Sender Herschorn, Stephanie Tam, Lesley Carr, Division of Urology, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

Introduction and Objectives: We aimed to correlate history, symptoms, and urodynamic findings in a large cohort of women undergoing videourodynamic testing (VUDS) for the main complaint of non-neurogenic stress urinary incontinence (SUI). We also aimed to determine the utility of leak point pressure (LPP) as a means of predicting for intrinsic sphincter deficiency (ISD) without hypermobility, or the classical Type III.

Methods: 2230 women had 2510 studies over a 20-year period. Each patient underwent a standardized history. VUDS was carried out with subtracted detrusor pressure, filling and voiding studies, and SUI testing with LPP measurements. Upright radiographic SUI testing was classified according to Blaivas (Types I, IIA, IIB, III and 0). Data analyzed included symptoms, presence of detrusor overactivity (DO), and radiographic type of SUI. LPP was analyzed by radiologic type and receiver-operator characteristics (ROC) curves to determine the clinical utility of LPP measurements.

Results: Mean patient age was 58.0 years (range 19-92) and 45% had previous surgery. In addition to SUI, 86% of patients had storage symptoms, with 77% reporting urgency incontinence (UUI). DO was demonstrated in 25.8% of those with storage symptoms and only 10.3% of those without storage symptoms (P<0.05). Overall SUI was not demonstrated in 726 studies (28.9% Type 0). There were 472 patients with Type I, 627 with IIA, 395 with IIB, and 290 with III. Mean ages of patients with Types IIB (64.2 years) and III (62.4 years) were higher than those with Types I (57.7 years) and IIA (56.0 years) (P<0.001). Storage symptoms were significantly more common in Type III compared to Types I and IIA (P<0.05). Type III patients also had the highest rate of previous surgery (P<0.01). Mean LPP was lowest for Type III (67 cm water) and highest for Type IIA (87 cm water) (P<0.05), whereas Types I and IIB had similar LPP results (~79 cm water). The areas of the ROC curves of LPP were significantly more for Types III (0.6402) and IIA (0.6054) than for I and IIB (P<0.0001). The best cutoff value of LPP for predicting Type III was <78.5 cm water, which yielded a sensitivity of .62 and specificity of .61. Given the prevalence of Type III in our sample (16.3%), the positive predictive value of LPP<78.5 cm water as a cutoff for detecting Type III was .24, with a likelihood ratio of 1.33. Lower cutoff LPP values yielded higher positive predictive values up to .294, but were also associated with lower specificities.

Conclusions: Storage symptoms were present in the majority of patients. DO was found in a minority but primarily in those with storage symptoms. Most patients had some degree of hypermobility. Older patients with previous surgery were more likely to have either Type IIB or III. Although the mean Type III LPP was significantly lower than that of other types, there was considerable overlap in the values. LPP had no value in predicting for Types I and IIB, and some predictive value for IIA and III. While the optimal cutoff LPP for predicting the presence of ISD was found to be <78.5 cm water, this LPP cutoff was found to have a low positive predictive value, and hence was of limited value in detecting Type III over other types of SUI. These results suggest that the clinical utility of LPP alone is very low for predicting for the presence of Type III or ISD without hypermobility.

UroToday.com Coverage of SUFU 2007

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