James P. Theofrastous

Valsalva leak point pressures in women with genuine stress incontinence: Reproducibility, effect of catheter caliber, and correlations with other measures of urethral resistance

Abstract OBJECTIVES: The Valsalva leak point pressure has been promoted as an alternative to urethral pressure profilometry as a measure of urethral resistance in women with genuine stress incontinence. Our aims were to evaluate the reproducibility of the Valsalva leak point pressure, to assess the effect of catheter caliber on the Valsalva leak point pressure, and to compare vesical Valsalva leak point pressure to other measures of urethral resistance. STUDY DESIGN: Sixty consecutive women with genuine stress incontinence underwent duplicate Valsalva leak point pressure determinations by use of 8F and 3F vesical and 8F vaginal catheters. Subjects also underwent a standard resting urethral pressure profilometry, cough leak point pressure determinations, and pressure-flow micturition studies. RESULTS: Leakage was demonstrated on both Valsalva maneuvers in approximately 80% of subjects with both catheters. In subjects who leaked with both strains there was an extremely high correlation between the test-retest Valsalva leak point pressure within both catheters. The intercatheter correlation between the 8F and 3F Valsalva leak point pressures was significant but much weaker than the intracatheter correlations; 8F Valsalva leak point pressures were significantly higher than 3F Valsalva leak point pressures, although there were individual exceptions to this observation. Urethral pressure profilometry measures and micturition opening pressures were poorly correlated with Valsalva leak point pressure. Cough and vaginal Valsalva leak point pressures were significantly correlated with vesical Valsalva leak point pressure, but cough leak point pressures were significantly higher and vaginal Valsalva leak point pressures were significantly lower than the vesical Valsalva leak point pressure. CONCLUSIONS: Valsalva leak point pressure is a simple and reproducible technique for evaluating urethral resistance in women with genuine stress incontinence. However, variations in Valsalva leak point pressure measurement must be precisely described, standardized, and validated before a technique can be advocated for clinical use.

Correlation of urodynamic measures of urethral resistance with clinical measures of incontinence severity in women with pure genuine stress incontinence

OBJECTIVE Our aim was to correlate multiple measures of urethral resistance with five clinical measures of incontinence severity in women with pure genuine stress incontinence. STUDY DESIGN Seventy-five women with pure genuine stress incontinence underwent passive and dynamic urethral pressure profilometry and Valsalva leak point pressure determinations. The standardized and validated measures of incontinence severity included (1) the number of incontinent episodes, (2) the number of continence pads used recorded in a prospective 1-week urinary dairy, (3) grams of fluid loss on a pad quantitation test, and (4) two condition-specific quality-of-life scales, the urogenital distress inventory and the incontinence impact questionnaire. The urodynamic and severity measures were compared with Pearson product-moment correlation analysis. RESULTS There were no significant correlations between dynamic urethral pressure profile pressure transmission ratios and any measure of incontinence severity. Passive urethral pressure profile variables correlated significantly with incontinence episodes and pad use. Valsalva leak point pressures correlated significantly with pad use and quantitation testing. None of the urodynamic measurements was significantly correlated with either of the quality-of-life scales, but our power to demonstrate a correlation was limited. CONCLUSIONS Both passive urethral pressure profile measures and Valsalva leak point pressures correlate with some severity measures of genuine stress incontinence. Although inefficient pressure transmission during stress is critical to the pathogenesis of genuine stress incontinence, the severity of the pressure transmission defect is not related to clinical severity. Conversely, impairment of intrinsic urethral resistance is not essential to the pathogenesis of genuine stress incontinence, but the degree of sphincteric impairment is related to severity once the condition exists.

The effect of vesical volume on valsalva leak-point pressures in women with genuine stress urinary incontinence

Objective To determine the effect of increasing vesical volume on the Valsalva leak-point pressure, examine the relationship between leakage at a given volume and clinical incontinence severity, and evaluate the relationships between leakage at a given volume and other measures of urethral resistance. Methods One hundred twenty women with genuine stress urinary incontinence (GSI) underwent serial Valsalva leak-point pressure determinations at vesical volumes of 100, 200, and 300 mL, and at maximum cystometric capacity. Urinary diary data, quantitative pad testing, and passive and dynamic urethral profilometry were also performed. Results Thirty-three women had leakage starting at a vesical volume of 100 mL, 18 at 200 mL, and 19 at 300 mL, and 17 had leakage only at maximum cystometric capacity. The mean first positive Valsalva leak-point pressures were significantly higher than Valsalva leak-point pressures at maximum capacity in all groups: in women who began to leak at 100 mL, 57 versus 36 cm H 2 O ( P 2 O ( P 2 O ( P = .01). Women who had leakage at lower vesical volumes had worse measures of clinical incontinence severity and lower maximum urethral closure pressures ( P 2 O) and pure intrinsic sphincteric deficiency (low urethral pressure and the lack of urethral hypermobility), but the specificities were 63 and 50%, respectively. Conclusions Women with GSI are more likely to leak during Valsalva with increasing vesical volume. Valsalva leak-point pressures decrease significantly with bladder filling. The volume at which leakage occurs correlates inversely with clinical severity and directly with maximum urethral closure pressure. A negative Valsalva leak-point pressure at 300 mL excludes the presence of low urethral pressure and pure intrinsic sphincteric deficiency; however, the specificity and positive predictive value are inadequate for making a clinical diagnosis of either condition.

Relationship between urethral and vaginal pressures during pelvic muscle contraction

Condensation is the performance of an effective pelvic muscle contraction increases urethral and vaginal pressures and is independent of demographic, clinical, and urodynamic factors.

Bladder compliance in neurologically intact women

No data currently exist to define normal bladder compliance (C) in women. This study was undertaken to establish normative data for C in neurologically intact women and to determine if detrusor instability (DI) is associated with changes in C. The multichannel urodynamic tracings of 270 patients (195 stable, 75 unstable) were reviewed according to a standard written protocol. Vesical and abdominal pressures (Pves, Pabd) were measured during retrograde filling after a stable baseline was established (<50 ml) and just prior to cessation of infusion. If a detrusor contraction occurred, measurements were taken during a 5‐sec window preceding onset of contraction. The vesical volume used to calculate C was the total bladder volume determined by completely emptying the bladder at the end of cystometry. Compliance was calculated by dividing this volume by the change in detrusor pressure (Pdet). For the purpose of some analyses, infinite C, i.e., no observed rise in Pdet, was arbitrarily assigned a value of 1,000. Overall, 47.6% of women had no increase in Pdet with filling to maximum cystometric capacity (MCC) and had infinite C. Women with instability were significantly less likely to have infinite C than those with stable bladders (32% vs. 53%; P = 0.003). In 75% of women, C was >130 ml/cm; in 90%, C was >60 ml/cm; and in 95%, C was >40 ml/cm. There were significant differences between the distribution of stable and unstable bladders above and below each of these percentile cutoffs. Only 2 women, both of whom had unstable bladders, had C <20 ml/cm water. Ninety‐five percent of neurologically intact women have C >40 ml/cm, and nearly half have no increase in Pdet during filling to MCC. Patients with DI have significantly less compliant bladders than do those with stable bladders. If C is <40 ml/cm, a woman is 16 times more likely to have DI. Decreased C may suggest the diagnosis of DI in patients with urge incontinence whose symptoms are not reproduced in the laboratory.

UNDERSTANDING LOWER URINARY TRACT FUNCTION IN WOMEN SOON AFTER BLADDER NECK SURGERY

The aim of this work was to correlate anatomic and urodynamic measures with function following bladder neck surgery. Eighty‐seven women who underwent bladder neck surgery at two tertiary academic medical centers in the southeastern U.S. were studied in this prospective outcomes analysis. Preoperative and 6‐week and 6‐month postoperative status was assessed with urodynamic testing, physical examination, and condition‐specific quality of life instruments. Correlations of dynamic urethral obstruction (quantified by pressure transmission ratio, PTR, determinations) and urethral support (quantified by urethral axis measurements) with functional status were determined. At 6 weeks, 50% of the subjects with inadequate dynamic obstruction (PTR < 90%) had genuine stress incontinence (GSI) compared to 5% of those with PTR ≥90% (P = .00002). Of those with excessive obstruction (PTR > 110%), 32% had detrusor instability (DI) and 47% had emptying phase dysfunction (EPD) compared to 6% and 24%, respectively, of those with PTR ≤ 110% (P = .006 and P = .04). At 6 months, subjects with excessive obstruction were more likely to have EPD than other subjects (75% vs. 27%, P = .001). Those with optimal dynamic obstruction (PTR ≥ 90% but ≤ 110%) were more likely to have normal function (no GSI, no DI, and no EPD) than those with higher or lower PTRs (59% vs. 34%, P = .04). Urethral axis measurements did not correlate with functional status at either follow‐up session. The magnitude of dynamic urethral obstruction is related to function after bladder neck surgery. Excessive obstruction is associated with DI and EPD, inadequate obstruction with GSI, and optimal obstruction with normal function. Neurourol. Urodynam. 18:629–637, 1999.

Pressure transmission ratio reproducibility in stress continent and stress incontinent women.

Our objective was to determine the effect of cough strength on pressure transmission ratios and establish quantitative and qualitative intra‐observer test‐retest reproducibility of pressure transmission ratios calculated from dynamic urethral pressure profilometry. The study included 242 consecutive urodynamic evaluations on women without pelvic organ prolapse. Dynamic urethral pressure profiles were performed in duplicate with coughs of different intensities. The analysis included pressure transmission ratios from the proximal 3 urethral quartiles (Q1 through Q3) and the mean pressure transmission ratio calculated from these quartiles. The final diagnoses were stratified into genuine stress incontinence, 135 (56%), and stress continence, 107 (44%).

The Effect of Vesical Volume on Valsalva Leak-Point Pressures in Women With Genuine Stress Urinary Incontinence

Objective To determine the effect of increasing vesical volume on the Valsalva leak-point pressure, examine the relationships between leakage at a given volume and clinical incontinence severity, and evaluate the relationship between leakage at a given volume and other measures of urethral resistance. Methods One hundred twenty women with genuine stress urinary incontinence (GSI) underwent serial Vlsalva leak-point pressure determinations at vesical volumes of 100, 200 and 300 mL, and at maximum cystometric capacity. Urinary diary data, quantitative pad testing, and passive and dynamic urethral profilometry were also performed. Results Thirty-three women had leakage starting at a vesical volume of 100 mL, 18 at 200 mL, and 19 at 300 mL, and 17 had leakage only at maximum cystometric capacity. The mean first positive Valsalva leak-point pressures were significantly higher than Valsalva leak-point pressures were significantly higher than Valsalva leak-point pressures at maximum capacity in all groups: in women who began to leak at 100 mL, 57 versus 36 cm H2O (P < .001); at 200 mL, 59 versus 45 cm H2O (P < .001); and at 300 mL, 61 versus 47 cm H2O (P = .01). Women who had leakage at lower vesical volumes had worse measures of clinical incontinence severity and lower maximum urethral closure pressures (P < .001 to .002). The presence of leakage at a vesical volume of 300 mL was 100% sensitive for the presence of both low urethral pressure (maximum urethral closure pressure less than or equal to 20 cm H2O) and pure intrinsic sphincteric deficiency (low urethral pressure and the lack of urethral hypermobility), but the specificities were 63 and 50%, respectively. Conclusions Women with GSI are more likely to leak during Valsalva with increasing vesical volume. Valsalva leak-point pressures decrease significantly with bladder filling. The volume at which leakage occurs correlates inversely with clinical severity and directly with maximum urethral closure pressure. A negative Valsalva leak-point pressure at 300 mL excludes the presence of low urethral pressure and pure intrinsic sphincteric deficiency; however, the specificity and positive predictive value are inadequate for making a clinical diagnosis of either condition.