Urge Incontinence and Detrusor Instability

Detrusor instability is a syndrome of urinary frequency, urgency and urge incontinence which can be demonstrated using urodynamic studies to document uninhibited bladder contractions. Idiopathic cases account for 90% and 10% are related to neurologic disorders. Several different treatment modalities are available, including bladder training/drill, electrical stimulation, medical and surgical therapies.     

Pharmacological Management of Detrusor Instability

Urinary incontinence and lower urinary tract dysfunction remain an important cause of morbidity, affecting at least 14% of women over the age of 30 years. Whilst the etiology and pathophysiology of detrusor instability remains to be elucidated drug therapy remains important in the management of women with the irritative symptoms of urgency, frequency and urge incontinence. The number of drugs which have been developed illustrates the point that none are ideal, often having systemic adverse effects limiting their therapeutic usage and affecting compliance. This review aims to assess the current pharmacological management of detrusor instability as well as examining recent progress in the development of new agents, some of which may prove to be efficacious.     

Evaluation and Management of Lower Urinary Tract Disorders in Women with Multiple Sclerosis

This paper outlines the evaluation and management of the lower urinary tract abnormalities related to voiding function in women with multiple sclerosis (MS). For the pelvic floor reconstructive surgeon, it is important to realize that every patient with MS may have voiding dysfunction unrelated to lower urinary tract symptoms, duration of disease or disability status. Proper evaluation and individualized management of the urinary tract reduces the morbidity and improves the quality of life of patients with this degenerative neurologic disorder.     

The Pain Cycle: Implications for the Diagnosis and Treatment of Pelvic Pain Syndromes

The aim of the study was to report our results of sacral nerve stimulation in patients with pelvic pain after failed conservative treatment. From 1992 to August 1998 we treated 111 patients (40 males, 71 females, ages 46 ± 16 years) with chronic pelvic pain. All patients with causal treatment were excluded from this study. Pelvic floor training, transcutaneous electrical nerve stimulation (TENS) and intrarectal or intravaginal electrostimulation were applied and sacral nerve stimulation was used for therapy-resistant pain. The outcome of conservative treatment and sacral nerve stimulation (VAS <3/10; >50% pain relief) was related to symptoms of voiding dysfunction and dyschezia, and urodynamic proof of dysfunctional voiding, not to the pain localization or treatment modality. Outcome was inversely related to neuropathic pain. When conservative treatment failed, a test stimulation of the S3 root was effective in 16/26 patients, and 11 patients were implanted successfully with a follow-up of 36 ± 8 months. So far no late failures have been seen. A longer test stimulation is needed in patients with pelvic pain because of a higher incidence of initial false positive tests. Our conclusion is that sacral nerve stimulation is effective in the treatment of therapy-resistant pelvic pain syndromes linked to pelvic floor dysfunction.     

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.     

Voiding Dysfunction following TVT Procedure

The aim of the study was to assess the incidence of abnormal voiding in patients who had undergone tension-free vaginal tape (TVT) placement. Women who had undergone a TVT sling procedure for stress or mixed incontinence more than 3 months previously reported their voiding habits (frequency, urgency, nocturia, urinary stream quality and incontinence) over the previous 3 days. A pelvic examination and ultrasound postvoid residual (PVR) were performed. Normal voiding was classified as a PVR <100 ml, frequency of six or fewer voids per day and two or fewer per night, and a urinary stream considered normal by the patient. Subjects were classified as either ‘normal’ (group 1) or ‘abnormal’ (group 2) voiders. Demographic factors, pre-operative urodynamic testing and concomitant surgical procedures were compared between groups. From September 1999 to November 2000, 59 women underwent a TVT procedure. Two were excluded from analysis [cervical malignancy (1), interstitial cystitis (1)]. There were no healing abnormalities and no patients displayed a positive empty bladder stress test. Forty-two (74%) women were included in group 1 and 15 (26%) in group 2. Urinary continence was reported by 49 (86%): 93% in group 1 and 67% in group 2. Factors highly correlated with postoperative voiding dysfunction included abnormal preoperative uroflow pattern and configuration (P = 0.007), preoperative low peak flow rate <15 ml/s (P = 0.049), preoperative vault prolapse or enterocele (P = 0.001), concurrent vault suspension surgery (P = 0.03) and postoperative urinary tract infection (UTI) (P = 0.0006). Preoperative urinary retention (postvoid residual >100 ml) or detrusor instability, age and body mass index differences were not statistically significant. Multivariate analysis revealed that preoperative abnormal uroflow and postoperative UTI were related to group 2 (P = 0.02). Our conclusions were that the TVT sling procedure has success and voiding dysfunction rates similar to those of other proven anti-incontinence procedures. Various factors were shown to be associated with postoperative voiding difficulties. Tension-free placement of the tape may not prevent the development of post-operative voiding dysfunction. Correspondence and offprint requests to: Dr G. Willy Davila, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, Florida 33331, USA. Tel: 888–978–0004; Fax: 954–659–5560; E-mail: davilag@ccf.org     

Evaluation of the Female with Neurogenic Voiding Dysfunction

Neurological disease can have a profound effect on the lower and upper urinary tracts. Symptoms, such as incontinence and inability to void, as well as sequelae of hydronephrosis and renal insufficiency, are not uncommon. It is imperative that neurogenic voiding dysfunction by aggressively treated to avoid these problems. Care of the patient with neurogenic voiding dysfunction starts with an understanding of the neurophysiology of micturition and how this can be affected by various neurological diseases. The clinician must also be able to classify voiding dysfunction through history and physical examination and urodynamic testing so that proper treatment can be instituted.     

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.     

Patient Satisfaction and Complications Following Sacral Nerve Stimulation for Urinary Retention, Urge Incontinence and Perineal Pain: a Multicenter Evaluation

The aim of the study was to determine the success rate, the complications, the failures and the solutions found in troublesome cases. A retrospective study was performed in three university centers in Belgium. Between March 1994 and April 1998, a quadripolar electrode and a pulse generator were implanted in 53 patients (8 men, 45 women, 43 ± 12 years, mean follow-up 24 ± 8 months, range 13–39 months). During the first few months, 45 (85%) of the 53 patients had an objective response. Eight late failures occurred, with a mean failure delay of 9 ± 5 months. We performed 15 revisions in 12 patients. Major complications were pain and current-related troubles. The outcome was significantly better (P= 0.001) in post-stress incontinence surgery patients. Device-related pain was found more frequently in patients with dysuria and/or retention or perineal pain, and the test stimulation was less reliable (P= 0.025) in patients with a psychiatric history. Sacral nerve stimulation is efficient in treating patients with refractory lower urinary tract symptoms and/or perineal pain.     

Female Voiding Dysfunction and Movement Disorders

Voiding dysfunction associated with Parkinson’s disease has been well described in male patients. Few studies detail voiding dysfunction in female Parkinson patients. Apparent differences between patients with Parkinson’s subtypes have also not been sufficiently defined. The majority of female Parkinson patients who have urinary symptoms (>70%) will manifest symptomatic urgency with or without urge incontinence. The remaining patients will have mixed irritative and obstructive or purely obstructive symptoms. Urodynamic evaluation demonstrates detrusor hyperreflexia in 70%–80% of female patients. However, women with Parkinson-related syndromes demonstrate detrusor hypocontractility or areflexia in 20%–30% of cases. Electromyography reveals sphincteric dysfunction (pseudodyssynergia, bradykinesia) in 30%–50% of female Parkinson patients. Also, in patients with Parkinson-related syndromes a high prevalence of peripheral denervation can be documented on electromyographic study of the pelvic floor. Voiding dysfunction associated with Parkinson’s disease in female patients is complex and not always congruent with symptoms. Urodynamic evaluation is crucial to fully elucidate lower urinary tract dysfunction in female patients with Parkinson’s and Parkinson-related disorders.     

Urodynamics in Female Urology

Urodynamics in female urology are often indicated when empiric or conservative treatment does not improve lower urinary tract symptoms. Based on the expected underlying lower urinary tract dysfunction, the urodynamic evaluation is designed by the clinician to reproduce a patient's symptoms and to identify underlying pathophysiological mechanisms, as well as to analyse other functions of the lower urinary tract which may be relevant for planning further (invasive) treatment. In this review, we describe the available urodynamic tests, the normal findings, and the evidence for the role of urodynamics, and on the specific measurements and parameters used to evaluate female lower urinary tract symptoms.In women with a suspected storage dysfunction, filling cystometry allows identification of detrusor overactivity or reduced bladder compliance as possible underlying causation of overactive bladder. Most women with stress incontinence have other storage and/or voiding symptoms and urodynamics should always be performed prior to invasive treatment. In the minority with pure stress urinary incontinence, urodynamic observations can guide the type of surgery chosen, but this has not yet been shown to change treatment outcome.Voiding dysfunction in women has recently received more research attention and various urodynamic parameters are being evaluated on their ability to distinguish detrusor underactivity from bladder outlet obstruction in pressure-flow studies. Video-urodynamics can provide a useful addition when anatomical information is needed in complex patients (eg, prior surgery or neurogenic patients).Finally, ambulatory urodynamics can be used when symptoms cannot be reproduced or explained by conventional urodynamics.     

Can Historical and Functional Risk Factors be Used to Predict Fractures in Community-Dwelling Older Adults? Development and Validation of a Clinical Tool

The objectives of the study were: (1) to evaluate the contribution of impaired functional status, cognition and medication to fracture risk; (2) to determine whether risk factor profiles differ between regionally and socially diverse populations; and (3) to develop and validate a simple fracture prediction instrument for use in older adults using easily obtainable clinical information. A prospective population-based cohort study with 6–10 years of follow-up was carried out: the Duke and Iowa Established Populations for the Epidemiologic Study of the Elderly (EPESE), with in-person interviews in North Carolina and Iowa. The participants were community-dwelling men and women aged 65 years or over without a history of previous fracture at the baseline interview (n = 7654). The measurements were potential risk factors for osteoporosis and falls including: demographic factors, co-morbidities, medications, functional status measures, and physical measures. These were examined for association with self-reported subsequent hip fractures and fractures at any site using survival analysis. The resulting multivariable model was simplified and validated in a separate cohort. Test operating characteristics at 3 years were estimated using logistic regression. There were a total of 842 fractures in both cohorts including 382 hip fractures. Significant risk factors for all subsequent fractures and/or hip fracture in the developmental cohort included female sex (relative hazard 1.9–2.3), lowest quartile of body mass index (1.3), Caucasian race (2.1–2.8), one or more Rosow–Breslau physical function impairments (1.8–2.1), age over 75 years (2.1), history of stroke (1.9), cognitive impairment (2.2), one or more impairments in the activities of daily living (1.5) and anti-seizure medication use (2.0). Three predicitive models were highly significantly correlated with subsequent fractures with c-statistics in the developmental cohort at 3 and 6 years of 0.640–0.789. A simple count of risk factors had similar discriminative ability to the full model with a linear 35–65% increase in hazard of all fractures and hip fracture for each additional risk factor. In the validation cohort, the above variables were less potent predictors of fracture with only sex, body mass index and Rosow–Breslau impairment achieving significance. The predictive models including risk factor count remained significant in the validation set although the discriminative ability of the model was poor, with c-statistics of 0.574–0.749. Although there is no cut-point where fracture risk dramatically increases, patients can be counselled that there is a linear 77% increase in risk of hip fracture, and 29% increase in any fracture risk, with each additional risk factor they possess. Functional status impairment is an important predictor of fracture in older community-dwelling adults. The contribution of risk factors to fracture risk may differ between distinct populations. Received: 28 January 2002 / Accepted: 8 July 2002     

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.     

An Evaluation of the Efficacy of In-Patient Bladder Retraining

This is a retrospective review of 50 consecutive patients with urinary frequency, urgency and urge incontinence, admitted in 1995 and early 1996 for bladder retraining in the form of timed voiding. At discharge 80% of the women were subjectively cured or satisfactorily improved, but this was significantly reduced to 32% of the 37 who replied to a postal survey between 12 and 29 months (mean interval 21.3 months) later. There were no significant associations between outcome and urodynamic diagnosis, reduced cystometric capacity, length of symptomatology, previous treatment or requirement for additional therapy, but this may have been in part due to small numbers. In conclusion, bladder retraining is a method of treatment for patients with both sensory urgency and detrusor instability which appears to be at least as successful as other modes of treatment for these conditions.     

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.     

VLPP in the Evaluation of the Female with Stress Urinary Incontinence

The Valsalva leak-point pressure has become an important urodynamic test in the evaluation of incontinent women. A review of the history of the test, its methodology, and variables that can influence its performance is presented. Correlation with clinical findings, reproducibility and comparison with other urodynamic tests are discussed. Although the test is still evolving and several major variables have been recognized as affecting its results, it remains sound and reliable. It has excellent correlation with the clinical severity of incontinence and a high degree of inter- and intraexaminer reproducibility.     

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.     

Pad Testing in Incontinent Women: A Review

This article reviews the literature on pad-weighing tests used for objectifying and quantifying incontinence in urinary incontinent women. The patients wear pads weighed before and after the test period. A weight gain is taken as a measure of the amount of urine loss. The tests are in principle of two different types: short-term office tests and long-term home tests, and measure different aspects of urinary control and dysfunction. Both have an inherent large intra- and interindividual variability. Pad weight gains obtained from patients referred for incontinence and those from self-reported continent controls overlap to a certain degree, and it is not possible to identify distinct numerical cut-off values separating continence from incontinence. This suggests that incontinence is a complex condition in which the amount of leakage, other sources of weight gain, and differences in the individual patients’ personal characteristics influence the identification and quantification of the problem. In spite of the shortcomings the pad tests remain a valuable tool for both the clinician and the researcher. The home pad tests are superior to the office tests in terms of authenticity, and should be performed with a concomitant systematic registration of the participant’s voidings, fluid intake and episodes of incontinence.     

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.