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ORIGINAL ARTICLE
Year : 2013  |  Volume : 2  |  Issue : 1  |  Page : 47-53

Urodynamic study of Iraqi female patients with urinary incontinence


1 Gazi Al-Hariri Hospital, Medical City, Baghdad, Iraq
2 Department of Physiology, College of Medicine, Al-Nahrain University, Baghdad, Iraq
3 Department of Physiology, College of Medicine, Baghdad University, Baghdad, Iraq

Date of Web Publication29-May-2013

Correspondence Address:
Farqad B Hamdan
Department of Physiology, College of Medicine, Al-Naharin University, Baghdad
Iraq
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-0521.112631

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  Abstract 

Background: Urodynamic study played a very crucial role in confirming urinary incontinence (UI), differentiating its type and assessing its severity. In addition, it is considered to be the gold standard tool for every patient with UI for directing the line of treatment and for follow up. Objective: To determine the role of urodynamic study in confirming the diagnosis of UI in Iraqi women. Differentiate the type of UI and assess the importance of risk factors in its development. Materials and Methods: This study was performed in the Urology Department, Gazi Al Hariri Hospital, Baghdad Teaching Medical City between January - May, 2011. Seventy five female subjects aged 18 to 78 years were studied (50 patients and 25 control subjects). Medical history, clinical examination and urodynamic tests were performed. Results: Twenty six patients suffer stress UI, 9 patients had urged UI, and 11 patients with mixed UI. Only 4 incontinent patients showed normal urodynamic study. The mean urinary bladder capacity of patients was smaller than those of control subjects, specifically those patients with stress and urge UI. Significantly less volumes of first desire and strong desire to void in most patients than those of control subjects. Urethral pressure profile and urethral closure pressure, values were significantly less in stress and mixed UI patients groups. However, urge and mixed UI patients show significantly higher maximum detrosal pressure. All UI patients have higher maximum urine flow rate and average urine flow rate values. The volume of post voiding residual urine was not different between UI patients groups and control subjects. Conclusion: Urodynamic study has an important role in confirming the diagnosis of UI and differentiating its type.

Keywords: Cystometry, Iraqi females, profilometry, urodynamics, uroflowmetry


How to cite this article:
Al Taee MY, Hamdan FB, Mohammed NH. Urodynamic study of Iraqi female patients with urinary incontinence. Saudi J Health Sci 2013;2:47-53

How to cite this URL:
Al Taee MY, Hamdan FB, Mohammed NH. Urodynamic study of Iraqi female patients with urinary incontinence. Saudi J Health Sci [serial online] 2013 [cited 2022 May 23];2:47-53. Available from: https://www.saudijhealthsci.org/text.asp?2013/2/1/47/112631


  Introduction Top


Normal urinary continence in women is the end-result of coordination between the bladder, urethra, pelvic muscles and surrounding connective tissue elements. [1] Disturbance in the storage function and occasionally in the emptying function, of the lower urinary tract or the existence of the two would results in urinary incontinence (UI). [1]

UI is defined by the International Continence Society (ICS) as "the complaint of any involuntary leakage of urine". [2] UI is a common and incapacitating problem in women [3] and has a reported prevalence, no matter the type, of 34% [4] during young adult life to almost 50% in the elderly. [5]

The main types of UI are: Stress UI (SUI) which is defined as involuntary urine loss during physical exertion/exercise (coughing, sneezing and sports) without urgency; urge UI (UUI) is involuntary urine loss combined with sudden sensation of urgency and lastly mixed UI (MUI) is involuntary urine loss associated with urinary urgency but also with physical exertion. In addition, special forms of UI were identified including neurogenic incontinence, extraurethral incontinence (for example, in the presence of fistula) over flow incontinence, giggle incontinence. [6]

Among the risk factors for UI are the pregnancy; [7] parity; [8] central obesity; [1] hysterectomy [9] and smoking as an independent risk factor. [10]

Urodynamic investigations are the only way to evaluate bladder and urethral functions. Urodynamic investigations allow characterization of the pathophysiological aspects of the different symptoms, give some elements to determine accurately the prognosis and help for the choice of the therapeutic strategy. In all cases, an urodynamic investigation must be considered as complementary and always interpreted in conjunction with clinical data and the results of the other morphological and/or radiological investigations. [11]

Urodynamic study includes cystometry which is the method used to measure the pressure-volume relationships of the bladder; [12] profilometry which is performed to assess the intrinsic sphincter resistances; [12] uroflowmetry which measure the urinary flow rate to confirm the presence of a bladder outlet obstruction. Uroflow depends on detrusor contractility and urethra-sphincter resistance which measure the urinary flow rate to confirm the presence of a bladder outlet obstruction. Uroflow depends on detrusor contractility and urethra-sphincter resistance. [13]

This study aimed to investigate the characteristics type of UI in Iraqi women and its relation to some confounding factors.


  Materials and Methods Top


The research was conducted at the Department of Urology of Gazi Al-Hariri Hospital/Medical City of Baghdad from January to May 2011. The study group included 78 female patients who had sought treatment for the problem of urinary incontinence (50 of them agreed to do urodynamic study). The control group consisted of 25 patients without urinary incontinence, who sought treatment for other reasons.

Patient with congenital incontinence, paraplegia, those under 18 years old, previous operation in the bladder, urethra or spinal cord, women with sever urinary tract infection detected by urinalysis and history of diabetes mellitus were excluded from the study.

A detailed patient history and questionnaire was recorded for each patient before physical examination and urodynamic study. A multi-channel urodynamic system with computer analysis was used (Wiest Company 2009, Germany).

The patients underwent the following tests according to the standards recommended by the ICS:

  1. Cystometry both filling cystometry (with infusion of distilled water) and voiding cystometry. This test records bladder capacity, detrosal contractions during filling, first desire to void, strong desire to void and maximum filling intravesical pressure.
  2. Profilometry which includes urethral pressure profile (UPP) and maximum urethral closure pressure (UCP).
  3. Uroflowmetry, which records average flow rate, maximum flow rate, voiding time, voided volume and volume of postvoid residual urine.
Incontinent patients with normal detrosal filling pressure (<20 cm water) and low UPP (below 90 cm water) or low UCP (below 85 cm water), were considered as having SUI. Those patients with detrosal filling pressure more than 20 cm water (detrosal over activity) were regarded as having UUI. If the latter was combined with low UPP or low UCP or leak of urine with cough, the patient was considered as having MUI. However, incontinent patients with normal UPP, UCP and detrosal pressure were considered as incontinent with normal urodynamic study (INU), (Smith, 2006).

Screening of urine for bacteriuria at the time of the test is important to rule out unrecognized infection. In this study Ciprfloxacine tablets 500 mg twice daily was used as a prophylaxis for bacterial infection with advise for patients to drink more than 2 liters of water per day after the test to wash the lower urinary tract and decrease dysuria which usually happened after performing the test.

Statistical analysis

Comparisons between the UI patients and control group concerning different confounding factors were performed with student T test. Benferroni test was used to do multiple comparisons between different patients group. Correlation coefficient r was used to test the relationship between different parameters. P < 0.05 was considered statistically significant.


  Results Top


[Table 1] clarifies that 29 (58%) of UI patients have significantly (P = 0.001) increased percentage of cystocele as compared to 6 (24%) control subjects. The presence of cystocele is highest (81.8%) in MUI patients and the lowest in INU patients (50%). The percentage of smokers among different UI patients ranges from 0% to 18.1% which was not significantly different from the control subjects.
Table 1: Risk factors for urinary incontinence


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Twenty (40%) of UI patients has symptom of cough in comparison to only 1 (4%) control subject. Of the 20 IU patients, the highest percentage was within SUI patients (50%) and the lowest in UUI patients (22.2%). Chronic constipation was present in 32 (64%) UI patients, a value that is significantly higher than 5 (20%) of control subjects (P < 0.009). INU patients show the highest percentage (75%), while UUI patients show the lowest one (55.5%).

No difference was found in the parity and number of vaginal deliveries between the control subjects and UI patients [Table 2]. Doing multiple comparisons using Benferroni test, [Table 3] showed significant difference in the parity and number of normal vaginal deliveries between control subjects and MUI patients (P < 0.043; P < 0.033 respectively).
Table 2: Age, parity and numbers of normal vaginal deliveries in the incontinent patients and control subjects

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Table 3: P values of multiple comparisons between incontinent patients and control subjects and in between different patients' groups

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[Table 3] and [Table 4] elucidate the values of urodynamic study in the control subjects and UI patients. Urinary bladder capacity of SUI and UUI patients were significantly low as compared to the control subjects (P = 0.0009; P = 0.001, respectively). Likewise, UUI show significant lower urinary bladder capacity as compared to SUI and INU (P = 0.014, P = 0.022, respectively).
Table 4: Urodynamic study of incontinent patients and control subjects

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The control subjects showed larger volume of first desire to void as compared to UUI, MUI and INU patients (P < 0.001; P < 0.001; P = 0.036, respectively). In the same manner, SUI patients have significantly larger mean volume of first desire to void as compared to UUI, MUI and INU patients (P < 0.001; P < 0.001; P = 0.021, respectively). Additionally, volume of first desire to void of UUI and MUI patients was significantly less than those of SUI and INU patients and control subjects (P < 0.001).

As regards to the mean volume of strong desire to void, [Table 4] demonstrate significantly decreased values of SUI, UUI and MUI patients in comparison to control subjects (384.54 ± 57.74; 265.89 ± 76.49; 289.18 ± 88.16 ml versus 441.48 ± 50.03, respectively (P < 0.001). In SUI patients, the volume of strong desire to void was much more than that of UUI and MUI (P < 0.001). Furthermore, the volume of strong desire to void in UUI patients was less as compared to that of INU patients (P < 0.017).

The mean detrosal maximum filling pressure of UUI and MUI patients (48.33 ± 9.15 and 40.45 ± 8.74 cm water) was greater than that of SUI, INU patients and control subjects (13.19 ± 3.13, 10.50 ± 2.38 and 11.36 ± 3.26 cm water, respectively (P < 0.001). Conversely, the mean detrosal maximum filling pressure of SUI patients was nearly similar to that of INU patients and control subjects which are already in the normal range.

In SUI and MUI patients, the urethral pressure profile was 62.88 ± 16.97 and 62.90 ± 12.66 cm water, respectively, the urethral closure pressure was 60.07 ± 16.09 and 57.45 ± 11.16 cm water, respectively. The values were low in respect to those of UUI, INU and control subjects. The least recorded UCP and UPP value was in the MUI and SUI patients, respectively and was nearly the same to that of MUI.

SUI and MUI patients exhibits low UPP and UCP (when compared with UUI, INU patients and control subjects (P < 0.001, P < 0.05, correspondingly). In opposition, UUI and INU patients demonstrates nearly normal UPP and UCP values.

The maximum voiding flow rate for all UI patients were higher (36.38 ± 7.09, 45.11 ± 5.06, 41.45 ± 6.66, 35.00 ± 3.91 ml/s) when equated to those of control subjects (33.68 ± 6.2 ml/s). The maximum flow rate of UUI and MUI patients were significantly higher as compared to the control subjects (P < 0.001, P = 0.013, respectively). On the contrary, SUI patients have significantly low maximum voiding flow rate as compared to that of UUI patients (P = 0.008).

In regard to the mean average flow rate, UUI patients have the highest values (25.67 ± 6.89 ml/s) in comparison with SUI, MUI, INU and control subjects (16.61 ± 3.35, 15.09 ± 186, 17 ± 3.82 and 13.4 ± 2.17 ml/s, respectively). SUI patients have markedly reduced mean average flow rate as compared to UUI patients (P < 0.001) which in turn have much higher mean average flow rate as compared to MUI and INU patients (P < 0.001).

The values of post voiding residual urine volume were comparable within the patients' groups and with the control subjects and show no significant difference. The least verified post voiding residual urine volume was in the INU patients (11.5 ± 7.72 ml) and the highest in the MUI patients (27.81 ± 21.15 ml).

In SUI patients, a positive correlation was observed between bladder capacity and each of the volume of first desire to void, volume of strong desire to void and urethral pressure profile (r = 412, P = 0.037; r = 0.940, P = 0.000; r = 0.443, P = 0.024, respectively). On the reverse, bladder capacity shows no relation to the detrosal maximum pressure [Figure 1].
Figure 1: Correlation between bladder capacity and each of volume of first desire to void, volume of strong desire to void and urethral pressure profile in stress incontinence patients

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With regard to UUI patients, positive correlation was noticed between bladder capacity and each of volume of first desire to void and volume of strong desire to void (r = 0.716, P = 0.03; r = 0.966, P = 0.00, respectively). Conversely, bladder capacity was negatively correlated with detrosal maximum pressure and maximum urine flow rate (r = -0.72, P = 0.029; r = −0.683, P = 0.042, respectively) as seen in [Figure 2]. Moreover, a non-significant correlation was observed between bladder capacity and urethral pressure profile.
Figure 2: Correlation between bladder capacity and each of volume of first desire to void, volume of strong desire to void, detrosal maximum pressure in urge incontinent patients

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  Discussion Top


In our study, MUI and UUI patients were the oldest while those belong to the SUI group were the youngest; a finding which also reported in two cross sectional studies. The relation between UI patient's age and type of incontinence may be explained on the base of decreased compliance and elasticity of bladder wall with advancing age.

Many studies showed an increase in the UI with age, with the prevalence of UUI appears to increase up to middle age, and then levels off between age 50 and 70, followed by a steady increase among the aged. [14] While SUI predominates in younger and middle aged women, UUI and MUI are more common in older women. [9],[14]

Out of total patients, 29 (58%), having cystocele; the highest percentage was demonstrated within MUI (81.8%) and SUI (57.6%) patients which denoted the important relation of cystocele presence and development of MUI and SUI. Nearly similar figures were reported by Carey and co-workers [15] and about 21% of SUI patients with cystocele have been cured from incontinence after cystocele was repaired. [16]

Fourteen percent of patients in the presented study were smokers. Howard et al. 2000 [17] reported approximately comparable figure; however, the number of smokers was generally less than those recorded in the western countries as this habit is more prevalent among their females than in this country. Smoking has been classified as a risk factor for UI in women by the international continence society (ICS) in 2009. Smoking contributes to the incontinence probably via two mechanisms; first by increasing intra-abdominal pressure during cough and second by inhibition of collagen formation. [18]

The current study also reveals that 40% of our patients having cough; the highest percent was within SUI and lowest within UUI group. This reflects a sphincter problem in former group as any increase in their intra-abdominal pressure (bladder pressure); the urethral sphincter tone cannot withstand this and ultimately leading to urine leak. Analogous to these percentages were also noticed worldwide. [19],[20]

Constipation represents a real trouble in 64% of our patients which is less than that reported by Lemack and Zimmern [21] which could be related to the dietary habits in western countries. Interestingly 75% of INU patients have constipation which might be one of the causes for their incontinence as they had normal values of their urodynamic test.

The number of normal vaginal deliveries was different between MUI patients and the control subjects. Similar finding was also described by Anger et al. [15] More importantly, the mean number of normal vaginal deliveries in our MUI patients was 5.36 ± 2.37 which is far more than the recorded data in many European studies. [22],[23] This difference could be attributed to high fertility ratee in our country when compared to western country or to the diversity in society culture considering the large families.

Pure SUI was the dominant type followed by the MUI and UUI in our study; similar results were observed in other studies worldwide. [15],[18],[24] The governance of SUI is most likely to be ascribed to the fact that vaginal birth has been recognized to be potentially traumatic to the pelvic floor muscles, connective tissue, and nerves [25],[26] Direct muscle damage results in an inability to augment support to the bladder neck during physical stress. [6]

Concerning incontinent patients with normal urodynamic study, they were 4 (8% of total patients), this percentage is nearly similar to the published papers. [27]

The BC of UUI patients was significantly less than that of control subjects and less than the normal range (400-600 ml) reported by Kim, (1998). [28] However, the BC was within lower normal range for SUI and MUI patients. Nearly similar data was obtained by Marshall et al. in 1998. [29]

Our UUI and MUI patients record lesser volume of first desire to void in comparison with control subjects. This may reflect the hypersensitivity and instability of detrosal muscle in those patients. Hashim and Abrams (2006) [30] report such difference in their research. On the contrary, SUI patients show volumes almost similar to that of control subjects which might signify normal filling sensations in these two groups, a finding also reported by Irwin and associated. [31]

Similar volume of strong desire to void of UUI and MUI patients was also demonstrated by Irwin et al. (2006). [31] Whereas, SUI and INU patients show none significant differences with respect to the control subjects. A findings also reported by other researchers. [30],[31]

The UUI and MUI patients exhibit higher Det. Max than that of the control subjects. This explained by the higher intravesical pressure and detrosal instability in those patients that ultimately ends with premature filling sensation (FD and SD). [32] This would make us to make the treatment directed toward reducing these pressures and so curing urgency and incontinence.

The UPP is the main indicator for urethral sphincter tone and its competence. UUI patients have the highest mean of UPP among patient groups. Similar results were obtained by Hsu et al. (1998). [33] Opposing to this, SUI patients have lower UPP by a mean of 37 cm water from that of control. This elucidate that a sphincter weakness is the cause and in need for treatment and nothing to do with the storage function of the bladder.

The mean UPP for UUI patients was nearly the same of that for control subjects. This finding indicates the cause behind UUI is not urethral sphincter problem but rather a storage function problem (decreased BC as said before). Additionally, UCP data were low in the MUI and SUI patients in respect to the control subjects, a finding that is in harmony with the findings of Lose (1997). [34]

The data of UPP and UCP confirms the effect of urethral sphincter weakness in SUI and MUI patients and directing the treatment towards that pathology. The patients with UUI will urinate very fast and in a short period as their bladder tend to contract suddenly and strongly, this is clear from the shape obtained during flowmetry which was not presented in this study.

Maximum urine flow rate and average flow rate values were highest in the UUI and MUI patients in comparison to those of healthy control subjects which could be due to rapid and strong contraction of detrosal muscle as shown above with rapid sphincter opening. [35],[36]

The residual urine volume was not different and almost comparable between the patients and control subjects and in between patients groups. This result contradicts the findings Schafer et al. (2002) [35] who found that 21% of UUI patients had high residual urine (more than 50 ml). This discrepancy in the results might be due to the small sample size of the present study.

In conclusion, urodynamic data of the female patients in our country is not different from those worldwide, regardless of the local higher fertility rate and social habits.

 
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31.Irwin DE, Milsom I, Hunskaar S, Reilly K, Kopp Z, Herschorn S, et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: Results of the EPIC study. Eur Urol 2006;50:1306-14.  Back to cited text no. 31
    
32.Mardon RE, Halim S, Pawlson LG, Haffer SC. Management of urinary incontinence in Medicare managed care beneficiaries: Results from the 2004 Medicare Health Outcomes Survey. Arch Intern Med 2006;166:1128-33.  Back to cited text no. 32
    
33.Hsu TH, Rackley RR, Appell RA. The supine stress test: A simple method to detect intrinsic urethral sphincter dysfunction. J Urol 1999;162:460-3.  Back to cited text no. 33
    
34.Lose G. Urethral pressure measurement. Acta Obstet Gynecol Scand Suppl 1997;166:39-42.  Back to cited text no. 34
    
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36.Sonke GS, Kiemeney LA, Verbeek AL, Kortmann BB, Debruyne FM, de la Rosette JJ. Low reproducibility of maximum urinary flow rate determined by portable flowmetry. Neurourol Urodyn 1999;18:183-91.  Back to cited text no. 36
    


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