Efficacy and perioperative safety of synthetic mid-urethral slings in obese women with stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Obesity is associated with an increased prevalence of female stress urinary incontinence (SUI). Mid-urethral polypropylene sling is considered the surgical gold standard for treatment of SUI. We reviewed the current literature on efficacy at 1 year (or more) and perioperative safety of synthetic mid-urethral sling procedures for SUI in obese women. METHODS: A systematic search of PubMed, Embase and the Cochrane databases was performed using the MeSH terms "Stress urinary incontinence", "Overweight", "Obesity" and "Surgery". We included 13 full-text papers published from January 1995 to May 2014. We defined two groups of women: non-obese (BMI below 30 kg/m(2)) and obese (BMI above 30 kg/m(2)). Data regarding subjective and objective cure and selected perioperative complications were pooled and compared. RESULTS: The pooled data from the 13 studies showed that 76.4% and 74.7% of non-obese and obese women, respectively, were subjectively cured (p = 0.70), and 83.3% and 79.2%, respectively, were objectively cured (p = 0.56). Bladder perforation was more frequently reported in non-obese women (p < 0.01). We did not detect a significant difference in postoperative urine retention or sling excision between the two groups (p = 0.36 and p = 0.17, respectively). CONCLUSIONS: Cure rates were found to be comparable in obese and non-obese women. Perioperative complications were not reported to occur more often in obese women. The outcomes of sling procedures for SUI appear to be comparable in obese and non-obese women, and counselling of obese women regarding outcomes and perioperative complications can be similar.

Anal acoustic reflectometry predicts the outcome of percutaneous nerve evaluation for faecal incontinence.

BACKGROUND: Sacral nerve stimulation (SNS) is effective for some patients with faecal incontinence. Before insertion of a costly implant, percutaneous nerve evaluation (PNE) is undertaken to identify patients likely to report success from SNS. The aim of this study was to determine whether variables of anal sphincter function measured by anal acoustic reflectometry (AAR) could predict the outcome of PNE for faecal incontinence. METHODS: Women with faecal incontinence undergoing PNE were recruited. AAR, followed by anal manometry, was performed on the day of surgery, immediately before PNE. The outcome of PNE was determined by bowel diary results and incontinence severity score. Patients with a successful PNE outcome were compared with those with an unsuccessful outcome; logistic regression analysis was used to identify any independent predictors of success. RESULTS: Fifty-two patients were recruited, of whom 32 (62 per cent) had a successful PNE outcome and 20 (38 per cent) an unsuccessful outcome. The AAR variable opening pressure was significantly greater in patients who subsequently had a successful PNE result compared with the pressure in patients who did not (28 versus 17 cmH2 O; P = 0·008). No difference was seen in the manometric equivalent, maximum resting pressure. Opening pressure was an independent predictor of success with an odds ratio of 1·08 (95 per cent confidence interval 1·01 to 1·16; P = 0·018). CONCLUSION: AAR is a sensitive test of sphincter function and can identify differences between patients who respond to PNE and those who do not. Opening pressure is an independent predictor of success in PNE, and may be of value in the selection of patients for this expensive treatment option.

Tissue engineering as a potential alternative or adjunct to surgical reconstruction in treating pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: Cell-based tissue engineering strategies could potentially provide attractive alternatives to surgical reconstruction of native tissue or the use of surgical implants in treating pelvic organ prolapse (POP). METHODS: Based on a search in PubMed, this review focuses on candidate cell types, scaffolds, and trophic factors used in studies examining cell-based tissue engineering strategies to treat POP, stress urinary incontinence (SUI), and the closely related field of hernias. RESULTS: In contrast to the field of SUI, the use of cell-based tissue engineering strategies to treat POP are very sparsely explored, and only preclinical studies exist. CONCLUSION: The available evidence suggests that the use of autologous muscle-derived cells, fibroblasts, or mesenchymal stem cells seeded on biocompatible, degradable, and potentially growth-promoting scaffolds could be an alternative to surgical reconstruction of native tissue or the use of conventional implants in treating POP. However, the vagina is a complex organ with great demands of functionality, and the perfect match of scaffold, cell, and trophic factor has yet to be found and tested in preclinical studies. Important issues such as safety and economy must also be addressed before this approach is ready for clinical studies.

Comparative study of anal acoustic reflectometry and anal manometry in the assessment of faecal incontinence.

BACKGROUND: Anal acoustic reflectometry (AAR) is a reproducible technique providing a novel physiological assessment of anal sphincter function. It may have advantages over conventional anal manometry. The aims of this study were to determine the ability of AAR and anal manometry to identify changes in anal sphincter function in patients with faecal incontinence (FI) and to relate these changes to the severity of FI. METHODS: Women with FI underwent assessment with AAR and anal manometry. All patients completed the Vaizey FI questionnaire and were classified according to symptom type (urge, passive or mixed) and integrity of the anal sphincters. The ability of AAR and anal manometry to correlate with symptom severity was evaluated. AAR was compared with anal manometry in detecting differences in anal sphincter function between symptomatic subgroups, and patients with and without a sphincter defect. RESULTS: One hundred women with FI were included in the study. The AAR variables opening pressure, opening elastance, closing elastance and squeeze opening pressure correlated with symptom severity, whereas the manometric measurements maximum resting pressure and maximum squeeze pressure did not. Unlike anal manometry, AAR was able to detect differences in anal sphincter function between different symptomatic subgroups. [corrected]. An anal sphincter defect was not associated with a significant change in anal sphincter function determined by either AAR or anal manometry. CONCLUSION: In the assessment of women with FI, AAR variables correlated with symptom severity and could distinguish between different symptomatic subgroups. AAR may help to guide management in these patients.

Anal acoustic reflectometry: a new technique for assessing anal sphincter function.

OBJECTIVE: Anal acoustic reflectometry (AAR) is a new technique that offers an assessment of anal sphincter function by the measurement of additional parameters not available with conventional manometry. The aim of this study is to describe the technique, methodology and initial pilot study results. METHOD: Wideband sounds (100 Hz to 16 kHz) are transmitted into a thin polyurethane bag placed within the anal canal. Calculation of cross-sectional area from reflected sound waves, over a range of pressures (0-200 cm H(2)O) during inflation/deflation of the bag, results in five physiological parameters of anal canal function. Five patients [three continent (two female) and two incontinent (both female)] were assessed with AAR and anal manometry. RESULTS: Anal acoustic reflectometry parameters were reduced in incontinent when compared with continent patients. Resting Opening Pressures (cmH(2)O) were 27 and 16 in patients with faecal incontinence (FI) vs 44 and 72 in continent patients; Resting Opening Elastance (cmH(2)O/mm(2)) was 0.88 and 1.08 in FI patients vs 1.65 and 1.34 in continent patients. The Resting Opening Pressure of a similarly aged continent male (55 cmH(2)O) was greater than three of the females. During assessment of voluntary contraction (one FI female vs one continent female), Squeeze Opening Pressure (cmH(2)O) was 31 vs 100 and Elastance (cmH(2)O/mm(2)) 0.61 vs 2.07. CONCLUSION: Anal acoustic reflectometry appears to be promising technique. Further work is in place to clarify whether it will be useful in clinical assessment of incontinent patients.

Measurement of urethral closure function in women with stress urinary incontinence.

PURPOSE: We assessed the use of urethral pressure reflectometry in detecting pressure increases in the female urethra and compared the usefulness of urethral pressure reflectometry vs urethral pressure profilometry in a pharmacodynamic intervention study. MATERIALS AND METHODS: In this randomized, double-blind, placebo controlled, crossover study 17 women with stress urinary incontinence or mixed urinary incontinence received 4 mg esreboxetine or placebo for 7 to 9 days followed by a washout period before crossing over treatments. Urethral pressure reflectometry and urethral pressure profilometry were performed before and at the end of each treatment period. RESULTS: The urethral opening pressure measured with urethral pressure reflectometry increased significantly compared to placebo by 13.7 cm H(2)O (p <0.0001) with an observed within subject standard deviation of 5.4. The increase in maximum urethral closure pressure was 8.4 cm H(2)O compared to placebo (p = 0.06) and for maximum urethral pressure the increase was 9.9 cm H(2)O (p = 0.04). However, the within subject SD for these parameters was higher at 11.4 and 12.2, respectively, implying lower power for these analyses. While receiving esreboxetine patients had significantly fewer incontinence episodes and reported a treatment benefit (global impression of change) compared to placebo. CONCLUSIONS: The opening pressure measured with urethral pressure reflectometry was less variable compared to the parameters measured with urethral pressure profilometry (maximum urethral closure pressure and maximum urethral pressure). Consequently using urethral pressure reflectometry would result in a more efficient study design when investigating pharmacological effects on the urethra in future studies. We also found that esreboxetine was well tolerated, and had a positive and clinically relevant effect on urethral closure function and symptoms of stress urinary incontinence.

Prevalence of endometrial polyps and abnormal uterine bleeding in a Danish population aged 20-74 years.

OBJECTIVE: To estimate the prevalence of endometrial polyps and to investigate associated abnormal uterine bleeding in a Danish population aged 20-74 years. METHODS: This was a study of a random selection of women from the Danish Civil Registration System: 1660 women were invited of whom 686 were included (429 pre- and 257 postmenopausal). AUB was assessed by a validated questionnaire. The women underwent transvaginal sonography (TVS) and saline contrast sonohysterography (SCSH). Hysteroscopic resection was performed in cases with suspected focal intrauterine pathology. Full evaluation was performed in 619 women (two failures of TVS and 60 failures of SCSH, in two women SCSH was contraindicated (endometrial cancer), in two women hysteroscopy was contraindicated, and one polyp was lost before histology). World Health Organization histopathological criteria were used for diagnosing true endometrial polyps. RESULTS: On final diagnosis there were 48 women with polyps, eight with submucosal myomas, four with other benign findings and one with polypoidal growing endometrial cancer. Complex hyperplasia without atypia was diagnosed in two women with polyps. The prevalence of endometrial polyps was 7.8% (48/619; 95% CI, 5.6-9.9%). The prevalence was influenced significantly by age (P<0.005); in women below the age of 30 years, the prevalence was 0.9%. Polyps were diagnosed in 5.8% of pre- and 11.8% of postmenopausal women (P<0.01). Thirty-nine (82%) of the women who had histopathologically verified polyps were asymptomatic. In asymptomatic premenopausal women the prevalence of polyps was 7.6%, while it was 13% in asymptomatic postmenopausal women. AUB, in particular intermenstrual bleeding, was more frequent among women without polyps (38%). By ultrasound examination, submucosal myomas were diagnosed in 4.2% (26/622; 95% CI, 2.6-5.8%) and intramural myomas in 11.1% (76/684; 95% CI, 8.8-13.5%) of women. Polyps were diagnosed in 2% of oral-contraceptive and 25% of hormone-therapy users. CONCLUSIONS: The overall prevalence of endometrial polyps was 7.8% and the prevalence increased with age. Polyps were rare (0.9%) in women below the age of 30 years. Surprisingly, AUB was less frequent among women with polyps than among those without polyps.

Value of endometrial thickness measurement for diagnosing focal intrauterine pathology in women without abnormal uterine bleeding.

OBJECTIVE: To assess the diagnostic value of transvaginal sonographic (TVS) measurement of endometrial thickness for diagnosing focal intrauterine pathology in women without abnormal uterine bleeding (AUB). METHODS: A random selection from the Danish Civil Registration System was made: 1660 women aged 20-74 years were invited to participate and 686 women were eligible and accepted inclusion (429 pre- and 257 postmenopausal). The women underwent TVS measurement of endometrial thickness and saline contrast sonohysterography (SCSH). Hysteroscopic resection with histopathology (gold standard) was performed when focal intrauterine pathology was suspected at SCSH. We excluded women with AUB (n = 237), failure of SCSH (n = 50), a scan that was not in the follicular phase (n = 11), hysteroscopy contraindicated (n = 2), and users of sequential hormone therapy (n = 9) or selective estrogen receptor modulators (n = 2). Thus, 375 women without AUB were included (217 pre- and 158 postmenopausal). Receiver-operating characteristics (ROC) curves for endometrial thickness and focal lesion were analyzed. RESULTS: Focal intrauterine pathology was confirmed in 41 women (35 with polyps, five with submucosal myomas and one with polypoidal growing cancer). For premenopausal women, the area under the ROC curve (AUC) was 0.79 (95% CI, 0.68-0.89) and for postmenopausal women it was 0.84 (95% CI, 0.76-0.92). For premenopausal women, the best negative likelihood ratio (LR- = 0.11) was obtained at an endometrial thickness of 5.2 mm, with a negative predictive value (NPV) of 99% and a positive predictive value (PPV) of 10%. For postmenopausal women the best LR- (0.08) was obtained at an endometrial thickness of 2.8 mm, with a NPV of 99% and a PPV of 26%. CONCLUSIONS: In women without AUB, TVS measurement of endometrial thickness is a poor diagnostic test, but is apparently efficacious in excluding focal intrauterine pathology, especially in postmenopausal women. The 4-5-mm threshold conventionally used to exclude endometrial malignancy in women with postmenopausal bleeding is not transferable to women without AUB for excluding focal intrauterine pathology.

Pregabalin and dexamethasone in combination with paracetamol for postoperative pain control after abdominal hysterectomy. A randomized clinical trial.

BACKGROUND: Multimodal analgesia may be important for optimal postoperative pain treatment and facilitation of early mobilization and recovery. We investigated the analgesic effect of pregabalin and dexamethasone in combination with paracetamol after abdominal hysterectomy. METHODS: One hundred and sixteen patients were randomly assigned to either group A (paracetamol+placebo x 2), group B (paracetamol+pregabalin+placebo) or group C (paracetamol+pregabalin+dexamethasone). According to randomization and preoperatively, patients received paracetamol 1000 mg, pregabalin 300 mg, dexamethasone 8 mg or placebo. General anaesthesia was performed. Postoperative pain treatment was paracetamol 1000 mg x 4 and patient-controlled intravenous morphine, 2.5 mg bolus. Nausea was treated with ondansetron. Morphine consumption, pain score (visual analogue scale) at rest and during mobilization, nausea, sedation, dizziness, number of vomits and consumption of ondansetron were recorded 2, 4 and 24 h after the operation. P<0.05 was considered statistically significant. RESULTS: The 24-h morphine consumption and pain score, both at rest and during mobilization, were not significantly different between treatment groups. The mean nausea score (P=0.002) was reduced in group C vs. A. The number of vomits was significantly reduced in both group B (P=0.041) and C (P=0.001) vs. A. Consumption of ondansetron was reduced in group C vs. A and B (P<0.001). Other side effects were not different between groups. CONCLUSION: Combinations of paracetamol and pregabalin, or paracetamol, pregabalin and dexamethasone did not reduce morphine consumption and pain score compared with paracetamol alone for patients undergoing abdominal hysterectomy. Dexamethasone reduced nausea, vomiting and use of ondansetron.

Surgical options in the treatment of stress urinary incontinence in women.

The aim of this review is to provide an update on the surgical options for treatment of stress incontinence in women. The efficiency of different procedures and the safety associated with each procedure are evaluated, mainly by reviewing the randomised controlled trials. The open retropubic colposuspension and the sling procedures are the most efficacious for treatment stress urinary incontinence especially in the long term. The laparoscopic colposuspension may be as good as the open colposuspension, but the long-term performance remains uncertain. The newer minimal access vaginal sling procedures appear to offer benefits of minimal access surgery with success rate similar to the colposuspension and the traditional slings and minor morbidity in the short and median-term. However long term data is still awaited. The transobturator technique does not seem to provide advantages compared to the classical TVT procedure. Urethral injection therapy does not seem to have the same efficacy as conventional surgery and long term data is still scanty. However, because of low operative morbidity it represents a favourable alternative to standard surgery in patients who prefer less invasive treatment, the frail elderly and other selected women where conventional surgery is problematic.

The effect of bilateral pudendal blockade on the static urethral closure function in healthy females.

OBJECTIVE: To evaluate the effect of bilateral pudendal blockade on the urethral closure function in the resting state in healthy women. METHODS: Synchronous measurements of pressure and cross-sectional area were recorded at the bladder neck, in the high-pressure zone, and in the distal urethra before and after the pudendal blockade in ten women. RESULTS: The blockade reduced the resting pressure significantly (P < .01) all along the urethra. The viscoelastic indices of elastance (reciprocal of compliance) and hysteresis (difference in pressure at a given degree of urethral dilation when this is increased and decreased stepwise) were significantly (P < .05) reduced. CONCLUSIONS: The striated muscles innervated by the pudendal nerve are of paramount importance for the closure function in the resting state all along the urethra. Urethral elastance and hysteresis seem to depend on activity in the surrounding striated muscle fibers.

Epidural anesthesia during labor and stress incontinence after delivery.

OBJECTIVE: To test the hypothesis that epidural anesthesia during labor prevents the development of stress incontinence after vaginal birth. METHODS: We interviewed 208 primiparas about stress incontinence 3 months postpartum. The women who developed stress incontinence after delivery were interviewed again 1 year postpartum. RESULTS: Twelve of 45 women (27%) who had epidural anesthesia developed stress incontinence de novo after vaginal delivery, versus 21 of 163 (13%) who did not receive epidural anesthesia, a marginally significant difference (P = .05). Those who had epidural anesthesia also had a significantly longer first stage of labor. One year after delivery, three of 42 (7%) in the epidural anesthesia group had stress incontinence, compared with five of 163 (3%) in the control group. CONCLUSION: Our results do not support the hypothesis that epidural anesthesia protects against the development of stress incontinence after vaginal delivery.

One-hour pad-weighing test for objective assessment of female urinary incontinence.

In a 16-month period the one-hour pad-weighing test proposed by the International Continence Society was used in 126 instances for objective assessment of the degree of incontinence in 81 women with urinary incontinence. The present study deals with applicability of the test, patient compliance, reproducibility of the test, and comparison of test results with conventional methods for objective assessment of urinary incontinence. In spite of a rather high mean age (55 years), 73 patients (88%) were able to perform the entire test program. In 85 tests (68%) the patients indicated the result to be in accordance with the daily leakage. The reproducibility of the test was relatively good (r = 0.68; P less than .01), but significantly better (r = 0.93; P less than .0001) when taking into consideration the bladder volume at test start and the diuresis during the test. When compared with the pad-weighing test, the stress test and voiding-cystourethrography gave false negative results in approximately half the cases. The one-hour pad-weighing test was found to be practical and useful in quantifying the degree of leakage in women with urinary incontinence.

The symptom of stress incontinence caused by pregnancy or delivery in primiparas.

Three hundred five primiparas were interviewed repeatedly about stress incontinence before and during pregnancy and after delivery. Eleven (4%) had stress incontinence before pregnancy and 98 (32%) during pregnancy, whereas 21 (7%) developed it after delivery. According to the International Continence Society definition, the corresponding frequencies were one (0.3%), three (1%), and one (0.3%), respectively. Obstetric factors such as length of the second stage of labor, head circumference, birth weight, and episiotomy seemed to be associated with, whereas cesarean delivery seemed to protect against, the development of stress incontinence after delivery. Three months after delivery, the statistically significant influence of the obstetric factors had vanished, as stress incontinence had disappeared in most women. However, 1 year after delivery eight of 292 women (3%) had stress incontinence, three with onset during pregnancy and five with onset after delivery. Three of these eight had stress incontinence according to International Continence Society criteria; four women wanted treatment. The symptom of stress incontinence occurs as a natural consequence of pregnancy and delivery and generally resolves in the puerperium. However, pregnancy and delivery carry a small risk (1% or less) of initiating persistent stress incontinence. The importance of various obstetric factors seems transient and their etiologic role remains unclear.

Risk factors for lower urinary tract symptoms in women 40 to 60 years of age.

OBJECTIVE: To determine the relationship between lower urinary tract symptoms and possible associated risk factors in women 40-60 years old. METHODS: In a normal population study, 502 women with lower urinary tract symptoms and 742 women with no symptoms (controls) were asked about possible associated factors. RESULTS: Four hundred eighty-seven women (97.0%) with symptoms and 564 controls (76.0%) completed the study. Stress incontinence was associated with parity (primipara odds ratio [OR] 2.2, 95% confidence interval [CI] 1.0, 4. 9; para 2 OR 3.9, 95% CI 1.9, 8.0; para 3 OR 4.5, 95% CI 2.1, 9.5), use of diuretics (OR 2.2, 95% CI 1.2, 3.9), hysterectomy (OR 2.4, 95% CI 1.6, 3.7), and increased body mass index (BMI). Urge incontinence was associated with use of diuretics (OR 4.0, 95% CI 2. 2, 7.1) and BMI. Urgency was associated with parity (primipara OR 1. 9, 95% CI 0.9, 4.2; para 2 OR 3.0, 95% CI 1.5, 5.9; para 3 OR 3.1, 95% CI 1.5, 6.5), use of diuretics (OR 2.7, 95% CI 1.5, 4.7) and BMI. Associations between non-incontinence symptoms (except urgency) and observed factors were weak and inconsistent. Straining at stool and constipation were inversely associated with lower urinary tract symptoms. Overall, lesion of sphincter ani, episiotomy, fetal weight, physical activity, and hormonal status had minor association with lower urinary tract symptoms. CONCLUSION: Lower urinary tract symptoms were associated positively with parity, BMI, prior hysterectomy, use of diuretics, straining at stool, and constipation.

Effect of a vaginal device on quality of life with urinary stress incontinence.

OBJECTIVE: To assess the effect of a vaginal device (Continence Guard) on urine leakage and quality of life. METHODS: Fifty-five women with stress incontinence participated in a 3-month study. They were assessed by the Incontinence Impact Questionnaire, two incontinence-related quality-of-life questions, a generic quality-of-life questionnaire (Short Form-36), two 24-hour home pad weighing tests, a 2-day voiding diary, uroflowmetry, urine cultures, and a questionnaire about subjective effectiveness of the device. RESULTS: Forty-one (74.5%) women completed the study. Estimated on an intent-to-treat basis, the vaginal device was associated with subjective cure in 11 women (20%) and improvement in 27 (49%). The mean 24-hour pad test leakage and leakage episodes in the voiding diary decreased significantly. Fifty-eight percent of the 55 women enrolled wanted to continue using the device after 3 months. The quality of life measured by the Incontinence Impact Questionnaire showed highly significant improvement, and the results of the two incontinence-related quality of life questions also showed significant improvement. Responses to the Short Form-36 general health questionnaire showed no significant changes. Improvement on the Incontinence Impact Questionnaire correlated with improvements in incontinence, whereas the Short Form-36 scores were unchanged. CONCLUSION: Treatment with the Continence Guard significantly decreases leakage and improves quality of life in women with symptoms of urinary stress incontinence. An incontinence-specific, rather than a generic, quality-of-life questionnaire was important in assessing treatment outcomes.

Voiding difficulties after colposuspension.

To study subjective and objective changes of micturition after colposuspension, 80 patients were evaluated before and after surgery. It was found that colposuspension may introduce an element of urethral obstruction, which leads to a significant proportion of immediate as well as late voiding difficulties. Thus, 25% of the patients developed severe voiding difficulties in the immediate postoperative course. Low pressure voiding (Pdet less than 15 cm water) preoperatively was found to predispose significantly to immediate postoperative voiding difficulties. Another 20% developed late voiding difficulties. Increased urethral resistance preoperatively was found to predispose significantly to late postoperative voiding difficulties. Increased urethral rigidity is suggested as an underlying factor. Only four (5%) of the patients developed both immediate and late postoperative voiding difficulties. The detrusor pressure at maximum flow was found to be an unreliable parameter in assessing the true potential of the detrusor. It is emphasized that a thorough preoperative evaluation of both bladder and urethral function and the use of a proper surgical technique are required to avoid voiding difficulties after colposuspension.

Pressure response to rapid dilation of resting urethra in healthy women.

Rapid urethral dilations were performed by a balloon mounted on a double-tip transducer catheter for simultaneous measurement of pressure in urethra and bladder. The cross sectional area of the urethra was measured according to the field gradient principle. Pressure and cross sectional area were recorded synchronously. The response of the female urethra to rapid dilation is a typical stress relaxation effect with a pressure peak followed by a pressure decay over a few seconds. The peak pressure response represents the bladder pressure required in producing a corresponding urethral dilation by the ingression of urine. The increase in pressure response was statistically significant by increasing rate as well as size of dilation. The method enables experimental simulation of stress urinary incontinence in vivo which may bring further insight into the physiology of the urethral closure function and the pathophysiology of stress incontinence. For comparative studies rapid dilation should be performed under standardized circumstances.

Spontaneous versus intubated flow in male patients.

The spontaneous flow rate was compared with the flow rate obtained during a pressure-flow study with two 5F catheters in the urethra, in 57 male patients with various lower urinary tract disorders. Intubation caused a median decrease in maximum flow rate of 1 mL/sec (95% confidence limits 0-2 mL/sec). In patients with infravesical obstruction a significant decrease in maximum and mean flow rates was found whereas the flow rate was unchanged in the group of patients without obstruction. It seems that changes in flow rate due to intubation of the urethra is of minor importance compared with other factors and intubation may actually provide diagnostic information in diagnosing mechanical obstruction. It is concluded that the transurethral technique for pressure-flow studies offers a simple and reliable method for obtaining simultaneous pressure-flow values. It can be performed without further invasion in conjunction with cystometry. Therefore this technique is recommended in the urodynamic testing of male patients with lower urinary tract disorders.