Glossary

AN IUGA / ICS JOINT REPORT ON THE TERMINOLOGY FOR FEMALE PELVIC FLOOR DYSFUNCTION - INDEX
Haylen et al. (2010) - International Urogynecology Journal 21:5-26 and Neurourology and Urodynamics 29:4-20

SECTION 1: SYMPTOMS

A: Urainary incontinence symptoms
B: Irritative bladder symptoms
C: Sensory symptoms
D: Voiding symptoms
E: Prolapse symptoms
F: Lower urinary tract pain / other pain
G: Other symptoms / other history
H: Quality-of-life (Q-o-L) symptom questionnaires

SECTION 2: SIGNS

A: Abdominal signs
B: Urinary incontinence signs
C: Signs of pelvic organ prolapse
D: Other physical examinations / signs
E: Frequency volume chart / Bladder diary

SECTION 3: URODYNAMIC INVESTIGATIONS AND ASSOCIATED IMAGING

A: Uroflowmetry
B: Post void residual (PVR)
C: Cystometry - General
D: Filling cystometry
E: Urethral function during filling cystometry
F: Voiding cystometry (pressure / flow studies)
G: Urethral function during voiding cystometry
H: Ultrasound imaging with urodynamics
I: Radiological imaging with urodynamics

SECTION 4: MOST COMMON DIAGNOSES

A: Urodynamic stress incontinence (USI)
B: Detrusor overactivity (DO)
C: Sensory urgency (SU)
D: Voiding difficulty (VD)
E: Pelvic organ prolapse (POP)
F: Recurrent urinary tract infections (UTIs)

SECTION 1: SYMPTOMS:

Symptom: Any morbid phenomenon or departure from the normal in structure, function or sensation, experienced by the patient and indicative of disease (1). Symptoms are either volunteered by, or elicited from, the individual or may be described by the individual's caregiver (2, 3, 5).

1A: Urinary Incontinence Symptoms:

(i) Urinary incontinence: Involuntary loss of urine.

(ii) Urinary incontinence (symptom): Complaint of involuntary loss of urine (3, 5).

(iii) Stress (urinary) incontinence: Complaint of involuntary loss of urine during coughing, sneezing or physical exertion such as sports activities etc. (3, 5)

(iv) Urge (urinary) incontinence: Complaint of involuntary loss of urine associated with urgency (3, 5).

(v) Postural (urinary) incontinence: Complaint of involuntary loss of urine associated with change of body position, e.g. rising from a seated or lying position. FN1.

(vi) Nocturnal enuresis: Complaint of urinary loss which occurs during sleep (3, 5).

(vii) Mixed (urinary) incontinence: Complaint of involuntary loss of urine associated with urgency and also with exertion, effort, sneezing or coughing (3).

(viii) Continuous (urinary) incontinence: Complaint of continuous involuntary loss of urine (5).

(ix) Unconscious (unaware, insensible urinary) incontinence: Complaint of involuntary loss of urine unaccompanied by either urgency or stress incontinence provocative factors. The only awareness of the incontinence episode is the feeling of wetness (5).

(x) Coital incontinence: Complaint of involuntary loss of urine with sexual intercourse.

(xi) Post void (micturition) dribble: Complaint of dribbling loss of urine after voiding (5).

1B: Irritative Bladder Symptoms:

. Irritative (adjective): To stimulate an organ (i.e the bladder) to an active response (6).

(i) Diurnal (daytime urinary) frequency: Complaint of passage of urine more than seven times during the day (wakeful hours) (7).

(ii) Nocturia: Complaint of interruption of sleep more than once each night because of the need to micturate (7). FN2

(iii) Urgency: Complaint of a compelling desire to void which is difficult to defer (3). FN3

(iv) Overactive bladder (OAB, Urge) syndrome: The combination of symptoms of urgency, frequency and nocturia with (OAB wet) or without (OAB dry) urge incontinence, in the absence of urinary tract infection or other obvious pathology. FN4

1C: Sensory Symptoms:

. Sensory symptoms: A departure from normal sensation or function, experienced by the patient during bladder filling (1, 3). Normally the individual is aware of increasing sensation with bladder filling up to a strong desire to void (3).

(i) Increased bladder sensation: Complaint of an early and persistent desire to void during bladder filling (3).

(ii) Reduced bladder sensation: Complaint of the absence of a definite desire to void despite awareness of bladder filling (3).

(iii) Absent bladder sensation: Complaint of both the absence of the sensation of bladder filling and a definite desire to void (3).

1D: Voiding Symptoms:

. Voiding symptoms: A departure from normal sensation or function, experienced by the patient during the act of micturition (1).

(i) Hesitancy: Complaint of difficulty resulting in delay in initiating micurition (3).

(ii) Poor stream: Complaint of a urinary stream perceived as inferior (slower or more interrupted) to that previously experienced or in comparison to others.

(iii) Straining to void: Complaint of the need to make an intensive effort to either initiate, maintain or improve the urinary stream. The Crede manoeuvre is when this effort is the application of suprapubic pressure (3).

(iv) Sense of incomplete (bladder) emptying: Complaint that the bladder does not feel empty after voiding.

(v) Need to immediately re-void: Complaint that a further void is necessary soon after passing urine.

1E: Prolapse symptoms

Prolapse: (From the Latin prolapsus, a slipping forth) refers to the falling out of place of a part or whole of a viscus, here generally the vagina or uterus (8).

Prolapse symptoms: A departure from normal sensation, structure or function, experienced by the individual in reference to the position of her pelvic organs. Symptoms are generally worse at the times when gravity might make the prolapse worse (e.g. after long periods of standing or exercise).

(i) Vaginal lump: Complaint of a "bulge" or "something" coming down towards or through the vaginal introitus.

(ii) Suprapubic dragging or heaviness sensation: Complaint of increased heaviness or dragging in the pelvis.

(iii) Need to manually assist voiding and/or defecation: Complaint of the need to digitally replace the prolapse or to otherwise manually apply pressure to assist voiding or defecation.

(iv) Sacral backache: Complaint of sacral backache (generally related to increased tension in the uterosacral ligaments).

(v) Deep dyspareunia: Complaint of discomfort on deep penetration (due possibly to impingement, particularly on a prolapsing uterine cervix, with intercourse).

1F: Lower Urinary Tract Pain / Other Pain

(i) Bladder pain: Complaint of pain felt suprapubically or retropubically, and usually increasing with bladder filling. It may persist after voiding (3).

(ii) Bladder pain syndrome: Complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased diurnal and nocturnal frequency, in the absence of proven urinary tract infection or other obvious pathology (3). FN4

(iii) Other possible areas of pain: Complaints of pain may be referable to the urethra, vulva, vagina and/or perineum.

(iv) Pelvic pain: The complaint of pain in the pelvis. It is less well-defined than the above types of pain. A cyclical basis will raise the possibility of a gynecological cause.

1G: Other Symptoms / Other History (2)

The general history should include questions relevant to:

(i) Neurological and congenital abnormalities:

(ii) Urinary tract infections (UTIs): Including the number of medically documented urinary tract infections over the previous 12 months. FN5

(iii) Relevant surgery: Including and especially prior hysterectomy, prolapse and/or continence surgery.

(iv) Medications: Including those with known or possible effects on the lower urinary tract.

(v) Obstetric history:

(vi) Assessment of menstrual function:

(vii) Assessment of bowel function:

(viii) Assessment of sexual function:

1H: Quality-of-Life (Q-o-L) Symptom Questionnaires

(i) Definition: Questionnaires developed to quantify the effect of chronic lower urinary tract symptoms on patients' lives. Aspects might include the family relationships, social life, work situation, sexual function and general well-being.

(ii) Application: These questionnaires might measure the impact of different interventions on psychosocial function.

SECTION 2: SIGNS

. Sign: Any abnormality indicative of disease, discoverable on examination of the female patient; an objective indication of disease, in contrast to a symptom which is a subjective indication of disease (1).

2A: Abdominal Signs:

Amongst numerous possible abdominal signs are:

(i) Bladder fullness/retention: The bladder may be felt by abdominal palpation or suprapubic percussion.

(ii) Other abdominal masses:

(iii) Scars: Indicating previous relevant surgery.

2B: Urinary Incontinence Signs: All examinations for urinary incontinence are best performed with the individual's bladder comfortably full.

(i) Urinary incontinence: Observation of involuntary loss of urine on examination: this may be urethral or extraurethral (3).

(ii) Stress (urinary) incontinence (clinical stress leakage): Observation of involuntary loss of urine from the urethra synchronous with coughing, sneezing or physical exertion (3, 5).

(iii) Urge (urinary) incontinence: Observation of involuntary urinary loss from the urethra synchronous with a compelling desire to void that can't be deferred (5).

(iv) Extra-urethral incontinence: Observation of urine leakage through channels other than the urethra.

(v) Occult (hidden or masked) stress incontinence: Stress incontinence only observed after the reduction of co-existent prolapse (which otherwise hinders or prevents urine loss). FN6.

2C: Signs of Pelvic Organ Prolapse:

All examinations for pelvic organ prolapse should be performed with the patient's bladder empty. An increasing bladder volume has been shown to restrict the degree of descent of the prolapse (9). Local practice will generally govern the choice of the patient's position during examination: left lateral (Sims), supine or standing. The degree of prolapse may be worse later in the day (after a lengthy time in the erect position) than it is earlier in the day.

(i) Pelvic organ prolapse (definition): The descent (towards or though the vaginal introitus) of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix) or the apex of the vagina (vaginal vault or cuff) after hysterectomy.

(ii) Pelvic organ prolapse (staging [3,8,10]):
Stage 0: No prolapse is demonstrated.
Stage 1: Most distal portion of the prolapse is more than 1cm above the level of the hymen.
Stage II: Most distal portion of the prolapse is 1 cm or less proximal to or distal to the plane of the hymen.
Stage III: The most distal portion of the prolapse is more than 1cm below the plane of the hymen.
Stage IV: Essentially complete eversion of the total length of the lower genital tract is demonstrated. FN7

(iii) Uterine/ cervical prolapse: Observation of descent of the uterus or uterine cervix.

(iv) Vaginal vault (cuff) prolapse:. Observation of descent of the vaginal vault (cuff scar after hysterectomy). If there is the observation of bowel peristalsis underneath the vaginal vault prolapse, an enterocoele can be diagnosed. FN8

(v) Anterior vaginal wall prolapse: Observation of descent of the anterior vagina. Most commonly this would be due to bladder prolapse (cystocoele). Higher stage anterior vaginal wall prolapse will generally involve uterine or vaginal vault (if uterus is absent) descent. Occasionally, there might be anterior enterocoele formation after prior surgery. FN8

(vi) Posterior vaginal wall prolapse: Observation of descent of the posterior vaginal wall. Most commonly, this would be due to rectal protrusion into the vagina (rectocoele). Higher stage posterior vaginal wall prolapse after prior hysterectomy will generally involve some vaginal vault descent and possible enterocoele formation. FN8

2D: Other Physical Examinations / Signs:

These examinations are generally best performed with the patient's bladder empty.

(i) Bimanual pelvic examination: Observations for any unusual pelvic mass or tenderness. The most common mass is an enlarged (generally fibroid) uterus with adnexal pathology less frequently diagnosed.

(ii) Urethral inspection/ palpation:

(ii:a)Urethral caruncle: Prolapse of the urethral (more commonly posterior) mucosa. This is often reflective of the presence of co-existent pelvic organ prolapse.

(ii:b)Urethral diverticulum: The presence of a sac opening from the urethra might be suspected by the presence of a lump along the vaginal aspect of the urethra. Tenderness or the observation of urethral discharge on palpation will increase the index of suspicion.

(ii:c)Urethral tenderness: Tenderness on urethral palpation might be an index of urethral inflammation or infection.

(iii) Pelvic floor muscle function (3): Can be qualitatively defined by the tone at rest and the strength of a voluntary or reflex contraction as strong, weak or absent or by a validated grading symptom (e.g Oxford 1-5). Pelvic muscle contractions may be assessed by visual inspection, by palpation, electromyography, perineometry or ultrasound. Factors to be assessed include strength, duration, displacement and repeatability. It is desirable to document findings for each side of the pelvic floor separately to allow for any unilateral defects.

(iv) Rectal examination: Observations can include:

(iv:a) Anal sphincter tone/ weakness/ defects:

(iv:b) Confirm rectocele:

(iv:c) Eliminate fecal impaction:

(iv:d) Other pathology: Rectal or anal lesion.

(v) Pad testing: Quantification of the amount of urine lost over the duration of testing, by measuring the increase in the weight of the perineal pads used. This may give a guide to the severity of incontinence. Different regimens from a short test to 24 hours have been used with provocation varying between everyday activities to set provocative programs.

2E: Frequency Volume Chart / Bladder Diary

(i) Frequency volume chart (FVC): The recording of the time of each micturition and the volume voided for at least 24 hours.

Information obtained will confirm:

(i:a) Diurnal Frequency: Number of voids by day (wakeful hours).

(i:b) Nocturnal Frequency: Number of times sleep is interrupted by the need to micturate.

(i:c) 24 hour urine production: Summation of all volumes voided in 24 hours.

(i:d) Maximum voided volume: Highest voided volume recorded.

(i:e) Average voided volume: Summation of volumes voided divided by the number of voids.

(i:f) Functional bladder capacity: Median maximum voided volume in everyday activities.

(i:g) Polyuria: Excessive excretion of urine resulting in profuse and frequent micturition (3). It has been defined as over 2.8 litres urine per 24 hours (12).

(i:h)Nocturnal urine volume: Cumulative urine volume from voids after going to bed with the intention of sleeping to include the first void of the morning.

(i:j)Nocturnal polyuria: Excess proportion of urine production occurs at night (or when patient is sleeping). More than 20% (young adults) to 33% (over 65 years) has been suggested as excessive (3).

(ii) Bladder diary: Adds to the FVC above, the fluid intake, pad usage, incontinence episodes and the degree of incontinence. Episodes of urgency might also be recorded.

Additional information obtained from the bladder diaries involve:

Severity of incontinence in terms of leakage episodes and pad usage.

SECTION 3: URODYNAMIC INVESTIGATIONS AND ASSOCIATED IMAGING

Mid-stream urine (MSU): A UTI may create or excacerbate symptoms of lower urinary tract dysfunction. An MSU should be a precursor to further investigations including urodynamics.

Urodynamics: The study of the storage of urine within, and the flow of urine from the urinary tract (1).

Clinical sequence of testing: The investigation of urogynecological patients after a full history is likely to involve a women having presented with a comfortably full bladder for free (no catheter) uroflowmetry and post-void residual urine volume (PVR) measurement prior to filling and voiding (with catheter) cystometry. Examination for clinical stress leakage will generally precede uroflowmetry with examinations for prolapse and intercurrent pathology following PVR measurement. The urodynamic investigations will be outlined in that order.

3A: Measurement of Urine Flow ( Free Uroflowmetry)

(i) Ideal conditions for free uroflowmetry: Women are used to voiding in circumstances of almost complete privacy. It is essential in the clinical situation that every effort is made to make the women feel comfortable and relaxed. If these requirements are ignored, a higher proportion of women will fail to void in a representative way. Ideally, all free uroflowmetry studies should be performed in a completely private uroflowmetry room / toilet lockable from the inside and out of hearing range of other staff and patients (13).

(ii) Urine flow: Voluntary urethral passage of urine which may be:

(ii:a) Continuous: No interruption to flow

(ii:b) Intermittent: Flow is interrupted (2, 3, 13)

(iii) Urine flow rate: Volume of urine expelled via the urethra per unit time. It is expressed in mls/sec (2, 3, 13).

(iv) Voided volume (mls): Total volume of urine expelled via the urethra (2, 3, 13).

(iv) Maximum (urine) flow rate (mls/sec): Maximum measured value of the flow rate (2, 3) correcting for artifacts (3).

(v) Flow time (sec): The time over which measurable flow actually occurs (2, 3).

(vi) Average (urine) flow rate (mls/sec): Voided volume divided by the flow time (2, 3).

(vii) Voiding time (sec): This is the total duration of micturition, i.e includes interruptions. When voiding is completed without interruption, voiding time is equal to flow time (2, 3).

(viii) Time to maximum flow (sec): This is the elapsed time from onset of flow to maximum flow (2, 3).

(ix) Interpretation of the normality of free uroflowmetry: Because of the strong dependency of urine flow rates on voided volume (14), they are best referenced to nomograms where the cutoff for normality has been determined and validated (13, 15). Referencing to a specific urine flow rate provided a volume of say over 150mls is voided has been used, though this method has not been adequately researched. This practice may also invalidate the data from a significant number of women whose presenting bladder volume is under this amount.

3B: Measurement of Post Void Residual (urine volume - PVR)

(i) Post void residual: Urine remaining in the bladder immediately following the completion of micturition (2, 3, 6 - referencing "residual")

(ii) Conditions for PVR measurement: Most accurate measurement is that achieved within the shortest possible time after voiding, in order to limit the main source of error (16), the renal input into bladder volume between voiding and PVR measurement. This would make the PVR falsely elevated. Ultrasound can achieve accurate PVR measurement in under 60 seconds whilst, even in ideal circumstances, urethral catheterization will take a minimum of nearly 5 minutes (16, 17). A short plastic female catheter provides the most effective bladder drainage for PVR with a Foley catheter relatively ineffective (18). Small bore catheters used for filling cystometry have not been tested for their efficacy in bladder drainage.

(iii) Assessment of normality of PVR: Quoted upper limits of normality reflect the accuracy of measurement discussed above. For series using ultrasound measurement within 60 seconds of voiding, an upper limit of 30mls is suggested (19); for series using urethral catheterization (unspecified) within 10 minutes of voiding, an upper limit of 100mls is suggested (20). An isolated finding of a raised PVR requires confirmation before being considered significant. Ultrasonic techniques allow an immediate further attempt at voiding rather than waiting for spontaneous or artificial bladder re-filling.

3C: Cystometry - General:

(i) Cystometry: Measurement of the pressure/volume relationship of the bladder during filling and voiding (1, 2).

(ii) Cystometrogram (CMG): Graphical recording of the pressure/volume relationship of the bladder (1, 2).

(iii) Conventional urodynamic studies: These usually take place in a special clinical room and involve (artificial) bladder filling with a specified liquid at a specified rate (3)

(iv) Conditions for cystometry (2, 3):

(iv:a)Pressures: All systems are zeroed at atmospheric pressure

(iv:b)External pressure transducers: Reference point is the superior edge of the pubic symphysis.

(iv:c) Catheter mounted transducers: Reference point is the catheter itself.

(iv:d) Initial bladder volume: Bladder should be empty.

(iv:e)Fluid medium: Usually water or saline.

(iv:f)Temperature of fluid: Should be warmed to body temperature.

(iv:g)Position of patient: Sitting position is more provocative for abnormal detrusor activity than the supine position.

(iv:h)Filling rate: Usually towards the upper end of the "medium fill" range of 10-100 mls/min, e.g. 75mls per min.

(v) Intravesical pressure: The pressure within the bladder (1-3).

(vi) Abdominal pressure: The pressure surrounding the bladder. It is usually estimated from measuring the rectal pressure, though vaginal and less commonly, experitoneal pressure or the pressure though a bowel stoma can be measured as an alternative. The simultaneous measurement of abdominal pressure is essential for interpretation of the intravesical pressure trace (2, 3). Artefacts on the detrusor pressure trace may be produced by intrinsic rectal contraction.

(vii) Detrusor pressure: The component of intravesical pressure that is created by forces in the bladder wall (passive and active). It is estimated by subtracting abdominal pressure from intravesical pressure.

(viii) Ambulatory urodynamics: These investigations are a functional test of the lower urinary tract, performed outside the clinical setting, involving natural filling and reproducing the woman's everyday activities.

3D: Filling Cystometry

(i) Filling cystometry: This is the pressure volume relationship of the bladder during bladder filling (1, 2). It begins with the commencement of filling and ends when a "permission to void" is given by the urodynamicist (3).

(ii) Aims of filling cystometry: These are to assess bladder sensation, bladder capacity, detrusor activity and bladder compliance (2, 3).

(iii) Bladder sensation during filling cystometry: This is usually assessed by questioning the patient in relation to the fullness of the bladder during cystometry (2).

(iii:a) First desire to void (2): This is the first feeling that the woman may wish to void.

(iii:b) Normal desire to void: This is the feeling that leads the patient to pass urine at the next convenient moment, but voiding can be delayed if necessary.

(iii:c) Strong desire to void: This is the persistent desire to void without the fear of leakage.

(iii:d) Urgency: compelling desire to void which is difficult to defer (3). FN3.

(iii:e) Pain: During filling cystometry, pain is abnormal. Its site, character and duration should be noted.

(iv) Bladder capacity during filling cystometry:

(iv:a) Cystometric capacity: Bladder volume at the end of filling cystometry, when a "permission to void" is usually given by the urodynamicist. This might be higher than normal in patients with reduced bladder sensation.

(iv:b) Maximum cystometric capacity: In patients with normal sensation, this is the volume when she can no longer delay micturition.

(v) Detrusor function during filling cystometry: The women is trying to inhibit detrusor activity and micturition until she is given a "permission to void".

(v:a)Normal (previously "stable") detrusor function: There is little or no change in detrusor pressure with filling. There are no involuntary phasic contractions despite provocation with such activities as standing, coughing, hearing the sound of running water, hand washing etc.

(v:b)Detrusor overactivity: Involuntary detrusor contractions occur during filling which may be spontaneous or provoked and which the patient cannot suppress. They take a wave (phasic) form, of variable duration, on the cystometrogram. Urgency is generally associated in women with normal bladder sensation though contractions may be asymptomatic or may be interpreted as a normal desire to void. Incontinence may or may not occur. A gradual increase in detrusor pressure without subsequent decrease is best regarded as a change in compliance.

(v:c)Neurogenic detrusor overactivity (previously detrusor hyperreflexia): This is where the detrusor overactivity is due to a disturbance of nervous control mechanism and there is objective evidence of a relevant neurological disorder.

(vi) Bladder compliance (2): This describes the change in bladder volume for a change in detrusor pressure. Compliance is calculated by dividing the volume change (?V) by the change in detrusor pressure (? P det) during that change in bladder volume. ( C = ?V / ? Pdet). Compliance is expressed as ml per cm H2O. Bladder compliance can be affected by:

(vi:a)Bladder Filling: Faster filling is more provocative.

(vi:b) BladderThickness: Greater thickness, generally less compliant.

(vi:c) Contractile/relaxant properties of the detrusor: More contractile, less compliant.

(vi:d) Starting point for compliance calculations (3): Usually the detrusor pressure at the start of bladder filling and the corresponding bladder volume (usually zero).

(vi:e)End point for compliance calculations (3): The detrusor pressure (and corresponding bladder volume) at cystometric capacity or immediately before the start of any detrusor contraction that causes significant leakage (and therefore causes the bladder volume to decrease, affecting compliance calculation). Both points are measured excluding any detrusor contraction.

(vii) Urodynamic (previously "genuine") stress incontinence: This is the involuntary leakage of urine during filling cystometry, associated with increased abdominal pressure, in the absence of a detrusor contraction (3). The sign of stress incontinence might have been already noted with the initial physical examination. Cystometry then completes the assessment of detrusor function to confirm the diagnosis.

3E: Urethral Function During Filling Cystometry

(i) Urethral closure mechanism (3):

(i:a) Normal urethral closure mechanism: A positive urethral closure pressure (bladder pressure minus urethral pressure) is maintained during bladder filling, even in the presence of increased abdominal pressure, although it may be overcome by detrusor overactivity.

(i:b) Incompetent urethral closure mechanism: Leakage of urine is allowed in the absence of a detrusor contraction.

(i:c) Urethral relaxation incompetence ("urethral instability"): Leakage due to urethral relaxation in the absence of raised abdominal pressure or detrusor overactivity.

(ii) Urethral pressure measurement (2): Urethral pressure and urethral closure pressure are idealized concepts which represent the ability of the urethra to prevent leakage. Urethral pressure is currently measured by a number of different techniques which don't tend to have consistent results, either between methods or for a single method. For example the effect of catheter rotation will be relevant when urethral pressure is measured by a catheter mounted transducer. Urethral pressure might be measured:

. At rest, with the bladder at a given volume

. During coughing or straining

. During the process of voiding

(ii:a) Urethral pressure (intraluminal): This is the fluid pressure needed to just open a closed urethra.

(ii:b)Urethral pressure profile (UPP): This is a graph indicating the intraluminal pressure along the length of the urethra.

. Resting UPP: The bladder and subject are at rest

. Stress UPP: Defined applied stress (e.g. cough, strain, valsalva)

(ii:c) Maximum urethral pressure (MUP): Maximum pressure in the UPP.

(ii:d) Urethral closure pressure profile (UCPP): The relevant pressure is the urethral closure pressure (defined above).

(ii:e) Maximum urethral closure pressure (MUCP): Maximum pressure in the UCPP, i.e. the maximum difference between the urethral pressure and the intravesical pressure.

(ii:f) Functional profile length: The length of the urethra along which the urethral pressure exceeds intravesical pressure in women.

(ii:g)Pressure "transmission" ratio: This is the increment in urethral pressure on stress as a percentage of the simultaneously recorded increment in intravesical pressure.

(iii) Leak point pressures (21, 22): There are two types of leak point pressure measurement. The pressure values at leakage should be measured at the moment of leakage.

(iii:a)Detrusor leak point pressure (detrusor LPP): This a static test. The pressure is the lowest value of the detrusor pressure at which leakage is observed in the absence of increased abdominal pressure or a detrusor contraction. High detrusor LPP (e.g over 40 cm H2O [21]) puts patients at risk for upper urinary tract deterioration or secondary damage to the bladder.

(iii:b)Abdominal leak point pressure (abdominal LPP): This is a dynamic test. It is the lowest value of the intentionally increased intravesical pressure that provokes urinary leakage in the absence of a detrusor contraction (22). The increase in pressure can be induced by a cough (cough LPP) or valsalva (valsalva LPP). Multiple estimates at a fixed bladder volume (200-300mls) are desirable. A low abdominal LPP indicates poor urethral function.

N.B. The correlation between MUCP and abdominal LPP may depend on catheter type used.

3F: Voiding Cystometry (Pressure Flow Studies)

(i) Voiding cystometry: This is the pressure volume relationship of the bladder during bladder emptying (1). It begins when "permission to void" is given by the urodynamicist and ends when the patient considers her voiding has finished (3). Measurements to be recorded should be the intravesical, intra-abdominal and urethral pressures and the urine flow rate.

(ii) Measurements during voiding cystometry (2, 3):

(ii:a) Opening Time: The time elapsed from initial rise in detrusor pressure to onset of flow. This is the initial isovolumetric contraction period of micturition. Flow measurement delay should be taken into account when measuring opening time.

(ii:b) Premicturition pressure: The pressure recorded immediately before the initial isovolumetric contraction.

(ii:c) Opening pressure: The pressure recorded at the onset of measured flow.

(ii:d) Maximum pressure: Maximum value of the measured pressure.

(ii:e) Pressure at maximum flow: Pressure recorded at maximum measured flow rate.

(ii:f) Closing pressure: Pressure recorded at the end of measured urine flow.

(ii:g) Contraction pressure at maximum flow: This is the difference between pressure at maximum flow and the premicturition pressure.

(ii:h)Flow delay: This is the delay in time between a change in bladder pressure and the corresponding change in measured flow rate.

(iii) Detrusor function during voiding (2, 3):

(iii:a)Normal detrusor function: Normal voiding in women is achieved by an initial (voluntary) reduction in intra-urethral pressure (urethral relaxation) (23). This is generally followed by a continuous detrusor contraction that leads to complete bladder emptying within a normal time span. Many women will void successfully (normal urine flow and no PVR) predominantly by urethral relaxation alone, without much of a rise in detrusor pressure (24). The amplitude of the detrusor contraction will tend to increase to cope with any degree of bladder outflow obstruction (25). FN9

(iii:a)Detrusor underactivity: Detrusor contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span.

(iii:b) Acontractile detrusor: The detrusor cannot be observed to contract during urodynamic studies. The term "areflexia" has been used where there is a neurological cause.

3G: Urethral Function during Voiding Cystometry.

(i) Normal urethral function: The urethra opens and is continuously relaxed to allow the bladder to be emptied at a normal pressure, urine flow and PVR. FN10.

(ii) Bladder outflow obstruction: This is the generic term for obstruction during voiding. It is a reduced urine flow rate and/or presence of a raised PVR and an increased detrusor pressure (FN10). It is usually diagnosed by studying the synchronous values of flow rate and detrusor pressure. A urethral stricture or obstruction due to higher degrees of uterovaginal prolapse might contribute to this picture.

(iii) Dysfunctional voiding: This is characterized by an intermittent and/or fluctuating flow rate due to involuntary intermittent contractions of the peri-urethral striated or levator muscles during voiding in neurologically normal women.

(iv) Detrusor sphincter dyssynergia (DSD): This is detrusor contraction synchronous with contraction of the urethral and/or periurethral striated muscle. This is a feature of neurological voiding disorders. Neurological features should be sought.

3H: Ultrasound Imaging with Urodynamics (Dietz HP, Sultan A, Starck M Shek C, Tunn T et al. The standardization of pelvic floor ultrasound (in preparation).

(i) Ultrasound in urogynaecology: Ultrasound has become an increasingly frequent adjunct investigation in urogynecology both in the office and the urodynamic laboratory. Its ability to augment the diagnostic accuracy in those settings justifies this summary of the various modalities and the applications.

(ii) Modalities in current routine clinical use:

(ii:a) Perineal: Curved array probe applied to the perineum. This term incorporates transperineal, translabial and introital ultrasound.

(ii:b) Transvaginal (T-V): Intravaginal curvilinear/ linear array or sector scanning.

(ii:c)Transabdominal (T-A): Curvilinear scanning applied to the abdomen.

(iii) Current routine possible diagnoses using ultrasound in urogynecology (26)

(iii:a) Bladder neck descent / mobility/ opening:

- Position of bladder neck at rest and on valsalva
- Retrovesical angle (RVA) or angle between proximal urethra and trigonal surface of the bladder
- Urethral rotation, i.e. rotation of the proximal urethra on valsalva
- Angle gamma: angle defined by lines from the inferoposterior symphyseal margin to the bladder neck at rest and on valsalva.
- Urethral funneling
- Urine loss: full urethral opening or colour Doppler
(iii:b) Post void residuals:

(iii:c) Intercurrent pelvic pathology: e.g Fibroids, ovarian pathology

(iii:d) Uterine version: Anteverted or retroverted as well as any further angulation of the body of the uterus at the level of the uterine isthmus (flexion).

(iii:e) Bladder abnormalities: e.g. Tumour; foreign body

(iii:f) Urethral abnormality: e.g. Diverticulum

(iii:g) Postoperative findings: e.g. Bladder neck mobility, position of meshes, tapes or implants.

(iii:h) Pelvic floor / levator defects:

(iii:j) Descent of pelvic organs:

(iii:k) Detrusor wall thickness

N.B. Diagnostic ability may be enhanced by the use of 3D or 4D ultrasound

3J: Radiological Imaging with Urodynamics

(i) Modalities in current routine clinical use (27):

(1:a) Videocystourethrography (VCU): Synchronous radiological screening of the bladder and measurement of the bladder and abdominal pressure during filling and voiding cystometry. Cost, time, personnel and space considerations restrict its routine use, even in tertiary centres. Women with complex neurological or voiding disorders or multiple prior surgery may benefit from VCU. When used, however, VCU allows the clinician to directly observe the effects of bladder events: the position and conformation of the bladder neck in relation to the pubic symphysis, bladder neck closure during rest and stress, diverticula of the bladder and urethra, vesicoureteral reflux and voiding events.

(ii) Other modalities: None of these are office or urodynamic laboratory based.

4: DIAGNOSES

A: Urodynamic Stress Incontinence (USI)

(i) Definition: As noted in section 3D:(vii), this urodynamic diagnosis is the involuntary leakage of urine during filling cystometry, associated with increased abdominal pressure, in the absence of a detrusor contraction. The sign of stress incontinence might been noted with the physical examination. Cystometry then completes the assessment of detrusor function.

(ii) Prevalence: This is the most common urogynecological diagnosis, occurring in up to 72% patients presenting for the first time (28).

B: Detrusor Overactivity (DO)

(i):Definition: As noted in section [3D:(v:b)], this urodynamic diagnosis is made in women with lower urinary tract symptoms (more commonly OAB-type symptoms - section [1B:(iv)] when involuntary detrusor contractions occur during filling cystometry. These contractions, which may be spontaneous or provoked, are unable to be suppressed by the patient.

(ii) Prevalence: The prevalence of DO ranges between 13% (28) and 40% (29) of patients attending for urodynamics. There may be a disparity between the severity of the woman's symptoms and the amplitude of the contractions.

C: Sensory Urgency (SU)

(i) Definition: Sensory urgency, a urodynamic diagnosis, generally occurs in a women with some of all of the symptoms of urgency, frequency and nocturia with or without urge incontinence and a voiding diary showing average voided volumes under 150mls. It can be defined as an increased perceived bladder sensation during filling [1C: (i)], a low first desire to void [3D:(iii:a)] (generally under 100mls) and a low maximum cystometric bladder [3D:(iv:b)] capacity (under 400mls in a predominantly Caucasian population) in the absence of recorded urinary tract infection (UTI) or detrusor overactivity[3D:(v:b)] (30, 31). FN11

(ii) Prevalence: The prevalence of sensory urgency in urogynecology patients is 10 - 13% (32, 31).

D: Voiding Difficulty (VD)

(i)Definition: Voiding difficulty, a urodynamic diagnosis, is defined as abnormally slow and/or incomplete micturition (33). The only validated definition of voiding difficulty is: (i) urine flow rate under the 10th centile of the Liverpool nomogram (15, 28) and/or a PVR (measured by transvaginal ultrasound) 30mls or under (17). Alternate criteria of a maximum urine flow rate less than 15ml/sec and/or PVR greater than 50ml with a minimum total bladder volume of 150ml before voiding, have been proposed but not validated (34). Pressure / flow studies are indicated to evaluate the cause of any voiding difficulty. Assessment of voiding difficulty from pressure / flow charts has been the subject of ongoing research (25).

(ii)Prevalence: Depending on definition, voiding difficulty has a prevalence of 14% (34) to 39% (28), the latter figure making it either the third or fourth most common urodynamic diagnosis (after USI, prolapse and possibly detrusor overactivity). FN12

(iii) Alternative presentations:

(iii:a) Acute retention of urine(3): This is defined as a painful, palpable or percussable bladder, when the patient is unable to pass any urine.

(iii:b)Chronic retention of urine: This defined as a non-painful bladder, where there is a chronic PVR of over 200mls (19).

E: Pelvic Organ Prolapse (POP)

(i)Definition: This diagnosis [2C:(i)] by clinical examination, involves the identification of descent (towards or through the vaginal introitus) of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix) or the apex of the vagina (vaginal vault or cuff) after hysterectomy.

(ii) Prevalence: Around 61% (28) of women presenting for initial urogynecological assessment will have some degree of prolapse, not always symptomatic. FN13

F: Recurrent Urinary Tract Infections (UTIs)

(i) Definition: The number of medically documented urinary tract infections (UTI) over the last 12 months is included as a "working diagnosis", by history, awaiting further research.

(ii) Prevalence: Using this definition, 2 or more and 3 or more UTI's can occur with a prevalence of 21% and 13% respectively (36). This then becomes a significant, generally intercurrent, diagnosis likely to require treatment additional to that planned for other diagnoses found. FN14.

Figures 1A and 1B shows prolapse staging - 0, I, II, III, IV. (uterine - by the position of the leading edge of the cervix).

Figure 1A

Figure1B

(vi) Posterior vaginal wall prolapse Observation of descent of the posterior vaginal wall. Most commonly, this would be due to rectal protrusion into the vagina (rectocele). Higher stage posterior vaginal wall prolapse after prior hysterectomy will generally involve some vaginal vault (cuff scar) descent and possible enterocele formation. FN15 (18). Enterocoele formation can also occur in the presence of an intact uterus.

2C: Other Pelvic Examinations / Signs (2, 3, 19): The internal examinations are generally best performed with the woman’s bladder empty.

(i)Vulval examination: Abnormalities include cysts, other tumors, atrophic changes or lichen sclerosis.

(ii) Urethral inspection/ palpation:

(ii:a)Urethral mucosal prolapse: Prolapse, generally circumferential and larger, of the distal urethral urothelium.

(ii:b)Urethral caruncle: Smaller eversion of the urethral urothelium, generally involving the posterior lip.

(ii:c)Urethral diverticulum: The presence of a sac opening from the urethra. It might be suspected by a lump or tenderness along the line of the urethra or external urethral discharge on urethral massage.

(iii) Vaginal examination: Examination for vaginal length and mobility, presence of scarring and/or pain and estrogenization. The location of any vaginal pain should be noted. Included here is any tenderness over the course of the pudendal nerve (see 1H (viii) pudendal neuralgia).

(iv) Bimanual pelvic examination: Observations for any pelvic mass or unusual tenderness by vaginal examination together with suprapubic palpation.

(v) Pelvic floor muscle function (3, 19): Can be qualitatively defined by the tone at rest and the strength of a voluntary or reflex contraction as strong, normal, weak or absent or by a validated grading symptom. Voluntary pelvic floor muscle contraction and relaxation may be assessed by visual inspection, by digital palpation (circumferentially), electromyography dynamometry, perineometry or ultrasound. Factors to be assessed include muscle strength (static and dynamic), voluntary muscle relaxation (absent, partial, complete), muscular endurance (ability to sustain maximal or near maximal force), repeatability (the number of times a contraction to maximal or near maximal force can be performed), duration, co-ordination and displacement. It is desirable to document findings for each side of the pelvic floor separately to allow for any unilateral defects and asymmetry. The ICS report into the standardization of terminology of pelvic floor muscle function and dysfunction (reference 19) provides a fuller description of the assessment of pelvic floor muscle function including the following:

(v:a) Normal pelvic floor muscles: Pelvic floor muscles which can voluntarily and involuntarily contract and relax.

(v:b) Overactive pelvic floor muscles: Pelvic floor muscles which do not relax, or may even contract when relaxation is functionally needed, for example, during micturition or defecation.

(v:c) Underactive pelvic floor muscles: Pelvic floor muscles which cannot voluntarily contract when this is appropriate.

(v:d) Non-functioning pelvic floor muscles: Pelvic floor muscles where there is no action palpable.

(vi) Examination for levator (puborectalis) injury: The puborectalis muscle may be assessed for the presence of major morphological abnormalities by palpating its insertion on the inferior aspect of the os pubis. If the muscle is absent 2-3cm lateral to the urethra, i.e. if the bony surface of the os pubis can be palpated as devoid of muscle, an “avulsion injury” of the puborectalis muscle is likely (20).

(vii) Perineal examination (19): When the patient is asked to cough or Valsalva, the perineum should show no downward movement; ventral movement may occur because of the guarding actions of the pelvic floor muscles.

(vii:a) Perineal elevation: This is the inward (cephalad) movement of the vulva, perineum and anus.

(vii:b) Perineal descent: This is the outward (caudal) movement of the vulva, perineum and anus.

(viii) Rectal examination: Observations can include:

(viii:a) Anal sphincter tone and strength: Assessment on digital examination, as good or poor in the absence of any quantitative assessment.

(viii:b) Anal sphincter tear: May be recognized as a clear “gap” in the anal sphincter on digital examination.

(viii:c) Confirm presence or absence of rectocele: and if possible, differentiate from enterocele. Diagnose perineal body deficiency.

(viii:d) Confirm presence or absence of fecal impaction:

(viii:e) Other rectal lesions: Intussusception, rectovaginal fistula or tumor.

(viii:f) Anal lesions: Hemorrhoids, fissure.

(viii:g) Other perianal lesions: Anocutaneous fistula.

2D: Other Relevant Examinations / Signs (2):

The following general examinations and signs may be relevant:

(i) Neurological Signs: For patients with possible neurogenic lower urinary tract or pelvic floor dysfunction, there should be particular note of those neurological signs related to S2-4, but these should be complemented by a more general neurological examination as indicated.

(ii) Abdominal Signs: Amongst numerous possible abdominal signs are:

(ii:a) Bladder fullness / retention: The bladder may be felt by abdominal palpation or suprapubic percussion.

(ii:b) Other abdominal masses: or distension (e.g. ascites).

(ii:c) Scars: Indicating previous relevant surgery or traumas.

(ii:d) Renal Area: Examination for tenderness, masses.

2E: Frequency Volume Chart / Bladder Diary

(i)Frequency volume chart (FVC): The recording of the time of each micturition and the volume voided for at least 24 hours. Two or three days of recording (not necessarily consecutive) will generally provide more useful clinical data.

Information obtained will confirm:

(i:a) Daytime urinary frequency: Number of voids by day (wakeful hours including last void before sleep and first void after waking and rising).

(i:b) Nocturnal frequency/ Nocturia: Number of times sleep is interrupted by the need to micturate. Each void is preceded and followed by sleep.

(i:c) 24-hour frequency: Total number of daytime voids and episodes of nocturia during a specified 24-hour period.

(i:d) 24 hour urine production: Summation of all urine volumes voided in 24 hours.

(i:e) Maximum voided volume: Highest voided volume recorded.

(i:f) Average voided volume: Summation of volumes voided divided by the number of voids.

(i:g) Median functional bladder capacity: Median maximum voided volume in everyday activities.

(i:h) Polyuria: Excessive excretion of urine resulting in profuse and frequent micturition (3). It has been defined as over 40ml/kg body weight during 24 hours or 2.8 litres urine for a woman weighing 70kg (21).

(i:j) Nocturnal urine volume: Cumulative urine volume from voids after going to bed with the intention of sleeping to include the first void at the time of waking with the intention of rising (excludes last void before sleep).

(i:k) Nocturnal polyuria: Excess (over 20-30% – age dependent) proportion of urine excretion (nocturnal voided volume /total 24hr voided volume x 100%) occurs at night (or when patient is sleeping). FN16.

(ii) Bladder diary: Adds to the FVC above, the fluid intake, pad usage, incontinence episodes and the degree of incontinence. Episodes of urgency and sensation might also be recorded, as might be the activities performed during or immediately preceding the involuntary loss of urine. Additional information obtained from the bladder diary involves:

Severity of incontinence in terms of leakage episodes and pad usage.

Figure 2: Bladder Diary

This simple chart allows you to record the fluid you drink and the urine you pass over 3 days (not necessarily consecutive) in the week prior to your clinic appointment. This can provide valuable information.

• Please fill in approximately when and how much fluid you drink, and the type of liquid.

• Please fill in the time and the amount (in mls, or ounces) of urine passed, and mark with a star if you have leaked or mark with a “P” if you have needed to change your pad.

(Please find below an example of how to complete this form.)

SUMMARY

Frequency = 9; Nocturia = 1; Urine production / 24hr = 1250ml;

Maximum voided volume = 300mls; Average voided volume = 125ml.

2F: Pad Testing

Quantification of the amount of urine lost over the duration of testing, by measuring the increase in the weight of the perineal pads (weighed pre- and post-testing) used. This may give a guide to the severity of incontinence. Different durations from a short (1 hour) test to a 24 and 48 hour tests have been used with provocation varying from normal everyday activities to defined regimens.

SECTION 3: URODYNAMIC INVESTIGATIONS AND

ASSOCIATED PELVIC IMAGING

Urodynamics: Functional study of the lower urinary tract.

Clinical sequence of testing: Urodynamic investigations generally involve a woman attending with a comfortably full bladder for free (no catheter) uroflowmetry and post void residual urine volume (PVR) measurement prior to filling and voiding (with catheter) cystometry.

3A: Uroflowmetry

(i) Ideal conditions for free (or spontaneous – no catheter) uroflowmetry: Ideally, all free uroflowmetry studies should be performed in a completely private uroflowmetry room. Most modern uroflowmeters have a high degree of accuracy ( +/- 5%) though regular calibration is important (22).

(ii) Urine flow: Voluntary urethral passage of urine which may be:

(ii:a) Continuous: No interruption to flow.

(ii:b) Intermittent: Flow is interrupted.

(iii) Flow rate: Volume of urine expelled via the urethra per unit time. It is expressed in ml/sec (2, 3).

(iv) Voided volume (ml): Total volume of urine expelled via the urethra (2, 3).

(v) Maximum (urine) flow rate (MUFR – ml/sec) – Qmax: Maximum measured value of the flow rate (2, 3) correcting for artifacts (3).

(vi) Flow time (sec): The time over which measurable flow actually occurs (2, 3).

(vii) Average (urine) flow rate (AUFR- ml/sec) – Qave: Voided volume divided by the flow time (2, 3).

FIGURE 3: A schematic representation of urine flow over time

(viii) Voiding time (sec): This is the total duration of micturition, i.e includes interruptions. When voiding is completed without interruption, voiding time is equal to flow time (2, 3).

(ix) Time to maximum flow (sec): This is the elapsed time from the onset of urine flow to maximum urine flow (2, 3).

(x) Interpretation of the normality of free uroflowmetry: Because of the strong dependency of urine flow rates on voided volume (23), they are best referenced to nomograms where the cutoff for abnormally slow (MUFR, AUFR) has been determined and validated (22, 24, 25) as under the 10th centile of the respective Liverpool nomogram (25). References to a specific urine flow rate as the lower limit of normal provided a specific volume has been voided require further validation studies (26).

FIGURE 4: Liverpool Nomogram for maximum urine flow rate in women (22, 24).

Equation: Ln (Maximum urine flow rate) = 0.511 + 0.505 x Ln (voided volume)?

Root mean square error = 0.340 References: 22, 24 (Reproduced with permission)

3B: Post Void Residual (urine volume)

(i) Post void residual: Volume of urine left in the bladder at the completion of micturition (1, 3).

(ii) Conditions for PVR measurement: PVR reading is erroneously elevated by delayed measurement due to additional renal input (1-14mls/min) into bladder volume (27). Ultrasonic techniques (transvaginal, abdominal, Doppler planimetry) allow immediate (within 60 seconds of micturition) measurement (27). A short plastic female catheter provides the most effective bladder drainage for PVR measurement (27).

(iii) Assessment of normality of PVR: Quoted upper limits of normal may reflect the accuracy of measurement. Studies using “immediate” PVR measurement (e.g. transvaginal ultrasound) suggest an upper limit of normal of 30mls (28). Studies using urethral catheterization (up to 10 minute delay) quote higher upper limits of normal of 50mls (26) or 100mls (28). An isolated finding of a raised PVR requires confirmation before being considered significant.

3C: Cystometry – General (2, 3, 29):

(i) Cystometry: Measurement of the pressure/volume relationship of the bladder during filling and/or pressure flow study during voiding (2, 29).

(ii) Cystometrogram (CMG): Graphical recording of the bladder pressure(s) and volume(s) over time. (2, 29).

(iii) Urodynamic studies: These usually take place in a special clinical room (urodynamic laboratory) and involve (artificial) bladder filling with a specified liquid at a specified rate (3, 29).

(iv) Conditions for cystometry (2, 3, 29):

(iv:a) Pressures: All systems are zeroed at atmospheric pressure.

(iv:b) External pressure transducers: Reference point is the superior edge of the pubic symphysis.

(iv:c) Catheter mounted transducers: Reference point is the transducer itself.

(iv:d) Initial bladder volume: Bladder should be empty.

(iv:e) Fluid medium: Usually water or saline (or contrast if radiology involved).

(iv:f) Temperature of fluid: Should ideally be warmed to body temperature.

(iv:g) Position of patient: Sitting position is more provocative for abnormal detrusor activity than the supine position. At some point in the test, filling might desirably take place with the patient standing.

(iv:h) Filling rate: The filling rate, including any changes during testing, should be noted on the urodynamic report.

(v) Intravesical pressure (p ves): The pressure within the bladder (1- 3).

(vi) Abdominal pressure (p abd): The pressure surrounding the bladder. It is usually estimated from measuring the rectal pressure, though vaginal and infrequently the pressure though a bowel stoma can be measured as an alternative. The simultaneous measurement of abdominal pressure is essential for interpretation of the intravesical pressure trace (2, 3). Artefacts on the detrusor pressure trace may be produced by an intrinsic rectal contraction.

(vii) Detrusor pressure (p det): The component of intravesical pressure that is created by forces in the bladder wall (passive and active). It is estimated by subtracting abdominal pressure from intravesical pressure (3).

(viii) Ambulatory urodynamics: These investigations are a functional test of the lower urinary tract, performed outside the clinical setting, involving natural filling and reproducing the woman’s everyday activities.

3D: Filling Cystometry (2, 3, 29)

(i) Filling cystometry: This is the pressure/volume relationship of the bladder during bladder filling (1, 2). It begins with the commencement of filling and ends when a “permission to void” is given by the urodynamicist (3).

(ii) Aims of filling cystometry: These are to assess bladder sensation, bladder capacity, detrusor activity and bladder compliance (2, 3).

(iii) Bladder sensation during filling cystometry: This is usually assessed by questioning the woman in relation to the fullness of the bladder during cystometry (2).

(iii:a) First sensation of bladder filling: The feeling when the woman first becomes aware of bladder filling (3).

(iii:b) First desire to void (2): The first feeling that the woman may wish to pass urine.

(iii:c) Normal desire to void: The feeling that leads the woman to pass urine at the next convenient moment, but voiding can be delayed if necessary.

(iii:d) Strong desire to void: The persistent desire to pass urine without the fear of leakage.

(iii:e) Urgency: Sudden, compelling desire to pass urine which is difficult to defer (3). FN6.

(iii:f) Bladder oversensitivity – also referred to as either “increased bladder sensation”(3) or “sensory urgency”(2- now obsolete): Increased perceived bladder sensation during bladder filling with: an early first desire to void; an early strong desire to void, which occurs at low bladder volume; a low maximum cystometric bladder capacity (3D(iv:b)); no abnormal increases in detrusor pressure.

(iii:g) Reduced bladder sensation: Bladder sensation perceived to be diminished during filling cystometry.

(iii:h) Absent bladder sensation: The woman reports no bladder sensation during filling cystometry.

(iii:j) Pain: The complaint of pain during filling cystometry is abnormal. Its site, character and duration should be noted.

(iv) Bladder capacity during filling cystometry:

(iv:a) Cystometric capacity: Bladder volume at the end of filling cystometry, when “permission to void” is usually given by the urodynamicist. This endpoint and the level of the woman’s bladder sensation at that time, e.g. “normal desire to void”, should be noted.

48 year old female with urinary frequency. No phasic activity during filling. Voided with normal urine flow rate at normal detrusor voiding pressure. Normal study. FD = First Desire to Void, ND = Normal desire to void, SD = Strong desire to void, U = Urgency, CC = Cystometric Capacity (permission to void given).

FIGURE 5: Filling Cystometry – Normal detrusor function..

(iv:b) Maximum cystometric capacity: In patients with normal sensation, this is the bladder volume when she can no longer delay micturition.

(v) Detrusor function during filling cystometry:

(v:a) Normal (previously “stable”) detrusor function: There is little or no change in detrusor pressure with filling. There are no involuntary phasic contractions despite provocation with activities such as postural changes, coughing, hearing the sound of running water, handwashing etc.

(v:b) Detrusor overactivity: The occurrence of involuntary detrusor contractions during filling cystometry. These contractions, which may be spontaneous or provoked, produce a wave form on the cystometrogram, of variable duration and amplitude. The contractions may be phasic or terminal. Symptoms, e.g. urgency and/or urgency incontinence may or may not occur. If a relevant neurological cause is present, then neurogenic detrusor overactivity is noted, otherwise idiopathic detrusor overactivity should be the term used.

52 year old female with urgency and frequency. Phasic detrusor activity during filling. Leakage is associated with urgency and detrusor contractions. FD = First Desire to Void, ND = Normal desire to void, SD = Strong desire to void, U = Urgency, L = leakage, MCC = Maximum Cystometric Capacity.

FIGURE 6: Filling Cystometry – Detrusor Overactivity.

(v:c) Neurogenic detrusor overactivity: This is where there is detrusor overactivity and there is evidence of a relevant neurological disorder.

(vi) Bladder compliance (2, 3): This describes the relationship between a change in bladder volume and change in detrusor pressure (3). Compliance is calculated by dividing the volume change (?V) by the change in detrusor pressure (? P det) during that change in bladder volume. ( C = ?V / ? Pdet). Compliance is expressed as ml per cm H2O. Bladder compliance can be affected by:

(vi:a ) Bladder filling: Faster filling is more provocative. An artifact may be produced which settles when filling is interrupted.

(vi:b) Contractile / relaxant properties of the detrusor: e.g. post-radiation changes of the detrusor wall.

(vi:c) Starting point for compliance calculations (3): Usually the detrusor pressure at the start of bladder filling and the corresponding bladder volume (usually zero).

(vi:d) End point for compliance calculations (3): The detrusor pressure (and corresponding bladder volume) at cystometric capacity or immediately before the start of any detrusor contraction that causes significant leakage (and therefore causes the bladder volume to decrease, affecting compliance calculations). Both points are measured excluding any detrusor contraction.

3E: Urethral Function During Filling Cystometry (Filling urethro-cystometry)

(i) Urethral pressure measurement (2, 3, 29): Urethral pressure and urethral closure pressure are idealized concepts which represent the ability of the urethra to prevent leakage. Urethral pressure is currently measured by a number of different techniques which don’t tend to have consistent results, either between methods or for a single method (30). For example the effect of catheter rotation will be relevant when urethral pressure is measured by a catheter mounted transducer. Urethral pressure might, nonetheless, be measured:

. At rest, with the bladder at a given volume.

. During coughing or straining.

. During the process of voiding.

(i:a) Urethral pressure (intraluminal): This is the fluid pressure needed to just open a closed urethra.

(i:b)Urethral pressure profile (UPP): This is a graph indicating the intraluminal pressure along the length of the urethra.

. Resting UPP: The bladder and subject are at rest.

. Stress UPP: Defined applied stress (e.g. cough, strain, Valsalva).

All systems are zeroed at atmospheric pressure. For external transducers, the reference point is the superior edge of the symphysis pubis. For catheter mounted transducers, the reference point is the transducer itself. Intravesical pressure should be measured to exclude a simultaneous detrusor contraction. Methodology should be noted (2) including: patient position; catheter type; transducer orientation; fluid and rate of infusion (if fluid-filling system); bladder volume; rate of catheter withdrawal.

(i:c) Maximum urethral pressure (MUP): Maximum pressure in the UPP.

(i:d) Urethral closure pressure profile (UCPP): The relevant pressure is the urethral closure pressure (urethral pressure minus the intravesical pressure).

(i:e) Maximum urethral closure pressure (MUCP): Maximum pressure in the UCPP, i.e. the maximum difference between the urethral pressure and the intravesical pressure.

(i:f) Functional profile length: The length of the urethra along which the urethral pressure exceeds intravesical pressure in women.

(i:g) Functional profile length (on stress): The length over which the urethral pressure exceeds the intravesical pressure on stress.

(i:h) Pressure “transmission” ratio: This is the increment in urethral pressure on stress as a percentage of the simultaneously recorded increment in intravesical pressure. For stress profiles obtained during coughing, pressure transmission ratios can be obtained at any point along the urethra. If single values are given, the position in the urethra should be stated. If several transmission ratios are defined at different points along the urethra, a pressure transmission “profile” is obtained. During “cough profiles”, the amplitude of the cough should be stated if possible.

(ii) Urethral closure mechanism (3):

(ii:a) Normal urethral closure mechanism: A positive urethral closure pressure is maintained during bladder filling, even in the presence of increased abdominal pressure, although it may be overcome by detrusor overactivity.

(ii:b) Incompetent urethral closure mechanism: Leakage of urine occurs during activities which might raise intra-abdominal pressure in the absence of a detrusor contraction.

(ii:c) Urethral relaxation incompetence (“urethral instability”): Leakage due to urethral relaxation in the absence of raised abdominal pressure or a detrusor contraction.

(ii:d) Urodynamic stress incontinence: This is the involuntary leakage of urine during filling cystometry, associated with increased intra-abdominal pressure, in the absence of a detrusor contraction.

(iii) Leak point pressures (2, 31, 32): There are two types of leak point pressure measurement. The pressure values at leakage should be measured at the moment of leakage.

(iii:a)Detrusor leak point pressure (detrusor LPP): This a static test. The pressure is the lowest value of the detrusor pressure at which leakage is observed in the absence of increased abdominal pressure or a detrusor contraction. High detrusor LPP (e.g over 40 cm H2O [31]) may put patients at risk for upper urinary tract deterioration, or secondary damage to the bladder in the cases of known underlying neurological disorders such as paraplegia or MS. There are no data on any correlation between detrusor LPP and upper tract damage in non-neurogenic patients.

(iii:b)Abdominal leak point pressure (abdominal LPP): This is a dynamic test. It is the lowest value of the intentionally increased intravesical pressure that provokes urinary leakage in the absence of a detrusor contraction (32). The increase in pressure can be induced by a cough (cough LPP) or Valsalva (Valsalva LPP). Multiple estimates at a fixed bladder volume (200-300mls) are desirable. Catheter size will influence LPP values and should be standardized. LPP values might also be affected by many other factors such as the technique to confirm urine loss, location of catheter, type of pressure sensor, bladder volume, rate of bladder filling and patient position. A low abdominal LPP is suggestive of poor urethral function. FN17

3F: Voiding Cystometry (Pressure Flow Studies)

(i) Voiding cystometry: This is the pressure volume relationship of the bladder during micturition (1). It begins when the “permission to void” is given by the urodynamicist and ends when the woman considers her voiding has finished (3). Measurements to be recorded should be the intravesical, intra-abdominal and detrusor pressures and the urine flow rate.

(ii) Measurements during voiding cystometry (2, 3, 29):

(ii:a) Premicturition pressure: The pressure recorded immediately before the initial isovolumetric contraction.

(ii:b) Opening Time: The time elapsed from initial rise in pressure to the onset of flow. This is the initial isovolumetric contraction period of micturition. It reflects the time taken for the fluid to pass from the point of pressure measurement to the uroflow transducer. Flow measurement delay should be taken into account when measuring the opening time.

(ii:c) Opening pressure: The pressure recorded at the onset of measured flow (consider time delay).

(ii:d) Maximum pressure: Maximum value of the measured pressure.

(ii:e) Pressure at maximum flow: Pressure recorded at maximum measured flow rate.

(ii:f) Closing pressure: Pressure recorded at the end of measured flow.

(ii:g) Contraction pressure at maximum flow: This is the difference between pressure at maximum flow and the premicturition pressure.

(ii:h) Flow delay: This is the delay in time between a change in pressure and the corresponding change in measured flow rate.

Figure 7 shows a schematic diagram of voiding cystometry.

(iii) Detrusor function during voiding (2, 3):

(iii:a)Normal detrusor function: Normal voiding in women is achieved by an initial (voluntary) reduction in intra-urethral pressure (urethral relaxation) (33). This is generally followed by a continuous detrusor contraction that leads to complete bladder emptying within a normal time span. Many women will void successfully (normal flow rate and no PVR) by urethral relaxation alone, without much of a rise in detrusor pressure (34). The amplitude of the detrusor contraction will tend to increase to cope with any degree of bladder outflow obstruction (35).

(iii:b)Detrusor underactivity: Detrusor contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span.

(iii:c) Acontractile detrusor: The detrusor cannot be observed to contract during urodynamic studies resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span. The term “areflexia” has been used where there is a neurological cause but should be replaced by neurogenic acontractile detrusor.

Figure 7: A schematic diagram of voiding cystometry

3G: Urethral Function during Voiding Cystometry (Voiding urethro-cystometry – 2, 3, 29).

This technique may assist in determining the nature of urethral obstruction to voiding. Pressure is recorded in the urethra during voiding. This may be at one specific point e.g. high pressure zone or it may be measured as a profile. A voiding urethral pressure profile (VUPP) uses a similar technique to that described above for the UPP measured during bladder filling. Simultaneous intravesical pressure measurement is required. Localization of the site of the intraurethral pressure measurement is desirable.

(i) Normal urethral function: The urethra opens and is continuously relaxed to allow micturition at a normal pressure, urine flow and PVR. FN18

(ii) Bladder outflow obstruction: This is the generic term for obstruction during voiding. It is a reduced urine flow rate and/or presence of a raised PVR and an increased detrusor pressure (FN19). It is usually diagnosed by studying the synchronous values of urine flow rate and detrusor pressure and any PVR measurements. A urethral stricture or obstruction due to higher degrees of uterovaginal prolapse or obstructed voiding after stress incontinence procedures are amongst possible causes.

(iii) Dysfunctional voiding: This is characterized by an intermittent and/or fluctuating flow rate due to involuntary intermittent contractions of the peri-urethral striated or levator muscles during voiding in neurologically normal women. This type of voiding may also be the result of an acontractile detrusor (abdominal voiding) with electromyography (EMG) or video-urodynamics required to distinguish between the two entities.

(iv) Detrusor sphincter dyssynergia (DSD): This is incoordination between detrusor and sphincter during voiding due to a neurological abnormality (i.e. detrusor contraction synchronous with contraction of the urethral and/or periurethral striated muscle). This is a feature of neurological voiding disorders. Neurological features should be sought. Videocystourethrography (VCU – 3J i:a) is generally valuable to conclude this diagnosis.

3H: Ultrasound Imaging (36)

(i) Ultrasound in urogynaecology: Ultrasound has become an increasingly frequent adjunct investigation in urogynecology and female urology both in the office and in the urodynamic laboratory.

(ii) Modalities in current routine clinical use:

(ii:a) Perineal: Curved array probe applied to the perineum. This term incorporates transperineal and translabial ultrasound.

(ii:b) Introital: Sector probe applied to the vaginal introitus.

(ii:c) Transvaginal (T-V): Intravaginal curvilinear, linear array or sector scanning.

(ii:d)Transabdominal (T-A): Curvilinear scanning applied to the abdomen.

(iii) Current routine possible uses of ultrasound in urogynecology.

(iii:a) Bladder neck descent / mobility/ opening:

. Position of bladder neck at rest and on Valsalva FN20.

NB: Ideally the valsalva should be standardized but it is appreciated that at present a reliable non-invasive method is lacking. Consensus has not been reached on criteria for excessive bladder neck mobility nor the relationship of this finding to a diagnosis of urodynamic stress incontinence (37).

. Position of bladder neck during pelvic floor contraction.

. Retrovesical angle (RVA): i.e. angle between proximal urethra and trigonal surface of the bladder.

. Urethral rotation: i.e. rotation of the proximal urethra on Valsalva FN20.

. Angle gamma: i.e. angle defined by lines from the inferoposterior symphyseal margin to the bladder neck at rest and on Valsalva. FN20

. Urethral funneling: i.e. opening of the proximal third of the urethra during coughing or on Valsalva. FN20

. Urine loss: full urethral opening during coughing, Valsalva (FN20), bladder contraction or micturition.

Figure 8

Figure 8: Ultrasound parameters according to the recommendations of the German speaking countries. ? (gamma), angle between the inferior edge of the symphysis and the urethrovesical junction (UVJ); h, distance between the UVJ and the horizontal; p, distance between the inferior edge of the symphysis and the UVJ; x and y, distance between the UVJ and the x- and y-axes; X, axis of the symphysis, with 0 at its lower edge; Y, axis perpendicular to that of the symphysis.

Reference: Tunn R, Schaer G, Peschers U, Bader W, Gauruder A, Hanzal E, Koelbl H, Koelle D, Perucchini D, Petri E, Riss P, Schuessler B, Viereck V. Updated recommendations on ultrasonography in urogynecology; Int Urogynecol J (2005) 16: 236–241

Figure 8 demonstrates schematically some of the ultrasound parameters

(iii:b) Post void residuals: See section 3B.

(iii:c) Intercurrent pelvic pathology: e.g. Uterine and adnexal pathology.

(iii:d) Uterine version: Anteverted or retroverted; flexion at level of isthmus. FN21 (38).

(iii:e) Bladder abnormalities: e.g. Tumor; foreign body.

(iii:f) Urethral abnormality: e.g. Diverticulum.

(iii:g) Postoperative findings: e.g. Bladder neck position and mobility, position of meshes, tapes or implants.

(iii:h) Pelvic floor / levator defects: Bladder neck elevation during pelvic floor contraction.

(iii:j) Descent of pelvic organs: Visualization of descent of the bladder, uterine cervix and rectum during Valsalva and coughing.

(iv) 3D and 4D Ultrasound: The potential of 3D ultrasound in urogynecology is currently being researched with validated applications likely to be included in future updates of this Report and/or separate ultrasound reports. Applications with the most current research include: (i) major morphological abnormalities such as levator defects (39) and (ii) excessive distensibility of the puborectalis muscle and levator hiatus (“ballooning” – 40). The additional diagnostic potential of 4D (i.e. the addition of movement) ultrasound awaits clarification by further research.

(v) Other assessments: Synchronous ultrasound screening of the bladder and/or urethra and measurement of the bladder and abdominal pressure during filling and voiding cystometry.

(vi) Anal ultrasound (Endosonography): (41) This is the gold standard investigation in the assessment of anal sphincter integrity. There is a high incidence of defecatory symptoms in women with anal sphincter defects.

3J: Radiological Imaging

(i) Modalities in current routine clinical use:

(i:a) Videocystourethrography (VCU): (42) Synchronous radiological screening of the bladder and measurement of the bladder and abdominal pressure during filling and voiding cystometry. When indicated for complex cases, VCU allows direct observation of the effects of bladder events, the position and conformation of the bladder neck in relation to the pubic symphysis, bladder neck closure during rest and stress, diverticula of the bladder and urethra, vesico-vaginal and urethro-vaginal fistulae, vesico-ureteric reflux and voiding events.

(ii) Other modalities: None of these are office or urodynamic laboratory based.

(ii:a) Intravenous urography (IVU) (42) This provides an anatomical outline of the urinary tract including a nephrogram prior to passage of the contrast to the calyces, renal pelvis, ureter and bladder.

(ii:b)Micturating cystogram (MCU) (43) The principal use is the detection of vesico-ureteric reflux, some fistulae and diverticula.

(ii:c) Defecography (41) This demonstrates normal anatomy of the anorectum as well as disorders of rectal evacuation. Barium paste is inserted rectally prior to defecation over a translucent commode. Measurement of the anorectal angle is allowed with evidence of the presence, size or emptying of any rectocele. Enteroceles, rectal intusssusception and mucosal prolapse might be diagnosed as well as a spastic pelvic floor (anismus).

(ii:d) Colporecto-cystourethrography: (Colpo-cystodefecography)(42) This involves the instillation of radio-opaque media into bladder, vagina and rectum simultaneously for pelvic floor evaluation with images obtained during rest and straining.

3K: Magnetic Resonance Imaging (44, 45)

(i)Magnetic resonance imaging (MRI) in urogynecology :

MRI provides the opportunity to examine the soft tissue structures of the pelvic support apparatus in toto. It is non-invasive, has excellent soft tissue contrast resolution without exposure to ionizing radiation and allows the study of function of pelvic floor structures under different dynamic conditions such as increased abdominal pressure during Valsalva (44, 45). Several anatomical landmarks used for pelvic measurements are also easily identified in MRI and most measurements are thus highly reproducible. Currently the clinical value of these examinations is still under investigation with its impact on therapeutic decisions not yet fully evaluated.

(ii) Current possible measurements using MRI in urogynecology (44, 45)

(ii.a) Bladder neck and cervical descent / mobility:

. Position of bladder neck and cervix at rest and on Valsalva.

. Pubo-coccygeal line: A line extending from the inferior border of the pubic symphysis to the last joint of the coccyx. Bladder neck or cervical descent > 2 cm below this line with straining indicates weakness of the pelvic floor. If alternative landmarks are used in scientific papers they should be clearly described.

Figure 9A:

Figure 9A: Axial T2-weighted image of the pelvic floor of a healthy nulliparous Caucasian woman showing measurement of the antero-posterior diameter of the genital hiatus between the arrows from midurethra to midanus at the level of the lower border of the pubic symphysis. Transverse diameter (width) of the levator hiatus was measured between the stars at the point of maximum extension of the levator muscles at the level of the urinary bladder and proximal urethra. Reproduced from Am J Obstet Gynecol with permission from the Publisher.

Reference: Rizk DE, Czechowski J, Ekelund L. Dynamic assessment of pelvic floor and bony pelvis morphologic condition with the use of magnetic resonance imaging in a multi-ethnic, nulliparous, and healthy female population. Am J Obstet Gynecol 2004; 191: 83-89.

Figure 9A shows a number of possible measurements using MRI imaging.

Figure 9B

Figure 9B: an example of a unilateral levator defect of the pubococcygeus muscle seen on MRI imaging. (Reference: Reproduced by kind permission from Mr. Olubenga Adekanmi; Image reviewed by Prof John DeLancey)

(ii.b) Intercurrent pelvic pathology: e.g. Fibroids, ovarian pathology.

(ii.c) Uterine version: Anteverted or retroverted; flexion at the isthmus (46).

(ii.d) Bladder abnormalities: e.g. Tumor; foreign body.

(ii.e) Urethral abnormality: e.g. Diverticulum.

(ii.f) Postoperative findings: e.g. Bladder neck mobility.

(ii.g) Pelvic floor measurements / levator defects: Assessment of the configuration of pelvic floor muscles, in particular, the levator ani.

(ii.h) Descent of pelvic organs:

N.B. Diagnostic ability may be enhanced by the use of 3D MRI. New

techniques with high speed sequence of pictures allow a functional MRI.

4: DIAGNOSES (MOST COMMON) FN22

This Report again (2, 3) highlights the need to base diagnoses for female pelvic floor dysfunction on the correlation between a woman’s symptoms, signs and any relevant diagnostic investigations.

A: Urodynamic Stress Incontinence

Definition: As noted in section 3E:(ii:d), this diagnosis by symptom, sign and urodynamic investigations involves the finding of involuntary leakage during filling cystometry, associated with increased intra-abdominal pressure, in the absence of a detrusor contraction. FN23

B: Detrusor Overactivity

(i):Definition: As noted in section 3D:(v:b), this diagnosis by symptoms and urodynamic investigations is made in women with lower urinary tract symptoms (more commonly OAB – type symptoms – section 1B(iv)) when involuntary detrusor muscle contractions occur during filling cystometry. FN24

C: Bladder Oversensitivity

Definition: Bladder oversensitivity, a diagnosis made by symptoms and urodynamic investigations, is more likely to occur in women with symptoms of frequency and nocturia, and a voiding diary showing a clearly reduced average voided volume. Also referred to as “increased bladder sensation” (3), bladder oversensitivity replaces the now obsolete term of “sensory urgency” (49, 50). As noted in section 3D (iii:f), it can be defined as an increased perceived bladder sensation during bladder filling 1C: (i) with specific cystometric findings of: (i) an early first desire to void 3D:(iii:b); (ii) an early strong desire to void, which occurs at low bladder volume 3D:(iii:d); (iii) a low maximum cystometric bladder capacity 3D:(iv:b); no abnormal increases in detrusor pressure (49, 50). Specific bladder volumes at which these findings occur will vary in different populations. There should be no known or suspected urinary tract infection. FN25.

D: Voiding Dysfunction

(i) Definition: Voiding dysfunction, a diagnosis by symptoms and urodynamic investigations, is defined as abnormally slow and/or incomplete micturition (52). Abnormal slow urine flow rates and abnormally high post void residuals, the basis of this diagnosis, are outlined in sections 3A(x) and 3B(iii). This diagnosis should be based on a repeated measurement to confirm abnormality. FN26

(ii) Further evaluation – Pressure/Flow Studies (Voiding cystometry) Pressure – flow studies are indicated to evaluate the cause of any voiding dysfunction. Some possible causes have been already defined:

3F (iii:b) Detrusor underactivity; 3F (iii:c) Acontractile detrusor;

3G (ii) Bladder outflow obstruction:

(iii) Alternative presentations:

(iii:a) Acute retention of urine (3): This is defined as a generally (but not always) painful, palpable or percussable bladder, when the patient is unable to pass any urine when the bladder is full.

(iii:b) Chronic retention of urine: This is defined as a non-painful bladder, where there is a chronic high PVR. FN27

E: Pelvic Organ Prolapse

Definition: This diagnosis 2B:(i) by symptoms and clinical examination, assisted by any relevant imaging, involves the identification of descent of one or more of the anterior vaginal wall (central, paravaginal or combination cystocele), posterior vaginal wall (rectocele), the uterus (cervix) or the apex of the vagina (vaginal vault or cuff scar) after hysterectomy FN28. The presence of any such sign should correlate with relevant POP symptoms.

Figure 10 demonstrates different types and stages of clinical presentations of prolapse. Figure 10A does not distinguish cystocele type.

F: Recurrent Urinary Tract Infections

Definition: This diagnosis by clinical history assisted by the results of diagnostic tests involves the determination of the occurrence of at least three symptomatic and medically diagnosed urinary tract infection (UTI) over the previous 12 months. FN29

FIGURES 10 A-C

A: Stage II Anterior Vaginal Wall Prolapse

A: Stage II Anterior Vaginal Wall Prolapse

B: Stage III Uterine Prolapse

C: Stage IV Vaginal Vault Prolapse

© Copyright Bernard T. Haylen 2017