Urogynaecology: Urethral retro-resistance pressure and urodynamic diagnoses in women with lower urinary tract symptoms

Correlation between urodynamic tests, history and clinical findings in treatment of women with urinary incontinence

ABSTRACT Objective: The aim of this study was to evaluate the role of urodynamic test in diagnosis of urinary incontinence, comparing detailed data of history and physical examination, and some easy- to-apply clinical tests. Methods: A cross-sectional retrospective study was carried out by reviewing the medical charts of 55 patients with complaint of loss of urine, seen at the Urogynecology Service of Women's Health Outpatient Clinic of Hospital Universitário de Jundiaí, between October 2006 and March 2007. The patients answered a specific questionnaire involving the epidemiological and physical examination variables considered in this study. They were submitted to physical examination and urodynamic tests. Results: The complaint of loss of urine upon exertion, either isolated or associated with urge incontinence, was confirmed by urodynamic tests in most women, and only 4 of 49 symptomatic women had negative results. The clinical sign was present in 35 patients (63.6%), and 46 patients (83.6%) had the exertion component in the urodynamic test. The exertion component was observed in 10 (18%) out of 15 patients without symptoms (30%). The positive and negative predictive values of the clinical sign for diagnosis of any type of urinary incontinence in this studied group were 97.1 and 26.7%, respectively. As for the clinical complaint of urinary loss upon exertion, the positive and negative predictive values for any type of urinary incontinence were 92 and 40%, respectively. For the clinical complaint of urge incontinence, the positive and negative predictive values of 92.5 and 23.1%, respectively. Conclusions: It was concluded that the urodynamic evaluation is an important instrument to evaluate the severity of incontinence, although it was not necessary to diagnose loss of urine. The finding of urinary loss during physical examination had low sensitivity and specificity in diagnosis of the type of loss of urine. Urodynamic tests had better performance in demonstrating urinary incontinence in patients with complaint of incontinence upon exertion and without loss of urine seen upon physical examination than in confirming urge incontinence in patients with those symptoms.

Preoperative urethral parameters at rest and objective cure following laparoscopic colposuspension

INTRODUCTION AND HYPOTHESIS

The aim of this study is to investigate associations between preoperative resting urethral parameters and objective outcome of laparoscopic colposuspension.

METHODS

Data from 219 stress incontinent women who underwent laparoscopic colposuspension, with leakage at standardized pad test repeated after surgery, were collected. Associations between objective cure and preoperative maximum urethral closure pressure, functional urethral length, and continence area were analyzed using receiving operator characteristics curves. The level for 75% cure for each parameter was identified.

RESULTS

All parameters were positively associated with cure. Continence area showed the strongest association. No cut-off values for prediction of failure were found. Women having levels equal or higher than the "75% cure level" for all urethral parameters had a cure rate of 88% compared with 55% for women with all parameters lower than this level.

CONCLUSIONS

A combination of the urethral parameters may be useful for identifying patients with excellent chance for cure after colposuspension. Further studies are needed on continence area.

Urethral retro-resistance pressure: association with established measures of incontinence severity and change after midurethral tape insertion

AIMS

Our study explored the relationship between URP and established measures of incontinence severity. We also report on change in URP after insertion of midurethral tape (MUT).

METHODS

All participants had incontinence secondary to urodynamic stress incontinence only. URP was measured using the Monitorr (Gynecare) device prior to and 3 months after MUT insertion. The following measures of incontinence severity were completed before and 3 months after insertion of MUT: 24-hour pad test; International Consultation on Incontinence Questionnaire for evaluating symptoms and impact of urinary incontinence; King's Health Questionnaire for evaluating disease-specific quality of life and a 3-day urinary dairy with episodes of incontinence recorded.

RESULTS

Preoperative URP and measures of incontinence severity were available for 100 women. Mean URP bore no relationship to the severity of urine loss assessed by 24-hour pad loss. There was no correlation between URP and other measures of incontinence severity. Pre and postoperative URP was available in 73 women. Although 84.9% were objectively cure (24-hour pad test of <5 g) after surgery, pre and postoperative URP was not significantly different [62.7 (+/-19.4) cmH(2)O vs. 61.2 (+/-204) cmH(2)O; p = 0.57].

CONCLUSIONS

Urethral retro-resistance pressure is not a useful measure of urethral function.

The effect of spinal anaesthesia on urethral function

This study was to assess the effect of spinal anaesthesia on urethral retro-resistance pressure (URP), cough pressures and tendency to leak. The population consisted of 32 women undergoing a tension-free vaginal tape (TVT) operation under a spinal anaesthetic. URP, cough pressures and an assessment of the degree of leak were performed before the spinal anaesthetic was placed. A standard anaesthetic technique was used, and measurements were repeated after the spinal anaesthetic was inserted. The degree of leak was assessed on a five-point scale with 350 ml in the bladder. The cough pressures and URP values were averaged over three or more measurements. The mean URP value fell from 75.0 to 54.0 cm/H2O (p = 0.0003) after the spinal was inserted. There was a non-significant fall in mean cough pressure from 85.0 to 67.5 cm/H2O (p = 0.06). The degree of leakage increased (p = 0.005). Spinal anaesthesia causes a fall in the resistance in the urethra but does not cause a significant fall in the pressure generated by a cough. Women are more likely to leak after coughing during the TVT operation under spinal anaesthesia than they are before the spinal is inserted. The cough test under spinal anaesthesia does not mimic the result of coughing without a spinal.

Opening vesical pressure: a new test to discriminate urethral sphincter deficiency?

Urethral sphincter deficiency (USD) is not standardised. Opening vesical pressure could reflect the pressure exerted to overcome urethral resistance during void; thus, we evaluated if it could discriminate USD. Women with urinary symptoms were prospectively assessed with a questionnaire and urodynamics and divided into three groups: urodynamic stress incontinence with USD (group 1), urodynamic stress incontinence related to urethral hypermobility without USD (group 2) and normal urodynamic (group 3). USD was defined as the concomitant presence of severe urodynamic stress incontinence, VLPP <60 cm H2O, MUCP <20 cm H2O and urethral mobility <30 degrees . A total of 145 women were enrolled: 56 in group 1, 50 in group 2 and 39 in group 3. The three groups did not differ for demographics, obstetric and surgical history. The median values for opening vesical pressures were 17.5 (15.6-22.2 95%CI), 30 (27.0-37.3 95%CI) and 30 (30.6-44.2 95% CI) for the groups 1, 2 and 3, respectively. A p value <0.0001 was found when comparing group 1 either with group 2 or 3. Opening vesical pressure is a promising parameter to detect USD.

Use of urodynamics prior to surgery for urinary incontinence: How helpful is preoperative testing?

It has not yet been definitively demonstrated that preoperative evaluation of women with stress urinary incontinence with urodynamic testing enhances presurgical counseling, more effectively models patients' expectations or improves postoperative outcome. Nonetheless, urodynamic testing is frequently utilized in the assessment of women with stress urinary incontinence and clearly accomplishes a number of goals when utilized for this purpose. For example, there are data to suggest that the risk of voiding dysfunction can be mitigated by utilizing data obtained from urodynamic testing to identify women more likely to void ineffectively after conventional stress incontinence procedures. Furthermore, it has been suggested though not proven, that patients with more severe forms of stress incontinence as identified by urodynamic testing, might be less likely to improve after surgery compared to others with more modest degrees of incontinence. Since urodynamic testing is invasive, costly and not always available, it is imperative that the usefulness of such testing be carefully explored and its utility appropriately defined. In this review, we discuss urodynamic techniques to assess stress urinary incontinence, particularly focusing on the ability of leak point pressure testing and urethral pressure profilometry to predict which patients would most likely benefit from surgery and which might be more likely to experience adverse events following surgery.

Clinical experience with urethral retro-resistance pressure measurement: A prospective pre- and postoperative evaluation in women with stress urinary incontinence

AIMS

To identify possible correlations of urethral retro-resistance pressure (URP) with clinically and urodynamically proven stress urinary incontinence (SUI) and the outcome of anti-incontinence surgery.

MATERIALS AND METHODS

URP was measured using the Monitorr system in women with clinically and urodynamically proven SUI without prolapse before and after anti-incontinence surgery (colposuspension n = 8, tension-free vaginal tape n = 6, tension-free transobturator tape n = 34).

RESULTS

Forty-eight women (mean age 61.8 +/- 8.9 years) were evaluated preoperatively and on average 10 weeks postoperatively. Mean URP was 75.6 +/- 20.8 cm H(2)O preoperatively versus 75.4 +/- 17.9 cm H(2)O postoperatively (P = 0.898). The type of anti-incontinence surgery performed had no significant effect on postoperative URP. While no association was found between age and URP (P = 0.35), there was a positive correlation between URP and body mass index (BMI; r = 0.49, P = 0.0004). There was no correlation of URP with the preoperative pad test (P = 0.17) and urethral closure pressure at rest (P = 0.51). Finally, URP did not correlate significantly with the preserved length of the continence zone (0-1/3-2/3-3/3) as determined by the urethral stress profile (P = 0.37-0.72) or with the objective cure rate (negative pad test).

CONCLUSIONS

Preoperative URP does not correlate with SUI in all women, has no predictive value, and does not correlate with the outcome of anti-incontinence surgery. However, there seems to be an association with biomechanical factors such as obesity, which may open up a new area of application for URP measurement in urogynecologic diagnosis.

The relationship of urethral resistance pressure and pressure flow parameters in women with lower urinary tract symptoms

This prospective study aims to evaluate the relationship between urethral resistance pressure (URP) and pressure flow parameters in women with lower urinary tract symptoms (LUTS). Consecutive women with LUTS attending three tertiary referral urodynamic clinics were asked to undergo urodynamic evaluation, pressure flow studies and URP measurement. The pressure flow parameters such as detrusor pressures at the start of flow (ODP), detrusor pressure at peak flow rate (PdetQmax), peak flow rate (Qmax) and detrusor pressure at the end of flow (CDP) were measured. The relationship between URP and pressure flow parameters was evaluated as well as differences between each urodynamic group. Two hundred seventy-nine women attended for urodynamic investigations. Two hundred twenty-three (79.9%) women had good quality pressure flow measurements and were included in the study. The mean age was 58 years (range 21-83). Women with urodynamic stress incontinence had significantly lower URP and ODP than those with detrusor over-activity [54.8 (+/-17.9) and 12.4 (+/-4.1) cmH(2)O, respectively, vs 85.6 (+/-21.4) and 33.7 (+/-13.3) cmH(2)O, respectively) (p<0.05, Bonferroni test). Furthermore, women with urodynamic stress incontinence have significantly lower PdetQmax values as well as higher Qmax than women with competent urethral sphincters (p<0.05, Bonferroni test). There was a significant correlation between ODP, PdetQmax, Qmax and URP measurements. In urodynamic stress incontinence, both URP and pressure flow parameters are reduced. Although the trend for values of both tests were similar and there was a significant correlation between these tests, we should consider that urethral function at rest differ from that during voiding due to activation of additional mechanisms. Therefore, further study is needed to confirm our results.