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Chapter 11 Diagnostic Methods to Detect Female Urinary Incontinence
11.1 Assessment of Genuine Stress Incontinence
The diagnosis of stress incontinence is based on demonstrating objective loss of urine
with physical exertion and ruling out other causes of urinary loss. The differential diagnosis not only includes functional disorders such as detrusor instability and overflow incontinence but anatomic abnormalities such as urogenital fistulae and ectopic
ureters.
11.2 Basic Investigations
A thorough evaluation consisting of patient history, neurological and physical examinations, and selected clinical testing will allow an expeditious diagnosis of stress incontinence, while avoiding an incomplete workup (Table 11.1). The history centers on
the patient’s complaints of urinary loss. Particular attention is directed toward menopausal status, history of previous surgery, and medication intake. Various questionnaires have been introduced into clinical practice. Most of them enable a redundant
sequence of questions related to urinary incontinence.However, because of low sensitivity and specificity, scoring systems retrieved from questionnaires with the aim to
conclusively assess the type of female urinary incontinence have been omitted in the
past.
In women whose sole or main symptom is stress incontinence, the likelihood of a
diagnosis of GSI approaches 100%, particularly where the physical sign of GSI is also
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Table 11.1. Assessment of genuine stress incontinence: basic evaluation
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present. In patients with mixed symptoms of stress and urge incontinence,the likelihood of GSI is between 30% and 60% depending on what additional symptoms are
present.
A catheterized urine specimen is obtained to rule out the presence of a bacterial
urinary tract infection. Neurological examination centers on the functional aspects of
anatomic areas innervated by the sacral nerve roots S
noted and proper referrals made. The physical examination must comprise a complete
gynecological investigation and especially notes the presence of pelvic relaxation,uterine prolapse, cystocele,rectocele, enterocele. The external genitalia should be examined for dermatologic lesions and evidence of irritative or inflammatory conditions.
The internal genitalia should be examined for estrogen deficiency, abnormal vaginal
secretion or urine, pelvic organ prolapse and abnormal pelvic masses. A pH indicator
paper may help to assess estrogen status showing a pH of generally less than 5 in women without infection and good estrogen effect.
Objective tests for the demonstration of urinary loss with physical exertion include
the cough stress test and various pad tests. The cough stress test is performed when
the patient has a full bladder,most easily after screening cystometry. While standing,
one leg is elevated on a stool, and the patient coughs vigorously several times.The patient with stress incontinence will leak in spurts simultaneously with coughing. Care
must be taken in this evaluation, for patients with cough-induced detrusor instability
may leak several seconds after a cough.A multitude of various pad tests have been described to demonstrate loss of urine. The 1-h pad test,introduced by the International
Continence Society, is probably the most accepted standard form (Bates et al. 1979).
After 1 h of a battery of physical activities, a preweighed pad is again reweighed for
evidence of urinary loss.
When nonsurgical treatment is being considered,the most appropriate would be to
rely on clinical assessment.Where surgery is being considered,the role of urodynamic investigation seems to be expanding (Table 11.2).
. Abnormalities should be
2–S4
11.3 Urodynamics
In the patient demonstrating objective urine loss with stress, a normal cystometrogram, and normal neurologic findings,a diagnosis of stress incontinence can easily be
made. However, a large number of patients may demonstrate mixed symptoms and
clinical findings. These patients require multichannel urodynamic testing to confirm
a diagnosis of stress incontinence and rule out other causes of urine loss. Other patients who may require multichannel testing include postmenopausal patients and patients with previous incontinence surgery or those who have planned to undergo antiincontinence surgery.
11.3.1 Uroflowmetry
Uroflowmetry is a measurement of the rate of flow of urine expelled via the urethra
during voiding. It should be carried out in privacy and prior to any urethral instrumentation with residual urine measurement in the initial work-up of any incontinent
subject. It gives an assessment of voiding in a simple, noninvasive and relatively inexpensive way. Its role in the assessment of patients with GSI is to establish voiding difficulties, especially prior to surgery,since voiding may be impaired postoperatively.
Chapter 11 Diagnostic Methods to Detect Female Urinary Incontinence
Table 11.2. Assessment of genuine stress incontinence: advanced evaluation
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11.3.2 Cystometry
Cystometry is the core test of a urodynamic investigation,where the pressure–volume
relationship of the bladder is measured to assess detrusor activity,sensation, capacity
and compliance of the bladder. Cystometry is of paramount importance to rule out the
presence of detrusor instability and to assess efficient storage of urine in incontinent
patients and thus is regarded as the gold standard procedure in the diagnosis of GSI.
11.3.3 Urethral Pressure Measurements
Various means to measure the functional integrity of the components that prevent
stress incontinence have long been studied and modified. As mentioned earlier, the
primary factor leading to the development of stress incontinence is the displacement
of the urethra from the intra-abdominal position, leading to impaired pressure transmission during stress.The most accurate measure of urethral function, sphincteric capacity, and support that provides pressure transmission is the urethral pressure profile, which is obtained by using multichannel urodynamic testing (Faysal et al. 1981).
The introduction of microtip pressure transducers by Asmussen and Ulmsten has allowed precise and reproducible recordings of these measurements (Asmussen and
Ulmsten 1975).
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With an understanding of how urodynamics represents the contribution to continence by the internal and external urethral sphincteric mechanisms and the pelvic
supporting structures, multichannel testing can also demonstrate how various etiologic factors produce stress incontinence. The resting urethral pressure profile reflects
the constant tonus and margin to incontinence provided by the components of the
internal urethral sphincteric mechanism and the external urethral sphincter.
Various etiologic factors can predispose to impairment of the internal urethral
sphincteric mechanism and external sphincter as they contribute to resting tonus and
continence during stress. These same factors also produce low urethral closure pressure. In studying 120 women with urodynamically proven stress incontinence, Hilton
found that repeated unsuccessful incontinence operations were associated with the
finding of low urethral pressure (Hilton and Stanton 1983a). Previous surgery may result in scar formation around and within the delicate urethral structures. Menopause
may also contribute to lower urethral pressure. Hypoestrogenism can result in atrophy
of urethral epithelium, urethral smooth muscle, and the submucosal cavernous plexus
(Asmussen and Miller 1983; Hilton and Stanton 1983b). Although not the major contributing factor to stress incontinence,resultant low urethral pressure may, in some instances, reduce the margin to incontinence such that only minor anatomic changes
can result in loss of urine during stress.
Studies have consistently shown that the resting urethral closure pressure falls with
increasing age in women and is lower in groups of GSI women. However, there is a big
overlap of values between continent and incontinent females, limiting the discriminatory power of resting profile variables.Variables of the stress urethral pressure profile
such as the pressure transmission ratio, maximum urethral closure pressure on stress,
and profile area on stress have been found to be the most reliable variables to diagnose
GSI, although sensitivity even with these remains poor.It has been shown that patients
undergoing unsuccessful surgery for GSI by several different procedures having lower
preoperative resting urethral closure pressures and functional urethral length than
those treated successfully.
The parameters measured with urodynamic testing allow both a quantitative and a
qualitative assessment of the contribution to continence made by the internal and external sphincteric components and the supporting pelvic structures. The urethral closure pressure profile reflects the urethral closure pressure over the entire functional
urethral length (length of the urethra over which intraurethral pressure exceeds intravesical pressure).The resting urethral pressure profile primarily reflects intrinsic urethral pressure,termed the urethral closure pressure. This intrinsic pressure maintains
continence at rest.
The urethral pressure profile performed during stress maneuvers (e.g., coughing,
Valsalva) reflects the positional, mechanical,and dynamic factors contributing to continence. A cough pressure profile is performed by withdrawing the dual microtransducer through the urethra as the patient coughs continuously. The resulting profile can
demonstrate the adequacy of pelvic support, represented by pressure transmission,
and the possible reflex contraction of pelvic floor musculature, demonstrated by the
augmentation of transmitted pressure.
Anatomic descent of the urethra and urethrovesical junction can result from a
number of causes. The trauma of childbirth is one of the primary etiologic factors resulting in pelvic floor weakness. Descent of the fetal head distends the genital hiatus
and levator muscles along with stretching pubocervical fascia, pubourethral ligaments, and the urogenital diaphragm. This weakening then leads to descent and pos-
Chapter 11 Diagnostic Methods to Detect Female Urinary Incontinence
terior rotation of the proximal urethra and bladder base. Other causes for pelvic floor
weakness include aging and neurologic deficits.
11.3.4 Valsalva Leak Point Pressure
The pressure at which the expulsion of urine from the urethral meatus is observed is
the leak point pressure (LPP).The LPP is a direct measurement of the closure function
of the entire urethra. Similarly,the intravesical pressure at leakage during abdominal
stress (coughing or a Valsalva maneuver) in the absence of a detrusor contraction is
called the abdominal leak point pressure. Although higher abdominal pressures are
reached on coughing, the Valsalva leak point pressure (VLLP) is better controlled and
less variable over time and thus has been established as the standard procedure in GSI
patients.VLLP is a promising method of quantifying GSI. However, standardization of
methods and conditions, definition and significance of cut-off values for diagnosis
and for prediction of GSI is awaited.
11.3.5 Videourodynamics
Videourodynamics combines a routine urodynamic study with X-ray or ultrasound
imaging. Urodynamics is used for patients with complicated lower urinary tract disorders mostly due to a neurological condition.It may also offer more accurate diagnosis
in patients with GSI or mixed incontinence.It is recommended when the diagnosis remains unclear after simple urodynamic tests or when complicated pathology is expected from the history and symptoms.
In the assessment of GSI, it helps to simultaneously follow pressure measurements
of the bladder and the urethra at rest and during stress and to check for descent of the
bladder base, hypermobility and leakage in the filling phase. During the voiding phase,
the start of voiding, the phase of maximum pressure and flow and the end of voiding,
and postvoid residual bladder volume can be investigated.Moreover, anatomic abnormalities of the bladder contour and vesicoureteral reflux can be observed.
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11.3.6 Ambulatory Urodynamic Monitoring
Ambulatory urodynamic monitoring (AUM) is most commonly used as a second line
test. Signals from a portable state memory unit obtaining abdominal (vaginal) pressure,maximal urethral pressure and intravesical pressure are recorded and downloaded after measurement.Unstable detrusor contractions were found in 89% and 56% of
patients undergoing AUM, where urge incontinence and mixed incontinence, respectively, were expected from the medical history,bladder diary, and 24-h pad test.It is a
sensitive but not very specific way of detecting urinary leakage, and may be indicated
for patients with mixed incontinence symptoms, for those complaining of incontinence without objective evidence of leakage.
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11.4 Electromyography
Electromyography (EMG) of the urethral sphincter, the anal sphincter, or the pelvic
floor is another method for the diagnosis of lower urinary tract function. It serves to
detect normal or abnormal muscle behavior and represents an electrical correlate of
muscle pathology.EMG has limited value in routine urodynamic diagnostic work-up.
Therapeutic use of surface EMG may be advised in rehabilitation or biofeedback procedures to improve pelvic floor function.
Using single-fiber EMG studies in women with stress incontinence, evidence of
chronic denervation was shown, reflecting damage to peripheral branches of the pudendal nerve (Anderson 1984).
Various studies have shown that this reflex contraction and the ability to augment
closure pressure are lost with stress incontinence (Faysal et al.1981). Therefore, the anatomic defect predisposing to poor pressure transmission may place the urethra and
its surrounding muscles in a suboptimal position to affect adequate pressure augmentation.
11.5 Ultrasound
Bladder and postvoid residual volumes can be determined transabdominally, although accuracy is not reliable for volumes less than 50 ml (Orgaz et al. 1981). With
transabdominal ultrasound, the bladder is scanned in two perpendicular planes
(transverse and sagittal) and three diameters (height,width, and depth) are measured.
Height corresponds to the greatest superoinferior measurement; depth corresponds to
the greatest AP measurement. Both are obtained in sagittal plane scan. The simplest
formula used to estimate volume by abdominal ultrasound is bladder vol (ml) = (H ×
W × D) × (0.7).The correction factor 0.7 is needed because the shape of the bladder is
not circular until it is almost completely full.
Transabdominal ultrasound has also proven valuable in the evaluation of the urinary tract in neuromuscular bladder dysfunction and detrusor instability. Brandt and
others found that ultrasound of the bladder yielded significantly more diagnostic information than radiography in 27% of their study group. Brandt also demonstrated
bladder trabeculation as well as dilated ureters in neuromuscular dysfunction using
abdominal sonography (Brandt et al.1981).
11.5.1 Sonographic Urethrocystography
Numerous studies have demonstrated real-time ultrasonography to be useful in evaluating the anatomic relationship of the bladder,the urethrovesical junction (UVJ),and
the proximal urethra.With careful observation,the changes in the shape and position
of the vesical neck and the proximal urethra can be determined while the patient is
performing a Valsalva maneuver or coughing.
Chapter 11 Diagnostic Methods to Detect Female Urinary Incontinence
11.5.2 Perineal Ultrasound
Newer applications of sonography place the transducer on the perineum.Avoiding excessive pressure to the perineal region, this scanning technique does not alter anatomic relationships. However, its application in patients with severe genitourinary prolapse is limited.
Ultrasonic urethrocystography by perineal scanning for evaluation of female stress
urinary incontinence was suggested by Kohorn and others (1986). The procedure is
carried out with the patient in various positions (upright, supine) with legs slightly abducted to allow access of the transducer to the perineum. A linear-array or curved-array transducer scanner is positioned in a sagittal orientation to visualize the bladder,
bladder base, urethrovesical junction, and the pubic symphysis. Comparative results
between radiologic and perineal sonographic urethrocystography have been reported,
giving comparable and reproducible results (Koelbl et al. 1988; Gordon et al. 1989;
Schaer et al. 1995). Moreover, changes in bladder neck mobility in nulliparous continent women,during pelvic floor muscle contraction,before and after tension-free vaginal tape (TVT) surgery and Burch colposuspension have been published recently
(Schaer et al. 1996a; Peschers et al.2001; Miller et al. 2001; Atherton and Stanton 2000;
Martan et al. 2001).
A standardization of functional sonography was published by the German Association of Urogynecology in 1996, aiming at a common understanding and interpretation of pictures with high quality and reproducibility (Schaer et al.1996b). Among the
various sonographic techniques to perform urethrocystography, perineal and introital
ultrasound have been widely used and recommended as the most reliable techniques.
163
11.5.3 Introital Ultrasound
Regional distortion using vaginal or rectal endosonography, even with small endoprobes, was the reason for development of introital sonography (Koelbl and Bernaschek 1989). The technique involves placing a vaginal sector scanner to the vulva just
underneath the external urethral orifice, visualizing the bladder, urethrovesical junction, urethra and symphysis. Modern vaginal probes are thin and give good visualization of the lower urinary tract when placed only a short distance into the vagina. Thus,
this technique is devoid of any potential morphological artifact as a result of urethral
or bladder neck distortion. Successful colposuspension is found to be associated with
a urethrovesical location that is more anterior, although not necessarily more elevated.
In addition, overcorrection at anti-incontinence surgery causing postoperative micturition disorders can be visualized by ultrasound.A hypermobile urethra is easily seen
on ultrasound and according to this study may help to distinguish different causes for
GSI. Movement of the bladder and the urethra during real-time sonography indirectly
reflects pelvic floor action during both contraction and relaxation.Pelvic floor defects
indirectly can be visualized with both perineal and introital sonography.However,due
to the prolapse, the probes may alter lower urinary tract anatomy and give erroneous
results.First attempts to identify lesions of the attachments of the lateral vagina to the
tendineal arc of the levator ani,termed paravaginal defects, are promising.
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Heinz Koelbl, Gert Naumann
11.5.4 Intraurethral Ultrasound
Intraurethral ultrasound (IUUS) is a new endosonographic technique providing highresolution imaging (20 MHz) of the urethra and the surrounding tissues. This technique is recommended for the diagnosis of diverticula and urinary incontinence, since
other imaging methods provide only little information on the urethra and its sphincter.A correlation of urethral anatomy carried out by IUUS with functional urodynamic parameters revealed a decreased rhabdosphincter thickness in patients with GSI
and a linear relationship between maximal urethral closure pressure and rhabdosphincter and longitudinal smooth muscle thickness (Heit 2000).The meaning of these
findings in relation to urethral pressure measurements merits further evaluation,
since it could be helpful in the choice of treatment. Endoluminal ultrasound has also
been applied during surgical treatment of urethral diverticula (Chancellor et al. 1995).
11.5.5 Three-Dimensional Ultrasound
The three-dimensional (3D) reconstruction of ultrasound images has become a widespread option in ultrasound equipment since the early 1990s. Three-dimensional
ultrasound of the urethra also has become part of scientific interest. Athanasiou et al.
(1999) scanned women with urinary symptoms with a 5-MHz three-dimensional perineal ultrasound. All women with urethral sphincter incompetence had a continuous
hypoechoic area from the bladder neck to the urethral meatus. Some of the women
with severe GSI had breaks in the continuous circle of the rhabdosphincter and it was
replaced by hyperechoic areas. The authors think that these observations may indicate
damage to the urethral sphincter. Further studies are needed to confirm these observations and to elucidate the clinical implications of 3D ultrasound findings.Moreover,
similar results have been obtained with 3D ultrasound of the female urethra comparing transvaginal and transrectal scanning (Umek et al.2001).
11.6 Conclusion
Urinary incontinence,whether present in the elderly or young female, can have devastating effects on a patient’s self-esteem, psychological well-being, and overall physical
health.Awareness of the prevalence and scope of stress incontinence is of paramount
importance to gynecologists and other primary care physicians.
The primary components that prevent urinary stress incontinence in the female include an internal urethral sphincteric mechanism, an external urethral sphincter,and
proper anatomic support of the urethra and urethrovesical junction. Genuine stress
incontinence results primarily from a defect in pelvic support of the urethrovesical
junction resulting in impaired transmission of intra-abdominal pressure to the proximal urethra and urethrovesical junction. Secondary defects that may contribute to
stress incontinence include impaired function of the urethral sphincteric mechanism,
which produces low urethral pressures, and dysfunction of reflex contraction of the
pelvic floor, resulting in reduced augmentation of transmitted pressure. Individualized therapies directed towards these defects result in correction or improvement of
urodynamically measured parameters that correlate with stress incontinence.
Chapter 11 Diagnostic Methods to Detect Female Urinary Incontinence
Basic investigations are recommended in all patients with symptoms of GSI where
conservative therapy is the first choice of treatment.In patients with a complex history, mixed symptoms and previous anti-incontinence surgery must undergo a full
urogynecological assessment consisting of urodynamics and imaging analysis. Since
GSI may be of multifactorial origin, such as an intrinsic and/or extrinsic defect, only a
complex assessment will help to identify its cause and find the appropriate treatment.
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