| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
ORIGINAL RESEARCH |
From the Cleveland Clinic Florida, Fort Lauderdale, Florida.
Address reprint requests to: G. Willy Davila, MD, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331; E-mail: davilag{at}ccf.org.
 |
ABSTRACT |
|---|
TOP
 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
METHODS: Twenty-six women with genital prolapse to or beyond the hymen and undergoing urodynamics for urogynecologic dysfunction were assessed by the Q-tip test. Measurements were obtained with the bladder empty, with and without the prolapse reduced by the posterior blade of a Graves speculum. Angles were repeated at bladder capacity. Measured Q-tip angles were compared using the Wilcoxon signed rank test.
RESULTS: Q-tip angles were significantly altered by vaginal prolapse and bladder fullness. With an empty bladder, the median Q-tip angle measured with the prolapse reduced was significantly less than that measured without reduction (53°, interquartile range 25–65, versus 68°, interquartile range 45–75; P < .001). With a full bladder, similar but lesser results were obtained (33°, interquartile range 15–55 [reduced] versus 48°, interquartile range 31–60 [unreduced]; P < .001). The median Q-tip angle with an empty bladder was greater than that with a full bladder. With the prolapse reduced, the Q-tip angle was 53° (interquartile range 25–65) with an empty bladder versus 33° (interquartile range 15–55) with a full bladder (P < 001). Without the prolapse reduced, the median Q-tip angle was 68° (interquartile range 45–75) with an empty bladder and 48° (interquartile range 31–60) with a full bladder (P < .001).
CONCLUSION: Measurement of urethral mobility by the Q-tip test is significantly affected by genital prolapse. Q-tip angles are less with the reduction of vaginal prolapse and with the bladder full. Standardization of measurement technique is necessary for the development of clinical management recommendations.
Assessment of bladder neck mobility is an important step in the evaluation of women with stress urinary incontinence. Most stress urinary incontinence evaluation algorithms include evaluation of urethral sphincteric function and bladder neck mobility. Studies have shown that traditional antiincontinence procedures are more likely to fail if a patient lacks urethral hypermobility. This appears to be a critical parameter regardless of the type of procedure performed (retropubic urethropexy, needle suspension, or sling procedure).1–3
Because the degree of bladder neck mobility is important in a clinician’s choice of antiincontinence therapy and its ultimate outcome, it is important that practitioners have an accurate evaluation method. A number of methods have been used for this determination, including ultrasound, radiographic studies, and the Q-tip test. Because the Q-tip test is simple to perform and inexpensive, it has become a widely used component of the urogynecologic evaluation.
Crystle et al4 introduced the Q-tip test and reported that its angle of deflection with straining reflected urethral axis rotation. By comparing the results of radiographic bead chain studies, they found that patients with good urethral support had rotational angles of less than 20° from the horizontal axis. Hence, rotational angles of greater than 30° have generally been considered excessive. However, few data exist to differentiate "normal" from "abnormal" Q-tip assessments.5,6
Although the Q-tip test is commonly used and widely accepted, its method has not been uniformly standardized. Variations in Q-tip test method and interpretation have included baseline from which to measure excursion,7 patient positioning,8 and location of the cotton swab end.6 The Q-tip test should be performed in a standardized fashion and interpreted uniformly to allow its use in the triage of a patient with urinary incontinence. Most protocols for Q-tip test performance entail positioning the patient in the lithotomy position with the back completely horizontal, placing the cotton swab end at the bladder neck, and measuring maximal excursion from the horizontal plane. The goal of the current study is to evaluate the effect of vaginal prolapse and its reduction, as well as bladder fullness, on Q-tip angle measurement.
|
MATERIALS AND METHODS |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
The prolapse was reduced using the posterior blade of a Graves speculum. Care was taken to support the vaginal vault with the speculum without stretching or compressing the anterior wall or impeding its mobility.
A Wilcoxon signed rank test was used to compare the measured Q-tip angles with an empty and full bladder and with and without the prolapse reduced. A Wilcoxon rank-sum test was used to evaluate the impact of the compartment of prolapse and the presence of a positive cough profile on the Q-tip angle measurements.
|
RESULTS |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
The measured Q-tip angle was significantly altered by the reduction of vaginal prolapse. Regardless of bladder fullness, the mean Q-tip angle measured with the prolapse reduced was significantly less than that measured without reduction (Ps < .001). Similarly, regardless of prolapse reduction, the mean Q-tip angle with an empty bladder was greater than that with a full bladder (Ps < .001) (see Table 1
for comparisons).
|
|
DISCUSSION |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
Because of the high incidence of occult stress incontinence masked by the advanced degrees of genital prolapse, preoperative assessment of such patients should include evaluation for stress incontinence. Various investigators have suggested performing preoperative urodynamic and provocative testing while reducing the prolapse with a pessary or speculum. This is important, as the urethra may become "unkinked" and reveal underlying stress incontinence.10,11 Richardson et al10 showed that 80% of symptomatically continent patients with advanced prolapse demonstrated stress incontinence by a cough urethral pressure profile after a pessary was placed. Additionally, the resting urethral pressure profiles with and without the pessary in place were different.
Severe genital prolapse may also mask an occult unstable bladder. Rosenzweig et al12 found occult incontinence by urodynamic testing in 59% of women with severe genitourinary prolapse. Thirty-one percent of these women had stress incontinence, 31% had evidence of detrusor instability, and 38% had mixed stress incontinence and an unstable bladder.
Yalcin et al13 studied 60 patients with a grade 3 or 4 cystocele. They reduced the cystocele with vaginal packing and found decreased postvoid residual volumes and increased urinary leakage on a pad test after the packing was placed. In addition, they noted increases in the posterior urethrovesical angle and the Q-tip angle after the cystocele was reduced with the vaginal packing. Although these results differed from our findings, the differences in technique used to reduce prolapse (vaginal packing versus posterior blade of a Grave speculum) make direct comparison difficult. Furthermore, they studied women with only cystoceles, whereas our patients had varying types of prolapse, including vault prolapse and large rectoceles, which might also explain the differences.
Hence, previous studies have demonstrated the impact of prolapse reduction on urodynamic and provocative testing and its ability to reveal occult urinary incontinence. Additionally, some authors have suggested that patients with stress incontinence or the potential for stress incontinence should have an antiincontinence procedure combined with the repair for vaginal prolapse.14,15
This study focused on the impact of prolapse reduction on the assessment of bladder neck mobility. Q-tip measurement differences were demonstrated with and without the prolapse reduced and with an empty versus a full bladder. We conclude that measurement of urethral mobility by the Q-tip test is affected by pelvic organ prolapse and bladder fullness because the Q-tip angle was significantly lower with prolapse reduction and bladder fullness.
Looking at each factor separately, how can we interpret the finding that prolapse reduction impacts the measurement of bladder neck mobility? Inferring from our data, reconstructive vaginal surgery (much like prolapse reduction) may restore the vaginal axis and artificially demonstrate improved bladder neck mobility without actually restoring bladder neck support. In addition, after comparing the pelvic organ prolapse quantification system16 with the Q-tip test, Cogan et al17 concluded that anterior vaginal topography does not necessarily represent the dynamics of the urethrovesical junction. It is possible that stress urinary incontinence would become clinically evident in the postoperative phase if bladder neck support was not appropriately restored. A randomized series would be necessary to demonstrate different clinical outcomes in patients whose bladder neck hypermobility was normalized with only prolapse reduction, versus those patients who underwent additional procedures to support the bladder neck. In addition, because Yalcin et al13 demonstrated increased bladder neck mobility once a cystocele was reduced with vaginal packing, it would be worthwhile to compare the effects of prolapse reduction using a speculum versus the pessary and packing. Because patients with severe genital prolapse have a weakened endopelvic fascia, it is likely that mere normalization of the vaginal axis, without specific correction of bladder neck support, is not sufficient to avoid development of postoperative stress urinary incontinence. We therefore suggest using the unreduced Q-tip angle when making decisions about surgical management.
The second factor we evaluated was the effect of bladder fullness on Q-tip measurement. In this study, the measured Q-tip angle with a full bladder was less than the measurement taken with an empty bladder. The clinical impact of bladder fullness on bladder neck mobility assessment is unclear. For instance, although we showed an effect of bladder fullness on Q-tip measurement, Karram and Bhatia6 failed to do so. However, they measured Q-tip angles with less than 150 mL in the bladder and with a symptomatically full bladder, whereas we measured them with an empty bladder and at maximum cystometric capacity. Discomfort resulting from having a full bladder or fear of urine loss with Valsalva may inhibit a patient from performing a maximal Valsalva effort, thus limiting the accuracy of the test. Additionally, cystometric bladder capacity may not be representative of symptomatic bladder fullness, as many patients who experience stress incontinence will not allow themselves to achieve such bladder volumes. We therefore suggest performing the Q-tip angle with an empty bladder.
The shortcomings of this series are primarily related to the small sample size. However, statistical analysis revealed significant differences in measured Q-tip angles with prolapse reduction and bladder fullness.
The demonstrated differences had a clinical impact in surgical procedure choice in 15% of the subjects: those who had a Q-tip angle of more than 30° without the prolapse reduced and less than 30° with the prolapse reduced. Because preoperative bladder neck mobility assessment is an important factor in delineating a successful treatment plan,1–3 our preoperative counseling was affected in these patients. In addition, for patients with intrinsic sphincter deficiency, we recommend urethral bulking when there is no hypermobility and a suburethral sling in the presence of hypermobility.
These data demonstrate significant differences in bladder neck mobility assessment based on prolapse reduction and bladder fullness in patients with severe vaginal prolapse. It exemplifies the need for standardization of the Q-tip measurement technique, as well as for further studies that will demonstrate the degree of clinical significance of these findings. Until then, we recommend using the measured Q-tip angle without the prolapse reduced and with the bladder empty in making surgical treatment recommendations.
|
Footnotes |
|---|
Received April 4, 2002. Received in revised form July 1, 2002. Accepted August 22, 2002.
|
REFERENCES |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
2. Summitt RL, Bent AE, Ostergard DR, Harris TA. Stress incontinence and low urethral closure pressure: Correlation of preoperative urethral hypermobility with successful suburethral sling procedures. J Reprod Med 1990;35: 877–80.[Medline]
3. Sand PK, Bowen LM, Panganiban R, Ostergard DR. The low pressure urethra as a factor in failed retropubic urethropexy. Obstet Gynecol 1987;69:399–402.[Medline]
4. Crystle CD, Charme LS, Copeland WE. Q-tip test in stress urinary incontinence. Obstet Gynecol 1971;38: 313–5.[Medline]
5. Walters MD. Evaluation of urinary incontinence: History, physical examination, and office tests. In: Walters MD, Karram MM, eds. Urogynecology and reconstructive pelvic surgery. 2nd ed. St. Louis: Mosby, 1999:45–53.
6. Karram MM, Bhatia NN. The Q-tip test: Standardization of the technique and its interpretation in women with urinary incontinence. Obstet Gynecol 1988;71:807–11.[Medline]
7. Swift SE. Basic evaluation of the incontinent female. AUGS Q Rep 1999;18(2):1–3.
8. Handa VL, Jensen JK, Ostergard DR. The effect of patient position on proximal urethral mobility. Obstet Gynecol 1995;86:273–6.[Abstract]
9. Baden WP, Walker TA. Genesis of vaginal profile: A correlated classification of vaginal relaxation. Clin Obstet Gynecol 1972;15:1048–54.[Medline]
10. Richardson DA, Bent AE, Ostergard DR. The effect of uterovaginal prolapse on urethrovesical pressure dynamics. Am J Obstet Gynecol 1983;146:901–5.[Medline]
11. Bump RC, Fantl JA, Hurt WG. The mechanism of urinary continence in women with severe uterovaginal prolapse: Results of barrier studies. Obstet Gynecol 1988;72:291–5.
12. Rosenzweig BA, Soffici AR, Thomas S, Bhatia NN. Urodynamic evaluation of voiding in women with cystocele. J Reprod Med 1992;37:162–6.[Medline]
13. Yalcin OT, Yildirim A, Hassa H. The effects of severe cystocele on urogynecologic symptoms and findings. Acta Obstet Gynecol Scand 2001;80:423–7.[Medline]
14. Weber AM. Surgical correction of anterior vaginal wall prolapse. In: Walters MD, Karram MM, eds. Urogynecology and reconstructive pelvic surgery. 2nd ed. St. Louis: Mosby, 1999:211–9.
15. Bergman A, Koonings PP, Ballard CA. Predicting postoperative urinary incontinence development in women undergoing operation for genitourinary prolapse. Am J Obstet Gynecol 1988;158:1171–5.[Medline]
16. Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JOL, Klarshov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10–7.[Medline]
17. Cogan SL, Weber AM, Hammel JP. Is urethral mobility really being assessed by the pelvic organ prolapse quantification (POP-Q) system? Obstet Gynecol 2002;99:473–6.
This article has been cited by other articles:
|
|
 |
|
  E. E. W. LeBrun, O. H. Harmanli, J. Lidicker, and V. Dandolu Can We Use a Catheter to Do the Q-Tip Test? Obstet. Gynecol., December 1, 2007; 110(6): 1297 - 1300. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
