Other tests of urethral competence

StudyStudy type and ELNo. of patientsPrevalencePatient characteristicsType of testReference standardSensitivity and specificityPPV and NPVAdditional comments
Montella 1997164DS
11175% had positive Q-tip testF mean age 64 years (33–89) with symptoms of prolapse (70%) and/or UI (30%). 36% had prior anterior vaginal wall surgery (3 pts > 1 procedure): 23% anterior colporrhaphy, 10% retropubic suspension, 6% a vaginal needle procedureVisual assessment and measurement of descent of point Aa*(POP-Q)Q-tip testAt different Aa descent cut-off points:
−2: sens 94%, spec 36%
−1: 67%, 61%
0: 39%, 93%
1: 24%, 96%
2: 7%, 100%
3: 2%, 100%
At different Aa descent cut-off points:
−2: PPV 80%, NPV 67%
−1: 84%, 41%
0: 94%, 34%
1: 95%, 30%
2: 100%, 27%
3: 100%, 26%
Funding: none declared.
*pts coughed 3×, and performed the Valsalva manoeuvre 3× for each test; max. value taken.
Max. descent of point Aa measured using a ruler. Descent of Aa to hymen = 0; −3 = no descent.
Q-tip test done blinded to Aa measurement, preceded by speculum and bimanual exam. Q-tip movement measured using orthopaedic goniometer.
Positive Q-tip test = max. straining angle of ≥ 30° relative to the horizontal plane.
No change in pattern of results found for women who had or did not have prior surgery.
Retest done in 10 pts.
Caputo 1993163DS
11464% had positive US testF presenting with UI or prolapse. Urodynamic diagnosis: 34% stress UI, 38% mixed UI, 21% DO, 7% no UI. 32% had prior anterior vaginal wall surgery/ ‘anti-incontinence’ procedures
Exclusions: prolapse beyond introitus while straining in the upright position
Q-tip testPerineal ultrasoundSens 25%
Spec 78%
PPV 67%
NPV 37%
Funding: none declared.
Same examiner performed both tests.
Q-tip angle from the horizontal measured using an orthopaedic goniometer; positive test ≥ 30° change between rest and straining angles.
A curved linear-array 3.5 MHz US transducer used; Millar microtransducer urethral catheter used to visualise the urethrovesical junction hypermobility. Distance in millimetres between the urethrovesical junction positions at rest and after max. strain; positive test > 10 mm movement.
Retest done in 10 pts.
Sutherst 1980171DS
67 (with SUI)
23 controls (no UI)
Positive Fluid-Bridge (FB) test 58%
36% clinical diagnosis stress UI
57% UD diagnosis stress UI
F mean age 52 years with symptoms of stress UI
Controls mean age 33 years
Fluid-Bridge test in supine positionClinical evidence of UISens 74%
Spec 62%
PPV 72%
NPV 64%
Funding: none declared.
Test point selected = 0.5 cm from urethrovesical junction. If the test point remains closed, the test is negative; if it opens, the test is positive.
UD: SUI diagnosed if evidence of stress leakage in the absence of detrusor contractions, or if UCPP measurements ‘small’. UD methods, definitions and units conform to ICS.
Positive FB test in 39 (58%) test grp, 1 (4%) control grp, P < 0.001.
UD diagnosis of stress UISens 72%
Spec 53%
PPV 54%
NPV 71%
Sutherst 1981172DS
100 (only 76 analysed*Positive FB test in 74% test grp when supine 89% erect
43% clinical diagnosis SUI
57% UD diagnosis
F mean age 52 years, attending a stress UI clinic for UD assessment
27 women mean age 41 years with no UI were also tested (were attending hospital for abnormal uterine bleeding or infertility).
Fluid-Bridge test in supine position
Fluid-Bridge test in erect position
Clinical evidence of UISupine:
Sens 89%
Spec 35%
Sens 100%
Spec 16%
PPV 43%
NPV 85%
PPV 40%
NPV 100%
Funding: none declared.
UD methods, definitions and units conform to ICS.
Test point selected = 0.5 cm from urethrovesical junction. If the test point remains closed, the test is negative.
*reasons for exclusion: 7 continent after surgery but UD abnormal; 7 owing to technical difficulties, 10 because change from supine to standing initiated detrusor contractions.
Positive FB test in 56 (74%) test grp when supine, 68 (89%) when erect.
4 (15%) control grp (supine and erect), P < 0.001 vs SUI grp.
Fluid-Bridge test in supine position
Fluid-Bridge test in erect position
UD diagnosis of stress UISupine:
Sens 86%
Spec 42%
Sens 100%
Spec 24%
PPV 66%
NPV 70%
PPV 37%
NPV 100%
Niecestro 1992173DS
6653% history of SUI
74% positive UPP test
61% positive FB test
66% positive Marshall test
F > 18 years referred for UD investigation owing to voiding symptoms
Exclusions: UTI, STI
Stresscath (modified Fluid-Bridge)Marshall testSens 86%
Spec 87%
PPV 77%
NPV 93%
Funding: none declared.
History followed by supine and sitting Marshall test, then by the ‘Stresscath’ procedure, a modified version of the Fluid-Bridge test (10F catheter passed into the bladder; with catheter eye in the bladder, urine flows out of the distal end; catheter slowly withdrawn until flow of urine stops, then pulled back 0.5 cm and the pt asked to cough. Diagnosis of bladder neck incompetence made if urine flows through catheter. Catheter pulled back 0.5 cm and test repeated until a negative result is achieved).
UPP diagnosis: if max. urethral pressure < 30.5 cmH2O, bladder neck incompetent; if > 30.5, considered not to have stress UI, and possibly no bladder neck incompetence.
*for a diagnosis of SUI owing to bladder neck incompetence.
StresscathHistorySens 73%
Spec 88%
PPV 85%
NPV 80%
UPPMarshallSens 50%
Spec 88%
PPV 69%
NPV 78%
UPPHistorySens 43%
Spec 91%
PPV 81%
NPV 65%
StudyStudy type and ELAim of studyNo. of patientsPatient characteristicsOutcomesResultsAdditional comments
Cogan 2002165Case series
EL = 3
To assess correlation between the Q-tip and Aa point of the POP-Q system274F enrolled in 2 studies:
Study 1; a RCT of anterior colporrhaphy; mean age 64 years (35–90), 93% had prior surgery for prolapse/UI, 92% prior anterior colporrhaphy, 14% prior retropubic urtheropexy (n = 71)
Study 2; a cohort study evaluating outcomes of continence/prolapse operations, mean age 57 years (27–85), 19% had prior surgery for prolapse/UI, 4% prior anterior colporrhaphy, 17% prior retropubic urethropexy (n = 203)
Exclusions: F needing a retropubic urethropexy
% with urethral hypermobility (Q-tip angle ≥ 30°) for each stage of prolapse at point Aa
(results for all pts)
Stage 0 (−3 cm):
62% (n = 5/8), 95% CI 24% to 91%
Stage I (−2 cm):
83% (n = 19/23) to 95% CI 61% to 95%
Stage II (−1, 0, or +1 cm):
95% (n = 161/170), 95% CI 90% to 98%
Stage III (+2 cm):
100% (n = 24/24) to 95% CI 86% to 100%
Stage IV (+3 cm):
100% (n = 49/49), 95% CI 93% to 100%
Funding: none declared.
Initial POP-Q and Q-tip tests done the day before the surgery.
Positive Q-tip test = max. straining angle of ≥ 30° relative to the horizontal plane (94% had urethral hypermobility based on this threshold).
ICS methods and definitions used for POP-Q.
r = Spearman’s correlation coefficient.
Correlation vs between Q-tip straining angle (degrees) and point Aa (cm) resultsr = 0.47, P < 0.001
Sensitivity and specificity of Aa measurementAt 3 cm cut-off: sens 28%, spec 100%
At 2 cm cut-off: sens 91%, spec 44%
Noblett 2005166DS
To evaluate the relationship between urethral mobility and stages 0 or 1 anterior wall prolapse and to determine whether a Q-tip test is necessary in this subgroup of patients134Consecutive F pts referred to urogynae unit for evaluation. 15% had prior surgery for UI and/or pelvic organ prolapse
24% stage 0 prolapse, 25% stage I, 39% stage II, 6% stage III, 6% stage IV
Correlation between POP-Q point Aa and Q-tip testSpearman’s correlation coefficient for POP-Q and Q-tip was 0.787, P < 0.001Funding: none declared.
POP-Q undertaken prior to Q-tip, but no assessor blinded to results of other test.
Hypermobility defined as a straining angle of ≥ 30° on Q-tip.
Sensitivity, specificity, PPV and NPV of point Aa also quoted relative to Q-tip angle for stages 0 vs I-IV, and for stage 0 vs I. Data not reproduced here.
% hypermobile for each stage of the POP-Q teststage 0: 6% hypermobile
stage I: 91% hypermobile
stages II to IV: 100% hypermobile
Migliorini 1987167Case series
EL = 3
Assess the validity of the Bonney test61F presenting at UI hospital clinic for assessment (history, examination, UD [as per ICS criteria]). Static and cough profile urethral pressure profiles repeated with bladder neck elevation (Bonney test)Diagnosis (based on cystometry)74% SUI (31 of the 45 had urine loss at the time of the investigation*)
16% MUI (6/10 had urine loss)
10% DO (none had urine loss)
Funding: none declared.
*without bladder neck elevation.
Bonney test (% with urine loss on bladder neck elevation)None (100% positive Bonney test)
Urethral closure pressure (cmH2O) without or with bladder neck elevation (Bonney test); median (range)In pts with SUI diagnosis: without 38 (8–78); with 117 (49–232)
In pts with MUI: without 38 (16–70); with 111 (59–148)
In pts with DO: without 45 (11–75); with 116 (86–124)
Bhatia 1983168Case series
EL = 3
Describe the changes in urethral and urethrovesical function under resting and stressful conditions when the Bonney test was used in F with stress UI12F history and UD diagnosis of stress UIUrethral closure pressure (cmH2O), mean (SD)Resting: 40.6 (14.4)
Bonney test: 210 (13.6), P < 0.0005 vs resting profile
Urethral occlusion*: 212 (13.5), P < 0.0005 vs resting profile
Funding: none declared.
Intravesical, intraurethral, and intra-abdominal pressures measured directly by 2 microtip pressure transducer catheters. Urethral and cough pressure profiles repeated during Bonney test (middle and index finger placed 1 cm lateral to each side of urethra; and repeated again with *middle and index fingers placed directly over the bladder neck with the intention of compressing the urethra and bladder neck).
All pts demonstrated urine loss during the recording of the cough urethral pressure profile (in the supine position with a full bladder), and none during Bonney test, nor with compression of the urethra or bladder neck.
*measured using a planimeter.
ICS terminology used.
No significant differences seen between Bonney test and Urethral occlusion in any outcome.
Urethral Closure Pressure Profile area (cm2)*, mean (SD)Resting: 2.11 (1.6)
Bonney test: 10.5 (1.7), P < 0.0005 vs resting profile
Urethral occlusion*: 11.1 (1.7), P < 0.0005 vs resting profile
Urethral cough pressure profile area* (cm2)Resting: 0.8 (0.95)
Bonney test: 9.0 (3.9), P < 0.0005 vs resting profile
Urethral occlusion*: 9.7 (3.98), P < 0.0005 vs resting profile
Miyazaki 1997169Case series
EL = 3
Re-evaluate the Bonney test and direct urethral compression, and to present a modification of the Bonney test (the Miyazaki–Bonney test)37F, genuine stress UI
Each pt underwent the Bonney test, direct urethral compression, and a Miyazaki–Bonney test* while the following observations made: urethroscopy of bladder neck and proximal urethra; resistance of cotton swab to withdrawal; proximal urethral pressures changes
Urethroscopic observationsBonney and Miyazaki–Bonney tests ‘produced concentric closure of the bladder neck and elongation and closure of the proximal urethra’Funding: none declared.
ICS methods, definitions and units used for UD studies.
*Miyazaki–Bonney test was performed in 2 ways:
  1. cotton swabs directed laterally to reapproximate anterolateral vaginal wall to pelvic sidewall;
  2. cotton swab handles depressed to −30° and pushed anteriosuperiorly and laterally to bring cotton swab down to 0°.
Bonney test used as ‘originally described’.
Two methods were used to measure proximal urethral pressure changes: 12 studied using a microtip catheter; 13 using both a microtip and Foley bulb; 12 using a Foley bulb set up only.
Proximal urethral pressure changesBonney: mean increase 52 cmH2O (25–100)
M-Bonney: ‘little or no increase’, mean 30 (20–40)
Direct urethral compression: no mean reported but ‘easily produced pressures > 250 cmH2O’
No overlap of values between Bonney and direct urethral compression
Pressure transmission ratioIncomplete numerical results reported
Bergman 1987170Case series
EL = 3
Record and compare the changes in urethral and urethrovesical function under resting and stressful conditions when the Marshall-Marchetti test and intentional occlusion of the urethra were used in women with UI16F mean age 53 years (36–64), genuine stress UIUCPP (AUC, cm2)Marshall test 8.7 ± 1.1
Urethral occlusion 9.1 ± 1.2
P = NS between tests
Funding: none declared.
Multi-channel UD done according to ICS standards.
Marshall test – moderate elevation of the urethrovesical junction using clamps on the anterior vaginal wall, one on each side and lateral to the urethrovesical junction.
AUC = area under the curve.
Cough PP (AUC, cm2)Marshall test 8.8 ± 2.8
Urethral occlusion 9.1 ± 2.4
P = NS between tests

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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