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A Prospective Study Investigating the Diagnostic Agreement Between Urodynamics and Dynamic Cystoscopy in Women Presenting with Mixed Urinary Incontinence

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A Prospective Study Investigating the Diagnostic Agreement Between Urodynamics and Dynamic Cystoscopy in Women Presenting with Mixed Urinary Incontinence International Urogynecology Journal (2019) 30:823–829 https://doi.org/10.1007/s00192-018-3671-x ORIGINAL ARTICLE A prospective study investigating the diagnostic agreement between urodynamics and dynamic cystoscopy in women presenting with mixed urinary incontinence Dobrochna Globerman1 & Louise-Helene Gagnon2 & Selphee Tang3 & Erin Brennand3 & Shunaha Kim-Fine3 & Magali Robert3 Received: 11 December 2017 /Accepted: 9 May 2018 /Published online: 29 May 2018 # The International Urogynecological Association 2018 Abstract Introduction and hypothesis Patient history is often insufficient to identify type of urinary incontinence (UI). Multichannel urodynamic testing (UDS) is often used to clarify the diagnosis. Dynamic cystoscopy (DC) is a novel approach for testing bladder function. The primary objective of this study was to investigate the diagnostic agreement of UDS and DC in evaluating women with mixed urinary incontinence (MUI). Methods Women presenting with MUI were approached for enrollment if UDS and DC were planned for further investigation. Investigators were blinded to history and comparative test results. McNemar’s test and kappa coeffi- cient were calculated to assess agreement between UDS and DC. Receiver operating characteristic (ROC) analysis was used to explore the best possible filling sensation cutoffs for DC that would best predict the filling sensation cutoffs from UDS. Results Sixty participants were included, of whom, four were excluded for protocol violation. For the primary outcome measure of agreement, UDS and DC were concordant in 44/56 of stress urinary incontinence (SUI) cases (79%) with a κ= 0.54 and in 43/ 56 of urinary urge incontinence (UUI) cases (77%) with a κ= 0.54, indicating moderate, nearly substantial agreement. ROC analysis identified the best prediction of DC first urge to void as 148 cm3,strongurge215cm3, and maximum capacity at 246 cm3. These parameters were used to compare UDS UUI to DC UUI and resulted in a κ = 0.61 (p = 0.37), indicating substantial agreement. Conclusions When compared with UDS, DC shows moderate agreement for detection of SUI and substantial agreement for detection of UUI. Keywords Cystoscopy . Stress urinary incontinence . Urgency urinary incontinence . Urinary incontinence . Urodynamics Abbreviations MUI Mixed urinary incontinence UDS Urodynamic testing ROC Receiver operating characteristic DC Dynamic cystoscopy SUI Stress urinary incontinence UUI Urge urinary incontinence ICS International Continence Society DO Detrusor overactivity * Dobrochna Globerman UU Urinary urgency [email protected] OAB Overactive bladder UTI Urinary tract infection 1 Department of Obstetrics and Gynecology, Division of POP-Q Pelvic Organ Prolapse Quantification Urogynecology, University of Manitoba, Winnipeg, MB, Canada PVR Postvoid residual 2 Department of Obstetrics and Gynecology, Division of MCC Maximum cystometric capacity Urogynecology, University of Toronto, Toronto, ON, Canada IUGA International urogynecological association 3 Department of Obstetrics and Gynecology, Division of ISD Intrinsic sphincter deficiency Urogynecology, University of Calgary, Calgary, AB, Canada MUCP Maximum urethral closure pressure 824 Int Urogynecol J (2019) 30:823–829 QUID Questionnaire for urinary incontinence diagnosis Materials and methods SUDS Subjective Units of Distress Scale Study design, setting, and participants Introduction This was a single-center, prospective, same-paired investiga- tion conducted in the outpatient Pelvic Floor Clinic located The International Continence Society (ICS) defines urinary within a tertiary care hospital in Calgary, Canada. The center incontinence as the complaint of any involuntary leakage of has five academic consultant urogynecologists, and access is urine [1, 2]. Urinary incontinence is generally classified as by medical referral for pelvic floor disorders. Recruitment for stress (SUI), urge (UUI), mixed (MUI), and other rare types the study began in May 2015 and was completed by March [2]. Determining type of incontinence is important, as it 2016. The study received approval from the Conjoint guides treatment and predicts its expected success and com- Research Ethics Board at the University of Calgary. plications [3]. Patient symptoms are important in assessing Successive female patients meeting inclusion and exclu- urinary incontinence; however, they may be unreliable in sion criteria were approached for enrolment. Women were distinguishing between the different types [3]. Multichannel included if they were initially diagnosed in the office with urodynamic testing (UDS) is widely used to clarify the diag- MUI by participating urogynecologists and had both UDS nosis and is considered the gold standard for assessing incon- and DC requested. With regard to MUI diagnosis, this referred tinence [3, 4]. MUI is a traditional indication for UDS, as the to a clinical diagnosis of both SUI and UUI/UU in the same test commonly reclassifies clinical diagnoses and potentially participant prior to any testing with UDS and DC. Thus, wom- identifies patients at risk for poor prognosis and surgical fail- en with SUI-only or UUI/UU-only diagnoses were ineligible. ure [4]. Exclusion criteria were inability to provide consent, inability The primary goal of testing in MUI is to objectively repro- to read English and to complete the study questionnaires, age duce patient symptoms by evaluating the storage phase of the <18 years, and diagnosis other than MUI, including recurrent bladder during cystometry [5]. Demonstration of detrusor urinary tract infection (UTI), suspected bladder pain syn- overactivity (DO) and/or decreased bladder sensation thresh- drome, suspected foreign body/neoplasm/fistula/diverticulum olds is indicative of urinary urgency (UU) and UUI, whereas in the lower urinary tract, evaluation for urethral obstruction or urinary leakage with increased intra-abdominal pressure in the hypotonic bladder and for gross or microscopic hematuria, absence of DO is a sign of SUI [4, 5]. As a gold standard, testing for latent SUI, or solely for documenting incontinence however, UDS is a lengthy test with a limited detection rate, prior to SUI surgery. Participants were asked to fill out a ques- particularly for overactive bladder (OAB) [4, 5]. For example, tionnaire on baseline demographic data and urinary symp- UDS may fail to identify DO in up to 46% of women with toms. Immediately after each test, participants were asked to symptoms of OAB, as it may not be able to capture it at that fill out an additional questionnaire measuring procedure ac- specific point in time [4, 6]. For women with SUI symptoms, a ceptability scores [8]. UDS and DC were performed in ran- cough leak is not seen in up to 15% of women during UDS [4, dom order. Pelvic examination was performed at the DC ap- 7]. This discrepancy between symptoms and UDS testing may pointment and included the Pelvic Organ Prolapse present a real clinical challenge to patient treatment. Quantification (POP-Q) examination [2, 9]. Once recruitment Dynamic cystoscopy (DC) is a novel approach for test- was complete, a qualified physician blinded to patient history ing bladder physiology and has been routinely used at this and DC results interpreted UDS data and provided final UDS study’s institution in women with symptoms of MUI. diagnoses based on prespecified definitions. A different phy- Currently, there is no reported literature on the compari- sician blinded to history and UDS results provided final DC son between UDS and DC as a single tool for evaluating diagnoses. incontinence. During direct-observed bladder filling, the woman is asked about filling sensations, as at UDS, and Testing protocol the bladder is inspected for changes consistent with DO. SUI is tested for at the completion of the procedure. With All participants were investigated with the UDS system respect to the storage phase, DC gathers the same infor- (Triton, Laborie Medical Tech., Canada) using a standardized mation as UDS, with the exception of urethral pressures. protocol according to international standards [10]. DC was DC has the added advantage of direct visualization of the performed with a rigid cystoscope (27,005 BA, 30°, 4-mm bladder for pathology. telescope, Karl Storz) attached to the UDS pump and soft- The primary aim of this study was to investigate the diag- ware. Prior to each test, the participant voided on a uroflow nostic agreement between DC and UDS for detecting SUI and (to measure maximum flow rate and voided volume) and was UUI in women with a history of MUI requiring further clari- then catheterized for a preprocedure postvoid residual (PVR). fication beyond that of history and physical examination. During the filling/cystometry portion of each test, volumes of Int Urogynecol J (2019) 30:823–829 825 instilled fluid at first urge to void, strong desire to void, and purpose of this study, it was defined as maximum flow rate < 3 maximum cystometric capacity (MCC) were ascertained as 12 cm /min with a detrusor pressure < 15 cm H2O on the per International Urogynecological Association/International pressure-flow component [13]. ISD was defined as lack of Continence Society (IUGA/ICS) terminology [2]. Detrusor, midurethral coaptation or open bladder neck on cystoscopy vesical, and abdominal pressures were gathered during filling and mean urethral closure pressure (MUCP) ≤20 cm H2Oon at UDS. Room-temperature normal saline was infused at a rate UDS [14, 15]. DC exclusively reported urologic pathology. of 60 cm3/min through a
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