Becky Clarkson

International continence society guidelines on urodynamic equipment performance

These guidelines provide benchmarks for the performance of urodynamic equipment, and have been developed by the International Continence Society to assist purchasing decisions, design requirements, and performance checks. The guidelines suggest ranges of specification for uroflowmetry, volume, pressure, and EMG measurement, along with recommendations for user interfaces and performance tests. Factors affecting measurement relating to the different technologies used are also described. Summary tables of essential and desirable features are included for ease of reference. It is emphasized that these guidelines can only contribute to good urodynamics if equipment is used properly, in accordance with good practice. Neurourol. Urodynam. 33:370–379, 2014.

Brain activity underlying impaired continence control in older women with overactive bladder.

To identify, in subjects with overactive bladder (OAB), differences in brain activity between those who maintained and those who lost bladder control during functional magnetic resonance imaging (fMRI) of the brain with simultaneous urodynamics.

Brain Mechanisms Underlying Urge Incontinence and its Response to Pelvic Floor Muscle Training

PURPOSE Urge urinary incontinence is a major problem, especially in the elderly, and to our knowledge the underlying mechanisms of disease and therapy are unknown. We used biofeedback assisted pelvic floor muscle training and functional brain imaging (functional magnetic resonance imaging) to investigate cerebral mechanisms, aiming to improve the understanding of brain-bladder control and therapy. MATERIALS AND METHODS Before receiving biofeedback assisted pelvic floor muscle training functionally intact, older community dwelling women with urge urinary incontinence as well as normal controls underwent comprehensive clinical and bladder diary evaluation, urodynamic testing and brain functional magnetic resonance imaging. Evaluation was repeated after pelvic floor muscle training in those with urge urinary incontinence. Functional magnetic resonance imaging was done to determine the brain reaction to rapid bladder filling with urgency. RESULTS Of 65 subjects with urge urinary incontinence 28 responded to biofeedback assisted pelvic floor muscle training with 50% or greater improvement of urge urinary incontinence frequency on diary. However, responders and nonresponders displayed 2 patterns of brain reaction. In pattern 1 in responders before pelvic floor muscle training the dorsal anterior cingulate cortex and the adjacent supplementary motor area were activated as well as the insula. After the training dorsal anterior cingulate cortex/supplementary motor area activation diminished and there was a trend toward medial prefrontal cortex deactivation. In pattern 2 in nonresponders before pelvic floor muscle training the medial prefrontal cortex was deactivated, which changed little after the training. CONCLUSIONS In older women with urge urinary incontinence there appears to be 2 patterns of brain reaction to bladder filling and they seem to predict the response and nonresponse to biofeedback assisted pelvic floor muscle training. Moreover, decreased cingulate activation appears to be a consequence of the improvement in urge urinary incontinence induced by training while prefrontal deactivation may be a mechanism contributing to the success of training. In nonresponders the latter mechanism is unavailable, which may explain why another form of therapy is required.

Multisite Evaluation of Noninvasive Bladder Pressure Flow Recording Using the Penile Cuff Device: Assessment of Test-Retest Agreement

PURPOSE We performed a pragmatic study of the penile cuff test, a noninvasive method of categorizing bladder outlet obstruction, at a number of United Kingdom urology centers remote from the originating site. We report the agreement of the test and the subsequent retest using the cuff test in the short term. MATERIALS AND METHODS Men requiring urodynamic investigation for lower urinary tract symptoms were recruited from 6 sites to perform a penile cuff test twice at an interval of approximately 4 weeks. Tests were analyzed by a single interpreter to assess differences in the flow rate, cuff interruption pressure and diagnostic categorization in an individual between the 2 tests due to measurement and physiological error. RESULTS A total of 136 men (69%) performed 2 suitable cuff tests at a median of 20 days (IQR 8-31). The mean +/- SD difference between the 2 tests in the maximum flow rate was 0.2 +/- 3.7 ml per second and in cuff interruption pressure was 4.0 +/- 26 cm H(2)O. Of the men 33% changed diagnostic category on the Newcastle nomogram, while 47% maintained a consistent diagnosis of obstruction or no obstruction. CONCLUSIONS Diagnostic category repeatability was similar to that of conventional urodynamics, although there was greater variability in pressure measurements. This supports widespread routine use of the penile cuff test.

Future Directions of Research and Care for Urinary Incontinence: Findings from the National Institute of Diabetes and Digestive and Kidney Diseases Summit on Urinary Incontinence Clinical Research in Women

Purpose: Female urinary incontinence is prevalent, costly and morbid. Participants in a NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) sponsored summit reviewed findings from NIH (National Institutes of Health) funded clinical research on urinary incontinence in women and discussed the future of urinary incontinence research. Materials and Methods: The NIDDK convened the Summit on Urinary Incontinence Clinical Research in Women on March 14, 2014. Participants representing a broad range of clinical expertise reviewed completed NIH sponsored urinary incontinence related studies, including results from community based epidemiological studies such as the BACH (Boston Area Community Health) Survey and from randomized clinical trials such as PRIDE (Program to Reduce Incontinence by Diet and Exercise), and studies conducted by the Pelvic Floor Disorders Network and the Urinary Incontinence Treatment Network. Results: BACH Survey results improved our understanding of precursors, incidence, prevalence and natural history of urinary incontinence in a diverse group of women. The Pelvic Floor Disorders Network study found that anticholinergic medications and onabotulinumtoxinA are efficacious for treating urge urinary incontinence, and Burch colposuspension and retropubic mid urethral polypropylene slings are efficacious for decreasing stress urinary incontinence following pelvic organ prolapse surgery in women with potential stress urinary incontinence. The Urinary Incontinence Treatment Network study found that fascial slings were better than colposuspension, and that retropubic and transobturator mid urethral polypropylene slings were equivalent for stress urinary incontinence. In patients with stress urinary incontinence a preoperative urodynamic study was noninferior to basic office examinations for surgical outcome. The addition of behavioral intervention did not allow female patients to discontinue antimuscarinics for urge urinary incontinence. PRIDE showed that modest weight reductions significantly decreased urinary incontinence. Conclusions: Strategies for future research on urinary incontinence should include a focus on early disease, risk factor identification, better phenotyping, incorporation of new technologies, patient centered research and prevention.

Continuous non-invasive measurement of bladder voiding pressure using an experimental constant low-flow test†‡

We developed a prototype device using an automatically controlled inflatable penile cuff to measure bladder voiding pressure continuously and non‐invasively in men. The purpose of this study was to validate the pressure measurements made by this device by comparison to those during simultaneous invasive PFS.

Interobserver Agreement for Noninvasive Bladder Pressure Flow Recording With Penile Cuff

PURPOSE We assessed variability in interpreting noninvasive measurements of bladder pressure and urine flow between experienced and novice users of the penile cuff. MATERIALS AND METHODS Urodynamicists at 6 sites were asked to use the penile cuff test as part of clinical assessment in 30 men presenting with lower urinary tract symptoms. After a short training period they measured maximum flow rate and cuff interruption pressure from penile cuff test recordings to enable categorization of bladder outlet obstruction using a nomogram. Similar measurements were then made on the same traces by 2 expert observers from the originating center. Interobserver differences were assessed. RESULTS Complete agreement on obstruction categorization was seen in 77% of subjects, which increased to 86% when plots positioned on category boundary lines were allocated to the favored category. The 95% confidence limits of interobserver variability in maximum flow rate and cuff interruption pressure measurements were +/- 1.7 ml per second and +/- 13 cm H(2)O, respectively, although a small number of studies yielded discrepancies between observers that were larger than expected. They arose from complex recordings but were equally likely between experts as between expert and novice. Investigation of the causes suggested in some cases how such discrepancies may be avoided in the future. CONCLUSIONS The excellent level of agreement in measurement and categorization after a short training period suggests that introducing the penile cuff test as part of assessment in men with lower urinary tract symptoms would be straightforward.

Do brain structural abnormalities differentiate separate forms of urgency urinary incontinence

Urgency urinary incontinence (UUI) is a major problem for seniors. The underlying mechanisms of disease and therapy are unknown. We sought structural brain abnormalities that might underlie the functional differences previously observed by functional Magnetic Resonance Imaging in UUI patients versus controls, or among UUI responders versus non‐responders to therapy—and thereby reveal potential disease mechanisms and therapeutic targets.

Test-retest repeatability of patterns of brain activation provoked by bladder filling

To assess short‐term repeatability of an fMRI protocol widely used to assess brain control of the bladder. fMRI offers the potential to discern incontinence phenotypes as well as the mechanisms mediating therapeutic response. If so, this could enable more targeted efforts to enhance therapy. Such data, however, require excellent test‐retest repeatability.

The questionable benefit of multiple free-flow studies in men with lower urinary tract symptoms†

The diagnostic accuracy of maximum flow rate (Qmax) for bladder outlet obstruction (BOO) is limited. In a much-cited study, Reynard et al. concluded that diagnostic accuracy can be improved by taking the maximum Qmax of multiple flow rate measurements, observing that it may be more representative of the man’s usual Qmax. This conclusion was based on improved specificity from multiple voids. Yet this might also be achieved from a single void simply by lowering the threshold for classifying obstruction. We revisited the data published by Reynard et al. to compare diagnostic accuracy from the highest Qmax of multiple measurements, with that from a single measurement of Qmax.