Reliability of the urethral closure pressure profile during stress in the diagnosis of genuine stress incontinence

Urethral pressure profile (UPP) measurements were recorded during stress using the method of Brown and Wickham in 981 patients with lower urinary tract symptoms. This procedure was used to identify patients with genuine stress incontinence (GSI). A clinical stress test in the supine and erect position served to confirm urinary leakage. GSI was diagnosed in 661 patients. (67%), whereas no incontinence was demonstrable in 320 (33%). UPP during stress has a high sensitivity (93.3%) and specificity (82.5%). Compared with other urodynamic investigations, the ease with which it can be performed at the same time as other urodynamic procedures makes a reliable diagnostic adjunct in the assessment of patients with GSI.     

Evaluation of urethral pressure profilometry for the diagnosis of genuine stress incontinence

Summary Given the expense of radiographic imaging facilities and the reproducibility of urethral pressure measurements with microtransducers, the use of urethral pressure profilometry (UPP) has been gaining widespread popularity for the diagnosis of genuine stress incontinence (GSI). However, the clinical usefulness of the technique has not been adequately evaluated against the best available technique, namely videocystourethrography. Using the latter technique as the Gold Standard, the UPP results of 114 normal women and 95 GSI patients have been compared. In order to determine the most diagnostic UPP measure, 25 parameters were examined for each patient. With the use of the Kappa statistic it was found that the area under the stress profile was the most discriminatory of the UPP parameters. Even using this measure, the overlap between normal and GSI is so great as to make accurate diagnosis impossible. It is therefore concluded that UPP is useless for the diagnosis of GSI.     

Factors associated with the presence of genuine stress incontinence in females

Forth-five premenopausal women were enrolled in the study. All patients underwent a complete diagnostic evaluation, which included the completion of a standardized questionnarie, a detailed history, a complete physical examination and multichannel urodynamic testing. Clinical findings and urodynamic parameters were recorded. Logistic regression analysis and ² comparisons were used to determine which factor(s) were most associated with the presence of genuine stress incontinence. Thirty patients had genuine stress incontinence, and 15 asymptomatic volunteers without subjective and objective lower urinary tract dysfunction served as controls. A significant difference in age, maximum urethral closure pressure, strength of cough and bladder-neck mobility was found between the two groups. Logistic regression analysis revealed that bladder-neck mobility was the variable most associated with the presence of genuine stress urinary incontinence. This study supports the concept the genuine stress incontinence is probably multifactorial, and its etiology remains unknown.Editorial Comment: This is one of the few studies that has attempted to correlate possible etiologic factors for genuine stress incontinence in both symptomatic subjects as well as asymptomatic controls. The factor found to be most associated with stress incontinence was the mobility of the urethrovesical junction, as measured by the angle of the Q-tip from the horizontal, when compared to the controls. We should not be misled by this, however, since hypermobility is so common that many patients have this anatomical abnormality without ever having stress incontinence. The diagnosis of stress incontinence cannot therefore be made by the simple presence of urethral hypermobility. The authors correctly conclude that the etiologic factors in stress incontinence are multifactorial, and the collage of information presented by the patient in both clinical and urodynamic terms must be considered in the determination of the ultimate diagnosis.     

Clinical relevance of urethral stress profile using microtransducers after surgery for stress incontinence in females

The value of the urethral stress profile after surgery for urinary stress incontinence in females was prospectively analyzed using microtransducers. 95 patients were clinically and urodynamically assessed at least 6 months after surgery. The success of the operation was based on subjective (patient's history) and objective (no urine loss, erect, with full bladder, on coughing and during a Urilos nappy test) criteria. In 20% of the cases, the interpretation of the urethral profiles did not correlate with the clinical objective criteria. Possible explanations for this discrepancy are discussed.     

Measurement of total urethral compliance in females with stress incontinence

Urodynamic evaluation of stress incontinence has failed to result in consistent diagnostic parameters. Using retrospective female bladder pressure and urine flow data, we evaluated two parameters based on a conductance formula. This formula was derived from fitting a classical fluid dynamic equation to published data of voiding cystourethography. The Area Equivalent Factor-female at maximal flow represents maximal urethral opening and this value further divided by the pressure is the total urethral compliance. A stress incontinent group had a strong trend toward greater maximal urethral opening and total urethral compliance than a continent group. These parameters may, therefore, have potential in the evaluation and understanding of stress urinary incontinence.     

Modified urethral sling for the treatment of genuine stress incontinence and latent incontinence

The results of 143 women who underwent a modified urethral sling using Marlex mesh for the correction of stress urinary incontinence and latent stress incontinence, as diagnosed by clinical and urodynamic testing, are examined. The overall success rate for the surgical correction of genuine stress urinary incontinence was 99% during a median follow-up time of 1 year (range 0.12–4 years). There was a 12% postoperative incidence of varying degrees of genital prolapse. Difficulty with voiding resulting in the need for self-catheterization occurred in 17% of patients in the first 6 weeks, but only 2.8% were needing self-catheterizing after 1 year. There was a difference in peak flow preoperatively compared with 1 year postoperatively (20.5 ml/s v 15.7 ml/s, P=0.0003). Patients with a normal peak flow preoperatively (>20 ml/s) were more compromised at 1 year postoperatively (28 ml/s preoperatively, 18.4 ml/s postoperatively, P=0.00001), than women with an abnormal preoperative flow (<20 ml/s), (13.2 ml/s preoperatively, 13.5 ml/s postoperatively). Whether the operation was done for overt or latent stress incontinence did not affect postoperative flow results. It was not possible to predict by preoperative uroflow testing which patients were likely to need intermittent self-catheterization postoperatively. One year after surgery there were no significant alterations in bladder capacity (CMG) or urethral pressure profile measurements. There were no statistically significant changes in uroflow patterns when comparing primary and secondary surgical groups.     

加压尿道压力测定在压力性尿失禁诊断与治疗中的应用

目的应用加压尿道压力测定（ＳＵＰＰ）方法诊断真性压力性尿失禁（ＧＳＩ）,并评价其手术疗效。方法对２２例临床诊断为ＧＳＩ的患者进行ＳＵＰＰ及静态尿道压力测定（ＲＵＰＰ）,比较其结果,并对５例接受手术治疗的女性患者术后再次进行ＳＵＰＰ,以１７例正常女性作为对照组。结果２２例患者ＳＵＰＰ结果中尿道闭合压（ＵＣＰ）为－０６２±０２２ｋＰａ,压力传导率（ＰＴＲ）为０６８±００６;与ＲＵＰＰ比较ＳＵＰＰ对ＧＳＩ的诊断阳性率为９００％,高于ＲＵＰＰ的７７３％;两者的诊断符合率为６８２％;ＲＵＰＰ阳性而ＳＵＰＰ阴性者２例,相反者有５例。５例ＧＳＩ女性患者经手术治疗后,ＳＵＰＰ测定各参数明显改善,各患者术前、术后ＵＣＰ及ＰＴＲ明显增高。结论ＳＵＰＰ在ＧＳＩ的诊断与疗效评价中均具有一定意义,但也具有某些局限性;临床应用时应与其它方法结合使用,以提高诊断水平     

Urodynamic evaluation of urethral opening area in females with stress incontinence

Urodynamic evaluation has been helpful in the diagnosis of stress incontinence in female patients. We evaluated two new parameters using standard urodynamic measures that were recorded during micturition. These two parameters were obtained by fitting a classic fluid dynamic equation for flow through short rigid tubes to published data of voiding, videourodynamics. This formula, an area equivalent factor female (AEFf) indicates urethral cross-sectional opening area based on bladder pressure and flow measures. The first parameter, maximal urethral opening or maximal AEFf, was observed at maximal flow, and this value further divided by the detrusor pressure determined the second parameter, the urethral total compliance. A preliminary retrospective study was conducted using detrusor pressure and urine flow data from stress incontinent (n=14) and continent (n=5) female patients. There was a trend toward greater maximal urethral opening at 14.2±5.9 mm² in the stress incontinent group compared to the continent group, 9.2±2.9 mm² (p=0.09). The stress incontinent group also showed a strong trend (p=0.09) toward greater total compliance values of 0.78±0.5 mm²/ cmH₂O, compared to 0.35±0.2 mm²/cmH₂O in the continent group. These parameters may have potential in the evaluation and understanding of stress incontinence.     

Predictive value of maximum urethral closure pressure, urethral hypermobility and urethral incompetence in the diagnosis of clinically significant female genuine stress incontinence

PURPOSE: We determined the value of urethral hypermobility, maximum urethral closure pressure (MUCP) and urethral incompetence in the diagnosis of stress urinary incontinence (SUI). MATERIALS AND METHODS: In this study 369 women with clinical symptoms suggestive of SUI without symptoms of bladder overactivity were evaluated in regard to urethral incompetence, urethral hypermobility and mean MUCP. The cohort was divided into 2 groups according to continence/incontinence status. ROC curves were used to test the performance of the various predicting factors. These factors were combined in forward stepwise logistic regression to find the cutoff point that simultaneously optimized sensitivity and specificity. RESULTS: Continent and incontinent patients differed with regards to urethral incompetence and hypermobility (each p <0.0001). Incontinent patients had a greater probability of a higher grade of each factor. Even after adjusting for the older age of incontinent patients by ANCOVA. MUCP was significantly lower in the incontinent group (p <0.001). The best univariate optimized cutoff point for discriminating continence from incontinence was obtained with urethral incompetence greater than grade I. CONCLUSIONS: The best single predictor of clinically significant SUI is urethral incompetence, followed by urethral hypermobility and MUCP. When combining several factors, namely grade II urethral incompetence with grade III hypermobility, grade III urethral incompetence with grades I to III hypermobility and grade IV urethral incompetence with or without urethral hypermobility, all indicated more than a 90% probability of clinically significant SUI.     

Efficacy of an external urethral device in women with genuine stress urinary incontinence

The efficacy of a new external anti-incontinence device in patients with a videourodynamic diagnosis of genuine stress incontinence (GSI) in an open longitudinal study is reported. Fourteen women with GSI underwent assessment before and after 3–4 weeks of device use. Assessment consisted of visual analog scores (VAS), quality of life (QOL) questionnaires, urine for culture and a 1 hour pad test. VAS scores showed a significant improvement for the symptom of stress incontinence (P<0.05). QOL scores improved significantly by 38% (P<0.05) and 29% (P<0.01) for the Incontinence Impact Questionnaire and Urogenital Distress Inventory, respectively. The mean pad weight decreased by 47% (P=0.056). Of the 9 women who had a positive pad test (>2 g) without the device, 5 were dry (<2 g) with the device (P<0.05). These preliminary data suggest that this device is effective in women with GSI.     

Effect of methoxamine on maximum urethral pressure in women with genuine stress incontinence: a placebo-controlled, double-blind crossover study

The aim of the study was to evaluate the potential role for a selective alpha1-adrenoceptor agonist in the treatment of urinary stress incontinence. A randomised, double-blind, placebo-controlled, crossover study design was employed. Half log incremental doses of intravenous methoxamine or placebo (saline) were administered to a group of women with genuine stress incontinence while measuring maximum urethral pressure (MUP), blood pressure, heart rate, and symptomatic side effects. Methoxamine evoked non-significant increases in MUP and diastolic blood pressure but caused a significant rise in systolic blood pressure and significant fall in heart rate at maximum dosage. Systemic side effects including piloerection, headache, and cold extremities were experienced in all subjects. The results indicate that the clinical usefulness of direct, peripherally acting sub-type-selective alpha1-adrenoceptor agonists in the medical treatment of stress incontinence may be limited by associated piloerection and cardiovascular side effects.     

The effects of long-term treatment with norephedrine on stress incontinence and urethral closure pressure profile.

Twenty-five women with stress incontinence of urine were given an alpha-adrenoceptor stimulating agent (norephedrine) and a placebo during respective 14-day periods according to a double-blind cross-over schedule. The results were classified as the patient's own assessment of therapeutic effect and as change in urethral closure pressure profile measured by a microtransducer catheter. Norephedrine had a significant therapeutic effect on the symptom stress incontinence and produced significant increase in maximum urethral pressure and maximum urethral closure pressure in the lithotomy and the erect position. Reduction of incontinence was associated with increase in maximum urethral closure pressure. The sum therapeutic effect was of moderate degree.     

静态尿道压力测定和应力性尿道压力测定在女性真性压力性尿失禁诊断中的应用

目的探讨静态尿道压力测定(RUPP)和应力性尿道压力测定(SUPP)在女性真性压力性尿失禁(GSI)诊断中的应用价值。方法对30例临床诊断为GSI的患者进行RUPP及SUPP测定,比较其结果,以15例正常女性作为对照。结果静态尿道压力测定,SCI组的最大尿道关闭压和控制带长度较正常对照组小。应力性尿道压力测定中,患者压力传导率(PTR)及尿道关闭压(UCP)以多次咳嗽的平均值计算,GSI组PTR及UCP各为(0.63±0.24)、(-26.58±21.43cmH2O),而正常组PTR及UCP各为(1.78±0.12)与(83.42±37.23cmH2O)。两组间上述指标的差异均有显著性意义(p<0.01)。结论SUPP和RUPP在GSI的诊断中均具有一定意义,对于症状较轻的尿失禁患者的诊断,两者联合应用可以提高GSI的诊断水平。     

Teflon injection in female stress incontinence. Effect on urethral pressure profile and flow rate

Thirty-six females with genuine stress incontinence (GSI) were treated by bladder neck teflon injection. Urethral pressure profilometry (UPP) and uroflowmetry were performed both pre- and post-operatively on 18 patients. In 24 patients who were either completely cured or improved by this procedure, the mean urine flow rate was reduced by 23% and the mean functional profile length increased by 9% compared with pre-operative values. Although these findings appear to explain the mechanism by which teflon improves continence, these differences were not statistically significant. Fourteen of the 18 patients who had not responded to previous anti-incontinence procedures were successfully treated by teflon injection. The improved response rate in these patients was not statistically significant. It was not possible to predict with certainty those patients most likely to respond to teflon injection. However, in women with normal or near normal pelvic floor anatomy the procedure had an acceptable success rate. In view of the simplicity, lack of morbidity and the ease with which it can be performed and repeated, bladder neck teflon injection deserves consideration as an alternative, particularly where open surgery has failed.     

Suburethral sling procedure for genuine stress incontinence and low urethral closure pressure. A continued experience

Forty-eight patients with genuine stress incontinence and low urethral closure pressure have undergone a suburethral sling procedure using polytetrafluoroethylene. Forty-five of the 48 patients have been followed up beyond 3 months, allowing assessment of postoperative complications. Ten patients required intermittent self-catheterization, 6 continuing beyond 3 months secondary to obstructed voiding or vesical dysfunction. Six slings were removed due to graft infection and/or vaginal mucosa erosion. All patients who were continent prior to removal remained so afterwards. Two slings were loosened secondary to obstructed voiding (1 patient experienced improved voiding, the other continued intermittent catheterization). Sixty-two per cent (28/45) of the patients followed, developed at least one documented urinary tract infection. Thirty-four of the 45 patients followed, underwent postoperative multichannel urodynamic testing. Ten patients (29%) demonstrated postoperative detrusor instability (5 were new onset, 5 were persistent). Six improved with medication and bladder retraining drills. Twenty-eight of the 34 patients tested (82.4%) were objectively cured of genuine stress incontinence. In spite of the complications noted, this suburethral sling procedure offers a high success rate and is a viable alternative in treating patients with genuine stress incontinence and low urethral closure pressure. Modifications in surgical technique have been made to reduce postoperative complications in the future.     

A comparison of the cough and standing urethral pressure profile in the diagnosis of stress incontinence

Controversy over the accuracy of the urethral pressure profile (UPP) and its role in the diagnosis of stress urinary incontinence (SUI) is unresolved. Different UPP methods and techniques have been introduced. In this study, we examined 78 female patients with mixed symptoms of stress and urge incontinence. Each had a history, physical examination, cystoscopy, and urodynamic assessment, which consisted of a cystometrogram (CMG), UPP (supine and standing), and “cough profile” by the Brown and Wickham (BW) method and also UPP (supine) and “cough profile” with the microtip transducer (MTT). The final diagnosis in 38 patients was SUI (group I) and in 40 patients, no SUI (group II). The maximum urethral closure pressure (MUCP) supine and standing was significantly lower in group I, but there was no significant difference between the two groups in the transmission index (TI) of the “cough profile.” MUCP standing showed the least overlap between the two groups, and with a cutoff point at 40 cm H₂O, the overall diagnostic accuracy was 69%, with 39% sensitivity and 98% specificity. By combining MUCP supine and standing and using cutoff points at 40 cm H₂O and 35 cm H₂O, respectively, the overall diagnostic accuracy was 72%, with 47% sensitivity and 95% specificity. We believe that the UPP is a useful ancillary tool in the assessment of complicated cases of urinary incontinence in the female.     

Time-series analysis of urethral electrical conductance measurements in the assessment of unstable urethral pressure: Results in normal patients and in those with genuine stress incontinence

It is well established that urethral pressure variations occur in patients with or without urinary incontinence, but to what extent they contribute to a patient's symptoms remains unclear. Previous work has suggested that in stress incontinent patients, a rise in bladder neck electrical conductance (BNEC) occurs simultaneously with a fall in urethral pressure, and that this represents bladder neck opening. Six patients with genuine stress incontinence (gsi), and six normal controls underwent simultaneous urethral pressure and BNEC measurements, the results being subjected to time-series analysis, to determine whether the previous finding could be confirmed statistically, and to establish whether a similar association was present in normal women. All six patients with gsi and five of the normal patients had unstable urethral pressure. Estimated cross-correlation of differenced data for the two parameters showed a significant negative correlation at zero time lag in three patients with gsi and two of the control group. There was no significant correlation between the two parameters in the other seven patients. We conclude that the previous finding of a correlation between urethral pressure variation and BNEC, suggesting bladder neck opening occurs as urethral pressure falls in patients with gsi is confirmed, but appeared to be present in only 50% of patients; the finding is just as likely in normal patients, and therefore whilst it may be of relevance to the severity of symptoms, could not be held to have any aetiological significance. © 1993 Wiley-Liss, Inc.     

Initial urethral pressure increase during stress episodes in genuine stress incontinent women.

The urethral and bladder pressure increments registered during a cough were investigated in 30 woman with genuine stress incontinence (GSI) and compared with those from 30 previously investigated healthy women. The pressures were measured by means of a double microtip transducer catheter with the bladder sensor uncovered and the urethral sensor covered with a water-filled rubber cylinder and placed at the bladder neck, midurethrally, or distally in the urethra. In GSI women the pressure increment preceding the pressure spike produced by coughing was significantly higher in the bladder compared with the urethra, and the pressure increment seemed to be initiated in the bladder and all along the urethra simultaneously. In healthy women the pressure increment preceding a pressure spike was significantly higher in the midurethra compared with the bladder and it seemed to be initiated in the midurethra. These findings seem to reflect a defective active closure mechanism in GSI which may be a contributing factor in its pathogenesis.     

Mechanical properties of the urethra in females with genuine stress incontinence: Static measurements in the resting urethra

The pressure (P_ura)-cross-sectional area (CA) relationship in the resting urethra was examined in 30 females with genuine stress incontinence (GSI). Measurements were performed at the bladder neck, in the high-pressure zone, and in the distal part of the urethra. From the two variables urethral elastance (dP_ura/dCA) and hysteresis were calculated. The results were compared with those obtained in normal females. Urethral elastance, hysteresis, and urethral pressure showed significant differences at the three sites of measurement. Urethral elastance was significantly decreased at the bladder neck in patients with GSI as compared to normal women, while the urethral pressure was significantly decreased all along the urethra. It is suggested that both mechanical weakness all along the urethra and decreased deformability of the urethral wall may be of pathophysiologic importance in GSI.