eMedicine Specialties > Obstetrics and Gynecology > Prolapse and Incontinence

Urinary Incontinence, Medical and Surgical Aspects: Workup

Author: Michael O'Shaughnessy, MD, FACOG, Assistant Chief, Director of Urogynecology, Assistant Clinical Professor, Department of Obstetrics and Gynecology, University of California at San Francisco, UCSF Fresno University Medical Center
Contributor Information and Disclosures

Updated: Feb 9, 2007

Workup

Laboratory Studies

  • Urinalysis and urine culture
    • UTIs can cause or contribute to urinary incontinence disorders in several ways. Local inflammation can serve as a bladder irritant, causing uninhibited bladder contractions. Endotoxins produced by some bacterial strains can have an alpha-blocking effect on the urethral sphincter, thereby lowering intraurethral pressures.
    • Postmenopausal women are especially susceptible to these effects on the urethra and bladder. Hypoestrogenism may enhance the effects. UTIs may present in postmenopausal women without the classic symptoms of irritation and pain. The predominant symptom in some patients may be the onset or the worsening of urinary incontinence.
    • Colony counts of less than 105 may be of significance in postmenopausal women and should be treated. Evidence of inflammation through urinalysis may be mild or entirely lacking despite bacterial growth from a culture. Women who are tested for urinary incontinence generally are recommended to have a screening urinalysis, and postmenopausal women also should have a urine culture.
  • Diabetes testing: Testing for diabetes is not routine in the setting of urinary incontinence but should be considered if polyuria and polydipsia are a part of the clinical picture or if risk factors are present.
  • Urine cytology: The role of urine cytology in the evaluation of urinary incontinence is unclear. Potential indications include persistent unexplained hematuria and bladder lesions and masses visible on cystourethroscopy. Routine use of urine cytology seems unwarranted.

Imaging Studies

  • Ultrasonography
    • US is a readily available and versatile tool that has many potential uses in urology and urogynecology. US is noninvasive, does not use ionizing radiation, and is relatively inexpensive. US is useful in the evaluation of the upper urinary tract.
    • Visualization and evaluation of hydronephrosis, hydroureter, and urinary tract stones are useful in clinical practice. US visualization of the genitourinary system has been used in the staging of gynecologic malignancies and for the evaluation of urinary tract anomalies. Recently, US has been used as a research and clinical tool in the evaluation of urinary incontinence.
    • Research still is in the preliminary phases; like most new procedural technology, a lack of standardization of technique makes comparison of data across studies difficult. Variables such as route of scanning, type of scan head, patient position, and bladder volume need to be evaluated further to arrive at the best techniques for particular clinical situations.
    • Postvoid residual volume determinations
      • The ability of US to visualize fluid collections clearly without the need for contrast makes it a potentially useful means of determining bladder volumes in a noninvasive way. Studies have been performed using transabdominal scanning to determine PVR volumes. Scanning is performed in the 2 perpendicular planes, transverse and sagittal. The following 3 diameters are obtained: height, width, and depth. The 3 diameters are multiplied by a correction coefficient of 0.7, which accounts for the nonspherical shape of the bladder when it is less than completely full. This formula probably is the simplest US formula for PVR volume determination.
      • Other methods and formulas have been described. The error using this formula, compared to the criterion standard of postvoid catheterization, is approximately 21%. The formula is not accurate at volumes less than 50 mL, but, in clinical applications, precise determination of PVR values of less than 50 mL usually are not needed. Some speculate that transvaginal methods may be more accurate at low bladder volumes.
      • Recently, a device called the Bladder Scan BVI 2500 (Diagnostic Ultrasound Corporation, Redmond, Wash) was introduced for the purpose of PVR volume measurements. Conflicting studies about the accuracy of this device have been reported. One study showed that the Bladder Scan underestimated true PVR volume, but the reported error was within acceptable limits. A second study reported gross underestimation of catheter-derived PVR volumes. The study found that the device was most accurate when volumes were less than 50 mL. US values were 60% of catheter-derived volumes in this setting.
      • This finding is in contrast to previous studies with standard transabdominal scanning. At greater than 150 mL, the device recorded PVR as only approximately 10% of the actual value. The authors could not explain these dismal results, but they believed that differences in calibration and user skills may have contributed, along with the possible inherent inaccuracy of the device. Researchers state that further study of the equipment and standardization of technique is needed.
    • Anatomic evaluation of the bladder neck
      • US has been used extensively to study bladder neck anatomy in individuals who are continent and incontinent. This technique has been referred to as US cystourethrography by some authors. Using a transperineal approach, one recent study looked at ureterovesical junction mobility in young females who are continent. Mobility was present but minimal in most subjects. Researchers reported a mean vertical movement of the UVJ in relation to the inferior border of the symphysis of 5.3 mm, with a maximum of 9 mm. Researchers also reported horizontal excursion of 11.2 mm or less in 95% of the test subjects. These findings appear consistent with another investigation that demonstrated vertical movement of 7 mm in parous females who are continent, 11 mm in females with stress incontinence, and 5 mm in females with past successful colposuspension.
      • Additional work with US cystourethrography has shown that the test is comparable with video cystourethroscopy in a clinical research setting. Urethral funneling also has been observed with US in the evaluation of individuals with stress incontinence. In one study, funneling with straining was observed in most subjects, and funneling at rest was observed in a significant number and seemed to correlate with more severe degrees of incontinence. Special contrast media designed for US applications can enhance bladder neck and urethral visualization.
      • One group found that mobility of the posterior urethral wall was greater than the anterior wall with straining. This group hypothesized that this divergence of the proximal urethral walls may be important in the pathophysiology of stress incontinence. Another author documented the presence of bladder neck dilation in addition to hypermobility in women with stress incontinence. This author found the bladder neck to be the point of continence in many women, especially the nulligravida. A subset of parous but continent women may maintain continence in the mid or proximal urethra area. Further study will determine whether these interesting findings are useful in the clinical management of stress incontinence. The lack of standardization makes interpretation of study findings troublesome.
    • One of the greatest controversies in genitourinary US is which scanning technique is best for incontinence evaluation. Most authorities agree that transabdominal scanning is suboptimal. Transvaginal scanning provides good visualization but may distort the bladder neck anatomy. Some evidence shows that transvaginal scanning increases maximal urethral pressure, functional urethral length, and pressure transmission. Transrectal scanning can be used in men and women, but the bladder neck area still may be compressed with this approach. Introital and perineal techniques do not distort the anatomy and, thus, hold much promise.
    • Endoluminal urethral US is a research tool that has increased the understanding of intrinsic urethral anatomy. Reduced rhabdosphincter muscle volume has been reported in incontinent women using this technique. Endoluminal US also may be useful in the diagnosis of urethral diverticulum and, perhaps, as an intraoperative imaging tool during surgical repair. Three-dimensional US study of urethral anatomy also has been reported. Doppler US studies have been conducted focusing on the urethral submucosa/sphincter area and the bladder neck. Blood flow to the urethral submucosa is increased during high estrogen states, such as pregnancy and the luteal phase of the menstrual cycle. Blood flow is diminished with menopause and in patients with ISD. Increased blood flow to the bladder fundus also has been noted in some patients with DI. Another possible use for Doppler US is in confirming ureteral patency through observation of the ureteric jets.
    • Many other potential applications for US technology in incontinence evaluation have been suggested. Some of the following are research applications; others are more directly clinical.
      • Real-time observation of the bladder neck and urethra during voiding
      • Study of pelvic floor muscles such as the levators
      • Observation of the effect of bladder volume on bladder neck anatomy
      • More precise diagnosis of pelvic organ prolapse, especially enterocele
      • Bladder wall thickness determinations to screen for DI
      • Patient visualization of bladder neck elevation as a biofeedback tool in pelvic floor exercise programs
      • Monitoring the progress of patients during and after pelvic floor exercise programs
      • Study of pelvic floor muscle function and bladder neck anatomy immediately after pregnancy
      • Precise anatomic localization of catheter tips during urodynamic studies
  • Fluoroscopy and video urodynamics
    • Fluoroscopic video urodynamics has become the investigative technique of choice for incontinence in many referral and research centers. This technique involves the simultaneous display of real-time images of the bladder neck and urethra and cystometric summaries of bladder, intra-abdominal, and, in some cases, urethral pressures.
    • The precise placement of pressure transducers and a constant understanding of their exact anatomic location is one of the advantages of this technique. Another advantage is the ability to fluoroscopically observe the bladder neck area throughout bladder filling and during stress maneuvers. Contrast material can be observed entering the proximal urethra just before leakage; thus, leak point pressure findings can be more precise. Cough profiles and pressure transmission ratios can be determined. The physical location of the transducer tip can be observed during urethral pressure profilometry (UPP) and correlated with the pressure findings. Although probably not necessary for the evaluation of straightforward stress incontinence, video urodynamics can be a valuable diagnostic tool in complex or confusing cases.
  • Cystourethrography
    • Antegrade or retrograde cystourethrography is a useful adjunct to incontinence workups in situations where urinary tract fistulas are suspected.
    • Voiding cystourethrography may reveal urethrovaginal fistulas and urethral diverticula.
  • Intravenous pyelography
    • Intravenous pyelography (IVP) may be useful in defining the course and caliber of the ureter preoperatively in cases of stress incontinence and coexisting severe apical or anterior vaginal wall prolapse.
    • An IVP also can help differentiate between ureterovaginal and vesicovaginal fistulas. Finally, if suspecting ureteral obstruction following incontinence surgery, an IVP is indicated.
  • Positive pressure urethrogram
    • The positive pressure urethrogram probably is the most useful single test in the workup of a known or suspected urethral diverticulum.
    • Dye is injected under pressure into the urethra through a specially designed catheter, which isolates the urethral lumen between 2 occluding balloons. One balloon occludes the urethra at the meatus/vaginal introitus. The other balloon rests snugly at the UVJ. Plain films are taken after the dye is injected.
    • This study helps define the anatomy of the diverticulum in terms of size, number, and location of loculations and the location of the orifice(s) along the length of the urethra. This information is essential in planning surgical therapy.
  • Chain-bead cystography
    • The significance of this test is largely historical. Chain-bead cystography consists of the passage of a radiopaque chain transurethrally, with a portion of the chain piled just within the bladder at the UVJ.
    • Urethra and bladder neck mobility, the presence or absence of urethral funneling, and the posterior urethrovesical angle can be determined with this test.
    • Less invasive techniques, including the cotton swab test, bladder neck US, video urodynamics, and dynamic pelvic floor magnetic resonance imaging (MRI), now are used to study bladder neck anatomy and function.
  • Magnetic resonance imaging
    • MRI is capable of demonstrating the gross morphology of the pelvic floor with excellent soft tissue differentiation. Other techniques of pelvic floor imaging do not offer adequate visualization of individual muscles and connective tissue components.
    • Structures that have been imaged successfully include the levator ani, pubourethral ligaments, and the compressor urethrae. Studies have demonstrated increased descent and rotation of the bladder neck in incontinent females. MRI can be performed in a sitting or supine position.
    • Higher resolution and dynamic scanning techniques promise even better understanding of the pelvic floor defects associated with urinary incontinence.
    • Another application of MRI in genitourinary incontinence evaluation is characterizing the size and location of urethral diverticula.

Other Tests

  • Electromyography
    • Electromyography (EMG) is a type of neurophysiologic testing. EMG studies have several potential roles in the evaluation of patients with urinary incontinence.
    • The test can be performed with surface electrodes, monopolar needle electrodes, or concentric needle electrodes. Each modality has distinct advantages and disadvantages. A detailed discussion of the technical aspects of EMG is beyond the scope of this article.
    • EMG studies can be used to test the neuromuscular integrity of the urethral and anal external striated sphincters, puborectalis, and pubococcygeus muscles. Digital palpation and manometric measurements are 2 other methods to assess the strength of voluntary pelvic muscle contractions. These methods correlate well with surface EMG findings, but only surface EMG measurements are predictive of pelvic floor pathology.
    • A recent study demonstrated that poor pelvic floor muscle function, based on surface EMG measurements, was predictive of symptoms of general incontinence, stress incontinence, urge incontinence, and parity. In addition, statistically significant lower microvoltage pelvic floor contractions were found in postmenopausal women not on estrogen replacement therapy.
    • EMG studies also can be combined with studies of bladder filling (eg, cystometry) and emptying (eg, uroflowmetry). Slowly increasing external urethral sphincter tone with filling and relaxation with emptying is a normal finding. When evaluating patients with neurological disorders and discoordination of the bladder and urethral sphincter, detrusor-sphincter dyssynergia can be revealed. EMG recordings also can be used as biofeedback in pelvic floor exercise therapy.
    • EMG studies are most useful in the research setting. Experience with recording and interpretation in the clinical setting by gynecologists and urologists is limited.
  • Pudendal nerve terminal motor latencies
    • Another type of neurophysiologic assessment is the pudendal nerve terminal motor latencies (PNTML) study, which is performed with bipolar electrodes. The stimulating electrode is placed at the ischial spine, close to the pudendal nerve. The recording electrode is placed in the area of interest such as the anal or urethral sphincter.
    • The St Marks electrode, which is worn on a gloved finger, is the most well known of these devices. With this technology, the association of pelvic floor denervation injury with urinary incontinence was uncovered.
    • In addition, age-related increases in pudendal nerve latencies have been described. Although PNTML studies have increased our understanding of the neuromuscular dysfunction component of pelvic support and incontinence disorders, their role in day-to-day clinical practice is unclear.

Diagnostic Procedures

  • Cystourethroscopy
    • In the 1970s, Jack Robertson, MD, introduced cystourethroscopy to urinary incontinence evaluation. The role of cystourethroscopy in an incontinence workup is not clear. Strong indications for visual evaluation of the lower urinary tract in the setting of incontinence include irritative symptoms, hematuria, persistent postoperative incontinence, voiding dysfunction, and findings suggestive of a diverticulum or fistula.
    • Comparisons of cystourethroscopy and multichannel urodynamics show the latter to be more sensitive and specific in diagnosing GSI and DI. Despite this finding, cystourethroscopy may contribute to an anatomic and functional assessment of the lower urinary tract; thus, in combination with urodynamics, this procedure aids in making the correct diagnosis.
    • Dynamic urethroscopy consists of visualization of the proximal urethra and UVJ during coughing, straining, and voluntary pelvic muscle contraction. Hypermobility of the UVJ can be observed readily in cases of stress incontinence.
    • A fixed, rigid, nonfunctioning urethra can be a finding in severe cases of ISD. Rounding of the urethra or the presence of bladder trabeculations (thick, bandlike cords of detrusor muscle) during bladder filling may point to the diagnosis of DI (see Image 3, Image 9).
    • Bladder neck fronds and polyps or cystitis cystica can indicate past or chronic inflammation. Occasionally, such unexpected findings as foreign bodies, stones, and neoplasms may be revealed. Finally, urinary tract fistulas, diverticular openings, and functional ureteral abnormalities can be visualized with cystourethroscopy.
    • Recently, a retrospective study of 84 patients in a referral urogynecology practice illustrated the potential importance of cystourethroscopy in incontinence evaluations. In this study, 19% of the cases had a cystourethroscopic finding that changed patient management. These findings included an intravesical suture, a urethral diverticulum, 2 cases of bladder cancer, and 2 cases of cystitis glandularis. In addition, a group of patients had urethroscopic findings that contributed to the ultimate diagnosis of ISD.
    • In most other cases, cystourethroscopic findings supported the urodynamic diagnosis. Researchers concluded that cystourethroscopy goes hand-in-hand with urodynamic testing and may enhance the diagnostic accuracy of the latter. Of note, patients with malignant and premalignant conditions of the bladder did not have the classic symptoms of pain and hematuria and did not necessarily have other commonly associated characteristics and risk factors such as age over 60, urinary urgency, and DI.
    • Other methods, such as fluoroscopy and videourodynamics, can be used to perform anatomic assessments of the lower urinary tract. These methods are more costly and less readily available in clinical practice. More research is needed to further define the role of cystourethroscopy in urinary incontinence evaluations.
  • Urodynamic studies
    • Urodynamics is the study of hydrodynamics and muscle activity for the purpose of defining the functional status of the lower urinary tract. The ultimate goal of urodynamics is to aid in the correct diagnosis based on pathophysiology.
    • Urodynamic findings of significance must be associated with reproduction of the patient's symptoms. Studies that do not reproduce the patient's symptoms are inconclusive. Likewise, studies that result in abnormalities with no associated symptoms or symptoms differing from the patient's complaints are not conclusive.
    • Urodynamic studies should assess both the filling-storage phase and the voiding phase of bladder and urethral function. In addition, provocative tests can be added to try to recreate symptoms and to assess pertinent characteristics of urinary leakage.
    • Selection of patients for complex urodynamic testing can be difficult. Universally agreed-upon criteria for complex testing do not exist. The criteria that do exist are rooted more in expert opinion than in evidence-based scientific findings.
    • Urodynamic testing is expensive and requires specialized equipment and expertise. The availability of testing facilities is not universal. The potential importance of urodynamic testing lies in the fact that the outcome of therapy is tied to understanding the pathophysiology in any given case and to making the correct and complete diagnosis. Surgery for incontinence carries with it substantial failure and complication rates. Many poor outcomes can be attributed to diagnostic failures.
    • The history and physical examinations alone may not provide sufficient and accurate information on which to base surgical therapy, but such basic data may provide the foundation from which to select patients for more invasive and complex testing.
    • The following historical factors suggest the need for complex testing.
      • Unclear or complicated history
      • Significant urge component
      • Irritative voiding symptoms
      • History of urinary retention
      • History of previous failed incontinence surgery
      • Continuous incontinence or leakage with minimal activity
      • Elderly patient (ie, >65 y)
      • Male patient
      • Blacks with stress incontinence history
      • History of advanced pelvic organ prolapse
      • History of advanced diabetes (bladder neuropathy)
      • Nocturnal enuresis
      • Nulliparous patient with stress incontinence
      • Known or suspected neurologic disease as a cause or contributor to incontinence
    • Physical examination findings that may prompt consideration of complex urodynamic evaluation include the following:
      • Evidence of severe pelvic organ prolapse
      • Abnormal CNS, lower extremity, or pelvic floor neurologic findings
      • High PVR
      • Stress incontinence with minimal increases in intra-abdominal pressure, with an empty bladder and positive results on supine stress test
      • Abnormal simple cystometry
    • Before urodynamic testing, the urine should be free from bacteria or evidence of inflammation. Many practitioners administer a single dose or short course of prophylactic antibiotics if invasive testing is scheduled. The literature suggests that this prophylaxis probably is not necessary if proper technique is used.
    • In female patients, some evidence shows that urodynamic findings do not change significantly in individuals when testing is performed at different times in the menstrual cycle. In another small retrospective study, cystometry was less likely to reveal an abnormality during the luteal phase, especially in patients who reported that their symptoms were influenced by the menstrual cycle. Researchers suggest avoiding urodynamic studies during the luteal phase if possible.
    • The individual components of urodynamic testing are numerous. Which of these components are essential, which may be important in specific and unusual circumstances, and which serve primarily as research tools is uncertain. Components that are most essential to planning surgical therapy are stress testing, cystometry, uroflowmetry, PVR urine determination, Valsalva leak point pressure, and the urethral pressure profile.
    • Within the scope of some of these tests, differing levels of complexity also exist. For example, the urethral pressure profile can consist of a simple determination of resting closure pressure, or, additionally, cough profiles, pressure transmission ratios, and measurements of functional urethral length can be obtained. In general, the more sophisticated the procedure, the more narrow the scope of current clinical usefulness. These procedures ultimately may increase the understanding of urinary incontinence and, thus, improve the physician's ability to manage these disorders.
    • Urodynamic studies are, by their nature, unphysiologic. Studies have shown that the reference range in such tests as uroflowmetry and cystometry is wide. Nevertheless, these are the best tests available for examination of lower urinary tract function. Again, any abnormal findings should correlate with the patient's symptoms to be of significance.
  • Uroflowmetry
    • Uroflowmetry is a method of measuring urine volume passed per unit time. The simplest method uses a stopwatch and a commode that is equipped to measure urine volume. More complicated devices use the increasing weight of the urine over time to determine flow rates.
    • Urine flow rates are a product of detrusor contraction strength, urethral resistance, and, in some instances, the contribution of abdominal straining. Normal flow curves are bell shaped and display a rapid rise to peak flow, a short duration of peak flow, and a rapid fall. In males, the resistance factor is greater because of the longer urethra and the presence of the prostate.
    • To compensate for these factors, the detrusor contribution to voiding must be greater. In males, maximum flow rates are affected greatly by age and range from 35 mL/s in males aged 14 years to approximately 5 mL/s in males aged 80 years. Low flow curves often are predictive of the need for surgery to protect the upper tract, but they do not provide specific information about the etiology.
    • Decreased detrusor contractility, outlet obstruction, or a combination of both may be responsible for low flows. In women, aging by itself results in little or no drop in flow rates.
    • Factors such as pelvic organ prolapse, stress incontinence, prior hysterectomy, increased parity, and, perhaps, hypoestrogenism are far more predictive of decreased flow rates than age alone. Note that flow rates are dependent on voided volume. Uroflow studies should be performed with a minimum of 150-200 mL in the bladder.
    • Flow patterns generally do not point to a specific urodynamic diagnosis, although some associations have been noted. DI often is associated with high flow rates, although the opposite can be true. In patients with aging bladders or in the early stages of neuropathy, DI may coexist with detrusor hypofunctioning. Stress incontinence sometimes is associated with low flow rates.
    • In some instances, such as in cases with a strong component of ISD, super flow patterns may be observed. Sensory-urgency syndrome may be associated with low flow rates, especially if the bladder is contracted. Noncontinuous patterns can indicate Valsalva voiding or detrusor sphincter dyssynergia. A prostatic uroflow curve has been described. This consists of an unbroken pattern with asymmetry and an elongated flattened area from Qmax to the end of voiding (see Image 7). Abnormal findings, especially low flow rates, should be confirmed by repeat studies. Nervousness or embarrassment can result in nonrepresentative dysfunctional voiding patterns.
    • In females, the role of uroflowmetry is controversial. Voiding dysfunction is uncommon, except in the patient who recently had incontinence surgery. Females can complete successful voiding in a number of ways. Valsalva voiding or Valsalva augmentation of voiding is not uncommon. Some females void by urethral relaxation alone. Reference range values for uroflow parameters are not well established for females. Maximum flow rates of greater than 20 mL/s generally are considered normal. Flow rates of less that 10 mL/s are considered low, but, if the PVR volume is minimal, this finding is of dubious clinical significance. A normal voiding time is considered 15-20 seconds. Most often in females, low flow rates indicate a functional rather than an obstructive problem.
    • Uroflow studies may be useful in predicting the risk for voiding dysfunction and high residual volumes after incontinence surgery. Patients with low flow rates may be at risk for prolonged catheterization. In one study, 38% of the patients with abnormal uroflow study results before surgery required postoperative catheter drainage for more than 1 week. Only 10% of those with normal study results required prolonged drainage. This prognostic information is important for both the physician and the patient. Teaching patients with low flow rates about ISC preoperatively may be prudent. Patients who are long-term Valsalva voiders also may be at increased risk for breakdown of surgical repairs.
    • Voiding cystometry or pressure-flow studies can be a valuable adjunct to standard uroflowmetry. To perform these studies, cystometry catheters are left in place during uroflowmetry. In males, these studies can be vital in differentiating outlet obstruction from functional detrusor problems. Low-flow, low-pressure findings would be consistent with the latter. High pressures and low-flow rates suggest outlet obstruction. Maximum detrusor pressures of less than 20 cm H2 0 generally are considered abnormal.
    • Normal parameters for pressure-flow studies have not been established for females. Many females void with very low detrusor pressures because of the short, relatively low-resistance urethra. Detrusor contraction during voluntary voiding may serve the purpose of bladder accommodation to decreasing volumes rather than the generation of significant expulsive forces. Successful voiding with urethral relaxation alone is not uncommon. Valsalva voiding and Valsalva augmentation of detrusor voiding also are observed. If residual volumes are low, then no specific treatment is required.
  • Cystometry
    • Cystometry is a technique of assessing the filling phase of bladder function. Abnormal cystometric findings also should be considered by patients to be consistent with their clinical complaint. Much information can be gained during cystometry, including the diagnosis of bladder instability, sensory-urgency syndrome, sensory neuropathy, loss of compliance, and determination of bladder capacities.
    • In addition, leak point pressures and cough stress tests can be performed during cystometry, and pressure-flow studies can be performed if the cystometry catheters are left in place during uroflow studies.
    • The simplest forms of cystometry can be performed with a catheter and syringe or manometer held 15 cm above the pubic bone. This inexpensive and readily available method may be adequate for screening in uncomplicated cases but may miss subtle findings.
    • Single-channel cystometry consists of recording isolated intravesical pressures during filling with a single catheter. With this method, increases in intra-abdominal pressure cannot always be differentiated from increases in true detrusor pressure. Multichannel cystometry is performed with a bladder catheter and a second catheter to approximate intra-abdominal pressure. The second catheter can be placed in the rectum or vagina. In cases of severe pelvic organ prolapse, a rectal catheter may perform more reliably.
    • The summary consists of a vesicle pressure channel, an abdominal pressure channel, and true detrusor pressure channel. The true detrusor pressure channel, also called the subtracted channel, is the bladder pressure minus the abdominal pressure. Depending on the individual set up, additional channels may accommodate simultaneous urethral pressure readings and continuous EMG readings.
    • The interested reader is referred to the Bibliography for several excellent publications on the finer technical points of complicated cystometry. Basic technical points include the choice of medium, the fill rates, and the types of catheters. Carbon dioxide gas is a convenient infuser; it is quick and clean but unphysiologic. Carbon dioxide gas may irritate the bladder and result in false-positive findings. A liquid medium, usually saline, is preferred. Most testing is performed with room temperature solutions. Cold solutions can be used as a provocative maneuver to promote bladder contractions.
    • The filling rate can vary but usually ranges from 10-100 mL per minute. Slower, more physiologic rates can be used if a suspected false-positive result is obtained at faster rates. Likewise, faster rates can be used to provoke subtle instability or can be used in patients with significant urgency who do not allow sufficient volumes to be infused if slower rates and longer infusion times are used.
    • Catheters generally should be 10F or less in caliber to avoid urethral irritation and obstruction of flow. Microtip transducers are used most commonly in clinical practice. Fiberoptic and piezoelectric catheters also are available.
    • Patient position during testing varies in the literature, but, most commonly, the patient is sitting, semierect, or standing. The catheters generally are calibrated so that zero corresponds to atmospheric pressure. A complete cystometric evaluation monitors the filling-storage segment and emptying segment of bladder function.
    • For clinical purposes, the emphasis often is on the filling-storage segment. During filling, normally, detrusor pressure does not rise. This finding reflects the compliance of the bladder. With rapid filling rates, a small-to-moderate increase in pressure may be noted. The 4 recognized cystometric phases of bladder function are described below. The first 3 of these phases make up the filling-storage segment of bladder function. The last phase represents the emptying segment. The 4 phases are as follows:
      1. Initial small increase in intravesical pressure at the beginning of filling
      2. Stable pressure that comprises the majority of the filling phase
      3. Terminal rise in pressure at bladder capacity representing the limit of viscoelastic expansion: In a clinical setting, this phase often is not reached due to patient discomfort.
      4. Voiding phase with an inconsistently observed small increase in intravesical pressure
    • Bladder sensation and capacity can be measured during filling cystometry. The first sensation is described as the volume at which the patient first is aware of fluid in the bladder (reference range of 50-150 mL). The second sensation (full) has been described as the volume at which the individual normally would consider voiding due to an urge sensation (reference range of 200-400 mL). Maximum capacity is when the patient is experiencing pain and does not allow continued filling (reference range of 400-600+ mL).
    • Low bladder capacities can be observed with UTIs, sensory-urgency syndrome, interstitial cystitis, DI, and stress incontinence. In the urodynamics laboratory, some patients prematurely terminate filling to avoid the possibility of having an accident. Considerable reassurance and clear instructions on the part of the practitioner usually help to avoid this type of false-negative study.
    • Increased capacity can be observed with a neurogenic bladder. Either increased or decreased bladder capacities can represent long-term abnormal voiding habits. These habits can develop in the presence or absence of identifiable pathology.
    • Low-compliance bladders are demonstrated through cytometry by a slowly rising bladder pressure through all or most of the filling segment. Compliance problems can be due to chronic infection, fibrosis, cancer, radiation effect, and inflammation from long-term indwelling catheters. As previously mentioned, supraphysiologic fill rates can result in nonpathologic loss of compliance.
    • Any bladder contraction during filling is considered abnormal, but the clinical significance of bladder contractions that are asymptomatic or not identified by the patient as representing their symptomatology are uncertain. ICS has identified a minimal contraction amplitude of 15 cm H2 O over baseline to be considered significant. Several experts believe that some contractions of lesser amplitude may be clinically relevant. Demonstration of urgency coincident with increased true detrusor pressure and urinary leakage in the neurologically intact patient defines the diagnosis of DI (see Image 2). Many urodynamics centers use provocative maneuvers consisting of common triggers for bladder contractions in an attempt to induce DI. These maneuvers may be important in patients with high clinical suspicion for DI but without instability findings on filling.
    • Provocative maneuvers, such as the sound and sight of running water, hand washing, coughing, and heel bouncing, are used commonly.
  • Valsalva leak point pressure
    • The clinical aim of Valsalva or abdominal leak point pressure determination is to provide an objective way of assessing passive incontinence. Phrased differently, the technique is intended to test the resistance of the urethral sphincter to increases in intra-abdominal pressure.
    • The Valsalva leak point pressure has been proposed as a tool in the diagnosis of ISD and as an objective indicator of the severity of stress incontinence. The overall assumption is that the lower the leak point pressure, the weaker the urethral sphincter and the more severe the stress incontinence.
    • Interestingly, no consensus exists as to how to perform the test. In addition, many assumptions have been made as to the validity and clinical utility. The results of the other major objective test of urethral sphincter function, the urethral closure pressure, do not always agree with leak point pressure findings. Some studies have shown a weak correlation between these tests, and other studies have found no correlation. Comparing these studies is difficult because of differences in technique.
    • The basic test involves placement of intravesical and intravaginal or intrarectal catheters. The bladder is filled to 150-200 mL. In either the sitting or standing position, the patient is asked to perform a Valsalva maneuver of slowly building intensity. The lowest pressure at which leakage from the urethral meatus is observed is recorded as the leak point pressure (see Image 1).
    • The test should be repeated several times to ensure consistency. If properly performed, the test has excellent test and retest reproducibility. If no leakage is produced or the patient is unable to perform the Valsalva maneuver properly, then a cough leak point pressure can be attempted. A cough leak point pressure is more difficult because pinpointing the precise pressure at which leakage occurs is difficult due to the fast-spiked increase in pressure associated with coughing. The cough leak point pressure overestimates the actual abdominal leak point pressure in many instances.
    • To prevent overestimation, the patient can be asked to cough until leakage occurs and, then, to perform less intense coughs until leakage disappears. The lowest value producing leakage is taken as the leak point pressure. Unfortunately, this technique is easier described than performed.
    • Another alternative, if no leakage occurs with the initial testing, is to repeat the Valsalva maneuver at a higher bladder volume or to perform the test with the bladder catheter removed.
    • A recent study looked critically at the lack of standardization of leak point pressure testing and the many variables that may affect the results, including the caliber of the catheter, patient position, bladder volume, and the presence of pelvic organ prolapse. Some generally believe that if pelvic organ prolapse is severe, then some form of prolapse reduction should be accomplished during the test. The best method of prolapse reduction for this purpose is uncertain.
    • Bladder volume has been shown to be related inversely to leak point pressure, even at volumes between 100 and 300 mL. Most protocols call for a bladder volume of 150-200 mL, although this has not been standardized. In the study mentioned above, no difference was found between the measurement of leak point pressures with the vaginal or bladder catheter when both are used simultaneously.
    • The presence of a transurethral bladder catheter was found to affect leak point pressure significantly, compared to measurements obtained only with a vaginal catheter. Leak point pressures are as much as 20 cm H2 O less without a transurethral catheter. Some think that transurethral catheters may cause some degree of obstruction and that the degree of obstruction may increase with the size of the catheter. The obstruction may elevate the leak point pressure artificially. Patient position also may affect leak point pressure, but this has not been studied.
    • Interpretation of the results also has generated some disagreement and controversy. Many authorities use leak point pressures below 60 cm H2 O to define ISD. Others have cited 80 cm H2 O. A recent study used a value of less than or equal to 50 cm H2 O in conjunction with urethral closure pressure and urethral angle parameters. This study defined leak point pressure as the increase in vesical pressure minus resting vesical pressure. Other studies have defined the leak point pressure as the actual vesical pressure at which leakage occurred.
    • Valsalva leak point pressures are used to make clinical decisions such as whether to perform a sling procedure versus a retropubic urethropexy. More research is needed to determine if meaningful clinical decisions can be based on the results of this test.
  • Urethral pressure profilometry
    • UPP is a technique of recording pressures along the length of the urethra with the bladder at rest. The maximal urethral closure pressure (MUCP) is the maximum urethral pressure minus intravesical pressure (see Image 10). The functional urethral length is the distance along the urethra in which urethral pressure exceeds bladder pressure.
    • Static UPP studies can be performed in a number of ways. Generally, a microtip pressure catheter is pulled through the urethra either manually or via a mechanical arm at a rate of 1-2 mm/s. The catheter can have a single transducer or 2 transducers, 1 in the bladder and 1 in the urethra, approximately 6 cm apart. The transducers are directed to the 3-o'clock or 9-o'clock lateral positions.
    • The test commonly is performed with the patient in the supine position, but the sitting and erect positions have been described. An increase in pressure of approximately 23% from the supine to the standing position can be expected, although the increase may be less in individuals with poor urethral support and greater in patients who are neuropathic.
    • The test most commonly is performed after cystometry; therefore, the bladder is full. Some investigators have recommended performing the test 2 or more times and averaging the results to increase accuracy. Fiberoptic transducers also are available but tend to record significantly lower urethral pressures.
    • Fluid perfusion profilometry via the Brown and Wickham technique is used in some centers. With this technique, a slow steady perfusion rate of 2-10 mL/min is maintained during withdrawal of the catheter.
    • In addition to resting or static UPP, cough or stress profiles can be performed. The procedure basically is the same, except that the patient coughs repeatedly throughout these profiles. The patient is asked to produce coughs of a consistent intensity every 2-3 seconds. Any urinary leakage is recorded. The pressure transmission ratio, expressed in percentage form, can be calculated at any point along the urethra. The change in urethral pressure from rest to the top of the cough spike is divided by the change in bladder pressure recorded at the same time. The result is multiplied by 100 to produce the pressure transmission ratio.
    • UPP has many clinical applications. MUCP of less than 20 cm H2 0 have been associated with higher failure rates when these patients are treated with a Burch colposuspension. Closure pressures below 20 cm H2 0 suggest ISD as an indication for a suburethral sling. Attempts have been made to explain and diagnose GSI with the use of pressure transmission ratios. No threshold value has been determined that is consistently associated with stress-induced leakage. At this time, cough profiles have limited clinical utility.
    • Urethral instability is a rare and controversial cause of incontinence. The diagnosis can be made with UPP if a decrease in urethral pressure is observed along with a stable bladder and urinary leakage.
    • Urethral diverticula can be suggested by a biphasic UPP curve. This type of curve also has been observed in cases of GSI. The presence of a diverticulum, if suspected, should be confirmed by imaging studies. If a diverticulum is confirmed, the location of the observed sudden fall in pressure on UPP can help in localizing the diverticular opening in relation to the striated sphincter. This information may aid in the planning of surgical therapy.
    • Urethral pressure profiles augmented by pelvic floor contraction are being investigated. Researchers hope that this variation of UPP may help in the clinical assessment of urethral competency. In addition, this technique may prove useful in selecting patients for pelvic floor physiotherapy. Some have observed that MUCP increases and functional urethral length decreases during pelvic floor contraction. The latter finding may be indicative of the presence and importance of longitudinal urethral musculature.
  • Pad testing
    • Pad testing is a method of verifying, objectifying, and quantifying incontinence episodes. Many different test protocols have been described.
    • Short-term tests generally involve the subject drinking a known volume of liquid or undergoing retrograde filling of the bladder. A preweighed sanitary pad is applied. The individual is instructed to perform specific activities such as coughing, running in place, bending and lifting, or hand washing. The testing interval can range from 15 minutes to 2 hours. At the end of the test period, the pad is removed and weighed.
    • Long-term tests are conducted under normal living conditions for 24-48 hours. Each pad is preweighed and then weighed again after use by the patient at home, or, alternatively, the pad is placed in an airtight plastic bag and weighed later by the clinician.
    • Short-term tests have the advantage of convenience and assured compliance. Long-term tests may be more representative of daily incontinence.
    • Universally accepted criteria for a positive test result do not exist. The ICS considers the finding of a weight change of less than 1 g during its standardized 1-hour test to be a negative result. Vaginal discharge and sweat can be other physiologic sources of pad weight gain.
    • Testing should not be conducted during menstruation for obvious reasons.
    • Conducting the test after administration of a substance, such as phenazopyridine, which colors the urine, can help differentiate urine loss from other sources of moisture.
  • Paper towel test
    • Recently, a simple paper towel test has been described that is a quick estimate of the degree of stress urine loss. The patient is asked to cough repetitively and forcefully with a paper towel held a short distance from the urethra.
    • Standardization is accomplished by dripping known volumes of liquid onto the same type of paper towel to be used in the test. The area of the visible spread of the liquid on the towel is calculated for each known volume. The area of staining on the paper towel used by the patient with incontinence can be measured and the volume of the loss estimated.
  • Ambulatory urodynamics
    • Ambulatory urodynamic monitoring was developed to address some of the many shortcomings of laboratory urodynamics. Ambulatory urodynamic monitoring is an attempt to record bladder function in a more physiologic setting through many natural fill-void cycles.
    • Microtip catheters are worn in the bladder (generally transurethral) and in the rectum or vagina. A portable, battery operated recording device is worn with a shoulder strap. Often, a fluid-sensing undergarment liner is used to record episodes of leakage objectively.
    • A universal finding in ambulatory monitoring is increased detrusor activity compared to conventional cystometry. Rates of detrusor activity of approximately 20% have been recorded in individuals who are asymptomatic. Other work has shown rates of detrusor contractions in 38-69% of volunteers who are asymptomatic. Several possible explanations exist for this phenomenon. Normal and physiologic, but previously unrecognized, phasic detrusor contractions may be occurring. Alternatively, contractions may be related to irritation of the urethra and trigone by the catheter.
    • Finally, the findings may represent a subclinical defect in bladder control. Bladder capacities also tend to be less with ambulatory monitoring. This finding has been demonstrated even when patients are provided the same reporting instructions that are provided in the urodynamic laboratory setting.
    • Artefacts resulting in a false-positive diagnosis of DI have been problematic and limit the usefulness of ambulatory cystometry. In an attempt to decrease monitoring artefacts, a group recently conducted monitoring with a double transducer catheter in the bladder. The group also stressed the importance of using a symptom diary. For a rise in detrusor pressure to be classified as abnormal, the rise had to be reflected in the urinary diary and observed in both transducer channels. The results demonstrated that a 58% reduction in detrusor pressure rises that were classified as abnormal was attributable to the symptom diary and that an additional 19% decrease was due to the second transducer.
    • Clinically, the role of ambulatory urodynamic monitoring in the evaluation of incontinence has not been studied adequately. Some investigations demonstrate high rates (60-91%) of the results of ambulatory monitoring influencing clinical management. No studies to date show any improvement in the results of treatment as a result of ambulatory urodynamics.
    • Possible clinical roles for this technology may include the workup of patients with suspected DI but negative findings on conventional studies. In addition, useful information in patients undergoing treatment for DI or in patients with incontinence after surgical procedures may be gained. Ambulatory monitoring is expensive, requires specialized equipment, and is time consuming. This type of urodynamic evaluation serves mainly as a research tool.
  • Bethanechol supersensitivity test
    • If conventional cystometry does not reveal DI in a patient strongly suspected of having this disorder, 2.5 mg of bethanechol can be administered subcutaneously, and the cystometrogram can be repeated 30 minutes later.
    • The validity of this pharmacologic intervention in cystometric testing has not been determined.
  • Bladder leak point pressure
    • The concept of a bladder leak point pressure is quite different from the Valsalva leak point pressure. Bladder leak point pressures were first described in the evaluation of patients with myelodysplasia.
    • The bladder leak point pressure is the pressure at which leakage occurs due to bladder contraction or the overwhelming of viscoelastic distensibility. The utility of this measurement is in determining the risk of upper tract damage in the setting of myelodysplasia.
  • Pessary trial
    • A pessary trial may be useful in the preoperative evaluation of patients with severe pelvic organ prolapse but with no complaints of urinary incontinence. The female patient can be fitted with a pessary, which effectively reduces her prolapse, and, then, she is asked to wear the pessary for a few days during usual activities.
    • In some instances, the patient may experience stress incontinence while using the pessary. Some think that this maneuver uncovers so-called potential stress incontinence. Phrased differently, in these instances, some believe that part of the individual's continence mechanism may be due to kinking of the urethra and/or limitation of urethral mobility secondary to the large prolapse. These patients may experience stress incontinence after the prolapse is corrected surgically.
    • The preoperative diagnosis of potential stress incontinence prompts the surgeon to add an anti-incontinence procedure to the overall surgical management scheme.
  • Cotton swab test
    • The technical steps of performing the cotton swab test were discussed in Physical examination. The cotton swab test is used to determine the presence or absence of urethral hypermobility. The definition of a positive test result is controversial. The most accepted cut-off point in determining urethral hypermobility is a change in angle from resting to straining of greater than 30 degrees.
    • An interesting study used receiver-operating characteristic curves to determine the angle or change in angle, which possessed the best discriminatory power in the diagnosis of stress incontinence. No resting angle value had sufficient discriminatory power to be useful. The optimal cut-off point for the change in angle from resting to straining was greater than or equal to 30 degrees with a sensitivity of 82% and a specificity of 54%. The very best discriminator was an absolute straining angle of greater than or equal to 40 degrees. A sensitivity of 83% and specificity of 64% was demonstrated.
    • The authors cautioned that the cotton swab test does not have sufficient discriminatory power to make urodynamics unnecessary. They do believe that the test has a role in conjunction with urodynamics and may be used as a screening test in situations where urodynamic testing is not readily available.
  • Cough stress test
    • Simple stress testing was discussed previously in the Physical examination section, but additional information will be mentioned briefly herein.
    • Stress testing in the uninstrumented urethra generally is performed with a full bladder and the patient in the standing position. A positive test result consists of urinary leakage directly observed from the urethral meatus coincident with the peak of intra-abdominal pressure.
    • When combined with a preceding negative finding on cystometrogram, a positive stress test result is 98% sensitive and 100% specific for the diagnosis of stress incontinence.
    • In a small study, the test-retest reliability of the cough stress test was investigated. In patients in whom the diagnosis of GSI was made by a negative finding on cystometrogram and a positive result on cough stress test, the reproducibility of a positive stress test result 1-4 weeks later was 100%. If the initial diagnosis was mixed incontinence, stress leakage was demonstrated on a second cough stress test 80% of the time. Conversely, if the initial diagnosis was DI with a negative result on cough stress test, the repeat cough stress test result was negative 86% of the time.
    • The authors point out that in the setting of pure stress incontinence, the cough stress test may be more useful than complex urodynamic cough profiles. Some believe that, in some cases, the presence of catheters may be sufficiently obstructive to cause a small number of false-negative test results. If mixed incontinence is diagnosed by a cystometrogram and cough stress test, more complex testing may be required to confirm the diagnosis. False-positive stress test results due to cough-induced DI may occur in this situation.
    • The supine stress test has been proposed as a simple method of diagnosing ISD. A recent study demonstrated a high correlation between a positive supine stress test and a Valsalva leak point pressure of less than 100 cm H2 0. The test was performed with 200 mL of fluid in the bladder, and patients with UTI, cystocele, rectocele, or vaginal vault prolapse were excluded. Because of these exclusions, whether the results of the study can be generalized to unselected populations is uncertain.
    • Before this study, an empty bladder variant of the supine stress test had been investigated as a means of diagnosing ISD. Due to the lack of standardization of the diagnosis of ISD and methodological differences in the studies, the role of supine stress testing in the diagnosis of ISD has not yet been determined. A positive supine stress test result should raise clinical awareness of the possibility of sphincter deficiency.
  • Residual urine volume determination
    • High residual volumes are uncommon in females. Only 5% of females who are asymptomatic and 13% of females who are symptomatic have PVR volumes greater than 30 mL. Abnormal residual volumes have been defined in several ways. No particular definition is clinically superior.
    • Some authorities consider volumes greater than 50-100 mL to be abnormal. Others use a value greater than 20% of the voided volume to indicate a high residual.
    • Abnormal findings should be confirmed by a second study. If the premeasurement void takes place in a public restroom and a high residual is obtained, the female patient should be asked if she was relaxed and if she sat on the toilet seat during voiding.
    • Voiding in a crouched but not fully seated position has been associated with PVR volumes in the 50-100 mL range. US can be used as a noninvasive means of obtaining PVR volume determinations, especially if a precise measurement is not required.
    • High PVR volumes in males often are indicative of prostate-related bladder outlet obstruction or functional detrusor problems. Uroflowmetry and pressure-flow studies can help clarify the diagnosis.

More on Urinary Incontinence, Medical and Surgical Aspects

Overview: Urinary Incontinence, Medical and Surgical Aspects
Workup: Urinary Incontinence, Medical and Surgical Aspects
Treatment: Urinary Incontinence, Medical and Surgical Aspects
Follow-up: Urinary Incontinence, Medical and Surgical Aspects
Multimedia: Urinary Incontinence, Medical and Surgical Aspects
References
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Further Reading

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Keywords

urinary incontinence, stress incontinence, SUI, enuresis, urinary leakage, urogynecology, bladder, urethra, ureters, pelvic floor, weakening of connective tissue, genitourinary atrophy due to hypoestrogenism, nocturnal diuresis, involuntary bladder contractions, detrusor hyperreflexia, vesicovaginal fistula, vesicocutaneous fistula, exstrophy of the bladder, genuine stress incontinence, GSI, urethral diverticula, epispadias, intrinsic sphincter deficiency, ISD, urethral instability, overflow incontinence, outlet obstruction, detrusor instability, DI, urge incontinence, continuous incontinence, functional incontinence, benign prostatic hyperplasia, BPH, mixed incontinence, Marshall-Bonney test, modified Marshall-Marchetti-Krantz procedure, Ball-Burch procedure, paravaginal repair, laparoscopic retropubic urethropexy, needle urethropexy, suburethral sling procedure, tension-free vaginal tape, patch sling with suture arms, paraurethral fascial slingurethropexy, microwave therapy, periurethral injectionprocedure, fistula repair, urethral diverticulum repair, cystoplasty, denervation procedure, implantable sacral neuromodulation device, artificial urethral sphincter, urinary diversion, complex reconstructive procedure, Kegel exercises

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Contributor Information and Disclosures

Author

Michael O'Shaughnessy, MD, FACOG, Assistant Chief, Director of Urogynecology, Assistant Clinical Professor, Department of Obstetrics and Gynecology, University of California at San Francisco, UCSF Fresno University Medical Center
Michael O'Shaughnessy, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Urological Association, Association of Professors of Gynecology and Obstetrics, California Medical Association, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Martha K Terris, MD, FACS, Professor, Department of Surgery, Medical College of Georgia
Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Urological Association, New York Academy of Sciences, and Society of University Urologists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Shlomo Raz, MD, Professor, Department of Surgery, Division of Urology, University of California at Los Angeles School of Medicine
Shlomo Raz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, and California Medical Association
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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