weight decreased by 47% (P=0.056). Of the 9 women who had a positive pad test (>2 g) without the device, 5 were dry (<2 g) with the device (P<0.05). These preliminary data suggest that this device is effective in women with GSI.

MR imaging of the female pelvic floor in the supine and upright positions

The goal of this study was to determine whether a .5-T open configuration magnet system could be used to evaluate the female pelvic floor support structures and their functional changes in the upright and supine positions. We evaluated five normal volunteers with full bladders in the supine and sitting positions. Multiple measurements were obtained, including distance between symphysis and urethra, bladder neck to fixed pubococcygeal line, and posterior urethrovesical angle. The pelvic floor was evaluated for integrity of the urethra, vagina, and supporting ligaments. High quality, interpretable images were obtained for all five patients in both positions. Most of the pelvic floor structures were stable, with the exception of the posterior urethrovesical angle, which increased in the sitting position. We conclude that the vertically open configuration magnet system shows promise for evaluation of the female pelvic floor, including urinary stress incontinence and prolapse.

Comparison of urethral pressure profilometry and contrast radiography in the diagnosis of incompetence of the urethral sphincter mechanism in bitches

Three diagnostic indicators of urethral sphincter mechanism incompetence were compared in 25 continent and 25 incontinent anaesthetised bitches: the resting urethral pressure profile, the stressed urethral pressure profile and the radiographic position of the bladder neck. Logistic regression indicated that the best predictor of continence status was the stressed urethral pressure profile as assessed by the percentage of negative peaks extending below the resting intravesical pressure; it classified 43 of the 50 dogs correctly. The radiographic position of the bladder neck was a better predictor of continence than either the measurement of functional profile length or the maximum urethral closure pressure from the resting urethral pressure profile, whether alone or in combination. By combining the percentage of negative peaks on the stressed profile with the position of the bladder neck, 46 of the 50 dogs were classified correctly. Cut-off values for the percentage of negative peaks on the stressed urethral pressure profile, and for the radiographic position of the bladder neck are suggested for use in evaluating incontinent bitches in clinical practice.

Intrasubject variability of the pressure-transmission ratio in patients with genuine stress incontinence

The aim of the study was to determine the intrasubject variability of the pressure-transmission ratio (PTR) with various cough intensities in subjects with genuine stress incontinence. Thirty-six patients with genuine stress incontinence underwent multichannel urodynamics and had a series of pressure-transmission ratios (PTRs) determined with the urethral transducer placed at the point of the maximal closure pressure. Patients were asked to cough with increasing intensities and three to four different cough-induced PTRs were recorded for each subject. The data were analysed using regression analysis, repeated measures analysis of variance and comparison of variance. The PTRs showed a high degree of variability within subjects. The mean within subject standard deviation was 18.5%. The effect of parity, maximal urethral closure pressure and age were insignificant on the variability. Cough intensities of greater than 90 cmH2O have a lesser degree of variability. The mean PTR across all cough intensities was fairly constant in the 82%-87% range. It was concluded that the PTR in an individual has a high degree of variability independent of cough intensity, and cannot be relied upon as a diagnostic measure in subjects with genuine stress incontinence. However, the PTR for the population as a whole was consistent across all cough intensities.

Reproducibility of a new method to determine cough-induced leak-point pressure in women with stress urinary incontinence

The aim of the study was to test the reproducibility of a new method of determining cough-induced leak-point pressure (CILPP). A cough-induced increased in intra-abdominal pressure was recorded vaginally in 26 women with stress incontinence and urinary leakage was detected electronically. CILPP determinations and short-term pad tests were carried out on two different occasions. Reproducibility is expressed by a coefficient of repeatability as limits of agreement. These indicate that, for 95% of the cases, a repeat measurement of CILPP will be between 0.72 and 1.28 times the first measurement. The coefficient of variation was 11.2%. There was a moderate inverse correlation between pad-test data and CILPP. It was concluded that the new method allows for an accurate determination of CILPP, which represents a quantitative and dynamic assessment of urethral function. The reproducibility of the method appears to be better than that of pad tests and standard urodynamic parameters. The correlation with pad-test data gives support to the validity of the method.

Long-term results after Burch colposuspension

OBJECTIVE

Our purpose was to review the long-term (5 to 10 years) clinical and urodynamic outcome in patients with stress urinary incontinence after Burch colposuspension.

STUDY DESIGN

A follow-up of 87 women with stress urinary incontinence who had a Burch colposuspension between 1979 and 1985 at the Department of Obstetrics and Gynecology, University of Berne, was performed by clinical and urodynamic reevaluation of the patients.

RESULTS

Stress incontinence was cured in 81.6% of patients. The cure rate was not significantly related to age, hormonal status, body weight, or previous surgical procedures for incontinence. Burch colposuspension stabilized the urethrovesical junction. Urodynamic measurement at follow-up compared with the preoperative evaluation showed in the cured group a significant increase in (1) the functional urethral length at rest and at stress, (2) maximum urethral closure pressure at stress, and (3) pressure transmission. On the contrary, in unsuccessful operations none of the recorded parameters had improved. Women with failed surgery had significantly lower preoperative maximum urethral closure pressures at rest and at stress, lower continence areas, smaller functional urethral lengths at stress, smaller length to peak pressures, and lower index values of urethral relaxation at stress. The procedure had a low operative and postoperative morbidity, with no significant disturbance of voiding function noted at 5 to 10 years' follow-up.

CONCLUSIONS

Our results with the Burch colposuspension showed a high success rate at 5 to 10 years' follow-up. The high cure rate and low operative and postoperative morbidity were related to careful preoperative selection.

Urinary incontinence: correlation of history and brief office evaluation with multichannel urodynamic testing

OBJECTIVE

Patients' histories of urinary incontinence and the results of several standard clinical tests were correlated with final diagnoses obtained by multichannel urodynamic testing. We used a combination of clinical test results to predict the final diagnoses.

STUDY DESIGN

Ninety consecutive women with a primary complaint of urinary incontinence completed a standardized questionnaire and underwent a structured clinical examination consisting of several standard clinical tests. Each patient later underwent multichannel urodynamic testing to obtain a final diagnosis.

RESULTS

Although the symptoms of stress incontinence were significantly associated with genuine stress incontinence and mixed incontinence, overlap in patients with detrusor instability did not allow the histories to be useful diagnostically. The only clinical tests showing significant association with the final diagnoses of incontinence were the cough stress test and single-channel medium-fill cystometry. Reliable prediction of the urodynamic diagnosis of incontinence could not be achieved with either of these two tests or with a combination of variables obtained by discriminant analysis.

CONCLUSIONS

Women with complaints of urinary incontinence, especially those for whom surgery is contemplated, should undergo complete urodynamic evaluation when it is available.

Role of the artificial urinary sphincter in the treatment of stress incontinence in women

The artificial urinary sphincter (AUS) is rarely indicated in the treatment of women with stress incontinence because most of these women have deficient urethral support rather than pure sphincter weakness and the AUS is a treatment specifically for pure sphincter weakness. The procedure is contraindicated after pelvic radiotherapy and after previous sling surgery because of the high incidence of cuff erosion. Otherwise the artificial sphincter gives excellent results comparable to those seen in men with post-prostatectomy incontinence and much better than in neuropathic bladder dysfunction.

Assessment of urinary symptoms in early pregnancy

OBJECTIVES

To determine the correlation between lower urinary tract symptoms and urodynamic findings in early pregnancy.

SETTING

The termination clinic and gynaecology ward at King's College Hospital.

DESIGN

Observational study.

SUBJECTS

47 women before termination of pregnancy at between 6 and 15 weeks.

INTERVENTIONS

Women filled in symptom questionnaires and then had urodynamic investigations, consisting of uroflowmetry and subtracted provoked cystometry.

MAIN OUTCOME MEASURES

The occurrence of lower urinary tract symptoms and their association with urodynamic findings.

RESULTS

Lower urinary tract symptoms were fairly common but there was poor correlation with the urodynamic findings.

CONCLUSIONS

The findings suggest that lower urinary tract symptomatology alone is insufficient to study lower urinary tract dysfunction in pregnancy.

Reliability of the urethral closure pressure profile during stress in the diagnosis of genuine stress incontinence

Urethral pressure profile (UPP) measurements were recorded during stress using the method of Brown and Wickham in 981 patients with lower urinary tract symptoms. This procedure was used to identify patients with genuine stress incontinence (GSI). A clinical stress test in the supine and erect position served to confirm urinary leakage. GSI was diagnosed in 661 patients. (67%), whereas no incontinence was demonstrable in 320 (33%). UPP during stress has a high sensitivity (93.3%) and specificity (82.5%). Compared with other urodynamic investigations, the ease with which it can be performed at the same time as other urodynamic procedures makes a reliable diagnostic adjunct in the assessment of patients with GSI.