Urethral Pressure Profilometry Research Articles

Short‐term test–retest reproducibility of urethral pressure profilometry in women with urodynamic stress incontinence with and without detrusor overactivity

To determine and compare reproducibility of urethral pressure profilometry (UPP) in women with urodynamic stress incontinence (USI) alone or together with detrusor overactivity (DO). Women were recruited from a urodynamic clinic diagnosed with USI using dual channel cystometry. UPP was performed with the technique described by Hilton and Stanton [Hilton P, Stanton SL. Br J Obstet Gynaecol 90:919-33,1983]. Different urethral function parameters were obtained. Two weeks later the tests were repeated. The precision and bias of the tests were measured using the Bland and Altman method [Bland JM, Altman DG. Lancet 1:307-10,1986]. The coefficient of variation (CV) value allowed direct comparison of repeatability of each test, with a lower value indicating less variation. Thirty-one women completed both visits. Fourteen women had USI, the other 17 diagnosed with USI with DO at the end of two visits. There was no significant difference between visits for all the parameters for all women recruited. The most reproducible parameter was functional urethral length and maximum urethral pressure as demonstrated by lowest CV. The women with USI group had more reproducible UPP parameters than those with mixed USI and DO in all parameters apart from pressure transmission ratio in Quartiles 2, 3, and 4. However, there was no significant difference between the two diagnostic groups. Tests of urethral function in urethral pressure profilometry are shown to have poor reproducibility in women with USI, but limit of agreement may be acceptable in some of the tests. The with-in subject CV appears to be higher in women with mixed USI and DO compared to USI only.

Urodynamics in women from menopause to oldest age: what motive? what diagnosis?

To analyze age-associated changes as a motive for urodynamics and urodynamic diagnosis in community-dwelling menopausal women and to discuss the role of menopause and ageing. Four hundred and forty nine consecutive menopausal women referred for urodynamic evaluation of lower urinary tract (LUT) symptoms, met the inclusion criteria and were stratified into 3 age groups: 55-64 years (A), 65-74 years (B), and 75-93 years (C). Comprehensive assessment included previous medical history and clinical examination. Studied items were motive for urodynamics, results of uroflows (free flow and intubated flow) and cystometry, urethral pressure profilometry, and final urodynamic diagnosis. The main motive was incontinence (66.3%) with significant increase of mixed incontinence in group C (p = 0.028). Detrusor function significantly deteriorated in the oldest group, mainly in absence of neurological disease (overactivity p = 0.019; impaired contractility p = 0.028). In the entire population, underactivity predominated in group C (p = 0.0024). A progressive decrease of maximum urethral closure pressure occurred with ageing. In subjects with no detrusor overactivity there was a decrease with age of detrusor pressure at opening and at maximum flow, and of maximum flow while post void residual increased only in the C group. In our population of community-dwelling menopausal women, incontinence was the main motive for urodynamics increasing with ageing. A brisk change in LUT function of women older than 75 years underlined deterioration in bladder function with a high incidence of detrusor hyperactivity with or without impaired contractility while change in urethral function was progressive. Effect of ageing appears to be predominant compared to menopause.

Transobturator Vaginal Tape Inside Out for Treatment of Urethral Sphincter Mechanism Incompetence in Female Dogs: Cadaveric Study and Preliminary Study in Continent Female Dogs

(1) To describe a surgical technique adapted from the "transobturator vaginal tape inside-out" (TVT-O) used in women and to define the trajectory of the tape on canine cadavers, and (2) to determine the urodynamic and morphological effects of the TVT-O in continent bitches. Cadaveric and experimental in vivo study. Fresh female canine cadavers (n=12) and spayed female Beagle dogs (2). (1) TVT-O was inserted in 12 cadavers. Dissection was performed and distances between the tape and neighboring structures were recorded. (2) TVT-O was inserted in 2 continent female Beagle dogs. Urethral pressure profilometry and vaginourethrograms were performed preoperatively, immediately after surgery, and 2, 4, and 6 months postoperatively. Histopathology was performed 6 months after surgery. (1) TVT-O tape was consistently located in a perineal space before entering the obturator foramina and was located at a safe distance from major neurovascular structures including the femoral vessels and obturator nerve. (2) TVT-O was performed without any surgical or postoperative complications in 2 continent bitches. Histopathologic examination of the tissues surrounding the tape revealed a mild fibroblastic proliferation with a mild to minimal lymphoplasmacytic inflammatory infiltration. TVT-O is a feasible and accurate procedure that can be performed in continent bitches with a low risk of complications.

Transobturator Vaginal Tape Inside Out for Treatment of Urethral Sphincter Mechanism Incompetence: Preliminary Results in 7 Female Dogs

To evaluate the clinical efficacy of the transobturator vaginal tape inside-out (TVT-O) in incontinent female dogs affected with urethral sphincter mechanism incompetence (USMI) and to determine its urodynamic and morphologic effects. Case series. Incontinent spayed female dogs (n=7). TVT-O tape was inserted in 7 incontinent female dogs diagnosed with USMI. Urethral pressure profilometry (UPP) and vaginourethrograms were performed preoperatively, and 1 and 3 months postoperatively. Clinical efficacy of the technique was evaluated and complications reported. Follow-up information was evaluated by a telephone questionnaire. All dogs were continent immediately after the procedure. Incontinence recurred 2 months after surgery in 1 dog and was treated by phenylpropanolamine administration. At mean follow-up time of 11.3 months, 6 of 7 dogs were continent. An iatrogenic urethral tear occurred intraoperatively in 1 dog. No postoperative complications were encountered. The postoperative UPPs showed significantly increased maximal urethral closure pressure and integrated pressure. Postoperative vaginourethrograms were unremarkable. The surgical procedure did not modify the location of the urinary bladder neck in dogs with a "pelvic urinary bladder" preoperatively. TVT-O was efficient in maintaining short term continence in 6 of 7 dogs affected with USMI.

Re: Urodynamics in a community-dwelling population of females 80 years or older: which motive? Which diagnosis?

PURPOSE: To determine why community-dwelling women aged 80 years or over were referred for urodynamic evaluation despite their advanced age and which urodynamic diagnosis was made. MATERIALS AND METHODS: One hundred consecutive females (80-93 years) were referred to our urodynamics outpatient clinic for evaluation of lower urinary tract symptoms (LUTS) between 2005 and 2008. Clinical evaluation comprised of a previous history of LUTS, previous medical history of neurological disease or dementia, pelvic floor dysfunction or prior pelvic surgery. Exclusion criteria were complete retention and severe dementia involving failure to understand simple instructions. Assessed items were results of uroflows (free flow and intubated flow), cystometry and urethral pressure profilometry, and final urodynamic diagnosis. RESULTS: The main complaint evoked by the patients was incontinence (65.0%) of which 61.5% was complicated and urgency was reported by 70.0%. Interpretable free flow at arrival was very low (44.0%). Prevalence of detrusor overactivity was high, found in 45 patients of whom 16 had detrusor hyperactivity with impaired detrusor contractility. Detrusor overactivity and urgency were strongly associated (p = 0.004). Twenty-five patients had intrinsic sphincteric deficiency alone and 15 detrusor underactivity. CONCLUSION: In this particular community-dwelling with an elderly female population, urodynamics is easily feasible. Incontinence, mainly complicated is the more frequent complaint and urgency the more frequent symptom. Urodynamic diagnosis underlines the high incidence of detrusor overactivity as well as impaired detrusor function.

Urodynamics in a community-dwelling population of females 80 years or older: which motive? Which diagnosis?

To determine why community-dwelling women aged 80 years or over were referred for urodynamic evaluation despite their advanced age and which urodynamic diagnosis was made. One hundred consecutive females (80-93 years) were referred to our urodynamics outpatient clinic for evaluation of lower urinary tract symptoms (LUTS) between 2005 and 2008. Clinical evaluation comprised of a previous history of LUTS, previous medical history of neurological disease or dementia, pelvic floor dysfunction or prior pelvic surgery. Exclusion criteria were complete retention and severe dementia involving failure to understand simple instructions. Assessed items were results of uroflows (free flow and intubated flow), cystometry and urethral pressure profilometry, and final urodynamic diagnosis. The main complaint evoked by the patients was incontinence (65.0%) of which 61.5% was "complicated" and urgency was reported by 70.0%. Interpretable free flow at arrival was very low (44.0%). Prevalence of detrusor overactivity was high, found in 45 patients of whom 16 had detrusor hyperactivity with impaired detrusor contractility. Detrusor overactivity and urgency were strongly associated (p = 0.004). Twenty-five patients had intrinsic sphincteric deficiency alone and 15 detrusor underactivity. In this particular community-dwelling with an elderly female population, urodynamics is easily feasible. Incontinence, mainly "complicated" is the more frequent complaint and urgency the more frequent symptom. Urodynamic diagnosis underlines the high incidence of detrusor overactivity as well as impaired detrusor function.

Incontinência urinária após gonadectomia em fêmeas caninas

A incontinência urinária adquirida é uma condição debilitante e, muitas vezes, incurável que acomete fêmeas castradas e raramente fêmeas inteiras ou machos. A manifestação clínica pode ocorrer em qualquer momento após a gonadectomia e resulta em graves problemas no manejo do paciente. Os mecanismos que desencadeiam a incontinência após ovariectomia envolvem decréscimo na pressão de fechamento uretral, alterações hormonais, aumento na deposição de colágeno na musculatura lisa da bexiga, diminuição na contratilidade do músculo detrusor e redução na resposta aos estímulos elétricos e ao carbachol. O diagnóstico é realizado pelo histórico do animal, pelo exame físico, pelos exames laboratoriais, pelo perfil de pressão uretral, pela ultrassonografia e pelas radiografias abdominais. O tratamento clínico envolve utilização de fármacos -adrenérgicos, estrógenos, análogos de GnRH e agentes antidepressivos. As técnicas cirúrgicas recomendadas correspondem à uretropexia, cistouretropexia, aplicação de colágeno na uretra e colpossuspensão. Melhor compreensão da etiologia, da fisiopatologia, dos métodos de diagnóstico e tratamentos é fundamental em razão do pouco conhecimento e da identificação dessa condição no Brasil.

Transrectal Ultrasound–Guided Transperineal Botulinum Toxin A Injection to the External Urethral Sphincter for Treatment of Detrusor External Sphincter Dyssynergia in Patients With Spinal Cord Injury

Chen S-L, Bih L-I, Chen G-D, Huang Y-H, You Y-H, Lew HL. Transrectal ultrasound–guided transperineal botulinum toxin A injection to the external urethral sphincter for treatment of detrusor external sphincter dyssynergia in patients with spinal cord injury. Objective To evaluate the effects of a single transrectal ultrasound (TRUS)–guided transperineal injection of botulinum toxin A (BTX-A) to the external urethral sphincter (EUS) for treating detrusor external sphincter dyssynergia (DESD). Design Descriptive study. Setting Rehabilitation hospital affiliated with a medical university. Participants Patients (N=18) with suprasacral spinal cord injury who had DESD confirmed on video-urodynamic study. Interventions A single dose of 100U BTX-A was applied into the EUS via TRUS-guided transperineal route injection. Main Outcome Measures Maximal detrusor pressure, detrusor leak-point pressure, integrated electromyography (iEMG), maximal pressure on static urethral pressure profilometry, and postvoiding residuals. Results There were significant reductions in iEMG ( P=.008) and static ( P=.012) and dynamic urethral pressure ( P=.023), but not in detrusor pressure and detrusor leak-point pressure after treatment. Postvoiding residuals also significantly decreased in the first and second month after treatment ( P<.012). Conclusions TRUS-guided transperineal injection of BTX-A has beneficial effects in treating DESD.

Urethral sleeve sensor: a non-withdrawal method to measure maximum urethral pressure

Introduction and hypothesisThis study seeks to evaluate axial variation, comparisons with current technology, performance during dynamic conditions, and patient tolerability of the urethral sleeve sensor (USS) for maximal urethral closure pressure (MUCP) measurements.MethodsEighteen continent and seven stress incontinent women underwent assessments with USS and urethral pressure profilometry (UPP) in random order. Intravesical (p ves) and urethral (p ura) pressure signals were collected and urethral closure pressure (p clo) was calculated. A visual analog scale (VAS) was used to evaluate subject discomfort.ResultsThe correlation coefficient between MUCP obtained by UPP and USS techniques was 0.86 (p < 0.001). Higher USS pressures were obtained with catheter oriented to 12 o’clock. Continent subjects demonstrated higher values of p clo. MUCP became <0 cm H2O in subjects with clinical leakage during Valsalva, but not in continent subjects. Subjects tolerated the USS technique better than the UPP technique on VAS (p < 0.001).ConclusionsUSS technology can be used to evaluate the urethra in both static and dynamic conditions and is better tolerated than withdrawal techniques.

Uterus-, Fallopian Tube-, Ovary-, and Vagina-sparing Cystectomy Followed by U-shaped Ileal Neobladder Construction for Female Bladder Cancer Patients: Oncological and Functional Outcomes

To evaluate oncological outcomes and voiding functions after orthotopic neobladder reconstruction with preservation of gynecologic organs in female bladder cancer patients. A total of 30 consecutive female patients who underwent radical cystectomy and U-shaped ileal neobladder (constructed using 40 cm of a double-folded ileal loop) substitution were retrospectively analyzed. Of the 30 patients, 29 had urothelial carcinoma and 1 had leiomyosarcoma. Computed tomography was performed every 6 months. Urethroscopic examination was performed at 3-month intervals during the first and second years, and at 6-month intervals thereafter. Pressure flow studies, including urethral pressure profilometry, were performed 3, 6, 9, and 12 months after surgery. During a median follow-up of 35.7 months, 1 patient exhibited local recurrence and 6 patients died of bladder cancer. Maximum neobladder pressure examined 12 months after surgery improved significantly as compared with that examined after 3 months (P<.01). Maximal urethral closure pressure also improved significantly 12 months after surgery as compared with that after 3 months (P<.05). The capacity of the ileal neobladder 3 months after operation was 204+/-84 mL, and it showed a gradual increase, reaching 311+/-95 mL at 12 months (P<.01). None of the patients required catheterization for residual urine. Twenty-four patients (80%) remained completely dry day and night, voiding once or twice during the night. Orthotopic neobladder reconstruction with preservation of gynecologic organs is feasible for female bladder cancer patients. Although the follow-up period was not long, the present technique provided acceptable oncological outcome and voiding function.

Early and Late Urodynamic Assessment of Padua Ileal Bladder

To report the data from a single series of 46 patients who underwent cystectomy and Padua ileal bladder (PIB) substitution during a 48-month period. Data are lacking concerning the changes in urodynamic characteristics of the orthotopic ileal neobladder. From January 2002 to April 2003, 46 consecutive male patients underwent radical cystectomy and PIB substitution for muscle-invasive bladder cancer. Uroflowmetry, cystometry, and urethral pressure profilometry were analyzed at 12 and 48 months after surgery. All patients were asked to complete a questionnaire regarding quality of life (the European Organization for Cancer Research and Treatment of Cancer Quality of Life Questionnaire and the bladder cancer-specific module). Of the 46 patients, 8 were lost to follow-up because of cancer-related death. When comparing the 12- and 48-month urodynamic characteristics, no significant changes were observed in cystometric capacity or urethral closing pressure. However, the end-filling pressure, peak flow pressure, and postvoid residual urine volume were significantly lower at the 48-month evaluation (P = .0005, P = .0007, and P = .013, respectively). The number of involuntary contractions at 48 months had increased significantly (P = .0012), and the amplitude of the contractions was comparable (P = .084). The daytime continence rate was 96% and 90% at 12 and 48 months, respectively. The nighttime continence rate was 60% at the 48-month evaluation. The questionnaires about the quality of life highlighted the excellent results. An ileal tone is maintained despite detubularization and most likely prevents enlargement of the neobladder. PIB was revealed to maintain an adequate capacity and low pressure during a 48-month period. The urodynamics results and quality of life support this urinary diversion as a valid treatment option for muscle-invasive bladder cancer.

Measurement of Urethral Closure Function in Women With Stress Urinary Incontinence

We assessed the use of urethral pressure reflectometry in detecting pressure increases in the female urethra and compared the usefulness of urethral pressure reflectometry vs urethral pressure profilometry in a pharmacodynamic intervention study. In this randomized, double-blind, placebo controlled, crossover study 17 women with stress urinary incontinence or mixed urinary incontinence received 4 mg esreboxetine or placebo for 7 to 9 days followed by a washout period before crossing over treatments. Urethral pressure reflectometry and urethral pressure profilometry were performed before and at the end of each treatment period. The urethral opening pressure measured with urethral pressure reflectometry increased significantly compared to placebo by 13.7 cm H(2)O (p <0.0001) with an observed within subject standard deviation of 5.4. The increase in maximum urethral closure pressure was 8.4 cm H(2)O compared to placebo (p = 0.06) and for maximum urethral pressure the increase was 9.9 cm H(2)O (p = 0.04). However, the within subject SD for these parameters was higher at 11.4 and 12.2, respectively, implying lower power for these analyses. While receiving esreboxetine patients had significantly fewer incontinence episodes and reported a treatment benefit (global impression of change) compared to placebo. The opening pressure measured with urethral pressure reflectometry was less variable compared to the parameters measured with urethral pressure profilometry (maximum urethral closure pressure and maximum urethral pressure). Consequently using urethral pressure reflectometry would result in a more efficient study design when investigating pharmacological effects on the urethra in future studies. We also found that esreboxetine was well tolerated, and had a positive and clinically relevant effect on urethral closure function and symptoms of stress urinary incontinence.

Aetiology and Management of Acute Female Urinary Retention

Aims:Interest in female urinary retention has increased recently because of improved understanding in the pathophysiology as well as the availability of specialised treatments such as sacral neuromodulation. There is little in the literature regarding the incidence and aetiology of urinary retention in females. We therefore undertook a review of all female retention patients presenting to our urology unit over an 11 year period.Methods:300 females presented with retention in 11 years January 1996 to January 2007 (7% of the male incidence). 81 presented more than once. Median age was 67. Aetiology included urethral stenosis ( n = 51), urinary tract infection ( n = 33), constipation ( n = 23), neurological causes ( n = 14), gynaecological causes ( n = 16), non urological post-operative patients ( n = 21), medications ( n = 7) and clot retention secondary to bladder cancer ( n = 12). Results: Ultrasound ( n = 240) was carried out in the majority, cystoscopy ( n = 140), and urodynamics in a minority ( n = 38). Urethral pressure profilometry ( n = 38) revealed significantly higher closure pressures as compared to a control group—median 90 vs. 57mmH20 ( p = 0.02). 245 had successful trials without catheter. Prior to this, treatments included cystoscopy and urethral dilatation ( n = 73), laxatives ( n = 25) or antibiotics ( n = 29). Initially 54 patients were taught intermittent self-catheterisation; 38 patients were unable to perform this, and left with a long-term catheter.Conclusions:The number of female retentions encountered in our practice is fairly high, with very few of these fitting the criteria for sacral nerve stimulation. In a third no aetiology was found. Approximately half of those who successfully voided did so with no treatment.

Three‐dimensional ultrasound of the urethral sphincter predicts continence surgery outcome

To assess the predictive value of three-dimensional (3D) ultrasound volumes of the urethral sphincter in women undergoing continence surgery. Women with urodynamic stress incontinence undergoing to Burch colposuspension were prospectively studied using videocystourethrography (VCU), urethral pressure profilometry (UPP) and a 3D transvaginal ultrasound scan of the urethra. The total urethral sphincter volume, urethral volume, maximum cross sectional area, and rhabdosphincter volume were calculated, preoperatively. Surgical outcome was assessed at 6 months using VCU. Urethral function parameters were correlated to surgical outcomes using the Mann-Whitney U-test. Ninety-one women were studied. Women who failed continence surgery had significantly smaller preoperative urethral sphincter volumes than those who had an objective cure (P < 0.001). UPP parameters were not found to be predictive of surgical outcome (P = 0.5). The assessment of the urethral sphincter using a 3D ultrasound scan predicts the outcome of continence surgery.

Urethral pressure reflectometry and pressure profilometry in healthy volunteers and stress urinary incontinent women

Urethral pressure reflectometry (UPR) is a novel reliable method for simultaneous measurement of pressure and cross-sectional area in the female urethra. The aim of this study was to report values for UPR parameters in healthy and stress urinary incontinent (SUI) women and compare UPR with urethral pressure profilometry (UPP) parameters. The study included 30 SUI women and 30 volunteers (23 "continent" and 7 "nearly continent"). The women were examined in the supine position both while relaxed and during squeezing, and upright position. The following UPR variables were measured; opening and closing pressure, opening and closing elastance, hysteresis(absolute) and hysteresis(percent). UPP with the perfusion technique was carried out with the women supine while relaxed and during squeezing. The maximum urethral pressure (MUP) and maximum urethral closure pressure (MUCP) were obtained. All parameters except the hysteresis(percent) were significantly decreased in the SUI group compared to the volunteers. The squeeze opening pressure increased in all women compared to the resting condition, while MUP and MUCP during squeeze increased in 78% and decreased in 22%. The separation between the continent and SUI women was better using the resting and squeezing opening pressure than the corresponding UPP parameters. UPR is a clinically reliable technique, which provides sound physiological parameters. The resting and squeezing opening pressures separate SUI from continent women better than the UPP parameters. The UPR parameters have the potential to provide a pathophysiologic subdivision of SUI and other dysfunctions.

Are There Any UPP Changes in Women with Stress Urinary Incontinence after Pelvic Floor Muscle Exercises?

Aim: This study examined the effect of pelvic floor muscle exercises after 12 months of successful treatment for stress urinary incontinence based on subjective (incontinence episodes and pad test) and objective outcome variables (urethral closure pressure, UCP, functional profile length and pressure transmission ratio, PTR). Methods: Fifty women aged 24–58 years old with genuine stress urine incontinence who successfully underwent pelvic floor muscle exercises, as measured by incontinence episodes and pad test, were included in the study. All women underwent a comprehensive standardized evaluation of urethral pressure profilometry at baseline assessment and at the end of 12 months of pelvic floor exercise program. Maximal UCP, mean UCP, functional profile length or PTR were recorded in all patients. Results: At baseline, the study population had a mean maximal UCP of 33 ± 20 cm H₂O, a mean UCP of 18 ± 10 cm H₂O, a mean functional urethral length of 22 ± 5 mm and a mean PTR of 81 ± 12%. At the end of 12 months of successful and continuous pelvic floor exercises and a significant improvement of incontinence episodes, no difference could be recorded concerning urethroprofilometry parameters studied apart from mean PTR, which was significantly increased. Conclusions: The results of this study indicate that apart from the mean PTR no other urodynamic parameter reflected the continence improvement of pelvic floor exercise program.

EVALUATION OF THE SENSITIVITY OF URETHRAL PRESSURE REFLECTOMETRY (UPR) AND URETHRAL PRESSURE PROFILOMETRY (UPP) TO DETECT PHARMACOLOGICAL AUGMENTATION OF URETHRAL PRESSURE, USING [S,S]-REBOXETINE

You have accessJournal of Urology1 Apr 2008EVALUATION OF THE SENSITIVITY OF URETHRAL PRESSURE REFLECTOMETRY (UPR) AND URETHRAL PRESSURE PROFILOMETRY (UPP) TO DETECT PHARMACOLOGICAL AUGMENTATION OF URETHRAL PRESSURE, USING [S,S]-REBOXETINE Niels Klarskov, David Scholfield, Koshika Soma, Amanda Darekar, Ian Mills, and Gunnar Lose Niels KlarskovNiels Klarskov More articles by this author , David ScholfieldDavid Scholfield More articles by this author , Koshika SomaKoshika Soma More articles by this author , Amanda DarekarAmanda Darekar More articles by this author , Ian MillsIan Mills More articles by this author , and Gunnar LoseGunnar Lose More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(08)61536-0AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "EVALUATION OF THE SENSITIVITY OF URETHRAL PRESSURE REFLECTOMETRY (UPR) AND URETHRAL PRESSURE PROFILOMETRY (UPP) TO DETECT PHARMACOLOGICAL AUGMENTATION OF URETHRAL PRESSURE, USING [S,S]-REBOXETINE." The Journal of Urology, 179(4S), pp. 521–522 © 2008 by American Urological AssociationFiguresReferencesRelatedDetails Volume 179Issue 4SApril 2008Page: 521-522 Advertisement Copyright & Permissions© 2008 by American Urological AssociationMetricsAuthor Information Niels Klarskov More articles by this author David Scholfield More articles by this author Koshika Soma More articles by this author Amanda Darekar More articles by this author Ian Mills More articles by this author Gunnar Lose More articles by this author Expand All Advertisement PDF downloadLoading ...

Urodynamic Measures Do Not Predict Stress Continence Outcomes After Surgery for Stress Urinary Incontinence in Selected Women

We determined the prognostic value of preoperative urodynamic results in patients with stress urinary incontinence. In a 9-center surgical trial, women with stress urinary incontinence were randomized to a Burch or pubovaginal sling procedure. Women were eligible for the study if they had predominant stress urinary incontinence symptoms, a positive cough stress test, a bladder capacity more than 200 ml and urethral hypermobility. Preoperative free uroflowmetry, filling cystometry and pressure flow studies were performed in all. Overall treatment success required a negative pad test, no urinary incontinence on a 3-day diary, a negative stress test, no self-reported stress urinary incontinence symptoms and no re-treatment for stress urinary incontinence. Stress specific success required all of the last 3 criteria. We examined urodynamic measures, and whether the presence of urodynamic stress incontinence, the presence of detrusor overactivity and Valsalva leak point pressure would predict surgical success. Subjects with urodynamic stress incontinence had a 2-fold greater odds of overall success when compared with the No urodynamic stress incontinence group, but this trend did not quite reach statistical significance (OR 2.26; 95% C.I. 0.99, 5.17). Odds of stress specific success did not differ by urodynamic stress incontinence status. Subjects with detrusor overactivity did not have significantly worse success rates. Stratifying by treatment group, there was no difference in mean Valsalva leak point pressure values between surgical successes and failures. We found a nearly statistically significant trend that women with urodynamic stress incontinence are twice as likely to have a successful overall outcome from surgical management of stress urinary incontinence as women without urodynamic stress incontinence. The level of Valsalva leak point pressure and the presence of detrusor overactivity do not predict the success outcomes after the Burch or autologous fascia sling procedures in women with pure or predominant stress urinary incontinence. The impact of urodynamic studies on surgical outcomes needs further investigation.

Urethral instability.

Urethral instability is still evolving as a clinical entity. Using pressure variation of 15 cm water or more at the point of maximum urethral pressure (MUP), urethral pressure profilometry on patients referred for urodynamic assessment for lower urinary tract symptoms revealed urethral instability in 6.4% of 608 patients. The close association between urethral and detrusor instability was noted. Urethral instability appears to be a cause of frequency and urgency of micturition, and its presence increase the risk of urinary incontinence.

Effect of single botulinum toxin A injection to the external urethral sphincter for treating detrusor external sphincter dyssynergia in spinal cord injury

To evaluate the effect of a single cystoscopic injection of botulinum toxin to the external urethral sphincter in treating detrusor external sphincter dyssynergia. An open treatment trial with pre- and post-treatment evaluations. A total of 20 suprasacral spinal cord injured patients with pure detrusor external sphincter dyssynergia. A single dose of 100 IU botulinum toxin A was applied into the external urethral sphincter via cystoscopy. Outcome measurements included maximal detrusor pressure, maximal urethral pressure, detrusor leak point pressure, integrated electromyography, and maximal pressure on static urethral pressure profilometry obtained 4 weeks post-treatment. Post-voiding residuals were checked pre- and post-injection. There were significant reductions in integrated electro notmyography and static and maximal urethral pressure, but not in maximal detrusor pressure and detrusor leak point pressure after treatment. Post-voiding residuals were significantly decreased at all evaluation periods. In the sub-group analysis, patients who showed good effects of treatment had significantly lower baseline integrated electro-myography (p<0.05). This study demonstrates the effect of a single cystoscopic injection of botulinum toxin in detrusor external sphincter dyssynergia. Integrated electromyography is a good evaluation tool for the net effect and dosage of botulinum toxin. Patients with severe spasticity over the external urethral sphincter may require repeated injections or higher doses.