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METHODS
Table 1. Characteristics of the women. Table 2. Reliability of measurement of the urethral angle.
10
5
Mean + 2SD
Differences 0
Mean
-5 Mean - 2SD
-10
5 10 15 20 25 30
10
8
6
Mean + 2SD
4
2 Mean
Difference 0
-2
-4 Mean - 2SD
-6
-8
-10
5 10 15 20 25 30
Mean of resting beta angle measurements
Fig. 4. Plot of differences of rest beta angle measurements before and after micturition in the 73 women. Only 41 points are represented because 32 are
superimposed.
The results of the ultrasound analyses by two indepen- differences was 2.4j to þ2.4j. Bladder fullness does not
dent investigators are reported in Fig. 3. This figure shows affect the reliability of measurements of the beta angle.
the plot of the differences between the two observers of Figure 5 shows the association between the mobility of
measurement of the beta angle at rest. The mean difference the bladder neck and urethral angle in the whole population
was 0j and the 95% data interval of the differences was by means of a regression line. We regressed bladder neck
3j to þ3j. This shows good agreement and shows that mobility on urethral angle; that is, the response variable is
measurement of the beta angle is a reliable clinical test. In urethral angle and the explanatory variable is bladder neck
order to demonstrate the reliability of the technique, we mobility. The regression coefficient is 0.375 and its 95%
placed these limits of agreement against a centile chart of confidence interval (CI) ranges from 0.486 to 0.264.
beta angle (Table 2). Table 3 shows the results of the ultrasound measurements
The effect of bladder fullness upon measurement of the in the incontinent women and in the controls. There is a
beta angle is reported in Fig. 4. The mean difference significant difference in all ultrasound variables between
between the beta angle when the bladder was empty and stress incontinent women and controls. The stress inconti-
when it was full was 0.01j and the 95% data interval of the nent women demonstrated significantly lower values of the
50
45
40
Urethral angle
35
30
25
20
15
10
5
0
0 10 20 30 40 50
Bladder neck mobility
Fig. 5. Relationship between the mobility of bladder neck and urethral angle. Only 63 points are represented because 10 are superimposed.
BN – S distance (mm)*
Rest 21 [2] 25 [3] <0.001
Valsalva manoeuvre 18 [2] 23 [3] <0.001
Pelvic floor contraction 17 [2] 24 [4] <0.001
beta angle. Beta angle lowers with straining in incontinent predictive value (85% vs 55%) and greater negative pre-
women, while it increases with straining in the controls. dictive value (98% vs 92%); the likelihood ratio of a
In Figs. 6 and 7, we constructed the ROC curves, positive test was 12 vs 2.72 and the likelihood ratio of a
respectively, for urethral angle and bladder neck mobility negative test was 0.04 vs 0.19.
to choose the cutoff values discriminating between con-
tinent and incontinent women. These are a plot of the true
positive rate against the false positive rate for the different DISCUSSION
possible cutpoints of a diagnostic test. In the first case, we
obtained an ROC area of 0.93 (95% CI 0.87– 0.99) and we Modern ultrasound examination allows adequate evalu-
chose 14j as the cutoff point: the value of the area shows ation of the dynamics of the bladder neck and the proximal
excellent accuracy of the test. In the second case, we urethra in women with stress urinary incontinence.
obtained an ROC area of 0.85 (95% CI 0.76– 0.94) and Ultrasonography can be used as an alternative to conven-
we chose 26 mm as the cutoff point: the value of the area tional radiological techniques for pre- and post-operative
shows good accuracy of the test. evaluation of women with incontinence15. Bladder neck
Table 4 shows the efficiency of measurement of the mobility can be demonstrated by perineal or vaginal
urethral angle compared with bladder neck mobility in ultrasound and measured using the symphysis pubis as
identification of genuine stress incontinence. The measure- the immobile reference point11. Moreover, perineal ultra-
ment of urethral angle shows greater sensitivity (96% vs sonography allows us to visualise and to measure the angle
87%), greater specificity (92% vs 68%), greater positive between the proximal mobile part and the distal fixed part
0.8
0.6
0.4
0.2
0
0 0.2 0.4 0.6 0.8 1
1
26
(sensitivity)
0.6
0.4
0.2
0
0 0.2 0.4 0.6 0.8 1
False positive rate (1-specificity)
Fig. 7. ROC curve for bladder neck mobility.
of the urethra. In our study, urethral angulation was angle and urethrovesical mobility are not entirely inter-
measured electronically by the ultrasound software. The dependent. The two variables seem to represent different
technique gives reliable results with different investigators mechanisms maintaining continence. The static measure-
and is not influenced by bladder fullness. On the other ment of urethral angle, when compared with measurement
hand, the angle can be easily visualised and exactly of urethrovesical mobility, shows a greater ability to
measured only at rest: Valsalva manoeuvre and pelvic distinguish genuine stress incontinence from other urolo-
floor contraction cause urethral distortion, which makes gical disorders.
the measurements difficult. Our data suggest that urethral angulation plays a signifi-
Is it possible to correlate the static observations of the cant role in female continence. With genuine stress incon-
urethra with the dynamic function of urethrovesical support tinence, the urethral angle is lower at rest and lowers with
structures? The proximal urethra is mobile, with a posterior straining. We also suggest that measurement of the urethral
movement of the vesical neck seen at the onset of mictu- angle can provide useful additional information to that
rition and an elevation noted when the woman is instructed found by ultrasound evaluation of bladder neck mobility.
to contract her levator ani muscles16,17. The distal urethra is
surrounded by two arches of striated muscle (compressor
urethrae and the urethrovaginal sphincter) in the region References
of the urogenital diaphragm. Activity of these muscles
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exceeds the increase in abdominal pressure during a technique and its interpretation in women with urinary incontinence.
Obstet Gynecol 1988;71(6 Pt 1):807 – 811.
cough18.
2. Mc Guire EJ, Lytton B, Pepe V, Kohorn EI. Stress urinary inconti-
It seems obvious that with the loss of urethrovesical nence. Obstet Gynecol 1976;47(3):255 – 264.
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urethrovesical mobility and urethral angle are inversely functional aspects of pelvic floor muscles in patients with pelvic
proportional. Nevertheless, bladder neck mobility seems relaxation and genuine stress incontinence. Obstet Gynecol 1989;
74(5):789 – 795.
dependent upon anatomical and functional integrity of the
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bladder neck mobility in identification of genuine stress incontinence. female continence mechanism. Urogyn Int J 1994;8(2):81 – 84.
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Urethral angle Bladder neck mobility
urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol
14 26
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12. Bland JM, Altman DG. Statistical methods for assessing agreement urine. Am J Obstet Gynecol 1952;64:721 – 738.
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(February 8). 18. DeLancey JOL. Structural aspects of the extrinsic continence mech-
13. British Standards Institution. Precision of Test Methods I: Guide for anism. Obstet Gynecol 1988;72(3 Pt 1):296 – 301.
the Determination and Reproducibility for a Standard Test Method
(BS 5497, Part 1). London: BSI, 1979. Accepted 9 April 2002