Committee 7 B Imaging and Other Investigations Chairman A. TUBARO (Italy) Members W. ARTIBANI (Italy), C. BARTRAM (U.K), J. DELANCEY (USA), V. KHULLAR (U.K), M. VIERHOUT (The Netherlands) Consultants M. DE GENNARO (Italy), K. KLUIVERS (The Netherlands) 541 ABBREVIATIONS 3D three dimensional PD Parkinson's disease ACC anterior cyngulate cortex PET positron emission tomography ACG anterior cyngulate gyrus PFMT pelvic floor muscle training ADH anti diuretic hormone PGPI patient global perception of improvement ARJ anorectal junction PICP propeptide of type I procollagen ATT alpha-1 antitrypsin PIIINP amino-terminal propeptide of procollagen BBI bladder base insufficiency III BCR bulbocavernosus reflex PIVS posterior intravaginal singplasty BMI body mass index PMC pontine micturition centre BOO bladder outlet obstruction POP-Q pelvic organ prolapse quantification BWT bladder wall thickness PNTML pudendal nerve terminal motor latency CCC concordance correlation coefficient PUV posterior urethrovesical (angle) CMAP compound muscle action potential PVR post-void residual CMCT central motor conduction time QST quantitative sensory testing CNEMG concentric needle electromyography CT computerised tomography SCP sacrocolpopexy DO detrusor overcativity SEP somatosensory evoked potential EAS external anal sphincter SERMS selective estrogen-receptor modulators EAUS endoanal ultrasound ultrasound SFEMG single fibre electromyography sonography SII symptom impact index ED erectile dysfunction SMA supplementary motor area EMG electromyography SO symphysis orifice (distance) FOV field of view SSF sacrospinous fixation HASTE single-shot turbo spin echo SSFSE single-shot fast spin echo HOXA Homebox A SSI symptom severity index IAS internal anal sphincter SSR sympathetic skin responses ICTP carboxy-terminal telopeptide of type I collagen STARD Standards for Reporting of Diagnostic IIQ-7 incontinence impact questionnaire Accuracy IP interference pattern SUI stress urinary incontinence ISD intrinsic sphincter deficiency T/A turns/amplitude IVU intra venous urography TE echo time LLM longitudinal layer muscle TGF-ß transforming growth factor-ß LMR longitudinal muscle of the rectum TIMP tissue inhibitor of metalloproteinases LUT lower urinary tract TR repetition time LUTD lower urinary tract dysfunction UAR urethral axis at rest LUTS lower urinary tract symptoms UAS urethral axis suring straining MCC maximum cystometric capacity UEBW ultrasound estimated bladder weight MEP motor evoked potential UP urethropelvic (angle) MMPS matrix metalloproteinases UPP urethral pressure profile MRI magnetic resonance imaging USI urodynamic stress incontinence MSA multiple system atrophy MU motor unit USS ultrasonography MUP motor unit potential UTI urinary tract infection PA puboanalis VCCU voiding colpo cystourethrography PAG periacqueductal grey VUCG voiding urethrocystogram PCL pubococcygeal line WA white American 542 CONTENTS II. OPEN BLADDER NECK AND A. INTRODUCTION URETHRA AT REST III. FEMALE URETHRAL B. IMAGING IN URINARY DIVERTICULA INCONTINENCE AND PELVIC FLOOR DYSFUNCTION IV. IMAGING OF THE NERVOUS SYSTEM B.1 IMAGING OF THE UPPER URINARY TRACT V. ENDOSCOPY OF THE LOWER URINARY TRACT B.2. IMAGING OF THE LOWER URINARY TRACT C. IMAGING IN ANAL INCONTINENCE I. X-RAY IMAGING II. ULTRASONOGRAPHY D. PAD TESTING III. MRI E. OTHER INVESTIGATIONS B.3 SPECIAL ISSUES F. CONCLUSION I. POST-VOID RESIDUAL 543 544 Imaging and Other Investigations A. TUBARO, W. ARTIBANI, C. BARTRAM, J. DELANCEY,V. KHULLAR, M. VIERHOUT M. DE GENNARO, K. KLUIVERS Proper design, implementation and reporting of studies on diagnostic accuracy are essential to improve their A. INTRODUCTION quality and make evaluation of research easier. Most of the issues discussed in the present chapter fall within the remits of diagnostic tests and the evaluation The Committee reviewed the evidence provided in of diagnostic accuracy as regulated by the Standards the 2005 edition and updated the chapter with data for Reporting of Diagnostic Accuracy (STARD) initiative from the peer-review literature published in the last 4 provides a checklist and flow diagram that are essential years. The chapter covers different issues including: to achieve transparent reporting [1]. The highly imaging, neurophysiological testing, and other dynamic world of diagnostic tests requires a rigorous investigations (laboratory tests, tissue analysis and Pad evaluation process to prevent premature dissemination test) with reference to paediatric and adult population, of tests of unproven clinical value. Studies in this male and female subjects, neurogenic and non- particular area provide additional information on patient neurogenic patients. health status that are important for managing the underlying condition or disorder such as pelvic organ Imaging: the Medline database was searched using prolapse, urinary or faecal incontinence. Evaluation the following keywords: imaging, urinary incontinence, of diagnostic accuracy can not be separated from continence, anal incontinence and faecal incontinence; the search has been limited to period from 2004 to analysis of the clinical benefit, in the absence of which 2008. Neurophysiology: clinical neurophysiology, diagnostic tests (laboratory and imaging tests, history, conventional urodynamics, neurourology, urinary physical examination or pathology) can not be dysfunction. Other investigations: keywords including recommended. urinary incontinence, continence, pad test, urinalysis, Imaging studies should follow the suggestions of the urine culture, tissue analysis were used. Members of STARD initiative and they differ substantially from the committee were allocated the different topics of clinical trials. The aim of clinical studies of diagnostic the chapter based on their specific expertise in the field. tests should in fact aim to provide information regarding All committee members reviewed the chapter draft, the diagnostic accuracy of the proposed test. Imaging recommendations were collegially discussed on at studies represent per se a unique category because the occasion of the ICI meeting in Paris (July 2008), of the known issues involving interrater variability in the final draft was then edited first by the Committee the interpretation of radiological pictures and the Chair and then by the book Editors. As far as imaging variability in imaging techniques (although this mainly is concerned, the chapter is structure based on applies to ultrasonography and endoscopy only). anatomical issues: upper, lower urinary tract, bowel, Consequently, the criteria proposed by the Agency central nervous system, and imaging technique: X- for Health Care Policy and Research endorsed by rays, ultrasonography, Magnetic Resonance Imaging. the Oxford Centre for Evidence Based Medicine for Imaging techniques were analysed taking into evaluating levels of evidence and for deriving grades considerations the technique and its standardisation, of recommendation do not apply as, for example, intraobserver and interobserver variability, diagnostic randomization is not a issue and consequently, levels accuracy, cost/benefit ratio and clinical benefit. of evidence 1 and 2 can not be found in the peer- Levels of evidence and grades of recommendations review literature and grades of recommendation A were provided according to the guidelines of the ICUD and B rarely occur. Furthermore recommendation for summarised elsewhere in this book. Areas of future imaging studies is not just related to the quality of the research were identified. The application of the ICUD published manuscripts but on the presence or absence guidelines to diagnostic issues such as those dealt with of clinical benefit for the patient category of interest. in this chapter is not without problems as they were Imaging is currently used in the field of urinary and anal developed for the evaluation of formal clinical trials. incontinence or pelvic organ prolapse to evaluate 545 parameters with proven positive or negative predictive value for patient management or to investigate the REFERENCES prognostic value of novel parameters. Imaging can be used to reduce the diagnostic burden providing 1. Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou information on parameters with known safety or PP, Irwig LM, et al. The STARD statement for reporting studies prognostic value (eg: ultrasound imaging of post void of diagnostic accuracy: explanation and elaboration. Clin Chem. 2003 Jan;49(1):7-18. residual) or to investigate new parameters that can not be investigated in any other way (eg: bladder wall thickness). B. IMAGING IN URINARY Afew considerations on the levels of evidence in INCONTINENCE AND PELVIC imaging studies may be instrumental in reading this chapter and are summarizsed herewith. FLOOR DYSFUNCTION Imaging of parameters with known prognostic value (e.g. PVR) B1. IMAGING OF THE UPPER • The first issue is to prove that imaging studies URINARY TRACT image what they are supposed to image. Although the issue may be trivial in case of PVR imaging or anal sphincter imaging, the issue is relevant in Urinary incontinence is defined as the complaint of any other areas (eg: enterocele imaging) and should involuntary leakage of urine, it can be urethral or be solved using imaging in cadavers or other extraurethral. This latter condition either results from approaches such as intraoperative confirmation congenital anomalies such as ectopic ureters (inserting of the observed condition. in the female distal urethra or vagina), iatrogenic or traumatic