Aims

There are competing hypotheses about the etiology of post prostatectomy incontinence (PPI). The purpose of this study was to determine the anatomical and functional differences between men with and without PPI.

Methods

Case-control study of continent and incontinent men after radical prostatectomy who underwent functional and anatomic studies with urodynamics and 3.0 Tesla MRI. All men were at least 12 months post prostatectomy and none had a history of pelvic radiation or any prior surgery for incontinence.

Results

Baseline demographics, surgical approach, and pathology were similar between incontinent (cases) (n = 14) and continent (controls) (n = 12) men. Among the cases, the average 24 hr pad weight was 400.0 ± 176.9 g with a mean of 2.4 ± 0.7 pads per day. Urethral pressure profiles at rest did not significantly differ between groups; however, with a Kegel maneuver the rise in urethral pressure was 2.6 fold higher in controls. On MRI, the urethral length was 31-35% shorter and the bladder neck was 28.9° more funneled in cases. There were no differences in levator ani muscle size between groups. There was distortion of the sphincter area in 85.7% of cases and in 16.7% of controls (P = 0.001).

Conclusions

Men with PPI were not able to increase urethral pressure with a Kegel maneuver despite similar resting urethral pressure profiles. Additionally, incontinent men had shorter urethras and were more likely to have distortion of the sphincter area. All suggesting that the sphincter in men with PPI is both diminutive and poorly functional.

Aims

One postulated cause of post-prostatectomy incontinence is urethral and bladder neck hypermobility. The objective of this study was to determine the magnitude of anatomical differences of urethral and bladder neck position at rest and with valsalva in continent and incontinent men post-prostatectomy based on dynamic MRI.

Methods

All subjects underwent a dynamic MRI protocol with valsalva and non-valsalva images and a standard urodynamic evaluation. MRI measurements were taken at rest and with valsalva, including (1) bladder neck to sacrococcygeal inferior pubic point line (SCIPP), (2) urethra to pubis, and (3) bulbar urethra to SCIPP. Data were analyzed in SAS using two-tailed t tests.

Results

A total of 21 subjects (13 incontinent and 8 continent) had complete data and were included in the final analysis. The two groups had similar demographic characteristics. On MRI, there were no statistically significant differences in anatomic position of the bladder neck or urethra either at rest or with valsalva. The amount of hypermobility ranged from 0.8 to 2 mm in all measures. There were also no differences in the amount of hypermobility (position at rest minus position at valsalva) between groups.

Conclusions

We found no statistically significant differences in bladder neck and urethral position or mobility on dynamic MRI evaluation between continent and incontinent men status post-radical prostatectomy. A more complex mechanism for post-prostatectomy incontinence needs to be modeled in order to better understand the continence mechanism in this select group of men.

Objective

To describe and evaluate the use of urodynamics (UDS) studies for all indications in an academic specialty referral urology practice.

Materials and methods

This is a prospective questionnaire-based study wherein clinicians completed a pre- and post-UDS questionnaire on each UDS that they ordered for all clinical indications between May 2013 and August 2014. Questions pertained to patient demographics and history, the clinical indication for the UDS, the clinician's pre- and post-UDS clinical impressions, and changes in post-UDS management plans. Pre- and post-UDS diagnoses were compared using the McNemar test.

Results

Clinicians evaluated a total of 285 UDS studies during the study period. The average age of study participants was 56.0 (±16.4) years, 59.5% were female, and 29.3% had a neurologic diagnosis. The most common indication for performing UDS was to discern the predominant type of urinary incontinence (stress vs urgency) in patients with mixed incontinence symptoms (38.5%) and to assess the safety of the bladder during filling (38.2%). UDS statistically significantly changed the ordering clinician's clinical impression of the patient's lower urinary tract diagnosis for stress urinary incontinence and for urgency and urgency urinary incontinence (both had P values of <.05). Fluoroscopy was found to be helpful in 29.5% of urodynamic studies, and clinicians reported that UDS changed their treatment plans in 42.5% of the studies, most commonly pertaining to changes related to surgery (35.0%).

Conclusion

Overall, UDS was a clinically useful tool that altered the clinical impression and treatment plan in a large percentage of carefully selected patients.

Objective

To determine predictors of physical and emotional discomfort associated with urodynamic testing in men and women both with and without neurologic conditions.

Methods

An anonymous questionnaire-based study was completed by patients immediately after undergoing fluoroscopic urodynamic testing. Participants were asked questions pertaining to their perceptions of physical and emotional discomfort related to the study, their urologic and general health history, and demographics. Logistic regression was performed to determine predictors of physical and emotional discomfort.

Results

A total of 314 patients completed the questionnaire representing a response rate of 60%. Half of the respondents (50.7%) felt that the examination was neither physically nor emotionally uncomfortable, whereas 29.0% and 12.4% of respondents felt that the physical and emotional components of the examination were most uncomfortable, respectively. Placement of the urethral catheter was the most commonly reported component of physical discomfort (42.9%), whereas anxiety (27.7%) was the most commonly reported component of emotional discomfort. Presence of a neurologic problem (odds ratio, 0.273; 95% confidence interval, 0.121-0.617) and older age (odds ratio, 0.585; 95% confidence interval, 0.405-0.847) were factors associated with less physical discomfort. There were no significant predictors of emotional discomfort based on our model.

Conclusion

Urodynamic studies were well tolerated regardless of gender. Presence of a neurologic condition and older age were predictors of less physical discomfort. These findings are useful in counseling patients regarding what to expect when having urodynamic procedures.