- Email: [email protected]
Urodynamic assessment and chain cystogram in women with stress urinary incontinence Clinical significance of detrusor instability
UROD;YNAMIC ASSESSMENT AND CHAIN CYSTOGRAM IN WOMEN WITH STRESS URINARY INCONTINENCE Clinical Significance of Detrusor Instability I. W. KUZMAROV,
M.D.
From the Department of Urology, Lakeshore General Hospital and McGill University, Quebec, Canada
ABSTRACT-A retrospective analysis of 51 women presenting with stress urinary incontinence was performed. Preoperative assessment protocol consisted of a careful history and physical examination, urinalysis and culture, cystoscopy, urodynamic study, beaded-chain cystogram, and intravenous pyelogram @VP). All patients in the study were subjected to the Marshall-MazchettiKsantz vesicousethral suspension procedure. The overall incidence of detrusor instability was 38.8 per cent. Sutgical succa rate was 92.5 per cent. Identification of detrusor instability was considered not to be a okterrent to surgery, nor a prognosticator of surgical failure. The chain cystogram was believed to be of little value in cases that had undergone previous surgical corrective attempts. Urodynamic studies were felt helpful in patients presenting with mixed symptom patterns, as well as in patients previously operated on fot stress urinary incontinence. The preoperative IVP was not found to be a cost-effective study.
Stress urinary incontinence (SUI) is defined as the involuntary loss of urine through the urethra as a result of a sudden increase in intraabdominal pressure in the absence of detrusor contraction. Controversy exists over the evaluation of women with SUI, namely, the role of urodynamic assessment and the beaded-chain cystogram. Proponents of urodynamic evaluation of women prior to surgical intervention point to a high incidence of detrusor instability in these patients and an even higher incidence of this problem in women with failed incontinence procedures. 1-5The implication is made that failure to recognize detrusor instability may lead to poor operative results. Proponents of radiographic study of urethrovesical relationships claim a distinct correlation between these parameters and potential surgical results.6.7Opponents of extensive preliminary evalulation Iksented at the AMU~ Meeting of the Canadian Udoglc ciation, Victoria, British Columbia, June 13, 1983.
236
ASSO-
believe that surgical decisions should be made on the basis of the clinical history. Some dispute the high incidence of detrusor instability;5 others dispute its clinical significance.3 Opponents of the chain cystogram claim a 50 per cent margin of error if the study is not correlated with the clinical history, and point to the fact that up to 65 per cent of parous continent women have positive findings.* To evaluate the role of the urodynamic assessment in private urologic practice and the place of radiographic study, a retrospective analysis of 51 women who presented to the urologic service of the Lakeshore General Hospital was undertaken. Material and Methods A retrospective analysis of 51 women subjected to vesicourethropexy (Marshall-Marchetti-Krantz operation)s was undertaken. Patients were drawn from the referral population
UROLOGY
I
SEPTEMBER 1984
I
VOLUME XXIV, NUMBER 3
of the Lakeshore General Hospital, a private practice community hospital, and surgery was performed by the same surgeon. All women were subjected to the same preoperative protocol, which consisted of a careful history of their symptoms, genitourinary examination, urinalysis and culture, IVP, cystoscopy, beaded-chain cystographic study, and urodynamic assessment consisting of cystometry and urethral pressure profilimetry. Cystometry was performed using a Heyer-Schulte cystometer with carbon dioxide being infused at a rate of 90 cclmin through a 14-F catheter. The study was performed in both the supine and standing position, with rectal monitoring performed in cases suspected of detrusor instability. The urethral pressure profile was performed using water infused with the aid of a Harvard pump, via an 8-F ureteral catheter, with four holes in the same plane. The data obtained were recorded on a Gibson polygraph machine. The studies were performed at the urodynamics laboratory of the Royal Victoria Hospital. For the purpose of data analysis in the present study, reports were divided into four main categories: (1) case studies interpreted as being within normal limits; (2) cases manifesting urethral sphincter dysfunction, without detrusor instability; (3) cases manifesting detrusor instability; and (4) cases demonstrating both detrusor instability and urethral sphincter dysfunction. The technique of beaded-chain cystography has been well described elsewhere.5 In analyzing the data, cystograms were categorized as being abnormal if they demonstrated either type I or type II abnormalities.6 In this context, studies in which interpretation was not possible due to angular distortion from previous surgery were not categorized as abnormal. The patient population was divided into two main groups: Group I, no previous surgery; Group II, failed incontinence surgery. Each major group was subdivided further on the basis of their presenting clinical symptoms. The first subgroup consisted of those patients who had loss of urine with increased intraabdominal maneuvers as the sole complaint. The second subgroup consisted of those patients who demonstrated a mixed pattern of stress and urgency or urgency incontinence, and the third subgroup was made up of patients with a somewhat atypical history of urine loss. There were 41 patients in Group I, 18 demonstrating pure stress symptoms, 20 presenting
UROLOGY
!
SEPTEMBER
1984
I
VOLUME
XXIV, NUMBER
with a mixed pattern of symptoms, and 3 giving an atypical history of urine loss. There were 10 patients in Group II, with 7 of the 10 presenting with a mixed pattern of symptoms. A total of 49 urodynamic studies were performed, and 48 radiographic studies were done. Urodynamic data and radiographic results were analyzed for the entire group as well as for the individual subgroups. This allowed us to obtain a perspective for a given symptom pattern, as well as for analysis of data in both subjects with no previous surgery and those with previous treatment failures. The IVP results were reviewed to obtain data on the costeffectiveness of this study in our patient population. Surgical results were categorized at the sixmonth visit as being excellent, showing marked improvement, moderate improvement, or no improvement at all. In calculating per cent success, only cases showing excellent or marked improvement were considered on the positive side of the data analysis; those categorized as moderate or no improvement were considered treatment failures. No follow-up urodynamic assessments were performed. Results Group I Analysis of urodynamic data of Group I patients presenting with pure stress incontinence symptoms revealed 11 studies demonstrating urethral sphincter dysfunction as the sole measurable abnormality. There were 3 normal studies, 1 study interpreted as being compatible with detrusor instability (DI), and 1 study showing a combination of DI and urethral sphincter dysfunction. In the mixed symptom subgroup, 10 cases manifested the combination of DI and stress, 4 showed pure stress pattern, 3 revealed DI as the sole abnormality; and 3 were normal. The atypical group revealed 1 case of urethral sphincter dysfunction, 1 case of DI, and 1 normal study. Overall data for this group revealed 9 of 39 studies (23 %) as being normal, emonstrating detrusor instabil16of39(41%)d ity, and 27 of 39 (69.2 % ) demonstrating evidence of urethral sphincter dysfunction. Analysis of beaded-chain cystography results yielded far higher corroborative results. Abnormal chain cystograms were obtained in 16 of 16 patients with pure stress symptoms; 18 of 20 mixed symptom patients and 2 of 3 atypical
3
237
symptom patients had abnormal radiographic studies. Overall there were 36 of 39 abnormal studies (92 % ) . Group II Although the sample population was small, 2 of 3 patients with pure stress symptoms demonstrated urethral sphincter dysfunction, and 1 patient showed DI as the sole abnormality. In the mixed symptom subgroup 5 of 7 patients demonstrated a stress pattern on urodynamic assessment, and 2 patients showed both DI and urethral sphincter dysfunction. Hence a total of 9 of 10 patients showed evidence of urethral sphincter dysfunction, supporting surgical intervention in these cases. DI was seen in 3 of 10 patients. Chain cystoscopy was disappointing in this group, with only 3 of 9 patients having abnormal findings. In the majority of cases angular measurements were difficult due to previous surgery. Urodynamic data from the entire study population revealed a stress pattern in 73.5 per cent of the cases, and an overall incidence of detrusor instability in 38.8 per cent. The significance of the DI can be inferred by analysis of surgical results. An excellent result was obtained in 44 of 51 cases, marked improvement of symptoms in 3 of 51 cases, moderate improvement in 2 of 51 cases, and no improvement in 2 of 51 cases. Overall if we consider only excellent and marked improvement as surgical success, 47 of 51 patients (92.5%) were greatly aided by surgical intervention. In the 2 treatment failures, urodynamic profiles failed to reveal detrusor instability. The discovery of detrusor instability did not delay surgery, and pre-treatment attempts with medication were not part of the protocol. Medical therapy was used postsurgery if urgency was found to be a problem. Data on abnormalities uncovered by the performance of preoperative IVP studies showed a total of 6 of 51 to be abnormal (chronic pyelonephritis, 1; atrophic kidney, 1; duplication of ureter, 2; nephrocalcinosis, 1; renal cyst, 1). Of these abnormal studies only 4 could be considered to be of any clinical significance in our population whose ages spanned four decades (30-70 years of age).
238
Conclusion Much has been written about the preoperative evaluation of women with SUI, and the best approach when urodynamic assessments reveal detrusor instability. Analysis of our results in a community population lead us to believe that stress urinary incontinence remains a clinical problem, dependent first and foremost on an accurate clinical history. Urodynamic studies are beneficial both to corroborate the findings, especially in “failed cases,” as well as to warn of potential clinical misdiagnosis, particularly in cases of mixed or atypical symptom presentation. Despite the fact that the incidence of detrusor instability in our study correlates well with published reports, we do not advocate a conservative approach in these cases. We believe that patients manifesting a mixed pattern of symptoms should be informed of the limitations of corrective vesicourethropexy, and of the potential persistence of urge components to their symptomatology. We find that radiographic assessments are of limited value in “failed cases” of stress urinary incontinence and have removed these studies entirely from our assessment protocol. We also do not believe that preoperative IVPs are cost-effective. 175 Stillview Road Pointe Claire, Quebec, H9R 4S3 Canada References 1. Lockhart IL, et al: Vesicourethral dysfunction following _ cystourethropexy, J Ural 128: 943 (1982). 2. Arnold El?. et al: Urodvnamics of female incontinence: factors influencingthe results of surgery, Am J Obstet Gynecol 117: 805 (1973). 3. McGuire EJ, et al: The value of urodynamic testing in stress urinary incontinence, J Urol 124: 256 (1980). 4. Stanton SL, et al: Clinical and urodynamic features of failed incontinence surgery in the female, Am J Obstet Gynecol51: 515 (1978). 5. Kaufman JL: Urodynamics in stress urinary incontinence, J Urol 122: 778 (1979). 6. Green TH: Urinary stress incontinence: differential diagnosis pathophysiology, and management, Am J Obstet Gynecoll22: 368 (1975). 7. Graber EA: Stress incontinence in women: a review-1977, Obstet Gynecol Surv 32: 565 (1977). 8. Greenwald SW, et al: Cvstourethrographv as a diagnostic aid in stress incontinence, Obstet Gynecol29‘ 324 (1967).9. Marshall VP. Marchetti AA. and Krantz KE: The correction of stress incontinence by simple v&x-urethral suspension, Surg Gynecol Obstet 88: 509 (1949).
UROLOGY
/
SEPTEMBER
1984
/
VOLUME XXIV, NUMBER 3
M.D.
From the Department of Urology, Lakeshore General Hospital and McGill University, Quebec, Canada
ABSTRACT-A retrospective analysis of 51 women presenting with stress urinary incontinence was performed. Preoperative assessment protocol consisted of a careful history and physical examination, urinalysis and culture, cystoscopy, urodynamic study, beaded-chain cystogram, and intravenous pyelogram @VP). All patients in the study were subjected to the Marshall-MazchettiKsantz vesicousethral suspension procedure. The overall incidence of detrusor instability was 38.8 per cent. Sutgical succa rate was 92.5 per cent. Identification of detrusor instability was considered not to be a okterrent to surgery, nor a prognosticator of surgical failure. The chain cystogram was believed to be of little value in cases that had undergone previous surgical corrective attempts. Urodynamic studies were felt helpful in patients presenting with mixed symptom patterns, as well as in patients previously operated on fot stress urinary incontinence. The preoperative IVP was not found to be a cost-effective study.
Stress urinary incontinence (SUI) is defined as the involuntary loss of urine through the urethra as a result of a sudden increase in intraabdominal pressure in the absence of detrusor contraction. Controversy exists over the evaluation of women with SUI, namely, the role of urodynamic assessment and the beaded-chain cystogram. Proponents of urodynamic evaluation of women prior to surgical intervention point to a high incidence of detrusor instability in these patients and an even higher incidence of this problem in women with failed incontinence procedures. 1-5The implication is made that failure to recognize detrusor instability may lead to poor operative results. Proponents of radiographic study of urethrovesical relationships claim a distinct correlation between these parameters and potential surgical results.6.7Opponents of extensive preliminary evalulation Iksented at the AMU~ Meeting of the Canadian Udoglc ciation, Victoria, British Columbia, June 13, 1983.
236
ASSO-
believe that surgical decisions should be made on the basis of the clinical history. Some dispute the high incidence of detrusor instability;5 others dispute its clinical significance.3 Opponents of the chain cystogram claim a 50 per cent margin of error if the study is not correlated with the clinical history, and point to the fact that up to 65 per cent of parous continent women have positive findings.* To evaluate the role of the urodynamic assessment in private urologic practice and the place of radiographic study, a retrospective analysis of 51 women who presented to the urologic service of the Lakeshore General Hospital was undertaken. Material and Methods A retrospective analysis of 51 women subjected to vesicourethropexy (Marshall-Marchetti-Krantz operation)s was undertaken. Patients were drawn from the referral population
UROLOGY
I
SEPTEMBER 1984
I
VOLUME XXIV, NUMBER 3
of the Lakeshore General Hospital, a private practice community hospital, and surgery was performed by the same surgeon. All women were subjected to the same preoperative protocol, which consisted of a careful history of their symptoms, genitourinary examination, urinalysis and culture, IVP, cystoscopy, beaded-chain cystographic study, and urodynamic assessment consisting of cystometry and urethral pressure profilimetry. Cystometry was performed using a Heyer-Schulte cystometer with carbon dioxide being infused at a rate of 90 cclmin through a 14-F catheter. The study was performed in both the supine and standing position, with rectal monitoring performed in cases suspected of detrusor instability. The urethral pressure profile was performed using water infused with the aid of a Harvard pump, via an 8-F ureteral catheter, with four holes in the same plane. The data obtained were recorded on a Gibson polygraph machine. The studies were performed at the urodynamics laboratory of the Royal Victoria Hospital. For the purpose of data analysis in the present study, reports were divided into four main categories: (1) case studies interpreted as being within normal limits; (2) cases manifesting urethral sphincter dysfunction, without detrusor instability; (3) cases manifesting detrusor instability; and (4) cases demonstrating both detrusor instability and urethral sphincter dysfunction. The technique of beaded-chain cystography has been well described elsewhere.5 In analyzing the data, cystograms were categorized as being abnormal if they demonstrated either type I or type II abnormalities.6 In this context, studies in which interpretation was not possible due to angular distortion from previous surgery were not categorized as abnormal. The patient population was divided into two main groups: Group I, no previous surgery; Group II, failed incontinence surgery. Each major group was subdivided further on the basis of their presenting clinical symptoms. The first subgroup consisted of those patients who had loss of urine with increased intraabdominal maneuvers as the sole complaint. The second subgroup consisted of those patients who demonstrated a mixed pattern of stress and urgency or urgency incontinence, and the third subgroup was made up of patients with a somewhat atypical history of urine loss. There were 41 patients in Group I, 18 demonstrating pure stress symptoms, 20 presenting
UROLOGY
!
SEPTEMBER
1984
I
VOLUME
XXIV, NUMBER
with a mixed pattern of symptoms, and 3 giving an atypical history of urine loss. There were 10 patients in Group II, with 7 of the 10 presenting with a mixed pattern of symptoms. A total of 49 urodynamic studies were performed, and 48 radiographic studies were done. Urodynamic data and radiographic results were analyzed for the entire group as well as for the individual subgroups. This allowed us to obtain a perspective for a given symptom pattern, as well as for analysis of data in both subjects with no previous surgery and those with previous treatment failures. The IVP results were reviewed to obtain data on the costeffectiveness of this study in our patient population. Surgical results were categorized at the sixmonth visit as being excellent, showing marked improvement, moderate improvement, or no improvement at all. In calculating per cent success, only cases showing excellent or marked improvement were considered on the positive side of the data analysis; those categorized as moderate or no improvement were considered treatment failures. No follow-up urodynamic assessments were performed. Results Group I Analysis of urodynamic data of Group I patients presenting with pure stress incontinence symptoms revealed 11 studies demonstrating urethral sphincter dysfunction as the sole measurable abnormality. There were 3 normal studies, 1 study interpreted as being compatible with detrusor instability (DI), and 1 study showing a combination of DI and urethral sphincter dysfunction. In the mixed symptom subgroup, 10 cases manifested the combination of DI and stress, 4 showed pure stress pattern, 3 revealed DI as the sole abnormality; and 3 were normal. The atypical group revealed 1 case of urethral sphincter dysfunction, 1 case of DI, and 1 normal study. Overall data for this group revealed 9 of 39 studies (23 %) as being normal, emonstrating detrusor instabil16of39(41%)d ity, and 27 of 39 (69.2 % ) demonstrating evidence of urethral sphincter dysfunction. Analysis of beaded-chain cystography results yielded far higher corroborative results. Abnormal chain cystograms were obtained in 16 of 16 patients with pure stress symptoms; 18 of 20 mixed symptom patients and 2 of 3 atypical
3
237
symptom patients had abnormal radiographic studies. Overall there were 36 of 39 abnormal studies (92 % ) . Group II Although the sample population was small, 2 of 3 patients with pure stress symptoms demonstrated urethral sphincter dysfunction, and 1 patient showed DI as the sole abnormality. In the mixed symptom subgroup 5 of 7 patients demonstrated a stress pattern on urodynamic assessment, and 2 patients showed both DI and urethral sphincter dysfunction. Hence a total of 9 of 10 patients showed evidence of urethral sphincter dysfunction, supporting surgical intervention in these cases. DI was seen in 3 of 10 patients. Chain cystoscopy was disappointing in this group, with only 3 of 9 patients having abnormal findings. In the majority of cases angular measurements were difficult due to previous surgery. Urodynamic data from the entire study population revealed a stress pattern in 73.5 per cent of the cases, and an overall incidence of detrusor instability in 38.8 per cent. The significance of the DI can be inferred by analysis of surgical results. An excellent result was obtained in 44 of 51 cases, marked improvement of symptoms in 3 of 51 cases, moderate improvement in 2 of 51 cases, and no improvement in 2 of 51 cases. Overall if we consider only excellent and marked improvement as surgical success, 47 of 51 patients (92.5%) were greatly aided by surgical intervention. In the 2 treatment failures, urodynamic profiles failed to reveal detrusor instability. The discovery of detrusor instability did not delay surgery, and pre-treatment attempts with medication were not part of the protocol. Medical therapy was used postsurgery if urgency was found to be a problem. Data on abnormalities uncovered by the performance of preoperative IVP studies showed a total of 6 of 51 to be abnormal (chronic pyelonephritis, 1; atrophic kidney, 1; duplication of ureter, 2; nephrocalcinosis, 1; renal cyst, 1). Of these abnormal studies only 4 could be considered to be of any clinical significance in our population whose ages spanned four decades (30-70 years of age).
238
Conclusion Much has been written about the preoperative evaluation of women with SUI, and the best approach when urodynamic assessments reveal detrusor instability. Analysis of our results in a community population lead us to believe that stress urinary incontinence remains a clinical problem, dependent first and foremost on an accurate clinical history. Urodynamic studies are beneficial both to corroborate the findings, especially in “failed cases,” as well as to warn of potential clinical misdiagnosis, particularly in cases of mixed or atypical symptom presentation. Despite the fact that the incidence of detrusor instability in our study correlates well with published reports, we do not advocate a conservative approach in these cases. We believe that patients manifesting a mixed pattern of symptoms should be informed of the limitations of corrective vesicourethropexy, and of the potential persistence of urge components to their symptomatology. We find that radiographic assessments are of limited value in “failed cases” of stress urinary incontinence and have removed these studies entirely from our assessment protocol. We also do not believe that preoperative IVPs are cost-effective. 175 Stillview Road Pointe Claire, Quebec, H9R 4S3 Canada References 1. Lockhart IL, et al: Vesicourethral dysfunction following _ cystourethropexy, J Ural 128: 943 (1982). 2. Arnold El?. et al: Urodvnamics of female incontinence: factors influencingthe results of surgery, Am J Obstet Gynecol 117: 805 (1973). 3. McGuire EJ, et al: The value of urodynamic testing in stress urinary incontinence, J Urol 124: 256 (1980). 4. Stanton SL, et al: Clinical and urodynamic features of failed incontinence surgery in the female, Am J Obstet Gynecol51: 515 (1978). 5. Kaufman JL: Urodynamics in stress urinary incontinence, J Urol 122: 778 (1979). 6. Green TH: Urinary stress incontinence: differential diagnosis pathophysiology, and management, Am J Obstet Gynecoll22: 368 (1975). 7. Graber EA: Stress incontinence in women: a review-1977, Obstet Gynecol Surv 32: 565 (1977). 8. Greenwald SW, et al: Cvstourethrographv as a diagnostic aid in stress incontinence, Obstet Gynecol29‘ 324 (1967).9. Marshall VP. Marchetti AA. and Krantz KE: The correction of stress incontinence by simple v&x-urethral suspension, Surg Gynecol Obstet 88: 509 (1949).
UROLOGY
/
SEPTEMBER
1984
/
VOLUME XXIV, NUMBER 3