Int Urogynecol J DOI 10.1007/s00192-013-2049-3
ORIGINAL ARTICLE
How often does detrusor overactivity cause urinary leakage during a stress test in women with mixed urinary incontinence? Sigurd Kulseng-Hanssen & Kjartan Moe & Hjalmar A. Schiøtz
Received: 12 November 2012 / Accepted: 10 January 2013 # The International Urogynecological Association 2013
Abstract Introduction and hypothesis The study examined how often detrusor overactivity (DO) causes leakage during a stress test in women with mixed urinary incontinence (MUI) and whether there are differences between those who do and those who do not have DO during the stress test. Methods A retrospective study was performed in 100 women who had an ambulatory urodynamic recording done where bladder, urethral, and vaginal pressures, and leakage were recorded. The stress test consisted of 20 jumping jacks and three forceful coughs. Results All the women leaked during the stress test: five due to simultaneous stress test and DO, 87 due to the stress test only, and eight during the stress test as well as due to DO before or after the stress test. Conclusions During the stress test, 5 % of women with MUI leaked due to the coughs and jumps and simultaneous DO. Women in whom DO was detected had significantly higher Urgency Incontinence Index and leakage during the 24-h pad test. Keywords Stress test . Detrusor overactivity . Ambulatory urodynamic recording
S. Kulseng-Hanssen (*) : K. Moe Department of Obstetrics and Gynecology, Bærum Hospital, PO Box 83, 1309 Rud, Norway e-mail:
[email protected] H. A. Schiøtz Department of Obstetrics and Gynecology, Vestfold Hospital, PO Box 2168, 3108 Tønsberg, Norway
Introduction Midurethral sling operations for stress urinary incontinence have revolutionized operative treatment of female stress and mixed urinary incontinence (MUI). Due to the large amount of women who are offered SUI surgery and the pressure on the hospitals to reduce treatment costs, there has been a search for what constitutes a minimum acceptable preoperative investigation in this patient group. Recently office evaluation alone was not found to be inferior to evaluation with urodynamic testing for women with uncomplicated, demonstrable stress urinary incontinence [1]. Women with MUI and predominant stress urinary incontinence (SUI) have only a slightly reduced outcome compared with women with pure SUI [2, 3]; those equally or predominantly bothered with urgency urinary incontinence (UUI) have a significantly poorer outcome [4]. Lose et al. concluded that invasive urodynamic investigation is mandatory in MUI if the urgency component is predominant or equal to the stress component so that initial treatment can be directed toward the main complaint [5] Because women with MUI have an increased risk of treatment failure [6–8], it is important to know whether their leakage is caused by stress or by DO. Patient history alone is not an accurate tool for diagnosing SUI [9], but rigorously defined clinical criteria, including stress testing, can predict 97 % of patients with urodynamic SUI [10]. Many colleagues use stress tests to document SUI. A stress test can detect and quantify SUI [11–13], but it does not exclude the possibility that leakage during the test was caused by DO. It is therefore of interest to know how often DO causes leakage during a stress test. The aim of our study was to evaluate how often DO causes
Int Urogynecol J
leakage during a stress test in women with MUI and whether there are differences between those who do and those who do not have demonstrable DO during the stress test.
Materials and methods A retrospective study was performed in 100 women with subjective MUI who underwent ambulatory urodynamic recording between January and June 2004 in a tertiary referral urodynamic clinic. All women were investigated according to a standardized protocol. A validated SUI and UUI questionnaire [14] and a 24-h pad test and micturition chart were completed by the patient at home and indices were obtained. The Stress Incontinence Index is derived from three questions regarding what kind of situations cause incontinence (when the woman coughs, sneezes, laughs, walks up or down stairs, rises from bed, lifts heavy objects, during physical activity or sports, and during intercourse), how often (never, one to four times a month, one to six times a week, once a day, more than once a day), and extent (nothing, drops/moist underwear, dripping/wet underwear, wet through all clothes and running down the legs or down to the floor). The Stress Incontinence Index ranges from 0 to 12. A high score is associated with severe leakage and bother. The Urgency Incontinence Index ranges from 0 to 8 and is composed of two questions: How often and to what extent is UUI experienced? An ambulatory urodynamic recording was performed in all women. After micturition, postvoid residual volume was recorded with a catheter, and the bladder then filled with 300 ml saline solution. A microtip catheter with bladder and urethral pressure transducers and a distal leakage detector was used to record bladder and urethral pressures and leakage. Abdominal pressure was measured with a vaginal microtip catheter. A fixation device consisting of two silicone tubes glued together was used (Fig. 1). The unit was fixed with a suture or tape. In order to locate the maximum urethral closure pressure, three urethral pressure profiles were recorded. The urethral and vaginal catheters were fixed, by pulling the metal ring over the wedge, in the desired position when the transducers were at the maximum urethral pressure point and the mid portion of vagina, respectively. The cough and jump stress tests were performed in the following standardized way. The women were asked to perform 20 jumping jacks (jumping on the spot, abducting and adducting the legs) and three forceful coughs. A pad was weighed before and after the stress test and urinary flow recorded. Twelve women who did not leak during the standardized stress test had the test repeated on a small trampoline. Women with an unclear leakage mechanism were asked to walk around in the hospital after the stress test and
Fig. 1 Fixation device. The bladder and urethral pressure catheter goes through the upper tube, and the vaginal pressure catheter goes through the lower tube. The fixation device is sutured to the urethral opening or taped to the vulva. The ring at b is pulled over the wedge to fix the catheter in the correct position
perform movements or mimic situations in which they usually leaked urine. The pads were changed as necessary. Methods, definitions, and units conform to the standards jointly recommended by the International Urogynecological Association and the International Continence Society [15]. The regional ethical committee of South-East Norway evaluated our study for quality assurance, and there was no need for committee approval. SPSS version 18 was used for statistical analysis. The Mann–Whitney U test was used with a 5 % significance level to compare distribution across groups. When the main conclusion in a study is based on a proportion—as in our study—it is recommended to use confidence intervals (CI) when judging whether the sample size is large enough [16]. In our study 5 % of the patients leaked simultaneously during jumping/coughing and due to detrusor contraction; 1–9 % represents a 95 % CI for the proportion observed in our study. We consider this CI to be
Table 1 Age and clinical variables at baseline of the 100 study participants Percentiles 25 Age Minutes recording Stress Incontinence Index Urgency Incontinence Index Stress test (g) 24-h pad test (G) Maximum closure pressure (cm H2O) Micturitions per 24 h Mean micturition volume (ml) Residual volume (ml) Maximum flow (ml/s)
Median
75
45.0
51.5
61.0
10.0 7.0 3.0 10.0 24.3 22.3 7.0 166.5 0.0 22.0
13.0 9.0 4.0 20.0 50.0 34.0 8.0 220.0 5.0 27.0
18.8 10.0 6.0 47.0 105.0 44.5 10.0 281.8 10.0 35.8
Int Urogynecol J Fig. 2 Simultaneous leakage due to detrusor overactivity and stress test. From top to bottom: leak detector, bladder pressure, urethral pressure, vaginal pressure, closure pressure, detrusor pressure. Between a and b, the woman is jumping and has no leakage. A detrusor contraction causes leakage between c and g. At points d, e, and f, the woman leaks due to coughing
sufficiently narrow to support our clinical conclusion that detrusor contraction occurs only rarely during stress testing.
Results Age and clinical variables at baseline of the 100 women are shown in Table 1. SUI was demonstrated in all women during the stress test. In five women, a detrusor contraction caused leakage synchronously with the leakage caused by the jumps and or coughs (Fig. 2). In eight women, DO caused leakage before or after coughing and jumping but not synchronously (Fig. 3). No DO was seen in 87 women (Figs. 3 and 4).
Fig. 3 Leakage due to detrusor overactivity not simultaneous with stress leakage. From top to bottom: leak detector, bladder pressure, urethral pressure, vaginal pressure, closure pressure, detrusor pressure. Between a and b, the woman walks and does not leak convincingly. A detrusor contraction causes leakage between c and d. At points e, f, and g, she leaks due to coughing
Age and clinical variables of the women with and without documented DO during the test are shown in Table 2. The Urgency Incontinence Index and 24-h leakage were significantly higher among those with documented DO. Women who had documented DO were recorded significantly longer than women without DO.
Discussion Because SUI operations are often performed without preoperative urodynamic investigation [17, 18] and only the simple, quick, and cheap stress test is used, it is important to be
Int Urogynecol J Fig. 4 No detrusor overactivity, stress leakage only. From top to bottom: leak detector, bladder pressure, urethral pressure, vaginal pressure, closure pressure, detrusor pressure. Between a and b, the woman jumps and leaks. At points c, d, and e, the woman leaks due to coughing
aware of how often detrusor contractions contribute to the leakage during stress tests. Using ambulatory urodynamic recording in this study of 100 women with MUI, we were able to confirm SUI in all patients, whereas leakage due to a detrusor contraction occurring simultaneously with coughing and/or jumping during the stress test was documented in 5 %. In eight other women, leakage due to a detrusor contraction occurred nonsynchronously. Detrusor contraction as the sole cause of leakage during the stress test was not seen in any of the patients. To our knowledge, ambulatory urodynamic recording has not previously been used to document how often DO causes leakage during a stress test.
Women in whom DO was found had a significantly higher Urgency Incontinence Index and 24-h pad-test leakage. This fits well with previous information [4, 6, 8]. The duration of the recording in women in whom detrusor contractions were detected was significantly longer than in women in whom detrusor contractions were not recorded (49 vs. 12 min). The difference in recording time was because documentation of SUI was the main interest and the test was terminated as soon as SUI was documented. If the group of women most bothered by SUI had been recorded for a longer time, DO after the stress test might have been detected in more women. Women with predominant UUI and severe leakage should be offered treatment for UUI first.
Table 2 Age and clinical variables of women without and with documented detrusor overactivity during ambulatory recording
Leakage due to stress test only (n 83)
Leakage due to stress test and overactive detrusor (n 13)
Percentile
Percentile
25 Age Stress Incontinence Index Urgent Incontinence Index Stress test (g) 24-h pad test (g) Maximum closure pressure (cm H2O) Recording (min) Micturitions per 24 h Mean micturition volume (ml) Residual volume (ml) Maximum flow (ml/s)
Median
75
25
Median
P value
75
45
51
61
47
58
60
7 2 10 20 22 9 6 170 0 22
9 4 18 45 34 12 8 225 5 27
10 6 42 90 45 16 10 291 10 36
8 6 5 55 23 18 7 146 0 23
9 6 48 97 29 49 10 183 20 29
10 6 66 140 41 55 11 207 20 35
n.s. n.s. 0.001 n.s. 0.046 n.s. 0,005 n.s. n.s. n.s. n.s.
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James et al. [19] performed cystometry in 555 women with symptoms of pure SUI and found that 5 % had DO as the sole cause of incontinence, whereas 4 % had leakage due to both DO and urethral sphincter weakness. The authors concluded that if no urodynamic investigation was performed before SUI operations, 5 % of women with symptomatically pure SUI would therefore be offered inappropriate bladder-neck surgery. The authors did not, however, describe how the stress test was performed. Some of their negative stress tests may have been false negatives. In a different study in our department in 147 women with SUI and MUI, we performed stress tests with the patient supine, jumping on the floor, and jumping on a trampoline. Leakage was found in 49 %, 93 %, and 99 %, respectively (to be published). The strength of this study is the standardized protocol for performing the stress test during ambulatory recording. We have found that the leak detector is especially important to show leakage during the test and during detrusor contractions. The main limitation of the study is the retrospective nature.
Conclusion The clinical implication of this study is that DO rarely causes leakage during a stress test in women with MUI. Women who had DO detected had significantly higher Urgency Incontinence Index and more severe leakage during the 24-h pad test. Conflicts of interest Sigurd Kulseng-Hanssen:, Nordic advisory board Allergan, Travel grant Pfizer, Kjartan Moe: none; Hjalmar Schiøtz: none
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