Multichannel Urodynamic Testing Research Articles

Urethral sphincter morphology in women with detrusor instability

OBJECTIVE: To determine whether sonographic urethral sphincter morphology is different in patients with detrusor instability than in those with normal urodynamic testing. METHODS: Patients from a population of women presenting for evaluation of urinary incontinence or pelvic organ prolapse underwent intraurethral ultrasonography before multichannel urodynamic testing. Maximal rhabdosphincter thickness, total urethral diameter, total urethral circumference, and longitudinal smooth muscle thickness, diameter, and circumference were measured. For patients with detrusor instability, the strength of the involuntary detrusor contraction and the bladder volume at its onset were recorded. These data were compared with information from history questionnaires and urodynamic evaluations. RESULTS: The 17 patients with detrusor instability and 16 patients with normal urodynamic testing did not differ with respect to age, vaginal parity, race, weight, body mass index, prior continence surgery, or maximal total urethral closure pressure. Patients with detrusor instability, had decreased urethral longitudinal smooth muscle thickness (3.0 ± 0.9 mm vs 4.1 ± 0.7 mm, P = .001), total urethral diameter (18.0 ± 1.6 mm vs 19.4 ± 1.4 mm, P = .01), and total urethral circumference (5.65 ± 0.5 cm vs 6.1 ± 0.4 cm, P = .012) compared with those with normal urodynamic tests. A linear relationship between rhabdosphincter thickness and strength of involuntary detrusor contraction was observed ( r = .686, P = .002). CONCLUSION: Urethral sphincter morphology is different in patients with detrusor instability compared with those who have normal urodynamic tests. These findings provide an anatomic basis for the physiologic findings in patients with “urethrogenic” detrusor instability.

Urinary incontinence symptom scores and urodynamic diagnoses.

The aim of this study was to determine whether scores on two validated urinary incontinence symptom scales predicted eventual urodynamic diagnoses. Two hundred ninety-three patients undergoing multi-channel urodynamic testing rated their symptoms of urinary incontinence and/or pelvic organ prolapse (POP), using the Incontinence Impact Questionnaire, the Urogenital Distress Inventory, and an obstructive symptom subscale from the long form of the Incontinence Impact Questionnaire. Among the 202 (69%) patients without advance-stage POP, increasing scores on scale items related to stress and urge incontinence predicted increasing frequency of the diagnoses of genuine stress incontinence (GSI) and detrusor instability, respectively. Among the 91 (31%) patients with advance-stage POP, there was no association. Among all patients with GSI, the presence of intrinsic sphincter deficiency could not be predicted by responses to the symptom scales. Scores on the symptom scales were inadequate predictors of eventual urodynamic diagnoses, especially among women with advance-stage POP.

Effect of Tension-Free Vaginal Tape Procedure on Urodynamic Continence Indices

In Brief OBJECTIVE To assess the difference in measured urethral function before and after tension-free vaginal tape procedure (TVT). METHODS Women who underwent TVT for genuine stress incontinence with or without intrinsic sphincter deficiency completed this study. Multichannel urodynamic testing was performed preoperatively and 6 weeks postoperatively. Maximum urethral closure pressure and pressure transmission ratio were recorded. Valsalva leak point pressures were determined at 150 mL and at full bladder capacity. Resting and straining urethral angles were measured using the cotton swab technique. Subjects completed both the Incontinence Impact Questionnaire and Urodynamic Distress Inventory preoperatively and postoperatively. RESULTS Thirty-five consecutive women were studied. Twenty-three (65.7%) had a preoperative diagnosis of intrinsic sphincter deficiency as defined by maximum urethral closure pressure less than 20 cm H2O and/or Valsalva leak point pressure less than 60 cm H2O. Subjective and objective success rates were 91% and 83%, respectively. Subjects showed an 86.8% (95% CI 71.9%, 100.0%) improvement in their Incontinence Impact Questionnaire score and a 72.9% (95% CI 62.6%, 83.1%) improvement in their Urodynamic Distress Inventory score. The mean change in maximum urethral closure pressure was −1.3 cm H2O (95% CI −5.9, 3.3), whereas the pressure transmission ratio increased 15.7% (95% CI 5.0%, 26.3%). The mean decrease in straining urethral angle was 16.3° (95% CI −23.9°, −8.7°). Cured subjects demonstrating hypermobility preoperatively continued to do so postoperatively. CONCLUSION There was a significant increase in pressure transmission ratio, but not maximum urethral closure pressure, after TVT. These changes are similar to those reported after retropubic urethropexy and traditional sling procedures. The effectiveness of the TVT sling does not appear to depend on a clinically significant change in the straining urethral angle. The tension-free vaginal tape procedure results in an increase in pressure transmission to the urethra without correcting urethral hypermobility.

Effect of tension-free vaginal tape procedure on urodynamic continence indices

OBJECTIVE: To assess the difference in measured urethral function before and after tension-free vaginal tape procedure (TVT). METHODS: Women who underwent TVT for genuine stress incontinence with or without intrinsic sphincter deficiency completed this study. Multichannel urodynamic testing was performed preoperatively and 6 weeks postoperatively. Maximum urethral closure pressure and pressure transmission ratio were recorded. Valsalva leak point pressures were determined at 150 mL and at full bladder capacity. Resting and straining urethral angles were measured using the cotton swab technique. Subjects completed both the Incontinence Impact Questionnaire and Urodynamic Distress Inventory preoperatively and postoperatively. RESULTS: Thirty-five consecutive women were studied. Twenty-three (65.7%) had a preoperative diagnosis of intrinsic sphincter deficiency as defined by maximum urethral closure pressure less than 20 cm H 2O and/or Valsalva leak point pressure less than 60 cm H 2O. Subjective and objective success rates were 91% and 83%, respectively. Subjects showed an 86.8% (95% CI 71.9%, 100.0%) improvement in their Incontinence Impact Questionnaire score and a 72.9% (95% CI 62.6%, 83.1%) improvement in their Urodynamic Distress Inventory score. The mean change in maximum urethral closure pressure was −1.3 cm H 2O (95% CI −5.9, 3.3), whereas the pressure transmission ratio increased 15.7% (95% CI 5.0%, 26.3%). The mean decrease in straining urethral angle was 16.3° (95% CI −23.9°, −8.7°). Cured subjects demonstrating hypermobility preoperatively continued to do so postoperatively. CONCLUSION: There was a significant increase in pressure transmission ratio, but not maximum urethral closure pressure, after TVT. These changes are similar to those reported after retropubic urethropexy and traditional sling procedures. The effectiveness of the TVT sling does not appear to depend on a clinically significant change in the straining urethral angle.

Suburethral sling using cadaveric dermis as a treatment for complicated stress urinary incontinence

Objective: To report our initial experience with the use of a cadaveric dermal allograft as a suburethral sling material. Methods: Ten patients who underwent a suburethral sling procedure vaginally, either alone or in conjunction with other pelvic reconstructive surgery, were monitored prospectively. Dermal allografts obtained from licensed tissue banks measured 2 × 18 cm. After periurethral tunnels were developed bilaterally, a Pereyra needle was passed from the lateral aspect of a 5-cm suprapubic skin incision through one tunnel into the vagina; 0-Ethibond was placed through the long end of the dermis and was used to pass the sling material up until it appeared through the suprapubic incision. This procedure was repeated on the opposite side, and the sling was adjusted underneath the urethra with appropriate tension. The ends of the dermis were sutured to the rectus fascia. All patients had a chief complaint either of stress incontinence alone or of significant genital prolapse (to the introitus or beyond) with ‘unmasked‘ stress incontinence after the prolapse was reduced. All patients had at least 30° of urethral hypermobility and demonstrable stress incontinence on physical examination. All underwent multichannel urodynamic testing with fluoroscopy preoperatively. The diagnosis of complicated stress incontinence was based on one or more of the following factors: open bladder neck on fluoroscopy, Valsalva leak point pressure less than 60 cm H 2O, maximum urethral closure pressure less than 30 cm H 2O, or demonstrable stress incontinence after reduction of major genital prolapse with the urethra supported in its normal position. Follow-up ranged from 3–8 months. Results: All patients were satisfied with the results of the operation. All were continent at 6 weeks, with minimal to no urethral hypermobility and no demonstrable stress incontinence on physical examination. All have remained dry thus far. The average period of postoperative urinary retention requiring intermittent self-catheterization was 7 days (range, 4–18 days). Conclusions: Dermis seems to be an effective sling material at short-term follow-up for this small group of patients. The quality and consistency of the dermis may prove advantageous over cadaveric fascia, which is at times of poor caliber and variable length. The use of dermis eliminates the need for harvesting the patient’s own fascia, thereby shortening operating time and reducing potential complications related to the donor site. It may be superior to synthetic slings in that dermis, a natural material, is unlikely to pose any erosion risk. Larger prospective studies and long-term data are needed to further evaluate the place of cadaveric dermis in incontinence surgery.

Postoperative resolution of urinary retention in patients with advanced pelvic organ prolapse

Objective: This study was undertaken to determine whether surgery for advanced pelvic organ prolapse corrects the voiding dysfunction commonly associated with this condition and if so to evaluate the ability of preoperative voiding studies to predict such correction. Study Design: We reviewed the records of all women who underwent surgery at our center between January 1996 and June 1999 for stage 3 or 4 pelvic organ prolapse. Patients were included in this review if they had a postvoid residual volume of >100 mL documented by catheterization on at least 2 occasions, had no normal postvoid residual volumes documented, and had undergone preoperative multichannel urodynamic testing that included an instrumented voiding study. Demographic and urodynamic data were analyzed for the ability to predict whether the elevated postvoid residual volume would be resolved after surgery. Results: Thirty-five patients satisfied the criteria for inclusion in the review. Twenty-six had stage 3 pelvic organ prolapse and 9 had stage 4 pelvic organ prolapse. The mean preoperative postvoid residual volume was 226 mL (range, 105-600 mL). Thirty-one patients (89%) had normal postvoid residual volumes after surgery. As a predictor of elevated postoperative postvoid residual volumes, the preoperative voiding study (performed with the prolapse reduced) had a sensitivity of 66%, a specificity of 46%, a positive predictive value of 12%, and a negative predictive value of 93%. Conclusion: In our center a preoperative voiding study performed with the pelvic organ prolapse reduced most accurately predicted postoperative voiding function when results of the voiding study were normal. Most patients with advanced pelvic organ prolapse and elevated postvoid residual volume had normalization of the postvoid residual volume after surgical correction of the pelvic organ prolapse. (Am J Obstet Gynecol 2000;183:1361-4.)

VOIDING CYSTOURETHROGRAPHY FINDINGS IN ELDERLY WOMEN WITH URGE INCONTINENCE

We report voiding cystourethrography findings associated with urge incontinence in elderly women. Two observers jointly reviewed voiding cystourethrograms of 50 cognitively intact and mobile elderly female participants in a drug trial for urge incontinence and 19 continent volunteers. Multichannel urodynamic testing was performed in all subjects. Bladder wall trabeculation and diverticula, cystocele and vesicoureteral reflux were noted. Maximal bladder capacity, post-void residual, and history of bladder suspension and hysterectomy were obtained from clinical records. Of the incontinent women 35 (70%) had trabeculation, which was mild in 30 (60%) and moderate in 5 (10%), and 41 (82%) had cystocele, which was mild in 23 (46%), moderate in 15 (30%) and severe in 3 (6%). Maximal bladder capacity ranged from less than 100 to more than 900 cc, and was greater than 500 in 37 incontinent women (74%). Of the continent women 16 (84%) had smooth bladders, 2 had mild (11%) and 1 had moderate (5%) trabeculation, and 11 (58%) had cystocele, which was mild in 8 (42%) and moderate in 3 (16%). In 7 continent women maximal bladder capacity was greater than 500 cc (37%). Differences between the 2 groups in regard to bladder wall trabeculation, maximal bladder capacity and presence of cystocele were significant at p<0.05. Large bladder capacity, bladder wall trabeculation and small to moderate cystocele on voiding cystourethrography are associated with urge incontinence in the elderly female population.

The rectus muscle suburethral sling as a treatment for complicated stress urinary incontinence

Objective: To report the use of a pedicled rectus muscle flap as a suburethral sling for the treatment of complex stress urinary incontinence (SUI).Methods: Thirty-five women underwent a rectus muscle sling procedure for the treatment of complicated SUI. All operations were performed by a single surgeon (JWS) between September 1995 and February 1997 and involved the harvesting of a rectus abdominis muscle flap unilaterally up to the level of its first tendinous intersection. The muscle flap was sewn into a tubular structure and swung down with its blood supply through the space of Retzius. Once underneath the urethra, the flap was brought up on the contralateral side back into the retropubic space and attached to Cooper’s ligament or to the fascia of the obturator internus. All patients had a chief complaint of either SUI alone or significant genital prolapse (to the introitus or beyond) with “unmasked” SUI after the prolapse was reduced. All patients had demonstrable SUI on physical examination, and all underwent multichannel urodynamic testing with fluoroscopy preoperatively. The diagnosis of complicated SUI was based on one or more of the following factors: open bladder neck on fluoroscopy (29 patients), Valsalva leak point pressure less than 60 cm H2O (28 patients), maximum urethral closure pressure less than 30 cm H2O (24 patients), or demonstrable SUI after reduction of major genital prolapse with the urethra supported in its normal position (8 patients). Follow-up ranged from 30 to 48 months, and was assessed by either physical examination or telephone interview.Results: Twenty-eight patients (80%) were satisfied with the results of the operation. Three patients (8.6%) had persistent SUI; two patients (5.7%) had no SUI, but developed new urge incontinence; and two patients (5.7%) who had mixed incontinence preoperatively had persistence of urge incontinence (but no SUI) postoperatively.Conclusions: The rectus muscle sling seems to be a successful technique for the treatment of complicated SUI. In this difficult group of patients with open bladder necks, some with other previously failed procedures, the long-term success rate is comparable with any other incontinence operation published in the literature. When considering other suburethral sling material, muscle seems superior to synthetics because it has no erosion potential, and has the advantage of its own blood supply and presumed longevity when compared with autologous or donor fascia. The major disadvantage is the need for a midline abdominal incision. The long-term follow-up data are promising, and prospective studies are needed to further evaluate this procedure.

A comparison of women with primary and recurrent pelvic prolapse

Objective: Our purpose was to identify clinically relevant differences in women with primary and recurrent pelvic organ prolapse. Study Design: Consecutive women undergoing reconstructive surgery completed a urogynecologic history and physical examination and underwent either multichannel urodynamic testing or pelvic floor fluoroscopy, or both. Two groups were compared: primary (no prior surgery for pelvic organ prolapse) and recurrent. Results: One hundred eighty-one consecutive women were studied—103 with primary and 78 with recurrent prolapse. The groups were similar with respect to age, race, weight, vaginal parity, prolapse stage, urodynamic diagnosis, extent of visceral malposition, and common urinary, anorectal, and sexual symptoms. Clinically relevant differences were found, with the recurrent group having shorter vaginal lengths ( P = .0005), being more likely to have had a hysterectomy for a nonprolapse indication ( P = .00018) and to be receiving hormone replacement therapy ( P = .00003). Conclusion: The women with primary and recurrent pelvic organ prolapse in this population were remarkably similar in many quantifiable parameters measured. The clinical differences may be related to previous surgery for pelvic organ prolapse. (Am J Obstet Gynecol 1999;180:1415-8.)

A bladder-neck support prosthesis for women with stress and mixed incontinence

Objective: To evaluate the safety and efficacy of a bladder-neck support prosthesis, a vaginal device designed to support the bladder neck, in women with genuine stress and mixed incontinence. Methods: For enrollment, incontinent women underwent a history, physical examination including cotton-swab test, urinalysis, postvoid residual urine, and multichannel urodynamic testing. Those with genuine stress incontinence or mixed incontinence and urethral hypermobility completed 7-day bladder diaries, the Incontinence Impact Questionnaire, and underwent standardized pad tests. They were fitted with a prosthesis and seen weekly to optimize fit and efficacy. At week 5, they underwent repeat evaluations with the best-fitting prosthesis in place. Results: Seventy women were enrolled and 53 completed the 1-month study (29 genuine stress incontinence, 24 mixed incontinence). The mean ages were 50.4 years for genuine stress incontinence (range 24–76) and 55.7 years for mixed incontinence (range 30–88). A statistically significant reduction in incontinence was noted on pad testing (genuine stress incontinence, mean 46.6–16.6 g; mixed incontinence, mean 31.9–6.8 g) and in the bladder diary (genuine stress incontinence, mean 28.6–7.8 losses per week; mixed incontinence, mean 30.2–15 losses per week). Quality-of-life scores improved in both groups. With the device in place, urodynamic testing indicated normalization of urethral function without evidence of outflow obstruction. Subjects found the device comfortable, easy to use, and convenient. Side effects included five urinary tract infections and 23 cases of vaginal mucosal soreness or mild irritation. Conclusion: The bladder-neck support prosthesis significantly reduced involuntary urine loss in women with stress and mixed incontinence.

A randomized trial of burch retropubic urethropexy and anterior colporrhaphy for stress urinary incontinence

Objective: In a randomized trial, we compared the success of Burch retropubic urethropexy to the modified anterior colporrhaphy for the treatment of genuine stress urinary incontinence. Methods: Thirty-five patients with stress incontinence were randomly assigned to undergo Burch retropubic urethropexy or modified anterior colporrhaphy. Subjects had preoperative and 1-year postoperative physical examinations, multichannel urodynamic testing, 20-minute pad test, and subjective grading of incontinence severity with questionnaires. Data were evaluated using Fisher exact test, Wilcoxon two-sample test, logistic regression analysis, and analysis of variance. Results: Objective cure 1 year postoperatively was significantly greater for the women treated by Burch retropubic urethropexy than by modified anterior colporrhaphy (16 of 18 [89%] versus five of 16 [31%], relative risk .15, 95% confidence interval .04, .59). Patients’ subjective ratings of incontinence severity 1 year after surgical treatment were significantly lower in women who had Burch retropubic urethropexy. Conclusion: Burch retropubic urethropexy yields a significantly superior objective cure for genuine stress urinary incontinence than the modified anterior colporrhaphy in a randomized trial.

Urinary incontinence and pelvic organ prolapse in nulliparous women

Objective: To determine differences between vaginally parous and nulliparous women presenting with urinary incontinence and pelvic organ prolapse. Methods: Seven hundred forty eight consecutive referrals with urinary incontinence or pelvic organ prolapse, 62 of whom were nulliparous, were included in the analysis. Five hundred thirty-seven (72%) had urinary incontinence and 235 (31%) had at least stage III pelvic organ prolapse. Each subject had standard history, physical examination, and multichannel urodynamic testing. Differences between parous and nulliparous women were compared using parametric and nonparametric analysis of variance and the χ 2 test with Yates correction where appropriate. Results: The only significant demographic difference between the groups was that parous women had more previous continence and prolapse surgery. There were significant differences in distribution of diagnoses according to parity, with the nulliparas much less likely to have pelvic organ prolapse. Among incontinent women without prolapse, nulliparas were significantly more likely to have pure detrusor instability. Of those with pure genuine stress incontinence, nulliparas were older, had less anterior vaginal wall descent, less bladder neck mobility, narrower genital hiatus and perineal body measurements, and lower maximum urethral closure pressures. Of those with pure detrusor instability, the only difference was that nulliparas were significantly younger. For women with stage III pelvic organ prolapse or worse, no significant difference in any measured characteristic was noted. Conclusion: Nulliparous women were less likely to present with pelvic organ prolapse and those with urinary incontinence differed little from incontinent parous women.

The “Femassist”: a new device for the treatment of female urinary incontinence

Objective: This study was undertaken in order to determine if the “Femassist” device is a safe and effective treatment for women with the diagnosis of urinary incontinence. Methods: The Femassist is a medical-grade silicon dome-shaped device, worn over the urethra and held securely via suction and a commercially available adhesive lotion. Women with a chief complaint of urinary incontinence responding to local newspaper advertisements were screened for inclusion. Potential candidates underwent medical history, physical (including gynecologic) examination, Papanicolaou test, urine culture and cytology, and multichannel urodynamic testing (including abdominal leak-point pressure measurements). A total of 38 women with documented genuine stress urinary incontinence (GSUI) or mixed incontinence were ultimately recruited into the study and fitted with either the standard or petite-sized Femassist device, according to their individual anatomy. Subjects were assessed before and after 1 month’s use. Subjective assessment included quality of life questionnaires, daily voiding and activity diaries, as well as ongoing patient comments retrieved through daily telephone contact with the study nurse. Objective assessment included blinded evaluation of bacteriuria and urinary infection rates and vulvar irritation and ulceration rates. Results: To date, of the 38 women who have completed the study, over 50% reported an improvement in their quality of life including comfort, convenience, and overall satisfaction. In total for all patients studied, the device was worn for a total of 886 days; 82% of these were dry days. Similar results were obtained for women with GSUI and mixed incontinence. Factors associated with successful experience with the device included degree of tissue estrogenization (either naturally or via a topical estrogen preparation), manual dexterity, and degree of motivation. One in five women reported vulvar irritation or urethral discomfort at some point; this was not correlated with percentage of dry days. There have been no reported significant increases in bacteriuria or urinary tract infection rates over patients’ baseline experiences. Conclusion: Our preliminary study suggests that the Femassist device is a safe and effective method for the management of female urinary incontinence.

Stress Incontinence Diagnosed Without Multichannel Urodynamic Studies

In Brief Objective To determine if the clinical diagnosis of stress urinary incontinence made on the basis of simple criteria correlates with the diagnosis of genuine stress incontinence as determined by provocative multichannel urodynamic testing. Methods The charts of 652 women who presented for clinical evaluation of a variety of lower urinary tract complaints were reviewed if they met all of the following criteria: 1) a predominant complaint of stress incontinence, 2) positive cough stress-test results, 3) postvoid residual urine volume no more than 50 mL, 4) a functional bladder capacity of at least 400 mL as determined by a completed 24-hour frequency-volume chart, and 5) a full multichannel urodynamic evaluation. Seventy-four patients met all these criteria. The clinical diagnosis of stress incontinence was based on the presence of factors 1-4; this diagnosis then was compared with the results of provocative multichannel urodynamic testing. Results Genuine stress incontinence was confirmed in 72 (97%) of 74 patients meeting the aforementioned clinical criteria. In one patient, detrusor instability alone was demonstrated during urodynamic testing. In 11 patients with genuine stress incontinence (15%), an element of detrusor instability was also present at the time of urodynamic testing. One patient had normal urodynamic study findings, with no incontinence demonstrated. Conclusion Rigorously defined clinical criteria are highly reliable in predicting the presence of genuine stress incontinence at the time of urodynamic testing. Because of the potential implications of this finding for clinical practice, further investigation is warranted. Simple but rigorous clinical diagnostic criteria are highly reliable in identifying genuine stress incontinence.

Stress Incontinence Diagnosed Without Multichannel Urodynamic Studies

Objective: To determine if the clinical diagnosis of stress urinary incontinence made on the basis of simple criteria correlates with the diagnosis of genuine stress incontinence as determined by provocative multichannel urodynamic testing. Methods: The charts of 652 women who presented for clinical evaluation of a variety of lower urinary tract complaints were reviewed if they met all of the following criteria: 1) a predominant complaint of stress incontinence, 2) positive cough stress-test results, 3) postvoid residual urine volume no more than 50 mL, 4) a functional bladder capacity of at least 400 mL as determined by a completed 24-hour frequency-volume chart, and 5) a full multichannel urodynamic evaluation. Seventy-four patients met all these criteria. The clinical diagnosis of stress incontinence was based on the presence of factors 1–4; this diagnosis then was compared with the results of provocative multichannel urodynamic testing. Results: Genuine stress incontinence was confirmed in 72 (97%) of 74 patients meeting the aforementioned clinical criteria. In one patient, detrusor instability alone was demonstrated during urodynamic testing. In 11 patients with genuine stress incontinence (15%), an element of detrusor instability was also present at the time of urodynamic testing. One patient had normal urodynamic study findings, with no incontinence demonstrated. Conclusion: Rigorously defined clinical criteria are highly reliable in predicting the presence of genuine stress incontinence at the time of urodynamic testing. Because of the potential implications of this finding for clinical practice, further investigation is warranted.

Efficacy of Nonsurgical Therapy for Urinary Incontinence

OBJECTIVE : To assess the efficacy of aggressive nonsurgical therapy for urinary incontinence in women and to determine if it is advantageous to perform invasive urodynamic testing prior to initiating treatment. STUDY DESIGN : We subjectively assessed 202 incontinent women three months to four years following nonsurgical therapy for urinary incontinence. Therapy in all patients included behavioral modification in the form of timed voiding and pelvic floor exercises. Depending on the suspected diagnosis and menopausal state, patients were also treated with various combinations of pharmacologic agents and estrogen replacement therapy. Based on initial evaluation, patient preference and referring physician preference, 100 women were started on therapy after a minimal evaluation, while 102 women were treated based on invasive urodynamic testing. A subjective assessment of treatment outcome was made via a telephone interview in which patients were asked standardized questions. RESULTS : One hundred nineteen cases (59%) were subjectively improved or cured with nonsurgical therapy. Performing urodynamic testing prior to initiating therapy did not increase the overall success rate : 69 of 100 patients (69%) treated on the basis of history, physical examination and a minimal office evaluation were improved or cured, while only 50 of 102 patients (49%) having electronic multichannel urodynamic testing were improved or cured. CONCLUSION : All women with urinary incontinence should be initially offered nonsurgical therapy since a large percentage will obtain satisfactory results. It is not beneficial or cost-effective to perform electronic urodynamic testing prior to initiating therapy.

Clinical use of the FemAssist device in female urinary incontinence.

We sought to determine the safety and effectiveness of a new, simple noninvasive device, "FemAssist" for women suffering from urinary incontinence. The "FemAssist" is a dome-shaped medical grade silicon device intended to be worn over the external urethral meatus and held in place by suction and an adhesive gel. Thirty eight women with varying degrees of genuine stress urinary incontinence (GSUI) or mixed incontinence on multichannel urodynamic testing were fitted with one of two sizes of "FemAssist" with regard to their anatomy and dexterity. Thus far, of the 38 women who have completed the study, there have been no reported significant increases in bacteriuria or urinary tract infection rates. Over half of the women reported an improvement in the quality of life including comfort, convenience, and overall satisfaction. The device was worn for a total of 886 days by the group; 82% of these were dry days. Our preliminary study suggests that the "FemAssist" device is safe and effective for some women with urinary incontinence.

Factors affecting detrusor contraction strength during voiding in women

To compare voiding mechanisms in continent and stress incontinent women and to assess the effects of aging, childbirth, menopausal status, and anterior vaginal wall relaxation on detrusor contraction strength during voiding. Thirty-eight asymptomatic female volunteers underwent a thorough evaluation including multichannel urodynamic testing and instrumented pressure-flow voiding studies. The voiding mechanisms and detrusor contraction strengths, available in 30 women, were compared with those of 70 women evaluated previously with objective evidence of genuine stress urinary incontinence. The effect of age, parity, bladder neck mobility, and anterior vaginal wall relaxation on maximum detrusor pressure was assessed using chi2 and linear regression analyses. Detrusor pressures in premenopausal and postmenopausal women and continent and stress incontinent women were also compared. Four types of voiding mechanisms were identified. All 30 of the continent women voided with a detrusor contraction, compared with 59 (84%) of genuine stress incontinent subjects. The mean +/- standard deviation [SD]) detrusor contraction was significantly stronger in continent women than incontinent women (20.3 +/- 14.2 cm H2O compared with 12.3 +/- 11.0 cm H2O; P < .01). In continent and incontinent subjects, maximum detrusor pressure did not correlate significantly with increasing age, parity, bladder neck mobility, or degree of anterior vaginal wall relaxation. Premenopausal women had significantly higher mean (+/- SD) maximum detrusor pressures than postmenopausal women (16.3 +/- 13.0 cm H2O compared with 11.5 +/- 11.0 cm H2O; P < .01). Women with genuine stress urinary incontinence may be more likely to void with a weak or absent detrusor contraction than continent women. Menopausal status was the only factor identified that significantly affected maximum detrusor pressure during voiding.

Transvaginal electrical stimulation for female urinary incontinence

Objective: Our purpose was to determine the objective and subjective efficacy of transvaginal electrical stimulation for treatment of common forms of urinary incontinence in women. Study design: A prospective, double-blind, randomized clinical trial included 121 women with either urinary incontinence caused by detrusor instability or genuine stress incontinence, or both (mixed incontinence). Participants used the assigned device for 8 weeks. Identical preintervention and postintervention assessment included multichannel urodynamic testing, quality-of-life scale, and urinary diaries. Results: A total of 121 women completed this study at four North American urogynecology centers. Detrusor instability was cured (stable on provocative cystometry) in 49% of women with detrusor instability who used an active electrical device ( p = 0.0004, McNemar's test), whereas there was no statistically significant change in the percentage with detrusor instability in the sham device group. There was no statistically significant difference between the preintervention and postintervention rates of genuine stress incontinence for either the active device group or the sham device group. Conclusion: This form of transvaginal electrical stimulation may be effective for treatment of detrusor overactivity, with or without genuine stress incontinence.

Retropubic Cystourethropexy: Is it an Obstructive Procedure?

Purpose We sought to establish whether colpocystourethropexy creates bladder outlet obstruction, as evaluated by pressure-flow studies. Materials and Methods We retrospectively analyzed the records of 50 women. Preoperative evaluation included a detailed questionnaire, physical examination, urine culture, cystourethroscopy and multichannel urodynamic testing. Every patient underwent retropubic colpocystourethropexy according to the Tanagho modification of the original Burch technique. An average of 3 months after the operation clinical evaluation and identical multichannel urodynamic testing were repeated. Preoperative and postoperative urodynamic parameters were compared for each patient and statistical differences were established using Student's 2-tailed t test. Results No statistically significant difference was demonstrated in static urethral pressure profile parameters and in parameters during the filling phase of the cystometrogram except for cystometric capacity, which decreased after surgery (p = 0.02). In contrast, all 5 pressure-flow parameters analyzed (minimum urethral opening pressure, detrusor pressure at maximum flow, maximum flow, theoretical cross-sectional area and theoretical diameter of the flow rate controlling zone) showed statistically significant differences induced by surgery. Pressure-flow data reported on Schafer's diagram and on the Abrams-Griffiths nomogram failed to demonstrate urodynamically significant obstruction created by surgery. Conclusions Our data suggest that colpocystourethropexy does not create obstruction but, rather, restores pressure-flow conditions to a normal or nearly normal level.