International Continence Society Criteria Research Articles

Overactive bladder ‘symptoms’ or ‘complaints’ in young and elderly patients or healthy volunteers?

Objective:The overactive bladder symptom complex is multifactorial and heterogeneously influenced by genetic and environmental factors. The role of ageing is not exactly known. Our objective is to evaluate age-related differences in bladder sensations in healthy volunteers and overactive bladder patients. Methods:68 patients with an overactive bladder, diagnosed by their urologist using the International Continence Society criteria, and 66 healthy volunteers were included: 41 patients and 20 volunteers were ≥60 years old. Subjects filled out sensation-related bladder diaries, for 2 periods of 3 days. Results:To obtain the following results, 6160 voids were assessed. Both young and older healthy volunteers experienced storage symptoms. However, older volunteers experienced more symptoms than younger ones. The healthy aged experienced more nocturia and voided 34% more often over 6 days, compared to the young people. They experienced more urge at a lower mean voided volume too. Younger OAB patients perceived their bladder to be ∼25% fuller at 100 ml compared to younger volunteers, older patients experienced a similar mean bladder fullness sensation to their healthy peers. Fourteen healthy older volunteers experienced voids with urge 3 (need to void now), however at a higher mean voided volume compared to the older OAB patients. They both experienced the same amount of nocturia. Conclusions:Storage symptoms are widespread throughout the population in a continuum of frequency and severity of symptoms. Ageing healthy volunteers shift on this continuum, from never having any urinary complaints towards experiencing (a severity of) symptoms that fit within the ICS definition of OAB. Hence, there is an important distinction between storage symptoms and storage complaints.

Urethral support in female urinary continence part 1: dynamic measurements of urethral shape and motion.

Urethral closure mechanism dysfunction in female stress urinary incontinence (SUI) is poorly understood. We aimed to quantify these mechanisms through changes in urethral shape and position during squeeze (voluntary closure) and Valsalva (passive closure) via endovaginal ultrasound in women with varying SUI severity. In this prospective cohort study, 76 women who presented to our tertiary center for urodynamic testing as preoperative assessment were recruited. Urodynamics were performed according to International Continence Society criteria. Urethral pressures were obtained during serial Valsalva maneuvers. Urethral lengths, thicknesses, and angles were measured in the midsagittal plane via dynamic anterior compartment ultrasound. Statistical shape modeling was carried out by a principal component analysis on aligned urethra shapes. Age, parity, and BMI did not vary by SUI group. Ultrasound detected a larger retropubic angle, urethral knee-pubic bone angle (a novel measure developed for this study), and infrapubic urethral length measurements at Valsalva in women with severe SUI (p = 0.016, 0.015, and 0.010). Shape analysis defined increased "c" shape concavity and distal wall pinching during squeeze and increased "s" shape concavity and distal wall thickening during Valsalva (p < 0.001). It also described significant urethral shape differences across SUI severity groups (p < 0.001). Dynamic endovaginal ultrasound can visualize and allow for quantification of voluntary and passive urethral closure and variations with SUI severity. In women with severe SUI, excessive bladder neck and distal urethra swinging during Valsalva longitudinally compressed the urethra, resulting in a proportionally thicker wall at the mid-urethra and urethral knee.

MP63-02 PURE STRESS URINARY INCONTINENCE: ANALYSIS OF THE PREVALENCE, ESTIMATION OF COSTS AND FINANCIAL IMPACT

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Incontinence: Evaluation (Urodynamic Testing)1 Apr 2017MP63-02 PURE STRESS URINARY INCONTINENCE: ANALYSIS OF THE PREVALENCE, ESTIMATION OF COSTS AND FINANCIAL IMPACT Emanuele Rubilotta, Matteo Balzarro, Silvia Bassi, Paolo Corsi, Marco Pirozzi, Trabacchin Nicolò, Antonio Benito Porcaro, Antonio D'Amico, and Walter Artibani Emanuele RubilottaEmanuele Rubilotta More articles by this author , Matteo BalzarroMatteo Balzarro More articles by this author , Silvia BassiSilvia Bassi More articles by this author , Paolo CorsiPaolo Corsi More articles by this author , Marco PirozziMarco Pirozzi More articles by this author , Trabacchin NicolòTrabacchin Nicolò More articles by this author , Antonio Benito PorcaroAntonio Benito Porcaro More articles by this author , Antonio D'AmicoAntonio D'Amico More articles by this author , and Walter ArtibaniWalter Artibani More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1954AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Aim of our study was to evaluate the prevalence of ‘pure' SUI (P-SUI), in a cohort underwent urodynamic test (UD) for urinary incontinence (UI), and the correspondence with UD findings. We also estimated the amount of costs of UD, and if the UD data could change the surgical indications. METHODS We did a retrospective evaluation of the UD-database selecting 544 women with UI between January 2012 and July 2016. Pure SUI was defined by the International Continence Society criteria (table 1). Two very experienced urologists evaluated data. Data researched were: - Prevalence of clinical and UD P-SUI - Correspondence between clinical P-SUI and UD findings - Accurate estimation in € of a single UD examination, including the human resources and materials used - Total amount of UD costs in € in P-SUI patients - Number of surgical procedures avoided due to UD results - Related avoided surgical costs in € in P-SUI patients RESULTS SUI was present in 323/544 (59.4%), in this group the prevalence of P-SUI was 20.7% (67/323) while the prevalence of complicated SUI was 79.3% (256/323). The correspondence between the clinical diagnosis of P-SUI and the UD findings was 88% (59/67 patients). For this reason after UD the number of patients with diagnosis of P-SUI decreased to 59/323 with a rate of 18.3%. The cost of each UD study was 383 € and the total amount for this cohort of patients was 25.661 €. As consequence of a change of the therapeutic treatment after UD findings we did not performed the scheduled middle urethral sling in 6 patients with a total amount saved of 10.800 €. CONCLUSIONS UD study detected a relevant prevalence of P-SUI as 1/5 of the amount of the SUI women. The correspondence between clinical and UD findings was high. A total amount cost of P-SUI patients is not negligible respect to the total UD budget. Nevertheless, UD was able to avoid an inappropriate procedure in 9% of the patients. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e836 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Emanuele Rubilotta More articles by this author Matteo Balzarro More articles by this author Silvia Bassi More articles by this author Paolo Corsi More articles by this author Marco Pirozzi More articles by this author Trabacchin Nicolò More articles by this author Antonio Benito Porcaro More articles by this author Antonio D'Amico More articles by this author Walter Artibani More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Postvoidal residual urine is the most significant non-invasive diagnostic test to predict the treatment outcome in children with non-neurogenic lower urinary tract dysfunction

Uroflowmetry (UF) alone is often inadequate or unreliable to diagnose lower urinary tract dysfunction (LUTD). Therefore, other non-invasive tests, such as ultrasound (US), post-voiding residual volume (PVR) assessment and symptom scales, are used as well for objective definition of the problem. The aim of this study was to investigate the possible predictive function of the non-invasive diagnostic tests for the response to treatment. The prospective registry data of 240 patients with LUTD, from November 2006 to September 2013, were retrospectively analyzed. All patients were aged 5-14 years old. Patients with a previous diagnosis of vesicoureteral reflux (VUR), neurogenic bladder, monosymptomatic nocturnal enuresis (NE) were excluded from the study. Uroflowmetry, US, PVR and the Dysfunctional Voiding and Incontinence Symptom Scale (DVISS) were performed on every patient at their first visit and follow-ups. A DVISS <9 was considered as the DVISS response; parental opinion was based on International Continence Society criteria of clinical response. Time passed until clinical response was the last outcome parameter. Mean age was 8.2 years. Median follow-up was 60.5 months. A total of 62% of patients had complete response, 28.1% had partial response, and 9.7% had no response. Demographic variables were not associated with clinical outcome. Co-existing enuresis nocturna, multiple pharmacotherapy, and increased DVISS were associated with longer time until clinical response. Post-voiding residual volume assessment was the only test to have a prognostic value. Resolution rates of LUTD ranged from 40 to 90%. High resolution rate could be attributed to the long follow-up period, and the chance of spontaneous resolution. Treatment modalities and co-existing NE were associated with longer time until clinical response. Only PVR was associated with prognosis. This was the first study in literature to report such findings. It was seen that the normalization of pathologic patterns was a good sign for treatment success. The DVISS results showed significantly higher rates of incontinence compared to initial symptoms defined by the patients and/or their parents. This showed the importance of using scoring systems to better define the severity of symptoms. It was hard to establish a standardized cut-off value for bladder wall thickness on US. However, US was a good test for diagnosing additional pathologies. Increased PVR was the single tool that was associated with prognosis and, therefore, should always be performed after UF. In addition, DVISS can help parents be counseled about their treatment expectations.

Relationship between urodynamic findings and sexual function in multiple sclerosis patients with lower urinary tract dysfunction.

Sexual dysfunction (SD) is prevalent in multiple sclerosis (MS) patients and affects quality of life. Furthermore, lower urinary tract dysfunction (LUTD) is common in MS patients. Our aim was to determine the relationship between urodynamic findings and SD in a cohort of MS patients with LUTD. From January 2011 to September 2013, 135 consecutive patients with MS in remission phase and LUTD underwent a first urodynamic examination, according to the International Continence Society criteria. Neurological impairment was assessed using the Expanded Disability Status Scale and SD was investigated with the Female Sexual Function Index (FSFI) or the International Index of Erectile Function (IIEF-15). Multivariate logistic regression analysis was performed to identify predictors of female SD (FSFI < 26.55) or moderate-severe erectile dysfunction (ED) (IIEF-EF ≤ 16), after adjusting for confounding factors including urodynamic findings. Subjects with maximum detrusor pressure during involuntary detrusor contraction (PdetmaxIDC) ≥20.0cmH2 O had lower IIEF-EF, IIEF overall satisfaction (IIEF-OS), FSFI-Arousal, FSFI-Lubrication and FSFI-Orgasm. Subjects with maximum cystometric capacity (MCC) ≥135 ml had higher IIEF-EF, intercourse satisfaction (IIEF-IS), orgasmic function (IIEF-OF), sexual desire (IIEF-SD), FSFI-Arousal, FSFI-Lubrication, FSFI-Orgasm, FSFI-Satisfaction and FSFI-Pain. On multivariate logistic regression analysis, PdetmaxIDC ≥20cmH2 O [odds ratio(OR) 6.7; P<0.05] and MCC <135ml (OR6.80; P<0.05) were predictors of moderate-severe ED. In a model including all previous variables, compliance ≤3ml/cmH2 O was an independent predictor of moderate-severe ED (OR 14.49; P<0.01). No relationship was found between the previous variables and FSFI <26.55. Neurogenic bladder is associated with SD in MS patients. The presence of PdetmaxIDC ≥20cmH2 O, MCC <135ml and compliance ≤3ml/cmH2 O may significantly predict the presence of moderate-severe ED.

Determinants of Sexual Impairment in Multiple Sclerosis in Male and Female Patients with Lower Urinary Tract Dysfunction: Results from an Italian Cross-Sectional Study

Sexual dysfunction (SD) is prevalent in multiple sclerosis (MS) patients and affects quality of life. Furthermore, lower urinary tract dysfunction (LUTD) is common in MS patients. This study aims to evaluate the relationship between SD, neurological disability, depression, anxiety, and urodynamic alterations in patients with MS and LUTD. From January 2011 to September 2013, 135 consecutive patients with MS in remission phase and LUTD underwent first urodynamic examination, according to the International Continence Society criteria. Depression and anxiety were evaluated with the Hamilton Depression Scale (HAM-D) and the Hamilton Anxiety Scale (HAM-A), neurological impairment was assessed using the Expanded Disability Status Scale (EDSS), and SD was investigated with the Female Sexual Function Index (FSFI) or the International Index of Erectile Function (IIEF-15). Multivariate logistic regression analyses were carried out to identify variables for predicting female sexual dysfunction (FSD) (FSFI < 26.55), male SD (IIEF-15 < 60), or moderate-severe erectile dysfunction (IIEF-EF ≤ 16), after adjusting for confounding factors. Total IIEF-15 and all subdomains (all P < 0.01), total FSFI, FSFI-arousal, FSFI-lubrication, and FSFI-orgasm (all P < 0.05) were lower in subjects with EDSS ≥ 4.5. We found inverse relationship between IIEF-15 and relative subdomains with EDSS (all P < 0.01) and between FSFI and relative subdomains with EDSS (all P < 0.01), HAM-D (all P < 0.01), and HAM-A (all P < 0.01). Continuous EDSS (odds ratio [OR] = 1.54; P = 0.03) and categorical EDSS (≥4.5) (OR = 6.0; P = 0.03), HAM-D (OR = 4.74; P = 0.03), and HAM-A (OR = 4.10; P = 0.02) were significantly associated with FSD (FSFI < 26.55). Detrusor overactivity (DO) was an independent predictor of moderate-severe ED (IIEF-EF ≤ 16) (OR = 2.03; P < 0.01), and of FSD (OR = 9.73; P = 0.04). Neurological disability, depression and DO are significantly predictive of SD in MS patients, irrespective of gender. An EDSS ≥ 4.5 may significantly predict the presence of SD.

Detrusor underactivity is prevalent after radical prostatectomy: A urodynamic study including risk factors

Introduction: The objective was to determine the prevalence of, and factors that predict, detrusor underactivity (DU) in patients presenting with incontinence or lower urinary tract symptoms (LUTS) following radical prostatectomy (RP). We also determined the prevalence of bladder outlet obstruction (BOO) and detrusor overactivity (DO) in this population.Methods: Patients who underwent urodynamics post-RP were identified. Detrusor underactivity was defined as a maximum flow rate (Qmax) of ≤15 mL/s and detrusor pressure (Pdet) Qmax &lt;20 cmH20 or maximum Pdet &lt;20 cmH20 during attempted voiding. Abdominal voiding (AV) was defined as sustained increase in abdominal pressure during voiding. Bladder outlet obstruction and DO were identified using the Abrams-Griffiths nomogram and the International Continence Society criteria. Univariate logistic regression was used to determine factors predicting DU. The following factors were analyzed: age, year of RP, procedure type (minimally-invasive surgery [MIS] or open), postoperative radiation, nerve-sparing, clinical stage, biopsy Gleason grade and interval between RP and evaluation.Results: Between 2005 and 2008, 264 patients underwent urodynamics post-RP. Detrusor underactivity was observed in 108 patients (41%; 95% CI 35%, 47%), of whom 48% demonstrated AV. Overall, BOO and DO were present in 17% (95% CI 12%, 22%) and 27% (95% CI 22%, 33%), respectively. On univariate analysis, only MIS RP was predictive of DU (univariate odds ratio 2.05 for MIS vs. open; p = 0.009).Conclusions: Detrusor underactivity and AV are common in patients presenting for evaluation of incontinence or LUTS following RP. The etiology of DU in this setting is likely related to the surgical approach. Because DU may affect the success of male incontinence treatment with the male sling or artificial urinary sphincter, it is useful to document its presence prior to treatment. More studies are needed to elucidate the influence of DU on treatment success for male urinary incontinence following RP.

Lower urinary tract symptoms and urinary incontinence in a geriatric cohort – a population‐based analysis

To assess prevalence and severity of lower urinary tract function in 85-year-old men and women. Little is known on the prevalence of lower urinary tract dysfunction in this geriatric age group, which is now the fastest growing sector of the population worldwide. The Vienna Trans-Danube Aging study (VITA) is a longitudinal, population-based study initiated in 2000 that included men/women aged 75 years living in a well-defined area in Vienna. The main purpose of the VITA study was to identify risk factors for incident Alzheimer's disease. All study participants alive in 2010 were contacted by mail to complete a detailed questionnaire on various aspects of lower urinary tract symptoms (LUTS) and urinary incontinence (UI). The response rate was 68%, resulting in a total of 262 questionnaires available for analysis (men n= 96; women n= 166). All study participants were 85 years of age. Urinary incontinence defined as any involuntary loss during the past 4 weeks was reported by 24% of men and 35% of women (P= 0.04). Stress UI was more frequent in women (39%) than in men (14%, P < 0.01), the difference for urge UI (women 35%, men 25%) was on the border of statistical significance (P= 0.05). Only four individuals (1.5%) needed permanent catheterization. Urgency (women 56%, men 54%) and daytime frequency (women 70%, men 74%) were equally distributed (P > 0.05). Nocturia more often than twice was more prevalent in men (69%) than in women (49%) (P= 0.02). Overactive bladder, according to International Continence Society criteria, was present in 55% of women and 50% of men. No difference regarding quality of life impairment as the result of LUTS and UI was noticed between sexes. A few co-morbidities were identified to correlate with UI and storage symptoms. These data provide insights into the prevalence and severity of LUTS and UI in individuals in their eighties, to our knowledge the largest population-based study in this age group. Demographic changes in upcoming decades underline the importance of a thorough understanding of lower urinary tract dysfunction in a geriatric population.

Detrusor underactivity is prevalent after radical prostatectomy: a urodynamic study including risk factors

The objective was to determine the prevalence of, and factors that predict, detrusor underactivity (DU) in patients presenting with incontinence or lower urinary tract symptoms (LUTS) following radical prostatectomy (RP). We also determined the prevalence of bladder outlet obstruction (BOO) and detrusor overactivity (DO) in this population. Patients who underwent urodynamics post-RP were identified. Detrusor underactivity was defined as a maximum flow rate (Qmax) of ≤15 mL/s and detrusor pressure (Pdet) Qmax <20 cmH20 or maximum Pdet <20 cmH20 during attempted voiding. Abdominal voiding (AV) was defined as sustained increase in abdominal pressure during voiding. Bladder outlet obstruction and DO were identified using the Abrams-Griffiths nomogram and the International Continence Society criteria. Univariate logistic regression was used to determine factors predicting DU. The following factors were analyzed: age, year of RP, procedure type (minimally-invasive surgery [MIS] or open), postoperative radiation, nerve-sparing, clinical stage, biopsy Gleason grade and interval between RP and evaluation. Between 2005 and 2008, 264 patients underwent urodynamics post-RP. Detrusor underactivity was observed in 108 patients (41%; 95% CI 35%, 47%), of whom 48% demonstrated AV. Overall, BOO and DO were present in 17% (95% CI 12%, 22%) and 27% (95% CI 22%, 33%), respectively. On univariate analysis, only MIS RP was predictive of DU (univariate odds ratio 2.05 for MIS vs. open; p = 0.009). Detrusor underactivity and AV are common in patients presenting for evaluation of incontinence or LUTS following RP. The etiology of DU in this setting is likely related to the surgical approach. Because DU may affect the success of male incontinence treatment with the male sling or artificial urinary sphincter, it is useful to document its presence prior to treatment. More studies are needed to elucidate the influence of DU on treatment success for male urinary incontinence following RP.

Prevalence of Erectile Dysfunction in HTLV-1–Infected Patients and Its Association With Overactive Bladder

To determine the prevalence of erectile dysfunction (ED) in human T-cell lymphotropic virus type I (HTLV-I)-infected patients, and its association with overactive bladder (OB). In a cross-sectional study, 111 male patients with positive serology for HTLV-I (by enzyme-linked immunosorbent assay and Western blot) were examined between October 2003 and December 2006. Exclusion criteria were age <18 and >80 years, other neurological diseases, penile prosthesis, neoplasm, and psychological and mental disease. Patients were evaluated by a urologist and neurologist. ED was determined by application of the abridged form of 5-item International Index of Erectile Function (IIEF-5). ED was defined as IIEF-5 <or= 21. OB was determined by International Continence Society criteria. Using the Expanded Disability Status Scale (EDSS) to determine disautonomy status, a neurologist classified all patients as either asymptomatic carriers (EDSS = 0), "oligosymptomatic myelopathy" (EDSS > 0 e <or= 2), or HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP); (EDSS > 2). Diagnosis of HAM/TSP was performed according to World Health Organization recommendations. Of the total of 111 patients, 6 were excluded and 105 were analyzed. The mean age was 48 +/- 10.7 years. ED was observed in 55.2%. ED was documented in all patients who had HAM/TSP, in 79% of the group with EDSS > 0 and <or=2, and in 35.9% of HTLV-1-infected individuals with EDSS = 0. OB was detected in 93.75%, 33.3%, and 4.6%, respectively. Moreover, there was an association observed between ED and OB. ED is a frequent disease in HTLV-I-infected individuals, and the prevalence is directly correlated to the degree of neurological disability measured by EDSS. ED was strongly associated with OB symptoms.

Quantifying the natural history of post-radical prostatectomy incontinence using objective pad test data

BackgroundUrinary incontinence (UI) following radical prostatectomy is a well-recognized risk of the surgery. In most patients post-operative UI improves over time. To date, there is limited objective, quantitative data on the natural history of the resolution of post-prostatectomy UI. The purpose of this study was to define the natural history of post radical prostatectomy incontinence using an objective quantitative tool, the 1-hour standard pad test.Methods203 consecutive patients underwent radical prostatectomy by a single surgeon between 03/98 & 08/03. A standardized 1-hour pad test was administered at subsequent postoperative clinic visits. The gram weight of urine loss was recorded and subdivided into four groups defined according to the grams of urine loss: minimal (<1 g), mild (>1, <10 g), moderate (10–50 g) and severe (>50 g). Patients were evaluated: at 2 weeks (catheter removal), 6 weeks, 18 weeks, 30 weeks, 42 weeks and 54 weeks. The data set was analyzed for average urine loss as well as grams of urine loss at each time point, the percentage of patients and the distribution of patients in each category.ResultsMean follow up was 118 weeks. The majority of patients experienced incontinence immediately after catheter removal at 2 weeks that gradually improved with time. While continued improvement was noted to 1 year, most patients who achieved continence did so by 18 weeks post-op.ConclusionWhile the majority of patients experience mild to severe UI immediately following catheter removal, there is a rapid decrease in leaked weight during the first 18 weeks following RRP. Patients continue to improve out to 1 year with greater than 90% having minimal leakage by International Continence Society criteria.

Efficacy of Functional Electrical Stimulation in Treating Genuine Stress Incontinence: A Randomized Clinical Trial

Our objective was to determine the efficacy of functional electrical stimulation as a stand-alone therapy for female stress incontinence. The study was conducted as a prospective, double-blind, randomized controlled trial using subjective and objective outcome criteria. Patients enrolled in this study had stress incontinence consistent with International Continence Society criteria. Patients with significant pelvic prolapse or detrusor instability were excluded. Patients underwent twice-daily treatment sessions for a total of 3 months. Results were analyzed for confounding variables between the treatment and control groups. Statistical analysis was performed utilizing Fisher's exact test and the paired t-test. Of the 54 patients enrolled in this study, 44 completed the program. The dropout rate was similar for both the treatment and control groups. There was no statistically significant difference between the treatment and control groups with regard to age, gravity, parity, previous antiincontinence surgery, menopausal status, or previous hysterectomy. Objective success for the treatment group was 15% and for the control group, 12.5% (NS). The subjective success for the treatment group was 25% and for the control group, 29% (NS). There was no relationship demonstrated between age, parity, previous surgery, hysterectomy, or menopausal status and the successful treatment of genuine stress incontinence with functional electrical stimulation. In this patient population, functional electrical stimulation was no more effective at improving or eliminating the symptoms of genuine stress incontinence than was the daily retention of the control probe. Neurourol. Urodynam. 16:543–551, 1997. © 1997 Wiley-Liss, Inc.

THE INCIDENCE OF A POSITIVE ICE WATER TEST IN BLADDER OUTLET OBSTRUCTED PATIENTS: EVIDENCE FOR BLADDER NEURAL PLASTICITY

Purpose The ice water test triggers a C fiber, capsaicin sensitive spinal micturition reflex. We postulated that the ice water test is positive in a high proportion of patients with compared to those without bladder outlet obstruction. Materials and Methods Prospective evaluation of 111 consecutive patients was undertaken. Symptoms of urgency, urge incontinence, nocturia and daytime frequency as well as the presence of neurological disease were obtained from history and physical examination. Fluorourodynamics, including ice water cystometry, and pressure-flow studies were done for all 111 subjects. Obstruction was defined using the Abrams-Griffith nomogram and urethral resistive index. A positive ice water test was defined as presence of uninhibited bladder contraction with instillation of 0C saline at 50 cc per minute up to a maximum of 250 cc. Detrusor instability was defined according to the International Continence Society criteria using room temperature saline instillation. Results When patients with neurological disease were excluded, a positive ice water test was found in 71% of subjects with bladder outlet obstruction (12 of 17), which was significantly higher (p <0.0005, Yates corrected chi-square test) than the 7% positive ice water test rate in nonobstructed subjects (3 of 44). Conversely, the incidence of positive detrusor instability was not statistically different between the patients with or without bladder outlet obstruction. Of the subjects with neurological disease 85% (42 of 50) had a positive ice water test. The incidence of a positive ice water test was only 5 to 9% in patients with storage lower urinary tract symptoms. Conclusions A positive ice water test has been previously described in infants and individuals with neurogenic bladders. However, subjects with bladder outlet obstruction had a significantly higher incidence of a positive ice water test compared to those without it, supporting the hypothesis of an enhanced spinal micturition reflex possibly due to plasticity of bladder afferents after bladder outlet obstruction. The ice water test may be useful in prognosticating bladder outlet obstruction treatment outcomes and determining the etiology of treatment failure.

Discussion: Epidemiology of urinary incontinence

T ables I and II represent a sample of definitions of urinary incontinence (UI) used in epidemiologic research.‘-’ 5 Table II lists the mean number of weekly incontinent episodes for 287 consecutive incontinent women referred to our laboratory. There is an obvious difference between the epidemiologic and clinical threshold for UI, a fact of which we must all remain cognizant. In the article in this supplement, Hampel et a116 have done an excellent job of raising our sensitivity to this issue. I congratulate these authors for their comprehensive and accurate review and analysis of the world’s epidemiologic literature regarding UI in women. They correctly emphasize the limitations of our current knowledge related to risk factors for and the prevalence, incidence, and natural history of female UI. They make several sensible recommendations for defining UI in epidemiologic studies, including 1) objective demonstration of loss, 2) documentation of the frequency and severity of loss, and 3) assessment of the distress or bother created by the UI. I would like to comment briefly on these recommendations and provide some observations from a recent pilot study we have completed. How does one objectively demonstrate UI? Most of us interpret the International Continence Society criteria as demanding that we observe leakage. Many of us feel comfortable only if we use urodynamics to define the condition causing UI. Most are willing to accept a positive quantitative pad test as an acceptable objective surrogate for direct observation. However, many balk at the suggestion that a validated, prospective urinary diary or a standardized and validated UI clinametric instrument is objective, branding them with the pejorative “subjective” label. However, many of these “subjective” measures have been more thoroughly studied for their reproducibility and reliability than some of our revered “objective” laboratory measures. In the end, no one of these domains stands alone as the gold standard for proving or disproving UI. Epidemiologic studies should try to assess as many domains as possible and should use only standardized and validated instruments. In most instances, the universal assessment of some domains (eg, determination of the physiologic subtype of UI by urodynamic testing) is not feasible. Evaluation of a portion of the surveyed population is acceptable and generalizable only if performed on a scientifically valid and representative portion of the population. Finally, no studies should be undertaken on anything other than a random sample population, with special efforts made to include racial and ethnic groups largely ignored by a half-century of epidemiologic research. How does one document bother? It is no longer enough to ask only, “Does this bother you?” or “Is this a social or hygienic problem?” Validated, condition-specific, quality-of-life instruments exist to assess both the distress caused by and the impact of U1.17 Researchers should either use established instruments or standardize and validate their own instruments and scales. Figure 1A represents a theoretic and nonvalidated model for