title: Magnetic resonance imaging in assessment of stress urinary incontinence in women: Parameters differentiating urethral hypermobility and intrinsic sphincter deficiency.
abstract: OBJECTIVE
  To define the magnetic resonance imaging (MRI) parameters differentiating urethral hypermobility (UH) and intrinsic sphincter deficiency (ISD) in women with stress urinary incontinence (SUI).
  
  
  METHODS
  The static and dynamic MR images of 21 patients with SUI were correlated to urodynamic (UD) findings and compared to those of 10 continent controls. For the assessment of the urethra and integrity of the urethral support structures, we applied the high-resolution endocavitary MRI, such as intraurethral MRI, endovaginal or endorectal MRI. For the functional imaging of the urethral support, we performed dynamic MRI with the pelvic phased array coil. We assessed the following MRI parameters in both the patient and the volunteer groups: (1) urethral angle; (2) bladder neck descent; (3) status of the periurethral ligaments, (4) vaginal shape; (5) urethral sphincter integrity, length and muscle thickness at mid urethra; (6) bladder neck funneling; (7) status of the puborectalis muscle; (8) pubo-vaginal distance. UDs parameters were assessed in the patient study group as follows: (1) urethral mobility angle on Q-tip test; (2) Valsalva leak point pressure (VLPP) measured at 250 cc bladder volume; and (3) maximum urethral closure pressure (MUCP). The UH type of SUI was defined with the Q-tip test angle over 30 degrees, and VLPP pressure over 60 cm H2O. The ISD incontinence was defined with MUCP pressure below 20 cm H2O, and VLPP pressure less or equal to 60 cm H2O. We considered the associations between the MRI and clinical data and UDs using a variety of statistical tools to include linear regression, multivariate logistic regression and receiver operating characteristic (ROC) analysis. All statistical analyses were performed using STATA version 9.0 (StataCorp LP, College Station, TX).
  
  
  RESULTS
  In the incontinent group, 52% have history of vaginal delivery trauma as compared to none in control group (P < 0.001). There was no difference between the continent volunteers and incontinent patients in body habitus as assessed by the body mass index. Pubovaginal distance and periurethral ligament disruption are significantly associated with incontinence; periurethral ligament symmetricity reduces the odds of incontinence by 87%. Bladder neck funneling and length of the suprapubic urethral sphincter are significantly associated with the type of incontinence on UDs; funneling reduced the odds of pure UH by almost 95%; increasing suprapubic urethral sphincter length at rest is highly associated with UH. Both MRI variables result in a predictive model for UDs diagnosis (area under the ROC = 0.944).
  
  
  CONCLUSIONS
  MRI may play an important role in assessing the contribution of hypermobility and sphincteric dysfunction to the SUI in women when considering treatment options.
authors.affiliation: Katarzyna Jadwiga Macura, Johns Hopkins University, Baltimore, MD 21287, United States.
authors.forename: Katarzyna Jadwiga
authors.initials: KJ
authors.lastname: Macura
authors.affiliation: Katarzyna Jadwiga Macura, Johns Hopkins University, Baltimore, MD 21287, United States.
authors.forename: Richard Eugene
authors.initials: RE
authors.lastname: Thompson
authors.affiliation: Katarzyna Jadwiga Macura, Johns Hopkins University, Baltimore, MD 21287, United States.
authors.forename: David Alan
authors.initials: DA
authors.lastname: Bluemke
authors.affiliation: Katarzyna Jadwiga Macura, Johns Hopkins University, Baltimore, MD 21287, United States.
authors.forename: Rene
authors.initials: R
authors.lastname: Genadry
keywords: Dynamic magnetic resonance imaging; Intrincic sphincter deficiency; Magnetic resonance imaging; Stress urinary incontinence; Urethra hypermobility; Urodynamics; Women