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Urodynamic Evaluation of Female Stress Urinary Incontinence

  • - Female Urology & Urogynecology - Urodynamic Evaluation of Female Stress Urinary Incontinence
  • Jul 09, 2010
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Tags: | bladder dysfunction | bladder overactivity | bladder pressure | cause of incontinence |

Introduction
The American Urological Association has published guidelines for the surgical management of female stress urinary incontinence (1). According to these guidelines, the objective demonstration of stress urinary incontinence should be documented prior to initiating surgical therapy.  This can be accomplished with physical examination (filling the bladder and observing stress incontinence with cough or Valsalva maneuver) or with urodynamic testing. This section reviews the various urodynamic techniques used to assess the presence and severity of female stress urinary incontinence.

Leak-Point Pressures
Leak-point pressures are an integral part of urodynamic testing. To understand the utility of leak-point pressures (LPPs) in the evaluation and management of the stress incontinent patient, it is critical to define our terms and the clinical situations to which they apply. There is considerable confusion because there are two main LPPs, and they are known by several names; in fact they are used in different clinical settings.

Detrusor Leak-Point Pressure
Detrusor leak-point pressure (DLPP), also referred to as bladder leak-point pressure, is not a measure of stress urinary incontinence (SUI). However, it is often confused with other LPP  measurements used to assess SUI, so a brief review is pertinent.  DLPP refers to the lowest measured value of bladder pressure at which urine leakage is noted without detrusor contraction or increases in abdominal pressure. In other words, DLPP is the bladder pressure required to overcome fixed urethral resistance during passive bladder filling in urodynamic testing, and it is marked by leakage.

DLPP was first described in a study of myelodysplastic children; it was noted that children with higher DLPPs (>40 cm H2O) developed upper tract damage; those with lower DLPPs did not (24).  Ultimately, DLPP  reflects urethral resistance and bladder compliance (C = ∆V/∆P). Whether a patient’s DLPP is high because of excess urethral resistance or low compliance, the end result is a high-pressure system that is at risk for upper tract damage as the increasing bladder pressure overcomes the ureteral expulsive pressure and reflux ensues. DLPP is useful in the evaluation and management of neurogenic bladders in relation to the storage and compliance as a predictor of upper tract health. However, it is not applicable for the assessment of SUI.

Urodynamic Evaluation of Female Stress Urinary Incontinence

Urodynamic Evaluation of Female Stress Urinary Incontinence

Abdominal Leak-Point Pressure (Valsalva Leak-Point Pressure)
Abdominal leak-point pressure is the lowest bladder pressure at which leakage occurs with stress (Valsalva or cough) without detrusor contraction. This measurement is commonly referred to as the Valsalva leak-point pressure (VLPP) but is also known as stress leak-point pressure or cough leak-point pressure (CLPP) depending on the source of increased intraabdominal pressure. For the purposes of this section, we use VLPP because Valsalva is the most common source of stress in urodynamic testing.

Conceptually, VLPP is a dynamic test that reflects the urethral resistance by measuring the intraabdominal pressure that is sufficient to drive urine across the urethral unit.

Stratification of severity and type of stress incontinence based on VLPP measurements are described in the section on interpretation.

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