Urodynamics in Elderly Women with Stress Urinary Incontinence

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TRANSVESICAL ULTRASONOGRAPHY FOR THE STAGING OF BLADDER

RELATIVE USEFULNESS OF PHYSICAL EXAMINATION, URODYNAMIC AND RADI0L03ICAL EXAMINATION IN THE DIAGNOSIS OF URINARY srRESS INCONTINENCE. Zafar Khan, *Maria Mieza, *Anita Bhola. New York, N. Y. (Presentation to be made by Dr. Bhola.) At present many tests are being used for the diagnosis of stress urinary incontinence in the female. It is our aim to evaluate the merit of physical examination urodynamic testing and radiological fluoroscopic observation. A total of 50 females with an established diagnosis of stress incontinence were studied retrospectively., Physical examination was performed both in the lithotomy and standing position to look for leakage and any anatomical deformity. Physical examination in the lithotomy position demonstrated stress incontinence in only 40% of all cases, while similar examination in the standing position with a full bladder during coughing and straining revealed stress incontinence in 84% cases. On urodynamic testing, only 4,6% patients demonstrated bladder instability, while the remaining 90. 6% revealed a normal bladder which was consistent with genuine stress incontinence. The stress urethral pressure was recorded by dual channel Miller Microtip transducers. It was perfomed on 25 females with demonstrable stress urinary incontinence and no bladder instability. In 72% of the cases, the characteristic decreased transmission of abdominal pressure to urethra was observed. In the remaining 28% of cases of stress incontinence, it was equivocal. The fluoroscopic examinations revealed stress incontinence in 92% of cases. It provided valuable information regarding anatomical deformity of bladder neck/ urethra. we found that examination of female in lithotomy position, and U.P.P. tests are of limited value. However, examination of female patients in the standing position with full bladder, cystometrogram and fluoroscopic examination under similar conditions to be the oost useful tests.

CANCER. Andrew C. von Eschenbach, Houston, Tx (Presentation to me made by Dr. van Eschenbach) Transvesical ultrasonography using 5.5 megahertz, 90 de-

gree and 135 degree transducers, allows for fine resolution of the architecture of the bladder wall making it a poten-

tially useful tool for the objective assessment of the depth of tumor invasion. In our initial experience, a correlation of approximately 80% was achieved between ultrasound and the clinical/pathologic stage of bladder tumors. Transvesical ultrasonography has now been used for clinical staging compared to pathologic stage in over 100 patients. With in-

creasing experience in performing the examination and image interpretation, and the addition of techniques such as 11post processing" of the real time gray scale image, the accuracy of this modality can be even further enhanced. This is particularly important for discrimination between superficial and deep muscle invasion. It is apparent that variation of the imaging parameters in order to achieve an optimal image and expertise in the interpretation of the images are critical factors for accurate staging of bladder turrors. Therefore, this procedure is done best by the experienced urologist at the time of staging endoscopy. The recent advent of laser photocoagulation of bladder tumors and the use of neoadjuvant chemotherapy have stressed the need for accurate objective staging and has added further impetus to the development of transvesical ultrasound as an objective and precise modality for evaluation of bladder cancers.

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THE SIGNIFICANCE OF PRIOR ANTI-INCONTINENCE SURGERY IN FEKALE PATIENTS WHO PRESENT WITH URINARY INCONTINENCE. Said A. Awad, Kelly L. Acker •, Hugh D. Flood •, Halifax, NS. (Presentation to be made by Dr. Awad), In a series of 148 consecutive patients with urinary incontinence 62 had previous anti-incontinence surgery (Group I: mean age 52 yrs> and 86 had no previous surgery in Group I was 28/62 (45¼) and in Group II 44/86 (51¼). A final diagnosis of stress urinary incontinence after clinical and urodynamic evaluation was made in 36/62 (58¼) of Group I and 33/86 (38%) of Group II. Associated DI was present in 39¼ of the patients with a final diagnosis of SUI in each group. In Group I 15 patients had >1 procedure previously and the ¼ figures quoted above for Group I were similar in these 15. These figures suggest that even in patients with previous anti-incontinence surgery the anatomical defect rather than DI is the important factor in the pathogenesis of incontinence. Forty of the 69 patients diagnosed as having SUI have been followed for )6 months post-surgery, 24 in Group I <8 with >1 procedure previously> and 16 in Group II. Of these 40, 20 had a U.-V. suspension (8 in Group I and 12 in Group II) and 20 had a pubovaginal fascial sling (16 in Group I and 4 in Group II). The fascial sling was selected in patients with a very short urethra and/or significant periurethral fibrosis. Of the 8 patients with )1 procedure previously 7 had a fascial sling. Fifteen of the 40 patients had DI pre-operatively (9/24 from Group I and 6/16 from Group II). Good results after surgery were obtained in 33/40 patients. DI was the cause of a poor result in 6/7 patients. All 6 were in Group I with a greater incidence in those who had had )1 procedure previously (3/8 v. 3/16). All 6 patients had a fascial sling. Three of the 6 had DI pre-operatively which persisted and 3 developed it de novo. We conclude that patients who have had prior antiincontinence surgery (particularly multiple procedures) are at a higher risk of developing DI after further surgery especially if a fascial sling proves neccessary.

URODYNAMICS IN ELDERLY WOMEN WITH STRESS URINARY INCONTINENCE. Kevin Pranikoff, Patricia A. Burns* and Janet S. Reis,* Buffalo, NY (Presentation to be made by

Dr. Pranikoff) Urinary incontinence in the elderly is a well-recognized problem. Most of our current urodynamic data in stress urinary incontinence (SUI) has been gathered from either a young population or a population with ages extending from the teens to the eighties. One hundred and twenty community based volunteer female

subjects 55 to 74 years of age with complaints of urinary incontinence were extensively screened to produce a group

of 59 subjects demonstrating SUI clinically.

These sub-

jects were studied in our urodynamic laboratory by residual urine, uroflornetry, supine and erect cystometry and ure-

thral pressure profilometry (UPP) in both of these positions .. Fifty subjects demonstrating pure SUI were analyzed. Uroflometry was normal. The mean cystometric capacity was 320 mls. supine and 333 standing. Functional urethral

length (FUL) averaged 29.9 mm. in supine position and shortened to 24.6 mm. with bladder distension. A further decrease in FUL to 20.1 mm. was noted in the erect position. Maximal urethral closure pressures (MUCP) under the same

conditions were 28.1, 30.2 and 30.8 cmH20 respectively and the points of maximal urethral pressure (MUP) were 16.3,

12,9 and 12,3 mm. respectively distal to the functional bladder neck. The plateau phase of the UPP (the distance over which the UPP is within 5 cmll20 of MUP) was evaluated and found to be 12.7, 9.9 and 8.2 mms. respectively under these conditions. In 49 subjects, a volitional perineal contraction produced a mean increase of MUP of only 16.9 cm

H20 with 17 (34.6%) unable to volitionally increase their MUP over 10 cmH20. Urethral pressures decrease with age. Changes in urodynarnic parameters with bladder distension and posture were

as reported in other populations except that MUCP held stable rather than decreasing.

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