Intrinsic Sphincter Deficiency

Poor function of the internal sphincter is referred to as intrinsic sphincter deficiency (ISD). McGuire (20) recognized this condition in some women with recurrent SUI and low urethral closure pressure, and defined it as type III SUI. Pure ISD is relatively easy to diagnose, because the urethra is fixed and incontinence occurs with low pressure. It is often seen after multiple failed incontinence surgeries or radiation therapy. The ALPP is used to determine whether ISD exists in the presence of urethral hypermo-bility. It is generally accepted that proximal urethral closure pressure less than 10 cm H2O, and that ALPP of 60 cm H2O

or less indicates ISD. A "gray zone" exists between 60 and 90 cm H2O. Ghoniem et al.25 classified ISD into three subgroups based on videofluorourodynamic findings and ALPP (Figure 3-2.11). ISD-A can be diagnosed only by

Figure 3-2.11. ISD classification (Ghoniem). ISD-A: Low poximal wetland pressure, high leak pressure. ISD-B: Beak-shaped bladder neck. ISD-C: Pipe stem urethra.

Table 3-2.1. Classification of ISD

ISD-A

ISD-B

ISD-C

Stress test

+

Mostly +

Always

Bladder neck at

Closed at rest, open

Beaked shaped,

Pipe stem open at

FUDS

with stress

open at rest

rest

ALPP (cm H2O)

<120

<90

<70

Source: Ghoniem et al.24

+ = positive

Figure 3-2.11. ISD classification (Ghoniem). ISD-A: Low poximal wetland pressure, high leak pressure. ISD-B: Beak-shaped bladder neck. ISD-C: Pipe stem urethra.

videofluorourodynamic, because radiographic diagnosis cannot be performed when the bladder neck is not open at rest (Figure 3-2.11a). ISD-B is characterized by a beak-shaped open bladder neck at rest and an ALPP of less than 90 cm H2O (Figure 3-2.11b). ISD-C is characterized by an open, fixed, nonfunctioning urethra (pipe stem) with the bladder neck in a high position, and an ALPP of less than 70cm H2O (Figure 3-2.11c) (see Table 3-2.1).

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