The Role of Urodynamics in Women with Stress Urinary Incontinence

Transcription

1 EAU Update Series 1 (2003) The Role of Urodynamics in Women with Stress Urinary Incontinence Gina Defreitas, Philippe Zimmern * Department of Urology, University of Texas, Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX , USA Abstract Objective: To examine the role of urodynamic (UDS) investigations in women with stress urinary incontinence (SUI). Methods: Emphasis will be placed on indications for UDS assessment as well as UDS techniques and findings which apply to women with this condition. Topics such as female bladder outlet obstruction (BOO), the utility of urethral pressure (P ure ) and valsalva leak point pressure (VLPP) measurements, and the prognostic value of UDS in this patient population will also be explored. Results: Noninvasive uroflowmetry (NIF), post-void residual (PVR) measurement, filling cystometrogram (CMG), valsalva leak point pressure (VLPP) and pressure-flow studies (PFS) can provide the urologist with a wealth of information which may be used to refine treatment decisions in complex cases of female urinary incontinence. The utility of P ure measurements in the pre- and postoperative work-up of stress incontinent women does not appear to be supported by the majority of urologic and urogynecologic studies to date. Conclusion: Prospective randomized controlled trials to evaluate the clinical efficacy, cost-effectiveness and effect on quality of life of a full pre-operative UDS assessment compared to a less invasive, more accessible basic office evaluation in different populations of women with SUI need to be conducted before any firm conclusion can be drawn regarding the superiority of one of these clinical approaches over the other. # 2003 Elsevier B.V. All rights reserved. Keywords: Female stress incontinence; Urodynamics; Pressure-flow studies; Valsalva leak point pressure; Urethral pressure measurements; Female bladder outlet obstruction 1. Introduction Urinary incontinence is a common condition which occurs in up to 55% of women in Europe and the United Kingdom [1 3]. Stress urinary incontinence (SUI), defined as the involuntary loss of urine during coughing, sneezing or physical exertion [4], affects a substantial proportion of patients with this condition. SUI can occur on its own or in combination with urge incontinence (UI), a condition termed mixed urinary incontinence (MUI). The diagnosis of SUI can be made using a variety of techniques ranging in complexity from a simple cough stress test to multichannel video urodynamics (UDS). The role of UDS in the * Corresponding author. Tel. þ ; Fax: þ address: philippe.zimmern@utsouthwestern.edu (P. Zimmern). assessment of women with SUI has been the subject of considerable debate, and there is a great deal of controversy in the literature as to what constitutes an adequate, cost-effective evaluation of women who complain of this condition. This review will examine the role of UDS investigations in stress incontinent females. It is not intended to be an in-depth discussion of UDS theory or methodology. All UDS terms used are in compliance with International Continence Society terminology [5]. 2. The urodynamic assessment The components of multichannel UDS are noninvasive uroflowmetry, post-void residual measurement, filling cystometry, valsalva leak point pressure measurement, urethral pressure measurement, pressure-flow /$ see front matter # 2003 Elsevier B.V. All rights reserved. doi: /s (03)

2 136 G. Defreitas, P. Zimmern / EAU Update Series 1 (2003) studies and electromyographic recording of the urethral sphincter [6]. If the patient s symptoms or urinalysis suggest UTI, then the study should be postponed until it is treated. Noninvasive uroflowmetry (NIF) is usually performed at the beginning of the assessment. The patient is told to report to the UDS lab with a comfortably full bladder and is allowed to void into a flowmeter. NIF is a product of detrusor contractility, urethral resistance and, in some cases, abdominal straining [7]. It represents a global assessment of voiding function and cannot be used to differentiate bladder outlet obstruction (BOO) from detrusor hypocontractility [8]. Parameters obtained include volume voided, maximum flow rate (Q max ), time to Q max, flow time and flow curve pattern. NIF is considered by many to be a screening test for voiding dysfunction in stress incontinent women [8] and has also been employed in the postoperative assessment of patients after anti-incontinence surgery. Q max, widely regarded to be the most useful parameter obtained from NIF, is dependent on a number of factors including gender, age, volume voided, lower urinary tract pathology and the psychological state of the patient [7 12]. It is well established that males have lower Q max than females and that Q max increases in a roughly linear fashion with volume of urine voided [9,10], but the effect of age and SUI on Q max in women is less clearly defined. Some authors have found Q max to decrease with increasing age in females [11], whereas others have not found age to affect this voiding parameter [7]. Lower Q max has been shown in women with SUI compared to asymptomatic women in some studies [7,12], whereas in others, SUI has been associated with a higher Q max than in normal controls [13,14]. Since anxiety can cause lack of pelvic floor relaxation, it is important to have the patient void into the flowmeter in privacy to ensure the best possible result. Confirmation from the patient that the void was representative of her usual experience outside the clinic setting is crucial when trying to put the information provided by NIF into its proper clinical context. If there is any doubt as to the quality of the void, or if the voided volume is below 100 to 150 cc [9,10], then the test should be repeated. Backman et al. showed a significant difference in Q max between the first and second voids in women, but not between the second and third or fourth tests [15]. In women, a normal Q max is considered to be greater than or equal to 20 cc/s [8]. A normal flow curve is unbroken and bell-shaped with only slight to moderate asymmetry [16]. Other curve patterns are considered to be abnormal and may be due to lower urinary tract dysfunction, valsalva voiding or equipment artifact. Jorgensen et al. have demonstrated that there is acceptable intra- and inter-observer agreement in the classification of flow curve patterns among physicians with UDS training [16], and this finding has been confirmed by recent data from our own institution. Flow curve pattern, however, is not specific enough to diagnose the cause of voiding dysfunction [17]. Post-void residual (PVR) is often obtained after NIF by measuring the amount of urine left in the bladder via the transurethral catheter used for filling cystometry. Elevations in PVR occur secondary to weak or poorly sustained detrusor contraction [18]. There is no absolute volume which defines an abnormally increased PVR, but 30 cc or less has been found in 90% of asymptomatic women and 80 to 85% of women with lower urinary tract symptoms on first and repeat voids [19]. Incomplete bladder emptying is common in middle-aged and elderly women. This finding can be associated with a large cystocele, an overdistended bladder as a consequence of infrequent voiding, ageassociated intrinsic detrusor weakness, diabetes or urethral obstruction secondary to anti-incontinence surgery or urethral stenosis [18]. A PVR of 0 to 100 cc is considered by most experts to be within acceptable limits. Filling cystometry (CMG) is performed by filling the patient with a fluid medium at body temperature with simultaneous recording of intravesical pressure (P ves ) and intra-abdominal pressure (P abd ). The detrusor pressure (P det ) is derived by subtracting P abd from P ves. Filling CMG assesses detrusor contractility, compliance, bladder sensation and capacity. It is used to diagnose overactive bladder and decreased compliance which, in women, can masquerade as severe SUI [20]. P ves is usually monitored by a transurethrally placed double-lumen catheter through which the patient can also be filled with saline or contrast media (for video UDS). The smallest catheter that can feasibly be used is 6F in diameter since narrower calibers would slow down the infusion rate too much. A separate filling catheter can also be used, but this does not allow for repetition of the fill/void sequence without recatheterizing the patient. P abd is measured via a rectal or vaginal balloon catheter. Two types of pressure transducer are commonly employed in the performance of multichannel UDS: external pressure transducers connected to fluid-filled lines and catheter-mounted microtip transducers [7,21,22]. The Good Urodynamic Practice guidelines recommend the use of fluid-filled transducers because they facilitate zeroing P ves and P abd to the environment and placement of the transducers at a reference height

3 G. Defreitas, P. Zimmern / EAU Update Series 1 (2003) which is defined as the upper edge of the symphysis pubis [22]. These maneuvers correct for the influence of atmospheric and hydrostatic pressure on P ves and P abd to allow for comparison of UDS studies between different patients and different institutions [22]. The typical range of P ves and P abd values are 5 20 cmh 2 O in the supine position, cmh 2 O in the sitting position and cmh 2 O in the standing position [23]. Prior to beginning fluid infusion the patient is asked to cough in order to ensure proper recording from all pressure transducers which is indicated by sharp positive spikes in the P ves, P abd and P det tracings. Baseline P det should range from 0 5 cmh 2 O and should always be a positive value. Filling commences at a rate of cc/min and the volumes at which the patient experiences the first sensation of bladder filling and maximum bladder capacity are recorded. Any increase in P det during filling which is accompanied by urgency and/or incontinence is termed detrusor overactivity (DO) [4]. The prevalence of urodynamicaly proven DO in women with SUI ranges from 15 to 64% [24,25]. The occurrence of DO is highly dependent on CMG methodology and can be increased by increasing the filling rate and by having the patient perform provocative maneuvers [26]. Mayer et al. have shown hand washing, heel bouncing and coughing to cause DO in 34 of 112 UDS subjects, with hand washing being the most effective precipitant [27]. VLPP measurements are carried out starting at a filling volume of cc and are performed every 100 cc until maximum capacity is reached. Urethral pressure measurements are usually made at maximum bladder capacity. These parameters are used to quantify the degree of incontinence. Table 1 compares VLPP to P ure measurement and includes cut-off values for the diagnosis of intrinsic sphincter deficiency (ISD) [28,29]. Pressure-flow studies (PFS) are carried out once the bladder has been filled to maximum capacity. The patient sits on a commode over a flowmeter and the pressure transducers are repositioned to the height of the pubic symphysis. The urethral and rectal catheters are left in to record P ves and P abd during voiding. If a separate filling catheter was used for the filling CMG, it is removed before the voiding phase of the study. It is important to use the smallest urethral catheter possible to record P ves since even the presence of a 6F tube can decrease Q max significantly when compared to NIF values in normal females [30]. It is estimated that 5 10% of urogynecologic patients have voiding difficulties [31]. PFS are particularly helpful in detecting this segment of the population, many of whom have a history of anti-incontinence surgery, neurologic conditions and/or severe pelvic organ prolapse. Women with large cystoceles should have a vaginal pack or pessary placed prior to filling CMG and PFS to return the urethrovesical axis to a more anatomic location. These segments of the study should be performed with and then without cystocele reduction in order to detect SUI which can be masked by the obstructive kinking Table 1 Comparison of valsalva leak point pressure (VLPP) and urethral pressure (P ure ) measurements VLPP P ure Definition Equipment required Lowest P ves at which leakage occurs with straining or coughing. When P abd is used, measurement is termed the abdominal leak point pressure (ALPP) Single channel external pressure transducer connected to fluid-filled line or Catheter-mounted microtip transducer. Urethral Pressure Profilometry (UPP) recording of P ure at multiple points along the whole urethral length as pressure transducer is withdrawn at a constant rate with simultaneous recording of P ves and P ure. Cough UPP patient coughs at regular intervals as recording catheter is withdrawn from urethra. Maximum Urethral Closure Pressure (MUCP) obtained by subtracting highest P ure from P ves. Pressure Transmission Ratio (PTR) measured on cough UPP; ratio of the increase in P ure vs. P ves 100 (1) Two high-frequency response pressure transducers: Catheter-mounted microtip or External pressure fluid-filled (infusion method) or Balloon method. (2) Mechanical puller arm. Factors affecting value Bladder volume Type of pressure catheter High grade cystocele Caliber of urethral catheter Caliber of urethral catheter Orientation of pressure sensor on catheter Bladder volume Speed of catheter withdrawal Patient position Cut-off value for ISD <30 60 cmh 2 O <30 cmh 2 O Abbreviations: ISD: intrinsic sphincter deficiency; P ves : vesical pressure; P abd : abdominal pressure.

4 138 G. Defreitas, P. Zimmern / EAU Update Series 1 (2003) effect of the cystocele on the urethra, and to determine whether the cystocele is affecting voiding pressure, Q max and/or bladder emptying. Three types of voiding patterns are observed on PFS in female subjects: type 1 voiding with increased P det and urethral relaxation without an increase in P abd ; type 2 voiding with urethral relaxation in the absence of a detrusor contraction and valsalva; and type 3 voiding with urethral relaxation and valsalva in the absence of a detrusor contraction (valsalva voiding) [32]. The majority of women void with a type 1 pattern (Fig. 1) [32], but type 2 voiding is also seen, especially in stress incontinent women who may have decreased urethral resistance. Data on normal PFS parameters in women is scant, but our receiver-operator curve-based data indicate that a Q max > 11 cc/s with a P det at Q max of <21 cmh 2 O and an uninterrupted, bell-shaped flow curve which may be slightly asymmetric is within acceptable limits [13]. Although the exact significance of valsalva voiding is unknown, most UDS experts believe it to be an indicator of abnormal voiding dynamics. Wyndaele, however, studied 28 male and Fig. 1. Multichannel urodynamic tracing showing type 1 voiding pattern in a woman with stress urinary incontinence. The slight drop in abdominal pressure (P abd ) is often seen with voiding in women. Surface EMG tracing shows appropriate relaxation of pelvic floor musculature during voiding.

5 G. Defreitas, P. Zimmern / EAU Update Series 1 (2003) female volunteers without any symptoms or signs of urologic disease and found that 39% displayed valsalva voiding, suggesting that this feature may not always be an indicator of voiding pathology and, in some cases, may be a test-induced artifact [33]. The unfamiliar environment of the UDS lab, the presence of catheters and a vaginal pack employed for cystocele reduction may impede pelvic floor relaxation so that a substantial proportion of women are unable to void for a PFS or strain to void. Electromyography (EMG) of the external urethral sphincter with surface EMG electrodes is performed in women with SUI to aid in the detection of abdominal straining and to ensure proper relaxation during voiding in suspected cases of BOO. Although many UDS labs routinely perform a two fill and void technique, the Good Urodynamics Practices guidelines recommends that a UDS test be repeated if the initial results suggest an abnormality, leaves the diagnosis unclear, is not representative of the patient s normal state, or if there are technical difficulties which prevent proper analysis of the tracing [22]. This decision requires that the study be reviewed by a person who is trained in UDS interpretation before the patient has left the UDS lab, and underscores that study quality is highly dependent on the expertise of the examiner and his or her interaction with the patient. 3. Indications for urodynamics The most common reasons for performing UDS in women with SUI are: 1. To distinguish pure SUI from MUI [34]. 2. To obtain an objective measure of the severity of SUI by VLPP or urethral pressure measurement [20,35]. 3. To assess patients with neurologic conditions that can affect bladder and/or sphincter function i.e. multiple sclerosis, Parkinson s disease, spinal cord injury, etc. [36] 4. To distinguish bladder outlet obstruction from detrusor hypocontractility in patients who have had anti-incontinence surgery, radical pelvic surgery, urethral surgery or gynecologic surgery and who have voiding dysfunction [35,37]. 5. To rule out DO and/or decreased compliance in patients with a history of pelvic radiation, radical pelvic surgery or prolonged indwelling catheter use [20,36]. 6. To assess patients with abnormal Q max, bladder capacity and/or flow curves on NIF and elevated PVR (>50 cc) for voiding dysfunction [7]. 7. To establish the diagnosis of intrinsic sphincter deficiency (ISD) in women with severe urine leakage and no or minimal urethral hypermobility (<20 degrees) on straining [37,38]. 8. To assess patients with significant (grade 3 or greater) pelvic organ prolapse [36,39]. 9. To determine the etiology of incontinence in women in whom conservative treatment (pelvic floor rehabilitation, medications, etc.) is not working [37]. Since multichannel UDS is costly, invasive and not widely available outside academic institutions, the need for its routine performance as part of the pre-treatment assessment of women with urinary incontinence has been questioned. The Female Stress Urinary Incontinence Clinical Guidelines Panel recommends that the preoperative evaluation of women with symptoms of SUI consist of a history which includes the impact of symptoms on lifestyle, a physical exam which includes an objective demonstration of SUI, urinalysis and other diagnostic studies designed to assess symptom causes [40]. The exact nature of these tests is left to the discretion of the treating physician. Similarly, the Agency for Health Care Policy and Research guidelines recommends a basic office evaluation which consists of a history, physical exam, urinalysis, cough stress test and PVR for the assessment of female urinary incontinence [41]. Recently, Weber et al. used decision analysis to compare this basic work-up to an assessment which included UDS for women 65 years of age or younger with SUI who were candidates for primary surgical therapy. They found that the two strategies resulted in equivalent cure rates and costs after initial and secondary treatment was taken into account. When MUI comprised more than 20% of the patient population, however, UDS was less costly and more effective overall [42]. Proponents of routine UDS in women with urinary incontinence cite the poor to moderate correlation of urinary symptoms and standardized questionnaire results to urodynamic findings [43 46] and the inability of less complex tests to diagnose SUI [45,47]. Those experts who advocate reserving UDS assessment for specific circumstances point to the high positive predictive value of the cough stress test for detecting SUI in uncomplicated cases, and the accuracy of simple standing CMG in excluding DO when compared to multichannel UDS [25,48,49]. Most authors, however, agree that there is a role for UDS assessment in this patient population, particularly if the results will affect therapy. One of the major reasons for performing UDS on stress incontinent women is to distinguish pure SUI

6 140 G. Defreitas, P. Zimmern / EAU Update Series 1 (2003) from MUI in order to decide on surgical versus medical treatment. The importance of this distinction, however, can be questioned since operative treatment is often employedin womenwith MUI [50]. Blaivas and Fissler advocate surgery as the first line of therapy in every case of MUI with urethral hypermobility [51], and it has been demonstrated that surgery can cure incontinence even if DO resolves in only 20 30% of patients [21]. On the other hand, some investigators have found that in women with MUI the cure rate is the same with surgery as it is with anticholinergic therapy and, therefore, advocate initial drug treatment in this condition, reserving surgery for medication failures [26,34]. Another common reason for performing UDS in women with SUI is to select the type of anti-incontinence procedure based on incontinence severity as indicated by the VLPP or UPP. If one performs pubovaginal slings (PVS) in all cases then preoperative UDS is not required since this operation will correct urethral hypermobility and ISD. If a retropubic or needle suspension is being considered, however, then UDS is recommended to exclude ISD [20]. Video UDS is the simultaneous radiographic and urodynamic examination of lower urinary tract function, and is considered to be the gold standard investigation for voiding dysfunction. Video UDS, however, is not needed in the vast majority of cases of female SUI. It is useful for patients who have failed previous surgery to assess position and mobility of the bladder neck at rest and with straining, and for patients with concomitant neurologic lesions to detect detrusorsphincter dyssynergia, but a separate standing VCUG can suffice in many cases [52]. 4. Prognostic value of urodynamics The ability of UDS to predict surgical outcome in women with SUI has been the subject of intense study in recent years, but has never been assessed prospectively in a randomized fashion. Lockhart et al. found that stress incontinent patients with DO greater than 30 cmh 2 O were more likely to fail surgery than those with stable bladders or low pressure DO [53]. Other investigators have also found that the likelihood of surgical cure correlates with the amplitude of unstable bladder contractions [54,55]. McGuire and Savastano, however, did not detect any feature on preoperative UDS evaluation which was able to differentiate women who had persistent DO after surgery from those in whom it had resolved [56]. Thompson et al. performed a retrospective study of 212 women with SUI who were 50 years old or younger and underwent retropubic surgery. They compared surgical outcome in women who had full UDS assessment compared to two levels of a preoperative evaluation which consisted of a history, physical exam, cough stress test, PVR and cotton swab test in one group and history, physical exam, urinalysis and cystourethroscopy in the other. An increase in postoperative voiding problems was found in patients in the cystourethroscopy group, but this could have been due to the different surgical techniques employed among the three cohorts [39]. Romanzi et al. examined the CMG tracings of 75 women with irritative symptoms and found that the UDS parameters were not distinct enough to distinguish idiopathic DO from DO associated with SUI [57]. Several authors have tried to predict which patients will experience delayed voiding and/or lower urinary tract symptoms after anti-incontinence surgery based on preoperative UDS parameters. Bhatia and Bergman found that preoperative PFS displaying decreased Q max and voiding P det < 15 cmh 2 O led to an increased risk of requiring prolonged (>7d) catheter drainage after Burch colposuspension [58]. All patients who were able to void after surgery demonstrated a normal Q max before surgery, although some did not have any detectable detrusor contraction [58]. Presumably a number of women regain the ability to generate an adequate voiding pressure post-anti-incontinence surgery, but our ability to predict in which patients this will not occur is currently limited. In a large study of 600 women with lower urinary tract symptoms suggestive of voiding difficulty, Stanton et al. found that symptoms were unable to predict which patients had abnormal Q max on NIF, leading them to advocate routine flow rate testing for this patient population [59]. The detection of voiding dysfunction by preoperative UDS assessment allows the patient and surgeon to be forewarned of delays in the resumption of spontaneous voiding after anti-incontinence surgery. UDS, however, does not seem able to reliably predict which patients will have persistent postoperative DO and/or urinary retention after surgical treatment. 5. Femalebladderoutletobstruction BOO is much less common in women than in men. Causes of BOO in women include anti-incontinence surgery, severe cystocele, urethral stenosis or stricture, and extrinsic anatomic causes such as pelvic masses [32]. While there are several validated nomograms which can be used to diagnose BOO in males, the definition of BOO is women is somewhat controversial

7 G. Defreitas, P. Zimmern / EAU Update Series 1 (2003) and has been made on the basis of symptoms, VCUG findings and UDS parameters [13,60]. Lemack and Zimmern found that 61% of women who stated that feeling of incomplete bladder emptying was their most bothersome symptom on the Urogenital Distress Inventory-6 questionnaire had BOO as defined by a Q max < 15 cc/s or P det at Q max > 20 cmh 2 O [44]. Lemack and Zimmern found that 20% of women seen in the clinic of their tertiary referral center for voiding complaints had BOO based on a Q max < 12 cc/s and P det at Q max of >21 cmh 2 O [12]. Nitti et al. compared women who had radiographic evidence of obstruction on VCUG with a susbtained detrusor contraction during PFS to those who did not and found that they had a lower Q max (9 vs cc/s), a higher P det at Q max (42.8 vs cmh 2 O) and a higher PVR (157 vs. 33 cc) [60]. No reliable pressure-flow nomogram has ever been validated in women using a normal control population. The Blaivas nomogram was created by plotting data from separate NIF and PFS performed on women with lower urinary tract symptoms [61], and the cut-off values for BOO obstruction obtained by Lemack and Zimmern cited above were calculated using women with SUI as controls [13]. Distinguishing BOO from detrusor hypocontractility in women can sometimes be difficult. Some investigators advocate measurement of the isometric detrusor contraction generated when the patient voluntarily stops her urine flow as a more relevant indicator of detrusor contractility than voiding P det [31], but in practice this maneuver has proved to be awkward and disappointing [18]. 6. Utility of valsalva leak point pressure and urethral pressure measurements VLPP is a reflection of urethral resistance under stress [62] and UPP is used to assess urethral closure pressure [63]. VLPP is favored by urologists whereas UPP is preferred by urogynecologists. Both tests suffer from methodologic difficulties and lack of standardization. VLPP increases with the degree of urethral hypermobility [28,64]. The severity of SUI as quantified by VLPP has not been found to correlate with severity as assessed by standardized, validated questionnaires or quality of life scales [44,62,65], but there is good agreement between VLPP, pad use and grams of urine loss. Using a microtip catheter, McGuire et al. found VLPP to be very reproducible with a mean difference of 8 cmh 2 O between the first and second readings [65]. P ure measurements do not correlate with urethral hypermobility or incontinence severity and cannot differentiate women with SUI from continent women [62,66,67]. The PTR does not change in a consistent fashion after pelvic floor exercises or successful anti-incontinence surgery [68 70]. Theofrastous et al. found that the UPP correlates with the number of incontinence episodes and pad use, but does not correlate with grams of urine loss or quality of life scales [70]. The range of MUCP values overlaps too much between continent women and incontinent women to enable use of this parameter to diagnose SUI [69]. On the other hand, a MUCP value of less than 20 cmh 2 O has been suggested as an harbinger of poor surgical outcome by several investigators [71 73]. Fig. 2. Multichannel urodynamic tracing to illustrate a series of the valsalva leak point pressure (VLPP) measurements in a woman with stress urinary incontinence. Repeating the VLPP at least 2 3 times with calculation of an average value may improve its accuracy and reliability.

8 142 G. Defreitas, P. Zimmern / EAU Update Series 1 (2003) The latest report from the Standardisation Sub- Committee of the International Continence Society has concluded that P ure measurement is, for the most part, a research tool since it has not been shown to predict the presence or magnitude of SUI and cannot be used to evaluate the effect of anti-incontinence surgery [20,63,74]. Since women leak with coughing and straining and not with valsalva, studies focused on improving the reliability of VLPP measurements are ongoing. Repeating the VLPP at least 2 3 times with calculation of an average value may improve its accuracy and reliability. (Fig. 2) 7. Conclusion The role which UDS plays in the evaluation of women with SUI is not clearly defined. While it is apparent from the literature that NIF, PVR measurement, filling CMG, VLPP and PFS can provide the urologist with a wealth of information which may be used to refine treatment decisions in complex cases, the need for these tests in the woman without symptoms of DO or UI, significant pelvic organ prolapse, a neurologic history or a history of anti-incontinence surgery, continues to be a source of controversy. The utility of P ure measurements in the pre- and postoperative workup of stress incontinent women does not appear to be supported by the majority of urologic and urogynecologic studies to date. Prospective randomized controlled trials to evaluate the clinical efficacy, cost-effectiveness and effect on quality of life of a full pre-operative UDS assessment compared to a less invasive, more accessible basic office evaluation in different populations of women with SUI need to be conducted before any firm conclusion can be drawn regarding the superiority of 1 of these clinical approaches over the other. The creation and validation of a pressure-flow nomogram which can reliably detect female BOO may aid the clinician in diagnosing patients with DO secondary to obstruction and recognizing women at risk for retention after antiincontinence surgery. References [1] Thom D. Variation in estimates of urinary incontinence prevalence in the community: effects of differences in definition, population characteristics and study type. J Am Geriatr Soc 1998;46: [2] Stuck AE, Elkuch P, Dapp U, Anders J, Iliffe S, Swift CG. Feasability and yield of a self-adminstered questionnaire for health risk appraisal in older people in three European countries. Age Aging 2002;31: [3] Van Oyen H, Van Oyen P. Urinary incontinence in Belgium; prevalence, correlates and psychosocial consequences. Acta Clin Belg 2002;57: [4] Blaivas JG, Appell RA, Fantl JA, Leach G, McGuire EJ, Resnick NM, et al. Definition and classification of urinary incontinence: recommendations of the Urodynamic Society. Neurourol Urodyn 1997;16: [5] Abrams P, Cardozo L, Fall M, Griffiths D, Rosner P, Ulmsten U, et al. The standardization of terminology of lower urinary tract function: report from the Standardization Sub-Committee of the International Continence Society. Neurourol Urodyn 2002;21: [6] Blaivas JG, Appell RA, Fantl JA, Leach G, McGuire EJ, Resnick NM, et al. Standards of efficacy for evaluation on treatment outcomes in urinary incontinence: recommendations of the Urodynamic Society. Neurourol Urodyn 1997;16: [7] Jorgensen JB, Jensen KME. Uroflowmetry. Urol Clin N Am 1996;23: [8] McLellan A, Cardozo L. Urodynamic techniques. Int Urogynecol 2001;12: [9] Drach GW, Ignatoff J, Layton T. Peak urinary flow rate: observations in female subjects and comparison to male subjects. J Urol 1979;122: [10] Drach GW, Layton TN, Binard WJ. Male peak urinary flow rate: relationships to volume voided and age. J Urol 1979;122: [11] Madersbacher S, Pycha A, Schatzi G, Milan C, Klinger CH, Margerer M. The aging lower urinary tract: a comparative urodynamic study of men and women. Urology 1998;51: [12] Bottacini MR, Gleason DM. Urodynamic norms in women. I. Normals versus stress incontinents. J Urol 1980;124: [13] Lemack GE, Zimmern PE. Pressure flow analysis may aid in identifying women with outflow obstruction. J Urol 2000;163: [14] Lemack GE, Baseman AG, Zimmern PE. Voiding dynamics in women: a comparison of pressure-flow studies between asymptomatic and incontinent women. Urology 2002;59:42 6. [15] Backnam KA. Urinary flow during urination in normal women. Acta Chir Scand 1965;30:357. [16] Jorgensen JB, Jensen KME, Klarskov P, Bernstein I, Abel I, Mogensen P. Intra- and inter-observer variations in classification of urinary flow curve patterns. Neurourol Urodyn 1990;9: [17] Chou TP, Gorton P, Stanton SL, Atherton M, Baessler K, Reinhart G. Can uroflowmetry patterns in women be reliably interpreted? Int Urogynecol J Pelvic Floor Dysfunct 2000;11: [18] Griffiths DJ. Pressure flow studies of micturation. Urol Clin N Am 1996;23: [19] Haylen BT. Voiding difficulties in women. Int Urogynecol J 2000;11:1 3. [20] McGuire EJ, Cespedes RD. Proper diagnosis: a must before surgery for stress incontinence. J Endourol 1996;10: [21] Vereecken RL. A critical review on the value of urodynamics in nonneurogenic incontinence in women. Int Urogynecol J Pelvic Floor Dysfunct 2000;3: [22] Schafer W, Abrams P, Liao L, mattiasson A, Pesce F, Spangberg A, et al. Good urodynamic practices: uroflowmetry, filling cystometry and pressure-flow studies. Neurourol Urodyn 2002;21: [23] Liao L, Kirshner-Hermanns R, Schafer W. Urodynamic quality control: quantitative plausibility control with typical value ranges. Neurourol Urodyn 1999;18: [24] Videla FLG, Wall LL. Stress incontinence diagnosed without multichannel urodynamic studies. Obstet Gynecol 1998;91: [25] Sand PK, Brubaker LT, Novak T. Simple standing incremental cystometry as a screening method for detrusor instability. Obstet Gynecol 1991;77: [26] Jorgensen L, Lose G, Mortensen SO, Molsted P, Kristensen JK. The Burch colposuspension for urinary incontinence in patients with stable and unstable detrusor function. Neurourol Urodyn 1988;7:

9 G. Defreitas, P. Zimmern / EAU Update Series 1 (2003) [27] Mayer R, Wells T, Brunk C, Diokno A, Lockett A. Handwashing in cystometric evaluation of detrusor instability. Neurourol Urodyn 1991;10: [28] Nitti VW, Combs AJ. Correlation of valsalva leak point pressure with subjective degree of stress urinary incontinence in women. J Urol 1996;155: [29] Cadogan M, Awad S, Field C, Acker K, Middleton S. A comparison of the cough and standing urethral pressure profile in the diagnosis of stress incontinence. Neurourol Urodyn 1998;7: [30] Baseman AG, Baseman JG, Zimmern PE, Lemack GE. Effect of 6F urethral catheterization on urinary flow rates during repeated pressureflow studies in healthy female volunteers. Urology 2002;59: [31] Haylen BT, Law MG, Frazer M, Schulz S. Urine flow rates and residual urine volumes in urogynecology patients. Int Urogynecol J 1999;10: [32] Bhatia NN. Dynamics of voiding in women. Cur Opin Obstet Gynecol 2000;12: [33] Wyndaele JJ. Normality in urodynamics studied in healthy adults. J Urol 1999;161: [34] Karram MM, Bhatia NN. Management of coexistent stress and urge urinary incontinence. Obstet Gynecol 1989;73:4 7. [35] Weber AM, Walters MD. Cost-effectiveness of urodynamic testing before surgery for women with pelvic organ prolapse and stress urinary incontinence. Am J Obstet Gynecol 2000;183: [36] Cornella JI, Margrina JF. An algorithm for the management of urinary stress incontinence. Int Urogynecol J 1996;7: [37] Holtedahl K, Verelst M, Schiefloe A, Hunskaar S. Usefulness of urodynamic examination in female urinary incontinence. Scand J Urol Nephrol 2000;34: [38] Diokno AC, Dimaculangan RR, Lim EU, Steinert BW. Office base criteria for predicting type II stress incontinence without further evaluation studies. J Urol 1999;161: [39] Thompson PK, Duff DS, Thayer PS. Stress incontinence in women under 50: does urodynamics improve surgical outcome? Int Urogynecol 2000;11: [40] Leach GE, Dmochowski RR, Appell RA, Blaivas JG, Hadley HR, Luber KM, et al. Female stress urinary incontinence clinical guidelines panel summary report on surgical management of female stress urinary incontinence. J Urol 1997;158: [41] Agency for Health Care Policy. Urinary incontinence clinical practice guidelines. Washington (DC): Dept. of Health and Human Services (US), Agency for Health Care Policy and Research; [42] Weber AM, Taylor RJ, Wei JT, Lemack G, Piedmonte MR, Walters MD. BJU Int 2002;89: [43] Weidner AC, Myers ER, Visco AG, Cundiff GW, Bump RC. Which women with stress incontinence require urodynamic evaluation? Am J Obstet Gynecol 2001;184:20 7. [44] Lemack GE, Zimmern PE. Predictability of urodynamic findings based on urogenital distress inventory-6 questionnaire. Urology 1999;54: [45] Fitzgerald MP, Brubaker L. Urinary incontinence symptom scores and urodynamic diagnoses. Neurourol Urodyn 2002;21:30 5. [46] Harvey MA, Kristjansson B, Griffith D, Versi E. The incontinence impact questionnaire and the urogenital distress inventory: a revisit of their validity in women without a urodynamic diagnosis. Am J Obstet Gynecol 2001;185: [47] Scotti RI, Ostergard DR, Guilaum AA, Kohatsu KE. Predictive value of urethroscopy as compared to urodynamics in the diagnosis of genuine stress incontinence. J Reprod Med 1990;35: [48] Wall LL, Wiskind AK, Taylor PA. Simple bladder filling with a cough stress test conmpared with subtracted cystometry for the diagnosis of urinary incontinence. Am J Obstet Gynecol 1994;171: [49] Sutherst JR, Brown MC. Comparison of single and multichannel cystometry in diagnosing bladder instability. Br Med J 1984;288: [50] McGuire EJ, Lyton B, Kohorn EL, Pepe V. The value of urodynamic tests in stress urinary incontinence. J Urol 1980;124: [51] Blaivas JG, Fissler DM. Combined radiographic and urodynamic monitoring: advance in technique. J Urol 1981;125: [52] Showalter PR, Zimmern PE, Roehrborn CG, Lemack GE. Standing cystourethrogram: an outcome measure after anti-incontinence procedures and cystocele repair in women. Urology 2001;58:33 7. [53] Lockhart JV, Vorksman B, Pohtano VA. Anti-incontinence surgery in women with detrusor instability. Neurourol Urodyn 1984;3: [54] Jorgensen L, Lose G, Mosted-Pedersen L. Vaginal repair in female motor urge incontinence. Eur Urol 1987;13: [55] Paw-Sang JM, Lockhart JL, Suarez A, Lausman H, Politano VA. Female urinary incontinence: preoperative selection, surgical complications and results. J Urol 1986;136: [56] McGuire EJ, Sarvastano JA. Stress incontinence and detrusor instability/urge incontinence. Neurourol Urodyn 1985;4: [57] Romanzi LJ, Groutz A, Heritz DM, Blaivas JG. Involuntary detrusor contractions: correlation of urodynamic data to clinical categories. Neurourol Urodyn 2001;20: [58] Bhatia NN, Bergman A. The use of preoperative uroflowmetry and simultaneous urethrocystometry for prediction risk of prolonged postoperative bladder drainage. Urology 1986;28: [59] Stanton SL, Ozsoy C, Hilton P. Voiding difficulties in the female: prevalence, clinical and urodynamic review. Obstet Gynecol 1983;61: [60] Nitti VW, Le Mai Tu, Gitlin J. Diagnosing Bladder outlet obstruction in women. J Urol 1999;161: [61] Blaivas JG, Groutz A. Bladder outlet obstruction nomogram for women with lower urinary tract symptomatology. Neurourol Urodyn 2000;19: [62] Theofrastous JP, Bump RC, Elser DM, Wyman JF, McClish DK. Correlation of urodynamic measures of urethral resistance with clinical measures of incontinence severity in women with pure genuine stress incontinence. Am J Obstet Gynecol 1995;173: [63] Lose G. Urethral pressure measurement. Acta Obstet Gynecol Scand 1997;76(Suppl 166): [64] Theofrastous JP, Cundiff GW, Harris RL, Bump RC. The effects of increasing serial volume and valsalva leak point pressures (VLPP) in women with pure genuine stress urinary incontinence (GSI). Neurourol Urodyn 1995;14: [65] McGuire EJ, Fitzpatrick CC, Wan J, Bloom D, Sanvordenker J, Ritchley M, et al. Clinical assessment of urethral sphincter function. J Urol 1993;150: [66] Myer S, degrandi P, Cacei G, Gerber S. Pressure transmission ratio: is it a reliable prameter in increased urethrovesical junction mobiliy? Neurourol Urodyn 1997;16: [67] Rosenzweig BA, Bhatia NN. Temporal separation of cough-induced urethral and bladder pressure spikes in women with urinary incontinence. Urology 1992;39: [68] Faysal MH, Constantinou CE, Rother LF, Govan DE. The impact of bladder neck suspension on the resting and stress urethral pressure profile: a prospective study comparing controls with incontinent patients preoperatively and postoperatively. J Urol 1981;125:55 9. [69] Ramon J, Mekras JA, Webster GD. The outcome of transvaginal cystourethropexy in patients with anatomical stress urinary incontinence and outlet weakness. J Urol 1990;144: [70] Beck RP, McCormick S, Nordstrom L. Intraurethral-intravesical cough-pressure spike differences in 267 patients surgically cured of genuine stress incontinence of urine. Obstet Gynecol 1988;72: [71] McGuire EJ. Urodynamic findings in patients after failure of stress incontinence operations. Diag Clin Biol Res 1981;78: [72] Weil A, Reyes H, Bischoff P, Rottenburg RD, Kramer F. Modification of the urethral rest and stress profiles after different

10 144 G. Defreitas, P. Zimmern / EAU Update Series 1 (2003) types of surgery for urinary stress incontinence. Br J Obstet Gynecol 1987;69: [73] Sand PK, Bowne LW, Panganiban R, Ostergard DR. The low pressure urethra as a factor in failed retropubic urethropexy. Obstet Gynecol 1987;69: [74] Lose G, Griffiths D, Hosker G, Kulseng-Hanssen S, Perucchini D, Schafer W, et al. Standardisation of urethral pressure measurment: report from the standardization sub-committee of the International Continence Society. Neurourol Urodyn 2002;21: CME questions Please visit to answer these CME questions on-line. The CME credits will then be attributed automatically. 1. Select the factor which does not influence Q max : A. gender; B. volume voided; C. PVR; D. psychological state of the patient; E. lower urinary tract pathology. 2. One of the following is not an indication for UDS: A. to distinguish SUI from MUI; B. to assess patients with neurologic conditions that can affect bladder function; C. to further evaluate women with abnormal NIF; D. to rule out BOO in patients with a history of prior anti-incontinence surgery; E. to diagnose SUI. 3. Which of the following statements about female BOO is incorrect? A. BOO can be caused by large cystoceles. B. BOO in women can be predicted using a pressureflow nomogram. C. BOO is less common in women than in men. D. Distinguishing BOO from detrusor hypocontractility in women can be difficult. E. Previous anti-incontinence surgery is a common cause for BOO in women. 4. Which statement concerning VLPP is correct? A. VLPP does not correlate with the degree of hypermobility. B. VLPP cannot be used to diagnose ISD. C. VLPP correlates with the severity of SUI as assessed by validated symptom questionnaires. D. There is good agreement between VLPP and grams of urine loss. E. VLPP is independent of bladder volume.