|Year : 2013 | Volume
| Issue : 3 | Page : 153-159
Correlation between clinical presentation and urodynamic findings in women attending urogynecology clinic
Deeksha Pandey1, Gasser Anna2, Ottenschlaeger Hana2, Fuenfgeld Christian2
1 Department of OBGYN, KMC Manipal, Manipal University, Karnataka, India
2 Department of OBGYN, Waldburg-Zeil Kliniken Klinik Tettnang, Tettnang, Germany
|Date of Web Publication||26-Sep-2013|
Department of OBGYN, Women and Child Block, KMC, Manipal - 576 104, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Urodynamic studies objectively observe lower urinary tract function and dysfunction so that an appropriate treatment can be planned. In the present study, we tried to evaluate the role of urodynamic studies in the final diagnosis and management plan in patients attending an urogynecology clinic.
Materials and Methods: This observational study was conducted in an urogynecology clinic. 202 women were included. After detailed history, pelvic examination and introital sonography these women were subjected to urodynamic study. During the filling cystometry detrusor activity, first desire to void and bladder capacity was recorded. This was followed by urethral pressure measurements, when functional urethral length, maximum urethral closure pressure and stress urethral pressure profile was recorded.
Results: Most prevalent complaint was mixed urinary incontinence (33.17%), followed by stress incontinence (31.68%) and urge incontinence (13.37%). According to the standard urodynamic definition 66.33% were normal in the population studied. None of the urodynamic parameters individually or in combination were found to be very useful for establishing a diagnosis.
Conclusion: Establishment of the final diagnosis of urinary incontinence and planning of management should be based on detailed history, physical examination, bladder diaries, and careful interpretation of urodynamic data. Urodynamic study; however, doesn't seem to be imperative to establish a diagnosis in uncomplicated cases where symptoms and signs are reliable and correlating.
Keywords: Mixed incontinence, stress incontinence, urge incontinence, urodynamic findings
|How to cite this article:|
Pandey D, Anna G, Hana O, Christian F. Correlation between clinical presentation and urodynamic findings in women attending urogynecology clinic. J Mid-life Health 2013;4:153-9
|How to cite this URL:|
Pandey D, Anna G, Hana O, Christian F. Correlation between clinical presentation and urodynamic findings in women attending urogynecology clinic. J Mid-life Health [serial online] 2013 [cited 2022 Dec 10];4:153-9. Available from: https://www.jmidlifehealth.org/text.asp?2013/4/3/153/118992
| Introduction|| |
Lower urinary tract is indeed an enormously important source of medical and social concern, not only for elderly, but for the women of reproductive age and beyond. Symptoms include urinary incon tinence (urge, stress or mixed), urgency, frequency, nocturia, urinary retention, urinary tract infections, and genital prolapse. Women might the present with one of these symptoms but usually the clinical scenario is complex with clustered complains complicated by findings on the pelvic examination. The conundrum for a Urogynecologist is that the symptoms, physical examination findings, voiding diaries, and pad testing do not correlate well. Thus, urodynamic studies objectively observe lower urinary tract function and dysfunction so that an appropriate treatment can be planned. 
Urodynamics testing refers to a combination of tests that involve simultaneous measurement of various physiologic parameters of urethral and bladder function during bladder filling and emptying. 
However, the argument is that urodynamic testing is not cost-effective, limits access to specialty care, and requires specialized and expensive equipment, special training, and interpretation skills. Though there is no consensus as to its real need, urodynamics has been broadly used in the diagnostic and prognostic evaluation of urinary incontinence. 
In the present study, we tried to evaluate the role of urodynamic studies in the final diagnosis in patients attending an urogynecology clinic in a period of 6 months.
Urodynamic studies include cystometry, urethral pressure measurements, uroflowmetry, pressure flow studies, surface electromyography, video urodynamics and ambulant urodynamic monitoring.  In the present study, however, only the first two components (cystometry, urethral pressure measurements) were studied in detail as these are the most frequently used in clinical practice involving women. Cystometry is the core test of an urodynamic investigation. It is the continuous measurement of the pressure/volume relationship of the bladder to assess sensations, detrusor activity, bladder capacity and bladder compliance. Urethral pressure has an important role in maintaining urinary continence. The urethral closure pressure represents the difference between the urethral pressure and the simultaneously recorded intravesical pressure, and conceptually, therefore, it represents the ability of the urethra to prevent urine leakage. 
| Materials and Methods|| |
This observational study was conducted in an Urogynecology Clinic of South Germany, with a patient influx of more than 1000/year. A total of 550 patients attended the clinic in last 6 months with some urogynecological complaint. All of them were subjected to urodynamic studies after a thorough history and clinical examination. Out of this, in the present study 202 women were included for whom, while performing urodynamic study one of the investigators was present for simultaneous interpretation and co-relation of findings.
Systematically all patients included in the study were inquired about their demographic characteristics (age, parity, mode of delivery, menopausal status, sexual activity, co-morbidities and previous pelvic surgeries). Their chief complaints were asked which was followed by some direct question to find out associated pathology like a component of urgency or associated prolapse in a patient who presented mainly with stress urinary incontinence and vice-versa. Micturition interval in the day and nocturia were also asked for. Impact of these complaints in their quality of life was assessed. Trial of pelvic floor muscle training PFMT and estrogen therapy too was enquired about.
Stress incontinence was defined as a complaint of involuntary loss of urine during coughing, sneezing, or physical exertion. The isolated complaint of stron g desire to void was taken as urgency (Overactive bladder dry or OAB dry), and when urgency was associated with sudden, involuntary loss of urine, it was termed urge incontinence (OAB wet). Mixed incontinence meant the presence of both stress and urge incontinence. Some patients (usually elderly) were not able to clearly elucidate their complaints, so this group was recorded as unspecified urinary incontinence. Women who presented with feeling of prolapse were also subjected to urodynamic study as to predict the incidence of de novo stress incontinence. In the present study, we included this group of patients (complain of prolapse without urinary symptoms) as the control group.
Pelvic examination of all these women was carried out by a senior Urogynecologist (Christian Fuenfgeld) and findings were recorded, which included genital prolapse quantified by POP-Q system. Same surgeon then performed a pelvic and introital sonography to look for mobility of urethra, urethrovesical angle, and genital prolapse and to rule out any other pelvic pathology.
Urodynamic assessment was then performed by a gynecologist (Deeksha Pandey, Anna Gasser) with a nurse trained in urodynamics (Hana Ottenschlaeger). For the urodynamic assessment patient were asked to empty their bladder in privacy and were explained the procedure in detail. Before starting the study the bladder was emptied with all aseptic precautions to estimate the residual urine, which was then used for routine and microscopic assessment with the help of dipstick. With all aseptic precautions, bladder was filled with normal saline at a rate of around 50 ml/min, to the maximal bladder capacity (based on patient's sensation of fullness) or 500 ml whichever came first. Urodynamic system used Andromeda Ellipse 4. Simultaneous abdominal (with the help of rectal transducer) and bladder (with vesicle transducer) pressures were recorded and detrusor pressure was obtaining by the computer program after subtracting the first two. Patients were instructed to cough at regular intervals of every 60 s or every 50 ml saline infusion, so as to increase the abdominal pressure and observe its effect. Simultaneous graphical recording of pressure were obtained. Consequently, one of the investigators noted and recorded all relevant events and simultaneously interpreted the findings. Patient was asked to inform as soon as she feel the desire to urinate. This was recorded as first desire. However, the infusion was continued, after explaining the woman that this desire will subside in due course of time and to report if it does not. Associated detrusor contraction with this, in the graphical record (if present) was noted. Bladder filling was stopped, once either the bladder was maximally distended up to its physiological limits (i.e., patient could not tolerate any more infusion, started leaking without effort) or the maximum infusion of saline (i.e., around 500 ml) was over. Pressures in the urethra were measured after this: At rest and during episodes of increased abdominal pressure respectively. The rate of catheter withdrawal was kept continuously at 2 cm/min. These urethral pressure recordings indirectly gave a measure of functional urethral length (FUL) (during rest and activity) also. After this, all the transducers and catheters were removed, and the patient was asked to cough (to increase the intrabdominal pressure) and leaking of urine in recumbent and standing positions was noted. This stress test had an advantage as now the patient's bladder was filled to its maximum capacity.
At the end of urodynamic study, a urodynamic diagnosis was made based on the definitions standardized by International Continence Society (ICS).  Urodynamic ally stress incontinence meant involuntary leakage of urine during raised intravesical pressure secondary to increased abdominal pressure, in the absence of a detrusor contraction. Detrusor over activity meant involuntary detrusor contractions during the filling phase at any time prior to "permission to void" being given. The current ICS terminology does not distinguish over activity accompanied by the sensation of urgency from sensation-free over activity. However, to aid clinical decision making both were taken as urgency.
During urethral pressure measurements, three variables were recorded: FUL, maximum urethral closure pressure (MUCP) and stress urethral pressure profile.
For those women in whom symptoms could not be explained after cystometry or urethral pressure study, and the residual volume of urine was more than the normal range (i.e., upto 100 ml), uroflowmetry was performed. Results of the same are not included in the present study, so as to reduce deviation from the primary objective.
| Results|| |
The mean age of the population of women studied was 62.71 ± 10.92 years. Around 84.16% (170 women) were post-menopausal. More than a third (36.22%) of the menopausal women had attained it surgically. However, in only two of these women ovaries were removed. Among the menopausal group the mean menopausal years at the time of presentation were 15.00 ± 11.33 years. Mean parity was 2.24 ± 1.26 with a predominance of vaginal deliveries. 19 (9.41%) women were nulliparous. Interestingly, only one woman in the study group had vacuum vaginal delivery while two had forceps delivery. Twelve women in the group underwent cesarean delivery and 3 out of these never experienced a vaginal birth. More than half (59.90%) women were sexually active.
There was history of one or more major gynecological pelvic surgeries in 88 women that included hysterectomy (abdominal, vaginal or laparoscopic), conventional repair of vaginal prolapse (without mesh) and mesh repairs (abdominal sacrocolpopexy or vaginal sacrospinus fixations). We also included mid urethral sling procedures in this group. Out of all women studied 28.21% had some kind of surgery for rectification of pelvic floor relaxation such as colporrhaphies, mesh fixations (abdominal or vaginal), and sling operations. It constituted around 48% of pelvic operations in the given population. Minor surgeries in pelvis like laparotomy or laparoscopic adhesiolysis, ovarian cyst removal were not included in this figure. Notably two women had undergone Wertheim's operation for early stage cervical carcinoma. Overall, around half (43.56%) had some kind of gynecological pelvic surgery. In other words, only 56.44% women were naïve to major pelvic operative procedures.
The incidence of more prevalent co-morbidities is represented in [Table 1]. Other than that seven women had a history of breast carcinoma and one had suffered Hodkin's lymphoma. There was one case of autoimmune hepatitis one Sjogren's syndrome, two fibromyalgia and three had rheumatoid arthritis. Two women had underlying cardiac disease one had chronic renal disease, and four had asthma. One woman had undergone surgery for varicose vein treatment. Notably nine women had a history of knee or hip surgery before. All these factors will be important while considering the management options.
The distribution of patient's symptoms has been tabulated in [Table 2]. Most prevalent complaint was mixed urinary incontinence (33.17%), followed by stress incontinence (31.68%) in our study group. Only 13.37% complained of urge incontinence (OAB wet). There were 4.46% of women who complained only of urgency without incontinence (OAB dry). 26 women had prolapse without urinary symptoms and were included in the analysis as a control group.
On comparing the demographic characteristics according to the presenting symptoms [Table 3], some interesting fact became evident. Women with stress incontinence were younger (59.84 ± 10.52 years) as compared to urge incontinence (65.33 ± 9.95 years), mixed incontinence (64.30 ± 11.01 years) and unspecified urinary incontinence (65.44 ± 13.77 years). Correspondingly less women in this group had attained menopause (71.88% as compared to 88-100% in other groups) and more were sexually active (70.31% as compared to 40-69% in other groups). Around half of women with stress urinary incontinence had tried pelvic floor muscle training before presenting to us. This was followed by 44.44% in urge incontinence and 38.81% in mixed incontinence. A high proportion of women (66.67%) who had undergone vaginal hysterectomy were noticed in the group of unspecified urinary incontinence.
|Table 3: Distribution of demographic characteristics with relation to clinical presentation|
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[Table 4] summarizes the correlation of symptoms and the ICS standardized urodynamic diagnosis of urinary incontinence. According to the standard urodynamic definition 66.33% were normal in the population studied. Among the control group who actually had no urinary symptoms two were found to have detrusor activity. It is very well evident from the table that the correlation between clinical presentation and urodynamic study was very poor in our study population.
Having observed this poor correlation we tried to analyze the other probable urodynamic parameters in relation with the symptomatology. We took into account residual urine, first void desire, bladder capacity, FUL, and MUCP [Figure 1]. Mean residual urine was found to be more in the group of unspecified urinary incontinence. As mentioned earlier women having more than 100 ml of residual urine were subjected to uroflowmetry, however, description of those findings is beyond the scope of this paper. Volume of infusion at which women experienced first void desire as expected was found to be lowest for urge incontinence group (138.59 ml) as compared to others (controls: 182.54 ml, stress incontinence: 168.17 ml and mixed incontinence: 178.24 ml). MUCP was the only parameter, which seemed to have maximum variation among the different presentations. The urethral closure pressure is related to the process of aging. A simple calculation to measure its adequacy, we do in clinical practice is that the pressure is good enough if it is more than 100 minus age of the woman. This calculation of MUCP in relation to age showed that as compared to controls more women in stress urinary continence (SUI), mixed incontinence (MI) and urge incontinence (UI) showed Pclo < 100-age (controls: 11.54%, SUI 25%, UI 37.04%, MI 25.37%). Though, among the incontinence patients it was more frequently found to be lower, the difference was not significant among the various type of incontinence. We also compared the uretral pressure profiles with coughing, in various group of incontinence patients and in controls [Figure 2]. In the controls and unspecified groups most of the women had urethral pressures of more than 40 cm of water (controls: 57.69% and unspecified: 55.55%). Least number of women in the stress incontinence group (18.75%), followed by mixed (25.37%) and urge incontinence (37.04%) had normal urethral pressures with increased intrabdominal pressure.
|Figure 2: Urethral pressure profiles in various groups of incontinence and controls|
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| Discussion|| |
It has been aptly put up by Jensen et al., is that the best anti-incontinence procedure as far as success is concerned is the correct evaluation.  Present study shows a poor correlation between symptoms and urodynamic diagnosis in cases of female urinary incontinence. Urodynamic study is an important adjuvant to history and clinical examination in establishing the diagnosis. The primary goal of urodynamic testing is to provide objective confirmation of the signs and symptoms of incontinence. Theoretically, it not only should help confirm the diagnosis, but also prove to be an important tool to add on to other pathological components to the diagnosis and annotate diagnosis in cases where history and examination findings were equivocal. However, in our study population we could not establish that much added benefit of urodynamic study in patient management. Recently, a retrospective study from Brazil concluded that the urodynamic evaluation represents an important tool to assess the degree of inconti nence; however, it did not prove necessary for the diagnosis of urinary loss. 
While performing the urodynamic studies for these women, we found some ancillary advantages. Stress test was more reliable after the bladder was filled at its maximal capacity. When the women were explained to wait after their first desire to void and consequently the desire subsided, it helped her in their bladder training programs. Urodynamic assessment prior to surgery not only helped to establish the diagnosis in some cases, but also enabled a discussion with the patient of any problems that might arise after intervention because of other co-existing abnormalities.
The strengths of our study are the comparatively big sample size in a clinic with a good load of urogynecology patients, in the direct supervision of a senior Urogynecologist and trained nurse in urogynecology. Moreover, in our study we tried to gather as much information possible for these women and simultaneously interpreted the urodynamic findings.
We found that mixed urinary incontinence was the most frequent complaint, followed by stress and urge. The trend is similar to that reported by other investigators. , However, the frequency varied.
Usually for urge urinary incontinence history elicited by the patient is the most important in making the diagnosis and to initiate treatment. There are no clinical tests to elicit it. With the help of urodynamic study OAB can be diagnosed. We, however, found that only around a third of these patients (29.63%) and one fifth (19.40%) of those with mixed urinary incontinence showed detrusor activity. However, two women (3.13%) in stress incontinence group and only two (7.69%) in the control group showed detrusor activity. In our opinion, the appearance of first desire to void occurs early if might add on to the diagnosis of urge incontinence alone or as a component in mixed incontinence. However, study with a bigger sample size is needed to establish it.
A group of investigators from the Netherlands with a multivariate logistic regression model, concluded that a low MUCP should influence the choice of surgery in cases of SUI.  During the early analysis of data, we presumed that urethral pressure profile might be used as a predictor of stress incontinence. Having carried out various sub analysis with respect to age and grades of urethral profiles during episodes of increased abdominal pressure, we did not find even this parameter very effective. Weber after his extensive literature survey also concluded that urethral pressure profilometry is not a useful diagnostic test for stress incontinence. The use of this parameter in clinical management of women with urinary incontinence is unsupported by current evidence. 
As in ICS committee opinion it has been aptly summarized that urodynamic test results should be interpreted and integrated with other clinical findings to make an appropriate clinical decision. We agree that different urodynamic findings are usually the present with a given clinical presentation, and the same urodynamic observations may be seen in different symptoms as many others. ,, As argued by Jensen et al., we agree that symptoms and urodynamic findings usually match. 
However, Nygaard and Heit brought up a very important point to be noted is that not only urodynamic studies rather even history and examination for women with urinary incontinence has not been rigorously tested. Even in our present study, we couldn't find much value of stress test. It was positive only for 57.80% of patients in the stress incontinence group and 38% of mixed incontinence group. The test was also found to be positive in 33.33% of women presenting with urgency only and in 14.81% with urge incontinence. 
We agree to Feldner Junior et al., that history backed up by clinical findings can guide the initial treatment and spare some women of the urodynamic test. Definitely urodynamic tests are relatively invasive when compared to clinical assessment, may yield different results according to different test modalities, and it is difficult to obtain an accurate correlation with the symptoms. Thus, conservative management can be initiated without these tests. 
A recent randomized trial on urodynamic testing before stress incontinence surgery conducted in 630 women concluded that for women with uncomplicated, demonstrable stress urinary incontinence, preoperative office evaluation alone is good enough. 
To conclude establishment of the final diagnosis of urinary incontinence and planning of management should be based on detailed history, physical examination, bladder diaries, and careful interpretation of urodynamic data. Urodynamic study, however, doesn't seem to be imperative to establish a diagnosis in uncomplicated cases where symptoms and signs are reliable and correlating.
The limitation of our study was the sample of convenience. However, we feel that a further study with a properly calculated sample size will be important to support or refute our findings. Moreover, a properly planned control group without even pelvic floor relaxation will be better able to compare the results.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]