The evidence for urodynamic investigation of patients with symptoms of urinary incontinence

Targeted Selection of Stimulation Parameters for Restoration of Motor and Autonomic Function in Individuals With Spinal Cord Injury

STUDY DESIGN

This is a report of methods and tools for selection of task and individual configurations targeted for voluntary movement, standing, stepping, blood pressure stabilization, and facilitation of bladder storage and emptying using tonic-interleaved excitation of the lumbosacral spinal cord.

OBJECTIVES

This study aimed to present strategies used for selection of stimulation parameters for various motor and autonomic functions.

CONCLUSIONS

Tonic-interleaved functionally focused neuromodulation targets a myriad of consequences from spinal cord injury with surgical implantation of the epidural electrode at a single location. This approach indicates the sophistication of the human spinal cord circuitry and its important role in the regulation of motor and autonomic functions in humans.

Urodynamic Values Role For Females With Different Types Of Urinary Incontinence

Aim — The aim of this study was to analyse how conventional urodynamic values differ between females with specific types of urinary incontinence (UI). Material and Methods — Cross-sectional study enrolled 666 females with UI. Based on patient history and questionnaires they were divided into three groups: stress (SUI), mixed (MixUI) and urgency (UUI). Physical investigation and urodynamics were performed. The continuous factors: age and urodynamic data were evaluated using Multinomial regression and ANOVA test using SUI, MixUI, UUI as outcome groups. Results — Analysing urodynamic parameters significant difference between at least two groups was shown by the cystometric capacity and maximum flow rate: both highest in the SUI group; residual urine, opening detrusor pressure, maximum urethral closure pressure at rest, functional urethral length at rest: all highest in the UUI group. Mainly all urodynamic data showed significant difference between SUI/UUI, and MixUI/UUI groups, while difference between SUI/MixUI were not significant. Conclusions — Most of urodynamic data for MixUI group patients do not differ from SUI group. UDS parameters like: maximum flow rate, residual urine, opening detrusor pressure, maximum urethral closure pressure at rest, functional urethral length at rest can help to distinguish SUI and MixUI groups from UUI group.

The Relationship between Vitamin D Level and Lower Urinary Tract Symptoms in Women

Objectives:

In the literature, the effects of vitamin D on lower urinary tract symptoms (LUTS) have been investigated. Conflicting results have been reported in these studies conducted. LUTS is more common in women. In this study, we aimed to evaluate the relationship between vitamin D and LUTS in female patients using the uroflowmetric method.

Methods:

This retrospective cohort study included 186 female patients who were admitted with LUTS. Demographic characteristics, medical history, calcium (Ca) and vitamin D, including laboratory studies and uroflowmetry results, as maximum urine flow rate (Qmax), average urine flow rate (Qav) and voided volume (V) were recorded. Patients were divided into two groups according to age (18-50 and ≥51) and vitamin D levels (<20 and ≥20). Laboratory parameters and uroflowmetry results were compared between groups.

Results:

Mean age was 56.85±12.95 years. Mean vitamin D level was 21.19±13.93 ng/mL (2.5-83.5). Mean Qmax value was 35.41±12.63, whereas the mean Qav was 19.13±9.89, and the mean V was 446.60±165.08 mL. Vitamin D levels differed according to age groups (p=0.044). No significant difference was observed between groups according to Qmax, Qav and V values (p>0.05). No significant correlation was detected between vitamin D level and Qmax, Qav and V values. However, a negative correlation was detected between serum Ca level and V values (p=0.042) in the low vitamin D group.

Conclusion:

There was no direct relationship between vitamin D levels and LUTS in respect to uroflowmetry. However, we determined that Ca levels affect the uroflowmetry parameter in patients with low vitamin D levels. There is a need for further studies emphasizing serum Ca levels in addition to vitamin D levels in patients with LUTS.

Can conventional urodynamic variables help to predict the necessity of overactive bladder symptomatic therapy in women after transobturator tape surgery?

Introduction

The aim of this study was to find out if there are any conventional urodynamic (UDS) variables that would help to predict the necessity of overactive bladder (OAB) symptomatic therapy in women after transobturator tape surgery (TOT).

Material and methods

A total of 487 females after TOT were enrolled in this retrospective study. Inclusion criteria (UDS before surgery, follow-up visit within 2–6 month after TOT) were met in 169 women. Based on patient history, questionnaires and physical examination, two groups were distinguished: pure stress urinary incontinence (SUI) and stress-predominant mixed urinary incontinence (MixUI). A statistical analysis was performed including age and UDS variables. T-test was used for continuous data and Chi-squared test for categorical data. Combinations of these factors were analyzed using binary logistic regression and surgery outcome as the target variable.

Results

Significant correlations between the probability of a need for OAB therapy after TOT were observed with age (higher age increases OAB therapy necessity, p <0.001) and such UDS variables as cystometric capacity (CC) p <0.001; maximum flow rate (Qmax) p <0.001; detrusor contractility index (DCI) p <0.015 – higher value decreased the need for OAB therapy. Critical limit for these values: 60 years for age, 300 ml for CC, 15 ml/s for Qmax, but no specific value for DCI was observed. Binary logistic regression showed that the UI Group (p <0.01) and CC (p = 0.01) allow correctly classify 78.9% of TOT outcome (increased CC and SUI group are factors for TOT normal outcome).

Conclusions

UI group, age, CC, Qmax, DCI can help to predict the necessity of OAB symptomatic therapy in women after TOT.

Is urodynamic evaluation able to change and improve the management of women with idiopathic overactive bladder?

BACKGROUND

For women with overactive bladder (OAB), current guidelines recommend the use of urodynamic studies (UDS) only in complicated cases. This study aimed to investigate whether UDS can also be helpful in uncomplicated cases. Specific aims of the study were: 1) to evaluate objective benefit and subjective patient satisfaction with tailored treatment based on the UDS diagnosis compared to the outcomes of the pharmacological treatment only based on the symptoms; 2) to investigate the correlation between symptoms and UDS findings in women with uncomplicated idiopathic OAB symptoms; 3) to assess the ability of UDS to modify management decisions in these patients.

METHODS

Women presenting to our clinic with a history of uncomplicated OAB symptoms for the past three months or more, and who completed the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), were considered for this study. We proposed UDS to all participants. In women who accepted UDS (group 1), management decisions were made on the basis of urodynamic findings and post-treatment evaluation was scheduled at three months. The outcomes of treatments in these patients were compared to the results in women who did not accept UDS and who received pharmacological treatment symptoms-based (group 2). Objective outcomes were based on completion of a 3-day micturition diary. Subjective outcomes were captured using the Overactive Bladder Questionnaire Short Form (OABq-SF), the Patient Global Impression of Improvement (PGI-I) scale, and a patient satisfaction scale.

RESULTS

A total of 680 women were enrolled in the study; 478 underwent UDS and 202, at the contrary, declined UDS. In 53.6% of cases, UDS led to modification of the proposed management approach. At the 3-month follow-up, the overall patient satisfaction rate in group 1 and group 2 was 77% and 65.8%, respectively (P=0.003).

CONCLUSIONS

We showed that OAB management tailored according to the UDS diagnosis results in higher subjective satisfaction if compared with a pharmacological treatment symptoms-based. Our study confirmed a lack of correlation between OAB symptoms and the urodynamically proven diagnosis of detrusor overactivity (DO). It also suggested that UDS can determine the underlying pathophysiology of every woman with OAB syndrome, whether complicated or uncomplicated, allowing treatment to be appropriately tailored with better results.

Impact of urodynamic evaluation on the treatment of women with idiopathic overactive bladder: a systematic review

INTRODUCTION

Overactive bladder (OAB) is a common clinical condition affecting women. The impact of urodynamics (UDS) on the management of idiopathic OAB in women is highly debated. This systematic review analyzes the impact of UDS on the choice and on the outcomes of treatment of female idiopathic OAB.

EVIDENCE ACQUISITION

A systematic literature search in the PubMed/Medline, Web of Science, Scopus and Cochrane databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement to identify clinical trials, randomized controlled trials, meta-analyses, and guidelines on female OAB and UDS published from 2000. A total of 1554 records were initially identified and 12 articles were included in the final qualitative synthesis.

EVIDENCE SYNTHESIS

UDS represents the main tool to diagnose detrusor overactivity (DO) in OAB female patients which is considered one of the major OAB underlying pathophysiology factor. UDS can underline the presence of voiding dysfunction that could be considered as another underlying cause of uncomplicated female OAB. On the basis of this urodynamic findings, we can better define different aspects of OAB syndrome leading to a more tailored and proper treatment.

CONCLUSIONS

UDS can have a useful role in the diagnosis of idiopathic OAB in women given the possibility to gain a precise diagnosis and, therefore, a tailored treatment based on the underlying cause. The integration of clinics with UDS and all the other diagnostic available tools is desirable.

The role of conventional urodynamic in diagnosing specific types of urinary incontinence in women

OBJECTIVE

To analyze the association between patient history profile, conventional urodynamic variables, and specific types of urinary incontinence (UI) in order to establish the role of urodynamic in differentiating various types of UI in women.

MATERIAL AND METHODS

This cross-sectional study enrolled 547 women with UI. All patients were divided into three groups according to the UI type based on questionnaires: stress UI (SUI), mixed UI (MixUI), and urgent UI (UUI). Patient history taking, physical examination, and conventional urodynamics were performed. The association between patient profile characteristics, urodynamic data, and type of UI were assessed using one-way analysis of variance and chi-square tests.

RESULTS

Significant correlations were observed between the age, body mass index (BMI), cystocele, menopausal status, and most urodynamic data in at least one UI group (p<0.05). Age differed among all three groups (p<0.001), with SUI group consisting the youngest patients. BMI was higher in the MixUI group (p=0.001). The maximum cystometric capacity differed among all three groups (p<0.001), with the highest in the SUI. The maximum flow rate was higher in the SUI group than that in the UUI group (p<0.001). Residual urine, opening detrusor pressure, and pressure transmission ratio were significantly higher in the UUI group. Detrusor overactivity and menopause were less frequently observed in the SUI group. The least pronounced urodynamic SUI was found in the UUI group. Spearman correlation for cystocele was negative in the SUI and positive in the UUI group.

CONCLUSION

Conventional urodynamics give additional information to correctly diagnose specific types of UI in women.

Prospective Evaluation of Urodynamic Utility in a Subspecialty Tertiary Practice

OBJECTIVE

To prospectively evaluated the utility of urodynamic evaluations (UDS) ordered in a tertiary referral center as part of a quality improvement project.

METHODS

Patients with UDS ordered by 3 subspecialty physicians were included. Physicians were surveyed when ordering UDS and at the post-UDS clinic visit to assess indications for UDS, pre- and post-UDS diagnosis, treatment plan, confidence level, and perceived helpfulness of UDS. UDS trained nurses conducting studies were surveyed on patient reported reproducibility of their symptoms and perceived difficulty of UDS.

RESULTS

From April 2017 to October 2017, 127 UDS were included of which 102 met study criteria. UDS were done for neurogenic (23%) and non-neurogenic lower urinary tract symptoms (76%). The majority were conducted for incontinence evaluation (79%), or after prior lower urinary tract surgery (33%). UDS nurses reported 90% of UDS fully or partially reproduced patient symptoms. Nurses found 18% of UDS difficult due to catheter malfunctions, physical limitations, and communication abilities. Post-UDS, providers found 97% of UDS interpretable. UDS resulted in a change in treatment plan in 78% of patients. On a Likert scale, mean pre-UDS confidence level was 2.9 ± 0.8 (range 0-5). This increased to 4.1 ± 0.6 post-UDS with 76% of evaluations having a change of at least 1 point.

CONCLUSION

UDS in a tertiary referral center result in change in patient treatment plans over three-fourths of the time with high rates of interpretability.

Urodynamics Useless in Female Stress Urinary Incontinence? Time for Some Sense-A European Expert Consensus

BACKGROUND

Routine use of urodynamics (UDS) for the assessment of female stress urinary incontinence (SUI) appears to be in decline across Europe. The reasons for this trend appear multifactorial, but the implications are of significant concern.

OBJECTIVES

To achieve an expert consensus viewpoint on the value of UDS in female SUI and current barriers to its use.

METHODOLOGY

A multidisciplinary group of UDS experts from six European countries was convened, and a modified version of the Delphi method was utilised to reach a consensus viewpoint structured around five key questions.

RESULTS

Consensus was achieved on all five questions. The group was unanimous that the decline in routine use of UDS is unjustified and misguided, driven by restrictions in funding and accelerated by the publication-and subsequent influence-of two trials that had major limitations.

LIMITATIONS

The authors comprised a selected group of UDS experts and the analysis is not a formal systematic review.

CONCLUSIONS

Extensive experience and observational studies have demonstrated the value of UDS for the assessment of female SUI and the dangers of empiric management. This evidence base should not be eclipsed by the findings of two randomised controlled trials that had numerous shortcomings.

PATIENT SUMMARY

A group of experts were worried that, even though the cause of incontinence varies, doctors seem to be skipping a diagnostic test called urodynamics (UDS) in some patients and just providing treatment-even surgery-without knowing exactly what is wrong. These experts analysed the situation in detail and reached agreement that UDS testing should not be skipped.

Association between detrusor muscle function and level of the spinal cord injury

Introduction

Traumatic spinal cord injury (TSCI) is among the most severe disabilities with an estimation of 2.5 million people affected worldwide. The purpose of this study was to investigate the association between detrusor muscle function and the level of the spinal cord injury.

Material and methods

All patients with TSCI who underwent urodynamic evaluation at the Brain and Spinal Injury Research Center (BASIR) of Imam Khomeini hospital complex from March 2014 to March 2016 were retrospectively entered in this cross-sectional study. The patients were divided into three groups of suprasacral (C1-T12), sacral (L1-S5) and combined (both suprasacral and sacral) lesions.

Results

Medical records of 117 patients with spinal cord injury were reviewed. The mean age of the patients was 35.64 (±12.01) years. 86 patients (73.5%) were male and 31 female (26.5%). While 66 (56.4%), 28 (23.9%) and 19 (16.2%) patients had suprasacral, sacral, and combined suprasacral and sacral lesions, respectively. The relationship between the level of injury and emptying disorder (P = 0.50), storage disease (P = 0.20), first desire to void (P = 0.82), hypocompliance (P = 0.95), voided urine volume (P = 0.38) and residual urine volume (P = 0.76) were not significant. We found a significant association between the level of injury and the type of detrusor function (P = 0.019).

Conclusions

Our study showed an association between detrusor muscle function and level of the spinal cord injury. However, there was no exact relationship between the level and the completeness of the spinal cord injury with the urodynamic characteristics.

Improvements in bladder, bowel and sexual outcomes following task-specific locomotor training in human spinal cord injury

OBJECTIVE

Locomotor training (LT) as a therapeutic intervention following spinal cord injury (SCI) is an effective rehabilitation strategy for improving motor outcomes, but its impact on non-locomotor functions is unknown. Given recent results of our labs' pre-clinical animal SCI LT studies and existing overlap of lumbosacral spinal circuitries controlling pelvic-visceral and locomotor functions, we addressed whether LT can improve bladder, bowel and sexual function in humans at chronic SCI time-points (> two years post-injury).

STUDY DESIGN

Prospective cohort study; pilot trial with small sample size.

METHODS

Eight SCI research participants who were undergoing 80 daily one-hour sessions of LT on a treadmill using body-weight support, or one-hour of LT and stand training on alternate days, as part of another research study conducted at the Kentucky Spinal Cord Injury Research Center, University of Louisville, were enrolled in this pilot trial. Urodynamic assessments were performed and International Data Set questionnaire forms completed for bladder, bowel and sexual functions at pre-and post-training time points. Four usual care (non-trained; regular at-home routine) research participants were also enrolled in this study and had the same assessments collected twice, at least 3 months apart.

RESULTS

Filling cystometry documented significant increases in bladder capacity, voiding efficiency and detrusor contraction time as well as significant decreases in voiding pressure post-training relative to baseline. Questionnaires revealed a decrease in the frequency of nocturia and urinary incontinence for several research participants as well as a significant decrease in time required for defecation and a significant increase in sexual desire post-training. No significant differences were found for usual care research participants.

CONCLUSIONS

These results suggest that an appropriate level of sensory information provided to the spinal cord, generated through task-specific stepping and/or loading, can positively benefit the neural circuitries controlling urogenital and bowel functions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03036527.

Clinical Evaluation of Urinary Incontinence

Pelvic organ prolapse is the downward descent of the pelvic floor organs and has a prevalence of 3%–6% and can even reach to 50% if defined by a vaginal examination. The anatomical concepts of pelvic diaphragm, lateral attachment of vagina to arcus tendineus fascia pelvis, and intrinsic and extrinsic sphincter control mechanisms are elaborated. The anatomic and physiological mechanisms of autonomic and voluntary control of continence are discussed. The clinical and urodynamic tests and their implications in guiding the management are explained. Finally, uroflowmetry, cystometry, urethral pressure profile, postvoid urine measurement, leak point pressure (LPP) test, video urodynamic tests, and electromyography studies of pelvic floor are discussed as an integral part of the assessment.

NEW CONCEPTS IN BLADDER SENSATION AND URINARY URGENCY

Purpose of Review

The purpose of this review is to summarize the current state of knowledge regarding the evaluation and measurement of urinary urgency and bladder sensation.

Recent Findings

New technologies have been developed to improve our diagnostic capabilities in urinary urgency and bladder sensation. Recent developments include MRI-based neuroimaging and novel tablet-based sensation meters that can be used during urodynamics as well as during oral hydration.

Summary

Commonly used metrics for urinary urgency and bladder sensation include the use of validated surveys/void diaries and standardized verbal sensory thresholds during urodynamics. However, these metrics are highly subjective and prone to significant bias. There has been an evolution in evaluation metrics ranging from the use of reflex testing to electrical perception testing to the use of neuroimaging and the development of sensation meters. Neuroimaging allows for mapping of specific brain areas involved in the different phases of voiding and provides an anatomic basis for different forms of overactive bladder. The sensation meter allows for generation of real-time sensation-capacity curves which enables easy and objective comparison between patients as well as potential sub-typing of different forms of overactive bladder. In addition, new research supports the concept of differing forms of urgency and the use of novel patient-derived terminologies for urinary urgency and bladder sensation.