PREDICTING TYPE I1 STRESS INCONTINENCE 1267 7. Wiskind, A. K., Creighton, S. M. and Stanton, S. L.: The inci-

dence of genital prolapse after the Burch colposuspension. Amer. J. Obst. Gynec., 167: 399, 1992.

EDITORIAL COMMENT

This is an interesting report on ofice based criteria for predicting anatomical type I1 stress incontinence. The authors developed these criteria in response to the AHCPR Clinical Practice Guidelines for Urinary Incontinence. According to the guidelines surgery is an option for the woman with uncomplicated nonrecurrent stress uri- nary incontinence following a basic evaluation. The criteria were developed by retrospectively reviewing the records of 101 women diagnosed as having pure type I1 incontinence. Of the 101 cases 44 used to develop the criteria did not have uncomplicated type I1 incontinence. The criteria when applied to the same group of pa- tients with no previous suspension had a specificity and positive predictive value of 100%. The criteria were further tested on a new group of 45 women with incontinence. When applied to the 19 un- complicated cases the criteria again had a specificity and positive predictive value of 100%. Although this finding ensures that no patient is classified as having type I1 stress urinary incontinence when they actually do not, it would be more reassuring to see these criteria tested on more than 19 patients, including 13 with type I1 and 6 with other diagnosis. The authors recognize that examiner expertise in performing a vaginal examination is important to their criteria. Will the average urologist who performs suspensions be as good as the authors a t performing a vaginal examination? Additional examiners could have been used to test examiner variability.

The authors conclude that their criteria will reduce the need for further invasive testing and consequently the cost of evaluating women with incontinence. However, if one considers what is recom- mended in the guidelines, these women without a history of suspen- sion would not undergo further evaluation. The authors have not shown us how their criteria differ from those recommended in the guidelines. Guidelines aside, many of us who practice female urology continue to evaluate most or all of our patients with urodynamics

before stress incontinence surgery. I perform preoperative urody- namics primarily to diagnose intrinsic sphincter deficiency, which can coexist with anatomical stress incontinence. In this report all patients who did not have type I1 stress urinary incontinence were categorized as having other diagnosis. If no cases in the new group, particularly the nonsurgical cases, had intrinsic sphincteric defi- ciency, then these criteria are not helpful. For these criteria to change my practice I need to know that a woman with no history of suspension who ultimately has either intrinsic sphincteric deficiency or intrinsic sphincteric deficiency and type I1 stress urinary inconti- nence on complete evaluation would not be classified as having pure type I1 incontinence by these criteria.

E. Ann Gormley Section of Urology Dartmouth-Hitchcock Medical Center Lebanon, New Hampshire

REPLY BY AUTHORS

Our message is that basic evaluation alone may be sufficient for the woman who presents with stress incontinence and who has had no previous bladder suspension operation (uncomplicated stress in- continence). Furthermore, basic evaluation criteria may be estab- lished by the operating surgeon so that there will be consistent application of the principle to every patient who presents with in- continence. Therefore, we hope that surgeons who automatically perform further invasive testing on all incontinent women who have not had surgery may be more discriminatory in preoperative evalu- ation. Our criteria are simple and easy to apply, and require minimal expertise. Our experience suggests that these criteria will identify all complicated cases that will require further testing. Although the criteria are 100% specific (all cases identified were type 2 inconti- nence), they will not identify all pure type 2 cases. However, the criteria will identify the majority of cases with savings in time and effort for us, and avoidance of invasive procedures and reduced cost for the patient.