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Translabial Ultrasonography in the Assessment of Urethral Diameter and Intrinsic Urethral Sphincter Deficiency
Fernando R. Oliveira, MD, PhD, Jose Geraldo L. Ramos, MD, PhD, Sergio Martins-Costa, MD, MS

Objective. The purpose of this study was to determine the role of translabial ultrasonography in the investigation of intrinsic urethral sphincter deficiency (ISD), assessing bladder neck hypermobility and urethral diameter in continent and incontinent patients. Methods. A case-control study evaluated 94 women with the diagnosis of urinary incontinence and 96 continent women. Both groups underwent translabial ultrasonography to assess bladder neck hypermobility by means of the x-y coordinate system and urethral diameter. The study was performed at Hospital de Clnicas de Porto Alegre. Results. Women with urinary stress incontinence showed significantly greater bladder neck descent than continent women and women with urge and mixed incontinence (P = .05). Women with ISD showed significantly larger urethral diameters than control subjects and incontinent women without ISD (P = .05). Of women with urinary incontinence, 78.7% had descent of greater than 10 mm, and 91.7% of the women with ISD had urethral diameters of greater than 6 mm. A urethral diameter of greater than 6 mm showed sensitivity of 91.7% and specificity of 75.6% for ISD. Conclusions. Translabial ultrasonography has an important role in the assessment of women with urinary stress incontinence and intrinsic urethral sphincter deficiency. Key words: female urinary incontinence; intrinsic urethral sphincter deficiency; translabial ultrasonography; urethral diameter.

Abbreviations ANOVA, analysis of variance; ICC, intraclass correlation coefficient; ISD, intrinsic urethral sphincter deficiency; MUI, mixed urinary incontinence; ROC, receiver operating characteristic; TLU, translabial ultrasonography; UI, urge incontinence; USI, urinary stress incontinence

Received February 14, 2006, from the Department of Obstetrics and Gynecology, Hospital de Clnicas de Porto Alegre, Medical School of Federal University of Rio Grande do Sul, Porto Alegre, Brazil. Revision requested March 12, 2006. Revised manuscript accepted for publication April 25, 2006. This study was sponsored by the Fundo de Incentivo a Pesquisa-HCPA. Address correspondence to Fernando R. Oliveira, MD, PhD, Rua Dr Florncio Ygartua 300/301, 90430-010 Porto Alegre-RS, Brazil. E-mail: oliveirafr@terra.com.br

emale urinary incontinence has a multifactorial etiology. It is harmful to the patients physical and mental health and is socially limiting, compromising the quality of life.1 Improvements in social and economic conditions and better access to medical care have increased life expectancy, making women more susceptible to the physical effects of aging. However, there are conditions that contribute to urinary incontinence regardless of the patients age. The correct diagnosis of urinary incontinence is essential because the therapeutic success depends on precise investigation and diagnosis. Patient history and clinical examination are important in the management of urinary incontinence but should not be used as the sole methods for diagnosis.2 A urodynamic study is mandatory in the assessment of lower urinary tract dysfunction. Unfortunately, in our field, it is not available to all patients. Furthermore, urethrocystography has potential side effects, and the Q-tip test is considered inaccurate.

2006 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2006; 25:11531158 0278-4297/06/$3.50

Translabial Ultrasonography in Urethral Sphincter Deficiency

Often the failure of urinary incontinence therapy is due to incorrect assessment and inappropriate treatment. The high index of surgical failure (15%30%) in the 5-year follow-up is a result of incorrect diagnosis and choice of treatment.3 Bladder neck hypermobility seems to be closely related to urinary stress incontinence (USI). The deficient anatomic support of the bladder neck and proximal urethra, resulting in their descent and hypermobility outside the intraabdominal transmission zone, is probably the pathologic basis of USI.4 Translabial ultrasonography (TLU) as a complementary examination in the evaluation of urinary incontinence is now one of the principal evaluation tools. The role of urethral images, although scant, is promising. Ultrasonography has become more popular among professionals who treat patients with urinary incontinence because it is easily manageable, inexpensive, and comfortable for most patients and does not use ionizing radiation. The aim of our study was to determine the bladder neck descent and the measurement of urethral diameter in women with urinary incontinence by TLU. It was also our objective to define a common and manageable technique that could be easily disseminated to professionals who work with this condition, as well as to sharpen the understanding of what ultrasonographic images can reveal in a urinary incontinence investigation.

Materials and Methods


Clinical Procedures Ninety-four women who had urinary incontinence and 96 women who had no involuntary urinary leakage were enrolled in our case-control study. All incontinent women were selected from the Urogynecology Unit of Hospital de Clnicas de Porto Alegre, and all control subjects were selected from the hospitals Radiology Service. This study was carried out from March 2003 to March 2005. All participants who had urinary incontinence were instructed to keep a monthly micturition diary and subsequently underwent a standard urodynamic study after a negative urine culture result. If incontinence was confirmed, these patients underwent TLU. All control subjects had TLU only. The control group included only patients who underwent ultrasonographic studies for any gynecologic reason but had no history of urinary leakage.
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The study excluded pregnant women and patients with neurologic diseases, history of trauma or medications that could cause incontinence, diabetes, urinary tract malformations, and pelvic tumors. Patients who already had undergone antiincontinence surgery were also excluded. Urodynamic studies consisted of postvoidance residual measurement, cystometry, and urethral pressure profilometry. All incontinent women were classified as having USI, urge incontinence (UI), or mixed urinary incontinence (MUI). Among patients with USI, a subgroup was classified with intrinsic urethral sphincter deficiency (ISD). Intrinsic urethral sphincter deficiency was defined as the presence of USI and Valsalva leak point pressure of less than 60 cm H2O. When there were characteristics of both groups, patients were classified as having MUI. For the urodynamic study, the patient was initially placed on a gynecologic table in a lithotomy position for an aseptic cleaning. Afterward, a double-lumen 9F intravesical catheter (flux and pressure) and a rectal catheter with a sensor balloon were introduced and fixed to an internal part of the thigh. For the urodynamic study itself, the patient was placed in an orthostatic position. Interpretation of the examination was always performed by 2 observers. For TLU, the transducer was positioned in a midsagittal orientation on the perineum to evaluate downward and posterior rotation of the bladder neck and urethra in basal conditions as well as during abdominal strain. We used a 7.5MHz transducer fitted with a thinly lubricated condom covered with acoustic gel. The patient was evaluated by TLU in a lithotomy position with a bladder volume of approximately 100 mL. The measurement of bladder neck displacement was determined by the rectangular coordinate system (x-y) described by Schaer et al5 using as the referential point the inferior border of the pubic symphysis and the bladder neck at rest and during the strain (Figure 1). The urethral diameter measurement was performed inside the lumen of the 2 internal mucous membranes in the medial length between the proximal and distal ends of the urethra and was performed only at rest. The margins of the urethra were the proper internal mucosa. Figure 2, A and B, shows bladder neck descent of 21 and 9 mm during strain and at rest, respectively. Figure 3, A and B, shows urethral diameters of 5 and 8 mm, respectively.
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Oliveira et al

Figure 1. Measurement of bladder neck mobility during strain and at rest. Location was measured relative to a coordinate system based on the longitudinal axis of the pubic bone. BN indicates bladder neck; Dx, Dx-axis; and Dy, Dy-axis.

(SPSS Inc, Chicago, IL). All data are reported as mean SD, sensitivity, specificity, and negative and positive predictive values. Differences in the variables among the groups were analyzed by 1-way analysis of variance (ANOVA) when the Levine test was indicated. The Tukey test was used to identify the differences among the groups. The sample size calculation indicated that for a variation of 1 SD for each ultrasonographic parameter, 41 patients would be necessary for each group. P = .05 was considered statistically significant.

Results
Ninety-four women with a diagnosis of urinary incontinence from urodynamic studies and 96 control subjects were assessed. Among the 3 groups of patients with urinary incontinence, 50% were classified as having USI, 18% as having UI, and 32% as having MUI. Among the group of patients with USI, 12 (12.7%) also had ISD. Table 1 shows the main clinical differences between case and control groups. Using ANOVA for comparison purposes among the 3 study groups of incontinence, we observed significant differences in the internal urethral diameter between the USI group and the control group (P = .02). For bladder neck mobility, we observed significant differences among the USI group compared with the MUI, UI, and control groups (P = .01) (Table 2). When the urethral diameter was separately analyzed, we observed a significant difference between the USI with ISD subgroup and the USI without ISD subgroup

The measurements were performed by 2 observers. The differences between them were assessed by the intraclass correlation coefficient (ICC). It was established that measurements greater than 10 mm were indicative of bladder neck hypermobility, and those greater than 5 mm were indicative of urethral diameter enlargement. Our study was approved by the Ethical Committee of Hospital de Clnicas de Porto Alegre. Informed consent was obtained from all participants after they had read about the potential risks and the objectives of the study. Statistical Analysis A database was created with the Epi Info 2000 program (Centers for Disease Control and Prevention, Atlanta, GA). Statistical analysis was carried out with the SPSS version 12 program

Figure 2. Ultrasonographic appearance of bladder neck descent by the coordinate (x-y) system. A, During strain, 21 mm. B, At rest, 9 mm.

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Translabial Ultrasonography in Urethral Sphincter Deficiency

Figure 3. Ultrasonographic appearance of urethral diameters measured at rest. A, Urethral diameter of 5 mm. B, Urethral diameter of 8 mm.

(P = .01) and also between the USI with ISD subgroup and the control group (P = .01) (Table 3). When we analyzed the urethral diameter of 5 mm as a referential measurement between the ISD subgroup and the incontinent without ISD subgroup, we found sensitivity of 91.7% and specificity of 64.6%. However, when we used a measurement value of 6 mm, the sensitivity was maintained, but the specificity increased to 75.6% (Table 4). For bladder neck mobility, when we adopted a value of 10 mm, we found sensitivity of 78.7% and specificity of 72.7% when comparing the study and control groups. When the measurement was 12 mm, the sensitivity decreased to 51.1%, and the specificity increased to 86%. We observed that 37 (78.7%) women with USI had bladder neck mobility of greater than 10 mm. Of the 12 women with ISD, 11 (91.7%) had urethral diameters of greater than 5 mm.

To determine a relationship between sensitivity and specificity, we adopted the receiver operating characteristic (ROC) curve for the measurements of urethral diameter and bladder neck mobility. For the evaluation of leak point pressure profiles, we performed an analysis using a multiple-comparison ANOVA test to ensure that the measurements of bladder neck mobility did not change significantly (P = .16). However, for a urethral diameter of greater than 5 mm, we observed a significant difference only when leak point pressures were lower than 60 cm H2O when compared with leak point pressures of greater than 90 cm H2O (P = .01). To evaluate the degree of concordance between the 2 observers for the ultrasonographic parameters, we used the ICC. We observed an ICC of 0.89 for bladder neck mobility and 0.98 for urethral diameter.

Discussion
Ultrasonography in the evaluation of urinary incontinence is an easy, inexpensive technique, and it is considered comfortable for most patients. Nowadays, it is becoming more widespread as a complementary examination in diagnosis investigation. In contrast to other radiologic techniques, it is a noninvasive procedure without exposure to x-ray hazards and with similar or even superior outcomes.6 The preference for TLU is due mainly to the reduced image quality and inconvenience of transrectal ultrasonography and also to the inevitable movement caused by the perineal transducer during the strain.7
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Table 1. Demographic Characteristics of the Study Group (Urinary Incontinence) and Control Group
Characteristic Study (n = 94) Control (n = 96) P

Age, y* 51.04 9.67 Body mass index* 26.98 4.87 Vaginal delivery* 2.69 1.95 Cesarean delivery* 1.34 0.55 Birth weight, kg* 3656.06 518.54 Postmenopausal status, % 51.1 Smoking, % 11.7 *Values are mean SD. P < .05.

45.59 13.44 26.34 4.42 2.14 1.41 1.70 0.82 3417.10 573.56 35.4 22.0

.009 .71 .28 .002 .25 .02 .03

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The reproducibility of the ultrasonographic technique is pivotal. Therefore, using the pubic symphysis and bladder neck as reference structures, the neck should be very well identified by the examiners. The coordinate system described by Schaer et al5 was chosen for showing easy repeatability. The measurements can be repeated until the patient executes the adequate strain through the Valsalva maneuver once it no longer produces any risk. Bladder neck mobility assessment in the study of patients with urinary incontinence is mandatory. The Q-tip test does not produce reliable results.8 A video urodynamic study is still an expensive method to use routinely. Magnetic resonance imaging is another viable alternative but has not become popular in the investigation of urinary incontinence. For all these reasons, ultrasonography is the principal modality for studies of the anatomy and functionality of the lower urinary tract in patients with a history of urinary leakage. Johnson et al9 measured the vertical component of bladder neck mobility in 297 incontinent patients and found that 291 (97.1%) of them showed mobility of greater than 10 mm, whereas in control subjects, the mean mobility was 3.2 mm. Demirci and Fine,10 using perineal ultrasonography, concluded that the cephalocaudal component of bladder neck mobility in patients with USI showed similar results when compared with control subjects at rest. However, there was a significant difference during stress. Yalcin et al11 also observed the same variation. In a study by Sendag et al,12 in which only the vertical component was used, the bladder neck mobility of patients with USI was significantly greater than that of control subjects (P = .05). From these findings, our study was performed with only the vertical component of the coordinate system (x-y). In this study, the variations of bladder neck mobility were significantly greater in the patients with USI (11.69 mm) when compared with patients with UI (7.77 mm) and MUI (7.80 mm) and control subjects (7.81 mm) (P = .05). The findings related to urethral diameter were significantly greater in patients with ISD (6.38 mm) when compared with patients with USI without ISD (4.91 mm) and control subjects (4.69 mm) (P = .05). The hypermobility of the bladder neck did not correlate with findings of leak point pressure. However, the urethral diameter showed a positive correlation with leak point
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Table 2. Urethral Diameter and Mobility of Bladder Neck Measurements Among the Urinary Incontinence Groups and Control Group
Group n Urethral Diameter, mm* Bladder Neck Mobility, mm*

USI UI MUI Control

47 17 30 96

5.29 5.12 4.67 4.69

1.29 1.62 0.86 1.09

11.69 7.77 7.80 7.81

2.88 3.02 3.43 3.76

*Values are mean SD. Stress urinary incontinence differs significantly from the control group (P = .022, ANOVA). Stress urinary incontinence differs significantly from other groups (P = .01, ANOVA).

pressure values of less than 60 cm H2O. The same results had been described by Dietz and Clarke.13 These results were already predictable because, to define the diagnosis of ISD by urodynamics, we established values of Valsalva leak point pressure of less than 60 cm H2O. The values of urethral diameter and bladder neck hypermobility did not show significant differences between incontinent patients and control subjects for menopausal status once we could attribute possible natural weakening of anatomic structures. In a study by Kondo et al,14 on transvaginal ultrasonographic images, the rhabdosphincter thickness at the mid urethra was significantly less in incontinent patients, especially in patients with ISD. Using dynamic transurethral ultrasonography, Mitterberger et al15 showed partial or complete loss of rhabdosphincter function in patients with USI. The findings correlated well with the grade of incontinence. Furthermore, under contraction of the rhabdosphincter, a median increase in urethral length was observed. In incontinent patients, the increase in the urethral length was statistically significantly less Table 3. Comparison of Urethral Diameter Among the Subgroup of USI With ISD and the Control Group
Group n Urethral Diameter, mm*

USI with IUSD USI without IUSD Control

12 35 96

6.38 1.11 4.91 1.13 4.69 1.09

*Values are mean SD. Significant difference between the USI group with ISD and the USI without ISD and control groups (P = .01, ANOVA).

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Table 4. Sensitivity, Specificity, and Predictive Values of Urethral Diameters Between Incontinent Study Groups With ISD and Without ISD
Parameter Urethral Diameter 5 mm Urethral Diameter 6 mm

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Schaer GN, Koechli OR, Schuessler B, Haller U. Perineal ultrasound for evaluating the bladder neck in urinary incontinence. Obstet Gynecol 1995; 85:220224. Herrmann V, Bedone AJ, Palma PCR. Ultra-sonografia transperineal versus uretrocistografia miccional na investigao da incontinncia urinria de esforo. RBM Ginecol Obstet 1995; 5:296-301. Quinn MJ, Beynon J, Mortensen NJ, Smith PJ. Transvaginal endosonography: a new method to study the anatomy of the lower urinary tract in stress urinary incontinence. Br J Urol 1988; 62:414418. Caputo RM, Benson T. The Q-tip test and urethrovesical junction mobility. Obstet Gynecol 1993; 82:892896. Johnson JD, Lamensdorf H, Hollander IN, Thurman AE. Use of transvaginal endosonography in the evaluation of women with stress urinary incontinence. J Urol 1992; 147: 421425. Demirci F, Fine PM. Ultrasonography in stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1996; 7:125132. Yalcin OT, Hassa H, Ozalp S. Effectiveness of ultrasonographic parameters for documenting the severity of anatomic stress incontinence. Acta Obstet Gynecol Scand 2000; 79:421426. Sendag F, Vidinil H, Kazandi M. Role of perineal sonography in the evaluation of patients with stress urinary incontinence. Aust NZ J Obstet Gynaecol 2003; 43:5457. Dietz HP, Clarke B. The urethral pressure profile and ultrasound imaging of the lower urinary tract. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12:3841. Kondo Y, Homma Y, Takahashi S, Kitamura T, Kawabe K. Transvaginal ultrasound of urethral sphincter at the mid urethra in continent and incontinent women. J Urol 2001; 165:149152. Mitterberger M, Pinggera GM, Mueller T, et al. Dynamic transurethral sonography and 3-dimensional reconstruction of the rhabdosphincter and urethra: initial experience in continent and incontinent women. J Ultrasound Med 2006; 25:315320.

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Sensitivity, % Specificity, % Positive predictive value, % Negative predictive value, %

91.7 64.6 27.5 98.1

91.7 75.6 35.5 98.4

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(P = .04), which was related to the reduced contractility of the rhabdosphincter. They concluded that dynamic transurethral ultrasonography allows for assessment of the function and morphologic characteristics of the rhabdosphincter and urethra. The etiology of decreased thickness may be neurogenic or myogenic, possibly caused by trauma, ischemia, or genetic predisposition.14 We also suggest the hypothesis that this enlargement of urethral diameter is caused by a weakening around support structures such as mucosa, the vascular plexus, and muscular layers. In conclusion, our study indicates that it is possible to simplify ultrasonographic evaluation in patients with urine loss once bladder neck hypermobility is identified, but this finding applies to patients with USI only as opposed to other types of incontinence such as UI and MUI. Hypermobility of 10 mm in the vertical axis has good sensitivity and specificity for the diagnosis of USI. With 12-mm hypermobility, there is a considerable gain in specificity but a loss in sensitivity. By the ROC curve, the accuracy of hypermobility was around 81%. Urethral diameter values of greater than 6 mm highly suggest the presence of ISD, with accuracy evaluated by an ROC curve of around 84%.

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References
1. Feldner JR, Bezerra LR, Sartori MG, et al. O valor da histria e exame clnico no diagnstico da incontinncia urinria. Femina 2003; 31:1721. Jensen JK, Nielsen FR, Ostergard DR. The role of patient history in the diagnosis of urinary incontinence. Obstet Gynecol 1994; 83:904910. Pastore AR, Giovanni GC. Ultra-sonografia Obsttrica e Ginecolgica. Sao Paulo, Brazil: Sarvier; 1997. Blaivas JG, Olsson CA. Stress incontinence: classification and surgical approach. J Urol 1998; 139:727731.

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