Valsalva Leak Point Pressure to Determine Internal Sphincter Deficiency in Stress Urinary Incontinence

Abstract

Introduction: Valsalva leak point pressure (VLPP) represents the global competence of the conjunctive forces around the urethra to support increased pressure from the abdominal cavity with transmission to the bladder. Assessment of VLPP has prognostic meaning, but measurement techniques are still subject to controversy. Patients and Methods: One hundred and eight consecutive women with no genital prolapse or bladder hyperactivity exclusively presenting with urinary stress incontinence were submitted to VLPP determination during urodynamic evaluation using a rectal and urethral catheter. Rectal pressure measurement served as the landmark in the determination of Valsalva’s maneuver. After determining the rectal pressure, the urethral probe was pulled out and the maneuver repeated. Results: Eighty-four cases (group I) presented leakage during Valsalva’s maneuver with the urethral catheter being in place. Group Ia (66.6%) had a reduction of 44.5 cm H₂O in the rectal pressure after catheter removal. In group Ib, rectal leakage pressure increased after catheter removal from 76.5 ± 18.7 to 79.5 ± 24.7 cm H₂O. Eight patients did not demonstrate urine leakage after catheter removal. In group II, 24 cases showed a rise in rectal leakage pressure to 76.2 ± 22 cm H₂O, but urinary leakage was only observed after catheter removal. In group IIa (19 cases), the VLPP decreased by 12.6 ± 15 cm H₂O, while in group IIb (5 cases) leakage occurred only in patients showing an increase of 22.2 ± 7 cm H₂O in the rectal pressure after the second maneuver with the urethral catheter in position. Conclusions: Precise determination of the abdominal leak point pressure through Valsalva’s maneuver may be critical. The different techniques used for VLPP determination may render comparisons difficult. Rectal pressure measurement with no urethral catheter in place to monitor abdominal leak pressure seems to be more appropriate because it resembles clinical practice. Although lower abdominal leakage pressures may be found, this is not a uniform finding, and a higher incidence of type III incontinence may be expected, and critical analysis or painstaking repetition may be required in the case of lack of demonstration of urinary loss.

Conversion of urodynamic pressures measured simultaneously by air-charged and water-filled catheter systems

“…Kim et al conducted a frequency assessment of select urodynamic signals, and concluded that CLPP and VLPP tests occur with frequency contributions as high as 14 and 7 Hz, respectively. The clinical urodynamic signals collected from the literature for our study show the relevant time to peak pressure as approximately 0.2–0.25 sec (or 4–5 Hz) for CLPPs and 1–2 sec (or 0.5–1 Hz) for VLPPs . This is consistent with the suggestion by Hogan et al that valsalva be defined as lasting more than 2 sec.…”

“…The CLPP signals obtained from literature have time to peak pressure 0.2–0.25 sec, while the VLPP signals have time to peak pressure 1–2 sec . Thus, VLPPs are in the range of slowly changing signals in which ACCs measured peak pressures similar to those measured simultaneously by WFCs.…”

“…The CLPP signals obtained from literature have time to peak pressure 0.2-0.25 sec, while the VLPP signals have time to peak pressure 1-2 sec. [6][7][8][9][11][12][13][14] Thus, VLPPs are in the range of slowly changing signals in which ACCs measured peak pressures similar to those measured simultaneously by WFCs. In contrast, CLPPs are in the range of more rapidly changing signals in which ACCs underestimated peak pressures (Fig.…”

“…Twenty-five additional bladder pressure waveforms recorded during either cough (n ¼ 20) or valsalva (n ¼ 5) events obtained from published literature [6][7][8][9][11][12][13][14] were simulated in the pressure chamber and detected simultaneously by RP, WFC, and ACC systems. Each of these signals was measured once by each WFC and ACC.…”

Preoperative MUCP and VLPP Did Not Predict Long-Term (4-Year) Outcome after Transobturator Mid-Urethral Sling

“…The maximum urethral closure pressure (MUCP) and the Valsalva leak point pressure (VLPP) were used separately and in combination as parameters to study urethral integrity and as outcome predictors in patients who underwent mid-urethral sling operations for SUI [4,5] . At a 3-month follow-up, Miller et al [6] found that TOT was nearly 6 times more likely to fail than TVT when subjects had a preoperative MUCP at or below 42 cm H 2 O.…”