The supine stress test: a simple method to detect intrinsic urethral sphincter dysfunction

The Role of the Supine Empty Stress Test in the Evaluation of Women with Stress Urinary Incontinence: A Retrospective Cohort Study

The International Continence Society recommends the supine empty stress test (SEST) as an accessory test in the evaluation of women with urinary incontinence, especially for the presence of intrinsic sphincter deficiency (ISD). The aim of this study was to investigate the relationship between the SEST and clinical findings in women diagnosed with stress urinary incontinence with single voiding cycle ambulatory urodynamics (AUM). AUM tracings of patients with lower urinary tract symptoms (LUTS = Lower urinary tract symptoms) (n = 513) were retrospectively reviewed, and 364 charts with urodynamic SUI were analyzed. Demographics, examination findings, scores of the Sandvik Incontinence Severity Index and validated questionnaires, and AUM findings were compared between SEST-positive and -negative groups. Additionally, the diagnostic accuracy of the SEST in the diagnosis of low abdominal leak point pressure (ALPP ≤ 60 cm H2O) in women with pure urodynamic SUI was calculated. The SEST was positive in 41.8% (n = 152) of the cohort. Women with a positive SEST had higher scores on the Sandvik severity index (9.2 ± 3.6 vs. 7.5 ± 3.8, p = 0.003) and lower ALPP (79.6 ± 29.3 vs. 98.4 ± 31.3, p < 0.001). The negative predictive value of the SEST for ISD was found to be 92.4%. Thus, the SEST seems to be an objective clinical test reflecting urinary incontinence severity while excluding the presence of ISD.

Does videourodynamic classification depend on patient positioning in patients with stress urinary incontinence?

INTRODUCTION AND AIMS

Videocystometrogram (VCMG) is used to assess patients with SUI. A common classification system of SUI is the Blaivas and Olsson classification. The position this grading is performed in has never been established.

MATERIALS AND METHODS

One hundred twenty-one women complaining of SUI refractory to conservative measures had video-urodynamic assessment prior to operative intervention. Grading of stored video SUI image traces was assessed as per Blaivas and Olsson criteria by two independent investigators whilst women were both lying and standing with bladder at maximum cystometric capacity.

RESULTS

Seventy-two (56.7%) patients' grading remained the same in both lying and standing positions. 49(40.5%) patients' grading altered on standing. twenty had non-demonstrable incontinence converted to demonstrable incontinence and 29 had demonstrable incontinence on lying that changed grading on standing; 22 of these by one grade and seven by two grades (from I to IIb). A Fisher's exact test demonstrated a statistically significant difference in the distribution of SUI grading between supine and standing positions (P < 0.01).

CONCLUSION

40.5% of women have a changed Blaivas and Olsson grade of SUI when assessed standing as opposed to lying. This has implications for surgical treatment options and patient counselling. While the Blaivas and Olsson grading system for SUI is simple and reproducible there is little standardisation as to which position this grading is to be performed. We recommend that an international consensus is agreed upon in order for results to be comparable and to help with future outcome studies.

Urinary incontinence in women

Urinary incontinence symptoms are highly prevalent among women, have a substantial effect on health-related quality of life and are associated with considerable personal and societal expenditure. Two main types are described: stress urinary incontinence, in which urine leaks in association with physical exertion, and urgency urinary incontinence, in which urine leaks in association with a sudden compelling desire to void. Women who experience both symptoms are considered as having mixed urinary incontinence. Research has revealed overlapping potential causes of incontinence, including dysfunction of the detrusor muscle or muscles of the pelvic floor, dysfunction of the neural controls of storage and voiding, and perturbation of the local environment within the bladder. A full diagnostic evaluation of urinary incontinence requires a medical history, physical examination, urinalysis, assessment of quality of life and, when initial treatments fail, invasive urodynamics. Interventions can include non-surgical options (such as lifestyle modifications, pelvic floor muscle training and drugs) and surgical options to support the urethra or increase bladder capacity. Future directions in research may increasingly target primary prevention through understanding of environmental and genetic risks for incontinence.

Self-created transobturator tape treatment of stress urinary incontinence without prior urodynamic investigation

OBJECTIVES

The purpose of this study was to evaluate and compare the results of tension free self-created transobturator tape (SCTOT) with the standard industrially created transobturator tape (ICTOT) in the treatment of stress urinary incontinence (SUI).

STUDY DESIGN

A prospective study of the treatment of SUI with SCTOT (67 patients) and ICTOT (47 patients) was performed. SCTOT was created from polypropylene mesh and monofilament sutures. The symptoms were evaluated before and after the surgery with the following: the Incontinence Impact questionnaire (IIC-7), the urogenital distress inventory (UDI-6), and the International Continence impact questionnaire short form (ICIQ5-SF). The overactive bladder symptom score (OABSS) was used to classify patients in the SUI or the mixed urinary incontinence (MUI) group. The follow up period was 18 months. Cure was defined as a negative stress test and no need for additional surgery.

RESULTS

Objective cure was achieved in 56/67 (83.5%) participants in the SCTOT group and in 40/47 (85.1%) participants in the ICTOT group (p>0.05). There was a significant improvement in IIC-7, UDI-6, ICIQ5-SF and OABSS in both groups. Improvement was better in the group with pure SUI than in patients with MUI, but this difference was not significant. Postoperative infection occurred in 5/67 (7.4%) participants and in 5/47 (10.6%) patients in the SCTOT and the ICTOT group, respectively. De novo overactive bladder symptoms occurred in 4/67 (5.9%) of the participants in the SCTOT group and in 3/47 (6.3%) of the patients in the ICTOT group. Operating time was longer in patients with SCTOT compared to those with ICTOT.

CONCLUSION

The results of the treatment with SCTOT are not inferior to the results of the treatment with ICTOT and other results reported in the literature.

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.

Are multichannel urodynamics required prior to surgery in a woman with stress urinary incontinence?

The National Institute for Clinical Excellence recommends that cystometry need not be performed before conservative therapy for incontinence in women, nor is cystometry routinely recommended in the small group of women with a clearly defined diagnosis of pure stress incontinence. Nonetheless, it is frequently utilized in the assessment of women with stress urinary incontinence in the hope that results will shed light on preoperative risk factors for failure or postoperative voiding dysfunction. The ability of urodynamic studies to characterize these parameters reliably remains under investigation. Because urodynamic studies are invasive, costly, and not always available, it is imperative that its benefit be carefully explored. This review highlights the recent arguments for and against this recommendation.

Intravaginal pressure generated during voluntary pelvic floor muscle contractions and during coughing: the effect of age and continence status

AIMS

The purpose of this study was to determine if, compared to continent women, women with stress urinary incontinence (SUI) generate lower intravaginal pressure (IVP) during maximum voluntary pelvic floor muscle contractions (PFM MVCs) or coughing, slower contraction times or less ability to sustain IVP, and if there are reductions in the ability to generate IVP during these tasks associated with increasing age.

METHODS

Eighty-seven (35 continent, 35 with mild SUI and 17 with severe SUI) women participated. IVP data were acquired while participants performed PFM MVCs, maximum effort coughs and a sustained PFM contraction. The maximum IVP amplitudes measured during the MVCs and coughs, the time for IVP to reach a peak during coughing and the time for the IVP to drop by 50% during the sustained contraction were compared among the groups using separate analyses of covariance, with age included as a covariate.

RESULTS

There were no differences in maximum PFM MVC IVP or in endurance time among the groups. Women with SUI produced higher cough IVP amplitudes than continent women. Age was associated with a reduction in IVP and with longer contraction times during coughing.

CONCLUSIONS

The data suggest that PFM weakness may not be an important factor in the pathophysiology of SUI. Women with SUI may intuitively use their PFMs to compensate for urethral sphincter or fascial deficits. The IVP generated during coughing and the speed at which peak IVP is attained are, however, substantially reduced with increasing age, which might affect continence in older women.

Women with stress urinary incontinence demonstrate motor control differences during coughing

INTRODUCTION

This study compared the patterns of pelvic floor muscle (PFM) activity during coughing between women with stress urinary incontinence (SUI) and continent women, using surface electromyography (EMG) and posterior vaginal wall (PVW) pressure.

METHODS

Twenty-four women participated: eight continent, eight with mild SUI and eight with severe SUI. Volunteers performed three maximum coughs in supine and standing. Maximum PFM EMG and PVW pressure amplitudes and the timing of the EMG peak relative to the PVW pressure peak were determined. Ensemble average PVW pressure versus EMG curves were created.

RESULTS

There were no significant differences among the groups in the maximum EMG or PVW pressure amplitudes. The EMG and PVW pressure peaked simultaneously in both positions in the continent group. In the mild SUI group, the EMG and PVW pressure peaked simultaneously in supine, but the EMG peaked before the PVW pressure in standing. In the severe SUI group, the EMG peaked before the PVW pressure in both positions. The shapes of the PVW pressure versus EMG curves were similar among the groups and positions, however the SUI groups displayed higher EMG-intercepts than the continent women.

CONCLUSION

These findings suggest that urine leakage during coughing in women with SUI may be related to delays in force generation rather than PFM weakness.

Is it possible to diagnose intrinsic sphincter deficiency in women?

PURPOSE OF REVIEW

The diagnosis of intrinsic sphincter deficiency became important about 20 years ago when it influenced the choice of operative procedure for women with stress urinary incontinence. However, it was ill-defined and diagnosed by a variety of techniques. The contemporary surgical treatment of urinary stress incontinence is by suburethral sling; so this review addresses three questions: is it still important to identify intrinsic sphincter deficiency prior to surgical intervention for stress incontinence? What techniques are available to do so? How robust are these measurements?

RECENT FINDINGS

There is some evidence that women with intrinsic sphincter deficiency have a poorer outcome if they are treated by a transobturator tape compared with a tension-free vaginal tape or a pubovaginal sling. Intrinsic sphincter deficiency continues to be mainly identified by low urethral closure pressures or low abdominal leak point pressures or both but the methodology is variable. There have been some attempts at using ultrasound to identify intrinsic sphincter deficiency but without any definite conclusions.

SUMMARY

Intrinsic sphincter deficiency is an imprecise diagnosis, which continues to be defined by a low pressure urethra. This can be measured in different ways but there is poor standardization of the tests to do so. Intrinsic sphincter deficiency appears to be clinically important but the full implications of this diagnosis will remain unknown until this imprecision is addressed.

The Volume at Which Women Leak First on Urodynamic Testing is Not Associated With Quality of Life, Measures of Urethral Integrity or Surgical Failure

PURPOSE

We determined if the bladder volume at which urodynamic stress incontinence is first detected is related to preoperative quality of life, urethral sphincter assessment or surgical outcome in women undergoing continence surgery.

MATERIALS AND METHODS

Charts of consecutive women who underwent a sling or Burch procedure were reviewed. Preoperative and postoperative assessment included the Incontinence Impact Questionnaire and Urogenital Distress Inventory. Urodynamic stress incontinence volume is the bladder volume at which urodynamic stress incontinence was first detected. Women were divided into 4 groups according to urodynamic stress incontinence volume, and compared with respect to maximum urethral closure pressure, Valsalva leak point pressure, Incontinence Impact Questionnaire and Urogenital Distress Inventory. Urodynamic stress incontinence persistence was evaluated only in patients who had sling surgery.

RESULTS

A total of 168 women were recruited for the study. Urodynamic stress incontinence volume was 100 ml for 31% of women, 200 ml for 17%, 300 ml for 17% and 400 ml or greater for 35%. Baseline and postoperative Urogenital Distress Inventory, Incontinence Impact Questionnaire, maximal urethral closure pressure and Valsalva leak point pressure did not differ by urodynamic stress incontinence volume. Among the 116 patients who had the sling procedure, urodynamic stress incontinence persistence did not differ by urodynamic stress incontinence volume (p=0.72).

CONCLUSIONS

Women who demonstrate urodynamic stress incontinence at lower bladder volumes do not report greater bother from incontinence than women who leak at higher volumes, suggesting leakage severity on urodynamics is not an adequate reflection of incontinence related quality of life.

Systematic review and meta-analysis of methods of diagnostic assessment for urinary incontinence

AIMS

To evaluate the performance of all tests proposed for the diagnosis of urinary incontinence.

METHODS

A systematic review and meta-analyses of the published literature of methods for diagnostic assessment of urinary incontinence.

RESULTS

One hundred twenty-one papers were included in the full review [Martin et al., 2006]. The quality of reporting in the primary studies was poor which reduced the number of studies that could be included in the data analysis. The literature suggests that women with urodynamic stress incontinence (USI) can be correctly identified in primary care from clinical history alone with a sensitivity of 0.92 (95% C.I.: 0.91-0.93) and specificity of 0.56 (0.53-0.60). A clinical history for the diagnosis of detrusor overactivity (DO) was found to be 0.61 (0.57-0.65) sensitive and 0.87 (0.85-0.89) specific. Within secondary care imaging of leakage by ultrasound was found to be effective in the diagnosis of USI in women with a sensitivity of 0.89 (0.84-0.93) and specificity of 0.82 (0.73-0.89).

CONCLUSIONS

Clinical interpretation of the results of the review is difficult because few studies could be synthesized and conclusions made. The published evidence suggests that a large proportion of women with USI can be correctly identified in primary care from history alone. Ultrasound offers a useful diagnostic tool which could be used prior to, and possibly instead of, multi-channel urodynamics in some circumstances. If a patient is to undergo urodynamic testing, multi-channel urodynamics is likely to give the most accurate result. Further primary studies adhering to STARD guidelines are required on commonly used tests.

Primer: questionnaires versus urodynamics in the evaluation of lower urinary tract dysfunction—one, both or none?

What is the role of urodynamic assessments and have we made too much use of them? Is there a correlation between symptoms and underlying pathophysiology? These questions are addressed in this article. There are disparities in the assessment of lower urinary tract dysfunction between the accuracy of symptomatic assessment and the underlying pathophysiology. This is particularly evident with voiding symptoms, in contrast to storage symptoms, and has fuelled the debates that have resulted in the abandonment of the term 'prostatism' in favor of 'lower urinary tract symptoms', whereas the term 'overactive bladder syndrome' has been embraced as a storage symptom complex. Clearly, voiding disorders principally affect men, whilst storage disorders are more common in women. Much has been written and spoken about regarding the use of symptomatic assessment versus urodynamics in the assessment of lower urinary tract symptoms in men, whilst there has been a clearer consensus on the potential usefulness of urodynamics in the assessment of storage disorders, and so this article focuses principally on the latter topic.

The role of urodynamics in the treatment of lower urinary tract symptoms in women

PURPOSE OF REVIEW

Urodynamic investigation was developed as an extension of patient history and physical examination in order to reveal the pathology of a patient's complaints. Much progress in standardizing definitions and procedures has been made in recent years. In particular, stress urinary incontinence and overactive bladder can be differentiated with urodynamics. The developed parameters, however, cannot distinguish the various types of stress urinary incontinence. Moreover the definition and diagnosis of voiding dysfunction is not clear. Finally our understanding of bladder sensations and the impact on voiding behaviour has only started to emerge. This review is about last year's publications that focus on urodynamics and lower urinary tract symptoms in women.

RECENT FINDINGS

Defining bladder outlet obstruction is based on voiding pressure, urinary flow speed and residual urine but standardization is lacking. Urodynamics to reveal occult stress urinary incontinence in patients with pelvic organ prolapse needs standardization of the reducing manoeuvres. The quest for urodynamic tools for distinguishing intrinsic sphincter deficiency from urethral hypermobility continues. Urodynamics are still not good enough to discriminate between treatment options for stress urinary incontinence. The use of urodynamics in overactive bladder is developing and has elicited new findings. Voiding habit seems to be independent from bladder sensations. Also bladder sensations appear to be imperfectly correlated with bladder filling. Even bladder volumes do not predict entirely bladder fullness sensations.

SUMMARY

In order to use urodynamics as a proper clinical tool, defining subtypes of stress urinary incontinence and standardization of urodynamics in pelvic organ prolapse and bladder outlet obstruction in women is needed.

Urodynamic assessment of patients with stress incontinence: how effective are urethral pressure profilometry and abdominal leak point pressures at case selection and predicting outcome?

PURPOSE OF REVIEW

Disagreement exists as to the extent of evaluation required prior to offering surgical intervention for the treatment of stress urinary incontinence in women. While few would argue that additional information can be gleaned from a properly performed urodynamic investigation, it remains unclear exactly which women would most benefit from such preoperative study, and if urodynamic evaluation definitively improves treatment outcome. Since such invasive studies may not be widely available in certain areas, can be costly, and are associated with a low, but defined risk of bladder infection, it is imperative that the appropriate indication for preoperative urodynamic evaluation be carefully defined. This review highlights recent reports and controversies concerning the use of urodynamics (focusing on leak point pressure testing and urethral pressure profilometry) prior to surgical treatment for stress urinary incontinence.

RECENT FINDINGS

There remains no clear consensus as to whether urodynamic testing enhances surgical outcome of stress urinary incontinence treatments by improving case selection or altering the surgical approach based on study findings. As treatment strategies for stress urinary incontinence have developed over the last several years to a more uniform approach, it is less clear that the severity of stress urinary incontinence, based on either abdominal leak point pressure or urethral pressure profilometry will influence the choice of surgical technique. Furthermore, there is little evidence to suggest that patients with more severe forms of stress urinary incontinence by urodynamic testing fare more poorly after the most commonly offered surgical treatment than those with less severe forms. There are certain sub-populations of women who appear to be at higher risk of voiding dysfunction following incontinence surgery, and urodynamic testing may aid in identifying this group.

SUMMARY

It is not apparent that either abdominal leak point pressure measurement or urethral pressure profilometry can accurately predict which patients will achieve the best outcome of surgical treatment for stress urinary incontinence. Other parameters assessed during urodynamic evaluation might provide prognostic information regarding the risk of voiding dysfunction postoperatively and the possibility of persistent urge-related leakage following surgery, though not directly predict cure. A multi-institutional randomized study comparing the outcome between patients in whom treatment was determined with the urodynamic information known, compared with patients in whom this information was unknown would further enhance our understanding of the usefulness of urodynamics in the preoperative evaluation of women with stress urinary incontinence.

Is the leak point pressure alone an accurate indicator of intrinsic sphincteric deficiency?

The aim of this study was to determine the characteristics of women who meet the criteria for intrinsic sphincteric deficiency (ISD) on maximum urethral closure pressure (MUCP) but not on leak point pressure (LPP) measurement. We performed a cross-sectional chart review of every patient who underwent multichannel, microtransducer urodynamic testing in our center between 1994 and 1996 (n=423). From this population we culled a sub-population of women who fit into one of the following two groups: women with no evidence of ISD on MUCP or LPP and women with evidence of ISD on MUCP only. Logistic regression was used to identify independent predictors of group membership. Increasing age (>60.5 years) and a positive supine empty stress test were the only independent predictors of membership in the group of women with ISD on MUCP only. Knowledge of these risk factors may help clinicians in choosing appropriate pre-operative testing.

Intrinsic urethral sphincteric deficiency: critical analysis of various diagnostic modalities

PURPOSE OF REVIEW

The proper diagnosis of intrinsic urethral sphincteric deficiency among women with urinary incontinence carries important implications for determining the most effective medical or surgical therapy. Numerous diagnostic tests have been described attempting to make an accurate and comprehensive assessment of urethral function, but all suffer from a lack of standardization or inconsistently quoted reference values. This paper will review the literature on the positive aspects and limitations of commonly employed procedures to diagnose intrinsic urethral sphincteric deficiency.

RECENT FINDINGS

Specific urodynamic studies, including the 'active' valsalva leak-point pressure and the 'static' urethral pressure profile are commonly used to determine urethral competence. However, these tests measure specific aspects of the continence mechanism under different clinical conditions, which limits the direct comparison between them. More complex techniques such as Doppler ultrasound, video-urodynamics and both static and dynamic magnetic resonance imaging are attempting to validate the urodynamic findings for urethral function. This approach may encourage the standardization of these procedures and parameters for diagnosing intrinsic urethral sphincteric deficiency.

SUMMARY

A single definitive test for the diagnosis of intrinsic urethral sphincteric deficiency does not exist. Instead, multiple tests should be employed to reach a consensus for the diagnosis. This should include a complete voiding history, simple office examinations, and advanced studies such as urethrocystoscopy, urodynamics and possibly radiological evaluations. Understanding the limitations and variabilities of their equipment and the specific studies utilized should enable practitioners to standardize the approach for determining the extent of urethral dysfunction.

Bladder neck funneling on ultrasound cystourethrography in primary stress urinary incontinence: a sign associated with urethral hypermobility and intrinsic sphincter deficiency

OBJECTIVES

To elucidate the implications of bladder neck funneling during straining in primary stress urinary incontinence.

METHODS

Ultrasonography was performed in 320 consecutive patients who underwent a full urodynamic study and whose only diagnosis was primary genuine stress incontinence. The ultrasound assessment included measurement of the bladder neck angle at rest and during stress, as well as observation of the development of bladder neck funneling during the Valsalva maneuver.

RESULTS

Of 320 study subjects, 111 had funneling of the bladder neck and 209 did not. Subjects with bladder neck funneling during stress had a significantly greater bladder neck angle at rest (P = 0.015) and during stress (P <0.001), greater rotation angle (P <0.001), lower maximal urethral closure pressure (P = 0.002), smaller proximal area under the urethral pressure profile curve (P = 0.002), higher incidence of low Valsalva leak point pressure (<60 cm H(2)O; P = 0.003), larger volume of urine leakage on a pad test (P = 0.006), and higher peak flow on a pressure-flow study (P = 0.028) than did those without. Bladder neck funneling on ultrasonography had a sensitivity of 59.5% and a specificity of 68.6% for the detection of low leak point pressure. The negative predictive value was 92.8%.

CONCLUSIONS

In primary genuine stress incontinence, bladder neck funneling on ultrasound cystourethrography implies the potential coexistence of poor anatomic support and an intrinsic sphincter defect, which require urodynamic investigation to verify. The high negative predictive value is useful in excluding the presence of low leak point pressure.

Incidence of concomitant procedures for pelvic organ prolapse and reconstruction in women who undergo surgery for stress urinary incontinence

OBJECTIVES

To determine the incidence of concomitant procedures performed for pelvic organ prolapse or vaginal reconstruction at the time of surgery for stress urinary incontinence in contemporary practice.

METHODS

We recorded all concomitant procedures for pelvic organ prolapse or vaginal reconstruction in 264 women who underwent surgery for stress urinary incontinence at our institution from January 1995 to August 1997.

RESULTS

Of 264 women, 111 (42%) had at least one concomitant procedure performed for pelvic organ prolapse or vaginal reconstruction, including 87 cystocele repairs, 31 rectocele repairs, 8 sacrospinous fixations, 5 enterocele repairs, 5 abdominal sacrocolpopexies, 4 perineoplasties, 3 urethral diverticulectomies, and 1 vaginal hysterectomy. Furthermore, 9% of patients had two or more procedures.

CONCLUSIONS

We found that women who undergo surgery for stress urinary incontinence have a high incidence (42%) of associated pelvic organ prolapse requiring surgical repair. These additional repairs contribute to the overall success of surgery and should not be overlooked.

Use of bone anchors in female urology

Stress urinary incontinence remains one of the most prevalent conditions encountered by urologists. In many cases, surgical correction of this condition is carried out using a pubovaginal sling procedure. Bone anchors were initially used in transvaginal needle suspension procedures to improve stabilization of the bladder neck. This technology has been extended to sling procedures, allowing completion of these procedures by an entirely transvaginal approach. Early results of these procedures are encouraging, and overall morbidity appears much less when compared with conventional pubovaginal sling procedures. In this article, the application of bone anchors in female urology is reviewed. Techniques of pubovaginal sling and abdominal sacrocolpopexy using bone anchors and potential complications of bone anchor implantation are discussed. Surgeons performing procedures for the treatment of stress incontinence should be aware of the benefits and potential risks of bone anchor implantation.

Identifying patients who require urodynamic testing before surgery for stress incontinence based on questionnaire information and surgical history

OBJECTIVES

To determine whether knowledge about previous surgical history for incontinence and responses to a validated lower urinary tract symptom questionnaire for women could identify those who should undergo urodynamic testing before surgery for stress urinary incontinence (SUI).

METHODS

A retrospective analysis of all women who completed the Urogenital Distress Inventory-6 questionnaire (UDI-6) and then underwent complete urodynamic studies was conducted. The critical urodynamic diagnoses to determine before anti-incontinence surgery were defined as coexisting SUI and detrusor instability (DI), Valsalva leak point pressure less than 60 cm H(2)O, and DI alone in women suspected clinically of having SUI. Models were established for deciding who should undergo urodynamic studies on the basis of questionnaire responses and information about previous surgical history. Cost savings and the ability of the various models to identify patients with critical urodynamic diagnoses were calculated.

RESULTS

A total of 174 women completed the UDI-6 and underwent urodynamics studies. Sixty-two had SUI (36%), 54 had DI (31%), 18 had both SUI and DI (10%), and 19 women suspected of having SUI were found instead to have DI (11%). Among women with SUI, 39 had a Valsalva leak point pressure less than 60 cm H(2)O (63%). No group of question responses or combination of question responses and presence of previous incontinence surgery was able to identify all three critical urodynamic diagnoses with statistical significance. Still, the combination of a response of "2" or "3" to question 3 on the UDI-6 and a positive history of previous surgery would have identified 91% of the critical diagnoses, and a substantial cost savings would have been realized.

CONCLUSIONS

Using the UDI-6 and information obtained from the patient's history to determine who should undergo urodynamic testing before surgery for SUI can result in substantial cost savings without sacrificing patient care.