COMMITTEE MEMBERS

Jerry Blaivas. MD

Roger Dmochowski, MD

Edward McGuire, MD

Peggy Norton, MD

[Note: While every effort has been made to ensure accuracy, this is NOT an official copy of the document, and may contain typographical errors outside the scope of Microsoft products, was well as British-American spelling discrepancies. Readers needing an official copy should contact the AUA directly at aua@auanet.org]

[End of cover page]

This ad hoc committee was convened by the American Urological Association consequent to a dialogue with the Health Care Financing Administration (HCFA) relating to the management of urinary incontinence. The facts and opinions expressed here represent a broad consensus of this multidisciplinary committee and follow the format of the recently completed 1st International Consultation on Incontinence, in which recommendations were made by focused subcommittees which based their composite opinion on a review of the available literature and global subjective opinion.

The document is not meant to be an all-inclusive treatise on the subject of urinary incontinence. Rather, the committee members intend it to be a brief review of the following subjects: definition and subtypes (classification) of urinary incontinence; scope and impact of urinary incontinence; pathophysiology (broadly) of the various types of urinary incontinence; and, broad guidelines for appropriate management (the term 'management" referring to evaluation and treatment). It was felt that the algorithms produced by the various subcommittees of the 1st International Consultation on Incontinence provided a broad consensus for appropriate management with some exceptions which are specifically noted. A limited number of source documents are cited as references.

II. DEFINITION AND CLASSIFICATION OF URINARY INCONTINENCE

Urinary incontinence is defined as the involuntary loss of urine. The term is used in various ways. It may denote a symptom, a sign, or a condition. The symptom is generally thought of as the patient's complaint of involuntary urine loss. The sign is the objective demonstration of urine loss. The condition is the underlying cause (pathophysiology). A simple classification of the various subtypes of urinary incontinence is seen in attachment 1. Most practitioners use definitions that conform, either exactly or approximately, to those formulated by the International Continence Society for lower urinary tract dysfunction. Attachments 2 and 3 define terms relevant to the description of urinary incontinence. These categorizations are further explained under the subheading, pathophysiology.

 [Page 1]

One additional fact with respect to definition, however, bears mention. The traditional perspective on urinary incontinence fails to account for instances in which symptoms of urinary frequency and urgency are present without the involuntary loss of urine. "Overactive bladder is a new term which is being applied to the symptoms of frequency, urgency, urge or reflex incontinence, alone or in any combination, when existing in the absence of local pathologic factors (urinary tract infection, bladder stone, bladder cancer, interstitial cystitis, etc.) explaining these symptoms. In the opinion of this committee, the management (evaluation and treatment) of these lower urinary tract symptoms should be the same as that of urgency incontinence or reflex incontinence.

III. SCOPE AND IMPACT OF URINARY INCONTINENCE

In 1996, the Agency for Health Care Policy and Research reported urinary incontinence as affecting 13 million Americans in community and institutional settings, with an annual cost, estimated in 1994 dollars, of 16.4 billion dollars. Reported prevalence rates of urinary incontinence vary considerably, depending on definition (how frequently, how much, how bothersome), how the information is obtained, and on the population studied. Reasonable estimates of the prevalence of urinary incontinence in the population between 15 and 64 years of age range from 1.5 to 5% in men and from 10% to 30% in women. For non-institutionalized persons older than 60 years of age prevalence estimates range from 15% to 35%, with women having twice the prevalence of men. Among the more than 1.5 million nursing facility residents, the prevalence of urinary incontinence is estimated at 50% or greater. Other data regarding incidence and prevalence are readily available from reference texts (see bibliography). Besides the strictly financial costs, urinary incontinence imposes a significant psychosocial impact on individuals, their families, and caregivers. Quality of life, as measured by both generic and lower urinary tract specific indices, is adversely affected to a significant degree. The primary spheres affected are (1) self esteem; (2) ability to maintain an independent lifestyle; (3) social interactions with friends and family; (4) activities of daily life; (5) sexual activity.

IV. PATHOPHYSIOLOGY

The lower urinary tract functions as a group of interrelated structures whose joint function in the adult is to bring about efficient and low pressure bladder filling, low pressure urine storage with perfect continence, and periodic voluntary urine expulsion, again at low pressure. The anatomic, morphologic, physiologic, pharmacologic, and mechanical factors involved in both the storage and expulsion of urine by the lower urinary tract have been detailed

 [Page 2]

by numerous authors in numerous texts. Our discussion here excludes so-called extraurethral incontinence (see attachment 1), which is due either to a fistula (an abnormal communication between the bladder and the vagina, ureter and vagina, or urethra and vagina), and those individuals with an ectopic ureter (a ureter which drains into an abnormal site with no sphincteric mechanism between it and the exterior environment). Excluding individuals with so-called functional incontinence (individuals who do not recognize a need to urinate in a socially acceptable manner or place, because of neural immaturity, cerebral disease or dementia and those who cannot access an acceptable place to urinate because of physical disability), the pathophysiology of urinary incontinence involves the bladder, the bladder outlet (the bladder neck and urethra), or both. One can summarize the requirements for normal bladder filling and urine storage very simply as

1. Accommodation of increasing volumes at a low intravesical pressure and with appropriate sensation

2. A bladder outlet that is closed and competent at rest and remains so during increases in intra-abdominal pressure

3. The absence of involuntary bladder contractions.

Any type of voiding dysfunction having to do with the filling/storage phase of micturition, including urinary incontinence, must result from an abnormality of one or more of the factors listed above. Overactivity of the bladder during filling/storage can be expressed as phasic involuntary contractions, as low compliance (a tonic increase in the pressure/volume curve), or as a combination of the two. Involuntary bladder contractions are most commonly seen in association with neurologic disease or after neurologic injury. However, they may be also associated with inflammation or irritation of the bladder wall, bladder outlet obstruction, aging, or they may be idiopathic. Decreased compliance during filling may be secondary to a neurologic injury or disease (usually at the level of the sacral spinal cord or below), but may result also from any process that destroys the viscoelastic or elastic properties of the bladder wall. Storage failure may occur also in the absence of hyperactivity, but secondary to hypersensitivity or pain during filling. In this instance, the incontinence results from an uncontrollable need to get rid of the painful bladder sensation, a circumstance which may be seen with irritation, inflammation, neurologic, or psychological causes. Incontinence due to decreased outlet resistance (so-called sphincteric related, as opposed to bladder related incontinence) may result from any process that damages the innervation or the structural

 [Page 3]

elements of the smooth or striated sphincter or their supports. This may occur with neurologic disease or injury, surgical or other mechanical trauma, or aging. Urethral instability refers to the rare phenomenon of episodic decreases in outlet pressure unrelated to increases in bladder or abdominal pressure. The term urethral instability is probably a misnomer, because many feel that the drop in urethral pressure represents simply the urethral component of a normal voiding reflex in an individual whose bladder does not measurably contract, either because of myogenic or neurogenic reasons. There are situations where urethral incontinence cannot be considered merely as an isolated abnormality of either bladder contractility or sphincteric resistance. These situations, listed in attachment 4, are more complicated to deal with, because they are more difficult to diagnose and because one entity may adversely affect or compromise treatment of the other. A brief description of the more common types of urinary incontinence follows:

Outlet Related Incontinence in the Female: In women there are two clinical types of sphincteric incontinence, that related to urethral hypermobility (so-called 'genuine" stress incontinence) and to intrinsic sphincter deficiency (ISD). With urethral hypermobility there is weakness of the pelvic floor. During increases in intra-abdominal pressure there is descent of the bladder neck and proximal urethra. If the urethra opens concomitantly, stress urinary incontinence ensues. In the classic form of urethral hypermobility, there is rotational descent of the bladder neck and urethra. However, the urethra may also descend without rotation (it shortens and widens) or the posterior wall of the urethra may be pulled open while the anterior wall remains fixed. It should be noted, however, that urethral hypermobility is often present in women who are not incontinent, and thus the mere presence of urethral hypermobility is not sufficient to make a diagnosis of a sphincter abnormality unless urinary incontinence is also demonstrated. The "hammock hypothesis" proposes that, for stress incontinence to occur with hypermobility, there must be a lack of stability of the suburethral supportive layer. This theory proposes that the effect of abdominal pressure increases on the normal bladder outlet, if the suburethral supportive layer is firm, is to compress the urethra rapidly and effectively. If the supportive suburethral layer is lax and/or movable, compression is not as effective. ISD denotes an intrinsic malfunction of the urethral sphincter mechanism itself. In its most overt form, it is characterized by a bladder neck which is open at rest, a low Valsalva leak point pressure and urethral closure pressure

[Page 4]

(specialized urodynamic studies -- see section on management) and is usually the result of prior surgery, trauma with scarring, or a neurologic lesion. As the physiology and pathophysiology of the bladder outlet is better studied, many individuals are beginning to feel that some element of intrinsic sphincter deficiency is present in every case of sphincteric incontinence, including "genuine" stress urinary incontinence. The two extremes, however, are clearly separate and readily recognizable.

Outlet Related Incontinence in the Male: In theory at least, categories of outlet related incontinence in the male are similar to those in the female. In reality, there is little if any information regarding the topic of urethral instability in the male. Sphincteric incontinence is due generally to neurologic impairment or anatomic disruption after prostatic surgery or urethral trauma. Sphincteric incontinence in the male is not associated with hypermobility of the bladder neck and proximal urethra, but is rather more similar to what is termed ISD in the female.

Bladder Related Incontinence in the Female; Bladder related abnormalities causing urinary incontinence consist of either detrusor overactivity or low bladder compliance. Detrusor overactivity is a generic term for involuntary bladder contractions. These can be either due to neurologic conditions (in which case detrusor hyperreflexia is the term applied) or non-neurologic in origin (in which case the term detrusor instability is employed). Neurologically, involuntary bladder contractions can be due to any lesion occurring above the sacral spinal cord. The cause(s) of detrusor instability in the female is (are) obscure. In addition to the prior etiologies, one subject that should be mentioned is the simultaneous occurrence of bladder instabilty in stress urinary incontinence. The fact that minor components of detrusor instability, and sometimes major ones, often disappear after successful surgery for stress incontinence suggest that these two phenomena may be causally related in an as yet unknown fashion.

Bladder Related Incontinence in the Male; The pathophysiology of bladder related incontinence in the male is similar to that in the female except that there is no known association between detrusor instability and stress incontinence in the male. There is, however, a unique association of detrusor overactivity with bladder outlet obstruction in the male. The incidence of detrusor instability in males with outlet

[Page 5]

obstruction secondary to prostatism ranges from 50 to 80%. When the outlet obstruction is relieved in such patients, there is a high reversion rate of the bladder status to stability (approximately 50%), although this reversion generally takes between one and six months, and may take as long as 12 months.

Overflow Incontinence; This is a descriptive term that denotes leakage of urine associated with urinary retention. This is more common in the male than female. The primary pathophysiology is actually a failure of emptying, leading to urinary retention with "overflow" incontinence, resulting from either continuous or episodic elevation of intravesical pressure over urethral pressure. This generally results in outlet obstruction or detrusor inactivity, either neurologic or pharmacologic in origin, or may be secondary to inadvertent overdistention of the bladder.

V. MANAGEMENT

Management includes the processes of evaluation and treatment. Various algorithms are available for each, ranging from the simplest to the most complicated. What is appropriate for one patient/health care provider combination may not be appropriate for another. The level of complexity of the evaluation and management depends on

A. The clinical problem at hand

B. The prior treatment experience(s)

C. The desire for an exact diagnosis

D. The patient's desire for treatment

E. The patient's goals of therapy

F. The patient's ability and desire to follow instructions or carry out specific tasks

G. The expected level of improvement under optimal circumstances

H. The health care provider's level of expertise Environmental considerations

J. Economic considerations

A complete idealized evaluation menu is seen in attachment 5. Not every test may be necessary or desirable for each patient. For behavioral modification and/or drug therapy in a patient who has previously received no treatment, these may be minimal. For treatment failures, for follow up when silent upper and lower tract deterioration can occur, for a situation where an exact diagnosis is desired, or prior to consideration for surgery or other irreversible therapy, these may be extensive. There are differences of opinion as to the value or non-value

 [Page 6]

of various studies under selected circumstances. The committee submits as attachment 6 a modification of pages 947-950 of the test [sic] Incontinence (see references) as a general guideline for the evaluation of incontinence. In addition, Dr. Blaivas has prepared, as attachment 7, a description of the various studies included under the term "urodynamic evaluation".

All known treatments for urinary incontinence are summarized in attachment 8. Inclusion in this list does not imply majority agreement on efficacy. Treatment should generally begin with the simplest most reversible forms of therapy, proceeding gradually up the order of complexity. A patient may elect to bypass a given form of treatment or choose not to remain on a given treatment for a period which the provider recommends. In deciding to proceed up the level of complexity of treatment or to remain at a given level, only the patient (and/or family) is (are) empowered to say when "enough is enough". A perfect result need not be achieved. Satisfaction is the goal, as long as the patient and/or family understands the possible benefits, practicalities, and risks of further therapy.

 [Page 7]

REFERENCES

 Abrams P Khoury S, Wein A (eds): Incontinence (1st International Consultation on Incontinence), Plymbridge Distributors, Ltd., Heath Publications Ltd., United Kingdom, 1999.

 Blaivas JG, Romanzi U, Heritz OM: Urinary Incontinence: pathophysiology, evaluation, treatment overview, and nonsurgical management. In, Walsh P, Retik A, Vaughan ED, Jr., Wein AJ: Campbell's Urology 7th edition, Saunders, Philadelphia, pp.1007-1043, 1997.

 Fantt JA, Newman DK, Coiling J, et al: Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline, No.2, 1996 Update. Rockville. MO; U.S. Department of Health and Human Services. Public Health Service. Agency for Health Care Policy and Research. AHC PR Publication No. 96-0682. March 1996.

 O'Donnell, PD. Urinary Incontinence.. Mosby Year-Book Inc. St. Louis. 1997.

 Steers WO. Barrett OM. Wein AJ: \/oiding Dysfunction: diagnosIs. classification, and managemenL In. Glilenwater JY, Grayhack JT. Howards SS. Duckert JW (eds): Adult and Pediatric Urology. Mosby Year-Book. Inc.. St. Louis. 1996. pp. 1220-1326.

 Urinary Incontinence Guideline Panel. Urinary Incontinence in Adults: Clinical Practice Guideline. AHCPR Pub. No.92-0038. Rockville. MO: Agency for Health Care Policy and Research. Public Health Service, U.S. Department of Health and Human Services, March 1992.

 Wein AJ, Barrett, DM: Voiding Function and Dysfunction: A Logical and Practical Approach. Year Book Medical Publishers. Inc., Chicago, 1988.

Attachment 1

 

CLASSIFICATION OF INCONTINENCE

Extraurethral

A. Fistula (vesicovaginal, ureterovaginal, urethrovaginal)
B. Ectopic ureter

II. Urethral

A. Functional

1. Because of physical disability
2. Due to lack of awareness or concern

B. Bladder abnormalities

1. Overactivity

a. Involuntary contractions
b. Decreased compliance

2. Sensory urgency with incontinence

C. Outlet abnormalities

1. "Genuine" stress incontinence
2. Intrinsic sphincter deficiency
3. Urethral instability
4. Post-void dribbling

a. Urethral diverticulum
b. Vaginal pooling of urine

D. Overflow incontinence

 

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Neurophysiologic testing

Attachment 6

HIGHLY RECOMMENDED TESTS DURING INITIAL EVALUATION

The main recommendations should be read in conjunction with the management algorithms for children, men, women, neurogenic patients and the frail older person.

· Nature and duration of genitourinary tract symptoms.

· Previous surgical procedures in particular as they affect the genitourinary tract).

· Environmental issues: these may include the social and cultural environment.

· Patient mobility: individuals who have compromised mobility may need to be managed differently.

· Mental status: each individual needs to be assessed for their ability to understand proposed management plans and to enter into discussions when there are a range of treatment options. In some groups of patients formal testing of cognitive function is essential, e.g., those thought to be suffering from dementia.

· Disease status: Coexisting diseases may have a profound effect on incontinence sufferers, for example asthma patients with stress incontinence will suffer greatly during attacks. Diseases may also precipitate incontinence, particularly in frail older persons.

· Patient medication: It is always important to review every patient's medication and to make an assessment as to whether the treatment is in fact causing or worsening the patient's condition.

· Sexual function. At present little information exists on the impact of incontinence: this aspect of the patient's life should be assessed where appropriate.

· Bowel function: Although urinary incontinence is the subject of this consultation, bowel function has considerable influence on urinary problems. In addition, certain groups of urinary incontinent patients may have co-existing fecal incontinence, and/or constipation which may trouble them as much or even more than their urinary leakage.

· Patient's fitness for possible surgical procedures.

2. Quantification of Symptoms:

a. The frequency of incontinence

b. The perceived quantity of urinary leakage

C. The perceived impact of urinary leakage on every day life.

The use of a urinary diary (frequency-volume chart), a simple chart, is highly recommended to document the frequency of micturition, the volumes voided, incontinence episodes and the use of incontinence pads.

· Abdominal examination in an effort to detect a palpable bladder.

· Perineal examination to assess sensation.

· Rectal examination to assess anal tone, the consistency of stool, and in the male, the prostate gland.

· Neurological examination: concentrating on the S24 segments (the nerve supply of bladder and urethra).

· External genitalia.

· Vaginal examination to assess pelvic organ prolapse and estrogen status.

· Stress test for incontinence - patients with suspected stress incontinence should be asked to cough repeatedly and to bear down.

a. Urinalysis: As urinary infection is a readily detected and easily treatable cause of LUTS, urine testing is highly recommended. Testing may range from examination of urine in a clear glass container, through dipstick testing, to urine microscopy.

b. Estimation of Residual Urine: In neurogenic patients and frail older persons and those with symptoms suggestive of bladder measured outlet obstruction or signs suggestive of an enlarged bladder, it is highly recommended to assess post-void residual urine (PVR) is measured during initial assessment as in these groups of patients the management is dependent on assessment of voiding efficiency. PVR may be assessed by abdominal examination or more accurately by ultrasound estimation. This will simultaneously provide information about bladder capacity and bladder wall changes, and can detect the presence of bladder stones, diverticula and a median lobe. The invasive nature of any other means (i.e. catheterization) to determine residual urine must be weighed against the benefits of the test. Because of the marked intraindividual variability of residual urine volume, the test should be repeated to improve precision, if residual urine volume is significant at the first measurement.

The use of a number of validated questionnaires is recommended for a more detailed assessment of the symptoms of incontinence and their impact on quality of life. The International Consultation on Incontinence aims to develop a standard questionnaire for the assessment of symptoms and impact on quality of life for use in assessing the effectiveness of treatments for incontinence.

2 Detailed Physical Examination

In female patients, formal assessment is recommended when initial evaluation indicates the possibility of estrogen deficiency, urethral diverticulum, urinary fistula or pelvic organ prolapse. Pelvic organ prolapse should be assessed. Urethral hypermobility should be addressed by visual inspection or a cotton swab test.

It is recommended that routine urodynamic evaluation should consist of:

· The detection of detrusor overactivity

· The assessment of urethral competence during filing

· The assessment of outlet function during voiding

· The measurement of residual urine

· When an exact diagnosis is desired

· Prior to invasive treatments

· After treatment failure

· As part of a long-term surveillance program in neurogenic lower urinary tract dysfunction

· In "complicated incontinence".

Filling and voiding cystometry are most accurately performed as part of multichannel urodynamic studies. For these studies, it is necessary to measure abdominal pressure and calculate detrusor pressure. For any given patient, the greater the degree of sophistication of urodynamic evaluation, the greater the diagnostic accuracy. Thus, cystometry with synchronous abdominal pressure recording and calculation of detrusor pressure is more accurate than single channel cystometry. Synchronous detrusor pressure/uroflow studies are more accurate than either parameter measured alone and videourodynamic is the most accurate of all. In all multichannel studies, each measured parameter serves as a check against the other and offers not only a higher degree of accuracy, but a means by which

· a. Imaging of the lower urinary tract is recommended in all patients referred for specialist management and particularly those with suspected lower tract pathology. This is most appropriately performed in conjunction with urodynamic studies.

· Low bladder compliance

· Neurogenic urinary incontinence, e.g., myelodysplasia, spinal cord trauma

· Severe urethral obstruction

· Incontinence associated with significant post-void residual

· Co-existing loin/kidney pain

· Severe untreated pelvic organ prolapse

· Suspected extra-urethral urinary incontinence

· All children with incontinence

1. Additional Urodynamic Testing

The term urodynamic studies refers to one or more of a series of diagnostic procedures designed to evaluate the lower urinary tract during its storage and emptying phase. Much of urodynamics is an interactive process between patient and physician and, as such, it requires live interpretation of the findings as they occur. During the testing it is usually necessary for the patient to be queried about what he or she is feeling or trying to do and to be instructed to perform certain maneuvers.

Depending upon the degree of sophistication needed, as many as nine components may be evaluated during a single diagnostic session. Simple studies such as uroflow and single channel cystometry may be performed in physician offices without specialized configurations, but sophisticated videourodynamic studies require a dedicated room with fluoroscopy, multichannel electronic urodynamic equipment and a nurse and/or radiology technician in addition to the physician. The examinations generally last from 30 minutes to 90 minutes, depending upon their complexity.

Cystometry

Cystometry is necessary to detect involuntary bladder contractions and abnormalities of bladder sensation, capacity, and compliance. When involuntary detrusor contractions are detected, the examiner/patient interaction is crucial to determine the patient's awareness, concern, ability to contract the sphincter, interrupt the urinary stream and abort the detrusor contraction.

Abdominal Pressure Recording

During cystometry, any rise in intra-abdominal pressure will be recorded by the cystometer as a rise in vesical pressure. This simulates a bladder contraction and is the source of many misdiagnoses. Moreover, if a patient strains in an attempt to urinate, the rise in abdominal pressure may obscure an underlying bladder contraction. For this reason, simultaneous measurement of intra-abdominal pressure (by inserting a rectal catheter) is necessary to recognize and exclude artifacts and a sophisticated examiner must be present to interpret these findings. Measurements of abdominal pressure is, thus, an integral part of multichannel urodynamic studies. As an isolated measurement, it is also useful to estimate the leak point pressure (described below).

Thus, abdominal pressure recording may be used as either part of a multichannel urodynamic study or as a single test for the estimation of leak point pressure.

Detrusor Pressure Recording

Detrusor pressure is determined by electronic subtraction of abdominal pressure from vesical pressure. Detrusor pressure is the driving force behind micturition and its estimation is a necessary component for diagnosing urethral obstruction and impaired detrusor contractility.

The synchronous measurement of detrusor pressure and uroflow is a basic tool of multichannel urodynamic studies. It is the only means by which a diagnosis of urethral obstruction can be confirmed. It is performed synchronously measuring vesical pressure, abdominal pressure and uroflow. Detrusor pressure is calculated electronically and displayed as a separate channel. The catheter for measuring vesical pressure may be placed transurethrally

By definition, detrusor pressure/uroflow studies are multichannel studies.

Sphincter Electromyography

There are two methods of sphincter electromyography. In the first method, it is performed by a competent electromyographer using coaxial needle electrodes in a fashion similar to electromyography performed elsewhere in the body. As such it provides objective diagnostic criteria that enables one to assess the integrity of the innervation to the external urethral sphincter. In addition, the coordination between the bladder and the external urethral sphincter can be accurately assessed.

In the second method, surface electrodes are used to identify contractions and relaxations of the striated component of the sphincter and pelvic floor muscles. It is most useful in determining (1) whether a urethral obstruction is due to detrusor-external sphincter dyssynergia or a "non-relaxing" sphincter; (2) whether the patient is able to voluntarily contract the sphincter; and (3) whether the patient is able to voluntarily relax the sphincter.

Except for use in biofeedback for pelvic floor physiotherapy, sphincter electromyography cannot be performed as an isolated test; it must always be done in conjunction with either cystometry or uroflow or part of more sophisticated multichannel urodynamic studies.

Voiding Cystourethrography/Cystogram

These procedures may be done as isolated examinations or as part of multichannel urodynamic studies.

Fluoroscopy

Fluoroscopy is an essential part of the radiographic examination because it is the only method by which the temporal relationship between physiologic measurements and anatomic function can be appreciated.

Vesical and Abdominal Leak Point Pressure (LPP)

The VLPP is the most accurate means of assessing sphincteric function because it actually measures the force that drives urine across the urethra. In some patients, however, urinary leakage is not seen with a urethral catheter in place. In those instances, the urethral catheter can be removed and the rectal catheter left in place. The abdominal pressure at which leakage occurs is recorded as the ALPP.

Detrusor Leak Point Pressure (DLPP)

By definition, DLPP cannot be done as an isolated procedure. It is always performed as part of multichannel urodynamic studies.

Micturitional Urethral Pressure Profile

The micturitional urethral pressure profile measures pressure for a specified length of urethra during micturition. It defines the point of urethral obstruction and/or the point of the flow controlling zone.

Stress Urethral Pressure Transmission Ratios

This procedure measures the ratio of pressure transmission from vesical and abdominal pressure to the urethra and is an indirect measure of sphincter strength. It requires simultaneous measurement of urethral and vesical and/or abdominal pressure and, for this reason, cannot be performed as an isolated test.

Synchronous measurement and display of urodynamic parameters with radiographic visualization of the lower urinary tract videourodynamics is the most precise diagnostic tool for evaluating disturbances of micturition. In these studies, radiographic contrast is used as the infusant for cystometry. Depending on the level of sophistication required, other urodynamic parameters such as abdominal, detrusor and urethral pressure, uroflow and sphincter electromyography may be recorded as well. There are important advantages to synchronous video/pressure flow studies compared to conventional single channel urodynamics and to conventional cystography and voiding cystourethrography. By simultaneously measuring multiple urodynamic variables one gains a better insight into the underlying pathophysiology. Moreover, since all variables are visualized simultaneously one can better appreciate their interrelationships and identify artifacts with ease.

Attachment 8

Bladder Related Incontinence (Inhibiting bladder contractility, decreasing sensory input and/or increasing bladder capacity)

Central (subarachnoid block)
Sacral rhizotomy, selective sacral rhizotomy
Perivesical (peripheral bladder denervation)

Augmentation cystoplasty; autoaugmentation

Behavioral therapy

Fluid restriction
Timed bladder emptying
Pelvic floor exercises +/- biofeedback
Bladder training

Electrical stimulation

Pharmacologic therapy

Alpha-adrenergic agonists
Tricyclic antidepressants
Beta-adrenergic antagonists, agonists
Estrogens

Antidiuretic hormone-like agents
Diuretics
Intermittent catheterization
Continuous catheterization
Urinary diversion
External collecting devices
Absorbent products

Attachment 9 (a&b)

(a) Thuroff, et al.  Clinical Guidelines for the Management of Incontinence

[Note: This document is a very poor photocopy of ten pages length that can not be scanned.]  Pages 933-943 from 1st International Consultation on Incontinence, 1998.

(b) Abrams, et al.  Recommendations of the International Scientific Committee: The Evaluation and Treatment of Urinary Incontinence.  1st International Consultation on Incontinece, 1998. 

[Note: the report consists of 20 color Xerox pages of complex flow charts and supporting material. It may be possible to reproduce this by Adobe Acrobat.  The section contains very important material.]

Included pages (from the published book) are: 945 and 951-969.  Most these pages are full-color flowchart diagrams showing treatment decision.