eMedicine Specialties > Urology > Incontinence

Pubovaginal Sling: Workup

Author: Sandip P Vasavada, MD, Physician, Center for Female Pelvic Medicine and Genitourinary Reconstructive Surgery, The Glickman Urological and Kidney Institute; Joint Appointment with Women's Institute, Cleveland Clinic
Coauthor(s): Raymond Rackley, MD, Professor of Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University; Staff Physician, Center for Pelvic Medicine and Pelvic Reconstruction, Glickman Urological Institute, Cleveland Clinic Foundation
Contributor Information and Disclosures

Updated: May 4, 2009

Workup

Laboratory Studies

• Urinalysis and urine culture: Urinary tract infection can cause irritative voiding symptoms and urge incontinence.
• Chem 7 profile
  • Check the blood urea nitrogen (BUN) and creatinine (Cr) if compromised renal function is suspected. This is especially important in the case of a stage-III or stage-IV cystocele (see Image 6).
    
    

    

    This photo illustrates a variety of pelvic organ prolapses, including grade-IV cystocele, uterine descensus, enterocele, and rectocele alone or in combination. In situations where a significant prolapse (eg, uterus, bladder) has occurred, evaluate for possible ureteral obstruction at the level of the pelvic inlet.

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    This photo illustrates a variety of pelvic organ prolapses, including grade-IV cystocele, uterine descensus, enterocele, and rectocele alone or in combination. In situations where a significant prolapse (eg, uterus, bladder) has occurred, evaluate for possible ureteral obstruction at the level of the pelvic inlet.

  • Stage-I cystocele is when the bladder drops to the mid vagina with abdominal strain.
  • Stage-II cystocele is when the bladder drops to within approximately 1 cm of the hymen.
  • Stage-III cystocele is when the bladder protrudes out of the vaginal introitus to greater than 1 cm outside of the hymenal ring upon abdominal strain.
  • Stage IV cystocele is when, at rest, the bladder protrudes out of the vagina to greater than 3 cm from the hymen.
  • When the bladder herniates out of the vagina, it may drag ureters with it. Both ureters can become trapped and obstructed at the bony pelvis, causing hydroureteronephrosis. This results in elevated BUN and azotemia.

Imaging Studies

• Static lateral cystography (usually used in conjunction with videourodynamics)
  • Static cystography (eg, anteroposterior [AP], lateral) helps to confirm the presence of stress urinary incontinence (SUI), the degree of urethral motion, and the presence of a cystocele.
  • Perform static cystography during videourodynamics under fluoroscopy. When the bladder is halfway full (ie, 200-250 mL), obtain AP and lateral images of the bladder and bladder neck at rest and using Valsalva and coughing maneuvers.
  • Intrinsic sphincter deficiency (ISD) is evidenced by an open bladder neck. The presence of a vesicovaginal fistula also may be identified.
• Voiding cystourethrography
  • This test can assess bladder neck and urethral function (ie, internal sphincter, external sphincter) during the filling and voiding phases.
  • Voiding cystourethrography (VCUG) can identify a urethral diverticulum, urethral obstruction, and vesicoureteral reflux. Static cystogram or VCUG may be performed with videourodynamics.
• Beaded-chain cystourethrography
  • In the past, physicians commonly used this method to assess urethral hypermobility and the degree of bladder descent. This test largely has been replaced by videourodynamics (see Videourodynamics) and other studies.
  • Incontinence experts no longer recommend the beaded-chain cystography test, which is mentioned here only for historical interest.

Other Tests

• Voiding diary
  • A voiding diary is a daily record of a patient's bladder activity.
  • The diary is an objective documentation of a patient's voiding pattern, incontinent episodes, and any inciting events associated with urinary incontinence.
• Pad test
  • The pad test is an objective test that documents urine loss.
  • Intravesical methylene blue test, oral Pyridium, or oral Urised may be used. Methylene blue and Urised turn the urine blue. Pyridium turns the urine orange.
  • Patients should resume their usual physical activities while wearing a Peri-pad. A Peri-pad is a sanitary pad placed against the vagina and the perineum. If the pads turn orange or blue, the patient is experiencing urine loss. If the pads remain white, the discharge is most likely normal vaginal fluid.
  • Provocative pad tests may entail a patient performing activity for 1 hour or longer to demonstrate how much leaks into the pad within that time frame. The patient then has the pads weighed.
• Cotton swab test
  • An abnormal upward deflection of the cotton swab (>30°) during the Valsalva maneuver is evidence of urethral hypermobility (see Image 7).
    
    

    

    A cotton swab angle greater than 30° denotes urethral hypermobility. Figure 1 shows that the cotton swab at rest is zero with respect to the floor. Figure 2 shows that the cotton swab at stress is 45° with respect to the floor.

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    A cotton swab angle greater than 30° denotes urethral hypermobility. Figure 1 shows that the cotton swab at rest is zero with respect to the floor. Figure 2 shows that the cotton swab at stress is 45° with respect to the floor.

  • The absence of hypermobility suggests that the cause of the SUI is ISD.
• Supine cough stress test
  • A critical part of the pelvic examination is direct observation of urine using the cough stress test (CST) or Marshall test.
  • Place the patient in a dorsolithotomy position. Insert a sterile catheter into the urethra, and fill the bladder with 200-250 mL of water. Remove the catheter. Instruct the patient to perform the Valsalva maneuver and cough in gradients (ie, mild, moderate, severe). Leakage during the Valsalva maneuver or cough denotes a positive CST.
  • If the CST is positive, a Marshall test may determine if the urine loss is caused by urethral hypermobility. In this test, place the index finger and the middle finger on either side of the bladder neck to provide anatomic support. With the bladder halfway full (ie, 200-250 mL), repeat the CST. The index finger and the middle finger provide anatomic support for the bladder neck and prevent urethral descent during the CST. If urine does not leak with this maneuver during the CST, the Marshall test is positive.
  • Some clinicians have criticized the Marshall test for yielding false-positive results due to examiner error. If one is not careful, the supporting fingers may accidentally occlude the urethra (ie, rather than supporting the bladder neck) and cause a false-positive result.
• Standing cough stress test
  • If the cough leak test is initially performed while the patient is in the lithotomy position and leakage is not observed, repeat this test with the patient in the standing position.
  • The patient stands upright with feet shoulder-width apart. Place a large towel under patient's feet. Instruct patient to perform the Valsalva maneuver and cough in gradients (ie, mild, moderate, severe). Observable urine leakage in this position constitutes a positive test.
• Standing pelvic examination
  • Perform a standing pelvic examination when pelvic organ prolapse is suspected. If doubt exists about pelvic organ prolapse, examine patients while they are in the standing position.
  • The patient stands with feet shoulder-width apart. Direct the patient to place 1 foot on the ground and the other foot resting on a step stool. Instruct the patient to perform the Valsalva maneuver in gradients (ie, mild, moderate, severe). When the patient performs the Valsalva maneuver, the force of gravity helps the pelvic organs (ie, uterus, rectum, bladder) slide down the vagina to enhance the diagnosis.
  • SUI may be masked by pelvic organ prolapse. Grade-III and grade-IV cystoceles may cause kinking of the urethra as they herniate out of the vagina. Urethral kinking hides preexisting SUI and causes a false-negative CST.
  • If a pelvic organ prolapse is present, push the prolapsed organ up with either a pessary or gauze. Repeat the cough stress test with the patient in the standing position. If the CST is positive, the patient has SUI in addition to pelvic organ prolapse.
• Urodynamic studies
  • Urodynamics are a means of evaluating the pressure-flow relationship between the bladder and the urethra. Specialists use many different types of urodynamic tests, as described below.
  • Simple urodynamic tests involve performing a noninvasive uroflow, obtaining a postvoid residual (PVR) urine sample, and performing a single-channel cystometrography (CMG). A single-channel CMG (ie, simple CMG) is used to assess the first sensation of filling, fullness, and urge. Bladder compliance and the presence of uninhibited detrusor contractions (eg, phasic contractions) can be noted during this filling CMG. A simple CMG may be performed using water or gas (carbon dioxide). Water is the most common filling medium.
  • Multichannel urodynamic studies are more complex than simple urodynamics and can be used to obtain additional information, including a noninvasive uroflow, PVR urine, filling CMG, ALPP, voiding CMG (pressure-flow), and electromyography (EMG). Water is the fluid medium used for multichannel urodynamics.
  • The most sophisticated study is videourodynamics, the criterion standard in the evaluation of a patient with incontinence (see Image 8). In this study, the following are obtained: noninvasive uroflow, PVR urine, filling CMG, ALPP, voiding CMG (pressure-flow), EMG, static cystography, and VCUG (see Image 9). The fluid medium used for videourodynamics is radiographic contrast.
    
    

    

    This illustration shows videourodynamic equipment (Aquarius XLT, Laborie Medical Technologies) used for evaluation of a patient with incontinence.

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    This illustration shows videourodynamic equipment (Aquarius XLT, Laborie Medical Technologies) used for evaluation of a patient with incontinence.

    
    

    

    Videourodynamics allow a comprehensive evaluation of a patient with incontinence. Information provided by videourodynamics includes filling cystometrogram, abdominal leak point pressure, pressure-flow, static and voiding cystograms, and electromyogram recordings.

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    Videourodynamics allow a comprehensive evaluation of a patient with incontinence. Information provided by videourodynamics includes filling cystometrogram, abdominal leak point pressure, pressure-flow, static and voiding cystograms, and electromyogram recordings.

• Performing urodynamics
  • Instruct the patient to arrive at the urodynamic laboratory with a full bladder. Perform a noninvasive uroflow and PVR urine test. Place the patient in the dorsolithotomy position. Prepare her genitalia, and drape using sterile technique.
  • Perform flexible cystoscopy. Survey the entire bladder urothelium and then retroflex the cystoscope to examine the bladder neck. Fill the bladder with 250 mL of water. Commence bladder filling using room temperature water. Cold water may evoke false-positive detrusor contractions (phasic contractions). Fill the bladder at a medium rate (eg, 60 mL/min).
  • Next, perform the CST and cotton swab test as described previously. Perform a detailed speculum examination with one half of the gynecology speculum pointing at the anterior, posterior, and vaginal apex for a view of pelvic organ prolapse. During the pelvic examination, assess the functional integrity of the pelvic floor muscles by examining the perineal body and checking the rectal tone. The presence of levator ani muscle dysfunction or tenderness may be elicited by gentle palpation of the levator ani musculature in the paravaginal fornices.
  • Perform a standing CST and/or pelvic examination as needed (see Supine cough stress test and Standing pelvic examination).
  • Drain the bladder. Place a urodynamic urethral catheter (ie, 7F Cook dual-lumen pigtailed catheter), rectal tube, and EMG electrodes.
  • Rotate the patient to a sitting position, and equalize transducers. Commence bladder filling using room-temperature contrast (Conray). Cold water may evoke false-positive detrusor contractions (ie, phasic contractions). Fill the bladder at a medium rate (eg, 60 mL/min). Assess the first sensation of filling fullness, and assess urge. Note bladder compliance, and mark the presence of uninhibited detrusor contractions.
  • When the bladder fills to 250 mL, measure the ALPP. Instruct the patient to perform the Valsalva in gradients (ie, mild, moderate, severe) followed by cough (ie, mild, moderate, severe). Observe the urine leakage fluoroscopically and by direct inspection. At this point, note the activity of the bladder neck, urethral mobility, and the presence of cystocele using fluoroscopy (static cystography).
  • Upon completion of ALPP, finish the filling CMG to completion. When the patient has a strong desire to void, perform a voiding CMG (pressure-flow). At this point, note urodynamic parameters, such as maximal flow rate (Qmax) and detrusor pressure at maximal flow rate (PdetQmax).
  • During the voiding CMG, note the activity of the EMG electrodes and voiding cystogram for possible detrusor sphincter dyssynergia (DSD). The presence of DSD is confirmed by increases in EMG activity during detrusor contraction or closure of the external sphincter on VCUG during voiding.
  • After the patient voids to completion, the videourodynamic study is complete. The patient is informed about the findings and is sent home with an oral antibiotic.

Diagnostic Procedures

• Postvoid residual urine volume
  • This measurement is part of the basic evaluation for urinary incontinence.
  • Healthy women usually have PVR urine volume of less than 100 mL.
  • If the PVR urine volume is high, the bladder may be acontractile or the bladder outlet may be obstructed. Both of these conditions cause urinary retention from overflow incontinence.
• Uroflow rate
  • The uroflow rate is a useful screening test used mainly to evaluate bladder outlet obstruction.
  • The uroflow rate is the volume of urine voided per unit of time. Women have no absolute normal maximal flow rate; however, a Qmax greater than 15 mL/s may be considered normal.
  • Low uroflow rates (<15 mL/s) may reflect urethral obstruction, a weak detrusor, or a combination of both.
  • This test alone cannot distinguish between obstruction and an acontractile detrusor.
• Filling cystometrography
  • In 40% of patients, stress and urge incontinence coexist. In many instances, SUI may lead to the development of urge incontinence. A filling CMG is used to assess bladder capacity, compliance, and the presence of phasic contractions. Most commonly, liquid filling medium is used. An average adult bladder holds approximately 450-500 mL of urine. During the test, provocative maneuvers, such as coughing, hand washing, sitting on the commode for 1 full minute, and heel jouncing, may help to unveil bladder instability.
  • A filling cystometry may be performed using the following techniques:
    • Insert a catheter (connected to a special computer) into the bladder for single-channel cystometry. Information recorded by the computer is interpreted.
    • Eyeball cystometry does not require special computers. Perform bedside cystometry by inserting a catheter into the bladder, hanging the irrigant bag at a predetermined height (eg, 100 cm water), and observing the fluctuation of the meniscus within the water chamber during uninhibited detrusor contractions.
    • Eyeball cystometry using a flexible cystoscope is the same as eyeball cystometry except that the flexible cystoscope acts as the connection tubing. This allows simultaneous cystoscopy.
    • Multichannel cystometry is a more sophisticated method of measuring filling CMG where intravesical pressure (Pves), intra-abdominal pressure (Pabd), detrusor pressure (Pdet), and Qmax are recorded simultaneously.
• Abdominal leak point pressure
  • As discussed above, ALPP should be measured when the bladder is half full (eg, 250 mL), and both the Valsalva and coughing maneuvers should be performed. Initially, instruct the patient to bear down in gradients (ie, mild, moderate, severe), and then note the ALPP as the lowest Pves at which leakage is observed. If Valsalva maneuvers fail to produce the desired response, instruct the patient to cough in gradients (ie, mild, moderate, severe) to obtain the ALPP. The Pves at which leakage is seen is the ALPP. The ALPP obtained with Valsalva maneuver is more accurate than the cough-induced ALPP. However, if Valsalva maneuvers fail to manifest SUI, both techniques should be used.
  • Alternatively, both Valsalva and cough-induced ALPP may be repeated by increasing the bladder volume in 100-mL gradients. Increasing the bladder volume reportedly increases the sensitivity of detecting ALPP.
• Voiding cystometrography (pressure-flow study)
  • A pressure-flow study simultaneously records the voiding detrusor pressure and the rate of urinary flow.
  • This is the only test that can assess bladder contractility and the extent of a bladder outlet obstruction.
  • Pressure-flow studies can be combined with a voiding cystography and videourodynamic study for complicated cases of incontinence.
• Cystography
  • A static cystography (eg, AP, lateral) helps to confirm the presence of SUI, the degree of urethral motion, and presence of cystocele. ISD is evident by the presence of an open bladder neck. Presence of a vesicovaginal fistula also may be noted.
  • A voiding cystography can assess bladder neck and urethral function (ie, internal, external sphincter) during filling and voiding phases. A voiding cystography can identify a urethral diverticulum, urethral obstruction, and vesicoureteral reflux.
• Electromyography: EMG helps to ascertain the presence of coordinated or uncoordinated voiding. Failure of urethral relaxation during a bladder contraction results in uncoordinated voiding (DSD).
• Cystoscopy
  • The precise role of cystoscopy in the evaluation of female urinary incontinence is controversial. Fewer than 2% of bladder tumors have been identified by routinely performing cystoscopy in women with incontinence. However, cystoscopy allows discovery of bladder lesions (eg, stitch in the bladder, bladder cancer, bladder stone) that would remain undiagnosed by urodynamics alone. A visual inspection of the urethra helps to establish the presence of urethral stricture or gross evidence of poor urethral closure.
  • Generally, cystoscopy is indicated for patients complaining of persistent irritative voiding symptoms or hematuria. Obvious causes of bladder overactivity, including cystitis, stones, and tumors, can be diagnosed easily. This information is important in determining the etiology of the incontinence and may influence treatment decisions.
  • The authors routinely use a flexible cystoscope (see Image 10) rather than a rigid cystoscope. A flexible cystoscope has excellent optics and enhances patient comfort during the examination. The authors also perform urethroscopy to assess the structure and function of the urethral sphincter mechanism.
    
    

    

    A flexible cystoscope is used to evaluate the anatomy of the bladder and the urethra. A flexible cystoscope is less rigid and more comfortable for the patient than the rigid cystoscope.

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    A flexible cystoscope is used to evaluate the anatomy of the bladder and the urethra. A flexible cystoscope is less rigid and more comfortable for the patient than the rigid cystoscope.

• Dynamic retrograde urethroscopy
  • The cystoscope is introduced into the bladder, which is filled to 250 mL with irrigant.
  • Turn off the flow of the irrigant. Withdraw the cystoscope to the mid urethra. Observe the activity of the urethral sphincter mechanism at rest and with Valsalva maneuvers.
  • Patients with a normal urethra have a closed bladder neck at rest, but with stress maneuvers, they demonstrate an excellent guarding reflex (see Image 11). Patients with type-II incontinence have a closed bladder neck at rest, with an intact voluntary guarding reflex (see Image 12). Patients with type-III incontinence have an open bladder neck at rest but have an impaired voluntary guarding reflex (see Image 13).
    
    

    

    This shows normal findings from a dynamic retrograde urethroscopy; the urinary sphincter is closed at rest (Figure a), closed with stress maneuvers (Figure b), and has excellent guarding reflex (Figure c). Note the urinary sphincter is contracted and elevated in Figure c; this is a normal guarding reflex.

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    This shows normal findings from a dynamic retrograde urethroscopy; the urinary sphincter is closed at rest (Figure a), closed with stress maneuvers (Figure b), and has excellent guarding reflex (Figure c). Note the urinary sphincter is contracted and elevated in Figure c; this is a normal guarding reflex.

    
    

    

    This shows classic type-II stress urinary incontinence seen on dynamic retrograde urethroscopy. Note that the sphincter is closed at rest (Figure a), remains open with stress maneuvers (Figure b), and has good guarding reflex (Figure c). Patients with classic type-II stress urinary incontinence are able to close their urinary sphincters voluntarily.

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    This shows classic type-II stress urinary incontinence seen on dynamic retrograde urethroscopy. Note that the sphincter is closed at rest (Figure a), remains open with stress maneuvers (Figure b), and has good guarding reflex (Figure c). Patients with classic type-II stress urinary incontinence are able to close their urinary sphincters voluntarily.

    
    

    

    This shows classic type-III stress urinary incontinence seen on dynamic retrograde urethroscopy. Note that the sphincter is open at rest (Figure a), remains open with stress maneuvers (Figure b), and has weak guarding reflex (Figure c). Patients with classic intrinsic sphincter deficiency a have difficult time closing their urinary sphincters voluntarily.

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    This shows classic type-III stress urinary incontinence seen on dynamic retrograde urethroscopy. Note that the sphincter is open at rest (Figure a), remains open with stress maneuvers (Figure b), and has weak guarding reflex (Figure c). Patients with classic intrinsic sphincter deficiency a have difficult time closing their urinary sphincters voluntarily.

• Videourodynamics
  • Videourodynamics combine the radiographic findings of VCUG and multichannel urodynamics. Videourodynamics is the most sophisticated diagnostic test for a patient with incontinence. Videourodynamics may be used for evaluating any patient with lower urinary tract voiding dysfunction.
  • In the absence of videourodynamics, the clinician may obtain adequate information from the following:
    • Noninvasive uroflow and PVR urine tests
    • Simple cystometry in combination with cystoscopy
    • Detailed speculum examination
    • CST and cotton swab test
    • Dynamic retrograde urethroscopy

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