The Significance of Inverted Tear-drop Sign in Cystography of Women with Stress Urinary Incontinence

Oh, Seung June; Moon, Kyung Hyun; Cho, Kyung Sik; Choo, Myung Soo

Abstract

PURPOSE: A finding of only subtle open bladder neck unaccompanied by leakage at resting state, without any other symptoms suggesting overt intrinsic sphincter incompetence, is commonly observed during cystographic evaluation for women with stress urinary incontinence (SUI). We tried to define whether this finding has any clinical significance in aspect of intrinsic sphincter deficiency.
MATERIALS AND METHODS
A retrospective study was undertaken in a series of women whose diagnoses were SUI in our hospital. The appearance of contrast medium in the proximal urethra at resting state without overt leakage on cystogram was named as inverted tear-drop (ITD) sign. Quantification of ITD sign was made by measuring vertical and anterior-posterior (AP) distances of this area. Various clinical and urodynamic parameters were compared between the patients who had inverted tear-drop sign (ITD group) and those not (non-ITD group).
RESULTS
A total of 453 women underwent fluoroscopic cystography and ITD sign was observed in 273 (60.2%). Analyses were performed in a total of 290 women (ITD group 186, non-ITD group 104). There was a significant difference in mean age between non-ITD (47.0+/-9.4 years) and ITD group (51.7+/-9.5 years). Several clinical factors such as frequency, urgency, urge incontinence, duration of symptoms, parity, previous pelvic surgery, previous anti-incontinence surgery, urine leakage volume by one hour pad test were not significantly different between two groups. However, a ITD sign was significantly more likely to be in groups of patients with menopause and those with a low valsalva leak point pressure (VLPP). VLPP was significantly lower in ITD group (87.1+/-2.7cmH2O) than in non-ITD group (99.0+/-4.1cmH2O). VLPP in ITD group has a negative correlation with vertical (p=0.0001. r=-0.498) and AP length (p=0.0014, r=-0.23) of tear-drop area. Maximal urethral closure pressure was significantly lower in ITD group (48.2+/-1.4cmH2O) than in non-ITD group (56.2+/-2.0cmH2O). ITD group has more advanced types by Blaivas classification than non-ITD group.
CONCLUSIONS
Our results suggest that cystographic ITD sign at rest might reflect some loss of intrinsic sphincter function. When surgeons are planning to operate SUI patients, ITD sign could be considered as an additional parameter in choosing operation method.