Lax Uterosacral Ligament and Urge Urinary Incontinence: MRI Findings in Symptomatic Patients Versus Healthy Volunteers.

INTRODUCTION AND HYPOTHESIS: The objective was to explore the association between urge urinary incontinence (UUI) and lax uterosacral ligaments (USL) using MRI. METHODS: Sixty-seven female participants were recruited prospectively: 41 continent volunteers (control group) and 26 patients with UUI. Static proton density- and T2-weighted turbo spin echo sequences of MR images were used. A radiologist employed a standardized grid system to record structural observations of the USLs on sequentially numbered axial MR images and then applied a four-point grading scale to assess ligament visibility. MR images were interpreted by a radiologist and a urologist, and then validated by an expert radiologist. RESULTS: The comparison between the mean length of uterosacral ligaments in the control and UUI groups was highly statistically significant (p < 0.001). The mean length of the right USL was 38 ± 11 mm, and the left USL was 35 ± 12 mm in the UUI group. In the control group, the mean length of the USL was 22 ± 9 mm on the right side and 18 ± 9 mm on the left side, along their craniocaudal extent. The highest inter-observer agreement was on the level of origin and insertion (image numbers), whereas the lowest agreement was on the anatomical site of origin and insertion of the USL in both the control and UUI groups. CONCLUSIONS: The average length of USLs in patients with UUI is significantly longer than that in healthy continent women, indicating laxity. Our findings support the relationship between the laxity of the USL and UUI symptoms and have therapeutic implications.

Characterizing the cortical pathways underlying visual trigger induced urinary urgency incontinence by functional MRI.

AIMS: Visual triggers have long been recognized clinically to stimulate urgency urinary incontinence (UUI). Current pathophysiology recognizes the importance of cortical control over micturition but there is no standardized methodology for clinicians to study the impact of visual triggers. Our aim was to develop an imaging protocol able to characterize the brain's response to personalized visual triggers, providing a methodology for evaluation on connectivity within the brain in patients with visually triggered urinary urgency. METHODS: A magnetic resonance imaging (MRI) methodology specific for urologic use was developed. A 3T-Elition Scanner was first used to acquire static structural images. These images were then used to define approximately 200 brain regions of interest (ROI) using a validated brain atlas. Then, real-time functional MRI (fMRI) scans were conducted during natural bladder filling, where study subjects were shown randomized block sequences of visual stimuli comprised of both subject-specific trigger images and neutral images. The fMRI scan data were merged to identify key ROI underlying UUI. RESULTS: Dynamic fMRI scans were conducted in 10 subjects, 4 with trigger-induced UUI, 2 with trigger-induced urgency, and 4 with no urgency or leakage to visual triggers. No subjects with UUI history lost continence during imaging, but all four subjects reported sensations of urgency in response to their own subject-specific trigger images. The ROI identified were the periaqueductal gray, anterior cingulate gyrus, pons, and prefrontal cortex. We found increased activity in the prefrontal cortex and limbic system ROI in response to subject-specific visual triggers of UUI. CONCLUSIONS: This information provides proof of principle for further exploration of subject-specific trigger image evaluation using fMRI to explore causation in patients with UUI.

Do brain structural abnormalities differentiate separate forms of urgency urinary incontinence?

AIMS: 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. METHODS: Secondary study of a trial of biofeedback-assisted pelvic floor muscle training (BFB) in 60 women (>60 yrs) with UUI, plus 11 age-matched continent controls. Brain structural abnormalities were investigated using: (1) white-matter hyperintensities (WMH); (2) diffusion tensor imaging (DTI) to reveal white-matter pathways with impaired integrity; and (3) voxel-based morphometry (VBM) to show regions of atrophy or hypertrophy. RESULTS: WMH burden was greater in UUI patients than controls (globally and in superior longitudinal fasciculus and cingulum), suggesting a possible causal connection. WMH burden was unexpectedly greater in responders than non-responders to BFB, and appeared to increase in non-responders but not in responders. DTI revealed even worse integrity of the cingulum than was apparent by WMH. VBM showed parahippocampal atrophy in UUI. CONCLUSIONS: Many women with UUI have white-matter damage that interferes with pathways critical to bladder control; they can be taught by techniques like BFB to exert stronger control over the bladder. For others, in whom abnormalities of key brain areas are less marked, UUI's cause may reside elsewhere, and therapy targeting these brain centers may be less effective than therapy targeting the bladder or other brain centers.

Rentabilidad diagnóstica de la resonancia magnética lumbosacra solicitada desde las consultas de urología pediátrica / Diagnostic yield of lumbosacral magnetic resonance imaging requested by paediatric urology consultations

Objetivos: En series históricas, la rentabilidad diagnóstica de la resonancia magnética lumbosacra para descartar disrafismo espinal oculto (o mielodisplasia oculta), solicitada desde urología pediátrica oscila entre el 2 y 15%. El objetivo del estudio es definir nuestra rentabilidad en niños con síntomas miccionales, y definir variables que aumenten la posibilidad de encontrar disrafismo espinal oculto. Pacientes y métodos: Selección de pacientes con disfunciones miccionales a los que se solicitó resonancia magnética desde las consultas de urología pediátrica, por persistencia de síntomas tras tratamiento, disfunción de vaciado, o por otros hallazgos clínicos o urodinámicos. Se analizaron variables clínicas (ITU, fugas diurnas, enuresis, disfunción de vaciado, urgencia, ecografía renal, radiografía lumbosacra, antecedentes de retención aguda de orina, estigmas cutáneos, mialgias) y urodinámicas (hiperactividad o arreflexia, micción disfuncional, patrón interrumpido, valor de acomodación y flujo máximo). Análisis univariante con SPSS 20.0 Resultados: Analizamos a 21 pacientes en el periodo 2011-2015. Mediana de edad: 6 años (3-10). Tres pacientes (14,3%) presentaron disrafismo espinal oculto: un lipoma raquídeo, un filum lipomatoso y un síndrome de regresión caudal con estenosis de canal. Las variables con diferencia estadísticamente significativa fueron las mialgias y el antecedente de retención aguda de orina (66,7 vs. 5,6%; p = 0,04; OR = 34; IC95%: 1,5-781 para ambas variables). Conclusiones: La rentabilidad diagnóstica de la resonancia magnética solicitada a niños con disfunciones miccionales sin estigmas cutáneos ni alteraciones neuroortopédicas es baja, aunque no desdeñable. En este grupo, los pacientes con antecedentes de retención aguda de orina y/dolor muscular (dolor, «calambres») pueden presentar una rentabilidad diagnóstica o valor predictivo positivo mayor

Objectives: In the historical series, the diagnostic yield of lumbosacral magnetic resonance imaging to rule out occult spinal dysraphism (or occult myelodysplasia), requested by paediatric urology, ranged from 2% to 15%. The aim of this study was to define our cost-effectiveness in children with urinary symptoms and to define endpoints that increase the possibility of finding occult spinal dysraphism. Patients and methods: A screening was conducted on patients with urinary dysfunction for whom an magnetic resonance imaging was requested by the paediatric urology clinic, for persistent symptoms after treatment, voiding dysfunction or other clinical or urodynamic findings. We analysed clinical (UTI, daytime leaks, enuresis, voiding dysfunction, urgency, renal ultrasonography, lumbosacral radiography, history of acute urine retention, skin stigma and myalgia) and urodynamic endpoints (hyperactivity or areflexia, voiding dysfunction, interrupted pattern, accommodation value and maximum flow). A univariate analysis was conducted with SPSS 20.0. Results: We analysed 21 patients during the period 2011-2015. The median age was 6 years (3-10). Three patients (14.3%) had occult spinal dysraphism: one spinal lipoma, one filum lipomatosus and one caudal regression syndrome with channel stenosis. The endpoints with statistically significant differences were the myalgias and the history of acute urine retention (66.7% vs. 5.6%, P = .04; OR = 34; 95%CI: 1.5-781 for both endpoints). Conclusions: The diagnostic yield of magnetic resonance imaging requested for children with urinary dysfunctions without skin stigma or neuro-orthopaedic abnormalities is low, although nonnegligible. In this group, the patients with a history of acute urine retention and muscle pain (pain, «cramps») can experience a greater diagnostic yield or positive predictive value

Quantitative Changes in Cerebral Perfusion during Urinary Urgency in Women with Overactive Bladder.

PURPOSE: To quantitatively measure changes in cerebral perfusion in select regions of interest in the brain during urinary urgency in women with overactive bladder (OAB) using arterial spin labeling (ASL). METHODS: Twelve women with OAB and 10 controls underwent bladder filling and rated urinary urgency (scale 0-10). ASL fMRI scans were performed (1) in the low urgency state after voiding and (2) high urgency state after drinking oral fluids. Absolute regional cerebral blood flow (rCBF) in select regions of interest was compared between the low and high urgency states. RESULTS: There were no significant differences in rCBF between the low and high urgency states in the control group. In the OAB group, rCBF (mean ± SE, ml/100 g/min) increased by 10-14% from the low to the high urgency state in the right anterior cingulate cortex (ACC) (44.56 ± 0.59 versus 49.52 ± 1.49, p < 0.05), left ACC (49.29 ± 0.85 versus 54.02 ± 1.46, p < 0.05), and left insula (50.46 ± 1.72 versus 54.99 ± 1.09, p < 0.05). Whole-brain analysis identified additional areas of activation in the right insula, right dorsolateral prefrontal cortex, and pons/midbrain area. CONCLUSIONS: Urinary urgency is associated with quantitative increase in cerebral perfusion in regions of the brain associated with processing emotional response to discomfort.

Urgency urinary incontinence and the interoceptive network: a functional magnetic resonance imaging study.

BACKGROUND: Treatment of urgency urinary incontinence has focused on pharmacologically treating detrusor overactivity. Recent recognition that altered perception of internal stimuli (interoception) plays a role in urgency urinary incontinence suggests that exploration of abnormalities of brain function in this disorder could lead to better understanding of urgency incontinence and its treatment. OBJECTIVE: We sought to: (1) evaluate the relationship between bladder filling, perceived urgency, and activation at brain sites within the interoceptive network in urgency urinary incontinence; (2) identify coactivation of other brain networks that could affect interoception during bladder filling in urgency incontinence; and (3) demonstrate interaction between these sites prior to bladder filling by evaluating their resting-state connectivity. STUDY DESIGN: We performed an observational cohort study using functional magnetic resonance imaging to compare brain function in 53 women with urgency urinary incontinence and 20 controls. Whole-brain voxelwise analyses of covariance were performed to examine differences in functional brain activation between groups during a task consisting of bladder filling, hold (static volume), and withdrawal phases. The task was performed at 3 previously established levels of baseline bladder volume, the highest exceeding strong desire to void volume. All women continuously rated their urge on a 0- to 10-point Likert scale throughout the task and a mixed measures analysis of variance was used to test for differences in urge ratings. Empirically derived regions of interest from analysis of activation during the task were used as seeds for examining group differences in resting-state functional connectivity. RESULTS: In both urgency urinary incontinent participants and controls, changes in urge ratings were greatest during bladder filling initiated from a high baseline bladder volume and urgency incontinent participants' rating changes were greater than controls. During this bladder-filling phase urgency incontinent participant's activation of the interoceptive network was greater than controls, including in the left insula and the anterior and middle cingulate cortex. Urgency incontinent participant's activation was also greater than controls at sites in the ventral attention network and posterior default mode network. Urgency incontinent participant's connectivity was greater than controls between a middle cingulate seed point and the dorsal attention network, a "top-down" attentional network. Control connectivity was greater between the midcingulate seed point and the ventral attention network, a "bottom-up" attentional network. CONCLUSION: Increasing urge was associated with greater urgency incontinent participant than control activation of the interoceptive network and activation in networks that are determinants of self-awareness (default mode network) and of response to unexpected external stimuli (ventral attention network). Differences in connectivity between interoceptive networks and opposing attentional networks (ventral attention network vs dorsal attention network) were present even before bladder filling (in the resting state). These findings are strong evidence for a central nervous system component of urgency urinary incontinence that could be mediated by brain-directed therapies.

Differences in pelvic floor morphology between continent, stress urinary incontinent, and mixed urinary incontinent elderly women: An MRI study.

AIMS: To compare magnetic resonance imaging (MRI) of the pelvic floor musculature (PFM), bladder neck and urethral sphincter morphology under three conditions (rest, PFM maximal voluntary contraction (MVC), and straining) in older women with symptoms of stress (SUI) or mixed urinary incontinence (MUI) or without incontinence. METHODS: This 2008-2012 exploratory observational cohort study was conducted with community-dwelling women aged 60 and over. Sixty six women (22 per group), mean age of 67.7 ± 5.2 years, participated in the study. A 3 T MRI examination was conducted under three conditions: rest, PFM MVC, and straining. ANOVA or Kruskal-Wallis tests (data not normally distributed) were conducted, with Bonferroni correction, to compare anatomical measurements between groups. RESULTS: Women with MUI symptoms had a lower PFM resting position (M-Line P = 0.010 and PC/H-line angle P = 0.026) and lower pelvic organ support (urethrovesical junction height P = 0.013) than both continent and SUI women. Women with SUI symptoms were more likely to exhibit bladder neck funneling and a larger posterior urethrovesical angle at rest than both continent and MUI women (P = 0.026 and P = 0.008, respectively). There were no significant differences between groups on PFM MVC or straining. CONCLUSIONS: Women with SUI and MUI symptoms present different morphological defects at rest. These observations emphasize the need to tailor UI interventions to specific pelvic floor defects and UI type in older women. PATIENT SUMMARY: Older women with UI demonstrate different problems with their pelvic organ support structures depending on the type of UI. These new findings should be taken into consideration for future research into developing new treatment strategies for UI in older women. Neurourol. Urodynam. 35:515-521, 2016. © 2015 Wiley Periodicals, Inc.

The "bother" of urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Patient reported measures are important for the evaluation of symptom-specific bother and the distinction between different types of urinary incontinence. The aim of the study was to assess the validity of physician administered visual analogue scales (VAS) for the bother from stress urinary incontinence (SUI) and urge urinary incontinence (UUI). METHODS: In this prospective cohort study based at a tertiary urogynecological unit, women attending for investigation of lower urinary tract symptoms (n = 504) were asked to indicate their subjective bother from SUI and UUI on a 10-cm VAS. Clinical assessment, including multichannel urodynamic testing and 4D translabial ultrasound was performed for clinical diagnosis. Linear regression was used to model the average increase in VAS bother score of SUI and UUI for each explanatory variable. RESULTS: 74 % (n = 375) reported symptoms of SUI, with mean bother of 5.7 out of 10 (SD 2.8), and 73 % (n = 370) symptoms of UUI, with a mean bother of 6.5 out of 10 (SD 2.6). Bother from UUI was positively associated with the symptoms of nocturia (p < 0.0001) and frequency (p = 0.002), and the urodynamic findings of detrusor overactivity (p < 0.0001). Bother from SUI was positively related to the urodynamic diagnosis of USI (p < 0.0001) and a low abdominal leak point pressure (ALPP) (p = 0.002), as well as to the ultrasound findings of cystourethrocele (p < 0.0001) and funnelling (p = 0.04). All univariate associations remained highly significant on multivariate analysis, controlling for age, BMI, parity, previous incontinence/prolapse surgery and previous hysterectomy. CONCLUSIONS: Physician-administered VAS are a valid, reliable and practicable tool to measure bother related to SUI and UUI.

Ultrasound assessment of bladder wall thickness as a screening test for detrusor instability.

PURPOSE: The aim of the current study was to evaluate the diagnostic accuracy of transvaginal ultrasound measurement of bladder wall thickness (BWT) in diagnosis of over active bladder (OAB). METHODS: The current prospective study was conducted at Ain Shams University Maternity Hospital over 2 years. Patients presented to the urogynecology outpatient clinic with symptoms of urinary frequency, urgency, nocturia and/or urge incontinence were included in this study. The allocated patients were divided into two groups; Group 1(study group): fifty (50) patients with urodynamic diagnosis of detrusor instability (OAB) were included. Group 2 (control): fifty (50) patients with urodynamic diagnosis of stress incontinence were included. Using a transvaginal probe, BWT was measured in three sites at the thickest part of (a) the dome of the bladder (b) the trigone, and (c) the anterior wall of the bladder. An average of the three measurements was considered as the mean bladder thickness. RESULTS: A total of 100 patients with lower urinary symptoms were finally analyzed. There were no statistical significant differences between both groups regarding age, parity and body mass index, while there was statistically longer disease duration in group 2. Excluding urgency, there was statistical significant difference (P < 0.001) regarding lower urinary tract symptoms namely frequency, urgency incontinence, coital incontinence and nocturia. Patients in group 1 were more positive to symptoms of frequency, urgency incontinence, and nocturia, while patients in group 2 were more positive regarding coital incontinence. The thickness of trigon, dome, anterior wall and mean BWT was significantly higher in group 1 when compared to group 2. Receiver operator characteristics curve was constructed for estimating the association between mean BWT and prediction of OAB in patients with lower urinary tract symptoms. Mean BWT at 4.78 mm was considered as best cut-off value for prediction of OAB with sensitivity of 90 % and specificity of 78 %. Mean BWT was significantly associated with OAB > 4.78 mm as denoted by the significantly large area under the curve [AUC], AUC was 0.905. CONCLUSION: In women with lower urinary tract symptom, transvaginal ultrasounds measured mean BWT seems to be an effective non invasive diagnostic tool for prediction of OAB.

Comparison between transperineal ultrasound and digital detection of levator ani trauma. Can we improve the odds?

AIMS: To investigate the predictive ability of four digital assessment parameters to detect levator ani (LA) muscle defects (avulsion injury) and compare these to transperineal tomographic ultrasound images. METHODS: This was an observational study imbedded in a larger quasi-experimental cohort study for women with urinary incontinence. Seventy-two women, ≥ 60 years who had attended or were going to attend physiotherapy for treatment of urinary incontinence, were included in the study. Inclusion criteria from the parent study were symptoms of stress, urge or both types of urinary incontinence. The predictive ability of the following digital parameters: direct palpation of a discontinuity of the LA muscle from insertion on the pubic ramus; palpation of the distance between the muscle insertion sites; palpation of LA strength; palpation of LA tone, were analyzed against findings from tomographic transperineal ultrasound images. Correlation between methods was measured using Cohen's kappa for each of the individual parameters. RESULTS: Seventeen women (24%) presented with a complete or partial avulsion of the puborectalis muscle as diagnosed with tomographic ultrasound imaging. Nine women (13%) had complete avulsions, one of which was bilateral. The predictive ability of the digital assessment parameters varied from poor (k = 0.187, 95% CI [0.02-0.36]) to moderate (k = 0.569, 95% CI [0.31-0.83]). The new parameter of 'width between insertion sites' performed best. CONCLUSIONS: Adding the parameter of "width between insertion sites" appears to enhance our ability to detect avulsion of the levator ani (LA) muscle by digital examination however it does not distinguish between unilateral or bilateral avulsion.

Clinical significance of postvoid residual volume in older ambulatory women.

OBJECTIVES: To examine the prevalence, natural history, and clinical significance of high postvoid residual (PVR) volume in ambulatory older women. DESIGN: Prospective cohort study. SETTING: Group health plan in Washington state. PARTICIPANTS: Nine hundred eighty-seven ambulatory women aged 55 to 75. MEASUREMENTS: PVR was measured using bladder ultrasonography at baseline, 1 year, and 2 years. Participants completed questionnaires about urinary symptoms and provided urine samples for microbiological evaluation. RESULTS: Of the 987 participants, 79% had a PVR less than 50 mL, 10% of 50 to 99 mL, 6% of 100 to 199 mL, and 5% of 200 mL or greater at baseline. Of women with a PVR less than 50 mL, 66% reported at least one urinary symptom at baseline. Of women with a PVR of 200 mL or greater, 27% reported no significant symptoms at baseline. In adjusted analyses using data from all study visits, women with a PVR of 100 mL or greater were more likely to report urinating more than eight times during the day (odds ratio (OR)=1.42, 95% confidence interval (CI)=1.07-1.87), and women with a PVR of 200 mL or greater were more likely to report weekly urgency incontinence (OR=1.50, 95% CI=1.03-2.18) than those with a PVR less than 50 mL. High PVR was not associated with greater risk of stress incontinence, nocturnal frequency, or urinary tract infection in adjusted analyses. Forty-six percent of those with a PVR of 200 mL or greater and 63% of those with a PVR of 100 to 199 mL at baseline had a PVR less than 50 mL at 2 years. CONCLUSION: More than 10% of ambulatory older women may have a PVR of 100 mL or greater, which is associated with greater risk of some urinary symptoms, but many with high PVR are asymptomatic, and high PVR frequently resolves within 2 years. Symptom-guided management of urinary symptoms may be more appropriate than PVR-guided management in this population.

Ultrasound assessment of tension-free vaginal tape (TVT).

PURPOSE: To date, no standardization for the visualization of tension-free vaginal tape (TVT) has been established in clinical practice. The aim of this prospective observational study was to evaluate the shape and position of the tape using ultrasound and to compare this data with clinical postoperative results. MATERIALS AND METHODS: In a three-year period, 296 patients with clinically and urodynamically proven stress urinary incontinence (SUI) were treated with TVT and received follow-up in our department. An additional 12 patients, who were initially treated in other hospitals and had postoperative problems, were included in this study. Depending on the outcome after 3 months, the patients were divided into groups with and without specific disorders. The TVT was evaluated by introital ultrasound. The position of the tape was established by its location in relation to the urethral length and the distance to the hypoechoic center of the urethra (HCU). RESULTS: A suitable TVT position was determined in patients without any postoperative disorders. The mean value for the TVT position at rest in relation to the urethral length was 61 %. The distance to the HCU was 4.6 ± 1.5 mm. In patients with persistent SUI, the tape was more often located under the inner (3 % vs. 0 %) or outer quarter (29 % vs. 13 %, p = 0.004). In patients with residual volume, the distance to the urethra was significantly lower (2.7 vs. 4.6, p < 0.001). CONCLUSION: TVT may be regularly investigated using ultrasound. In combination with the clinical outcome, it represents an important method of evaluating the tape and assists in the planning of a future therapeutic course of action in cases of postoperative problems.

Sonographic basal ganglia alterations are related to non-motor symptoms in multiple sclerosis.

The anatomical basis of cognitive dysfunction and other non-motor symptoms in multiple sclerosis (MS) is poorly understood. In MS patients, transcranial sonography (TCS) shows neurodegenerative disease-like lesions of the substantia nigra (SN) and basal ganglia, thought to reflect iron accumulation. The present study deals with the question of whether sonographic changes of SN, brainstem raphe, lenticular nucleus (LN) or caudate nucleus are related to non-motor symptoms of MS. We used TCS to investigate 54 MS patients and 54 age- and sex-matched healthy subjects. Degree of cognitive (executive) dysfunction, fatigue, depression, and urinary urge incontinence in MS patients was assessed using the Paced Auditory Serial Addition Test, the Faces Symbol Test, the Modified Fatigue Impact Scale, the Beck Depression Inventory, and the Urinary Distress Inventory. Abnormal TCS findings of SN, brainstem raphe, LN, and caudate nucleus were found in 13, 7, 11, and 6% of the healthy subjects, but in 54, 43, 62, and 41% (each, p < 0.001) of the MS patients, with similar frequency in relapsing-remitting and primary or secondary progressive MS patients. Sonographic alteration of the LN correlated with cognitive dysfunction. Combined alteration of both, LN and SN, was clearly associated with cognitive dysfunction and cognitive fatigue. The combined sonographic alteration of SN and brainstem raphe indicated severe urinary urge incontinence irrespective of the presence of spinal MS lesions. No relation was found between depression and any of the TCS findings. These findings suggest that neurodegenerative processes affecting deep brain structures contribute to cognitive and autonomic dysfunction in MS.

Sonographic appearance of transobturator slings: implications for function and dysfunction.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to determine associations between the ultrasonic appearance of Monarc suburethral slings and postoperative bladder symptoms at an average follow-up time of 11 months. METHODS: A prospective clinical audit was conducted on 98 patients after Monarc suburethral sling. The assessment included pelvic floor ultrasound to determine the gap between the sling and symphysis pubis, the angle formed by cranial and caudal ends of the sling at rest and on Valsalva, and the location of the sling relative to the urethra. RESULTS: Patients who reported postoperative stress incontinence (SI) or urge incontinence (UI) had a significantly wider gap between the symphysis pubis and sling (P = 0.032 and P = 0.006, respectively). CONCLUSIONS: A narrower gap between the tape and symphysis pubis is associated with both SI and UI cure. Tighter transobturator sling placement seems to be advantageous for the cure of both SI and UI.

Inter- and intra-rater reliability of fluoroscopic cough stress testing.

The aim of this study was to assess inter- and intra-rater reliability in the interpretation of severity and type of stress urinary incontinence (SUI) during fluoroscopic cough stress testing. A total of 32 videourodynamic clips were selected from women presenting with stress, urge or mixed urinary incontinence. On two separate occasions, six urogynaecology healthcare professionals independently assessed the clips and classified the severity and type of SUI. Fleiss' and Cohen's kappa coefficients were calculated to assess strength of inter- and intra-rater reliability, respectively. Absolute inter-rater agreement for severity of SUI was observed in 24 of the 32 (75%) and 26 of the 32 (81%) cases for the first and second occasion, respectively. Absolute inter-rater agreement for type of SUI was seen in 16/32 cases (50%). Corresponding Fleiss' kappa coefficients supported reliability. Both the severity and, to a lesser degree, type of SUI assessed using fluoroscopic cough stress testing can be reliably interpreted.

Ultrasound measurement of bladder wall thickness is associated with the overactive bladder syndrome.

AIMS: To assess the relationship between mean bladder wall thickness and components of the overactive bladder (OAB syndrome). METHODS: Women attending urogynaecology clinic was categorized into overactive bladder syndrome, stress urinary incontinence (SUI), and mixed urinary continence (MUI) according to International Continence Society (ICS) definitions based on symptom history. Women completed a bladder diary, visual analog score (VAS) for urgency, and the mean bladder wall thickness (BWT) was determined. Comparison was made between the mean BWT and symptom history, daytime frequency, nocturia, VAS scores. RESULTS: Three hundred seventy-nine women were recruited to the study with a mean age of 56 years (range: 24-92 years). The mean bladder wall thickness did not show any age-related difference. Of these women 138/379 (36%) reported overactive bladder symptoms (mean BWT = 5.6 mm) 75/379 (20%) gave a history of stress urinary incontinence (mean BWT = 4.7 mm), and 166/379 (44%) had mixed urinary incontinence (mean BWT = 5.4). Women with nocturia >1 had mean BWT 5.6 mm, with nocturia <1 a mean BWT 4.9 mm. Women with daytime frequency >7 had mean BWT 5.7 mm and those <7 had mean BWT 5.1 (P < 0.001). Women with a mean BWT of ≤5 mm had a mean VAS score lower than women with a BWT >5 mm (P < 0.001). CONCLUSIONS: Mean BWT is associated with a symptom history of OAB and MUI, higher daytime and nightime frequency, and higher VAS scores.

Urodynamic characteristics of mixed urinary incontinence and idiopathic urge urinary incontinence.

PURPOSE: To evaluate and compare the clinical and urodynamic findings in patients with either mixed urinary incontinence (MUI) or simple urge urinary incontinence (UUI). MATERIALS AND METHODS: A series of 100 consecutive female patients with MUI and UUI were identified from a database. Patients with neurogenic bladder, fistula, urethral diverticulum, prior urologic surgery or known urinary tract obstruction were excluded. All patients were classified according to the urodynamic classification of overactive bladder of Flisser et al. and all patients underwent history, physical examination, validated incontinence questionnaire, 24-hour voiding diary, 24-hour pad test, video urodynamic study (VUDS), and cystoscopy. RESULTS: A significantly higher proportion of patients with UUI exhibited detrusor overactivity at VUDS, (67% of the patients with UUI vs. 24% of the MUI, P < 0.05). Patients with UUI had fewer episodes of incontinence (6.7 vs. 4.2, P < 0.05) with slightly less objective urine loss (24-hour pad test 94 gm vs. 128 g of loss, P < 0.05) and voided at higher pressures (p(det) at Q(max) 21.4 vs. 15.6 cm H(2)O, P < 0.05). Patients in both groups had functional and urodynamic bladder capacities that were not statistically different. CONCLUSIONS: Women with UUI were more likely to exhibit detrusor overactivity but experienced fewer episodes of incontinence and less urinary loss when compared with women who had MUI. The "urge incontinence" component of MUI appears to be different than that of UUI, and suggests that urge incontinence may be overdiagnosed in patients with SUI who misinterpret their fear of leaking (because of SUI) for urge incontinence.

[Causes and diagnosis of female urinary incontinence]. / Die wichtigsten Ursachen und wie Sie sie erkennen.

The primary cause of stress incontinence is birth traumata. However, obesity, asthma, chronic constipation or hard physical work can also overtax the pelvic floor and lead to injury of the connective tissue and a slackening of the ligamentous apparatus. Pelvic floor defects are initially diagnosed simply through a thorough urogynaecological examination. To predict the success of a surgical treatment, the functions can be tested by performing simulated operations.