General Considerations

A recent upsurge in research efforts has resulted in the emergence of new diagnostic and therapeutic techniques to address PFDs. As QoL impact has become a focus, many current research efforts include detailed QoL assessment and attempts to quantify and assess the relationship between PFDs and their effects on QoL. Correlating the bother caused by a given PFD with the risk of available therapies is an important consideration.

The type of incontinence affecting an individual must be defined and quantified in order to guide proper treatment planning. Transient or unrelated conditions that can cause leakage should be identified before proceeding with definitive therapy. Table 64–1 contains a mnemonic of transient causes of incontinence (Resnick, 1984). Table 64–2 lists current International Continence Society (ICS) nomenclature and definitions for types of incontinence (Abrams et al, 2002, 2009b). The terminology continues to adjust to reflect the evolving understanding of the condition. The importance of this flexibility has been realized and acknowledged by leaders in the subspecialty of pelvic floor medicine (Chapple, 2009).

Table 64–1 Causes of Transient Incontinence (DIAPPERS)

Table 64–2 Standard International Continence Society Terminology of Lower Urinary Tract Symptoms Pertaining to Continence

The classification of POP is categorized according to the affected compartment. Simply put, anterior compartment prolapse (cystocele) generally involves descent of the bladder toward the vaginal lumen, posterior prolapse (rectocele) involves the rectum compressing the posterior vaginal wall into the vagina, and apical prolapse is associated with descent of the uterus (uterine procidentia) and/or the bowel (enterocele) at the top of the vagina. Several grading systems exist to quantify the severity of POP and are discussed later and illustrated in Figure 64–1.

Figure 64–1 Visual comparison of systems used to quantify pelvic organ prolapse

(From Theofrastous JP, Swift SE. The clinical evaluation of pelvic floor dysfunction. Obstet Gynecol Clin North Am 1998;25:783–804.)

Regarding incontinence specifically, the substantiation of a proper diagnosis requires direct observation of urinary leakage by the clinician (Nitti and Blaivas, 2007). It is the belief of many experts that no patient should undergo invasive or irreversible therapies without definitive establishment of the cause of their incontinence. Complete and extensive evaluation can facilitate accurate diagnosis of PFDs to promote optimal treatment planning and counseling of patients.

History of Present Illness

A thorough history is imperative in the evaluation of incontinence. Several queries should be included in a continence and pelvic floor history in order to best portray the patient’s symptoms (Holroyd-Leduc et al, 2008). The incontinence should first be characterized subjectively. Does the leakage occur (1) with physical activity? (2) with a sense of urgency? or (3) without sensory awareness? If the nature of the incontinence is mixed, does one component cause more bother or occur more frequently than the other? Second, the leakage should be quantified if possible. Appraisal of the degree of leakage before therapy can be helpful during postoperative assessment of treatment impact. For the purposes of routine outpatient assessment, this quantification can be achieved on the basis of the number of pads used per day or the frequency of clothing changes due to urinary leakage. In the setting of research or an academic practice, more stringent and objective measures such as pad weight testing are often used (see “Supplemental Evaluation” later). Third, the voiding pattern should be defined. What is the frequency of urination during the day? During the night? Are there any obstructive symptoms? Does the patient feel as though he or she empties the bladder completely? Is the stream strong or does it “trickle”? Does the stream fluctuate during the void? Is it necessary to push or strain or change posture to void or empty the bladder? Fourth, establishment of the duration of symptoms and any inciting events that contributed to the onset of leakage is important. Did the leakage follow a pregnancy or a vaginal delivery? How long ago? Did the leakage start after a strain, a fall, or trauma? Has the patient undergone pelvic or back surgery? In males, has there been any prostate or urethral surgery for benign or malignant disease? Has there been any lower urinary tract instrumentation? Are there any accompanying neurologic symptoms such as numbness or tingling in the extremities, blurry/double vision, balance or coordination changes, or tremor? Finally, it is helpful to determine the impact that the leakage has on the patient’s daily life and activities. Does the incontinence limit the individual’s activity? Has the patient changed his or her lifestyle due to the threat of leakage?

Regarding pelvic prolapse specifically, important questions focus on whether or not the patient is aware of any prolapse and what, if any, symptomatology and bother the prolapse may be causing. Does the patient feel that anything is falling down out of place in the vagina? Does she need to reduce the prolapse for comfort? Or empty her bladder completely? Or facilitate evacuation of her bowels?

Past medical and surgical histories are vital to the assessment of incontinence insofar as medical conditions and surgeries can affect urinary tract function. Childhood and adult urologic history should be obtained, as should a neurologic history. Neurologic conditions such as Parkinson disease, multiple sclerosis, stroke, spinal cord injury, back surgery, and myelodysplasia can have a considerable impact on lower urinary tract (LUT) function. Medical diagnoses such as diabetes mellitus and dementia can affect continence. Similarly, a history of radiation therapy or neurologic or urologic trauma can affect LUT function, specifically with regard to outlet resistance and/or bladder contractility, stability, and compliance. Although outlet resistance may be compromised by trauma or LUT surgery, urethral strictures related to trauma or neurologic dysfunction that abnormally increase outlet resistance during voiding can cause obstruction and secondary symptoms related to the obstruction.

In women the gynecologic and obstetric history including gravity, parity, and hormonal status is important. Determination of whether the patient is premenopausal, perimenopausal, or postmenopausal, and whether or not she has used any exogenous hormones such as oral contraceptives or local or systemic hormone replacement therapy can be helpful in her overall assessment. As mentioned earlier, although beneficial effects of local hormone replacement therapy are well-established, there have been reports that exogenous hormone therapy can actually increase the risk of SUI (Townsend et al, 2009).

Clearly, previous pelvic surgery can affect LUT function. Anti-incontinence surgery, POP repair, and hysterectomy can contribute to a variety of urinary symptoms in women. Similarly, a history of prostate surgery can give rise to voiding or leakage complaints in men. Abdominoperineal resection can result in neurologic injury that can affect the function of either the bladder or the sphincter (Petrelli et al, 1993), and back surgery can cause a variety of symptoms dependent on the level affected.

Medications

An accurate assessment of medications is critical, particularly in the elderly patient population in whom polypharmacy is common. Many agents can affect urine production, LUT function, and mental status, all of which can have an impact on continence. Special attention should focus on agents that can affect bladder/sphincteric function. Table 64–3 categorizes some commonly used classes of medications by mechanism of action and potential effect on the LUT.

Table 64–3 Pharmacologic Agents That Can Affect the Lower Urinary Tract

Other

As genetics can influence connective tissue integrity, it stands to reason that there may be a potential hereditary role in continence and POP (Twiss et al, 2007). Therefore inquiry about family history of POP may be helpful. Additionally, a thorough review of systems may reveal symptoms that suggest other conditions that could affect pelvic floor function.

Male incontinence, also a prevalent health issue, should be assessed in much the same way as female incontinence, although specific consideration of the impact of the anatomy specific to the male should be considered. Benign prostatic hyperplasia, the evaluation of which is covered in detail in Chapter 92, can cause secondary urgency and urgency incontinence in addition to more “typical” obstructive symptoms such as a decreased force of stream, urinary hesitancy, intermittency, and incomplete bladder emptying. Prostate surgery for benign or malignant disease can contribute to SUI. With this in mind, full assessment of male LUT symptoms (LUTS) should be performed to facilitate proper treatment planning.

Symptom Quantification Instruments

Questionnaires and Quality of Life Instruments

Questionnaires can provide a helpful complement to the patient history and patient-reported outcomes (PROs). A plethora of instruments to evaluate symptoms, degree of bother, and QoL in patients with incontinence and PFDs have been developed in an effort to provide optimal assessment of outcomes and to eliminate the confounding issue of physician bias; many have been validated. Table 64–6 contains validated questionnaires highly recommended by the International Consultation on Incontinence (ICI). One such instrument, the modular ICIQ, was developed by the ICI in an effort to collaboratively develop a universally applicable instrument that could be used internationally to assess pelvic floor function in both clinical practice and research settings (Abrams et al, 2005) and has accordingly been translated in 38 languages. The short form of the ICI questionnaire (ICIQ-SF) has been shown to correlate nicely with both the 1-hour (Franco et al, 2008) and 24-hour (Karantanis et al, 2004) pad test for evaluation of the severity of SUI. Another comparison of the 24-hour pad test, the ICIQ-SF, the International Prostate Symptom Score (IPSS), and the Postoperative Patient Global Impression of Improvement (PGI-I) score in 26 men following perineal sling placement confirmed the construct validity of these instruments (Twiss et al, 2007). There was a strong correlation demonstrated between the ICIQ-SF and PGI-I scores and the percentage reduction in 24-hour pad weight. Appendices 1 to 6 on the Expert Consult website contain the ICIQ-MLUTS (male LUTS), ICIQ-FLUTS (female LUTS), ICIQ-SF (short form), ICIQ-OAB (overactive bladder), ICIQ-VS (vaginal symptoms), and the recently developed ICIQ-B (bowel). At the time of this writing, additional modules covering QoL, sexual function, pediatric LUTS, neurogenic LUTS, nocturia, and bowel function are available or are in development and are or will be available through the ICI (2010).

Table 64–6 Instruments Highly Recommended by the International Consultation on Incontinence (Fourth ICI) for Urinary Incontinence, Overactive Bladder (OAB), Lower Urinary Tract Symptoms (LUTS), and Pelvic Organ Prolapse Patient Reported Outcomes (PRO)

A study examining the incontinence- and nonincontinence-related pelvic floor symptoms evaluated by two widely used symptom tools, the UDI-6 and the ICIQ-UI, demonstrated that both symptom questionnaires were sound and correlated with each other and independently with the QoL scores, as measured by the IIQ-7 and IQOL (van de Vaart et al, 2010). This study also uncovered the interesting finding that the delay in time to consultation with a physician was associated with greater bother, emphasizing the importance of heightened awareness of PFDs in the female patient population.

In Martin’s meta-analysis, two studies showed a high sensitivity (0.82 to 0.92) of question 3 in the Urogenital Distress Inventory for SUI; the specificity was 0.51 to 0.69 (Martin et al, 2006). In this study, history alone had a pooled sensitivity of 0.92 (95% CI) and a specificity of 0.56 for the diagnosis of SUI and a sensitivity of 0.61 and specificity or 0.87 for the diagnosis of DO. It should be borne in mind, however, that for higher-risk interventions such as surgery, the most accurate testing available remains multichannel UDS studies.

Pad Tests

Pad tests are generally used for academic purposes. The ICS recommends both a three-day bladder diary and pad weight test as proper measures for symptom quantification in incontinence research (Lose et al, 2001). However, although pad tests can be helpful in quantifying leakage, they are tedious and cumbersome for the patients. Moreover, they do not provide information that is necessary for daily routine clinical practice. The Fourth ICI Committee on initial assessment did not recommend pad tests as part of the initial evaluation in the incontinent patient (Staskin, 2009). From an academic standpoint, however, many investigators advocate for pad tests in clinical trials because pad tests can provide objective, precise information for assessment of actual volume of urine lost over an established period of time.

According to the Third ICI, greater than 1.3 g of urine loss is considered a “positive” 24-hour pad test (Tubaro, 2005), whereas others consider up to 8 g of urine loss in 24 hours to be normal (Lose et al, 1989). Vaginal secretions should also be taken into consideration, although the volume attributable to normal vaginal secretions may be as low as 0.3 g in 24 hours (Karantanis et al, 2003). O’Sullivan et al (2004) evaluated 110 women with incontinence with two 1-hour pad tests and 7 consecutive days of 24-hour pad tests. The severity of the leakage was analyzed in relation to UDS parameters, age, parity, and pelvic floor muscle strength, showing increased severity with increasing age and parity and in those women who demonstrated DO. The authors proposed that 24-hour loss of 1.3 to 20 g, 21 to 74 g, and greater than 75 g signifies “mild,” “moderate,” and “severe” incontinence, respectively. Another study of 144 randomly selected Danish women who underwent 24-hour pad testing revealed a similar loss of urine in the self-reported continent and incontinent groups, or 3.1 and 3.3 g, respectively (Ryhammer et al, 1998).

It is generally agreed that the 24-hour pad test is a clinically more useful tool than the 1-hour pad test (Lose et al, 1989; Matharu et al, 2004); in fact, the test-retest reliability and the predictive value of the 1-hour test in the diagnosis of female incontinence has been shown to be poor (Lose et al, 1986; Lose et al, 1988; Simons et al, 2001; Constantini et al, 2008). Others have advocated the opposite extreme, suggesting that a 20-minute pad test with a standardized bladder volume of 250 mL instilled into the bladder via catheterization had superior sensitivity as compared with the 1-hour test conducted via the ICS standardized method of pad testing (Wu et al, 2006). The ICS method, described in 1988, requires the patient to drink 500 mL of sodium-free liquid in 15 minutes followed by a 30-minute resting period before proceeding with the recommended physical activity (Abrams et al, 1988). One potential concern about this method is the lack of standardization of bladder volume.

Parenthetically, pad use per day (PPD) obtained via patient history is a measure frequently used to quantify urine loss, but one study demonstrated that this is an unreliable measure of incontinence (Dylewski et al, 2007). A retrospective chart review of 145 males and 116 females who underwent artificial urinary sphincter placement and sling surgery, respectively, and who had completed a self-reported pad-use query was performed, and the patients were asked to bring three pads into their clinic visit: one dry “reference” pad and the incontinence pads used for the 24-hour periods preceding and including the day of their visit. The pads were quantified and weighed to determine the grams of urine per pad (GPP). All patients also underwent a 24-hour pad weight test. Only a weak correlation was found between reported pad usage and the 24-hour pad weight, with pad usage measuring only 38% of the variability of incontinence volume. Additionally, although the PPD decreased, the GPP increased with increasing age.

Dye Testing

Dye testing can be helpful to verify that the leakage represents urine versus another fluid such as vaginal discharge or peritoneal fluid and to substantiate the diagnosis of urinary tract fistulae. Oral phenazopyridine 200 mg three times a day colors the urine orange, and this simple test can confirm that the leaking fluid is indeed urine. Diagnosis of a vesicovaginal or urethrovaginal fistula can be supported by blue or orange staining of an intravaginal tampon following intravesical instillation of methylene blue or phenazopyridine hydrochloride (Pyridium) dissolved in sterile water or saline. In the case of a suspected ureterovaginal fistula, intravesical methylene blue with concurrent oral Pyridium can elucidate the fistula location on the basis of the staining pattern on the vaginal tampon. Orange staining suggests a ureteral communication, whereas blue staining connotes a bladder communication (Raghavaiah, 1974). The clinician must keep in mind that simultaneous vesicovaginal and ureterovaginal fistulae can occur.

Urinalysis

It is generally agreed that urinalysis plays a fundamental role in the evaluation of the incontinent patient or the patient with lower urinary tract symptoms (LUTS) (Abrams et al, 2009a). The urinalysis provides information such as the presence of hematuria, pyuria, glucosuria, or proteinuria that can be indicative of conditions that can cause secondary incontinence. As indicated by the screening dipstick analysis, a microanalysis and/or culture should be performed that may provide guidance regarding further testing or therapy for conditions related to or independent of urinary incontinence.

Postvoid Residual

The volume of urine left in the bladder following routine voiding is termed the postvoid residual (PVR) and should be evaluated in all incontinent patients (Tubaro, 2005; Gormley, 2007). This simple test, which can be performed via in-and-out catheterization or using noninvasive transabdominal ultrasonography, evaluates the bladder’s emptying ability and can be helpful in the diagnosis of overflow incontinence. It is also essential to establish baseline bladder emptying, particularly in stress incontinent patients who may be considered for an anti-incontinence procedure or patients with urinary urgency who may be candidates for therapies aimed at decreasing bladder contractility.

A number of studies have demonstrated that ultrasound is comparable to catheterization in evaluating the PVR, although there are no officially established volumes that define normal or impaired emptying. The Agency for Healthcare Policy and Research (AHCPR) suggests that PVR less than 50 mL represents adequate emptying and PVR greater than 200 mL represents inadequate emptying (U.S. Department of Health and Human Services, 1992). There is no consensus recommendation regarding the significance of PVR between 50 and 200 mL. In one study, Gehrich and colleagues (2007) enrolled 96 healthy women who presented for routine “well-women” checkups. Exclusion criteria included urinary incontinence more than twice a week, urinary retention, neurologic disease, or symptomatic POP. The mean and median PVRs were 19 mL (0 to 145 mL) and 24 ± 29 mL. Fifteen percent had PVR greater than 50 mL, and 95% had PVR less than 100 mL. Another study compared PVR measurements obtained by 3-D bladder scan versus catheterization in 170 women who were undergoing evaluation for SUI but who had never undergone previous pelvic surgery (Tseng et al, 2008). In addition, 35.5% had PVR greater than 50 mL and 15.9% had PVR greater than 100 mL. Ultrasound offered a sensitivity of 64.7% and a specificity of 94.3% in detecting PVR greater than 100 mL. Although several studies support the accuracy of the bladder scan (Al-Shaikh et al, 2009), some suggest that certain sonographic devices may provide more accurate information than others (Ghani et al, 2008).

Cystoscopy

Endoscopic examination of the bladder is important as a means to evaluate for intravesical or intraurethral pathology that may be contributing to the patient’s symptomatology. Bladder tumors, bladder stones, cystitis, and intravesical or intraurethral foreign bodies such as mesh or suture can contribute to irritative voiding symptoms, recurrent urinary tract infections (UTIs), and incontinence. Patients with a history of previous pelvic floor reconstructive surgery should be evaluated for eroded materials into the LUT. The ureteral orifices should be identified and evaluated for morphology, position, number, and efflux. The bladder mucosa is examined for trabeculation (which can be indicative of bladder outlet obstruction [BOO] and/or overactivity) and estrogen status, and the urethra is assessed for foreign bodies, stricture, diverticulum or fistula, and position.

The role of preoperative cystourethroscopy has been addressed by few authors. Anger and colleagues (2007) analyzed Medicare claims data to assess the effects of preoperative cystoscopy and UDS studies on sling outcomes. The data of a random 5% sample of Medicare beneficiaries during an established 18-month period were used to assess the likelihood of undergoing postoperative studies in those who did and did not undergo the same studies preoperatively. Although patients who underwent preoperative cystoscopy were less likely to undergo postoperative cystoscopy (23.4% vs. 35.2%, P < 0.0001) or UDS (19.3% vs. 34%, P < 0.0001), there were no significant differences in complications or repeat incontinence procedures between the groups. However, Cundiff and Bent (1996) reported that cystoscopy changed the diagnosis and management in 6 of 84 women (7%) who underwent both cystoscopy and UDS for evaluation of LUT dysfunction. Findings included transitional cell carcinoma, cystitis glandularis, intravesical suture, and a urethral diverticulum.

Although the use of routine cystoscopy in the evaluation of the “index” stress urinary incontinence patient is controversial, it should be performed in patients who present with urinary urgency, hematuria, or other irritative symptoms, particularly if they have previously undergone a previous anti-incontinence procedure, pelvic radiation, or pelvic prolapse repair.

Urodynamics

Similar to cystourethroscopy, the routine use of UDS is the subject of much debate; however, one should strongly consider UDS in patients who have failed previous pelvic floor reconstruction or who complain of mixed incontinence, urinary urgency, or obstructive symptoms, and in those who have elevated PVRs or neurologic disease. The benefit of UDS in these situations is to establish baseline bladder capacity, compliance, sensation, stability, and sphincter function before further surgical or therapeutic manipulation. A comprehensive review of UDS is presented in Chapter 62.

LUT function can be simply categorized into storage and emptying. Each of these categories is affected by the bladder (detrusor) and the outlet. Two main questions should be considered in the evaluation of the incontinent patient: (1) Is the problem at hand a storage issue, an emptying issue, or a combination of the two? and (2) Is the etiology of the first question due to a detrusor issue, an outlet issue, or a combination of both?

“Eyeball UDS” is a simple economically favorable alternative to full multichannel UDS that can be helpful in selected patients. The study can determine bladder sensation, compliance, stability, and capacity, as well as outlet competence and PVR. Following voiding, the patient is placed in the lithotomy position and a Foley catheter is placed and the PVR measured. A 60-mL catheter tip syringe with the barrel removed is placed into the end of the catheter. With the syringe held upright, the bladder is filled with sterile fluid through the syringe. The height of the meniscus above the bladder represents the intravesical pressure. The volumes at first sensation, sensation to void, and strong sensation are recorded. During the filling phase, the meniscus in the syringe is observed for a rise and fall that may represent bladder overactivity or a consistent gradual rise that suggests compromised detrusor compliance. The catheter is removed, and a cough stress test is performed by observing the urethra for incontinence during coughing and straining.

Multichannel UDS offers an extensive evaluation of LUT function. This degree of accuracy is important in a variety of circumstances including when conservative treatment methods fail, when the diagnosis is unclear or when previous diagnostic procedures are inconclusive, in patients with clinical pictures complicated by radiation therapy, neurologic disease, or prior failed pelvic floor reconstruction or anti-incontinence surgery, or when patients describe symptoms that cannot be confirmed by the clinician. A complete UDS study evaluates the filling/storage phase by filling cystometrogram and the voiding/emptying phase by uroflowmetry.

Catheters are placed into the bladder and the rectum. The bladder catheter measures the actual pressure within the bladder, termed the vesical pressure (Pves). The rectal catheter measures the abdominal pressure (Pabd). The detrusor pressure (Pdet) is a calculated value (Pves − Pabd) that represents the pressure created by the detrusor independent of the influences of intra-abdominal pressure. During the filling phase, the Pdet is expected to remain low and stable to allow for low-pressure bladder filling. Poorly compliant bladders will show a gradual steady rise in the Pdet as the bladder volume increases. Detrusor overactivity is manifest by intermittent and unpredictable rises in the Pdet. During the voiding phase, the Pdet may rise as the urine flows. Many women normally void with virtually no rise in Pdet. High Pdet with low flow during voiding suggests BOO. Inability to produce a flow with no Pdet, particularly when accompanied by abdominal straining (represented by an undulant Pabd), may indicate an atonic or hypotonic detrusor.

Electromyogram (EMG) and fluoroscopic imaging (“videourodynamics,” VURDS) are helpful adjuncts to the UDS study in selected patients and are covered in detail in Chapter 62. EMG activity is reflective of the activity of the striated muscles of the urethral and anal sphincters and the perineal musculature and can be measured using either surface electrodes or needle electrodes. Although the latter provides more accurate readings, the discomfort caused to the patient and the expertise required for the technique render it far less popular than surface electrodes. The coordination of the EMG and detrusor activity is most helpful during the voiding phase, when failure to relax the pelvic floor can be indicative of pathology. Similarly, recruitment of activity should be noted with BCR and increased abdominal pressure, such as occurs during coughing. VURDS can be useful in the demonstration of anatomy in the upright position, and because the bladder and outlet are visualized “real time,” VURDS can confirm incontinence in patients in whom the diagnosis is difficult and can provide an accurate measure of leak point pressure. It is also helpful to assess the bladder outlet in patients in whom detrusor-sphincter dyssynergia or primary bladder neck obstruction is suspected. Patients can be evaluated for vesicoureteral reflux (VUR). Assessment of detrusor pressures in the face of reflux can provide important information that would be missed without video-imaging.

Recent attention has been placed on scientifically establishing the role and clinical value of UDS. The worth of a test is not solely in its diagnostic accuracy but also in the improvement of the outcomes of subsequent interventions. UDS is frequently used in the evaluation of patients with PFDs. Suboptimal outcomes of anti-incontinence procedures are generally attributed to intrinsic sphincter deficiency (ISD), DO, or baseline dysfunctional voiding. The deliberation regarding the merit of these theories and the ability of UDS to accurately establish these conditions continues. In a study of 655 women with positive stress tests, 10% did not demonstrate urodynamic-SUI (UDS-SUI) (Nager et al, 2007). A meta-analysis based on a Medline search of the literature between 1975 and 1998 suggested that UDS has a positive predictive value (PPV) of only 56% and 79% for pure SUI and SUI with other abnormalities, respectively, while a positive cough test has PPVs for the same of 55% and 91%, respectively (Harvey and Versi, 2001). The Urinary Incontinence Treatment Network (UITN) reported that UDS did not predict postoperative voiding dysfunction or the risk for need of postoperative surgical intervention (Lemack et al, 2008). In another retrospective study in women who underwent retropubic midurethral sling placement for treatment of mixed incontinence, the median opening detrusor pressure was higher in women with postoperative DO than in those with normal postoperative UDS (Panayi et al, 2009).

Much of the literature to date has been limited by the retrospective design and small cohorts of the available studies. The UITN found that the success of anti-incontinence surgery in patients who demonstrated UDS-SUI was nearly twice that of those with non-UDS-SUI (type 0 SUI), although this trend did not reach statistical significance (Nager et al, 2008). Similarly, although the study by Anger and colleagues (2007) did not definitively establish an effect of preoperative UDS specifically on sling outcomes, there was a clear demonstration of a twofold (significant) increased likelihood of undergoing postoperative UDS studies in those patients who did not undergo the study preoperatively as compared with those who did.

With healthcare reform increasingly at the forefront of discussion, cost-effectiveness continues to be a subject of great debate. On the basis of decision-analytic (hypothetical) models, one group deemed UDS not cost-effective relative to the basic office evaluation (Weber and Walters, 2000; Weber et al, 2002). However, one must remain mindful that UDS provides information, not only about the overall diagnosis but also regarding important subtle findings that may direct the clinician in treatment planning and counseling (Summitt et al, 1992; Patel and Chapple, 2008). Although it has been suggested that UDS may not be necessary or useful in straightforward, non-neurologic patients who would be considered for initial conservative management (Colli et al, 2003; NICE, 2006), others have shown that up to 20% of patients with presumed pure SUI may have UDS findings that might alter their treatment or outcomes (Digesu et al, 2009).

Reproducibility of UDS studies, as well as the interpretation of the examination, has been questioned by several studies (Van de Beek et al, 1997; Gupta et al, 2004; Zimmern et al, 2006; Gacci et al, 2007). Others have demonstrated that intraobserver (interpretation repeated by the same individual) interpretation is superior to interobserver (same study read by two different individuals) interpretation for both pressure-flow analyses (Digesu et al, 2003) and filling/voiding studies (Whiteside et al, 2006). Still others have demonstrated no difference in interobserver and intraobserver interpretation, but that live interpretation of a study provides different readings than post hoc interpretation, suggesting that intangible experiential factors may play a role in the interpretation of UDS studies (Smith et al, 2009).

Approximately 40% of patients with POP describe SUI symptoms (Grody, 1998), and UDS-SUI is demonstrated in 70% to 75% of prolapse patients (Roovers and Oelke, 2007). Occult SUI unmasked by reduction of prolapse is reported to be present in 36% to 80% (Richardson et al, 1983; Bergman et al, 1988; Chaikin et al, 2000), and 11% to 50% of clinically continent patients will develop de novo SUI following repair of high-grade prolapse (Bergman et al, 1988; Borstad and Rud, 1989; Gallantine and Cespedes, 2001). Women who demonstrated preoperative UDS-SUI before sacrocolpopexy were more likely to develop postoperative SUI irrespective of whether they received a concomitant Burch colposuspension (Visco et al, 2008). Conversely, following a retrospective review of the records of 76 patients who underwent POP repair, Roovers and colleagues (2007) reported that no UDS parameters predicted postoperative incontinence. In an effort to determine the need for prophylactic sling placement in patients undergoing surgery for high-grade POP, Ballert and colleagues (2009) followed a UDS protocol designed to address the urethra in a standardized fashion. They concluded that in patients who did not subjectively describe or urodynamically demonstrate SUI preoperatively, the risk of intervention due to BOO following sling placement was equivalent to the risk of intervention for SUI in patients who did not receive a sling.

In select patients, particularly those with OAB symptoms and/or known neurogenic bladder, UDS can be helpful in determining the risk of progression to upper tract deterioration. DO, poor compliance, detrusor–external sphincter dyssynergia (DESD), high detrusor storage pressures, VUR, and BOO all represent potential risk factors or the development of upper tract disease, particularly in those patients with sustained Pdet greater than 40 cm H₂0 (McGuire et al, 1981; Blaivas and Barbalias, 1984; Ghoniem et al, 1989, 1990).

Although multichannel UDS remains the most accurate tool with which to evaluate LUT function, it is clear that multi-institutional randomized prospective studies are of dire importance in addressing many of the unanswered questions regarding the role and contribution of UDS. The accuracy of the study and impact of the findings on treatment outcomes must be established.

Radiographic Imaging

Incontinence Treatment Overview

The approach to treatment of incontinence is contingent on a clear understanding of the etiology and pathophysiology underlying the patient’s symptoms. The clinician must first determine whether the cause of the symptomatology complex is a bladder or an outlet problem or, not uncommonly, a combination of both. Therapeutic options should be considered with the goal of providing an individualized patient-directed treatment plan on the basis of the patient goals and risk-benefit and cost-benefit ratios.

Management of incontinence can be categorized into nonsurgical and surgical options. Underlying causes such as UTI, BOO, bladder stones, foreign body, or bladder tumor should be identified and addressed first. Table 61–3 in Chapter 61 provides an overview of the treatment options available for the management of incontinence; a detailed review of the various therapeutic options is presented in Chapters 68 through 79.

Treatment of incontinence must be tailored to the patient’s needs, goals, and expectations and requires proper counseling on the part of the clinician. Some patients may be satisfied with protective garments and/or urine collection devices such as indwelling or condom catheters or barriers such as urethral plugs or external occlusion devices. Intervention for patients with urgency incontinence may range from behavioral and dietary modification to biofeedback or pharmacotherapy. Sacral neuromodulation, off-label botulinum toxin A detrusor injection, and enteric augmentation of the bladder may be considered in patients with refractory symptoms.

Similarly, patients with SUI may benefit variably from conservative measures using pelvic floor muscle exercises, biofeedback, electrical stimulation, and pharmacotherapy. Urethral bulking injection therapy can provide an intermediate option between nonsurgical and surgical therapies, but surgery remains the mainstay of treatment for SUI. Although needle suspensions remain only as a point of historic discussion, retropubic suspensions have persisted as a reasonable treatment option for SUI. However, slings, using a variety of materials, insertion approaches, and anchoring techniques, have effectively become the standard of care for women with SUI. Injection therapy has not proven a particularly viable option for the treatment of male SUI (which occurs most commonly following prostatectomy for treatment of adenocarcinoma of the prostate), and follow-up of the outcomes with male slings is still early. The artificial urinary sphincter (AUS) remains the prevailing treatment option for postprostatectomy incontinence. The AUS has rarely been used for treatment of SUI in women. In the fortunately rare cases of complete urethral devastation, bladder neck closure or urinary diversion can be considered.