Diagnosing intrinsic sphincteric deficiency: Comparing urethral closure pressure, urethral axis, and Valsalva leak point pressures

VOIDING FUNCTION AND DYSFUNCTION, AND FEMALE UROLOGY

billion (1984dollars) to $16.4billion (1993dollars). Both of these cost-of-illness estimates, however, relied on data and factors that have changed over time. This study updates these cost estimates. The 1995 societal cost of incontinence for individuals aged 65 years and older was $26.3 billion, or $3565 per individual with urinary incontinence. Limitations, implications, and directions for future research are also discussed.

Editorial Comment: Hu is the acknowledged guru of the economic aspects of incontinence. This article updates his 1986 estimates. It should be noted that costs associated with individuals younger than 65 years with incontinence were not included in the study. The authors state that the data by which they could reliably estimate these costs simply do not exist. They also state that the population older than 65 years is different in that some issues, such as falls and nursing home admissions, are less relevant, whereas other issues, such as indirect costs of lost earnings, are more important. If one tries to correlate scope and impact of various conditions with attention paid to the condition at various levels of research support, incontinence seems woefully underrepresented. Alan J. Wein, M.D. Diagnosing Intrinsic Sphincteric Deficiency: Comparing Urethral Closure Pressure, Urethral Axis, and Valsalva Leak Point Pressures

R. G. BUMP,K. W. COATES, G. W. CUNDIFF, R. L. HARRIS AND A. C. WEIDNER, Division of GynecoZogic Specialties, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina J. Obst. Gynec., 177: 303-310, 1997 OBJECTIVES: Our purpose was to compare three measures proposed to diagnose intrinsic sphincteric deficiency: maximum urethral closure pressure, Valsalva leak point pressure, and straining urethral axis. STUDY DESIGN: A total of 159 women with pure genuine stress incontinence had the three measures determined in a standardized fashion. Critical cutoff values for the Valsalva leak point pressure (52cm) and urethral axis (22 degrees) were established by examining relative frequency distribution curves, using closure pressure of 20 as the arbitrary benchmark value for the prevalence of intrinsic sphincteric deficiency. The distribution of cutoff values is described and differences among the measures with respect to risk factors for intrinsic sphincteric deficiency and incontinence severity were determined. RESULTS: Half the subjects fell below at least one cutoff value, but only 10% fell below all three. Sixty-four percent of subjects with either low closure pressure or leak point pressure had low values for the other, whereas 21% had discordance between them. Only 53% of subjects with low closure pressure and 40% with low leak point pressure had an axis 522 degrees. Conversely, a substantial portion (36%) of subjects with pure genuine stress incontinence without urethral hypermobility had neither low urethral or leak point pressures. All three cutoff values were associated with risk factors for intrinsic sphincteric deficiency, but only low closure and leak point pressures had significant associations with the severity of incontinence. CONCLUSIONS: Intrinsic sphincteric deficiency should be diagnosed by a composite of historic, urodynamic, anatomic, and clinical severity criteria. We would include a maximum urethral closure pressure 520, a Valsalva leak point pressure 550,and a stress urethral axis 520 in this composite. Editorial Comment: McGuire and Woodside first described the phenomenon that is now called intrinsic sphincter dysfunction, referring to it as type I11 stress incontinence.' In the past this condition had also been described as a nonfunctional bladder neck and proximal urethra. The term intrinsic sphincter deficiency seems to have been first introduced in the 1992 version of the Agency for Health Care Policy and Research guidelines for incontinence. Classically, sphincteric incontinence in female patients has been categorized into genuine stress incontinence, associated with hypermobility of the vesicourethral junction and an outlet that is competent at rest but loses its competence only during increases in intraabdominal pressure and intrinsic sphincter deficiency. The implication of the diagnosis of intrinsic sphincter deficiency is that a surgical procedure designed to correct only urethral hypermobility will have a relatively high failure rate as opposed to one designed to increase urethral resistance. This article is worth reading because it emphasizes the fact that the division between these 2 situations is not absolute and that a decision as to the type of surgical therapy for a given case of sphincteric incontinence in female patients must be made, at least at this time, not on the basis of a single isolated symptom or criterion but by considering a number of factors. Alan J. Wein, M.D. 1. McGuire, E. J. and Woodside, J. R:Diagnostic advantages of fluoroscopic monitoring during urodynamic evaluation. J. Urol., 125: 850,1981.

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