Incontinence history as a predictor of detrusor stability

Between January 1983 and July 1985, 218 women underwent preliminary evaluation and urodynamic testing in our laboratory. Their symptoms and urodynamic diagnoses were compared to evaluate the ability of a patient's history to predict the stability of the detrusor. The symptom of stress incontinence was a sensitive detector of genuine stress incontinence (100% sensitivity) but was not very specific (65.2%). The symptoms of urgency and urge incontinence were found to have limited sensitivity (77.9%) and specificity (38.7%) in the detection of detrusor instability. Even patients with isolated complaints of stress incontinence had an incidence of detrusor instability of 34.9%, whereas 76.9% of those with a history of isolated urgency and urge incontinence had detrusor instability. Three percent of patients complaining of either type of incontinence had no objective evidence of incontinence on urodynamic investigation. The results of this study demonstrate that a patient's history is a poor predictor of the underlying cause of incontinence.     

Stimulation or blocking of the periurethral region--an expansion of conservative therapeutic measures in irritable bladder and urge incontinence

In an open study we report about the therapeutic influence of neural therapy in the periurethral region in patients with urgency. We treated 50 patients with neurohormonal urgency three times in 2-weeks interval by periurethral injections of 10 ml 0.25% Bupivacaine. Success was controlled in 46 patients with clinical and urodynamical methods. 10% of the least one time treated patients had the same complaints after therapy, 60% were improved by therapy and 30% were free of symptoms. We registered with urodynamic measurements a significant increase of the bladder volume up to the first sensation to void and a significant reduction of the bladder compliance. In a second randomized study the influence of a single acute maximum functional electrostimulation (AMFES) by vaginal electrode was tested. 10 patients with anamnestic urge incontinence in each case with uninhibited detrusor contractions and 10 patients without detrusor contractions was treated. The subjective statements yielded in urge incontinence without detrusor contractions a higher percentage of improvement than in motoric urge incontinence. The urodynamic diagnostic evaluation showed a relation between the unchanged objective conditions and the symptoms of complaint four weeks after treatment in patients with motoric urge incontinence. We recommend the use both of the neural therapy and functional electrostimulation as additional methods besides the dominant medicamentous treatment of the urgency and the urge incontinence.     

Is the irritable bladder associated with anterior compartment relaxation? A critical look at the 'integral theory of pelvic floor dysfunction'

The 'integral theory of pelvic floor dysfunction', first proposed by Petros and Ulmsten in 1990, claims that anterior vaginal wall relaxation is associated with symptoms of urgency, frequency, nocturia and urge incontinence. A retrospective study was designed to test this hypothesis. Imaging data and urodynamic reports from 272 women suffering from symptoms of lower urinary tract dysfunction were evaluated. Opening of the retrovesical angle, bladder neck descent, urethral rotation and descent of a cystocele during Valsalva were used to quantify anterior vaginal wall laxity. None of the tested parameters were associated with symptoms and signs of detrusor overactivity On the contrary, patients with higher grades of urethral and bladder descent were less likely to suffer from nocturia and urge incontinence and were less likely to have sensory urgency and detrusor instability diagnosed on urodynamic testing. The findings of this study therefore do not support this hypothesis of the 'integral theory'.     

Detrusor instability--an important but underestimated factor in urinary incontinence in women

157 consecutive female patients complaining of urinary incontinence were studied by history and urodynamics. 21 of them (13.4%) demonstrated urge-incontinence due to severe detrusor instability, 20 (12.7%) showed mixed (both urge and stress) incontinence, 14 (9%) only detrusor instability and 12 (7.6%)--stress incontinence accompanied by detrusor instability. Pure stress incontinence was diagnosed in 79 cases (50.3%) while 11 patients (7%) manifested no abnormality during the urodynamics. A total of 67 patients (42.7%) showed urodynamic evidence of detrusor overactivity. In 55 (35% of the studied subjects) it was the main urodynamic finding. The prevalence of detrusor instability was higher among those with recurrent incontinence and was the highest (60%) among the women with more than one previous operations. When urge incontinence was present it occurred at detrusor pressures lower than the maximum urethral closure pressure, which implies possible failure of the sphincteric mechanisms associated with detrusor instability. 14% of the women with detrusor instability did not report complaints typical for this disorder but had history of stress incontinence alone. The authors confirm the necessity of objective assessment of the lower urinary tract in all cases with history suspicious of detrusor instability as well as when surgical treatment for stress incontinence is planned.     

The relationship between urinary symptom questionnaires and urodynamic diagnoses: an analysis of two methods of questionnaire administration

OBJECTIVE: To assess whether method of administration of a standard urinary symptom questionnaire alters the relationship of symptoms with urodynamic diagnoses. DESIGN: Randomised crossover study. SETTING: Tertiary Urogynaecology Unit, London, UK. PARTICIPANTS: One hundred and fourteen women attending a tertiary urogynaecology clinic. METHODS: Women were randomised to either an initial interview-assisted questionnaire in the clinic with a follow up postal questionnaire or an initial pre-outpatient questionnaire followed by an interview-assisted questionnaire at the clinic visit. Video cystourethrography or saline cystometry was performed at the clinic visit. MAIN OUTCOME MEASURES: Question responses were compared with urodynamic diagnoses. RESULTS: With an interview method, only severity of incontinence was significantly associated with detrusor overactivity (U= 593.5, P= 0.012). With self-completion, severity of nocturia (U= 477, P < 0.05), urgency (U= 395, P= 0.003), urge urinary incontinence (U= 392, P= 0.003), leakage without warning (U= 443, P= 0.035) and incomplete voiding (U= 413, P= 0.01) were significantly associated with detrusor activity. On interview the symptom of stress urinary incontinence (U= 523, P= 0.002) and use of pads (U= 564.5, P= 0.011) were significantly associated with a diagnosis of urodynamic stress incontinence. Severity of stress urinary incontinence (U= 276, P < 0.001), frequency of leakage (U= 348.5, P= 0.004), use of protection (U= 432.5, P < 0.018), nocturnal incontinence (U= 393.5, P= 0.002) and quantity of leakage (U= 441.5, P < 0.05) on self-completion were strongly associated with diagnosed urodynamic stress incontinence. There was no association between the symptoms of urgency or urge incontinence and the urodynamic stress incontinence. CONCLUSIONS: Postal questionnaire responses have a better relationship with urodynamics, both for urodynamic stress incontinence and detrusor over activity, than interview-assisted questionnaire responses. However, no symptom has a high enough specificity and sensitivity to replace urodynamic testing.     

Patient characteristics that are associated with urodynamically diagnosed detrusor instability and genuine stress incontinence

OBJECTIVE: We sought to compare characteristics of patients with urodynamically diagnosed detrusor instability or genuine stress incontinence. STUDY DESIGN: A retrospective audit of 293 consecutive women who were referred to a urogynecologist for evaluation of urinary incontinence between June 1996 and April 2000. RESULTS: Of the 293 patients, 289 women had a physical examination and urodynamic testing, which revealed genuine stress incontinence (35%), detrusor instability (32%), mixed incontinence (29%), or normal urodynamic function (4%). Compared with patients with detrusor instability, those women with genuine stress incontinence were more likely to be white than African American (P <.0001) and to have a cystocele(P =.027), rectocele (P <.0001), or paravaginal defect (P =.004). No differences in age, gravidity, parity, estrogen treatment, or previous anti-incontinence procedure were identified between women with detrusor instability and women with genuine stress incontinence. CONCLUSION: In a tertiary referral center, the distribution of urinary incontinence is evenly divided among genuine stress incontinence, detrusor instability, and mixed incontinence. Patients with genuine stress incontinence are more likely to be white and to have pelvic floor prolapse and symptoms of pure stress incontinence.     

Which women with stress incontinence require urodynamic evaluation?

OBJECTIVE: This study was undertaken to determine the predictive value of the symptom of stress urinary incontinence and to evaluate the ability of other factors suggested by a published Agency for Health Care Policy and Research guideline for the discrimination of patients unlikely to require urodynamic testing before surgical management. STUDY DESIGN: We evaluated 950 consecutive women without advanced (stage III or IV) pelvic organ prolapse who were referred with symptoms of incontinence. Incontinence was recorded by means of standard forms and was characterized as "any stress loss" (76.4%), "primarily stress loss" (58.9%), "stress loss only" (29.8%), "stress and urge loss" (52.2%), "urge loss only" (13.8%), "constant and stress loss" (1.9%), or "constant loss" (2.3%). Other variables were assessed by means of a standardized history, physical examination (including urethral axis determination and stress test), 1-week urinary diary, and postvoid residual volume measurement. A urodynamic diagnosis of pure genuine stress incontinence was used as the criterion standard. Sensitivity, specificity, and positive and negative predictive values were calculated. Logistic regression models incorporating various combinations of stress loss only, previous prolapse or incontinence surgery, nocturia, voiding frequency, urethral hypermobility, and postvoid residual volume <100 mL (the factors recommended by the Agency for Health Care Policy and Research guidelines), along with age and race as predictors of genuine stress incontinence, were constructed to evaluate the predictive ability of the guideline in a subset of 447 patients for whom data on all variables were available. RESULTS: Of the entire population 480 (50.5%) had pure genuine stress incontinence, 134 (14.1%) had both genuine stress incontinence and detrusor instability, 180 (18.9%) had pure detrusor instability, and 40 (4.2%) had intrinsic sphincter deficiency. Fifty-four (5.7%) had normal study results, and 62 (6.5%) had other nonincontinence diagnoses. Among the subjects with symptoms of stress loss only, 10.8% did not have genuine stress incontinence confirmed on urodynamic examination. Agency for Health Care Policy and Research guideline criteria had excellent discrimination (C statistic of 0.807) compared with the sole criterion of stress urinary incontinence only (C statistic of 0.574), with a positive predictive value of 85.7%. Only 7.8% of subjects met all the criteria, however, and 5.7% of these ultimately had a urodynamic diagnosis of either detrusor instability or normal study result. CONCLUSION: The predictive value of stress symptoms alone was not high enough to serve as the basis for surgical management. Agency for Health Care Policy and Research guidelines improved the predictive value but were applicable to only a small subset of patients referred with urinary incontinence.     

A urosynamic analysis of micturition symptoms in the female.

The presenting symptoms of 570 females with micturition disorders have been studied with particular reference to the urodynamic state of the detrusor in an attempt to define those symptoms and symptom complexes which are associated with the presence of absence of detrusor instability. The results show that patients who complain of recurrent urinary tract infection or stress incontinence in the absence of any other micturition symptoms usually have stable bladders and do not require cystometric confirmation of this fact. When the symptom of urge incontinence is associated with persistent frequency and nocturia, there is a high correlation with detrusor instability, although hypersensitive urethral states which may present with identical symptoms and are usually associated with stable bladders are difficult to differentiate clinically. Groups of patients in whom it was difficult to predict the detrusor state from the symptoms were studied, and the results of a prospective analysis, predicting the detrusor state from the micturition history of 230 incontinent females, have been presented.     

Detrusor instability following colposuspension for urinary stress incontinence

Summary. Sixty-two patients with genuine stress incontinence (group A) and 30 women with combined detrusor instability and genuine stress incontinence (group B) had a colposuspension operation. The proportion with symptoms of detrusor instability was significantly reduced from 24% before operation to 9% after operation in group A and from 73% to 33% in group B. Urodynamically, detrusor instability developed after surgery in 17 of the 62 patients (27%) in group A whereas only 12 of the 30 women (40%) in group B had detrusor instability after surgery. No urodynamic explanation was found to explain the effect of colposuspension in relieving the symptoms of detrusor instability in some and causing them in others. Nevertheless, it is suggested that colposuspension is helpful for most patients with combined detrusor instability and genuine stress incontinence.     

Ultrasound assessment of bladder wall thickness as a screening test for detrusor instability

Purpose

The aim of the current study was to evaluate the diagnostic accuracy of transvaginal ultrasound measurement of bladder wall thickness (BWT) in diagnosis of over active bladder (OAB).

Methods

The current prospective study was conducted at Ain Shams University Maternity Hospital over 2 years. Patients presented to the urogynecology outpatient clinic with symptoms of urinary frequency, urgency, nocturia and/or urge incontinence were included in this study. The allocated patients were divided into two groups; Group 1(study group): fifty (50) patients with urodynamic diagnosis of detrusor instability (OAB) were included. Group 2 (control): fifty (50) patients with urodynamic diagnosis of stress incontinence were included. Using a transvaginal probe, BWT was measured in three sites at the thickest part of (a) the dome of the bladder (b) the trigone, and (c) the anterior wall of the bladder. An average of the three measurements was considered as the mean bladder thickness.

Results

A total of 100 patients with lower urinary symptoms were finally analyzed. There were no statistical significant differences between both groups regarding age, parity and body mass index, while there was statistically longer disease duration in group 2. Excluding urgency, there was statistical significant difference (P < 0.001) regarding lower urinary tract symptoms namely frequency, urgency incontinence, coital incontinence and nocturia. Patients in group 1 were more positive to symptoms of frequency, urgency incontinence, and nocturia, while patients in group 2 were more positive regarding coital incontinence. The thickness of trigon, dome, anterior wall and mean BWT was significantly higher in group 1 when compared to group 2. Receiver operator characteristics curve was constructed for estimating the association between mean BWT and prediction of OAB in patients with lower urinary tract symptoms. Mean BWT at 4.78 mm was considered as best cut-off value for prediction of OAB with sensitivity of 90 % and specificity of 78 %. Mean BWT was significantly associated with OAB > 4.78 mm as denoted by the significantly large area under the curve [AUC], AUC was 0.905.

Conclusion

In women with lower urinary tract symptom, transvaginal ultrasounds measured mean BWT seems to be an effective non invasive diagnostic tool for prediction of OAB.     

Reliability of the patient's history in the diagnosis of urinary incontinence

The reliability of a patient's history has been challenged in the preoperative evaluation of stress urinary incontinence. In this study, 122 consecutive patients referred to our Gynecology/Urology clinic were evaluated and an additional 32 control patients (continent women with no urinary symptoms) were evaluated. All patients answered a detailed 64-item questionnaire, and all patients received a complete urodynamic evaluation. Our detailed questionnaire provided a mean positive predictive value of 80% for genuine stress incontinence and 25% for detrusor instability. The conditions leading to a false positive history suggestive of genuine stress incontinence were detrusor instability and urethral diverticulum. The conditions leading to a false positive history suggestive of detrusor instability were urethritis, unstable urethra, vaginitis and polyuria. History alone can be misleading in diagnosing urinary incontinence.     

Management of coexistent stress and urge urinary incontinence

Fifty-two patients with objective evidence of pressure equalization incontinence and detrusor instability were evaluated retrospectively to compare nonsurgical modes of therapy with retropubic surgery. Based on the patient's desire for surgery and her overall medical condition, 27 women were treated primarily with retropubic urethropexy (modified Burch procedure) and 25 with various combinations of oxybutynin, imipramine, and estrogen. Thirty-two percent of the patients treated medically were cured and 28% were markedly improved, whereas 59% of patients treated surgically were cured and 22% improved. There was no statistically significant difference in the results between medical and surgical therapy. All failures in the surgically treated group were due to persistent detrusor instability after surgery. We identified no preoperative urodynamic criteria that consistently and accurately predicted surgical outcome in patients with combined stress and urge incontinence. Patients with combined stress incontinence and detrusor instability should initially be managed medically, as this will reduce the incidence of surgical intervention.     

The Stamey operation for correction of genuine stress incontinence in the elderly woman

Forty-four elderly women underwent the Stamey procedure for urethral sphincter incompetence; six had coincidental detrusor instability. All had pre- and postoperative urodynamic assessment. At follow-up, 15 patients continued to complain of stress incontinence and 11 of urge incontinence. Overall, 27 patients still had objective evidence of genuine stress incontinence, and 15 had evidence of detrusor instability. Although the operation has minimal operative and postoperative morbidity, we do not consider its success rate satisfactory for use in the elderly.     

Detrusor overactivity

Urodynamic detrusor overactivity is defined as the urodynamic observation of involuntary detrusor contractions during the filling phase that may be spontaneous or provoked associated with urgency. The most common symptoms are urgency, nocturia, frequency and urge incontinence. Causes include idiopathic, neurological and iatrogenic, and the diagnosis by definition requires urodynamic investigations. Treatment comprises conservative measures such as lifestyle changes and bladder retraining. The most commonly used medical management is anticholinergic medication, but this is of limited efficacy due to the side effects of dry eyes, dry mouth and constipation. Any role of conventional surgery is diminishing with the advent of botulinum A toxin therapy and tends to be reserved for patients in whom all other forms of treatment have failed and quality of life is severely affected. In the future, sympathetic modulators or purinergic blockade may offer treatment with fewer side effects.     

Clinical and urodynamic effects of anterior colporrhaphy and vaginal hysterectomy for prolapse with and without incontinence

Summary. The clinical and urodynamic effects of anterior colporrhaphy and vaginal hysterectomy were studied in 73 patients, of whom 29 had incontinence due to urethral sphincter incompetence. Pre- and post-operative urodynamic assessment was made and follow-up continued for 2 years. Symptoms of urge incontinence, stress incontinence and prolapse were significantly reduced following surgery. Urodynamic data showed no significant change. The incidence of detrusor instability and voiding difficulties was not increased.     

The Stamey operation for correction of genuine stress incontinence in the elderly woman

Summary. Forty-four elderly women underwent the Stamey procedure for urethral sphincter incompetence; six had coincidental detrusor instability. All had pre- and postoperative urodynamic assessment. At follow-up, 15 patients continued to complain of stress incontinence and 11 of urge incontinence. Overall, 27 patients still had objective evidence of genuine stress incontinence, and 15 had evidence of detrusor instability. Although the operation has minimal operative and postoperative morbidity, we do not consider its success rate satisfactory for use in the elderly.     

Prevalence of faecal incontinence among women with urinary incontinence

Four hundred and sixty-five women attending a urodynamic clinic were interviewed, and completed a detailed bowel questionnaire, about their urinary and bowel symptoms. All the women underwent video-cystourethrography with pressure and flow studies. The reported incidence of faecal incontinence was 15.3% (   n = 71  ) on direct questioning and 26% 0(  n = 121  ) on the postal questionnaire. Faecal incontinence was more common in women with a urodynamic diagnosis of detrusor instability (30'%1 (   n = 26  )) than among women diagnosed as having genuine stress incontinence (21% (   n = 38  )). Denervation and myogenic injuries sustained during childbirth have been suggested as a common cause for genuine stress and faecal incontinence, but there may be an alternative mechanism to explain why women with detrusor instability suffer from faecal incontinence.     

Cost-effectiveness of urodynamic testing before surgery for women with pelvic organ prolapse and stress urinary incontinence

OBJECTIVE: This study was undertaken to compare cost-effectiveness between 2 preoperative testing strategies for women with pelvic organ prolapse and stress urinary incontinence symptoms. STUDY DESIGN: We developed decision-analytic models that evaluated the cost-effectiveness of basic office evaluation before surgery in women with prolapse and stress urinary incontinence symptoms and contrasted it with that of urodynamic testing. Costs were obtained from the Federal Register; effectiveness of treatment for urinary incontinence was based on the published literature. RESULTS: The strategies of basic office evaluation and urodynamic testing had the same cure rate of urinary incontinence (96%) after initial and secondary treatment. Under baseline assumptions incremental cost-effectiveness (cost for single extra cure of urinary incontinence) of urodynamic testing was $328,601. According to sensitivity analyses, basic office evaluation was more cost-effective than urodynamic testing when the prevalence of pure detrusor instability was <8% or when the cost of urodynamic testing was >$103. CONCLUSION: Urodynamic testing before surgery in women with prolapse and stress urinary incontinence symptoms is not cost-effective relative to basic office evaluation.     

Pure stress leakage symptomatology: is it safe to discount detrusor instability?

OBJECTIVE: To determine whether the combination of a urological history and urinary diary, with rigorous selection criteria, can be used to define a group of women on whom urodynamic assessment is unnecessary prior to offering surgery for urinary stress incontinence. DESIGN: Retrospective review of the urodynamic records of women attending for assessment between January 1992 and December 1996. SETTING: Urodynamic Department, Southmead Hospital, Bristol. POPULATION: 5193 women who attended the urodynamic clinic during the five year study period. METHODS: Self-completion of a urinary diary in the preceding week before urodynamic assessment and a detailed urological history before undergoing cystometry by all women in the study period. Data were entered onto a computer database. Women reporting stress incontinence in the absence of bladder filling symptoms, with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once, had the results of their filling cystometry analysed. RESULTS: Of 5193 women, 555 had symptoms of pure stress incontinence and a normal urinary diary. Incontinence was confirmed objectively in 81%, with 9% having incontinence secondary to detrusor instability; 5% had detrusor instability as the sole cause of their incontinence with 4% having a mixed picture of detrusor instability incontinence and urethral sphincter weakness. CONCLUSION: Genuine stress incontinence cannot be diagnosed reliably from a urological history, even when rigorous selection criteria are used in combination with a normal urinary diary. Without cystometry, incontinence secondary to detrusor instability will be missed.     

Urinary nerve growth factor levels in overactive bladder syndrome and lower urinary tract disorders

Overactive bladder (OAB) is a syndrome based on self-reported symptoms of urgency and frequency with or without urge incontinence. Although urgency is the core symptom of OAB, patients might have difficulty to distinguish urgency from the urge to void. Urodynamic study is a useful diagnostic tool to discover detrusor overactivity (DO) in patients with OAB; however, not all OAB patients have DO. Therefore, a more objective and non-invasive way to diagnose and assess OAB including DO is needed. Recent research has focused on urinary biomarkers in assessment of OAB. Urinary nerve growth factor (NGF) level increases in patients with OAB-wet, bladder outlet obstruction, mixed urinary incontinence and urodynamic DO. Urinary NGF levels are correlated with severity of OAB symptoms. In patients with OAB and DO who have been well treated with antimuscarinics or botulinum toxin injection, urinary NGF levels have been shown to decrease significantly in association with reduction of urgency severity. However, not all patients with OAB have an elevated urinary NGF level. It might also be increased in patients with interstitial cystitis/painful bladder syndrome, cerebrovascular accident and lower urinary tract diseases such as urinary tract stone, bacterial infection and urothelial tumor. It is possible to use urinary NGF levels as a bio-marker for diagnosis of OAB as well as for the assessment of therapeutic outcome in patients with OAB or DO. Here, we review the latest medical advances in this field.