Imaging

StudyStudy type and ELNo. of patientsPrevalencePatient characteristicsType of testReference standardSensitivity and specificity*Positive and negative predictive valueAdditional comments
Bergman 1988177DS
EL = II
67UD diagnosis: 66% SUI, 34% DOF mean age 39 years (21–78)US (drop in urethrovesical junction of ≥ 1 cm positive for stress UI diagnosis)UD diagnosis (water urethrocystometry at filling rate 60 ml/min resting; and stress UPP)For SUI
Sens 86%
Spec 91%
(no pts with DO or normal diagnosis had positive US result)
Unable to calculate from data givenFunding: none declared.
US of bladder base and urethrovesical junction at rest and on maximal straining in the supine position. Drop in urethrovesical junction on straining measured in cm on US.
Investigator blind to clinical and UD diagnosis.
Q-tip angle also measured; the distance between the edge of the Q-tip and the examination table measured at rest and straining.
ICS terminology used.
*values quoted in paper.
Q-tip (change in angle of ≥ 35° indicative of positive test)UD diagnosis (water urethrocystometry at filling rate 60 ml/min resting; and stress UPP)For SUI:
Sens 90%
Spec 55%
Unable to calculate from data given
StudyStudy type and ELAim of studyNo. of patientsPatient characteristicsOutcomesResultsAdditional comments
Khullar 1996178Case series
EL = 3
To compare bladder wall thickness measured by transvaginal US scan with UD diagnosis of DO by VCU ± ambulatory UD180F mean age 54 years (20–85) with urinary symptoms attending UD clinic for investigationUD diagnosis29% SUI, 24% DO, 24% MUI, 19% normal UD, 3% sensory urgency, 2% voiding difficultyFunding: none declared
ICS terminology used.
Bladder wall thickness taken as mean of 3 measurements (perpendicular to the luminal surface of the bladder at the thickest part of the trigone; at the dome of the bladder; at the anterior wall of the bladder.
Provocative cystometry conducted. Those with bladder thickness > 5 mm on US but not found to have DO also had ambulatory UD (n = 42, of whom 36 showed DO on ambulatory UD).
*calculated by authors.
Bladder wall thickness (median, IQR)In DO grp: 6.3 (5.3, 7.7)
Other grps 3.9 (3.4, 4.5)
P < 0.0001
Accuracy of bladder thickness > 5 mm for diagnosing DO*Sens 84%
Spec 89%
PPV 94%
Robinson 2002179Case series
EL = 3
Investigate whether transvaginal US assessment of bladder wall thickness could replace ambulatory UD when investigating women with equivocal lab UD128F mean age 54 years (20–85) with irritative lower urinary tract symptoms (frequency and urgency with or without urge UI) with normal lab UD; and F with equivocal UD lab UD (where UD do not correlate with clinical symptoms); attending tertiary referral ambulatory UD clinicAmbulatory UD diagnosisSUI 34%, normal 29%, MUI 20%, DO 16%, voiding difficulties 1%Funding: none declared.
Bladder wall thickness taken as mean of 3 measurements (perpendicular to the luminal surface of the bladder at the thickest part of the trigone; at the dome of the bladder; at the anterior wall of the bladder.
No overlap between 95% CI for either the ‘normal’ or stress UI groups compared with the DO group.
Bladder wall thickness (mean)SUI 4.8 mm (95% CI 4.4 to 5.3)
normal (no UI) 5.1 mm (95% CI 4.6 to 5.6)
MUI 5.8 mm (95% CI 5.1 to 6.5)
DO 6.7 mm (95% CI 6.0 to 7.4)
P = 0.0001 between all diagnostic groups
Heit 2000180Case series
EL = 3
To use intraurethral ultrasonography o correlate urethral anatomy with functional UD parameters for the purpose of distinguishing patients with intrinsic urethral sphincter deficiency from those with genuine SUI39F mean age 51 years (27–74) undergoing UD evaluation for symptoms of UI. 14 (36%) had prior continence surgery (6 retropubic urethropexies, 6 anterior colporrhaphies, 2 needle suspensions
Exclusions: prolapse of the anterior vaginal wall beyond the hymenal ring in the standing position with straining; UD diagnosis of DO (= 18 of 57 originally investigated)
UD diagnosis24 SUI; 5 (17%) Intrinsic urethral sphincter deficiency (ISD); 10 normalFunding: none declared.
UD done blind to results of US.
UD: including digitally subtracted retrograde filling urethrocystometry, static and dynamic cough UPP at max. cystometric capacity, pressure-flow and Valsalva leak-point pressure studies.
UD stress UI diagnosed if urine leakage demonstrated during dynamic cough UPP, Valsalva LPP determinations at 150 ml bladder vol., or max. cystometric capacity and continuous cough at max. cyst capacity in the standing position with and without the transurethral catheter in place.
Intrinsic urethral deficiency diagnosed if LPP < 60 cmH2O and a MUCP < 20 cmH2O.
ICS terminology used.
Spec, PPV, and NPV of urethral measurements (longitudinal smooth muscle thickness and outer circumference, rhabdosphincter thickness) for distinguishing ISD from SUI, having assumed sensitivity of 80%Specificities 58–75%
PPV 30–40%
NPV 93–95%
Grischke 1991181Case series (retrospective review of 4 years data)
EL = 3
Determine how bladder neck descent and posterior urethrovesical angle correlated with UD diagnosis84F mean age 51 years (24–70), who had both UD and radiological data
UD diagnosis: 40% SUI, 25% mixed UI, 20% urge UI, 15% normal
Correlation between UD and radiological diagnosisBladder neck descent (radiological diagnosis) found in 91% of women with stress UI, 90% with mixed UI, 75% with urge UI, and 53% with normal UDFunding: none declared.
MC UD performed.
Posterior urethrovesical angle during straining152 ± 33 in SUI
142 ± 23 in MUI
138 ± 40 in MUI
126 ± 30 in normal UD
Bergman 1988182Case series
EL = 3
To prospectively assess the role of cystourethrography in the diagnosis of stress UI and to determine whether a surgical plan can be based on cystographic results59F mean age 57 (41–70) with ‘pelvic floor relaxation; with (54%) or without (46%) stress UIPrevalence of posterior urethrovesical angle ≥ 115°, angle of urethral inclination ≥ 45°, urethra at most dependent point in bladder funneling of proximal urethra, flatness of bladder base in continent vs incontinent grpsNo significant differences between incontinent and continent groups in the prevalence of the parameters measuredFunding: none declared.
MC UD performed; ICS terminology followed.
Bead chain cystourethrography – bead chain inserted into bladder, which was filled to capacity with iodine-containing liquid. 5 radiographic landmarks measured: posterior urethrovesical angle, angle of urethral inclination (change ≥ 45° in erect position considered loss of anterior angle), most dependable portion of the bladder base, □rethra□n□ of the proximal urethra, flatness of the bladder base.
Bergman 1988183Case series
EL = 3
Evaluate and compare information obtained by a small transrectal ultrasonic transducer and by X-ray cystography before and after surgery85F mean age 56 years (36–72), stress UI (n = 32)
Control groups:
  1. symptomatic pelvic relaxation, no urinary complaints (n = 29)
  2. Symptoms and UD diagnosis of bladder instability (n = 24); mean age 39 (21–57)
Prevalence of urethra at the most dependable position in the bladder by cystography and USSUI: 94%, 88%
Control grp 1: 55%, 52%
Control grp 2: 42%, 42%
Funding: none declared.
MC UD performed; ICS terminology followed.
A ≥ 1 cm drop in urethrovesical junction measured on US was considered poor anatomical support to the urethrovesical junction.
X-ray landmarks viewed were (1) most dependent position of the bladder base = at or posterior to the urethrovesical junction; (2) relationship between bladder base and inferior ramus of symphysis pubis; both evaluated in erect position on a lateral straining film.
Pts with urethrovesical jct descended below posterior lower edge of the symphysis pubis on straining considered to have poorly supported urethrovesical jct on cystography.
Sensitivity and specificity of 2 parameters (urethra at most dependent point in bladder; urethral descent on straining) reported with reference to two control groups (continent women with POP, and women with DO), though these were not sensitivities and specificities in the diagnostic accuracy sense; not possible to follow the calculations made in the published report.

From: Evidence tables for included studies

Cover of Urinary Incontinence
Urinary Incontinence: The Management of Urinary Incontinence in Women.
NICE Clinical Guidelines, No. 40.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2006 Oct.
Copyright © 2006, National Collaborating Centre for Women’s and Children’s Health.

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