4th International Consultation On Incontinence (ICI) - Imaging, Neurophysiology And Other Investigations Committee Highlights
Dr. Tubaro began by addressing imaging of the upper urinary tract. Imaging may be useful in select cases of ureterovaginal fistula, ureteral ectopia, severe POP and select cases of vesicovaginal fistula. Imaging may also be useful in patients with high storage pressures (e.g. neurogenic) but is generally not recommended in non-neurogenic uncomplicated UI (Level 3 Grade C). A variety of tests can be used with the suggestion to start with the least invasive and least costly studies first.
Dr. Tubaro then addressed imaging of the lower urinary tract. With respect to cystography, it is not recommended in cases of uncomplicated UI but may be useful in complex or refractory cases and in neurogenic etiologies (Level 3 Grade C). Similarly, videourodynamics is not recommended in uncomplicated cases and is considered optional in patients with neurologic lesions (Level 3 Grade C). Post-void residual measurement was recommended in the initial evaluation of UI (Level 3 Grade C), although this somewhat conflicts with the recommendations of other committees. Imaging was recommended for suspected female urethral diverticulum, and the committee noted that MRI appears to be the most accurate test (Level 3 Grade C).
With respect to cystoscopy, routine use is not recommended in uncomplicated female UI but is necessary in patients with concomitant microhematuria or if surgical treatment is being considered in cases of recurrent or iatrogenic UI. Cystoscopy is also recommended in cases of vesicovaginal fistula, during anti-incontinence surgery, and in post-prostatectomy incontinence (Level 3 Grade C).
Dr. Tubaro went on to describe the various techniques and parameters that can be utilized with pelvic ultrasound. It is generally not useful in uncomplicated patients, but it is recommended in cases of mesh erosion/extrusion and optional in posterior compartment vaginal prolapse (Level 3 Grade C). Another interesting area is the use of static and dynamic MRI in the evaluation of POP. Many clinicians find this test useful in planning surgical correction, as the physical exam can be misleading. The committee recommended its use in complex cases (Level 3 Grade C), and there are several areas requiring further study where MRI of the pelvis may yet prove to be very useful.
Imaging of fecal incontinence was briefly addressed, and the committee recommended anal sphincter ultrasound as the initial investigation of FI with dynamic studies such as evacuation proctography being useful in cases where prolapse is suspected (Level 3 Grade C). There is not yet enough evidence concerning the utility of MRI.
The second portion of this committee's presentation was presented by David Vodusek (Slovenia) and focused on neurophysiological testing. Dr. Vodusek described the various tests and stated that neurophysiological testing can be used to diagnose muscle behavior abnormalities and/or muscle abnormalities that may be attributable to a neurological lesion. The EMG signal is a test of muscle activity and can be used to detect denervation or re-innervation. Pathological spontaneous muscle activity is generally a sign of denervation and is best detected with concentric needle EMG. Concentric needle EMG is also the recommended test to detect re-innervation that may reveal specific interference patterns and motor unit potentials. Tests of conduction were outlined next, which generally test for demyelination and axonal loss.
The committee recommended that concentric EMG needle testing is optional for patients with incontinence with known or suspected peripheral neurological lesions (Grade C). Testing of the bulbocavernosous reflex was recommended as an adjunctive test with concentric needle EMG to determine the state of the S2-S3 reflex arc (Grade C).
This presentation and several of the questions highlighted the potential for interdisciplinary collaboration in evaluating and treating patients with UI. It was recognized that the complex neurophysiological testing is outside the scope of even a subspecialized urologic or gynaecologic practice.
Moderated by Saad Khoury, MD, and Tomohiro Ueda, MD, at the Fourth International Consultation on Incontinence (ICI) - July 5 - 8, 2008. Palais des Congres, Paris, France.
Andrea Tubaro, MD, Committee Chair
Written by William Jaffe, MD, a Contributing Editor with UroToday.
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