Author: Christian Cobreros
Last Updated: November 2018
Current definition:
Abdominal leak point pressure (abdominal LPP): this is a dynamic test. It is the lowest value of the intentionally increased intravesical pressure that provokes urinary leakage in the absence of a detrusor contraction [32]. The increase in pressure can be induced by a cough (cough LPP) or Valsalva (Valsalva LPP).
Valsalva leak point pressure is a dynamic test. It is the lowest value of the intentionally increased intravesical pressure that provokes urinary leakage in the absence of a detrusor contraction. The increase in pressure can be induced by a cough (cough LPP) or the Valsalva maneuver (Valsalva LPP).(1)
History
Abdominal leak point pressure (ALPP): the intravesical pressure at which urine leakage occurs due to increased abdominal pressure in the absence of a detrusor contraction(2).
The present definition emphasizes the fact that this is really a test that needs the participation of the patient. Furthermore, the actual definition of ALPP include the definition of the Valsalva leak point pressure (VLPP).
The VLPP is one of the methods to get a ALPP, but more specific than the cough LPP, which induce a sudden increase in the abdominal pressure which interfere with measurement.
Valsalva leak point pressure (VLPP) has first been described by Mc Guire(3), by his works it was admitted that VLPP of less than 60cmH2O is thought to represent intrinsic sphincter deficiency, VLPP of 60–90cmH2O is said to be equivocal and VLPP more than 90cmH2O suggests sphincter competence and the need to look further for case of symptoms. An ALPP >150cmH2O suggests incontinence is unlikely to be because of the urethra not being able to contain urine.
Controversy
Mid urethral sling surgery is the most accepted surgery for the treatment of female urinary stress incontinence, but the procedure itself has a failure rate which tends to be minimize using urodynamic parameters. There are several studies that shows that a low preoperative VLPP is related with failure surgical outcomes(4), and using the data from de TOMUS trial Nager et al, had described ALPP and MUCP were the only parameters consistently associated with objective failure, but there was no absolute cutoff value. Conversely, Ryu et al.(5) studied 204 patients before placement of MUS and found preoperative VLPP was not related to cure rate or quality of life. Rodriguez et al.(6) also found no difference in cure rate when grouping women into different levels of ALPP before MUS placement. Nager et al (7) also found ALPP did not predict success after Burch or autologous sling placement after 24 months follow up.
So there is evidence for both sides, creating a gap in which VLPP as a urodynamic parameter, for female or male urinary incontinence surgical outcome, is another tool to discuss with the patient choosing the best operation along the available ones.
Pelvic floor response to valsalva versus bearing down and straining has been shown to be different (8). Valsalva is defined as forcible exhalation against a closed mouth, glottis and nose. This may be related to pelvic floor muscle contraction in a normal individual where bearing down as if defecation may be related to pelvic floor muscle relaxation and descent. This distinction should be considered when performing the test. If the test is performed by having the patient bear down as if straining to defecate, the name of the test should be changed to drop the word "valsalva" and use a more correct descriptor.
References
1- Haylen, B.T., de Ridder, D., Freeman, R.M. et al. Int Urogynecol J (2010) 21: 5. https://doi.org/10.1007/s00192-009-0976-9
2- Abrams P, Artibani W, Cardozo L, et al. Reviewing the ICS 2002 terminology report: the ongoing debate. Neurourol Urodyn 2009; 28:287.
3- McGuire EJ, Woodside JR, Borden TA, et al. Prognostic value of urodynamic testing in myelodysplastic patients. J Urol 1981; 126:205–209.
4- Iancu G, Peltecu G. Predicting the outcome of mid-urethral tape surgery for stress urinary incontinence using preoperative urodynamics – a systematic review. Chirurgia (Buchar) 2014; 109:359–368.
5- Ryu JG, Yu SH, Jeong SH, et al. Transobturator tape for female stress urinary incontinence: preoperative valsalva leak point pressure is not related to cure rate or quality of life improvement. Korean J Urol 2014; 55:265–269
6- Rodrı´guez LV, de Almeida F, Dorey F, et al. Does valsalva leak point pressure predict outcome after the distal urethral polypropylene sling? Role of urodynamics in the sling era. J Urol 2004; 172:210–214.
7- Nager CW, FitzGerald M, Kraus SR, et al. Urodynamic measures do not predict stress continence outcomes after surgery for stress urinary incontinence in selected women. J Urol 2008; 179:1470–1474
8. Baessler K, Metz M, Junginger B. Valsalva versus straining: There is a distinct difference in resulting bladder neck and puborectalis muscle position. Neurourology and Urodynamics. 2017;36:1860–1866.