Air filled, including "air-charged," catheters in urodynamic studies: does the evidence justify their use?

AIMS: Air filled catheters (AFCs) have been actively marketed for the past few years and in some geographic areas are widely used. However, as the scientific basis for introduction of this technology for pressure measurement in urodynamics was not clear, a study group examined the evidence. METHODS: A search of the peer reviewed literature was carried out. RESULTS: Four papers were identified, of which two were laboratory experiments and two were clinical papers, in female patients, that compared the pressures recorded by AFCs and those recorded using the traditional water filled catheters (WFCs). These data show that there are differences between the pressures measured by the two types of catheters. As yet, the reasons for these differences are not clear. CONCLUSIONS: There should be further systematic laboratory and clinical research before AFCs can be recommended for routine clinical use. We would recommend that a professional worldwide multidisciplinary scientific society, such as the International Continence Society, should work with manufacturers and regulatory bodies to ensure that this urodynamic method is properly scientifically evaluated, in the wider interests of patient safety.

Viscoelastic assessment of anal canal function using acoustic reflectometry: a clinically useful technique.

BACKGROUND: Anal acoustic reflectometry is a new reproducible technique that allows a viscoelastic assessment of anal canal function. Five new variables reflecting anal canal function are measured: the opening and closing pressure, opening and closing elastance, and hysteresis. OBJECTIVE: The aim of this study was to assess whether the parameters measured in anal acoustic reflectometry are clinically valid between continent and fecally incontinent subjects. DESIGN: This was an age- and sex-matched study of continent and incontinent women. SETTING: The study was conducted at a university teaching hospital. PATIENTS: One hundred women (50 with fecal incontinence and 50 with normal bowel control) were included in the study. Subjects were age matched to within 5 years. MAIN OUTCOME MEASURES: Parameters measured with anal acoustic reflectometry and manometry were compared between incontinent and continent groups using a paired t test. Diagnostic accuracy was assessed by the use of receiver operator characteristic curves. RESULTS: Four of the 5 anal acoustic reflectometry parameters at rest were significantly different between continent and incontinent women (eg, opening pressure in fecally incontinent subjects was 31.6 vs 51.5 cm H2O in continent subjects, p = 0.0001). Both anal acoustic reflectometry parameters of squeeze opening pressure and squeeze opening elastance were significantly reduced in the incontinent women compared with continent women (50 vs 99.1 cm H2O, p = 0.0001 and 1.48 vs 1.83 cm H2O/mm, p = 0.012). In terms of diagnostic accuracy, opening pressure at rest measured by reflectometry was significantly superior in discriminating between continent and incontinent women in comparison with resting pressure measured with manometry (p = 0.009). CONCLUSIONS: Anal acoustic reflectometry is a new, clinically valid technique in the assessment of continent and incontinent subjects. This technique, which assesses the response of the anal canal to distension and relaxation, provides a detailed viscoelastic assessment of anal canal function. This technique may not only aid the investigation of fecally incontinent subjects, but it may also improve our understanding of anal canal physiology during both the process of defecation and maintenance of continence.

Anal acoustic reflectometry: a new reproducible technique providing physiological assessment of anal sphincter function.

BACKGROUND: Anal acoustic reflectometry is a new technique of assessing anal sphincter function. Five new variables reflecting anal canal function are measured: the opening and closing pressure, the opening and closing elastance, and hysteresis. OBJECTIVE: This study aimed to compare the reproducibility of this new technique, in terms of test-retest and interrater reliability, with manometry, the current standard test of sphincter function. DESIGN: This is a comparative study of reproducibility between anal acoustic reflectometry and manometry. SETTINGS: This study was conducted at a university hospital (outpatient clinic and endoscopy unit). PATIENTS: Twenty-six (21 female) subjects were assessed with both anal acoustic reflectometry and manometry on 2 separate occasions (test-retest reliability) and 22 (16 female) subjects were assessed with both methods by 2 separate investigators (interrater reliability). MAIN OUTCOME MEASURES: Reproducibility was assessed according to the Bland-Altman method. RESULTS: All of the measured novel anal acoustic reflectometry parameters had acceptable mean differences and repeatability coefficients. Comparison of the 2 methods of sphincter assessment (anal acoustic reflectometry vs manometry) was made for measurements taken at rest and during voluntary contraction. There was no significant difference in terms of test-retest reliability between the manometry maximum resting pressure vs the reflectometry opening pressure (P = .57) or manometry maximum squeeze pressure vs the reflectometry squeeze opening pressure (P = .68). No significant difference between methods was found in interrater reliability during assessments at rest (P = .62) and voluntary contraction (P = .96). LIMITATIONS: Anal acoustic reflectometry is limited, as with all tests of anorectal function, in that the device is placed within the anal canal, causing stimulation of sensory and stretch receptors. CONCLUSIONS: Anal acoustic reflectometry has a reproducibility comparable to manometry in terms of both test-retest and interrater reliability. Anal acoustic reflectometry is a promising technique that allows an assessment of anal canal physiology that is not available with manometry.

Executive summary: The International Consultation on Incontinence 2008--Committee on: "Dynamic Testing"; for urinary or fecal incontinence. Part 2: Urodynamic testing in male patients with symptoms of urinary incontinence, in patients with relevant neurological abnormalities, and in children and in frail elderly with symptoms of urinary incontinence.

AIMS: The members of 'The International Consultation on Incontinence 2008 (Paris) Committee on Dynamic Testing' provide an executive summary of the chapter 'Dynamic Testing' that discusses (urodynamic) testing methods for patients with signs and or symptoms of urinary incontinence. Testing of patients with signs and or symptoms of fecal incontinence is also discussed. METHODS: Evidence based and consensus committee report. RESULTS: The chapter 'Dynamic Testing' is a continuation of previous Consultation reports added with a new systematic literature search and expert discussion. Conclusions, based on the published evidence and recommendations, based on the integration of evidence with expert experience and discussion are provided separately, for transparency. CONCLUSION: This second part of a series of three articles summarizes the committee's recommendations about: 'Urodynamic testing of male patients with symptoms of incontinence, of patients with relevant neurological abnormalities, testing of children and of frail elderly with symptoms of incontinence' and includes only the most recent and relevant literature references.

Executive summary: The International Consultation on Incontinence 2008--Committee on: "Dynamic Testing"; for urinary incontinence and for fecal incontinence. Part 1: Innovations in urodynamic techniques and urodynamic testing for signs and symptoms of urinary incontinence in female patients.

AIMS: The members of The International Consultation on Incontinence 2008 (Paris) Committee on Dynamic Testing' provide an executive summary of the chapter 'Dynamic Testing' that discusses (urodynamic) testing methods for patients with signs and or symptoms of urinary incontinence. Testing of patients with signs and or symptoms of faecal incontinence is also discussed. METHODS: Evidence based and consensus committee report. RESULTS: The chapter 'Dynamic Testing' is a continuation of previous Consultation-reports added with a new systematic literature search and expert discussion. Conclusions, based on the published evidence and recommendations, based on the integration of evidence with expert experience and discussion are provided separately, for transparency. CONCLUSION: This first part of a series of three articles summarizes the committees recommendations about the innovations in urodynamic study techniques 'in general', about the test characteristics and normal values of urodynamic studies as well as the assessment of female with signs and or symptoms of incontinence and includes only the most recent and relevant literature references.

Executive Summary: The International Consultation on Incontinence 2008--Committee on: "Dynamic Testing"; for urinary or fecal incontinence. Part 3: Anorectal physiology studies.

AIMS: The members of 'The International Consultation on Incontinence 2008 (Paris) Committee on Dynamic Testing' provide an executive summary of the chapter 'Dynamic Testing' that discusses testing methods for patients with signs and or symptoms of incontinence. Testing of patients with signs and or symptoms of urinary as well as testing of patients with fecal incontinence is discussed. METHODS: Evidence based and consensus committee report. RESULTS: The chapter 'Dynamic Testing' is a continuation of previous Consultation-reports added with a new systematic literature search and expert discussion. Conclusions, based on the published evidence and recommendations, based on the integration of evidence with expert experience and discussion are provided separately, for transparency. CONCLUSION: This third part of a series of three articles summarizes the recommendations given in the paragraph: 'Anorectal physiology studies' with regard to fecal incontinence (whether or not in combination with urinary incontinence) and includes only the most recent and relevant literature references.

Is it possible to diagnose intrinsic sphincter deficiency in women?

PURPOSE OF REVIEW: The diagnosis of intrinsic sphincter deficiency became important about 20 years ago when it influenced the choice of operative procedure for women with stress urinary incontinence. However, it was ill-defined and diagnosed by a variety of techniques. The contemporary surgical treatment of urinary stress incontinence is by suburethral sling; so this review addresses three questions: is it still important to identify intrinsic sphincter deficiency prior to surgical intervention for stress incontinence? What techniques are available to do so? How robust are these measurements? RECENT FINDINGS: There is some evidence that women with intrinsic sphincter deficiency have a poorer outcome if they are treated by a transobturator tape compared with a tension-free vaginal tape or a pubovaginal sling. Intrinsic sphincter deficiency continues to be mainly identified by low urethral closure pressures or low abdominal leak point pressures or both but the methodology is variable. There have been some attempts at using ultrasound to identify intrinsic sphincter deficiency but without any definite conclusions. SUMMARY: Intrinsic sphincter deficiency is an imprecise diagnosis, which continues to be defined by a low pressure urethra. This can be measured in different ways but there is poor standardization of the tests to do so. Intrinsic sphincter deficiency appears to be clinically important but the full implications of this diagnosis will remain unknown until this imprecision is addressed.

The long-term outcome of laparoscopic colposuspension: a 10-year cohort study.

INTRODUCTION AND HYPOTHESIS: The aim of this study is to provide long-term outcome data, at least 10 years, following laparoscopic colposuspension. METHODS: The study includes a control group who underwent open colposuspension. A consecutive series of 139 women who had undergone laparoscopic colposuspension were reviewed and compared to 52 women who had an open colposuspension in the same unit. Subjects were contacted by telephone, at least 10 years post-operatively, at which time a structured interview was performed which included the short-form Bristol Female Lower Urinary Tract Symptom questionnaire. RESULTS: There was deterioration in subjective cure rates from 71% and 67% at 6 months to 52% and 36% at 10 years for the laparoscopic and open procedures, respectively. CONCLUSION: This study provides evidence that laparoscopic colposuspension is probably as durable as open colposuspension. However, cure rates for both procedures appear to deteriorate over time, emphasising the importance of long-term follow-up.

Opening detrusor pressure and the influence of age on success following colposuspension.

OBJECTIVE: Women with urodynamic stress incontinence (USI) have lower opening and closing detrusor pressures than women without USI. This study was undertaken to determine whether a change occurs in opening and closing detrusor pressures after colposuspension, whether cure is associated with change, and whether age influences cure. DESIGN: Retrospective cohort study. SETTING: Tertiary referral urogynaecology department. PARTICIPANTS: Consecutive women who had undergone colposuspension between 1998-2000 and 1993-1995. METHODS: Pre- and post-operative urodynamic records were reviewed. Eighty eight women were included. Objective cure was defined as an absence of USI and subjective cure as an absence of symptoms of stress incontinence. RESULTS: Mean age was 52.4 (11.0) years. Sixty nine percent (61/88) were objectively cured and 48% (42/88) were subjectively cured. Postoperatively, opening detrusor pressure increased (P = 0.0001) and maximum flow rate decreased (P= 0.0464) in women objectively cured but these parameters did not change in the not cured group (P > 0.05). Women had a 4.5 times higher chance of failed surgery if post-op opening detrusor pressure was < or =20 cmH2O (P = 0.035). Opening detrusor pressure declined with age (P < 0.001) and women who were objectively cured were on average almost 7 years younger (P = 0.0330). CONCLUSIONS: Increase in opening detrusor pressure occurs only in women who are cured following colposuspension. Change in opening detrusor pressure is dependent on age and objective cure is higher in younger women. The effects of ageing on sub-urethral supports might explain why surgery is more likely to fail in older women.

Stress incontinence and pelvic floor neurophysiology 15 years after the first delivery.

UNLABELLED: HEADLINE: This is a longitudinal study of a cohort of primigravidae recruited between 1985 and 1987 and followed up 7 and 15 years later. Pelvic floor neurophysiology was performed and questionnaires were administered to determine the natural history of stress incontinence and to establish whether pelvic floor denervation after the first delivery is associated with symptoms of stress urinary incontinence in the future. OBJECTIVES: To study the natural history of stress urinary incontinence arising during the first pregnancy, to determine whether postnatal pelvic floor denervation progresses with time and whether it predisposes to stress urinary incontinence in the future. DESIGN: Prospective longitudinal cohort study. SETTING: Tertiary referral urogynaecology unit. SAMPLE: Cohort of 96 primigravidae studied prospectively between 1985 and 1987 and followed up 7 years (n = 76) and 15 years (n = 55) later. METHODS: Urinary incontinence symptoms were recorded and pelvic floor neurophysiology was performed antenatally and postnatally between 1985 and 1987. Repeat neurophysiological tests and questionnaires were completed by those relocated 7 and 15 years later. MAIN OUTCOME MEASURE: Symptoms of stress urinary incontinence. SECONDARY OUTCOMES: Symptoms of urge urinary incontinence and anal incontinence; motor unit potential duration and pudendal nerve terminal latency; vaginal squeeze pressure measured by perineometry. RESULTS: Prevalence of stress incontinence was highest during pregnancy and had increased seven years after the first postnatal period (P = 0.0129). Two-thirds of women with antenatal stress incontinence had stress incontinence 15 years later. One-third of women with stress incontinence at any time appear to undergo resolution of symptoms. Motor unit potential duration increased at seven years (P = 0.036). Vaginal squeeze pressure improved during the same period (P = 0.0007). CONCLUSIONS: When stress urinary incontinence arises during the first pregnancy, the risk of stress incontinence occurring 15 years later is doubled. Although pelvic floor reinnervation progressed after the postnatal period, the absence of an adequate marker for pelvic floor denervation makes it of uncertain clinical significance.