Michael Verhaaren

THE PATHOPHYSIOLOGY OF POST-RADICAL PROSTATECTOMY INCONTINENCE: A CLINICAL AND VIDEO URODYNAMIC STUDY

PURPOSEnWe examine various mechanisms of post-radical prostatectomy incontinence.nnnMATERIALS AND METHODSnA total of 83 consecutive men (mean age 68 +/- 6.6 years) referred for evaluation of persistent post-radical prostatectomy incontinence were enrolled in the study. All patients underwent clinical and urodynamic evaluation. Final diagnosis was based on clinical judgment considering patient history, pad test, voiding diary, free (unintubated) uroflow measurements, video urodynamics and linear passive urethral resistance relation curves. We compared free uroflow and pressure flow obtained with a 7Fr urethral catheter in place, and empirically defined low urethral compliance as at least 10 ml. per second difference between these measurements.nnnRESULTSnSphincteric incontinence was the most common urodynamic finding, occurring in 73 patients (88%). Detrusor instability was identified in 28 patients (33.7%) and in 6 (7.2%) was the main cause of incontinence. In 2 other patients bladder outlet obstruction (1.2%) or impaired detrusor contractility (1.2%) was the only urodynamic finding. Impaired detrusor contractility was diagnosed by linear passive urethral resistance relation in 82% of cases but considered to be clinically relevant in only a third. In 25 cases (30.1%) low urethral compliance was noted, which we consider nearly synonymous with urethral scarring.nnnCONCLUSIONSnSphincteric incontinence is the most common urodynamic finding in patients with post-radical prostatectomy incontinence, although other findings may coexist. The most accurate diagnosis is attained when all objective measures are put in perspective with the clinical setting.

Atlas of Urodynamics

Section One - Patient evaluation. Overview. Pre-urodynamic evaluation. Section Two - Techniques. Cystometry. Leak Point Pressure. Uroflowmetry. Electromyography. Urethral pressure measurement. Synchronous pressure/uroflow. Video-urodynamics. Sphincter electromyography. Section Three - Diagnosis. A Neuro-urology. Normal and abnormal physiology of micturition. Spinal cord injury. Cerebrovascular accident, Parkinsons Disease and other intracranial diseases. Multiple sclerosis and other demyelinating disorders. Diabetes Mellitus. Cauda equina, Infections and other spinal diseases. B Male voiding disorders. BPH, bladder neck obstruction and prostatitis. Post-prostatectomy incontinence. C Female Urology. Stress incontinence. Mixed incontinence. Overactive bladder. Bladder outlet obstruction. Pelvic organ prolapse. Leak point pressure in stress incontinence. Painful bladder syndrome and interstitial cystitis. D Pediatrics, geriatrics and bladder reconstruction. Pediatric urodynamics. Geriatric urodynamics. Urodynamic evaluation of urinary tract reconstruction. Appendix. ICS recommendations on good urodynamic practice

Does the method of cystometry affect the incidence of involuntary detrusor contractions? A prospective randomized urodynamic study.

The International Continence Society (ICS) defines overactive detrusor as “one that is shown objectively to contract during the filling phase while the patient is attempting to inhibit micturition.” The aim of the present study was to assess whether instructing the patient neither to try void nor to inhibit micturition during filling cystometry may improve the detection rate of involuntary detrusor contractions (IDCs). Forty‐two consecutive patients (mean age 65u2009±u200913.5 years), referred for urodynamic evaluation of persistent irritative lower urinary tract symptoms were prospectively enrolled. All patients were presumed, by history, to have IDCs. Cystometry was performed twice at the same session, each time by using randomly different instructions: Method 1, patients were instructed to try to inhibit micturition during bladder filling; and Method 2, patients were instructed to neither try to void nor try to inhibit micturition, but simply report his or her sensations to the examiner. The occurrence, as well as the urodynamic characteristics of IDCs, were analyzed separately and compared between the two filling methods. Method 1 identified only 20 cases of IDCs, while Method 2 identified 27 cases (48 versus 64u2009% of the study population, respectively; Pu2009=u20090.02). Analysis of urodynamic characteristics revealed a clear trend of reduced bladder volume at which IDCs occurred when patients were instructed to neither try to void nor to inhibit micturition during bladder filling; however, statistical significance was not established (189u2009±u2009122 versus 240u2009±u2009149 mL, respectively; Pu2009=u20090.13). All other urodynamic characteristics of IDCs were similar in both methods. In conclusion, better detection rates of IDCs were achieved by instructing the patient to neither try to void nor try to inhibit micturition, but simply report his or her sensations to the examiner, during filling cystometry. If the patient is instructed to inhibit micturition during bladder filling—about 26u2009% of the IDC cases are misdiagnosed. Neurourol. Urodynam. 20:141–145, 2001.