Q-Tip Test

The Q-tip test is an office test to evaluate the adequacy of anatomic

support to the bladder neck and to determine an abnormal urethrovesical
angle. It may be part of a pelvic exam to evaluate incontinence, but is not
commonly done by internists.

With the patient in the supine position, the urethral meatus is cleaned
with providone-iodine and a cotton swab (Q-tip) is introduced into the
urethra to the bladder. The cotton tip should be well lubricated with
anesthetic cream so that discomfort is avoided. The cotton swab is then
gently pulled back out of the bladder until some resistance is
encountered. At this point, the cotton tip is at the level of the
urethrovesical junction.

In a normal patient, the angle of the Q-tip is less than 30 degrees from the
horizontal, and will remain at this angle when the patient strains. In
patients with inadequate bladder neck support and stress incontinence,
the Q-tip angle generally exceeds 30 degrees from the horizontal.

http://www.ouhsc.edu/geriatricmedicine/education/incontinence/INCONT.ht
m#INCONTVidQtip.htm
Pada saat bladder neck turun (melebihi 30 drjt, maka tekanan intrauretra
akan lebih rendah dari tekanan intravesica..
Tekanan ini normalnya sama antara vesica dan uretra

Q-tip Test

The mobility of the urethrovesical junction (UVJ) should be assessed by

the Q-tip or cotton swab test or by imaging techniques such as ultrasound
or cys- tography (25). The Q-tip test is performed by first cleaning the
external urethral meatus with an appro- priate antibacterial solution. Next,
a sterile Q-tip that has been lubricated with an anesthetic ointment is
gently inserted into the urethra until the tip has reached the bladder.
Generally, there is a slight decrease in resistance as the tip passes the
bladder neck. The Q-tip is then drawn back until a slight re- sistance is
felt, which ensures that the tip is at the UVJ. The resting angle is measured
with a simple goniometer, with the reference being parallel to the floor.
The subject is then asked to perform the Valsalva maneuver or cough, and
the excursion is measured. By the Q-tip test, hypermobility is defined as
an excursion with straining of more than 30 degrees from the resting
angle or more than 30 degrees from the horizontal (26,27) (Fig. 5.4). The
Q- tip test has been a mainstay of the basic evaluation since its
introduction in 1971 and has demonstrated good interobserver reliability
(2830). It has never demonstrated clinical utility in diagnosing the type of
incontinence but can only determine whether there is UVJ hypermobility or
good support.
 priate antibacterial solution. Next, a sterile Q-tip that A postvoid residual (PVR) urine determination
has been lubricated with an anesthetic ointment is should be made immediately after spontaneous
gently inserted into the urethra until the tip has voiding to rule out overflow incontinence in most
reached the bladder. Generally, there is a slight de- patients. It has been suggested that PVR can be es-
crease in resistance as the tip passes the bladder timated on bimanual examination by feeling for an
neck. The Q-tip is then drawn back until a slight re- enlarged distended bladder. However, this tech-
sistance is felt, which ensures that the tip is at the nique had a 14% sensitivity rate for detecting PVR
It UVJ.
hasThe beenrestingsuggested
angle is measuredthatwithmobility
a simple of the UVJ
of greater can
than 50 mL.be as-accurate
A more sessed by simply
technique
visualizing
goniometer, with the degree
the reference of parallel
being descent to the of the anterior
is performed by a vaginal wall catheteriza-
simple in-and-out with Valsalva.
However, when
floor. The subject direct
is then askedvisual assessment
to perform the wasscan,
tion, bladder compared
or ultrasound,with the Q-tip
if available (32).
Valsalva maneuver or cough, and the excursion is Consensus
test, it was deemed inadequate (31). For a full discussion of ultrasound seems to exist that a PVR of less than
measured. By the Q-tip test, hypermobility is de- 50 to 100 mL is normal, a PVR of more than 200
andfinedcystourethro- graphic
as an excursion with straining definitions
of more than 30 mLofishypermobility,
abnormal, and any values refer to Chapter
in between require 26.
If degrees
surgery is not
from the restingbeing
angle or contemplated,
more than 30 de- the Q-tip
clinical test
correlation (1). can be tests
Abnormal omitted
should befrom a
basic evaluation.
grees from Its main
the horizontal (26,27) roleTheisQ-to determine
(Fig. 5.4). repeated becausewhich subjects
the reliability would
of a single determi-
tip test has been a mainstay of the basic evaluation nation is poor (33). There are currently few if any
benefit from a surgical elevation of the bladder neck and which subjects
since its introduction in 1971 and has demonstrated data available to determine what constitutes a clin-
already have adequate UVJ support
good interobserver reliability (2830). It has never and may beelevated
ically significant better PVRsuited toininjectable
that results mor-
therapy.
demonstrated clinical utility in diagnosing the type bidity (i.e., increased UTIs, overflow inconti-
of incontinence but can only determine whether nence, sensation of bladder pressure or urgency, or
there is UVJ hypermobility or good support. It has reflux with upper tract damage). Therefore, most

FIGURE 5.4 The Q-tip test demon-

strating a resting angle of 0 degrees
(bladder outlined in bold line) and the Q-
tip angle with strain of about 40 degrees.

( Osteogard)

Q-Tip Test

During a Q-tip test, the urethral angle is assessed by placing a cotton

swab in the urethra to the level of the bladder neck and then measuring
deflection from the horizontal at rest and with straining. This simple test
can be con-ducted in the office and without more invasive or costly
testing, and it seems a fairly reliable indicator of urethral mobility
associated with straining maneuvers (75). However, some investigators
question its accuracy and overall value. For example, like any assessment
of urethral position, the presence of hypermobility alone does not
necessarily indicate SUI. That is, the specificity of this test for predicting
SUI is quite low (76), and using specific cutoff values (such as 30- to 35-
degree deflection with straining) to differentiate incontinent women is
unreliable (77). Thus, although a properly performed Q-tip test gives
reasonably accurate

assessment of urethral position, its current role in evaluating incontinent

patients and the outcome of procedures aimed at treating incon- tinence
is questionable.

(vaginal surgery for incontinence and prolapse, Philippe E. Zimmen)