Objective To determine whether transvaginal ultrasound measurement of bladder wall thickness could replace ambulatory urodynamics when investigating women with lower urinary tract dysfunction not explained by conventional laboratory urodynamic studies. Design A blinded prospective study.Setting Tertiary referral unit in a London teaching hospital.Population One hundred and twenty-eight women referred for ambulatory urodynamics with equivocal laboratory urodynamic findings or whose symptoms were not explained by the laboratory urodynamic findings. Methods Transvaginal ultrasound assessment of bladder wall thickness was performed in three planes with an empty bladder prior to ambulatory urodynamics. Mean bladder wall thickness was calculated and the results analysed with respect to the ambulatory urodynamic diagnosis. Main outcome methods Mean bladder wall thickness in women with a normal ambulatory study or a diagnosis of detrusor instability, genuine stress incontinence (GSI) or mixed incontinence. Results Using a one way analysis of variance (ANOVA) bladder wall thickness was found to be significantly different in all diagnostic groups and this reached significance ( P ¼ 0.0001). There was no overlap in the 95% confidence intervals representing a diagnosis of detrusor instability or genuine stress incontinence. Conclusions Transvaginal ultrasound assessment of mean bladder wall thickness is a sensitive screening tool, which can detect detrusor instability in those women with equivocal laboratory urodynamics. In women who have no evidence of GSI on laboratory studies, a cutoff of 6.0mm is highly suggestive of detrusor instability. However, in those women with GSI then ambulatory studies probably remain the investigation of choice.

Objective To determine the efficacy of GAX collagen in the treatment of elderly women with genuine Design A single centre prospective study.Setting A London teaching hospital.Participants Thirty-four women older than 60 years of age with genuine stress incontinence diagnosed Interventions Up to three paraurethral injections of GAX collagen. Main outcome measuresstress incontinence. on videocystourethrography.Subjective and pad test assessments performed pre-operatively, after one month, one year and two years after the first injection of collagen. Videocystourethrography and urethral pressure profilometry were carried out pre-operatively, after three months and one year.Results There was a reduction in urinary leakage as measured on pad testing. After two years 77% of the surviving 26 women were symptomatically cured. Objectively after two years 48% of the women were cured and 9% were improved over their initial pre-treatment level of incontinence. The cure rate was the same whether or not the women had undergone previous vaginal surgery. The maximum urethral closure pressure was not increased with treatment indicating that collagen injections do not act by producing obstruction, but this should be interpreted with caution due to the small sample size.Conclusion GAX collagen is an effective method of treating urinary incontinence in the elderly and especially women who have undergone previous continence procedures. The technique is easy to perform and particularly suitable in those who are frail, but if failure occurs after two years consideration needs to be given to its cost effectiveness.

There is currently a paucity of information regarding clinicians' expectations of treatment and whether their perception of bothersome symptoms is similar to that of the patient. Equally there is often a dichotomy of opinion when comparing clinician-centered evaluation with that of patients. The objectives of this study were to determine clinicians' expectations following treatment, to assess the methods of outcome assessment used in the clinical and research settings, and to compare clinician's expectations with those of patients. This was a prospective postal questionnaire-based study sent to members of the International Continence Society (UK). The questionnaire asked about expectations following treatment and use of outcome measures. These results were also compared to those of an identical patient questionnaire that have previously been published. Tests of agreement were performed between clinicians and patients using Cohen's kappa statistic. Two hundred ninety-nine questionnaires were distributed with a response rate of 52.7%. Overall, 85.9% of responding clinicians felt a good improvement in urinary symptoms, so that they no longer interfered with quality of life, was a realistic outcome. The majority of clinicians thought that small or infrequent episodes of leakage were acceptable following treatment, although frequent or large leaks were not. Irritative urinary symptoms such as urgency and urge incontinence were felt to be less acceptable as were the symptoms of frequency and nocturia. Overall, there was found to be poor agreement between clinicians and patients attitudes to acceptability of symptoms with values of kappa ranging from -0.103 to 0.105, indicating that this agreement was no better than chance. In the research setting, 61% felt both subjective and objective outcome measures should be used, whereas in clinical practice, 42% thought subjective improvement alone, and 36% subjective improvement in QoL, were appropriate. Clinicians have realistic expectations following treatment, although there is poor agreement with those expectations expressed by patients. These findings may help to explain why patients may be disappointed regarding treatment outcomes and why there may be a difference between subjective clinical impression of success and patient satisfaction. In addition there is a lack of conformity in the use of outcome measures in both the clinical and research settings.

The aim of the study was to evaluate the use of a vaginal pessary in the detection of genuine stress incontinence (GSI) in women with urogenital prolapse undergoing urodynamic investigation. Continent women with urogenital prolapse, with or without associated urinary symptoms, were studied. All underwent videocystourethrography using a standardized protocol. None had evidence of incontinence on provocative testing in the upright position. A well-fitting vaginal ring pessary was inserted to reduce the prolapse and mimic a vaginal repair. The provocative tests were then repeated while the bladder was screened. Seventy women with a mean age 59.0 years (range 34-83) were recruited over a 21-month period: 15 women complained of prolapse alone and 55 had concurrent urinary symptoms; 19 women (27%) developed GSI only following the insertion of a vaginal pessary. The women who became incontinent were significantly older (mean age 63.9 years) than those who remained continent (mean age 56.8 years) (P < 0.020). The use of a vaginal pessary increases the detection rate of GSI in continent women with urogenital prolapse undergoing videocystourethrography. These findings are important because women with prolapse and coexisting incontinence should be offered a continence procedure rather than a simple vaginal repair.

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Urinary symptoms and morbidity after ambulatory monitoring is low.

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