Stress incontinence and urethral obstruction in women: value of uroflowmetry and voiding urethrography

Physiologic evaluation of the pelvic floor

This article has addressed the value, technique, rationale, and limitations of the commonly performed physiologic tests of the pelvic floor. Urodynamics provides a means for evaluation of the lower urinary tract and for assessment of the filling and emptying phases of the bladder. Neurophysiologic tests including EMG and nerve conduction studies offer methods to assess the neuromuscular integrity of the urethral and anal sphincteric mechanisms and the pelvic floor. Anorectal manometry studies provide a means of measuring pressure in the rectum and anal canal, rectal compliance, and anorectal reflexes and sensation in patients with anal incontinence and select patients with constipation. Colonic transit studies permit an assessment of functional constipation and may be helpful in the evaluation of patients in whom standard management of constipation has failed. Any test used in the evaluation of patients with pelvic floor dysfunction should be validated and found to be reliable. Most patients in need of complex physiologic evaluation are identified on the basis of their history and physical examination findings.

Uroflow in women: an overview and suggestions for the future

The literature on uroflowmetry in women is presented and evaluated. Uroflowmeters are described and found generally sufficiently accurate, although the errors arising from electronic evaluation may invalidate the test. Six flow curve patterns are proposed in accordance with described pathological conditions. From the literature it is summarized that the normal Qmax is 20-36 ml/s. Qmax is linearly correlated to the voided volume, increasing by 5.6 ml/s/100 ml. Pregnancy, age and menstrual cycle do not influence Qmax. Several pathological conditions have been associated with specific flow curve patterns. These conditions are described and associations with the proposed flow definitions made.

Uroflowmetry

Uroflowmetry is a widely used noninvasive screening modality for patients who present with symptoms of lower urinary dysfunction. However, it should be recognized that uroflowmetry represents the compound effect of bladder and urethral function because it may easily be misinterpreted. In elderly men with "prostatism", uroflowmetry is often sufficient to indicate treatment, while the value in women is less prominent. In pediatrics, more sophisticated urodynamic testing is crucial.

A combined urodynamic and continence unit--a review of the first 19 years

We have completed a 19-year audit of all patients referred to the urodynamic/continence unit since its inception in 1972 and their subsequent clinical management; a total of 20,437 patients were referred, increasing from 51 in the first year to 1564 in 1990. Although the annual number of referrals has remained constant for the last 8 years, the need for more complex urodynamic assessment such as video-cystourethrography has increased from 5% (56/1164) in 1981 to 25% (385/1564) in 1990. The number of out-patient attendances to medical, physiotherapy and continence clinics has also increased over that period. We conclude that the number of referrals represents increasing recognition of the value of urodynamic assessment. Accurate diagnosis leads to more effective treatment, whether surgical, medical or conservative. Some methods of diagnosis are complex and suitable only for a tertiary referral centre.

Fluid weight uroflowmetry in women

This study evaluates fluid weight uroflowmetry as a screening technique for urogynecologic conditions. Sixty women with no known pathologic condition volunteered for the evaluation of normal uroflowmetric parameters and curve patterns. Forty were menstruating cyclically, and 20 were postmenopausal. The parameters studied included: (1) total voided volume, (2) flow time, (3) peak flow rate, and (4) time to peak flow rate. In addition, uroflowmetric tracings were classified according to their patterns of configuration into: (1) normal, (2) multiple peak, and (3) interrupted. The parameters studied showed no difference in the two normal groups. A wide range of values was observed. Neither age, parity, weight, height, nor menstrual cycle phase affected the data. Values obtained from patients with idiopathic instability of the detrusor muscle, sensory urgency, and stress urinary incontinence did not show differences or trends. Seventeen percent of the tracings of the normal population group showed either multiple peak or interrupted patterns. Patients with sensory urgency (p less than 0.001) had a higher incidence of multiple peak and interrupted flow rate patterns.

Study of micturition parameters in healthy young adults using a uroflowmetric method

Using the 21 F 01 DISA Mictiograph, the instant urine flow curves of fifty normal males and thirty-three females (aged from 18 to 35 years) were analysed. A total of 363 micturitions was obtained (146 in the female group, 217 in the male group). Ten parameters were derived from each of the urine flow curves. These parameters were: the voided volume, the micturition time, the average-flow rate, the flow at 2 s, the maximum flow rate, the percentage of difference between the maximum flow rate and the average-flow rate, the duration until the maximum flow rate, the initial slope of the curve, the slope at the time from micturition initiation of voiding to maximum flow, and the difference between the two slopes. This study demonstrated that the urine flowmeter allowed, even at very low voided volume, a complete interpretation of micturition flow curves, a finding which might be useful in paediatric patients. It was also shown that the flow parameters were significantly more favourable in females than in males, and consequently that better hydrodynamics conditions for micturition exist in women compared to men.

Operative management of stress urinary incontinence

A total of 132 women with stress urinary incontinence underwent thorough radiographic and urodynamic evaluation in private urologic practice. With heavy reliance on the readily available technique of bead-chain cystography to differentiate between types I and II abnormalities, and to demonstrate the extent of bladder neck descent, the surgical success rates were 95.8 per cent over-all and 97.3 per cent using the Marshall-Marchetti-Krantz procedure. Postoperative complications were minimal and infrequent except for urinary retention in 31.7 per cent, which was managed easily by intermittent self-catheterization that allowed early hospital discharge without an indwelling catheter.

Urodynamic norms in women. I. Normals versus stress incontinents

Urodynamic statistics for normal women were compared to similar norms for stress incontinent women. It was concluded that 1) the reduction of flow rate in stress incontinent patients appears to be the result, with high probability of pathologic changes in the function of the distal urethra, 2) stress incontinence does not affect the combined effects of bladder pressure and the proximal urethral resistance during voiding as reflected in velocity, 3) the distal urethral cross-sectional area appears to be under neuromuscular control and 4) the distal urethra of stress incontinent women appears to be incapable of opening as widely as the distal urethra of normal women. It is not currently possible to assign anatomical or physiological causes to the observed phenomena.

Carbon dioxide uroflowmetry

A method using pneumatic compression to determine flow rate is described. The procedure is best suited for physicians using carbon dioxide instrumentation for a urodynamic assessment of patients since the carbon dioxide cystometer is readily converted to a uroflowmeter. Values obtained with this method are similar to values reported in the literature using other techniques. When voided volumes are more than 200 ml. the values for peak flow rate are reproducible within subjects and are volume-dependent.

Role of uroflowmetry in the assessment of lower urinary tract obstruction in adult males

A group of 173 prostatic patients were submitted to a prospective study to determine the respective value of symptoms, uroflowmetry, endoscopic and radiological findings in the assessment of the degree of urinary obstruction. Uroflowmetry proved to bring objective evidence of the degree of obstruction with a reasonable degree of accuracy. Maximum urinary flow appears to be more accurate than other flow parameters in the determination of lower urinary tract obstruction.

Evolution of urinary flow rate with prostatectomy

Urinary flow rate was studied before and after transurethral prostatectomy in 53 patients. An average of 43.8 percent improvement in maximum flow rate after transurethral prostatectomy was observed in this series. Improvement of maximum flow rate occurred in 71 per cent of patients. Half of the cases in which flow rate did not improve were chronic prostatitis. Uroflowmetry cannot be utilized as a quality index of a transurethral prostatic resection as long as the degree of detrusor deterioration is not assessed. There is a relationship between the degree of preoperative symptoms and the degree of postoperative urinary flow improvement. The degree of preoperative symptoms and urinary flow deviation are not related which suggests that uroflowmetry adds to the assessment of symptoms in the determination of the degree of obstruction. Patients presenting difficulty of urination have a greater chance to demonstrate urinary flow improvement after surgery than patients complaining of urinary frequency.