Urodynamic findings in women with insensible incontinence

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1 bs_bs_banner International Journal of Urology (2013) 20, doi: /j x Original Article: Clinical Investigation Urodynamic findings in women with insensible Benjamin M Brucker, Eva Fong, Daniela Kaefer, Sagar Shah, Nirit Rosenblum and Victor W Nitti Department of Urology, New York University Langone Medical Center, New York, New York, USA Abbreviations & Acronyms ALPP = abdominal leak point pressure DO = detrusor overactivity DOI = detrusor overactivity associated with ICS = International Continence Society IDC = involuntary detrusor contraction II = insensible IUGA = International Urogynecological Association MCC = maximum cystometric capacity MUI = mixed urinary PdetQmax = detrusor pressure at maximum flow rate PVR = post-void residual Qmax = maximum flow rate SUI = stress urinary UDS = urodynamic study USUI = urodynamic stress urinary UUI = urgency urinary Correspondence: Benjamin M Brucker M.D., NYU Urology Associates, 2nd Floor, 150 East 32nd Street, New York, NY 10016, USA. benjamin.brucker@nyumc.org Received 12 March 2012; accepted 13 August Online publication 12 September 2012 Objectives: To define the urodynamic study findings among women with insensible urinary. Methods: Women complaining of insensible who underwent urodynamics at our center were identified. Coexisting symptoms of stress, urgency and/or mixed were recorded. The primary outcome was the urodynamic study finding. Urodynamic stress, detrusor overactivity, combination of both or neither (no ) were the possible diagnoses. Results: A total of 58% of patients had insensible alone and 42% had insensible combined with other urinary symptoms. Of the patients with insensible alone, 37% had no on urodynamics, whereas urodynamic stress was diagnosed in 52%. Isolated urodynamic stress was found in 73% of patients with insensible and stress symptoms. In patients with insensible plus urgency, isolated detrusor overactivity and detrusor overactivity with urodynamic stress were found in the same percentage of women (40% each). In patients with symptoms including stress urinary, stress was the predominant urodynamic finding. Conclusions: In patients who have symptoms in addition to insensible, these symptoms are highly predictive of urodynamic findings. In particular, women with insensible, concomitant stress symptoms are most predictive of urodynamic findings (i.e. urodynamic stress urinary ). In contrast, where insensible represents the only symptom, urodynamic findings vary widely, with a significant proportion having non-diagnostic studies. Key words: Introduction insensible, terminology, urinary, urodynamics. Urinary can occur as a result of bladder dysfunction, sphincter dysfunction or from an extra-urethral source, such as a fistula or ectopic ureter. Typically, caused by urethral dysfunction manifests as the symptom of SUI or the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing. 1 Incontinence as a result of bladder dysfunction commonly manifests as the symptom of urgency or the complaint of involuntary leakage accompanied by or immediately preceded by urgency. 1 However, some patients with urinary experience urine loss without symptoms typical of SUI or UUI. The recently published IUGA/ICS Joint Report on the Terminology for Female Pelvic Floor Dysfunction described insensible (urinary) as the complaint of urinary where the woman has been unaware of how it occurred. 2 Previously, this symptom or complaint has also been called unaware or unconscious. 3,4 In patients who do not have an extra-urethral cause of, II must be caused by urethral and/or bladder dysfunction. In these patients, can often be challenging to treat based solely on symptoms. There is a paucity of literature describing UDS findings in patients who present with II. Knowing the likely cause of II based of UDS findings and other associated symptoms could 2012 The Japanese Urological Association 429

2 B BRUCKER ET AL. Table 1 Female patients: symptoms versus urodynamic findings Urodynamic findings II alone n = 43 II + SUI n = 19 II + UUI n = 5 II + MUI n = 7 Total n = 74 DOI 12% (5) 5% (1) 40% (2) 14% (1) 12% (9) USUI 40% (17) 73% (14) 20% (1) 57% (4) 49% (36) DOI + USUI 12% (5) 5% (1) 40% (2) 14% (1) 12% (9) No 37% (16) 16% (3) 0% (0) 14% (1) 27% (20) Percentages in this column are column percentages. Total percentages are row percentages. lead to a more effective and efficient treatment of patients. The aim of the present study was to establish the predominant UDS findings in patients with II and to see if these findings correlate with other symptoms, such as concomitant SUI or UUI. Methods After obtaining Institutional Review Board approval, a series of consecutive cases of patients undergoing UDS testing from 1 January 2003 to 31 October 2009 at a single institution were reviewed. The patients represented a mixed primary and tertiary referral population, and only women were included in the analysis. It had been our practice during this time period based on the patients symptoms of to classify as stress, urgency, mixed and/or unaware (heretofore referred to as insensible). The distinctions of SUI, urge (now referred to as urgency) urinary and mixed urinary continence were based on 2002 ICS definitions. 1 Patients were all directly questioned to identify during what situations they experienced urinary (i.e. cough, sneeze, strain, accompanied or immediately proceeded by urgency). We classified II (what we called unaware before 2010) in women as the complaint of urinary where the woman has been unaware of how it occurred. From all patients with, we identified patients who had a complaint of II and underwent UDS. If patients had isolated nocturnal enuresis or isolated situational (e.g. giggle or during intercourse [now referred to by IUGA/ICS as coital ]) or they complained of continuous, they were not included in the analysis. In some cases, II was the main or most bothersome symptom, and in some cases it was not. Coexisting SUI or UUI symptoms were also noted. Demographic factors pertaining to presentation of were also taken from a chart review. This included patients age and a genitourinary history. Patients with neurogenic bladder dysfunction or urinary diversion were excluded, as these can affect the presentation of typical or insensible symptoms. Patients with extra-urethral (e.g. vesicovaginal fistula) or anatomical abnormalities (e.g. urethral diverticulum, urethral stricture, urethral masses) as a source of were also excluded. The complaint of postvoid dribbling was not considered to be II. Patients presenting symptoms were classified into the following four categories: (i) II alone (II); (ii) II and SUI (II + SUI); (iii) II and UUI (II + UUI); or (iv) II and MUI (II + MUI; when they had complaints of both SUI and UUI symptoms). UDS were carried out in accordance with guidelines from the ICS. 1,5 Filling cystometry was typically carried out at a rate of 50 ml/min, but this was reduced to 30 ml/min in patients with small functional capacity on voiding diary before the study or if they showed DO at low volumes during filling cystometry. In most cases, bladder filing was carried out first in the standing position, and a second filling cycle was carried out in the seated position (unless the patient was unable to stand). The primary outcomes assessed for the present study were the UDS diagnoses also classified into four categories as per ICS definitions: (i) USUI; (ii) DOI; (iii) a combination of both (USUI + DOI); or (iv) no (when neither USUI or DOI were identified on UDS). Patients that had no seen on UDS had the results of a cough stress test recorded for analysis. A supine cough stress test in women was carried out. UDS findings were correlated with symptoms to determine if presenting symptoms of SUI, UUI or MUI correlated with the UDS diagnosis and predicted the cause of II. Descriptive statistics and percentages calculations were carried out using SPSS version 19 (SPSS, Chicago, IL, USA). Results A total of 74 women met the study criteria. The mean age was 70 years. The UDS findings and clinical symptoms for the patients are summarized in Table 1. Overall, 43 (58%) patients had II alone compared with 31 (42%) patients that had II combined symptoms. Prior genitourinary history for the patients included pelvic organ prolapse (9 patients), anti- surgery (mid-urethral sling, bladder neck sling or abdominal suspen The Japanese Urological Association

3 Insensible Table 2 Urodynamic parameters in patients with II Urodynamic parameters II alone n = 43 II + SUI n = 19 II + UUI n = 5 II + MUI n = 7 Total n = 74 MCC (ml) ALPP (cmh 20) PdetQmax (cmh 20) Qmax (ml/s) Volume at first IDC (ml) PVR (ml) Values represent mean urodynamic values. sion; 21 patients), urethral bulking (8 patients), hysterectomy (10 patients) and pelvic radiation (4 patients). A total of 36 women had no prior genitourinary surgery. In women with II alone, USUI was the most common UDS finding, discovered in 52%. USUI more often occurred as an isolated finding (40% USUI and 12% USUI + DOI). DOI was found in just 24% of patients. DOI was frequently accompanied by USUI (50%). Women with II with UUI were equally as likely to have DOI or DOI + USUI (40% each). Conversely, women with II and SUI were highly predictive of USUI (73%). UDS findings were mixed in patients who had all three symptoms (II + MUI). A significant percentage (37%) of patients with II alone had a non-diagnostic UDS, meaning that was not demonstrated during the study. Of these, just 6% (1/16) had DO without, and only one woman with concomitant pelvic organ prolapse had a positive supine cough stress test. In patients who presented with symptoms of II + SUI, USUI was found in the majority (78%), II + SUI was usually associated with USUI alone (73% USUI and 5% USUI + DOI). Only one woman (5%) with II + SUI had DOI as her only UDS finding. In patients who presented with symptoms of II + UUI, 80% had DOI on UDS. This finding was as likely to be associated with USUI as it was with DOI alone (40% DOI + SUI and 40% DOI alone). In the II + UUI group, USUI was the only UDS diagnosis in 20% of women. There were no non-diagnostic studies in this group. Less than 10% of patients presented with symptoms of II + MUI. USUI was the most common UDS finding and again it was more commonly an isolated finding. Overall (out of the 74 women), USUI was found in 61% of women regardless of presenting symptoms. The remaining urodynamic parameters are presented as average values in Table 2. There were no significant differences when patients were divided into four groups based on presenting symptoms. No patients were noted to have significantly impaired compliance on bladder filling. Discussion The term unconscious was first found in the medical literature in 1893, describing loss of urine caused by lesions of afferent sensory nerves. 6 In 1988, the ICS recognized the term unconscious as that may occur in the absence of urge and without conscious recognition of the urinary loss. 3 In 1997, Blaivas et al. expanded the description and used the term unconscious (unaware) to describe the symptom of involuntary loss of urine that is unaccompanied by either urge or stress. 4 They stated that the patient may be aware of the incontinent episode by feeling wetness. They also described the sign of unconscious as the observation of loss of urine without patient awareness of urge or stress. Finally, they stated that the condition of unconscious might be caused by DO, sphincter abnormalities, overflow or extra-urethral. Despite these two publications, the term was not broadly used and the symptom was not broadly described by investigators or in the literature. In 2009, IUGA and ICS released the Joint Report on the Terminology for Female Pelvic Floor Dysfunction where they used the new term of insensible urinary to describe the complaint of urinary where the woman has been unaware of how it occurred. 2 This is distinguished from continuous urinary or the complaint of continuous involuntary loss of urine. II is usually not something that can be observed on a physical examination, and the symptom of II often coexists with symptoms of stress and/or urgency. Therefore, the cause of the insensible component of the diagnosis can be difficult to make without further diagnostic testing, such as UDS. Therefore, we sought to determine if the presence of other coexisting symptoms might help to predict the cause of II. In that way, patients might be offered non-invasive empiric treatments before going on to UDS testing. We chose a patient population where the source of II was not obvious. Patients with extra-urethral causes of inconti The Japanese Urological Association 431

4 B BRUCKER ET AL. nence were excluded. In addition, patients with anatomical abnormalities that could be associated with were excluded (i.e. urethral diverticulum, urethral stricture and urethral masses). 7,8 Also, we did not consider patients with post-void dribbling as having II. In this first study that addresses UDS findings in patients with II, the urodynamic parameters were consistent with other published data on asymptomatic control women, women with stress and urgency We were able to make a number of associations regarding the presence of coexisting symptoms. For women with II alone, when a cause of was demonstrated, USUI was found in 81% of women. However, the additional finding of DOI was seen in 18% of these women. This is very similar to what is seen in women evaluated for surgical treatment of SUI, 12,13 where there is a similar percentage of women with DO, but it does not seem to affect the outcome of the SUI treatment. Thus, it is reasonable to assume that a high proportion of women with II alone will have USUI as the predominant component of their. The present study reports on 74 patients with II. Of these, 43 had II without other symptoms that could be classified as stress, urgency or mixed. USUI was the most common finding in women. However, we found a significant number of non-diagnostic UDS (failure to demonstrate ) in this group. UDS were non-diagnostic in slightly over one-third of patients if they did not have concomitant symptoms of stress and/or urgency. This fact can now be explained (and quantified) to these patients considering UDS. We found that they are approximately twice as likely to not have a non-diagnosis UDS compared with those that have concomitant symptoms. When patients had that they could relate to stress or urgency symptoms in addition to II, there were differences in the correlation with UDS findings. In patients with II + SUI symptoms, 73% had USUI and just 10% were found to have a component of DOI. In contrast, in those with II + UUI symptoms, just 40% had DOI, but 60% were found to have a component of USUI. Thus, women were more likely to have the unexpected finding of SUI based solely on symptoms. Other possible causes of II are impaired compliance and overflow. Impaired compliance is more commonly seen in patients with neurogenic lower urinary tract dysfunction, chronic outlet obstruction or structural abnormalities of the bladder, such as tuberculosis or radiation cystitis. UDS are usually critical in the evaluation of in these types of patients. None of the patients in the present study had significantly impaired compliance. Likewise, there were no patients with urinary retention and overflow. The obvious limitation of this retrospective analysis is that standardized questionnaires to classify were not used. Nevertheless, we believe that the observations made here show some important associations that should encourage further research on the topic. Ideally, the use of validated questionnaires to more accurately classify symptoms related to stress and urgency, as well as the symptom of II, would be very helpful. Furthermore, it might be useful to assess the severity of and see if this parameter adds any useful information to the likelihood of uncovering the underlying cause on urodynamics. In addition, because of the retrospective nature of the present study, we are unable to comment on how the presence of II might have affected treatment outcomes for SUI and UUI. To date there are no series that have been published discussing UDS findings that correlate with presenting symptoms of II. UDS are an important tool when the patient cannot characterize her own symptoms. In the present study, we showed characteristic findings and an association of with other symptoms. This might help to guide in the implementation of first-line, empiric treatments. However, when more invasive treatments are considered, UDS remains a very important tool in these women. Conflict of interest None declared. References 1 Abrams P, Cardozo L, Fall M et al. The standardization of terminology in lower urinary tract function: report from the standardization sub-committee of the International Continence Society. Neurourol. Urodyn. 2002; 21: Haylen BT, deridder D, Freeman RM et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol. Urodyn. 2010; 29: Abrams P, Blaivas JG, Stanton SL et al. Standardization of terminology of lower urinary tract function. Neurourol. Urodyn. 1988; 7: Blaivas JG, Appell RA, Fantl JA et al. Definition and classification of urinary : recommendations of the Urodynamic Society. Neurourol. 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5 Insensible 8 Bellina J, Kelly R, Sartin B. A unique cause of unconscious urinary. Int. Urogynecol. J. Pelvic Floor Dysfunct. 1999; 10: Defreitas GA, Zimmern PE, Lemack GE, Shariat SF. Refining diagnosis of anatomic female bladder outlet obstruction: comparison of pressure-flow study parameters in clinically obstructed women with those of normal controls. Urology 2004; 64: 675 9; discussion Paick J-S, Oh S-J, Kim SW, Ku JH. Tension-free vaginal tape, suprapubic arc sling, and transobturator tape in the treatment of mixed urinary in women. Int. Urogynecol. J. Pelvic Floor Dysfunct. 2008; 19: Cruz F, Herschorn S, Aliotta P et al. Efficacy and safety of onabotulinumtoxina in patients with urinary due to neurogenic detrusor overactivity: a randomized, double-blind, placebo-controlled trial. Eur. Urol. 2011; 60: Albo ME, Richter HE, Brubaker L et al. Burch colposuspension versus fascial sling to reduce urinary stress. N. Engl. J. Med. 2008; 356: Richter HE, Albo ME, Zyczynski HM et al. Retropubic versus transobturator mid-urethral slings for stress. N. Engl. J. Med. 2010; 362: The Japanese Urological Association 433