Do sensation-related bladder diaries differ between patients with urodynamically confirmed and non-objectivised urinary incontinence?

The aim of the study is to investigate whether sensation-related bladder diary (SR-BD) differs between women with symptoms of urinary incontinence (UI) in whom incontinence is not demonstrated during investigation and women with demonstrated UI. Two hundred and six patients with stress UI, urge UI and mixed UI filled out a SR-BD for 3days. They graded the perception of bladder sensation at each micturition and measured the voided volume. Incontinence episodes and the severity of leakage were recorded. All had cystometrogram. The patients were divided in urodynamically confirmed and non-objectivised UI within each type. More disturbed bladder sensation was present in urodynamically confirmed urge UI and to a lesser extent in mixed UI than in the respective non-confirmed groups. No such difference could be seen in stress UI. Close interpretation of the SR-BD may indicate to a certain extent the presence of detrusor overactivity in urge UI and to a lesser degree in mixed UI.     

尿动力学检查在耻骨上前列腺切除术后尿失禁诊断中的应用

目的:探讨尿动力学检查在耻骨上前列腺切除术后尿失禁诊断中的应用价值。方法:对23例耻骨上前列腺切除术后尿失禁患者进行尿动力学检查,包括膀胱压力容积测定、Valsalva漏尿点压力测定、压力-流率测定、静态尿道压力测定。结果:11例诊断为运动急迫性尿失禁,2例诊断为感觉急迫性尿失禁,5例诊断为压力性尿失禁,3例诊断为混合性尿失禁,2例诊断为充盈性尿失禁。结论:尿动力学检查能准确判断耻骨上前列腺切除术后尿失禁的类型,为治疗提供客观依据。     

Unstable bladder: urodynamic diagnosis and observations in evaluating urinary incontinence in the female

Unstable bladder in the female has been the subject of controversy with regard to its etiology, identification, and treatment. One hundred thirty consecutive female patients referred with incontinence were evaluated as to their symptoms and urodynamic findings. A stress cystometrogram, systematically done, was introduced and observations were made regarding certain findings on the urodynamic examination. These criteria were used subsequently for making a diagnosis of unstable bladder. Forty per cent of these patients were found to have an unstable bladder. History of frequency and urgency correlated best with a diagnosis in 70 to 80 per cent of our cases, and the new stress cystometrogram proved to be the most sensitive urodynamic test (78%) for detecting this condition. A systematic approach such as we describe is advocated as a first step toward gaining a better understanding of this puzzling entity.     

Clinical versus urodynamic diagnosis in an incontinent geriatric female population

The clinical presentation of incontinence was compared to diagnoses based on urological and urodynamic evaluation in 135 elderly women assessed consecutively in an outpatient clinic. Most patients (64 per cent) presented with mixed symptoms: 16 per cent presented with pure stress and 16 per cent with pure urge incontinence. After evaluation 46 per cent of the patients had stress incontinence with a stable bladder, 27 per cent had detrusor instability or hyperreflexia without sphincter weakness and 19 per cent had mixed urodynamic abnormalities. Presenting symptoms were predictive of urodynamic diagnosis in 64 per cent of the patients with pure stress incontinence and 55 per cent with pure urge incontinence. In general, symptoms in our patient population were less predictive of urodynamic findings than in previously reported series of younger incontinent women but they were more predictive than in other series of elderly women. Predictive values for some urodynamic findings were enhanced by combining a symptom with certain physical findings. Implications of these data for the evaluation and treatment of incontinence in the geriatric population are discussed.     

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.     

Stress incontinence surgery for patients presenting with mixed incontinence and a normal cystometrogram

OBJECTIVE: To evaluate the outcome of surgery for stress urinary incontinence (SUI) in patients presenting with a combination of stress and sensory urge UI. PATIENTS AND METHODS: The study comprised 75 women presenting with mixed incontinence; the most important inclusion criterion was a negative cystometrogram for detrusor overactivity. Based on random selection, a third of the patients received a 6-month course of anticholinergic treatment (group 1) and 50 (group 2) had surgery for SUI. The surgical procedure depended on the Valsalva leak-point pressure (VLPP); those with a VLPP of > or = 90 cmH2O underwent Burch retropubic bladder neck suspension (group 2a, 24 patients) while 26 (group 2b) with a VLPP of < 90 cmH2O had pubovaginal sling (PVS) surgery. A further group of 20 patients with pure SUI (no urge UI) underwent surgery (PVS in 12 and Burch in eight) as a control group (group 3). After at least 6 months of follow-up (mean 9.3, sd 1.7), 68 patients were evaluable; they were assessed subjectively and objectively for dryness, and by a urodynamic evaluation and quantitative assessment using the SEAPI scoring system. RESULTS: In group 1 none of the patients became completely dry; there was persistent stress with and without urge UI in nine (43%) and 12 (57%) of the available 21 patients, respectively. Only three of those who had persistent SUI with no urge in the whole study group were satisfied and chose to continue anticholinergic therapy despite SUI. In this group the mean (sd) improvement in the subjective and objective SEAPI score was 3.4 (1.0) and 2.3 (3.8), respectively. In group 2a, 20 of the available 23 patients (87%) became completely dry (both stress and urge continent). The mean improvement in the SEAPI scores was 7.8 (0.9) and 7.8 (1.3), respectively. In group 2b, 20 of the 24 patients (83%) became completely dry, with mean improvements in SEAPI scores of 8.2 (0.4) and 7.9 (0.3), respectively. The improvement was statistically significant after surgery, vs anticholinergic therapy, for all variables (P < 0.05). The incidence of persistent urge UI was highest in group 1 (43%), being 13% in group 2 (13% and 12% in 2a and b, respectively). In group 3 there was de novo urge UI in four of the 20 patients, and not significantly different from that in group 2. CONCLUSION: Most patients with mixed stress and urge UI and a normal cystometrogram were cured of both symptoms by surgery. The incidence of residual urge in such patients was no higher than that of de novo urge after surgery in patients with genuine SUI.     

Mixed urinary incontinence��time to uncouple urgency from stress?

Introduction  

“Mixed incontinence” is defined as a combination of stress and urge symptoms. Over time, it has morphed into a single entity, encompassing etiology and treatment. My perspectives are: (a) Stress incontinence (SI) and urge incontinence (UI) are different symptoms with often different anatomical causation and so should be treated separately; (b) It is illogical to group urgency with SI. Urgency may also be associated with frequency, nocturia, abnormal emptying and pelvic pain in patients with no SI (“posterior fornix syndrome”); and (c) There is growing evidence that urgency may be cured by surgical correction of a cystocele and/or apical prolapse in up to 80% of patients who do not have SI. In this anatomical context, sensory urgency, urge incontinence and urodynamic detrusor overactivity may all be hypothesized as different manifestations of a prematurely activated micturition reflex, caused by a lax vagina’s inability to support bladder base stretch receptors. This statement can be tested with a simple clinical test, “simulated operations”, whereby digitally supporting in turn the midurethra, bladder base and posterior vaginal fornix may cause a significant decrease in the urgency felt by the patient.     

Can scoring the severity of symptoms help to predict the urodynamic diagnosis?

A very detailed history, including the scoring of symptoms, was taken from 207 patients in an effort to determine whether one could predict the urodynamic diagnosis. Using a previously devised model the symptoms of frequency, urgency, nocturia, urge incontinence, frequency of leakage and amount of protection required gave an index which predicted either genuine stress incontinence (GSI) or detrusor instability (DI). All patients underwent uroflowmetry and subtracted dual-channel cystometry. 124/207 patients had a pure diagnosis of either GSI or DI, and in these cases the model gave the correct answer 79% of the time. An analysis of variance demonstrated that patients with GSI, DI and a combined diagnosis had statistically different index values. However, the large number of patients with neither diagnosis (48) of which 39 had no urodynamic abnormality detected, limits the clinical application of this model and leads us to conclude that even a very detailed history does not allow one to predict the urodynamic diagnosis.EDITORIAL COMMENT: The unreliability of patients' symptoms in predicting a urodynamic diagnosis of urinary incontinence is well recognized [1]. Ramsay and his associates attempt to use a detailed history and symptom score to help predict the diagnosis of genuine stress urinary incontinence, detrusor instability or mixed incontinence, but find no advantage to this method in determining the cause of the patient's incontinence. The study also presents the limitations of urodynamic testing, in that 39 patients showed no abnormality on urodynamic evaluation. As clinicians we should never forget that urodynamic evaluation is performed in an artificial environment under artificial conditions over a limited period of time. Normal results found in patients that complain of urinary leakage require further reflection and evaluation. Once fully developed, ambulatory urodynamic monitoring may represent the necessary next step in such patients [2,3].     

The effect of bladder training, pelvic floor muscle training, or combination training on urodynamic parameters in women with urinary incontinence. Continence Program for Women Research Group.

The purpose of this study was to compare the effect of three conservative interventions: pelvic floor muscle training, bladder training, or both, on urodynamic parameters in women with urinary incontinence. Two hundred four women with genuine stress incontinence (GSI) or detrusor instability with or without GSI (DI +/- GSI) participated in a two-site trial comparing pelvic floor muscle training, bladder training, or both. Patients were stratified based on severity of urinary incontinence, urodynamic diagnosis, and treatment site, then randomized to a treatment group. All women underwent a comprehensive standardized evaluation including multi-channel urodynamics at the initial assessment and at the end of 12 weeks of therapy. Analysis of covariance was used to detect differences among treatment groups on urodynamic parameters. Post-treatment evaluations were available for 181 women. No differences were found among treatments on the following measurements: maximum urethral closure pressure, mean urethral closure pressure, maximum Kegel urethral closure pressure, mean Kegel urethral closure pressure, functional urethral length, pressure transmission ratios, straining urethral axis, first sensation to void, maximum cystometric capacity, and the MCC minus FSV. The effect of treatment did not differ by urodynamic diagnosis. Behavioral therapy had no effect on commonly measured urodynamic parameters. The mechanism by which clinical improvement occurs remains unknown. Neurourol. Urodynam. 18:427-436, 1999.     

Effect of functional continuous magnetic stimulation for urinary incontinence

PURPOSE: We evaluated the therapeutic efficacy of continuous magnetic stimulation on urinary incontinence by studying the urodynamic effect on urethral closure and bladder inhibition. MATERIALS AND METHODS: A total of 11 patients with stress incontinence and 12 with urge incontinence (7 males and 16 females, mean age 55.8 years) were evaluated. In the pilot study urethral pressure profile was performed before and after 20 Hz. 15-minute (with 1-minute on/30-second off cycles) stimulation, and maximum intraurethral pressure was recorded during stimulation in stress incontinence cases. Cystometry was performed before and during 15-minute stimulation at 10 Hz. in urge incontinence cases. In the therapeutic study 8 females with stress incontinence, and 3 males and 5 females with urge incontinence were treated with magnetic stimulation twice a week for 5 weeks. RESULTS: In the pilot study maximum intraurethral pressure increased by 34% during stimulation and maximum urethral closure pressure increased by 20.9% (p = 0.0409) after stimulation in stress incontinence cases. In urge incontinence cases significant increases in bladder capacities at first and maximum desire to void during stimulation were noted (p = 0.0164 and 0.0208, respectively). In the therapeutic study 86% of 7 patients with stress incontinence and 75% of 8 with urge incontinence were improved, and 1 dropped out of the study. CONCLUSIONS: Continuous magnetic stimulation was effective on urethral closure and bladder inhibition, and as treatment of urinary incontinence.     

DETRUSOR INSTABILITY IN MEN: CORRELATION OF LOWER URINARY TRACT SYMPTOMS WITH URODYNAMIC FINDINGS

PURPOSE: We evaluated the correlation of lower urinary tract symptoms suggestive of detrusor instability with urodynamic findings in men. MATERIALS AND METHODS: Enrolled in our prospective study were 160 consecutive neurologically intact men referred for urodynamic evaluation of persistent lower urinary tract symptoms. All patients had storage symptoms suggestive of detrusor instability. Patients were further clinically categorized according to the chief complaint of urge incontinence, frequency and urgency, nocturia or difficult voiding. The clinical and urodynamic diagnosis in all patients as well as specific urodynamic characteristics of those with detrusor instability were analyzed according to the these 4 clinical categories. RESULTS: Mean patient age was 61 +/- 15 years. The chief complaint was urge incontinence in 28 cases (17%), frequency and urgency in 57 (36%), nocturia in 30 (19%) and difficult voiding in 45 (28%). Detrusor instability was diagnosed in 68 cases (43%). A higher incidence of detrusor instability was associated with urge incontinence than with the other clinical categories (75% versus 36%, p <0.01). Of the patients 109 (68%) had bladder outlet obstruction, including 50 (46%) with concomitant detrusor instability. The prevalence of bladder outlet obstruction was similar in all patients regardless of the chief complaint. All other urodynamic diagnoses were also similar in the 4 clinical categories. The mean bladder volume at which involuntary detrusor contractions occurred were lower in patients with urge incontinence and frequency and urgency than in those with nocturia and difficult voiding (277.1 +/- 149.4 and 267.7 +/- 221.7 versus 346.7 +/- 204.6 and 306.2 +/- 192.1 ml., respectively, not statistically significant, p = 0.07). CONCLUSIONS: Detrusor instability and bladder outlet obstruction are common in men with lower urinary tract symptoms. The symptom of urge incontinence strongly correlated with detrusor instability. Other lower urinary tract symptoms did not correlate well with any urodynamic findings. Therefore, we believe that an accurate urodynamic diagnosis may enable focused and more efficient management of lower urinary tract symptoms in men.     

Are urodynamic tests useful tools for the initial conservative management of non-neurogenic urinary incontinence? A review of the literature

OBJECTIVES: To summarise the evidence for the role of urodynamic tests in the diagnosis and classification of urinary incontinence. METHODS: Reference lists in relevant papers were reviewed and MEDLINE searches conducted. RESULTS: The mean sensitivity (specificity) of clinical history versus urodynamic tests was 0.82 (0.57) for stress incontinence, 0.69 (0.60) for urge incontinence/overactive bladder, and 0.51 (0.66) for patients with mixed incontinence. The proportion of women with a clinical diagnosis of urinary incontinence but with normal findings from urodynamic tests ranged from 3 to 8%. Overall sensitivity of urodynamic tests was about 85-90% in the diagnosis of urodynamic stress incontinence, but generally lower following diagnosis of urge and mixed incontinence. No relationship emerged between urodynamic test results and response to medical treatment. CONCLUSIONS: This literature review shows that the sensitivity of clinical history versus urodynamic tests was 0.82, 0.69 and 0.51 respectively for stress, urge and mixed urinary incontinence. It also suggests that urodynamic diagnosis does not predict response to treatment. These data add to the ongoing 'urodynamics or no urodynamics' debate in the evaluation of urinary incontinence and show that urodynamic testing may not be helpful for patients receiving initial non-invasive therapy. These data are in line with the conclusions of the 1st and 2nd International Consultations on incontinence.     

Correlation between urodynamics and perineal ultrasound in female patients with urinary incontinence

AIMS: We performed urodynamics and perineal ultrasound in female patients with urinary incontinence to assess morphology and function of the bladder base-urethra complex and of the detrusor muscle, and to find the correlation between these investigations in the diagnosis of (a) bladder neck and urethral hypermobility and (b) detrusor overactivity; we wanted to compare the tolerabililty of the urodynamic investigation and of the perineal ultrasound. METHODS: We considered 66 female patients referred to our outpatient clinic for urinary incontinence; we also studied 14 healthy control patients. After accurate case-history collection and physical examination, urodynamic investigation and perineal ultrasound were performed, with recording of parameters specific to both investigations. The statistical analysis was performed by ANOVA, Bonferroni post hoc test, and Spearman correlation test. The tolerability index between the diagnostic investigations performed was assessed by a 3-point scale suggested by the patient. RESULTS: In patients with stress incontinence the posterior urethro-vesical angle, the angle of urethral inclination, and the proximal pubo-urethral distance are significantly different under stress compared to the resting phase; in patients with urge incontinence, the detrusor wall is thicker and is accompanied by an increase in opening detrusor pressure and detrusor pressure at maximum flow; it is also accompanied by detrusor overactivity with increased urethral functional length. Increased urethral functional length is suggested on axial US images by alteration of its normal characteristic target-like appearance with four concentric rings of different echogenicity. In all cases the tolerability of perineal ultrasound has been higher than that of urodynamics. CONCLUSIONS: There is a good correlation between urodynamic and perineal ultrasound in the diagnosis of bladder neck and urethral hypermobility; perineal ultrasound can also be useful in the diagnosis of urge incontinence. Functional compressive urethral obstruction can be diagnosed on the basis of the ultrasound aspect of the urethral sphincter.     

Changes in urodynamic measurements after successful anal electrostimulation in female urinary incontinence

Fifty-five of 71 women with stress, motor urge and mixed stress and motor urge urinary incontinence were treated successfully with a new integrated electrostimulation device (Incontan) used anally. Changes in urodynamic measurements were evaluated when the patients themselves reported cure or significant improvement. The duration of the treatment was 9 to 20 h/day for at least 2 months (mean 9 months). According to the patients' subjective evaluation, 71% were cured of their incontinence and 29% were markedly improved. In motor urge and mixed incontinence a significant increase in bladder volume at first sensation and at maximum cystometric capacity was found, and 45% of these patients had a normal, stable bladder after treatment. A significant increase in functional urethral length was observed in patients who had had stress incontinence, but the measured increase in maximum urethral pressure was not significant. Of the 16 patients with stress and mixed incontinence who reported cure, 15 had a positive urethral closure pressure during coughing after treatment. Urodynamic analysis confirmed the positive clinical effect observed after electrostimulation therapy. It is recommended as primary therapy in stress, motor urge and mixed stress and motor urge incontinence in women.     

Bladder Neck Mobility and Urethral Closure Pressure as Predictors of Genuine Stress Incontinence

Two hundred and seventy-five consecutive patients with symptoms of lower urinary tract dysfunction underwent urodynamic evaluation, including multichannel urodynamics, urethral pressure profilometry, X-ray and ultrasound imaging. After women with previous incontinence or prolapse surgery or pelvic radiotherapy and those with evidence of urethral kinking on ultrasound had been excluded, 179 datasets were analyzed. Both bladder neck descent (P<0.0001) and maximum urethral closure pressure (P<0.0001) were strongly associated with a fluoroscopic diagnosis of GSI. Only weak correlations between bladder neck mobility and urethral pressure parameters (highest r=−0.17) were observed. Regression analysis yielded a mathematical model that demonstrated a wide spread of odds ratios for GSI for the measured values (from <0.2 to >100). Bladder neck descent explained 29% and urethral closure pressure 12% of overall variability. Both bladder neck mobility and maximum urethral closure pressure are strong predictors of the diagnosis of GSI, provided major confounders are excluded. Bladder neck mobility appears to be the stronger predictor.     

The impact of detrusor overactivity on the management of stress urinary incontinence in women

The presence of overactive bladder symptoms, urodynamic detrusor overactivity, and urge incontinence can complicate the diagnosis and management of stress urinary incontinence in women. The exact pathophysiology of mixed incontinence is not well characterized; in some patients, the stress and urge etiology may be pathologically linked. The role of urodynamics in evaluating patients with mixed incontinence remains controversial. Conservative therapies, such as bladder training, pelvic floor exercise, biofeedback, and electrical stimulation, offer moderate success in women with mixed incontinence. Surgery (colposuspension, bladder neck pubovaginal slings, and midurethral slings) offers excellent subjective and objective cure rates in patients with mixed incontinence. Preoperative detrusor overactivity is cured consistently ≥ 50% of the time with colposuspension and slings. Overall, the presence of preoperative detrusor overactivity does not appear to significantly worsen the outcome of conservative and surgical treatments for stress urinary incontinence in women.     

Urodynamically age-specific prevalence of urinary incontinence in women with urinary symptoms

AIMS: To determine the age-specific prevalence rates of different types of urinary incontinence in women with urinary symptoms using urodynamic studies (UDS). METHODS: One thousand five hundred women with urinary symptoms who underwent UDS in our department from January 1997 through December 1999 were enrolled. A detailed history, physical examination, and data of multi-channel UDS including uroflowmetry, filling and voiding cystometry, stress urethral pressure profile, and 20-minute pad test were obtained for each patient. The urodynamic findings of each patient were analyzed and correlated with age in decades. RESULTS: Of 1,500 women, 329 were excluded from analysis because they had undergone anti-incontinence surgery (n=27), had undergone treatment for cervical cancer (n=147), or were being followed-up after medication (n=155). Of the remaining 1,171 patients, 656 (56%) had genuine stress incontinence (GSI), 68 (5.8%) had detrusor instability (DI), 187 (16%) had mixed GSI/DI, 245 (20.9%) had either voiding or storing dysfunction without concomitant incontinence, and 15 (1.3%) had normal urodynamic findings. The 41-50- and 51-60-year age groups had the highest prevalence rates of urinary incontinence, accounting for 31% and 28% of GSI cases, 35% and 25% of DI cases, and 40% and 27% of mixed GSI/DI cases, respectively. The prevalence of GSI and mixed GSI/DI increased consistently with age, but the prevalence of DI decreased after age 66. Thus, the prevalence rates of GSI, DI, and mixed GSI/DI were 56%, 5.8%, and 16%, respectively, in women with urinary symptoms. CONCLUSIONS: Female urinary incontinence had a biogenic peak prevalence in the 41-50-year and 51-60-year age groups.     

Identifying types of female incontinence with retrograde urethrocystography

The most specific radiographic findings characterizing stress incontinence (SI) on upright retrograde urethrocystography include replacement of a flat or rounded bladder base with a concave funnelled base; patency of the bladder neck with contrast material pooling in the proximal urethra; the descent of the intravesical Foley balloon beyond the internal meatus and into the proximal urethra. We found that neither a cystocele nor the dependent position of the urethra at the bottom of the bladder were diagnostic of SI if the above stigmata were absent. On the other hand the defect of urgency incontinence (UI) is functional. The bladder can usually be filled by retrograde urethral infusion (though in severe UI this may not be the case). An alert technician can frequently obtain a film when the patient is experiencing uninhibited voiding. The finding of contrast material throughout the urethra, in the distal urethra alone, or in the parameatal area is strongly suspicious for UI, especially when trabeculation is also seen. These findings in association with the stigmata of SI give warning of combined SI and UI.     

Urodynamics of female urinary incontinence with emphasis on stress incontinence

More than 500 female patients with urinary incontinence were studied in our urodynamic laboratory by simultaneous recordings of urethral pressure at 2 levels, bladder pressure, intra-abdominal pressure, and by uroflowmetry and cine-fluoroscopy. Urethral pressure profile under basal conditions was compared to that in patients with a full bladder, under the stress of sharp or sustained increase in intra-abdominal pressure, voluntary perineal muscle activity and patient's position. From these studies stress and urge incontinence, and neurogenic varieties (or a combination of several types) could be differentiated. The clinical application of our findings will be discussed.