Repeated pressure-flow studies in the evaluation of bladder outlet obstruction due to benign prostatic enlargement. Finasteride Urodynamics Study Group

Test-retest reliability of repeated voids in pressure-flow studies and the influence on maximum flow rate (Q(max)pQ), detrusor pressure at maximum flow rate (p(det)Qmax), voided volume, and residual urine were studied. Also the agreement in interpretation of pressure-flow tracings between investigators and a single blinded central reader acting as a quality control center (QCC) were assessed. In addition, correlations between p(det)Qmax and patient age, International Prostate Symptom Score (IPSS), free maximum flow rate (Qmax), and prostate volume were calculated. Using suprapubic pressure recording, 216 men with lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE) were investigated in 11 centers. In each pressure-flow study, three sequential voids were performed, and quality controlled recordings were analyzed for Q(max)pQ and p(det)Qmax by the QCC. Trans rectal ultrasound was used to measure the prostate volume. Mean Q(max)pQ did not change, but p(det)Qmax decreased significantly in the second and third sequential voids. Using the Abrams-Griffiths nomogram definition of obstruction, 125 patients (67%) were classified as obstructed from the first void, but only 111 patients (59%) from the third void. The agreement between the investigator assessment and that of a single blinded reader was good. There was no significant correlation between p(det)Qmax and patient age, IPSS, and Qmax, whereas a modest correlation was found between p(det)Qmax and prostate volume. In summary, there was no significant change in Q(max)pQ, but p(det)Qmax decreased for the three consecutive voids, which can be explained by a decrease in outlet resistance. The agreement between the investigator and QCC interpretations shows the value of a standardized technique, supporting the feasibility of multicenter urodynamic studies. There is a modest, but statistically significant, correlation between detrusor pressure and prostate size, supporting the hypothesis that prostate size is a contributing factor in symptomatic BPH.

Role of ambulatory urodynamic monitoring in clinical urological practice

A retrospective review was conducted of 125 ambulatory monitoring (AM) studies performed on 111 women and 11 men between 1992 and 1996. All patients had had conventional cystometry prior to AM. All tests were interpreted with the aid of event markers and urinary diaries. Ambulatory traces were reported using the definitions derived from Coolsaet's work. To assess the role of AM in routine clinical urological practice, ambulatory diagnoses were compared with those of conventional cystometry. A survey of patient management was carried out by postal questionnaire or review of hospital notes to determine whether AM had influenced patient management. The study showed that 53 of 94 (56.3%) patients with symptoms suggestive of detrusor overactivity had detrusor instability diagnosed on AM. Of those with symptoms suggestive of stress incontinence, 5 (29%) had genuine stress incontinence and 5 (29%) had detrusor instability. The remainder (42%) had normal tests. Overall in 79 of 125 tests (63.2%), additional urodynamic findings were made that correlated with symptoms. Following the survey of patient management, AM was shown to influence management in all but 8.7% patients. In summary, AM was felt to have been shown to be a useful additional tool in clinical urological practice for those patients where conventional cystometry had failed to explain their symptoms.

Relationships between lower urinary tract symptoms and bladder outlet obstruction: results from the ICS-"BPH" study

Despite the lack of evidence in the literature for close relationships between lower urinary tract symptoms and bladder outlet obstruction, the majority of urologists rely on symptomatology when selecting patients for prostatic surgery. We investigated the relationships between a wide range of lower urinary tract symptoms from the ICSmale questionnaire and the results of urodynamic pressure and flow studies. We evaluated 933 patients with lower urinary tract symptoms suggestive for bladder outlet obstruction from 12 countries who participated in the ICS-"BPH" study with the ICSmale questionnaire and urodynamic pressure and flow studies. Spearman rank correlation coefficients were obtained between symptoms and measures of bladder outlet obstruction. There was little or no correlation between a wide range of symptoms and the results of free uroflowmetry and pressure and flow studies. From symptoms alone, it is not possible to diagnose bladder outlet obstruction. Pressure and flow studies and symptom profiles measure different aspects of the clinical condition that should be viewed separately in the evaluation and treatment decision of the patient presenting with lower urinary tract symptoms.

Lower urinary tract symptoms, benign prostatic obstruction and the overactive bladder

Lower urinary tract symptoms (LUTS), benign prostatic obstruction (BPO), and the overactive bladder have increasing prevalence with age in both men and women (with the obvious exception). The question is, are they interrelated or independently related to age? The specific issue is whether BPO causes the overactive bladder. There are two pieces of evidence that might appear to suggest such a cause and effect. First, the overactive bladder is more common in men than in women of the same age, although physiologically, men are 5-10 years older at the same biological age. Second, the overactive bladder resolves in two-thirds of individuals after surgical interventions such as transurethral prostatectomy. The symptoms suggestive of an overactive bladder are the most troublesome, even though they may not be the most prevalent. Long-term follow-up studies with repeated urodynamic investigations have shown that the incidence of the overactive bladder and its attendant symptoms increases despite there being no deterioration in outlet obstruction over follow-up periods of 10 and 20 years. These data, and others, indicate that the situation is not as straightforward as some believe. The statement that 'the overactive bladder is secondary to BPO' cannot be made, as there are too many unanswered questions and pieces of the puzzle that do not fit. The overactive bladder is undoubtedly associated with BPO, and it leads to the most troublesome LUTS in older men. Epidemiological research, coupled with urodynamic evaluation, may provide further evidence. We also need better and more relevant models (e.g. ageing animals), together with further histological and other biological data before the waters become crystal clear.

Pure stress leakage symptomatology: is it safe to discount detrusor instability?

OBJECTIVE

To determine whether the combination of a urological history and urinary diary, with rigorous selection criteria, can be used to define a group of women on whom urodynamic assessment is unnecessary prior to offering surgery for urinary stress incontinence.

DESIGN

Retrospective review of the urodynamic records of women attending for assessment between January 1992 and December 1996.

SETTING

Urodynamic Department, Southmead Hospital, Bristol.

POPULATION

5193 women who attended the urodynamic clinic during the five year study period.

METHODS

Self-completion of a urinary diary in the preceding week before urodynamic assessment and a detailed urological history before undergoing cystometry by all women in the study period. Data were entered onto a computer database. Women reporting stress incontinence in the absence of bladder filling symptoms, with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once, had the results of their filling cystometry analysed.

RESULTS

Of 5193 women, 555 had symptoms of pure stress incontinence and a normal urinary diary. Incontinence was confirmed objectively in 81%, with 9% having incontinence secondary to detrusor instability; 5% had detrusor instability as the sole cause of their incontinence with 4% having a mixed picture of detrusor instability incontinence and urethral sphincter weakness.

CONCLUSION

Genuine stress incontinence cannot be diagnosed reliably from a urological history, even when rigorous selection criteria are used in combination with a normal urinary diary. Without cystometry, incontinence secondary to detrusor instability will be missed.

Urinary symptoms and incontinence in women: relationships between occurrence, age, and perceived impact

BACKGROUND

The prevalence of urinary symptoms that impact on quality-of-life will be important in determining resource allocation in primary care groups.

AIM

To determine the prevalence of urinary symptoms and their perceived impact in a community population of women.

METHOD

A postal survey using a validated self-completed questionnaire among all women aged over 18 years and registered with one general practice in a major British city. The prevalence rates and perceived impact of a wide range of urinary symptoms and their relationship with age was determined. Data were analysed using the chi-squared test and the chi-squared test for trend. Spearman's rank correlation was used to assess the relationship between symptom severity and perceived impact.

RESULTS

The number of completed questionnaires returned was 2075, giving an 80% response rate. Of these, the number of women who reported some degree of incontinence in the previous month was 1414 (69%), although only 578 (30%) indicated that it had social or hygienic impact. Other lower urinary tract symptoms reported included nocturia (19%), poor stream (19%), urgency (61%), and dysuria (23%). The most troublesome symptoms were incontinence for no obvious reason, nocturnal incontinence, and nocturia, with 73%, 69%, and 63% of sufferers, respectively, finding these symptoms troublesome.

CONCLUSIONS

Incontinence and other urinary symptoms are more common than previously thought. These symptoms are not always perceived as bothersome or as having a social or hygienic impact, and therefore many women who report urinary leakage do not require treatment. Nocturnal symptoms in women are commoner than might have been supposed and are extremely troublesome to sufferers.

The overactive bladder: neuropharmacological basis of clinical management

The overactive bladder continues to pose a major challenge to clinicians treating lower urinary tract disorders, not least because our understanding of the pathogenesis of detrusor overactivity is still relatively limited. However, progress in understanding the basis of the overactive bladder is moving steadily forward, accompanied by a growing number of different forms of treatment. New pharmacological treatments and variations in the mode of delivery of older agents offer hope of efficacy with fewer side-effects. Neuromodulation is also offering a viable alternative to surgery in patients unresponsive to medical treatment.

Transurethral resection or incision of the prostate and other therapies: a survey of treatments for benign prostatic obstruction in the UK

OBJECTIVE

To establish the current usage of transurethral incision of the prostate (TUIP) and other forms of treatment for benign prostatic obstruction (BPO).

METHODS

The Prostate Trial Office (PROTO) sent a survey questionnaire to all 376 consultant urologists in the UK which asked for estimates of their clinical practice in treating BPO. The survey had three principle aims: to assess the role that the determination of prostate size has in clinical practice, to determine the nature and frequency of use of a range of therapies including TUIP, and to examine the feasibility of conducting a randomized controlled trial comparing transurethral resection of the prostate (TURP) and TUIP.

RESULTS

Of the 376 urologists, 349 replied (response rate 93%); most respondents used prostate size as a determinant when deciding on therapy for BPO (60%). Of their patients with BPO who were treated, 38% received surgical treatment, 33% drug therapies and 29% conservative management. Of the types of surgical treatment, the most commonly used procedure was TURP, in 79% of patients, with only 15% undergoing TUIP. When compared with TURP, TUIP tended to be used for patients with a mean prostate volume of </=25 mL. Only 6% of surgical patients were treated using minimally invasive techniques.

CONCLUSION

This survey provides some evidence that prostate size plays an important role in determining the treatment; TUIP appeared to be under-used and other minimally invasive techniques are rarely used in the UK.

Role of atrial natriuretic peptide in nocturnal polyuria in elderly males

OBJECTIVES

To demonstrate nocturnal polyuria objectively and to assess the role of atrial natriuretic peptide (ANP) in healthy elderly males with and without nocturnal polyuria (NP).

PATIENTS AND METHODS

31 healthy elderly men known to have NP (passing more than 33% of their 24-hour urine output during an 8-hour period overnight) and 12 controls without NP were invited to take part in the study. Blood and urine samples were collected at 4-hourly intervals in order to measure urine output, serum and urine electrolytes and osmolality as well as serum cortisol, renin, aldosterone, arginine vasopressin (AVP) and ANP.

RESULTS

26 men with NP and 8 controls agreed to take part in the study. Subjects with NP were found to have a diuresis and natriuresis as well as a significant increase in ANP overnight compared to the control group. There was no difference in the other parameters between the 3 groups, with the exception of aldosterone and AVP.

CONCLUSIONS

This study has shown a group of subjects with increased natriuresis and diuresis overnight, associated with an increase in ANP. It is possible that subclinical cardiac failure causes an increase in ANP therefore causing nocturnal urinary symptoms and this theory needs further exploration.

Continued improvement in pressure-flow parameters in men receiving finasteride for 2 years. Finasteride Urodynamics Study Group

OBJECTIVES

To assess the long-term effects of finasteride on pressure-flow parameters in men with urodynamically documented bladder outflow obstruction (BOO).

METHODS

One hundred twenty-one men with benign prostatic enlargement (BPE) and lower urinary tract symptoms (LUTS) underwent a pressure-flow study (PFS) at 1 of 11 clinical centers. The PFS technique was standardized, and all tracings were read by a single reader unaware of the treatment group. Patients who were obstructed according to a modified Abrams-Griffiths nomogram were randomized to 5 mg finasteride (n = 81) or placebo (n = 40) for 12 months; all patients continuing into an open extension received finasteride during the second 12 months of therapy. Results of the initial 12-month study demonstrated the benefit of finasteride treatment on PFS parameters. To examine the continuing effects over time, an analysis of the data from 54 patients who completed 24 months of treatment with finasteride is provided.

RESULTS

Detrusor pressure at maximum flow (PdetQmax) continued to decrease during the second 12 months of therapy (decreases of 5.3 and 11.7 cm H2O at months 12 and 24, respectively). The percentage of patients obstructed by Abrams-Griffiths classification decreased from 76.2% at baseline to 66.7% at month 12 and 59.6% at month 24. An intention-to-treat analysis yielded similar results.

CONCLUSIONS

Finasteride improves urodynamic measures of obstruction in men with BPE and LUTS, with continued improvement during the second 12 months of therapy.

Pharmacological management of incontinence

Many patients with incontinence do not need surgery - for these patients symptoms can often be considerably improved by conservative measures, including drugs. Several different pharmacological actions are potentially useful depending on the underlying cause of the incontinence: a) Detrusor instability (DI) responds to drugs reducing bladder contractility: Anticholinergic agents, e.g. oxybutynin and tolterodine, act at postganglionic parasympathetic cholinergic receptor sites on the detrusor muscle, reducing the strength of the detrusor contraction. Tricyclic antidepressants, e.g. imipramine, have anticholinergic effects, block presynaptic uptake of amine neurotransmitters and directly inhibit detrusor muscle. Alpha-adrenergic antagonists may have a role to play by dual actions on bladder overactivity (due to altered receptor function) and by reducing outlet resistance. b) Genuine stress incontinence (GSI) may be treated using alpha-adrenergic agonists, e.g. phenylpropanolamine, to increase outlet resistance by stimulating smooth muscle of the urethra and bladder neck. c) In nocturnal enuresis reduction of nocturnal urine output with the anti-diuretic hormone (ADH) analogue DDAVP (1-deamino, 8-arginine vasopressin) is beneficial. d) Bladder emptying may be facilitated in patients with retention and 'overflow' incontinence by alpha-adrenergic antagonists, which reduce outlet resistance, and perhaps by parasympathomimetics, e.g. bethanecol. e) In postmenopausal women, systemic oestrogen replacement reduces filling symptoms including urge incontinence. Evidence for oestrogen replacement alone in GSI is lacking, but combination with alpha-agonists is beneficial in milder GSI. For the future, tolterodine and other new anticholinergics offer the hope of treatment for DI with fewer of the side effects that limit the use of established drugs. Better understanding of the pathophysiology of DI may provide new targets for drug therapy, such as hyperpolarisation of detrusor muscle membrane. Alpha-agonists may find a greater role in the future, as may ADH analogues for noctural symptoms.

The effect of oestrogen supplementation on post-menopausal urinary stress incontinence: a double-blind placebo-controlled trial

OBJECTIVE

To investigate the effect of hormone replacement therapy on post-menopausal urinary stress incontinence.

DESIGN

Double-blind, placebo-controlled, randomised trial.

SETTING

University associated teaching hospital.

POPULATION

Post-menopausal women with genuine stress incontinence, not taking hormone replacement therapy.

METHODS

Randomisation to six months therapy with oestradiol valerate 2 mg daily or placebo. Assessment prior to treatment and upon study completion with the SF-36 health status questionnaire, the Bristol Female Lower Urinary Tract Symptoms questionnaire, a one week urinary diary, one hour perineal pad test, cystometry and urethral profilometry.

RESULTS

Sixty-seven women consented to participate, 33 were randomised to receive oestradiol. Mean age was 63 years. Five women failed to undergo repeat assessment, three of whom were receiving oestrogen. Six women receiving oestradiol experienced breakthrough bleeding during the six months and were subsequently treated with additional monthly progestogen. No significant effect of oestrogen over placebo was observed for any subjective or objective clinical outcome.

CONCLUSIONS

This trial is one of the largest controlled studies yet reported, with the longest duration of treatment. No improvement in post-menopausal stress incontinence was demonstrated after six months therapy with oestradiol. This concurs with another study reported recently; it seems unlikely that oestrogen has a significant role to play in this condition.

Overactive detrusor

Detrusor overactivity poses a major challenge to physicians from many specialities. Progress in our understanding of the pathogenesis of detrusor overactivity is slow but steady. Advances in treatment continue to be made, both with new agents and new methods of delivering older drugs. Neuromodulation is showing great promise as experience increases, and developments in bladder augmentation offer hope for lower morbidity treatments in future.

Desmopressin in the treatment of nocturnal polyuria in the male

OBJECTIVES

To assess whether desmopressin (1-desamino 8-d-arginine vasopressin) is safe and effective in the treatment of nocturnal polyuria in elderly men.

PATIENTS AND METHODS

Twenty men (age 52-80 years) complaining of nocturia were found to have nocturnal polyuria, determined from frequency-volume charts and defined as the production of >33% of the 24 h urine volume overnight, averaged over a 1-week period. In a double-blind study of cross-over design, a 1-week placebo run-in period was followed by two 2-week periods of placebo or 20 microg intranasal desmopressin, and ended with an open 2-week treatment period with 40 microg desmopressin.

RESULTS

Desmopressin caused a significant reduction in nocturnal urine volume and the percentage of urine passed at night, but the reduction in nocturnal frequency was only significant during treatment with 40 microg desmopressin. Four patients on desmopressin experienced side-effects, three of which were thought to be due to fluid retention.

CONCLUSION

Desmopressin is an effective treatment for nocturnal polyuria in some elderly men. However, it can cause fluid retention and should not be given to patients with cardiac failure. Those undergoing treatment must be closely monitored.