1.  Stephen T Jeffery University of Cape Town, South Africa Urogynaecology and laparoscopy clinic www.urogynaecology.co.za

2. An example  49 yr old, P3  Has history of severe stress incontinence  No urgency, urgency incontinence or nocturia  No voiding problems  Very obvious stress leak on examination THAT’S EASY

3. Another example  46 year old, P2  Has stress incontinence with some significant urgency incontinence, stress worse  Nocturia x 4  Leaks on standing up  Has bladder pain occasionally  No stress incontinence demonstrated

4. Example 2: Options ① Start on anticholinergics ② Go straight ahead and put in a sling Or ① Start on anticholinergics ② Investigate – but what and why?

5. Example 2: What the investigations will tell us 1. Urodynamics  Give us an idea about voiding dysfunction  Will demonstrate stress incontinence  May show detrusor overactivity  May help our lawyer if we get sued

6. Example 2: What the investigations will tell us 2. Perineal Ultrasound  Quick look at residual  Bladder neck mobility  Bladder wall thickness  Bladder neck funneling  Diverticulum  Demonstrate any impact that prolapse may be having on her bladder function

7. Example 2: What the investigations will tell us 3. Positive pressure urethrogram Diverticulum 4. Bladder diary May demonstrate excess nocturnal urine production “Fluid abuse” 5. Cystoscopy Cancer

8. What is the use of urodynamics?

9. An interesting statistic 80 % of Dutch gynaecologists said they would operate on women with Stress Incontinence without doing UDS (Van Leijsen)

10. Why would you not want to do urodynamics?  Bother for the patient (time, pain, shame)  Hassle for the surgeon  Urinary tract infection  Costs!!!  Risk of wrong conclusions / decisions

11. Some good news There is data to support not doing UDS

12. Nager et al NEJM 2012 - VALUE trial non-inferiority RCT, 630 women (2x315) SUI or MUI with predominant SUI, + cough test office assessment +/- urodynamics Primary outcome: treatment success after 12 months (70% reduction of urogenital distress inventory (UDI) score and response of "much better" or "very much better" on the Patient Global Impression of Improvement)

13. Value study Inclusion criteria  MESA questionnaire score was important: stress> urge  Post Void Residual <150 ml  Clinical assessment of urethral hypermobility  Positive cough stress test

14. Conclusion: For women with uncomplicated, demonstrable stress urinary incontinence (incl. MUI with predominent SUI), preoperative office evaluation alone was not inferior to evaluation with urodynamic testing for outcomes at 1 year

15. Urodynamics So – not necessary in all patients When are they necessary?

16. Use of UDS: 1. Prediction of Intrinsic Sphincter Deficiency

17. Aetiology of Stress Incontinence Intrinsic Sphincter DeficiencyBladder Neck Hypermobility

18. Synthetic sling options for stress incontinence Retropubic Tension –Free Vaginal Tape (TVT) Transobturator Tape ( TOT)

19. RCT : Repeat surgery TOT vs TVT in women with ISD  TVT 1:16  TOT 1:6 Do we need to look for Intrinsic Sphincter Deficiency (ISD)? Schierlitz et al 2008

20. Intrinsic Sphincter Deficiency How to diagnose  Leak Point Pressure < 60cmH 2 O  Maximal Urethral Closure Pressure < 20cmH 2 O

21. For ISD are there alternatives to UDS  Bladder neck ultrasound  Q-tip test

23. Use of UDS: 2. Prediction of Voiding Dysfunction

24. Use of UDS: 3. Diagnosing Detrusor Overactivity

25. My recommendation on UDS ? Indications for UDS  Significant urgency and urgency incontinence symptoms no respondng to treatment  Unable to demonstrate stress incontinence on examination  Profound voiding dysfunction symptomatology  Recurrent stress incontinence  Unexplained Incontinence after prolapse operation

26. MESA questionnaire

27. Low cost approach ① MESA questionnaire to determine stress and urge component ② Come with full bladder ③ Stress test standing ④ Uroflow only followed by ultrasound Post-void residual

28. What about ultrasound?

29. Perineal Ultrasound

30. Ultrasound

31. 1. Residual A (cm) x B (cm) x C(cm) x 0.6= volume in ml A B C

32. 1. Residual A(cm) x B (cm) x 5.6= volume in ml A B C A B

33. 2. Bladder neck mobility Bladder neck descent of > 2.5cm is considered to be hypermobility

34. 3. Bladder wall thickness  Bladder wall thickness more than 5mm suggests Detrusor Overactivity

35. Trigone + Anterior wall +Bladder dome Bladder wall thickness = _______________________________ 3

37. 4. Funneling

39. 5. Demonstration of stress incontinence

41. 6. Exclude other pathology

43. 7. Evaluate sling complication

45. Imaging Slings  Useful in voiding dysfunction post tape insertion  Failed tapes  Helps to see if tape has indeed been cut

48. 8. Evaluate voiding dysfunction

50. Other radiological tests: Cystogram

52. Cystoscopy

53. Investigations for faecal incontinence

54. Endoanal Ultrasonography  360 degree rotating probe  Simple and relatively painless  Excellent visualization of the 5 layers of the anal canal

55. Endoanal Ultrasonography  Muscle thickness  Scarring  Loss of muscle tissue

56. Endoanal Ultrasonography

59. Take Home  UDS not indicated in all cases of SUI  Basic ultrasound useful in evaluation of:  Residual volume  Bladder neck mobility  Sling complications  Don’t forget to think about other pathology  Eg Diverticula and OAB

60. www.urogynaecology.co.za