Morbidity of Urodynamic Investigation in Healthy Women

The morbidity of diagnostic catheterization in healthy women has never been described. In order to further elucidate the natural history of postcystometry bacteriuria we studied a group of healthy women without lower urinary tract symptoms. Thirty female volunteers aged 39–72 years underwent urine sampling prior to and at day 3 after invasive urodynamic evaluation. One case of asymptomatic bacteriuria was detected among pretest samples. On post-test sampling 10 of 29 cultures were positive. With a cut-off level of >10⁵ CFU/ml only 2 cases could be classified as significant bacteriuria. Only 1 was symptomatic. The remaining 29 women had no symptoms following the examination. Thus the incidence of lower urinary tract infection was 3.3% following repeated diagnostic catheterization. We concluded that although bacteriuria is common after diagnostic catheterization, it is essentially asymptomatic.     

Cystometry Techniques in Female Infants and Children

Cystometry is increasingly used in children, being an important diagnostic tool for congenital and acquired malformations such as neurogenic bladder, vesicoureteric reflux, urinary tract infection, urge syndrome, nocturnal enuresis, urinary incontinence and anorectal malformations. During cystometry bladder storage and voiding function can be evaluated. Carefully conducted urodynamic studies provide an insight into the pathophysiologic mechanisms involved in voiding dysfunctions that cannot be obtained by any other diagnostic technique. A variety of methods are available, the most sophisticated being filling and voiding cystometry with flowmetry and electromyography (EMG) under fluoroscopy, i.e. videocystometry. A detailed home recording of the frequency and volume of micturition can provide important clues as to the underlying bladder dysfunction, and can significantly aid in the choice of appropriate investigative techniques, as well as in the interpretation of subsequent urodynamic findings. It must be realized that urodynamic studies are invasive procedures and that artifacts may occur and influence the correct interpretation of the results. Infants and children have a different spectrum of bladder dysfunctions from adults and are generally much less cooperative during a urodynamic study. Therefore, cystometric techniques must be significantly modified. This article reviews cystometry techniques and their application in female infants and children. Cystometry/flow/EMG studies with or without fluoroscopy, ambulatory urodynamics and telemetric urodynamic measurement and their application are outlined.     

A Critical View on the Value of Urodynamics in Non-Neurogenic Incontinence in Women

The requirements for reliable urodynamics are standardized techniques, including uniform pressure sensors, filling rates, position and posture during the investigation, and uniform diuresis. Physiological variations in flow and urethral pressure profile (UPP) (menstrual cycle, intensity of coughing, circadian variations) must be considered. Parameters of the UPP (maximum (closure) urethral pressure, pressure–transmission ratio and leak-point pressure) are useful if interpreted with caution. Uninhibited detrusor contractions are more frequently recorded in ambulatory urodynamics, and range from ‘subthreshold’ to very strong. No quantification formulae correlate with subjective symptoms or degree of urge (incontinence). Mixed incontinence can make the results of surgery worse, but do not so necessarily. Postoperative dysuria cannot be predicted from urodynamics, as surgical factors are more important. Electromyography is not useful in non-neurogenic female incontinence. For routine non-neurogenic incontinence extensive urodynamic testing can be reduced to one pressure measurement; more complicated cases must be tested by a physician with large practical experience and a theoretical background.     

A Prospective Clinical and Urodynamic Study of Bladder Function During and After Pregnancy

The aim of the study was to determine whether clinical and/or urodynamic changes in bladder function occur during pregnancy. Assessment consisted of a urinary symptom questionnaire, urogynecological examination and urodynamic investigations, which were repeated 6 weeks after pregnancy. Sixty-six patients had the initial and 40 the follow-up assessments. Statistical analysis was done by 95% confidence intervals (95% CI). Nocturia, frequency, dysuria, urgency and stress incontinence occurred significantly more frequently during pregnancy. Urinary tract infection was diagnosed in 18% of patients during pregnancy and asymptomatic bacteriuria in 9%. Genuine stress incontinence was diagnosed in 12% during pregnancy and in none after pregnancy (95% CI 1% to 24%). An unstable detrusor was diagnosed in 23% of patients during pregnancy and in 15% after pregnancy (95% CI –8% to 23%). Strong desire to void, urgency, maximum cystometric capacity, maximum flow rate and average flow rate were all statistically significantly decreased during pregnancy. It is concluded that significant changes occur in bladder function during pregnancy.     

Antibiotic Treatment to Prevent Urinary Tract Infections after Urodynamic Evaluation

The aim of the study was to determine the efficacy of cotrimoxazole administration after urodynamic testing to prevent urinary tract infections. In a single-blind prospective randomized study 94 women who attended for urodynamic evaluation were included. After multichannel urodynamic testing, including two catheterizations, the women received a single dose of cotrimoxazole or placebo. A clean-catch urine specimen was tested for infection after 1 week. Seventy women returned a urine specimen after 1 week: 2/37 (5.4%) in the treatment and 2/33 (6.1%) in the placebo group had acquired a new urinary tract infection after urodynamics. One major and one minor adverse reaction to cotrimoxazole were reported. The power of the sample size was unfortunately too small to draw conclusions as to the efficacy of prophylaxis.     

Urodynamic Assessment of Voiding Dysfunction and Dysfunctional Voiding in Girls and Women

Voiding dysfunction is defined as impaired bladder emptying, and presents with a mixture of lower urinary tract symptoms. Dysfunctional voiding is a condition in which there is a lack of coordination between the sphincter and detrusor during emptying in a patient without overt uropathy or neuropathy. Assessment of voiding dysfunction is important in women and girls in the prevention and treatment of urinary incontinence, retention, urinary tract infection and subsequent kidney damage. Accurate diagnosis is essential in order to select the correct treatment. Screening can be done by history-taking: symptom scores can help to guide the screening. More objective measures are uroflowmetry, ultrasonography and videourodynamics. The latter is the gold standard for the diagnosis of voiding dysfunction and consists of simultaneous registration of pressure in the bladder and rectum and external sphincter behavior, either by electromyographic recording of pelvic floor activity or by pressure recording at the external sphincter, during the whole bladder cycle of filling and emptying. On fluoroscopy the bladder can be visualized throughout the filling and emptying phase. In dysfunctional voiding, hypertonicity and instability of the external urethral sphincter during filling cystometry and impaired external sphincter relaxation during emptying are pathognomonic findings. Pressure–flow analysis reveals no obstruction and the detrusor contractility is low.     

Cystoscopic Confirmation of Inadvertent Ureteral Catheterization during Cystometry

A patient in whom the right ureter was inadvertently catheterized at the time of cystometry is described. Upon filling, the patient immediately developed severe colicky right flank pain and the vesical pressure of 150 cmH₂O triggered the pump’s automatic shut-off mechanism. Cystoscopy was performed and confirmed the inadvertent placement of the microtip catheter in the right ureteral orifice. After the catheter was repositioned, symptoms resolved and the remainder of the examination was performed routinely, with normal vesical and urethral pressures.     

Intraurethral Ultrasonography: Correlation of Urethral Anatomy with Functional Urodynamic Parameters in Stress Incontinent Women

To determine whether differences in functional urodynamic parameters can be explained by changes in urethral anatomy, 39 patients underwent intraurethral ultrasonography to obtain a 360° view of the urethra. The point of maximal rhabdosphincter thickness was identified in all patients. The thickness, circumference and area of the urethral smooth and skeletal muscle layers were calculated. Data from patient histories and urodynamic evaluations were compared with this anatomical survey. The urodynamic diagnoses were as follows: 10 patients were normal, 24 had genuine stress incontinence and 5 had intrinsic sphincter deficiency. These patients had decreasing rhabdosphincter thicknesses of 3.91, 3.35 and 2.70 mm (P= 0.048). A weak linear relationship was found between maximal urethral closure pressure and rhabdosphincter (r= 0.40, P= 0.013) and longitudinal smooth muscle (r= 0.35, P = 0.027) thickness. It was concluded that a loss of urethral resistance as measured by maximal urethral closure pressure is associated with changes in urethral anatomy identified by intraurethral ultrasonography.     

Ambulatory monitoring

Ambulatory monitoring has been hailed as the ‘way forward’ in urodynamic investigation. Its introduction has caused much excitement and there is no doubt that it detects more abnormalities than does conventional cystometry. It is, however, labour intensive and time consuming for both operator and patient, and requires commitment from both to be successful. No standards have been set as to how long a test ought to last, how many voids are required and how to interpret traces. To date the standard cystometric criteria of normality have been applied, but this would appear to be inappropriate. Several commercial companies have developed systems and are marketing them widely as an adjunct, or alternative, to conventional cystometry. It is recommended that before this technique is introduced into routine clinical practice it is fully evaluated, with standardization of terminology relating to its use.     

Bladder Augmentation Techniques in Women

Augmentation cystoplasty is performed in women for a variety of indications, including neurogenic bladder dysfunction, inflammatory diseases, small fibrosed bladders, idiopathic urge incontinence and enuresis. The preoperative evaluation, surgical techniques and postoperative management are reviewed. Complications of stone formation, urinary tract infections, mucus production, metabolic disturbances, hematuria and dysuria syndrome, tumors and perforations are addressed. In addition, alternative techniques such as ureterocystoplasty, autoaugmentation, seromuscular cystoplasty and the future of augmentation of the bladder utilizing techniques of tissue engineering are discussed. The management of pregnancy in women who have previously undergone augmentation cystoplasty is also reviewed.     

Predictive Value of Clinical Evaluation of Stress Urinary Incontinence: A Summary of the Published Literature

Our objective was to evaluate the symptom and sign of stress incontinence in predicting the presence of urodynamically diagnosed genuine stress incontinence (GSI). The study was a computation of the sensitivity and predictive values from the published literature (1975–1998), evaluating the history and/or physical examination for the diagnosis of GSI, with calculation of efficacy variables. Results show that the isolated symptom of stress incontinence has a positive predictive value (PPV) of 56% for the diagnosis of pure GSI and 79% for GSI with additional abnormalities. The PPV of stress incontinence in association with other symptoms is 77% in detecting GSI (with or without additional abnormalities). A positive cough stress test has a PPV of 55% for detecting pure GSI and 91% for the mixed condition (GSI plus additional diagnosis). When isolated, the symptom or the sign of stress incontinence is a poor predictor of GSI. In combination, the prediction may be more promising.     

Repeatability of Cystometry and Pressure–Flow Parameters in Female Patients

The repeatability of cystometric and pressure–flow data was studied in 31 female patients. The measured parameters had poor correlation coefficients, and logarithmic transforming of the data was generally not warranted. Previous studies and statistical methods of reliability measurement are reviewed. It is suggested as a subject for future studies, that urodynamic measurements are repeated in each patient so that confidence limits can be established within disease entities.     

‘Nerve-Sparing’ Cystectomy in Women

Although the indications for cystectomy other than for cancer are few, it is occasionally necessary for severe interstitial cystitis or hemorrhage due to radiation cystitis. The use of substitution cystoplasty after cystectomy has increased in men in the last decade, and this has resulted in the development of ‘nerve-sparing’ approach to cystectomy to improve continence and potency. The use of substitution cystoplasty in women after cystectomy has lagged behind that in men because it was considered necessary to remove the entire urethra, making orthotopic substitution impossible. Recently the need to remove the entire urethra has been questioned, with the finding that if the bladder neck is free of tumour, recurrence of disease in the urethra has not so far been found to occur. In addition, it appears possible to substitute on to the urethra without incontinence. This has led to the development of a ‘nerve-sparing’ technique of cystectomy, and renewed interest in the anatomy of the urethra. This paper reviews the current literature on ‘nerve-sparing’ cystectomy and describes our technique.     

Bladder Substitution in Women

Although numbers are still small and follow-up is often limited, female orthotopic bladder reconstruction has been shown to provide excellent, near-normal voiding and storage function in selected patients, and its popularity has been growing over the last decade. The true role of this form of surgery, however, is not yet fully established. This paper discusses the indications for patient selection, operative technique and outcome of female bladder substitution. Outcome is equivalent to that seen in male patients, although in some series there is a higher rate of voiding dysfunction requiring intermittent self-catheterization. Although further data regarding urethral recurrence rates are awaited, it would seem that with careful patient selection and operative technique, cancer surgery may not be compromised. Functional results have been excellent and patient satisfaction is very high. Provided there is a functional external sphincter and tumor margins can be safely cleared, this form of surgery offers patients the best opportunity to preserve quality of life following cystectomy.     

The Effect of Patient Position on Leak-Point Pressure Measurements in Women with Genuine Stress Incontinence

The aim of this study was to determine the quantitative and qualitative effects of patient position on coughing and Valsalva leak-point pressure in women with genunie stress incontinence. Thirty-seven patients with genuine stress incontinence and 4 with mixed incontinence underwent multichannel urodynamics using a standardized protocol. Leak-point pressures were performed using 8 Fr microtip catheters placed in the bladder and vagina at a bladder volume of 250 ml in the supine, semirecumbent and standing positions. Urethral pressure profilometry was performed in the semirecumbent position at a bladder volume of 250 ml. The mean (range) age, and median (range) gravidity, parity, body mass index (BMI), and mean (range) Q-tip deflection angle were 61 years (36–80), 3 (1–8), 3 (1–6), 26 (22–30) and 55.8° (25°–80°), respectively. The mean (± standard deviation) Valsalva leak-point pressures in the supine, semirecumbent and standing positions were 82 ± 23, 73 ± 24 and 63 ± 22 cmH₂O, respectively (P<0.001). The mean (± standard deviation) cough leak-point pressures also decreased as the patients were moved from the supine (98 ± 29 cmH₂O) to the semirecumbent (88 ± 24 cmH₂O) and standing positions (77 ± 24 cmH₂O) (P<0.001). The correlation between leak-point pressure and maximum urethral closure pressure was statistically significant and was dependent upon patient position and the provocative maneuver used.     

Use of the Artificial Urinary Sphincter in Women

Persistent urinary incontinence after failed surgical repair can be successfully treated with the artificial urinary sphincter. The English literature was reviewed from 1985 to 1996. Eleven articles and abstracts addressing placement of the artificial urinary sphincter in women were identified. Discussion includes two operative techniques. Success rates were in the range of 91%–99%. Erosion rates were 7%–29%. The artificial urinary sphincter is an effective treatment for women failing other procedures. Appropriate work-up and diagnosis for type III stress urinary incontinence is crucial.     

Retropubic Urethropexy (Burch Colposuspension)

Many varied procedures have been described for the surgical treatment of female stress incontinence. Over the years these have had enthusiastic proponents, but not until the recent publication of two systematic literature reviews did their relative efficacies become apparent. At present it would appear that open suprapubic urethropexy is the current ‘gold standard’ procedure. Many new minimal-access techniques aimed at reducing the morbidity of a Burch colposuspension have been proposed. However, careful analysis of the medium- to long-term success of these procedures and their associated complications is needed before they are adopted universally.     

Pharmacologic Causes of Female Incontinence

The etiology of female urinary incontinence is complex and multifactorial. Many medications have adverse effects on the lower urinary tract, including the promotion of incontinence in certain women. Medications may cause incontinence through three main mechanisms: decreased intraurethral pressure, increased intravesical pressure, and indirect effects on the lower urinary tract. Careful adjustments of a patient’s medications based on a knowledge of pharmacologic mechanisms of action may restore continence in some women.     

Voiding Dysfunction in Women with Diabetes Mellitus

Voiding dysfunction is a common finding in women with diabetes mellitus. A full spectrum of bladder dysfunction, from areflexia to detrusor instability, can result. Urodynamics is frequently required to identify the specific disorder. Current concepts regarding the evaluation and treatment of these patients are reviewed.     

Evaluation of Pelvic Floor Muscle Strength Using Four Different Techniques

The aim of the study was to evaluate whether four different techniques were able to correctly measure pelvic floor muscle strength only. Sixteen volunteers performed a set of muscle contractions using the pelvic floor muscles (PFM) only, the abdominal muscles with and without PFM, gluteal muscles with and without PFM, adductor muscles with and without PFM and Valsalva maneuver with and without PFM. Pelvic floor muscle strength was evaluated by digital palpation, intravaginal EMG, pressure perineometry and perineal ultrasound. A “non-pelvic muscle induced” reading was defined as a significant increase even though the pelvic floor muscles were not contracted. Results were as follows: isolated abdominal muscle contraction: non-pelvic muscle induced readings in 3/8 women with EMG and in 3/8 with pressure perineometry; isolated gluteal muscle contraction: non-pelvic muscle induced readings in 1/2 women with EMG perineometry; isolated adductor muscle contraction: non-pelvic muscle induced readings in 6/11 women with EMG perineometry and in 2/11 women with pressure perineometry; Valsalva maneuver: non-pelvic muscle induced readings in 4/9 women with EMG perineometry and 9/9 women with pressure perineometry. It was concluded that EMG and pressure perineometry do not selectively depict pelvic floor muscle activity.