Can ultrasound replace ambulatory urodynamics when investigating women with irritative urinary symptoms?

Transabdominal ultrasonography of detrusor wall thickness in women with overactive bladder

OBJECTIVE

To determine the clinical usefulness of measuring detrusor wall thickness (DWT) as a noninvasive test in women with overactive bladder (OAB).

PATIENTS, SUBJECTS AND METHODS

We prospectively enrolled 122 women with dry OAB, wet OAB, and women with no OAB symptoms (control group). A 3-day voiding diary was used to differentiate between wet and dry OAB. Transabdominal ultrasonography (TAUS) measurements of DWT were taken at bladder volumes of 250-300 mL and the maximal bladder capacity by both catheter- and natural-filling. Video-urodynamic studies (VUDS) were used to classify bladder dysfunction in 88 of the women.

RESULTS

The mean (range) age of the women was 58 (20-94) years. There were 39 'normal' controls, 44 women had dry OAB, and 39 had wet OAB. Of the 88 women who had VUDS, 28 had a 'normal' test, 30 had increased bladder sensation (IBS), and 30 had detrusor overactivity (DO). The mean DWT at 250-300 mL among three symptomatic subgroups or urodynamic subgroups showed no significant difference by either catheter- or natural-filling methods. The women with wet OAB had significantly greater DWTs than the controls at maximal bladder volume. The maximal bladder capacity was significantly greater in 'normal' women than in those with OAB. If we corrected maximal bladder volume to 250 mL, DWT at corrected 250 mL showed no significant difference among three symptomatic subgroups.

CONCLUSIONS

DWT measured by TAUS in women with OAB and without OAB was not different and did not differ with urodynamic status. Thus, TAUS measurement of DWT is not recommended as a useful diagnostic test for DO in women with OAB.

Measurement of detrusor wall thickness in women with overactive bladder by transvaginal and transabdominal sonography

INTRODUCTION AND HYPOTHESIS

Women with overactive bladder (OAB) might have a greater detrusor wall thickness (DWT) suggestive of detrusor overactivity (DO).

METHODS

DWT was measured by transabdominal ultrasonography (TAU) and transvaginal ultrasonography (TVU) in normal and women with OAB-dry and OAB-wet. The subjects were further classified as normal, hypersensitive bladder, or DO by urodynamic results. DWT measured by TVU at empty bladder, and TAU at 250 ml and bladder capacity were compared among symptom and urodynamic subgroups.

RESULTS

TVU-measured DWT was significantly greater at the bladder neck than other sites of the bladder wall. No significant difference of TVU-measured DWT was noted among subgroups. No significant difference of TAU-measured DWT among subgroups at 250 ml, but DWT at bladder capacity was significantly greater in OAB-wet or DO than other subgroups.

CONCLUSIONS

A greater DWT at bladder capacity measured by TAU can be useful as biomarker for DO in patients with OAB.

Detrusor wall thickness as a test for detrusor overactivity in women

OBJECTIVE

The measurement of detrusor wall thickness has been used as a screening test for detrusor overactivity and bladder outlet obstruction in men and women. The aim of this study was to determine, using receiver-operating characteristics (ROC) analysis, the diagnostic value of detrusor wall thickness in predicting detrusor overactivity in women.

METHODS

The records of 686 women who attended a tertiary urodynamics service from November 2002 to January 2006 were retrospectively reviewed. The patients had undergone an interview, clinical examination, multichannel urodynamic studies and translabial ultrasound examination. Detrusor wall thickness measurements were taken at the bladder dome, after bladder emptying. ROC analysis was used to identify the optimal cut-off of detrusor wall thickness in predicting detrusor overactivity.

RESULTS

Average detrusor wall thickness in the detrusor overactivity group was 4.7 +/- 1.9 mm (mean +/- SD), compared to 4.1 +/- 1.6 mm in the non-detrusor overactivity group (P < 0.001). Using a cut-off of detrusor wall thickness of 5.0 mm gave a sensitivity of 37% and a specificity of 79% for diagnosing detrusor overactivity. The ROC analysis revealed an area under the curve (AUC) of 0.606 (95% CI, 0.56-0.65).

CONCLUSIONS

There is a statistically significant association between detrusor wall thickness and detrusor overactivity (P < 0.001). However, ROC analysis demonstrated that detrusor wall thickness as measured by translabial ultrasound is of little use as a diagnostic test for detrusor overactivity, giving an AUC of only 0.606. Measurement of detrusor wall thickness should therefore not be used as a diagnostic parameter for detrusor overactivity in women.

Correlation between ultrasonographic bladder measurements and urodynamic findings in children with recurrent urinary tract infection

OBJECTIVE

To evaluate the role of bladder variables measured by ultrasonography (US) in assessing bladder dysfunction in children with urinary tract infections (UTIs).

PATIENTS AND METHODS

Children presenting with recurrent UTI (with or with no vesico-ureteric reflux) were prospectively recruited. At entry, each patient had US and both natural- filling (NFC) and conventional-filling (CFC) cystometry. Bladder volume and wall thickness index (BVWI) was calculated, and based on US studies and the bladder pattern on US, were classified as thick (BVWI <70), normal (70-130) and thin (>130) as previously reported. The criteria for diagnosing urodynamic patterns included normal, overactive and hypocontractile, as reported previously. The correlation between the US measured variables and urodynamic findings were then evaluated. Sixty-one children (38 boys and 23 girls; mean age 4.82 years, range 1-11) were selected for further evaluation.

RESULTS

Of the 61 children, 16 had a normal BVWI, 36 a 'thick' value and nine 'thin'. When the BVWI was correlated with the urodynamic findings, 14 of 16 with a normal BVWI had a normal bladder pattern, whereas 92% of the patients with a BVWI of <70 had overactive bladder (P < 0.001). Among children with a BVWI of >130, six of nine had a hypocontractile pattern. The mean (sd) bladder capacity (on CFC) compared to that expected for age was significantly lower, at 56.7 (32.3)% in 'thick' bladders, vs children with normal and thin bladders, at 91.3 (23.8)% and 98.7 (31.8)%, respectively (P < 0.001). A high voiding detrusor pressure was significantly associated with children who had a thick bladder rather than normal or thin bladder (P < 0.001).

CONCLUSIONS

This study further confirmed that the BVWI is a sensitive tool for diagnosing bladder dysfunction in children, and it can be used as a reliable guide for the appropriate choice of further invasive urodynamic studies.

Nomograms of total renal volume, urinary bladder volume and bladder wall thickness index in 3,376 children with a normal urinary tract

BACKGROUND

We have previously shown that urinary bladder volume index (BVI = length x width x depth of bladder) and bladder volume wall thickness index (BVWI = BVI at full bladder/average bladder wall thickness) are useful indicators of bladder dysfunction in children with enuresis and urinary tract infection. These indices show a good correlation with urodynamic studies. We have expanded the study to include normal paediatric subjects with a wide age range. We illustrate a simple sonography protocol with nomograms of different parameters, which provide useful references for functional assessment in children with urological abnormalities.

OBJECTIVE

To construct nomograms of total renal volume, maximum BVI and BVWI based on a Chinese paediatric population with age range from newborn to adolescence.

MATERIALS AND METHODS

Sonography was performed in consecutive children with normal urinary tracts on imaging, using a standardized protocol. Data were collected for construction of nomograms for different parameters.

RESULTS

Nomograms of total renal volume, BVI and BVWI were constructed based on 3,376 consecutive paediatric subjects. All parameters consistently increased with age.

CONCLUSION

Nomograms of total renal volume, BVI and BVWI could provide useful references for studying bladder dysfunction in children using noninvasive dynamic sonography.

Introital ultrasonography: a comparison of women with stress incontinence due to urethral hypermobility and continent women

OBJECTIVE

To determine if there is a variable on introital ultrasonography (IUS) that can be used to distinguish between women with stress urinary incontinence (SUI) due to urethral hypermobility (UH) and continent women.

PATIENTS AND METHODS

This single-centre, prospective, blind, cohort, observational study comprised 383 women (245 continent and 138 incontinent) who were all appropriately informed volunteers selected according to the inclusion criteria. IUS with a convex probe was performed on all women; the measurement plane was standardized and coordinates were obtained at rest and on straining. Several distances were measured to determine if any provided an objective distinction between continent and incontinent women.

RESULTS

Among all the IUS variables assessed, sliding (calculated as the difference between the distance urethra-bladder neck, U-BN, at rest and under stress) was the best for distinguishing continent and incontinent women. The receiver operating characteristic curves showed that with a threshold of 8 mm, sliding had a sensitivity of 92% and a specificity of 79.6% for detecting SUI due to UH. The distances symphysis-urethra (S-U) and U-BN at rest could also discriminate, but with lower significance.

CONCLUSIONS

IUS is an important tool for diagnosing SUI; there are three independent variables, one dynamic (sliding) and two static (distances S-U and U-BN), that can be used to distinguish between continent women and those with SUI due to UH. Sliding is the most reliable, as it has the highest sensitivity and specificity. We think that the simplicity, low financial cost and reliability of IUS could allow it to be a routine procedure for physicians working in incontinence units.

ULTRASOUND BLADDER MEASUREMENTS IN PATIENTS WITH PRIMARY NOCTURNAL ENURESIS: A URODYNAMIC AND TREATMENT OUTCOME CORRELATION

PURPOSE

Accurate assessment of bladder dysfunction associated with voiding dysfunctions often necessitates invasive urodynamic (UD) studies. We evaluate the use of a special ultrasound (US) protocol for the assessment of bladder dysfunction compared with urodynamic findings, and for prediction of treatment outcome in children with primary nocturnal enuresis (PNE).

MATERIALS AND METHODS

US measurements were performed on 514 children 5 to 18 years old (mean age 11.2) with PNE, and compared with those of 339 normal age matched children. A US protocol was specially designed for the evaluation of bladder parameters using bladder volume and wall thickness index (BVWI %), and expected percentage bladder volume index for kidney volume. Of the enuretic children 218 had severe enuretic symptoms with more than 3 wet nights a week. They underwent urodynamic studies for detailed assessment of any underlying bladder dysfunction. A standard 4-week course of desmopressin was given to these children after the US and UD studies. The US bladder parameters were then correlated with the UD findings and treatment response to desmopressin.

RESULTS

Comparing the BVWI in normal and enuretic children in correlation with functional bladder capacities we were able to delineate bladder wall thickness and capacity as BVWI less than 70-small capacity bladder with thick wall, BVWI 70 to 130-normal bladder capacity with normal wall thickness and BVWI greater than 130-large bladder capacity with thin wall. There were statistically significant correlations between BVWI and treatment response. In addition, there was a high predictive value of normal bladder function with a normal BVWI. Patients with good response to treatment had normal BVWI, whereas poor response to treatment was significantly associated with pathological bladder conditions, that is small bladder capacity with thick bladder wall or large bladder capacity with thin bladder wall (p <0.0001). Of note, abnormalities detected by UD correlated well with bladder abnormalities measured by US.

CONCLUSIONS

PNE comprises a diverse spectrum of conditions resulting in a mismatch of nocturnal urine production in excess of nocturnal functional bladder capacity, and underlying bladder dysfunction has an important role in the pathophysiology especially in refractory cases. This US protocol can provide useful predictive clues, which may be helpful to differentiate treatment subtypes, guide clinical management and minimize the need for invasive urodynamic studies.

Ultrasound imaging of the pelvic floor. Part I: two-dimensional aspects

Ultrasound imaging is rapidly replacing radiological methods in the investigation of pelvic floor disorders. Transrectal, transvaginal/introital and transperineal/translabial methods are being employed, with the latter probably the most widespread due to ease of use and availability of equipment. Position and mobility of the bladder neck, bladder wall thickness, pelvic floor muscle activity and uterovaginal prolapse can be quantified, and color Doppler may be used to document stress urinary incontinence. Ultrasound imaging has simplified audit activities and enhanced our understanding of the effects of incontinence and prolapse surgery, such as the new synthetic suburethral slings. In recent years, imaging methods have contributed significantly to our understanding of the traumatic effects of childbirth on the pelvic floor. Finally, the assessment of pelvic floor biomechanics may have implications for clinical obstetrics and ultimately for the prevention of delivery-related pelvic floor trauma.

Urodynamic investigations for management of urinary incontinence in adults

BACKGROUND

Urodynamic tests are used to investigate people who have urinary incontinence or other urinary symptoms in order to make a definitive objective diagnosis. The aim is to help to select the treatment most likely to be successful. The investigations are invasive and time consuming.

OBJECTIVES

The objective of this review was to discover if treatment according to a urodynamic-based diagnosis led to clinical improvements in urinary incontinence, compared to treatment based on history and examination.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register. Date of the most recent search: April 2002.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing clinical outcomes in groups of people who were and were not investigated using urodynamics, or comparing one type of urodynamics against another.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Authors of one study were contacted for more information, including adverse effects.

MAIN RESULTS

Two small trials involving 128 women were included. In one small trial, women who were investigated with urodynamics were more likely to receive active treatment with drugs or surgery. However, the numbers in both trials were too small to determine if this affected clinical outcomes such as a reduction in incontinence.

REVIEWER'S CONCLUSIONS

A larger definitive trial is needed, in which people are randomly allocated to management according to urodynamic findings or to standard management based on history and clinical examination.