Bonneys test
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Bonney's test urogynecology stress urinary incontinence
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Bonney test procedure stress urinary incontinence
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Based on my research across textbooks and clinical sources, here is a comprehensive overview of the Bonney Test:
Bonney Test (Marshall-Bonney Test)
What It Is
The Bonney test (also called the Marshall-Marchetti test or Marshall-Bonney test) is a bedside clinical test used in the evaluation of stress urinary incontinence (SUI) in women. Its primary purpose is to predict whether surgical bladder neck suspension will be successful in correcting the incontinence.
Principle
Stress urinary incontinence often results from urethral hypermobility — the bladder neck and proximal urethra descend below their normal retropubic position when intra-abdominal pressure rises (e.g., with coughing). The Bonney test assesses whether mechanically restoring the bladder neck to its normal anatomic position abolishes the stress leakage.
Procedure
- The patient's bladder is filled (or she presents with a full bladder).
- The examiner inserts one or two fingers into the vagina, lateral to the urethra (one on each side of the bladder neck — NOT compressing the urethra directly).
- The bladder neck is gently elevated toward the pubic symphysis to simulate the effect of a bladder suspension procedure.
- The patient is then asked to cough or perform a Valsalva maneuver.
- The examiner observes whether urine leakage is prevented by the elevation.
Positive test (favourable result): Leakage is abolished with elevation → suggests anatomical weakness of the bladder neck → good candidate for a bladder-suspension surgery (e.g., Burch colposuspension, MMK procedure, or mid-urethral sling).
Important Technical Note — Avoiding False Positives
A critical pitfall: if the examiner's fingers compress the urethra against the pubis, continence is restored by mechanical obstruction, not genuine anatomical correction. This gives a false-positive result.
To avoid this, some clinicians prefer to use a slightly opened ring forceps placed in the vagina at the level of the bladder neck to elevate it without urethral compression. If the patient remains continent, the result is more reliable.
Interpretation
| Result | Implication |
|---|---|
| Continent with elevation | Bladder neck hypermobility is the cause; surgical suspension likely to succeed |
| Still leaks with elevation | May suggest intrinsic sphincter deficiency (ISD) rather than hypermobility; surgery less likely to be curative |
| Immediate leak on cough (without elevation) | Confirms stress urinary incontinence |
| Delayed leak (several seconds after cough) | Suggests detrusor overactivity, not pure SUI |
Relationship to Other Tests
- Q-tip test: Measures urethral hypermobility by angle deviation (>30°). No longer recommended due to discomfort; has been largely replaced by vaginal swab assessment during Valsalva. — Berek & Novak's Gynecology
- Pessary/diaphragm test: A pessary placed in the vagina after the Bonney test; if it restores continence, it confirms anatomical bladder neck weakness and supports a good outcome from suspension surgery.
- Cough stress test: The pre-requisite — must confirm actual stress leakage before performing Bonney test.
Clinical Limitations
- False positives due to urethral compression (as above)
- Does not distinguish between hypermobility and ISD reliably in all cases
- Urodynamic studies (urethral pressure profilometry, leak-point pressure) may be needed for definitive assessment
- Modern practice often proceeds directly to mid-urethral sling with clinical diagnosis alone, reducing the role of this test
Surgical Procedures It Predicts
A positive Bonney test supports candidacy for:
- Burch colposuspension (sutures from para-urethral vaginal wall to Cooper's ligament)
- Marshall-Marchetti-Krantz (MMK) procedure (sutures to periosteum of pubic symphysis)
- Mid-urethral sling (tension-free vaginal tape / transobturator tape)
— Berek & Novak's Gynecology; Campbell-Walsh-Wein Urology; Schwartz's Principles of Surgery
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