Good evening, everyone. Welcome to the AUG's FVMRS webinar series. I'm Dr. Kimi Amano-Hodgie, moderator for tonight's webinar. Today's webinar is the role of your dynamics in FVMRS, presented by Dr. Charles Nager. Dr. Nager will present for 45 minutes. The last 15 minutes of the webinar will be dedicated to Q&A. Dr. Charles Nager has served as FVMRS division director, fellowship program director, and department chair at UC San Diego. In 2018, he served as president of the American Urogynecologic Society. His research focus has been on your dynamics and clinical trials in pelvic floor disorders in both the NIH Urinary Incontinence Treatment Network and the Pelvic Floor Disorder Network. He has been selected by his peers as one of San Diego's best doctors for 14 consecutive years. Before we begin, I'd like to review some housekeeping items. This webinar is being recorded and live streamed. Please use the Q&A feature of the Zoom webinar to ask any of the speakers questions. Use the chat feature if you have any tech issues. AUG staff will be monitoring the chat and can assist. Thank you so much and welcome, Dr. Nager. Great, and thank you, Kimia. Thank you for the nice introduction, and thank you for inviting me to talk about your dynamics, and good evening to everyone around the country. I was asked to talk about your dynamics because of my involvement in both the Urinary Incontinence Treatment Network and in the Pelvic Floor Disorders Network, where I was often, I was the chair of the aerodynamics working groups for a lot of the UITN studies, and we did some early studies on your dynamics, and it's been a real passion of mine and interest of mine for quite some time. My disclosures include that I received some royalties from up-to-date chapter contributions, and I'm on the editorial board of the FPMRS journal. So, these are the specific objectives I hope to cover tonight. I want to understand, I want you all to understand what we know about normal values, understand the pitfalls of diagnosing detrusor underactivity, understand the limitations of perineal surface EMG, and I want to critically evaluate the arguments for your dynamics for stress incontinence. Namely, these include things like confirm the diagnosis of stress incontinence, assess for poor urethral function, diagnose other disorders which could change management, for example, detrusor overactivity or voiding dysfunction. I will review the RCT data for uncomplicated stress incontinence patients, the value trial, and I'm also going to compare the stress tests and your dynamics for the evaluation of occult stress incontinence in prolapse patients, and I'll be showing these objectives periodically. Now, before you start to think I'm a urodynamic nihilist, which I have been accused of being, I want to tell you that I actually do believe in your dynamics. I order a fair number of your dynamics, and these are what I consider to be some of the strong indications for your dynamics. Certainly, it is a diagnostic tool, and if you have an uncertain diagnosis and difficulty with your treatment plan, it can be a really helpful tool. If you're uncertain about the relative contribution of urgent stress incontinence and mixed incontinence, your dynamics can help sort that out. If you're unable to demonstrate stress incontinence despite a standing full bladder stress test when the history is very suggestive, your dynamics may be indicated. If a patient fails to respond to treatment or fails surgery, you need to reconsider your diagnosis, and your dynamics can help you with that. When you have someone who has both combined incontinence and emptying disorders, these are very difficult patients to treat because anything you do for incontinence could potentially worsen the emptying disorder, and those patients, it's helpful to have a lot of information on hand for those patients. If you have symptoms of difficult bladder emptying, an elevated post-void residual, and concern about voiding dysfunction, these are all really strong indications for your dynamics. I will argue throughout the course of this evening, but it's not needed for women with uncomplicated demonstrable stress incontinence, and you notice that I bolded and underlined demonstrable because it's important to remember that we're not saying you don't need it if you don't see your dynamics, but you should see your dynamics. You should have a positive stress test on patients, and I'll argue that a prolapse reduction stress test without your dynamics is just as good as your dynamics. So let's continue. So first, let's talk about what we know about normal values, and for this, I'm going to talk to you about some studies we did early on in the Urinary Incontinence Treatment Network that we published in 2007 that we called Reference Urodynamic Values for Stress Incontinent Women. Now granted, I'm calling these normal values, but realize that these are stress incontinent women, and I wish we had, you know, 655 normal women who underwent urodynamics, then we could truly say that, but you can argue that women with stress incontinence at least should have normal bladders. They may not have a great urethra, but they should have essentially normal bladders. So this data comes from, again, 655 women. They had predominant stress incontinence, and they were enrolled in the Urinary Incontinence Treatment Network sister trial. You may recall that was a randomized trial of BIRCWH versus pubovaginal sling. We, in all these patients, we performed a standardized urodynamics, including preoperative free uroflometry, filling systometry, and pressure flow studies that were performed using a standardized research protocol, standardized urodynamic interpretation guidelines that was supervised by a urodynamics work group, and they were following ICS guidelines and terminology, and we've published about our quality process that we developed. In this group, about 14% had previous incontinence surgery, and 10% who qualified for stress incontinence surgery with a positive cough stress test did not demonstrate urodynamic stress incontinence, and in this group, just to characterize them a little more, less than 10% of the subjects demonstrated detrusor overactivity. So what were some of the things we found, and I hope you can use these in your practice to try to ascertain if you're dealing with normal or abnormal values. So these were the free uroflometry values in 588 women, and what you see here are mean, median, two and a half percentile, fifth percentile, 95th, and 97 and a half percentile for various different urodynamic parameters. And what do you see here? Well, you can see that quite often women void with relatively low flow rates, and I would, based on this, I would consider a flow rate of about, you know, 10 to 12 mLs per second, the lower limits of normal. Now, the other thing we did is we did filling systometry for a very large number of patients, and people often wonder, what are normal sensation parameters? What should you expect? What should the average sensation parameters be? And we had a standard script that used a watching a television kind of protocol to determine when was first desire, strong desire, and maximum systematic capacity. And the neat thing about this data is it kind of followed what I call the rule of 120s. So, on average, the median volume at first desire was 120, at strong desire is about twice that, 235, or you can call it 240, and maximum systematic capacity was about 360. So, if you want to know, but notice the standard deviations are quite large, the percentiles are quite different, but if you want to say just what should you expect for median sensation parameters, I think this is a pretty real perspective. One thing I want to also point out is, you know, people talk about compliance. Now, compliance is actually measured as, you know, volume over pressure, but most people look at compliance by saying, how much does the tritucer pressure go up during the course of a fill up to a normal maximum systematic capacity? And we found it to be, you know, the 95th percentile is about 19. So, a lot of times people talk about the tritucer pressure should go up less than 15 over the course of a fill, and that's very similar to what we found in this study. Now, one area that I see in the literature is people diagnosing sometimes tritucer underactivity, and I want to just point out, you know, some of the characteristics of what adds to tritucer pressure, and I just want to show you an example from a urodynamic signal. Now, in this urodynamic signal, and I'll orient you here, this is a patient who was filled to 300. You can see the filling study before then. So, right before we're going to do a pressure flow study, she reached capacity here, and she got her, this was her PFS baseline pressures, which are pretty typical pressures in the 45 degree or standing position. Tritucer pressure is here, so she was given permission to void. This is her vesicle pressure, her abdominal pressure, her tritucer pressure, and this is her flow rate, and you can see after she was given permission to void, she voided, she reached a peak of about 23 mLs per second, and this is her voided volume over that period of time and her EMG activity. So, she has a tritucer pressure of 11. Does she have a weak tritucer? And the answer is no, and let me show you why. I'm now going to show you the later half of the signal. If you go to the later half of the signal, what do you see? This woman, although it only required tritucer pressures about 11 to void at a fairly nice flow rate of 23, and she voided pretty much everything that was left out, you can see that her tritucer pressures went up after voiding, and actually, they start going up right around as her urethra is closing, and the point I want to make about this is clearly, this woman does not have a poorly functioning tritucer. She can amount to tritucer pressures of 46, but if her tritucer is contracting and the urethra is wide open, letting out urine at 23 mLs per second, you're never going to show a significant tritucer pressure because there's no resistance there, and so that's why it's really important to look, before diagnosing tritucer in your activity, to look at the whole view and realize that as the outlet resistance drops during flow, the tritucer muscle might be perfectly strong and perfectly capable, but you're not going to generate those pressures, and to really diagnose tritucer under activity, you need a low tritucer pressure or a short tritucer contraction, usually in combination with a low urine flow, resulting in a prolonged bladder emptying and a failure to achieve complete bladder emptying within a normal span, and she doesn't meet any of these criteria. She voids entirely within a minute, she has a high urine flow rate, and she voided 407 even though she was only filled with 300, so be very wary about ever diagnosing tritucer under activity. The other point about this is if you look at what normal pressure flow study values are, you can see that women really void often with relatively low flow rates, and if we look at these flow rates here, you see that they can be as low, but also with relatively low tritucer pressures. Women do not need high tritucer pressures to void, and when we look at the two and a half and fifth percentile, these values were almost around zero for these patients, so the point is, again, tritucer pressure when the urethra is wide open does not really reflect the bladder contractile ability. The other topic that I want to talk about is the limitations of the perineal surface EMG. I think it's common practice to use perineal surface EMG electrodes, and when we started looking at all these aerodynamics signals, we were wondering just how valuable was that, because the textbooks will say that normal voiding requires external sphincter relaxation, followed by contraction of the tritucer, and that failure of the sphincter to relax or stay completely relaxed during micturition is abnormal. Thus, normally EMG activity decreases before a voluntary bladder contraction, so we would all expect that urethra relax and EMG activity to decrease, but the real question is, is that perineal surface EMG really measuring the urethral sphincter and pelvic floor, or is it measuring other nearby large muscles? To look at this, we reviewed this in a study, and this is a study that was done largely by Anna Kirby and our group here. Anna is now a urogynecologist at the University of Washington. She completed her residency and fell here, and when she was a resident, she and I went back to New England Research Institute in Boston, and we looked at urodynamic signals, specifically about the EMG, for about a week, and we tried to determine what is the perineal surface EMG really doing during that period of time. In this study, we said that we wanted the signals, we wanted annotations to occur for 10 predetermined and annotated time points, and of all these signals, we had 321 with interpretable EMG signals, of which 131 had EMG values at all of these 10 preset, predetermined, annotated time points. We looked at it in relation to whether the patient subsequently had voiding dysfunction or not, and we really didn't get any difference in this. So what did we find? So these were the 10 predetermined annotated time points, and they're pretty common time points in urodynamics. You know, we annotated the CMG baseline, first desire, strong desire, maximum systematic capacity. We do a prevoid cough all the time, as you all do, to check and make sure the signals are working, functioning. Then we have PFS baseline, then we started the pressure flow studies, and also check to make sure the signals are still working at the end with a post-void cough. And what did we find? Well, these are the EMG signals during the pressure flow study. And actually, as you can see here, typically the EMG signals are higher during the flow than they were during any of the filling periods of time. Higher than MCC, when maybe the patient is trying to contract her urethral sphincter. So we found, and our conclusion is, is that the perineal EMG is really not a very good measure of what's happening to the urethral sphincter, and it's probably got so much artifact because of other large muscles and contractions going on that it's really not a very helpful test in my mind during urodynamics. So one of the other questions that, you know, often comes up is, well, we need urodynamics for a lot of reasons for stress incontinence, and some of those include these that I mentioned below in the small value, in small bullets there. So one of the arguments for urodynamics for stress incontinence is that what you needed to confirm the diagnosis of stress incontinence, implying that if you don't have it, the patients might do worse. So we looked at that in our studies, and this data comes from the TOMAS study. The TOMAS was a UITN study. You might know it's a randomized trial of the retropubic midurethral sling versus the trans-opterator midurethral sling. To be eligible for this study, patients had to have predominant stress incontinence, and they had to have a positive stress test. So everyone demonstrated stress incontinence, and we did urodynamics on all these folks, and the study surgeon was blinded to the preoperative urodynamic results. Well, of all those urodynamics we did, we actually did 551 urodynamics, and we did not find urodynamic stress incontinence in 14 percent. As you might expect in someone who has a positive stress test, we found it in most of them. We actually found it in 86 percent, but if you didn't demonstrate stress incontinence, you did not have a higher failure rate, and actually you had a lower failure rate than the patients who had urodynamic stress incontinence. So it argued that in the presence of a positive stress test, urodynamics were not needed, and in the absence of urodynamics, stress incontinence does not lead to worse outcomes. Well, one of the more common arguments for doing urodynamics is to assess for poor urethral function. So what is poor urethral function? Well, it's also known as intrinsic sphincter deficiency. Now this is a term that has gone through a tremendous amount of mutation over the years. It didn't even exist until about 1996. And at that time, the Agency for Healthcare and Policy and Research was really trying to determine who should be eligible for this new technology we had called collagen urethral bulking injections. And they didn't think it should be, everyone should be eligible. Anyone with stress incontinence should be eligible. Now, we're actually treating patients differently with Bulkamid now than that. But at that time, they wanted to limit it, who was supposed to get, to be eligible for urethral bulking injections. So they called, they developed this term called ISD. And it was also known as type three incontinence or drain pipe urethra. And to have ISD, you had to have the clinical symptoms of severe leakage with minimal exertions. You typically had risk factors that included advanced age, radiation or prior incontinence surgery. Typically you had minimal urethral mobility. You had a positive empty bladder stress test. You might've had poor coaptation on urethroscopy or an open bladder neck or fluoroscopy. And there were urodynamic parameters that were associated with it, including low urethral closure pressures or low leak point pressures. Now what's happened in the ensuing years is all of these original characteristics of ISD really were just sort of dropped, not clear why, but now ISD is just someone with low urethral function tests, either defined as a low MUCP or a low LPP. And this is what, you know, we largely consider ISD at this current time. The question I think we shall ask ourselves is, do these cutoffs make any biological sense? I mean, is someone with an MUC of 19 that much different than someone with an MUC of 21 or someone with a leak point pressure of 55 different from someone with 65? And we looked at this actually in the TOMA study. This was the TOMA study where we did those blinded urodynamics on everybody. And we put together some receiver-operated curves for objective failure for different VLPP and MUCP values. And these horizontal lines here and vertical lines here represent the sensitivity and one minus specificity using lower quartile cut points for urethral functions. This happened to be 86 centimeters of water for VLPP and 25 centimeters for the MUCP. And remember, we're measuring from atmospheric pressure, which is why that might seem a little high. Now, you can argue that there's no real good cutoff here, but this is probably as good as any that we have. But this by itself tells you there's probably not good evidence for discrete cutoffs for MUCP and VLPP. Well, what did we find? So this graph here shows the objective failure rate and this is looking at VLPP and this is looking at MUCP. And most patients are gonna be above the 25th percentile and that's gonna be in the light gray. If they were in the lower 25th percentile, that's the darker gray. And what do you see? You do see that if you were in the lower quartile for your VLPP or your MUCP, you had almost a twofold gray risk of failure. It was about 1.7 risk of failure. It held for both VLPP and held for both for MUCP and it held for both trans-obturator and retropubic. So based on the fact that it was true for all of these, it did not suggest that these lower values should suggest a change in the surgical management. Now let's look at what we know about retropubics and trans-obturators and SUI success. So I think there's pretty good evidence that retropubics do a little better for SUI for almost all groups. If this is the TOMA study and this was the initial report and if you looked at objective success, the retropubic was better by about three percentage points. Subjective success, it was better by about six percentage points. For low VLPP, same thing held about six percentage points. A little bit more for MUCP, we saw about a 14% difference. Now around this time, there was a group from Australia that published a study that looked at patients with only low MUCP or low VLPPs and they reported a 24% difference in an outcome of post-stop urinary stress incontinence. Now, if you go to clinicaltrials.gov, you'll find out that they actually had three primary outcomes. Their first primary outcome was some subjective measures. Their second primary outcome was the need for repeat surgery and there was no difference in that. Then they had a third primary outcome which was urodynamic stress incontinence and which where they found a difference. They later published that patients who had a obturator sling had 19% more salvage TVTs. So their salvage operation was a retropubic midurethral sling in these patients because they published that the retropubic midurethral sling was a more successful operation than the obturator sling for patients who had a previous midurethral sling. Now, the concern I have about all this is the evaluators weren't ever blinded to what surgeries they did on the patients. And I think if I'm seeing a patient in the clinic who's bordering on failure, and I know she had a previous TOT and my salvage operation was a TVT, I might be more inclined to do a TVT rather than do a TVT again in a patient like this. So there are concerns about this, but really this has been evaluated in other ways. And really there was a nice systematic review published in IUJ a few years back that looked at basically the outcomes for ISD. And they looked at 55 randomized trials comparing retropubic versus trans-obturator midurethral sling. In only eight trials with only 399 women was their data that was reported specifically for intrinsic sphincter deficiency. What'd they find? Well, they did find that there was a 12% difference, a 12% relative risk reduction in achieving subjective cure with a trans-obturator midurethral sling. The relative risk was 0.88 and the confidence intervals did not overlap one. So it was significant for subjective cure. The objective cure was not statistically significant. It crossed one. There was no difference in quality of life. And these differences are not that much different than what you observe in a non-ISD population. So I think we have pretty good data that suggests retropubics do better. They do better whether you have ISD or not, or not. And probably you shouldn't use urodynamics as a way to differentiate how you're gonna operate on these patients. And if you do nothing but retropubic midurethral slings, then certainly urodynamics are not gonna help you in that decision-making. So some other arguments that have come up sometimes is, well, we do urodynamics because we can diagnose other disorders which could change management. And the most common one that's mentioned is detrusor overactivity. So let's critically evaluate whether detrusor overactivity should make you change your management. Well, these are the results from our two large randomized trials. Again, I've already mentioned the SISTR trial, which is retropubic versus MIRCH. The UIT and TOMAS trial, which is retropubic versus transopterator. Large numbers here. And in these patient populations who had predominant stress incontinence, we found detrusor overactivity at 9% and 14%. And they did do slightly different or they did do slightly worse. By nine percentage points, they did worse. By seven percentage points, they did worse in our primary outcome of incontinence. But in no case was that significant despite the relatively large numbers here. And in fact, there've been systematic reviews that have looked at this and their conclusion was the midurethral sling cures the stress component very well, cures the urge component not so well, but there was no overall differences, no difference in the overall subjective and urinary incontinence rate between the retropubic and transopterator routes, arguing that detrusor overactivity shouldn't keep you from operating, one, and it shouldn't determine your route of surgery. And probably the most, I think the most interesting information is the study that came out most recently in the PFD in a STEAM trial. Now, if you remember this trial, it really was a trial, it was a randomized trial for mixed incontinence. So these patients had both stress and urge incontinence. And these patients either got a midurethral sling or they got a midurethral sling plus pelvic floor muscle therapy. And it was a large study, 480 women were randomized. The primary outcome was the urogenital distress inventory. And you probably know that that has a maximum score of about a 300. And what was found in this study? In these patients with mixed incontinence who started on average with a UDI of 177, it dropped to 34 in the midurethral sling group. So we had a drop here of a really what you see, 177 to 34 drop in this group. And you saw it in both groups and they were not really clinically different in between these groups. So you saw significant improvement in a global measure of incontinence in someone who got sling only or sling with pelvic floor muscle therapy. What I think is one of the most interesting parts of this study is that worsening urgency incontinence occurred in only 2.1% of the midurethral sling group, significantly less than what we typically counsel our patients about the urgency incontinence, but really pretty remarkable. So the presence of, so mixed incontinence should, is easily should be treated with a sling at least it responds well to a sling. And the presence of detrusor overactivity on urodynamics should not dissuade you from doing that sling in these patients because urgency incontinence is really unlikely to worsen. So the other argument is sometimes, well, I do urodynamics to diagnose voiding dysfunction, arguing that this may predict, maybe I should change my management or maybe I should, maybe I can predict who's gonna go into retention. Now, in all of our studies, patients all had normal post-void residuals. So that is probably your best test to figure out if someone has a voiding dysfunction. But in these two trials, which I've already talked about, the SISTER trial, 655 women, and the TOMAS trial, let's, what did we find? We specifically looked at this. We had all this urodynamics data, what happened? Well, in the SISTER trial, because a lot of these patients had pubovaginal slings, we found a fair amount of voiding dysfunction. It was actually identified in 57, and that was defined as either a catheter at six weeks or requiring takedown. So obviously this is, pretty significant amount of voiding dysfunction, but the urodynamics did not predict this group who needed this. In the TOMAS trial, which was mid urethral slings, again, a large group, well, we didn't have voiding dysfunction very common at six weeks, only 2% of patients had it. But, so we looked at, well, what about those patients who required a repeat voiding trial? And this is kind of a typical number. You see patients who failed that early voiding trial. And the question was, did urodynamics predict this group? And urodynamics did not predict this group either. So urodynamics and especially the voiding studies during urodynamics are not gonna predict who's gonna have voiding dysfunction in most of the patients you're gonna operate on. But really, I think after we did all these studies and we were trying to say, well, gosh, we don't really see a good argument for urodynamics, we had to do a randomized trial and figure out if patients who get urodynamics do better or do worse. So that led to the VALUE trial, which is a randomized trial of urodynamic testing before stress incontinence surgery. And our question was, would a woman with uncomplicated predominant, notice the word demonstrable, that means she had a positive stress test, have inferior outcomes if she does not receive preoperative urodynamic studies? So who were the patients we studied? Well, these were patients who wanted stress incontinence surgery. They had stress predominant stress incontinence. This was determined by the MESA score, which is a series of questions that ask about stress and a series of questions that ask about urge and you had to have a higher score on stress than urge. But notice these weren't pure stress incontinence patients. They were just stress predominant incontinence. They all had to have a positive cough stress test and this was pretty tested typically with a median of about 200 mLs. They all had to have a normal post-float residual, which we defined as 150. They had a negative UA or culture and they were uncomplicated. In fact, by the fact that they didn't have previous incontinence surgery, they hadn't had pelvic radiation and they couldn't have anterior apical prolapse more than a centimeter, one centimeter or more past the introitus. So really your garden variety stress incontinence. And what happened in this study? Well, we consented 683, 630 were randomized. They turned out to be randomized and to either office evaluation or office evaluation and urodynamics. And we had pretty good followup with this with about 260 for the primary outcome. Our primary outcome was a 70% reduction in the UDI because we wanted a fairly good global measure of incontinence and that turned out to be a pretty good measure based on some of our earlier studies. So our primary outcome was treatment success rate. And once you got your office evaluation or you got your urodynamics, you were treated by the author's discretion of what they thought was most appropriate based on putting all their data together. Most patients got mid urethral slings. And the success rate in the office evaluation only was 77%. Urodynamic testing was pretty much the same, no real difference. And the interpretation was office evaluation was not inferior to urodynamic testing. So the major findings were is that for women with uncomplicated demonstrable stress incontinence, the office evaluation is not inferior to evaluation with urodynamics for outcomes in one year. And your preoperative urodynamics are not needed in this subset of patients. What we also found is that urodynamics commonly change the secondary diagnosis, but it rarely changed the first diagnosis or rarely changed the management. And what's really interesting in these uncomplicated patients is that if we demonstrated stress incontinence in the office, which we did as a requirement for the study, 97% of these patients had urodynamic stress incontinence, which is really remarkable why management was hardly ever changed and probably the main reason both groups were similar. So it's long been said that goes back many decades that you need to do urodynamics in these patients because the bladder is an unreliable witness. But in reality, what we found is that the stress test suggests that the urethra is actually a reliable witness for urinary incontinence. And actually, all the professional societies now agree that preoperative urodynamics are not needed in women with uncomplicated stress incontinence. OGS, just in June of 2020, choosing widely said, do not perform multichannel urodynamics in women with uncomplicated stress incontinence. Now the AUA SUFU guideline put out a urodynamics guideline. And they said that while urodynamic assessment may provide valuable information for some clinicians and stress incontinence patients who are considering definitive therapy, urodynamics are not absolutely necessary as a component of the preoperative evaluation in uncomplicated patients. And one of the really interesting things I think in this urodynamics guideline is one of the recommendations, which says that clinicians should perform repeat stress testing with the catheter removed in patients suspected of having SUI who do not demonstrate this finding with the catheter in place during urodynamic testing. In other words, if you can't find urodynamic stress incontinence, just do a stress test. So it's commonly said, urodynamics are the gold standard for diagnosing stress incontinence. I will argue, really, is that really the gold standard? If you're supposed to take the catheter out to make the diagnosis. And what I would argue is the gold standard is actually the stress test for stress incontinence. And NICE, the National Institute for Clinical Excellence in the UK, also said, do not perform multi-channel filling and voiding cystometry before primary surgery if stress urinary incontinence or stress predominant mixed urinary incontinence is diagnosed based on a detailed clinical history and demonstrated stress urinary incontinence at examination. So finally I'd like to stop by talking about what about in patients with prolapse patients who don't who may who may not have any incontinence but you're concerned that with prolapse reduction and when you do your prolapse surgery they're going to have stress incontinence and should you do um urodynamics in them. So let's let's look at what we know and I'm going to show you now data from the OPUS trial. So the OPUS trial is a PFDN trial and one of the things that's sort of missing from the publication here although it's in there but the data on this got published in a supplemental appendix is that all this if you remember this was a randomized trial of patients who are undergoing vaginal surgery for prolapse and they were randomized to get either a mid urethral sling or not and their outcomes were compared. One of the things we did when we designed this study is we did a pre-operative standardized prolapse reduction cough stress test with 300 mls in the bladder. So all these patients who did not complain of incontinence they had their prolapse reduced with proctoswabs in a standing position and we did a stress test on them and that data did not influence how they were randomized but in this what we found when we did this is about a third of the patients 111 had a positive pre-operative stress test two-thirds did not 220 and these are the results with these outcomes whether they got a sling or a sham. If you look at overall at the group there was a suggestion certainly a pretty strong suggestion that if they had a positive stress test they would do worse the endpoint that what we call is the endpoint is typically failure it's stress incontinence by symptoms or pre-treatment or a positive stress test post-op and you can see that if you had a positive stress test you were more likely to fail especially if you got the sham and really this test of interaction didn't quite meet significance which is why it didn't make but the supplemental paper but the real value I want to show you is here and this is the value I use in my practice is if I'm doing someone if I'm doing a prolapse operation and they don't have stress incontinence but I get a positive prolapse reduction stress test on them I'm really concerned that they're going to have stress incontinence and those are the ones that I typically will perform a concomitant stress incontinence operation on so that's that's what we know about a prolapse reduction stress test the question is how does that compare to a urodynamic reduction reduction stress test and we actually have that data because the same group the PFDN did urodynamics in the care trial so these are patients the care trial as you may recall was abdominal sacral copal plus or minus birch the randomization was plus or minus birch and in this study they did urodynamics with prolapse reduction and determine who had these were positive urodynamic stress prolapse reduction this is the data I already showed you down here which is not urodynamics but just the standard stress test well what did we see well you can see here that again if you had a positive urodynamic prolapse reduction stress test and you got a birch you did better than if you got sham you had a sham you had a 58 percent chance of still having stress incontinence is that a better prediction urodynamically than it is if we do office reduction and here's the office reduction test I showed you earlier and I would argue that the office reduction test is every good if not better than a urodynamic reduction stress test to determine if someone has occult stress incontinence so in conclusion you'll still do a lot of urodynamics you've got patients with uncertain diagnosis and treatment plan difficulty I mean I mean if you if you just spent 30 minutes seeing a new patient and you just ask them about incontinence in a million different ways and at the end of 30 minutes you're still saying I still don't know what kind of incontinence you have by all means get your dynamics to help you figure it out if you're not sure about the relative contribution if you really think this patient has stress incontinence but you didn't demonstrate it with your single test you can consider it if they fail to respond or failed surgery reconsider your diagnosis your dynamics is a fantastic diagnostic test combined incontinence emptying disorders to me this is a knee-jerk automatic aerodynamics because I want to understand you know what is going on in their filling and emptying phases for me to sort this out symptoms of difficult bladder emptying elevated post-flood residual all of those but not for women with uncomplicated demonstrable stress incontinence and really not for women with prolapse when you can get the same information with a prolapse reduction stress test so thank you for your attention I'm happy to answer any questions thank you Dr. Nager that was great we now have 15 minutes for questions and you can submit your questions in the Q&A box so I guess I'll start off what do you what do you tell your fellows to do exactly what I just said here I believe in all this I believe in it very very strongly so we we try to practice like this you know I'm not a doctor I'm not a psychiatrist I'm not a psychologist I'm not a psychologist I'm not a psychologist I'm not a psychologist I'm not a psychologist strongly so we we try to practice like this you know and we'll get we'll get your dynamics I mean if the fellow presents a patient to me after they've spent a lot of time with them and and then I go and talk to them and I've spent a lot of time with them and I still don't what know what the heck is going on we'll get your dynamics on them I think it's I think it's a it's a it's a good way to get some objective data you know there's been some interesting studies that have looked at this actually at our Kaiser which is affiliated with our fellowship they looked at who got your dynamics and patients with language barriers were more likely to get your dynamics and that's easy to understand you know if you've if even with the you know interpreters everything else you you might still not be able to get that history that tells you what you're dealing with and they were they were more likely to end up with your dynamic studies makes perfect sense I feel like that's what we experienced here too for that population unfortunately the language barrier so we have a question here from Dr. Nemi Shaw and they are curious to know what you think the roles of video your dynamics in FPMRS are okay good so Nemi nice question so so your dynamics so your dynamics are a functional test they tell you the functional they tell you functional but they don't tell you anything about anatomy and video your dynamics adds a functional test with an anatomical study so if you've got questions about anatomy that you want to know then that can be really helpful now what kind of anatomy does it tell you well if you're concerned about reflux you know video your dynamics is ideal for reflux it's going to help you you know you may see even urethral diverticulum I don't for a long time before people really experienced in our field with doing good quality quantitative prolapse exams video your dynamics were used at the time and how much of a cysticil someone had or how much anterior vaginal wall probes said well we can do that with a pop q exam we don't need that to do this the open bladder neck is a real question mark in my mind you know that used to be a marker for ISD but it's found you know in in a lot of patients that don't necessarily meet other criteria for ISD so I think the role for video your dynamics is looking for reflux some people will argue that it may be a good way to look for detrusors sphincter dysinertia it's probably one of the better things we have since I just told you perineal surface EMG is worth worthless for that so if you're suspicious of someone with those that's where you're gonna you're gonna be more helpful with this but you don't need it to diagnose leakage and you don't really do diagnose need to diagnose it bladder anatomy oh bladder bladder diverticula might be helpful with but rare occasions and and the real question you have to ask yourself is it worth the radiation and the expense and the inconvenience of that versus just functional your dynamics for most of our patients the answer is no if you're seeing a complicated neurogenic patient it may be different sentence we have another question given what you said about the unreliability of CMG how do you diagnose this inertia so that so oh about the perineal surface EMGs so that's that's really where if you have someone strong with multiple sclerosis someone who's high risk for that you probably are gonna you know want to use your video your dynamics for that I think it's a really hard diagnosis to make and I think there's not good iterator reliability for making that diagnosis what happens in practice I think happen is if someone has a neurological condition that makes sense that they might have it like multiple sclerosis or something like that and they have high pressure voiding they're diagnosed with DSD and I think you'll you'll see that not uncommonly but you're gonna see you can you're gonna see that you should be suspicious of it when you've got some you know some high pressure voiding and without any other good reason for it that's a good question that's great um this is another question I'm sorry I think I'm not understanding it well but I'll read it out to you um it the commentator says standardized POP reduction to what extent are we reducing the urethral pressure I guess when we're reducing the prolapse so the the idea with a prolapse reduction is you're trying to mimic your apical suspension procedure you're trying to you're trying so you're basically reducing apex probably to some reason an anterior wall it should not be forcefully straightening out the anterior anterior wall uh there with that in in the um in the sister in the sister urodynamics trial I'm sorry the care study with urodynamic prolapse reduction they used a lot of different methods to do prolapse reduction and try to figure out if a pessary was better than a swab which was better than a finger or anything like that um I think largely that was not all that conclusive for the for the um study in opus where we did prolapse reduction it was just one or two practice swabs reducing the apex back to a place where we thought it would be with surgery without extensive stress do you change the urethral pressure at rest with that probably not um the thing that the thing that's important to remember is there's there is not necessarily all that much difference in sort of resting pressures um in um in a lot of patients it's how the urethra responds to a dynamic condition that influences whether you have stress incontinence or not and we don't have great techniques to measure that in studies that have tried to look at resting urethral closure pressures and discriminating between continence and incontinent patients those those have largely been unsatisfactory we have another question are there studies comparing skinny emg pads versus needle emg recordings um so the knee if you really wanted to know what was happening with the urethral sphincter a needle emg is the way to go um and people argue that's a way to diagnose detrusor sphincter dysinertia um and it probably is better is you know going to be the better test um i'm not where i'm not aware of comparative studies of the two they're they're not commonly done um they take some expertise they certainly are more uncomfortable than a patch in the perianal area there too they're a little they're significantly harder to interpret and get good signals but if you really want to know what's happening in the urethral sphincter that would be the way to go makes sense thank you and dr sawyer has another question um actually thanks you for your last response and asks if you recommend a pessary trial for patients with prolapse and failure to demonstrate the stress incontinence in clinic and do you favor your dynamics over pessary trial for those patients so i would i think a pessary trial is really helpful for those patients i treat a pessary trial like a prolapse reduction stress test if you treat someone you know those patients if you put a someone's prolapse and so what is a pessary trial it's it's reducing their prolapse for a long period of time maybe weeks or months so you've got some reliable information in there and if someone tells you that you know they they were dry and you gave them a pessary and they can't stand it because they leak like crazy you you would better be concerned that they're if you surgically treat their prolapse they're going to have leakage too i would treat that like a prolapse reduction stress test yeah that's a that's a real good point the other thing is you're going to see patients who when you take a history from them they'll tell you they had stress incontinence and as their prolapse got worse their stress incontinence got better and that's because you've got you know the hairpin turn and urethra and the kinking that occurred there and and if you get that history you better be pretty worried they're going to have occult stress and de novo stress incontinence when you do your prolapse surgery we have another question for stress incontinence and low pressure voiding or retention or even reducing prolapse would you use your dynamics i believe that's the question sorry okay so uh let me get that again stretch they have stress incontinence and they have low pressure voiding is that what i saw or retention that's what i'm seeing okay yes so they have retention yeah so yes those are the patients who have a combined storage and a combined emptying disorder and uh those are good candidates for urodynamics low pressure voiding in the absence of retention in the absence of i hope i've reassured you is a very common finding in women uh for that you know low pressure voiding if they still are emptying well they still have a reasonable flow rate they still have a reasonable flow time that should not be a significant concern but if they have retention they do i think one of the challenging things that sometimes happens is you'll see someone with really advanced prolapse this is usually stage three or four prolapse you know complete proxidentia and um they come in and you evaluate them and you know they they don't have incontinence but their pvr is 400 or 500 or something like that because they've got this huge prolapse and proxidentia the question on them is if they have a positive prolapse reduction stress test should you still do a sling at the same time and i'm i'm actually reluctant to do that because you know i'm not sure how much bladder injury they have from chronic over distension and i'll often i'll often tell them you know i'd much rather stage your procedure here and take care of your prolapse let's get your urethra and your bladder in a normal position let's see how it works when it's in normal position and then we will reassess you're probably at high risk for needing a stage sling down the road but i'm i'm just really reluctant um to do a sling in someone who has a high residual and and um stressing continents why because you do your operation you do your sling and their residuals 400 and then you don't know well is this just the chronic chronic injury is this just is just is this you know they haven't emptied their bladder well in a long time how long it's going to take to recover i just assume not complicate things in those patients makes sense absolutely that may be it for questions at this time well i appreciate all your attention everyone i hope uh hope you had a good evening and uh and you got something out of this and uh you know enjoy uh this post-covid life i hope we still we all have now this has been a great discussion on behalf of aux i'd like to thank you dr niger and everyone for joining us today our next fmrs webinar will be held on wednesday july 6 at 7 p.m eastern time and visit dog's website for sign up sign up and updates thank you all so much thank you dr niger bye

urodynamics

female voiding dysfunction

stress incontinence

perineal surface EMG

bladder emptying

diagnosing other disorders

treatment plans

specific cases

uncertain diagnoses