Standardization of terminology of lower urinary tract function: pressure-flow studies of voiding, urethral resistance, and urethral obstruction. International Continence Society Subcommittee on Standardization of Terminology of Pressure-Flow Studies

The Immediate and 6-mo Reproducibility of Pressure–Flow Studies in Men with Benign Prostatic Enlargement

OBJECTIVES

Urodynamics is an objective method of diagnosing bladder outlet obstruction (BOO) in men. This study examined the immediate and 6-mo reproducibility of this investigation.

METHODS

Urodynamics was performed in men as part of a multinational, multicentre, double-blind, placebo-controlled drug trial. Each patient had two fill/void cycles both at baseline and 6 mo. The BOO index (BOOI) and bladder contractility index (BCI) were calculated for each cycle and data analysed to look for changes in immediate and 6-mo reproducibility between the two fill/void cycles.

RESULTS

A total of 114 patients had urodynamics at baseline. In the immediate term, although there was a small but statistical fall in both the BOOI and BCI, with cycle one figures greater than those in cycle two, 81% and 79% of patients remained in the same BOOI and BCI category, respectively. At 6 mo, the differences were not statistically different with 70% of patients remaining unchanged in their BOOI category in cycle one and 71% in cycle two; 65% remained unchanged in their BCI category in cycle one and 74% in cycle two. No patient with a BOOI > 65 changed category in the second investigation, and only 5 of 103 first cycles with a BOOI > or = 50 changed category to equivocal obstruction.

CONCLUSIONS

Urodynamics has good reproducibility when looking at the BOOI and BCI, indicating that a second study is not necessary in most patients and one investigation is sufficient for an accurate diagnosis on which treatment options can be based.

Pathophysiological Aspects of Nocturia in a Danish Population of Men and Women Age 60 to 80 Years

PURPOSE

We applied the International Continence Society Guidelines and categorized men and women with nocturia 2 or more times a night in pathophysiological groups based on selected lower urinary tract symptoms, clinical examination, frequency volume charts and urodynamics, and categorized the most likely pathophysiological causes of nocturia.

MATERIALS AND METHODS

Participants were randomly selected among respondents in a population study of 4,000 individuals 60 to 80 years old living in Copenhagen County. Nocturia was assessed using the new and validated Nocturia, Nocturnal Enuresis, and Sleep-interruption Questionnaire. Nocturic (2 or more voids) or control (less than 1 void) status was assessed by a 3-day frequency volume chart. Participants were interviewed regarding lower urinary tract symptoms, and physical examination was performed. Nocturia pathophysiology was divided in 4 groups according to frequency volume chart variables, that is nocturnal polyuria, low bladder capacity, nocturnal polyuria and low bladder capacity in combination, and polyuria. Spontaneous flow rate and post-void residual urine were determined, and invasive urodynamic examination was performed in patients.

RESULTS

Of 1,111 eligible individuals 75 patients and 75 controls were included. More patients vs controls had daytime frequency, urgency and urge incontinence. However, the difference was not significant in men. Nocturnal polyuria was the only pathophysiological finding that differed significantly in prevalence between patients and controls. The most prevalent urodynamic finding in patients was detrusor overactivity incontinence (26%) in women and detrusor overactivity (64%) in men.

CONCLUSIONS

Urgency in women, and symptoms suggestive of bladder outlet obstruction in men were the major complaints. Frequency volume charts demonstrated that 55% of patients had nocturnal polyuria which was significantly more than controls. From frequency volume chart variables alone we could categorize 84% of the patients. When symptoms and urodynamic examination were added to the assessment, the most likely cause of nocturia was categorized in 96% of participants.

Relationships Between Micturition Urgency and Involuntary Voiding Dynamics in Men With Urinary Incontinence From Idiopathic Detrusor Overactivity

PURPOSE

In men with urinary incontinence from idiopathic detrusor overactivity we determined whether bladder voiding dynamics differs between those with and without urgent micturition.

MATERIALS AND METHODS

We retrospectively assessed urodynamic findings in 3 groups of 22 men each. Groups 1 and 2 had idiopathic detrusor overactivity with detrusor overactivity incontinence and with micturition urgency in group 1. Group 2 showed no urgency but felt a strong voiding desire just after the onset of involuntary micturition. Control group 3 included nonneurological unobstructed men undergoing urodynamic examination for mixed reasons who proved to be urodynamically normal. Patients with detrusor overactivity and controls were assessed by nonparametric statistics for significant differences in bladder voiding dynamics.

RESULTS

Detrusor contraction strength proved to be increased in groups 1 and 2 with the highest levels in group 1. Detrusor contraction velocity had the highest levels in group 1 and it differed insignificantly in groups 2 and 3. Voiding contractions were equally well sustained in groups 1 and 3, and proved to be less well sustained in group 2.

CONCLUSIONS

Detrusor overactivity involves enhanced detrusor contraction strength levels, particularly in patients who feel urgency. In urgency-free patients with detrusor overactivity detrusor contraction velocity differs insignificantly from that in controls and voiding detrusor contractions proved to be less well sustained than in controls and patients who experienced urgency. This suggests that detrusor contraction velocity may have a role in causing urgency and urgency may have a role in enhancing and sustaining involuntary voiding detrusor contractions in patients with detrusor overactivity.

Videourodynamic Analysis of Pathophysiology of Men with Both Storage and Voiding Lower Urinary Tract Symptoms

OBJECTIVES

Lower urinary tract symptoms (LUTS) are highly prevalent among men; however, not all men with LUTS have urodynamically confirmed bladder outlet obstruction. Overactive bladder symptoms are often caused by bladder dysfunctions alone or in combination with bladder outlet obstruction. A detailed diagnosis to identify the causes of LUTS in men seems mandatory to correctly target different therapy to the various underlying pathologic features.

METHODS

A total of 1407 male patients referred for investigation of LUTS were included in this study. All patients had both storage and voiding symptoms. A videourodynamic study was performed for the diagnosis of bladder dysfunction and bladder outlet dysfunction. The videourodynamic results were also correlated with patient age and compared with the presenting symptoms.

RESULTS

The videourodynamic study revealed that of the 1407 patients with bladder dysfunction, 148 (10.5%) had increased bladder sensation, 724 (51.5%) had detrusor overactivity, 149 (10.6%) had detrusor underactivity, and 82 (5.8%) had a combination of detrusor overactivity and detrusor underactivity. The causes of bladder outlet dysfunction included bladder neck dysfunction in 19 patients (1.4%), benign prostatic obstruction in 413 (29.4%), urethral sphincter pseudodyssynergia in 30 (2.1%), and poor relaxation of urethral sphincter in 283 (20.1%).

CONCLUSIONS

The results of this study have indicated that LUTS can result from a complex interplay of pathophysiologic features that can include bladder dysfunction and bladder outlet dysfunction such as benign prostatic obstruction or poor relaxation of the urethral sphincter. About one third of men with LUTS who were older than 55 years of age had benign prostatic obstruction. Patients younger than 55 years old were more likely to have poor relaxation of the urethral sphincter as a likely cause of LUTS.

Urodynamic outcome of waterjet-assisted total mesorectal excision

Background

Waterjet dissection has been proposed for total mesorectal excision. The present study investigated its impact on urodynamic function and oncological outcome.

Methods

Thirty patients with rectal cancer were recruited to this prospective study, of whom 25 underwent urodynamic evaluation both before and after surgery.

Results

All patients were capable of spontaneous micturition at a median of 5 months after surgery. Urodynamic measurements revealed a decrease in detrusor pressure of more than 30 mmHg, and residual urine volumes of between 100 and 200 ml, in three patients. No patient had a complete neurogenic voiding disorder. Local recurrences developed in two of 22 patients.

Conclusion

The extent of micturition disorders observed after total mesorectal excision using the waterjet method in this small series is encouraging.

Urodynamic Findings Suggesting Two-Stage Development of Idiopathic Detrusor Underactivity in Adult Men

OBJECTIVES

To assess the evolution of bladder voiding dynamics from the onset of symptoms to the final diagnosis of idiopathic detrusor underactivity (DUA) in men with storage and voiding lower urinary tract symptoms (LUTS) and otherwise normal clinical findings.

METHODS

We retrospectively analyzed the urodynamic findings in two patient groups of 25 men each. Group A, with storage and voiding LUTS and otherwise normal clinical findings, had an inconclusive urodynamic test at time 1 and were re-assessed after a mean (+/- SD) of 17 +/- 5 months for worsened symptom severity (time 2). The control group B was formed by age-matched men with unexplained recurrent urinary tract infections who, when seen by us, showed normal clinical and urodynamic findings. Nonparametric statistics were checked for significant differences between groups A and B and between times 1 and 2 in group A.

RESULTS

At time 1, group A had moderately high symptom scores, but the urodynamic findings (normal detrusor contraction strength with a lower detrusor contraction velocity than in group B) seemed to be inconclusive; thus no clear-cut diagnosis was made. At time 2, compared with time 1, group A had higher symptom scores, and the urodynamic findings (lower detrusor contraction strength and shortening velocity, unchanged urethral resistance, lesser voiding efficiency) suggested a diagnosis of idiopathic DUA.

CONCLUSIONS

Idiopathic DUA would likely imply a two-stage development (ie, would be preceded by a phase of low detrusor contraction velocity occurring even several months before a decrease in detrusor contraction strength).

Rising PSA in patients with minor LUTS without evidence of prostatic carcinoma: a missing link?

OBJECTIVES

To determine the role of pressure flowmetry in patients without bothersome lower urinary tract symptoms (LUTS), rising prostate-specific antigen (PSA) levels and diagnosed as having clinical benign prostatic hyperplasia (BPH) after negative (multiple) extended multi-site biopsy.

METHODS

The study enrolled patients with minor LUTS who were referred to our urological practice by their general practitioner because of a rising PSA level (>/=4 ng/ml). After exclusion of clinical prostatic carcinoma by digital rectal examination and transrectal ultrasound, all patients underwent at least one set of extended multi-site biopsies to exclude T1c prostate cancer. Patients with negative biopsies (clinical BPH) were subjected to pressure flowmetry whereafter those with bladder outlet obstruction underwent TURP.

RESULTS

The study included 82 patients, with a mean age of 64.8 years (50.2-78.2 years), satisfying the inclusion criteria. Urodynamic analysis showed that all patients had bladder outlet obstruction. After TURP, eight patients (9.8%) were diagnosed as having histologically proven prostate cancer; 74 patients (90.2%) were diagnosed as having BPH. Patients of the BPH group had a mean preoperative PSA level of 8.8 ng/ml (4.3-25.8 ng/ml) and a mean international prostate symptom score of 8.8 (2-18). The mean detrusor pressure at maximum flow in BPH patients was 89.5 cmH(2)O (20-200 cmH(2)O).

CONCLUSIONS

An increased PSA in patients with minor or no LUTS, clinical BPH and negative extended multi-site prostate biopsy is strongly correlated to bladder outlet obstruction. Therefore, patients with these characteristics should be treated with TURP.

Bladder outlet obstruction index and maximal flow rate during urodynamic study as powerful predictors for the detection of urodynamic obstruction in women

AIMS

To evaluate whether bladder outlet obstruction index (BOOI), a mathematical index of outlet resistance, in association with maximal flow rate (Qmax) obtained during multichannel urodynamics (UDS) or detrusor pressure at maximal flow rate (PdetQmax) could help the identification of obstruction in women.

METHODS

From January 2004 to February 2005, 401 women were assessed in our urodynamic unit. Of these, 133 were neurologically intact women, referred symptoms suggestive of voiding disorders and had an abnormal non-intubated uroflussometry (NIF) (BOO group). A normal NIF was defined as a bell-shaped curve in presence of a Qmax >15 ml/sec and a PVR <50 ml. Symptoms of voiding disorders were ascertained by interview and rated positive if they occurred more than occasionally. Thirty-seven women were enrolled as unobstructed if they presented a normal NIF and symptoms suggestive of voiding disorders less than occasionally (unobstructed group).

RESULTS

ROC curve demonstrated similar diagnostic accuracy in the diagnosis of urodynamic obstruction for Qmax obtained during UDS (AUC = 0.908; P < 0.0001; CI99% = 0.831 to 0.985) and BOOI (AUC = 0.879; P < 0.0001; CI99% = 0.794 to 0.918) and the least was seen for PdetQmax (AUC = 0.706; P = 0.001; CI99% = 0.620 to 0.830). A Qmax obtained during UDS cut-off < or =15 ml/sec provides specificity of 85.9% and sensitivity of 78.9%. A BOOI cut-off > or = -8 provides a sensitivity of 80.8% and specificity of 86.1%. The weakest sensitivity (64.2%) and specificity (64.6%) was recorded for PdetQmax > or =28 cmH(2)O.

CONCLUSIONS

BOOI and Qmax obtained during UDS appears to be the most discriminating urodynamic parameters of female BOO. The use of these cutoff might facilitate the identification of women with functional and anatomical obstruction.

Invasively estimated International Continence Society obstruction classification versus noninvasively assessed bladder outlet obstruction probability in treatment recommendation for LUTS suggestive of BPH

OBJECTIVES

To investigate the contribution of urodynamically proven presence or absence (International Continence Society classification) of bladder outlet obstruction (BOO) to treatment recommendations for lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia, and to investigate the impact of the replacement of the invasively estimated BOO classification with the noninvasively assessed BOO probability on treatment recommendations.

METHODS

Mandatory tests, recommended tests, and pressure-flow studies (with BOO classification) were performed in 150 consecutive men with LUTS suggestive of BPH. Three experienced urologists proposed, independently of each other, the treatment for each patient: watchful waiting, pharmacologic treatment, or surgery. After repeat randomization of the patients and replacement of the BOO classification with the BOO probability, the procedure was repeated 1 month later. A third treatment proposal was done after repeat randomization and after replacement of the BOO probability with the BOO classification.

RESULTS

The symptom score and quality-of-life score were the most decisive in the treatment recommendations, followed by the BOO probability and BOO classification. The medical history, physical status, and duration of the complaints did not significantly affect the treatment recommendations. The intraindividual agreement between the judgments that included the BOO classification and the judgments that included the BOO probability was comparable to the agreement between both judgments that included BOO classification. The interindividual agreement between the judgments that included the BOO classification was not significantly different from that of the judgments that included the BOO probability.

CONCLUSIONS

The symptom score and quality-of-life score were the most decisive in the medical treatment recommendations, followed by the BOO probability and BOO classification. The noninvasively assessed BOO probability was as valuable as the invasively estimated BOO classification in the medical treatment recommendations.

Durability and Cost-Effectiveness of Transurethral Needle Ablation of the Prostate as an Alternative to Transurethral Resection of the Prostate When α-Adrenergic Antagonist Therapy Fails

PURPOSE

We analyzed the adverse event profile, long-term efficacy and cost-effectiveness of transurethral needle ablation of the prostate for lower urinary tract symptoms associated with benign prostatic hyperplasia as an alternative to transurethral resection of the prostate in men with symptoms uncontrolled by medical therapy.

MATERIALS AND METHODS

A total of 71 men on a waiting list for transurethral resection of the prostate after failed medical therapy underwent transurethral needle ablation of the prostate. Symptom scores, uroflowmetry and residual urine were measured before and up to 10 years following treatment. Transrectal ultrasound and pressure flow studies were performed before, and 3 and 12 months following treatment, respectively. Treatment failure was defined as lower urinary tract symptoms progression requiring further therapy or associated with deteriorating quality of life assessment.

RESULTS

Apart from transient postoperative urinary retention, no significant treatment emergent adverse events due to transurethral needle ablation of the prostate were observed. Treatment failure occurred in 58 men (83%) at a median of 20 months. A total of 36 men (51%) underwent invasive treatment (transurethral resection of the prostate 33, bladder neck incision 2, microwave thermal ablation 1), 2 men (3%) were deemed unfit for anesthesia and now practice clean intermittent self-catheterization, 14 men (20%) reported improvement following resumption of treatment with an alpha-adrenergic antagonist after transurethral needle ablation of the prostate and 6 men (9%) have experienced deterioration in lower urinary tract symptoms with reduction in quality of life assessment (International Prostate Symptom Score 3 or greater) but have declined further intervention. There were 12 men (17%) who remained symptom-free up to 10 years after transurethral needle ablation of the prostate. The estimated additional cost of treatment for lower urinary tract symptoms per man treated with transurethral needle ablation of the prostate during the 10-year followup was $1,377.

CONCLUSIONS

Despite documented safety and lack of morbidity, the high re-treatment rate associated with transurethral needle ablation of the prostate renders it relatively expensive when viewed as a long-term alternative to transurethral resection of the prostate for the management of lower urinary tract symptoms associated with benign prostatic hyperplasia in men in whom medical therapy failed. Of men failing alpha-blockade therapy 20% will benefit from a combination of transurethral needle ablation of the prostate and alpha-blockade.

Process for development of multicenter urodynamic studies

OBJECTIVES

To describe our experiences with a continuous quality improvement process for the standardization of multicenter urodynamic studies (UDSs) in a multi-institutional network. Multicenter UDSs can have considerable variations in testing procedures, training, equipment, and reviewer biases.

METHODS

A quality control process was developed that included protocol development, certification of urodynamic testers, central review to assess compliance with protocol and quality, protocol modifications, standardization of equipment and signal configuration, development of an electronic signal repository, and the development of UDS Interpretation Guidelines.

RESULTS

We describe our experience and process in the development and implementation of a standardized UDS protocol in a multicenter surgical trial for stress urinary incontinence. The process included our protocol development, quality control measures, standardization processes, electronic signal repository, and the need for UDS Interpretation Guidelines. A urodynamic testing procedures protocol was implemented successfully by 20 urodynamic testers at nine continence treatment centers. The protocol provides explicit and detailed guidelines for equipment, calibration, patient position, specific annotations, lay language bladder sensation parameters, visual leak point pressure techniques, modifications for prolapse, and data recording. A UDS Interpretation Guidelines document provides specific suggestions for validity and plausibility determination, expected ranges of urodynamic variables, and reasonable agreement of measuring systems. Both documents are available to urodynamic investigators on the Urinary Incontinence Treatment Network website (http://www.uitn.net/resourcesforphysicians.htm).

CONCLUSIONS

Multicenter UDSs require a continuous quality improvement process and the development of UDS testing procedures and interpretation guidelines.

Application of artificial neural network in prediction of bladder outlet obstruction: a model based on objective, noninvasive parameters

OBJECTIVES

An artificial neural network model previously described by us that was based on lower urinary tract symptoms yielded a modest prediction of bladder outlet obstruction. The aim of this study was to establish another model, using more objective parameters, that could better predict for bladder outlet obstruction.

METHODS

The records of 457 patients were used in the construction of the model. Of the 457 records, 300 were allocated to the training phase and 157 to the testing phase. All patients had the average flow rate, maximal flow rate, postvoid residual urine volume (PVR), and total prostate volume recorded. The results of the pressure flow study of those patients were considered the reference standard against which the artificial neural network was tested.

RESULTS

Three models were tested. Models 1 and 2 were based on a three-output design (ie, nonobstructed, equivocal, and obstructed). The only difference was the number of iterations. The accuracy of the first model was 60.5% compared with 46.5% for the second. For a third model, in which the equivocal pressure flow study results were added to the nonobstructed group, the accuracy rose to 72%. Deletion of equivocal cases (around 19% of the total) was associated with an accuracy of 76% in the prediction of obstruction.

CONCLUSIONS

An artificial neural network based on objective and noninvasive parameters could replace the pressure flow study in only 72% of cases. An accuracy of 76% in the detection of bladder outlet obstruction is rather impractical, because an equivocal zone has always been available on pressure flow study nomograms.

Comparison of diagnostic criteria for female bladder outlet obstruction

PURPOSE

There is no universally accepted definition of bladder outlet obstruction in women. We compared 5 contemporary urodynamic definitions and determined how well they correlated with each other and with clinical suspicion of bladder outlet obstruction.

MATERIALS AND METHODS

A total of 154 women who underwent videourodynamics were prospectively evaluated. Clinical obstruction was suspected when history, physical examination, symptoms and basic testing before urodynamics raised the suspicion. Women were classified as having obstruction based on 5 contemporary definitions, including 3 pressure flow cutoff point criteria, videourodynamic criteria and the Blaivas-Groutz nomogram. The McNemar Test was used to compare each definition to the others and to suspicion of clinical obstruction.

RESULTS

Of the women 91 were evaluable, including 26 (29%) with obstruction by videourodynamic criteria, 28 (31%) with obstruction by 1998 cut point criteria, 18 (20%) with obstruction by 2000 cut point criteria, 13 (14%) with obstruction by 2004 cut point criteria and 38 (42%) with obstruction by the Blaivas-Groutz nomogram. Videourodynamic and 1998 cut point criteria were not significantly different from each other (78.9% concordance) and each agreed with the clinically obstructed category in the comparison. Compared to the other criteria, the Blaivas-Groutz nomogram overestimated obstruction, while 2004 cut point criteria tended to underestimate it.

CONCLUSIONS

Each urodynamic definition of female bladder outlet obstruction has merit. Videourodynamic criteria and 1998 cut point criteria have the highest concordance. The Blaivas-Groutz nomogram overestimates obstruction compared to the other criteria. Therefore, it should not be used as the sole or standard definition of obstruction in women.

Diagnostic accuracy of noninvasive tests to evaluate bladder outlet obstruction in men: detrusor wall thickness, uroflowmetry, postvoid residual urine, and prostate volume

OBJECTIVES

The aim of this prospective study was to compare the diagnostic accuracy of detrusor wall thickness (DWT), free uroflowmetry, postvoid residual urine, and prostate volume (index tests) with pressure-flow studies (reference standard) to detect bladder outlet obstruction (BOO) in men.

METHODS

During a 2-yr period, men older than 40 yr with lower urinary tract symptoms and/or prostatic enlargement had the following tests: ultrasound measurements of DWT, free uroflowmetry (Q(max), Q(ave)), postvoid residual urine, and prostate volume. Pressure-flow studies were used to divide obstructed from nonobstructed bladders.

RESULTS

One hundred sixty men between 40-89 yr of age (median: 62 yr) were included in the study; 75 patients (46.9%) had BOO according to pressure-flow studies. The results of all investigated index tests differed significantly between obstructed and nonobstructed men. DWT was the most accurate test to determine BOO: the positive predictive value was 94%, specificity 95%, and the area under the curve of ROC analysis 0.93. There was an agreement of 89% between the results of DWT measurement and pressure-flow studies.

CONCLUSIONS

Measurements of DWT can detect BOO better than free uroflowmetry, postvoid residual urine, or prostate volume. In clinical routine, DWT measurements can be used to judge BOO noninvasively.

Development of a CFD urethral model to study flow-generated vortices under different conditions of prostatic obstruction

A novel, non-invasive method to diagnose bladder outlet obstruction involves the recording of noise with a contact microphone pressed against the perineum (between anus and scrotum). This noise results from flow-generated vortices caused by prostatic obstruction. We developed a computational fluid dynamic (CFD) urethral model including urethral geometry to study the relation between generated noise and the degree of obstruction. This model comprised a bladder, bladder neck, prostate and urethra. Calculations were carried out at four bladder pressures, five degrees of obstruction and three obstruction shapes. For each of the sixty simulations, the velocity and pressure distributions along the urethra were calculated including wall shear stresses to localize flow transition from disturbed to normal. Negative pressures at the obstruction outlet induced recirculation of flow. The location of transition was independent of the applied bladder pressure, but it depended primarily on the degree and secondarily on the shape of the obstruction. Based on the presented results, we hypothesize that the location of the maximum amplitude of perineal noise mainly depends on the degree and shape of the prostatic obstruction. Our future aim is to test our hypothesis in male patients and to extend the presented model to 3D with a viscoelastic urethral wall to calculate the fluid-wall interaction.

Comparison of intravesical prostatic protrusion, prostate volume and serum prostatic-specific antigen in the evaluation of bladder outlet obstruction

AIM

The aims of this study were to define the relationship between intravesical prostatic protrusion (IPP), prostate-specific antigen (PSA) and prostate volume (PV) and to determine which one of them is the best predictor of bladder outlet obstruction (BOO) due to benign prostatic enlargement.

METHODS

A prospective study of 114 male patients older than 50 years examined between November 2001 and 2002 was performed. They were evaluated with digital rectal examination, International Prostate Symptoms Score, PSA, uroflowmetry, postvoid residual urine measurement, IPP and PV using transabdominal ultrasound scan. Statistical analysis included scatter plot with Spearman's correlation coefficients and nominal logistic regression

RESULTS

Prostate volume, IPP and PSA showed parallel correlation. Although all three indices had good correlation with BOO index, IPP was the best. The Spearman rho correlation coefficients were 0.314, 0.408 and 0.507 for PV, PSA and IPP, respectively. Using receiver-operator characteristic curves, the areas under the curve for PV, PSA and IPP were 0.637, 0.703 and 0.772, respectively. The positive predictive values of PV, PSA and IPP were 65%, 68% and 72%, respectively. Using a nominal regression model, IPP remained the most significant independent index to determine BOO.

CONCLUSIONS

All three non-invasive indices correlate with one another. The study showed that IPP is a better predictor for BOO than PSA or PV.

Bladder outlet obstruction in women: iatrogenic, anatomic, and neurogenic

This paper outlines the presentation, evaluation, and management of bladder outlet obstruction (BOO) in women as it relates to iatrogenic, anatomic, and neurogenic causes. Attention is given to the different diagnostic criteria used by various authors in their case series and studies. The lack of standardization with regard to the diagnosis of BOO in women emphasizes the fact that BOO is often a clinical diagnosis that is made by taking into account the history, physical examination, imaging of the lower urinary tract, and urodynamic pressure-flow parameters. Individual obstructive conditions including urethral stricture, postsurgical obstruction, primary bladder neck obstruction, pelvic organ prolapse, and neurogenic causes are addressed briefly.

Safety and efficacy of tramadol in the treatment of idiopathic detrusor overactivity: a double-blind, placebo-controlled, randomized study

AIM

To evaluate the efficacy and safety of tramadol in patients with idiopathic detrusor overactivity (IDO).

METHODS

A total of 76 patients 18 years or older with IDO were randomly assigned to receive 100 mg tramadol sustained release (group 1, n = 38) or placebo (group 2, n = 38) every 12 h for 12 weeks. Clinical evaluation was performed at baseline and every 2 weeks during treatment. All patients underwent urodynamics and ice water test at baseline and 12-week treatment. Main outcome measures were number of voids per 24 h, urine volume per void and episodes of urge incontinence per 24 h on a frequency volume chart and detailed recording of adverse effect.

RESULTS

After 12 weeks of treatment mean number of voids per 24 h +/- SD decreased from 9.3 +/- 3.2 to 5.1 +/- 2.1 (P < 0.001 vs. placebo) [95% confidence interval (CI) -5.1--0.4]. At that time mean urine volume per void increased from 158 +/- 32 to 198 +/- 76 ml (P < 0.001 vs. placebo) (95% CI 8-22), while mean number of incontinence episodes per 24 h decreased from 3.2 +/- 3.3 to 1.6 +/- 2.8 (P < 0.001 vs. placebo) (95% CI -2-0.3). Tramadol induced significant improvements in urodynamic parameters. More adverse effects were associated with tramadol treatment than with placebo (P < 0.05). The main adverse event with tramadol was nausea.

CONCLUSIONS

In patients with non-neurogenic IDO tramadol provided beneficial clinical and urodynamic results. Further studies are required to draw final conclusions on the efficacy of this drug in IDO.

Therapeutic effect of multiple resiniferatoxin intravesical instillations in patients with refractory detrusor overactivity: a randomized, double-blind, placebo controlled study

PURPOSE

Previous study has shown that multiple intravesical instillations of resiniferatoxin (Sigma) at 10 nM has therapeutic effects in patients with detrusor overactivity. To our knowledge the placebo effect of multiple instillations of low dose resiniferatoxin for neurogenic and nonneurogenic detrusor overactivity has not been investigated. In this randomized, double-blind, placebo controlled study we evaluated the therapeutic effects of this resiniferatoxin treatment.

MATERIALS AND METHODS

A total of 54 patients with detrusor overactivity refractory to anticholinergics were enrolled and randomly treated with 4 weekly intravesical instillations of 10 nM resiniferatoxin (26) or vehicle, consisting of 10% ethanol in normal saline, as the control group (28). The clinical effects of treatment on incontinence grade, incontinence episodes, general satisfaction, lower urinary tract symptoms and urodynamic parameters were assessed.

RESULTS

Three months after completing the 4 intravesical treatments the resiniferatoxin treatment group had a significantly higher percent of patients with excellent and improved results compared to the control group (19.2% vs 7.1% and 42.3% vs 14.2%, respectively, each p < 0.001). Treatment remained effective at 6 months in 13 patients (50%) in the resiniferatoxin group but in only 3 (11%) in the control group (p < 0.001). Bladder capacity was significantly increased and symptom scores significantly improved 3 months after treatment in the resiniferatoxin group but not in the control group.

CONCLUSIONS

Multiple intravesical instillations of 10 nM resiniferatoxin were effective for improving the incontinence grade in 62% of patients at 3 months, of whom 50% maintained a therapeutic effect 6 months after treatment. The therapeutic effect of resiniferatoxin was significantly superior to that of placebo.

Variation in invasive and noninvasive measurements of isovolumetric bladder pressure and categorization of obstruction according to bladder volume

PURPOSE

We developed a noninvasive test that provides an estimate of isovolumetric bladder pressure by measuring the pressure required to interrupt voiding using controlled inflation of a penile cuff. We noted variation in serial measurements obtained during a single void and, therefore, we determined whether this represents variation in detrusor contraction strength, as predicted in previous studies, or measurement error.

MATERIALS AND METHODS

A total of 36 symptomatic men underwent simultaneous invasive and noninvasive pressure flow studies. Corresponding values of isovolumetric bladder pressure and cuff interruption pressure were recorded at each flow interruption and grouped according to bladder volume to calculate measurement error and bias at various points during a void. Individual variation in the 2 measurements across a range of normalized bladder volumes was then examined using ANOVA.

RESULTS

Cuff interruption pressure showed a consistent level of accuracy as an estimate of isovolumetric bladder pressure across a range of volumes. There were similar, statistically significant differences in isovolumetric bladder pressure and cuff interruption pressure recorded at specific volume increments with the highest values seen in the mid range and the lowest seen at lower bladder volumes (each p <0.01). When plotting, the maximum recorded value of cuff interruption pressure in each individual on our proposed noninvasive pressure flow nomogram provided the best diagnostic accuracy for obstruction.

CONCLUSIONS

This study shows that cuff interruption pressure varies in the expected manner with bladder volume and provides a consistent estimate of isovolumetric bladder pressure throughout a void. These data provide important guidance for interpreting noninvasive pressure flow studies and classifying obstruction on the proposed nomogram.

Urodynamics after TURP and HoLEP in urodynamically obstructed patients: are there any differences at 1 year of follow-up?

OBJECTIVES

To compare urodynamic findings after holmium laser enucleation of the prostate (HoLEP) and transurethral resection of the prostate (TURP) for the treatment of benign prostatic hyperplasia-related bladder outlet obstruction.

METHODS

From January to October 2002, 100 consecutive patients with benign prostatic hyperplasia with obstructive lower urinary tract symptoms were randomized to surgical treatment with either HoLEP (group 1, n = 52) or TURP (group 2, n = 48). All patients were preoperatively assessed using the International Prostate Symptom Score and quality-of-life question, total serum prostate-specific antigen measurement, transrectal ultrasonography, and complete urodynamic study. The operative time, catheterization time, and overall hospital stay were also recorded for both groups. All patients were assessed at 1, 6, and 12 months postoperatively using a complete urodynamic evaluation.

RESULTS

All patients were obstructed preoperatively (Schäfer grade greater than 2). Both groups were comparable in terms of age, total serum prostate-specific antigen level, International Prostate Symptom Score, and urodynamic results. At 1, 6, and 12 months of follow-up, no statistically significant differences were recorded in terms of detrussor pressure at maximal urinary flow rate, Schäfer grade (linear passive urethral resistance relation), maximal urinary flow rate, International Prostate Symptom Score, and quality-of-life score. In the HoLEP group, the catheterization time and hospital stay were significantly shorter. Transitory lower urinary tract symptoms after 3 months of follow-up and dysuria were more frequent in the HoLEP group than in the TURP group, although at 12 months of follow-up, the results were comparable.

CONCLUSIONS

Both HoLEP and TURP were equally effective in relieving bladder outlet obstruction. Although associated with greater early self-resolving irritative symptoms, HoLEP can guarantee a shorter catheterization time and hospital stay with longer operative times, proposing itself as an attractive alternative to standard TURP.

[Non-invasive urodynamics in male patient]

PURPOSE

Pressure-flow studies are currently recognized as the criterion standard to quantify urethral obstruction and its consequence on detrusor contractility. These tests have some disadvantages: they are invasive, time-consuming and expensive and entail risk of disease for the patient. Less invasive methods have been proposed to give the same results without the disadvantages. In this study, we conducted a critical analysis of the devices and techniques and their results.

METHOD

After a brief reminder of the general behavior of the flow in an obstructed urethra, we describe the main non-invasive techniques: penile urethral compression-release (PCR), cuffs, and condoms. Using the VBN method, we tried to quantify data from these techniques to specify the relation with the usual parameters of bladder outlet obstruction.

RESULTS

In the absence of brisk change of the flow rate, the voiding phases are easily analyzed. With minor corrections, recorded external or cuff pressures could be used in the ICS nomogram; unfortunately, these pressures are greatly modified by perturbations of the nervous control. The spike of flow (due to urine storage in the urethra) observed at resumption of flow after each interruption presents mathematical difficulties for quantitative and reliable modeling but could give a consistent empirical interpretation.

CONCLUSION

Of the reported non-invasive tests, all except PCR have an important instrumental heaviness and induce strong perturbations of the nervous control. If they cannot allow an accurate quantification of urethral obstruction and detrusor contractility, they could allow for classification of benign prostatic hypertrophy (BPH) patients. Despite the mathematical problems set by the theory of spikes, the empirical use of the spikes amplitude could perhaps be clinically useful.

Urgency degree and bladder contraction velocity: Sequential changes in women with idiopathic detrusor overactivity

AIMS

In patients with idiopathic detrusor overactivity (DO) who showed storage symptoms worsening with time, we checked whether and which urodynamic parameter changes are associated with an increased urgency degree.

MATERIALS AND METHODS

We analyzed retrospectively the urodynamic findings in 54 women -27 with storage symptoms (Group A, mean age 32 +/- 7 years) and 27 controls (Group B, mean age 30 +/- 9 years). These latter had a history of recurrent UTIs (urinary tract infections), but when seen by us had no UTI, DO, lower urinary tract symptoms, or any other pathological finding. Group A had a first urodynamic examination when first referred (time 1) and were re-assessed a mean of 16 months later (time 2) for worsened storage symptoms.

RESULTS

In Group A, an idiopathic DO was shown at both times 1 and 2; urgency of voiding could be delayed during cystometry for >or=2 min (= moderate urgency) at time 1 and for <2 min (= severe urgency) at time 2; detrusor contraction strength or contractility proved higher than in Group B (P < 0.001) and increased from time 1 to time 2 (P < 0.001), detrusor shortening velocity being always the major component of the higher contractility levels.

CONCLUSIONS

A DO-related increase in bladder contractility may have been further enhanced by severe urgency through a positive feedback mechanism. The urgency degree proved closely associated in DO patients with the level of detrusor shortening velocity rather than with detrusor pressure.

Videourodynamic characteristics and lower urinary tract symptoms of female bladder outlet obstruction

OBJECTIVES

To analyze the lower urinary tract symptoms (LUTS) and videourodynamic characteristics of female bladder outlet obstruction (BOO).

METHODS

Videourodynamic studies were performed in 207 women with signs and symptoms of BOO. Bladder outlet obstruction was defined as the radiologic evidence of bladder outlet narrowing plus a voiding pressure greater than 35 cm H2O and a maximum flow rate less than 15 mL/s or a voiding pressure greater than 40 cm H2O. Women with BOO were categorized into five groups on the basis of the videourodynamic findings. The LUTS and urodynamic parameters were analyzed according to these classifications.

RESULTS

Videourodynamic study revealed bladder neck obstruction in 18 patients (8.7%), urethral sphincter obstruction in 56 (27.1%), pelvic floor muscle obstruction in 106 (51.2%), high-grade pelvic organ prolapse and BOO in 13 (6.3%), and urethral stricture in 14 (6.8%). Urgency frequency was reported by 94% and difficult urination by 57% of the total patients. Among the 17 patients with urinary retention, obstruction was noted at the urethral sphincter in 10, pelvic floor muscle in 5, bladder neck in 1, and urethral stricture in 1. Detrusor overactivity was found in 52.7% of total patients and was most frequent in those with urethral sphincter obstruction (78.6%). Patients with bladder neck obstruction had the highest voiding pressure and lowest maximum flow rate.

CONCLUSIONS

Differences in videourodynamic characteristics of women with BOO might be associated with the underlying pathophysiology of the bladder, urethral, and pelvic floor muscle dysfunction.

Prostate botulinum A toxin injection--an alternative treatment for benign prostatic obstruction in poor surgical candidates

OBJECTIVES

To evaluate, in a prospective study, the effectiveness of prostate injection of botulinum A toxin in patients who were poor surgical candidates. Patients with benign prostatic hyperplasia (BPH) are usually successfully treated with medical treatment or transurethral resection. However, some patients with chronic urinary retention or a large postvoid residual urine volume due to BPH are poor surgical candidates or are patients in whom medical treatment has failed.

METHODS

Ten patients with BPH and urinary retention or a large postvoid residual urine volume received 200 U botulinum A toxin injection into the transition zone of the prostate. The clinical results and urodynamic parameters at baseline and after treatment were compared.

RESULTS

All patients had an improvement in spontaneous voiding after treatment. Of them, 8 had an excellent result (80%) and 2 had an improved result. Both voiding pressure and postvoid residual volume were significantly decreased after treatment. The total prostate volume was significantly reduced, and the maximal flow rate was significantly increased after treatment. The maximal effects of botulinum A toxin appeared at about 1 week and were maintained at 3 and 6 months after treatment. At 6 to 12 months (mean 9) of follow-up, no patient had had recurrence of urinary retention and the voiding condition in all patients remained at the post-treatment status. No adverse effect was noted.

CONCLUSIONS

Prostate injection of botulinum A toxin is an effective alternative treatment with minimal adverse effects for patients with benign prostatic obstruction who are poor surgical candidates or in whom medical treatment has failed.

Tolerability and morbidity of urodynamic testing: a questionnaire-based study

OBJECTIVES

To determine the tolerability and morbidity rate of multichannel urodynamics (UDS).

METHODS

A total of 154 consecutive patients were included in the present study; 87 men and 67 women underwent UDS and completed a questionnaire. All patients undergoing UDS were given a two-part questionnaire. The first part, given immediately after UDS, contained four questions regarding pain, embarrassment, and physical burden (assessed with a visual analogue scale on which 0 = not at all, 10 = unbearable), as well as willingness to undergo UDS again. The second part, given within 2 weeks after UDS, contained five questions regarding micturition pain, gross hematuria, dysuria, cloudy urine, and fever episodes after UDS. Urine specimens were also analyzed.

RESULTS

The mean (+/-SD) degrees of pain, embarrassment, and physical burden were 2.27 +/- 2.53, 2.59 +/- 2.69, and 1.76 +/- 2.43, respectively, and 73.6% of men and 80.6% of women were willing to repeat UDS. The most common complaint after UDS was micturition pain. Two men and 1 woman had fever after UDS; there was no relationship between fever and urinary tract infections. Urinalysis showed that 4.6% of men and 7.5% of women had leukocyturia after the investigation.

CONCLUSIONS

The complication rates of UDS were relatively low. For most patients, UDS were tolerable and acceptable. Proper informed consent is necessary.

The natural history of lower urinary tract dysfunction in men: minimum 10-year urodynamic followup of transurethral resection of prostate for bladder outlet obstruction

PURPOSE

Despite long-term symptomatic and uroflowmetry studies following transurethral prostate resection (TURP) there are sparse pressure flow data. Consequently there is minimal information to account for the long-term symptomatic failure and flow rate decrease seen with time following early improvements after surgery.

MATERIALS AND METHODS

Men older than 45 years who were investigated at our department between 1972 and 1986, diagnosed with bladder outlet obstruction and elected surgical intervention were invited for repeat symptomatic and urodynamic assessment. Identical methods were used, allowing direct comparison of results.

RESULTS

A total of 1,068 men were initially diagnosed with bladder outlet obstruction, of whom 428 (40%) died in the interim. Of the men who were followed 217 underwent TURP with a mean followup since surgery of 13.0 years. A significant, sustained decrease in the majority of symptoms and improvements of urodynamic parameters was seen. Long-term symptomatic failure and decreased flow rate were principally associated with detrusor under activity (DUA) rather than obstruction. Presentation predictive factors for the future development of DUA were decreased detrusor contractility and a lesser degree of obstruction.

CONCLUSIONS

This unique long-term study provides valuable information on surgically treated bladder outlet obstruction. The association of long-term failure following surgery with DUA emphasizes the importance of pressure flow studies before repeat surgery. However, our faith in the long-term efficacy of TURP is justified.

Effect of different sized transurethral catheters on pressure-flow studies in women with lower urinary tract symptoms

INTRODUCTION

The study evaluates the impact of three different sized (4.5-, 6- and 7-Fr) catheters on pressure-flow studies in women undergoing urodynamic evaluation for lower urinary tract symptoms.

MATERIAL AND METHODS

60 women referred for the evaluation of lower urinary tract symptoms were enrolled in this randomized controlled study. Patients were divided into two groups (A and B) of 30 women each. The patients underwent non-invasive free-flow uroflowmetry with determination of post-void residual urine volume (PVR) and two consecutive pressure-flow studies using two different transurethral catheters. In group A the two consecutive pressure-flow studies were performed using a 4.5-Fr catheter once and a 6-Fr catheter once; in group B the two consecutive pressure-flow studies were performed using a 4.5-Fr catheter once and a 7-Fr catheter once. Patients were also randomized for the consecutive order in which the two different transurethral catheters were used.

RESULTS

The pressure-flow parameters were significantly different from the equivalent free-flow findings. The maximum and average flow rate in all pressure-flow studies performed were significantly lower than the equivalent free-flow parameters and the flow time was significantly longer for all pressure-flow versus free-flow studies. Furthermore, there was a significantly larger PVR for pressure-flow than for free-flow measurements. There was no significant difference in maximum flow rate, average flow rate and flow time between 4.5- and 6-Fr pressure-flow studies (group A). However, there was a statistically significant difference between 4.5- and 7-Fr pressure-flow studies (group B) in those uroflowmetry parameters. Detrusor pressure at maximum flow (Pdet. Qmax) and maximum detrusor pressure (P(det. max)) in group A did not show statistically significant differences between 4.5- and 6-Fr pressure-flow studies whereas in group B Pdet. Qmax and P(det. max) were significantly different between 4.5- and 7-Fr pressure-flow studies.

CONCLUSIONS

A 4.5-, 6- or 7-Fr transurethral catheter may obstruct micturition changing uroflowmetry parameters. A statistically significant difference was found in all but PVR parameters particularly in all detrusor parameters between 4.5- vs. 7-Fr whereas no statistically significant difference was found in all but PVR parameters between 4.5- vs. 6-Fr. We can thus state that pressure-flow findings may be influenced by different sized transurethral catheters. A misinterpretation of pressure-flow findings may have clinical implications on establishing an accurate diagnosis.

Primer: questionnaires versus urodynamics in the evaluation of lower urinary tract dysfunction—one, both or none?

What is the role of urodynamic assessments and have we made too much use of them? Is there a correlation between symptoms and underlying pathophysiology? These questions are addressed in this article. There are disparities in the assessment of lower urinary tract dysfunction between the accuracy of symptomatic assessment and the underlying pathophysiology. This is particularly evident with voiding symptoms, in contrast to storage symptoms, and has fuelled the debates that have resulted in the abandonment of the term 'prostatism' in favor of 'lower urinary tract symptoms', whereas the term 'overactive bladder syndrome' has been embraced as a storage symptom complex. Clearly, voiding disorders principally affect men, whilst storage disorders are more common in women. Much has been written and spoken about regarding the use of symptomatic assessment versus urodynamics in the assessment of lower urinary tract symptoms in men, whilst there has been a clearer consensus on the potential usefulness of urodynamics in the assessment of storage disorders, and so this article focuses principally on the latter topic.

Effectiveness of Urethral Injection of Botulinum A Toxin in the Treatment of Voiding Dysfunction after Radical Hysterectomy

OBJECTIVE

After radical hysterectomy for cervical cancer patients may have difficulty in urination due to detrusor underactivity and a non-relaxing urethral sphincter. This study evaluated the effectiveness of urethral injection of botulinum A toxin in treating voiding dysfunction in these patients.

METHODS

Thirty patients with difficult urination after radical hysterectomy due to cervical cancer were enrolled to receive urethral injection of 100 units of botulinum A toxin (n=20) or medical treatment as controls (n=10). The clinical results and urodynamic parameters at baseline and after treatment were compared in the study group, and the quality of life (QOL) index was compared between the study and control groups.

RESULTS

After urethral injection of botulinum A toxin, 8 patients had excellent results (40%) and 8 had improved results (40%) in the study group. Both voiding pressure (115.2+/-63.7 vs. 90.2+/-49.5 ml, p=0.025) and post-void residual volume (330.9+/-124.9 vs. 183.9+/-183.4 ml, p=0.011) improved significantly after treatment. The obstructive symptom score was significantly reduced (17.5+/-4.7 vs. 5.7+/-2.3 points, p=0.000) and the QOL index also improved (4.5+/-2.7 vs. 2.3+/-2.3 points, p=0.000) after treatment. The success rate was 80% in the study group. There were no significant changes in obstructive symptom scores or the QOL index in the control group. The maximal effect appeared about 1 week after treatment. The duration of the therapeutic effect ranged from 3 to 9 months. Mild stress urinary incontinence and nocturnal enuresis were noted in 7 patients (35%).

CONCLUSION

Urethral injection of botulinum A toxin can be effectively used to treat patients with detrusor underactivity and non-relaxing urethral sphincter after radical hysterectomy with few adverse effects.

Transurethral incision of bladder neck in treatment of bladder neck obstruction in women

OBJECTIVES

To report our preliminary experience with transurethral incision of the bladder neck in the treatment of female voiding dysfunction due to bladder neck obstruction. Bladder neck obstruction in women is an infrequently diagnosed urologic condition.

METHODS

Bladder neck obstruction was diagnosed in 11 women 41 to 80 years of age, who presented with difficult micturition or urinary retention. Preoperative investigations included a full urodynamic examination and urethrocystoscopy. Transurethral bladder neck incision was performed in all patients. Urodynamic results and clinical improvement in voiding symptoms were assessed.

RESULTS

Of the 11 patients, 5 had chronic urinary retention and 6 had difficult micturition; 3 also had recurrent urinary tract infection or upper urinary tract deterioration. The most frequent findings on video-urodynamic study were a high voiding pressure plus low flow rate and a narrow bladder neck during voiding on cinefluoroscopy. After treatment, the lower urinary tract symptoms were resolved or improved in all patients. Ten patients resumed spontaneous voiding with a small postvoid residual urine volume; the remaining patient was able to void by abdominal straining after adjuvant urethral botulinum A toxin injection. Urodynamic study revealed a decreased voiding pressure and postvoid residual urine volume and an increased maximal flow rate. The overall satisfactory rate was 91%.

CONCLUSIONS

Transurethral incision of the bladder neck is effective in relieving voiding difficulty owing to anatomic or functional bladder neck obstruction in women. A full video-urodynamic evaluation is essential in making the correct diagnosis and formulating a treatment plan.

Trying to predict 'dangerous' bladders in children: the area under the curve concept

OBJECTIVE

Children with neurological and non-neurological lower urinary tract dysfunction normally undergo video urodynamics. One reason is to try to diagnose 'dangerous' bladders. Currently, bladder compliance is used to predict 'dangerous' bladders; however, in children there are no standardized methods of measurement and thus no 'cut-off' values. Compliance may also be normal even though high-pressure detrusor overactivity waves may exist during the filling phase of urodynamics. We tried to determine whether measuring the area under the detrusor pressure curve (AUC) during the filling phase of urodynamics would be a useful parameter in predicting 'dangerous' bladders.

PATIENTS AND METHODS

Children referred to the urodynamics unit at Southmead Hospital, a tertiary referral centre, from 2000 to 2004 were investigated. Although 130 patients were identified, only 15 patients had raw data which were analysable using the available computer software.

RESULTS

There was no correlation between the AUC and predicting 'dangerous' bladders possibly due to limitations in the computer software.

CONCLUSION

Although the study did not reveal any correlation between the AUC and 'dangerous' bladders, it revealed the limitations of the available computer software in determining AUC, and highlighted the need for new standardized software and multinational, multi-centre trials to look into the concept of AUC. There is also a need for the International Continence Society to standardize methods and terminology in predicting 'dangerous' bladders.

Perineal noise recording as a non-invasive diagnostic method of urinary bladder outlet obstruction: a study in polyvinyl alcohol and silicone model urethras

AIMS

At present, an invasive pressure flow study is recommended to diagnose urinary bladder outlet obstruction. This method induces the risk of urinary tract infection and urethral trauma. We studied perineal noise recording as an alternative, non-invasive diagnostic method in three flexible/extensible model urethras and two silicone tubes.

METHODS

The flexible/extensible model urethras were made of a 10% aqueous solution of polyvinyl alcohol (PVA) and differed in wall- stiffness, the silicone tubes differed in diameter and wall-thickness. Three degrees of obstruction were applied by inflating a cuff placed around the PVA-urethras and by compressing the silicone tubes with an adjustable clamp. Noise, produced during flow, was recorded at three positions distal to the obstruction using a piëzoceramic contact microphone.

RESULTS

The average amplitude of the noise and the essential frequency of the power spectrum of each noise recording depended significantly on the degree of obstruction, the position of the microphone and the wall-stiffness in PVA-urethras and the diameter in silicone tubes.

CONCLUSIONS

Based on the results of this study perineal noise recording shows good potential as an alternative method for diagnosing bladder outlet obstruction.

Natural history of detrusor contractility--minimum ten-year urodynamic follow-up in men with bladder outlet obstruction and those with detrusor

OBJECTIVE

To check the long-term effect, in male patients, of treated and untreated bladder outlet obstruction (BOO) on detrusor contractility and to explore the relationship between ageing and detrusor underactivity (DUA).

MATERIAL AND METHODS

Men investigated at the urodynamic department of Southmead Hospital in Bristol between 1972 and 1986 were traced and three groups were invited for repeat pressure-flow urodynamic studies (PFS). The first two groups included patients over 40 years old, with untreated or surgically treated BOO, and the third group had patients with DUA from all age groups.

RESULTS

196 patients (with a minimum 10 year gap from the first assessment) agreed to have repeat PFS. There was no statistically significant change in bladder contractility index (BCI) in patients with BOO treated by transurethral resection of the prostate (TURP) (mean difference in BCI was 0.01, 95% confidence interval -0.07 to 0.09, n=114). There was also no significant difference in BCI in untreated patients with BOO (p=0.10, n=53). The follow-up BCI was higher in untreated patients than in the surgically treated group. The BCI in patients with DUA did not change significantly after a minimum of 10 years' follow-up.

CONCLUSIONS

There is no evidence to suggest that detrusor contractility declines with long-term BOO. Relieving the obstruction surgically does not improve the contractility. This is important when considering and counselling for TURP. Underactive detrusors remain underactive, but do not get worse with time, which could indicate that this is not an ageing process per se and may even have a congenital basis.

Feedback microwave thermotherapy with the ProstaLund Compact Device for obstructive benign prostatic hyperplasia: 12-month response rates and complications

PURPOSE

To evaluate the effectiveness of the ProstaLund Compact Device in the treatment of benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

A series of 38 consecutive patients with a mean age of 72.6+/-8.2 years, 19 with an indwelling catheter, underwent transurethral microwave thermotherapy (TUMT) with the ProstaLund Compact Device. Pretreatment evaluation included transrectal ultrasonography (TRUS), urodynamics, and cystoscopy for all patients and flow rate (Qmax), postvoiding residual urine volume (PVR), International Prostate Symptom Score (IPSS), and quality-of-life (QoL) assessment for those without a catheter. The mean prostate volume was 63.5+/-30 cc. The Qmax, IPSS, and QoL studies were repeated at 3, 6, and 12 months, while urodynamics, cystoscopy, and TRUS were repeated at 6 and 12 months.

RESULTS

The treatment lasted a mean of 43.1+/-17.1 minutes, achieved a maximal intraprostatic temperature of 58.7+/-7.2 degrees C, and destroyed 18.4+/-14.3 g of prostatic tissue. Twelve months post-treatment, for the patients without a catheter preoperatively, the IPSS was improved from 21.5+/-6.3 to 6.5+/-3.1 (P<0.001), Qmax from 7.2+/-3.1 mL/sec to 18.1+/-7.4 mL/sec (P<0.001), detrusor pressure at Qmax from 87.5+/-15 cm H2O to 48.4+/-16.4 cm H2O (P<0.001), and PVR from 113.2+/-78.2 mL to 34.6+/-36.7 mL (P<0.01). The good-response rates for IPSS (<or=7 or >or=50% improvement), Qmax (>or=15 mL/sec or >or=50% improvement), PVR (<50 mL or >or=50% decrease), and QoL (<or=2) were 73.7%, 84.2%, 73.7%, and 94.7%, respectively. For the patients with a catheter preoperatively, the IPSS improved from 9.5+/-6 at 3 months to 5.1+/-5.3 (P<0.05) at the end of the follow-up period. The Qmax was 13.2+/-6.4 mL/sec at 3 months and remained stable throughout the follow-up period. Patient good-response rates for IPSS (<or=7), PVR (<150 mL), and QoL (<or=2) were 75%, 87.5% and 75%, respectively. Only two patients were unable to void after the treatment. Complications were similar to those presented in the literature, and bladder stone formation was noted as well (five patients).

CONCLUSIONS

ProstaLund thermotherapy is a highly promising alternative treatment for BPH, improving substantially both objective and subjective measures of bladder outflow obstruction.

Long-Term Surgical Results of Pubovaginal Sling Procedure Using Polypropylene Mesh in the Treatment of Stress Urinary Incontinence

INTRODUCTION

Surgery for stress urinary incontinence (SUI) in women might cure incontinence symptom but develop new problems. This study assessed the long-term outcome of pubovaginal sling procedure using polypropylene mesh in patients with SUI.

MATERIALS AND METHODS

A total of 108 patients with various types of SUI received pubovaginal sling procedure using polypropylene mesh. A surgical technique that did not create bladder outlet obstruction after operation was used in all the patients. Video urodynamic study was performed at baseline, 2 weeks and 3 months after operation. The long-term surgical results and patients' satisfaction were assessed.

RESULTS

The age of patients ranged from 33 to 94 years (mean 62.6 +/- 12.0 years). The follow-up period ranged from 24 to 72 months (median 46 months). Among the 108 patients, a successful result was noted in 92 (85.2%), including a continence rate of 65.7% and mild SUI in 19.4% of patients. Treatment failure was noted in 16 patients (14.8%), including 13 (12%) with urge incontinence and 3 (2.8%) with severe SUI that was cured by a second sling. There were 104 patients (96.3%) who could void volitionally with little residual urine, whereas 4 (3.7%) needed transvaginal urethrolysis. Urodynamic study revealed no significant changes in the mean values of parameters at 3 months after operation. However, 22 (20%) patients had an increase in voiding pressure by 50% at 3 months postoperatively. The reported satisfactory rate was 89.8%.

CONCLUSIONS

Pubovaginal sling procedure using polypropylene mesh had a high success rate in all types of SUI. The continence rate was suboptimal, indicating that the absence of bladder outlet obstruction might result in inadequate urethral compression after pubovaginal sling procedure.

Accuracy of two noninvasive methods of diagnosing bladder outlet obstruction using ultrasonography: Intravesical prostatic protrusion and velocity-flow video urodynamics

OBJECTIVES

We assessed the accuracy of two noninvasive, ultrasound methods of diagnosing bladder outlet obstruction (BOO). The potential for the combined methods to enhance the accuracy of diagnosis was also assessed.

METHODS

We evaluated 30 male outpatients using two recently developed diagnostic methods, transabdominal ultrasound grading of intravesical prostatic protrusion (IPP) and Doppler ultrasound urodynamics (Doppler UDS), as well as conventional pressure flow studies according to the research protocol. IPP has been reported to be a useful anatomic parameter for the assessment of BOO. Doppler UDS uses transperineal ultrasonography to measure the velocity flow of urine at the prostatic and sphincteric urethras. We recruited 168 outpatients; however, of the 57 patients who fulfilled all the research criteria, only 30 were able to undergo conventional pressure flow study analysis. The results of all three diagnostic methods were analyzed statistically for reliability and relationship in the 30 patients with a BOO index from the conventional pressure flow study.

RESULTS

IPP grading correlated well with the BOO index (Spearman's rho 0.624), as did the Doppler UDS parameter (Spearman's rho 0.736). The combination of IPP grading and Doppler UDS showed good sensitivity and specificity.

CONCLUSIONS

We confirmed the accuracy of the two novel methods. The combination of the two methods may be a novel standard in the diagnosis of BOO in male patients.

Lower urinary tract function in patients with pituitary adenoma compressing hypothalamus

BACKGROUND

The micturition reflex is under the tonic influence of suprapontine structures including the anteromedial frontal cortex, basal ganglia, and hypothalamus. However, there have been few reports about the role of the hypothalamus on the lower urinary tract (LUT) function in humans.

OBJECTIVE

To investigate LUT function in patients with pituitary adenomas.

METHODS

Urodynamic studies were carried out in three patients with LUT symptoms who had pituitary adenomas extending upwards to the hypothalamus.

RESULTS

All three male patients (age 28 to 62 years) developed LUT symptoms (urinary urgency and frequency (3); urinary incontinence (3); voiding difficulty and retention (2)) along with weight loss, psychiatric symptoms, unsteady gait, and/or visual disturbances. One had the syndrome of inappropriate secretion of antidiuretic hormone, but none had diabetes insipidus. Two had resection of the tumour and subsequent radiation therapy, but LUT dysfunction persisted. The third patient had partial resection of the tumour to ameliorate hydrocephalus. Urodynamic studies showed detrusor overactivity during the storage phase in all patients; during the voiding phase there was underactive detrusor in two and non-relaxing sphincter in one.

CONCLUSIONS

Hypothalamic lesions can cause severe LUT dysfunction in both the storage and voiding phases of micturition. This may reflect the crucial role of the hypothalamus in regulating micturition in humans.

Can the outcome of transurethral resection of the prostate be predicted preoperatively?

OBJECTIVES

To establish a formula for predicting the outcome of transurethral resection of the prostate using noninvasive parameters of preoperative evaluation.

METHODS

The data of 54 men with a mean age of 57 years (range 43 to 78) were retrospectively analyzed. The International Prostate Symptom Score, quality-of-life score of the International Prostate Symptom Score questionnaire, maximal flow rate (Qmax) recorded during uroflowmetry, age, prostate volume calculated by transrectal ultrasonography, postvoid residual urine volume, and results of pressure-flow studies were evaluated to find a formula that would predict the outcome of transurethral resection of the prostate. The patients were evaluated by uroflowmetry, postvoid residual urine volume determination, and International Prostate Symptom Score questionnaire at 3 months postoperatively. Four different success criteria were investigated with the calculated equations.

RESULTS

According to the discriminant analysis, two new scores were calculated as S(1) = (0.169 x age) - (0.0075 x Qmax) and S2 = (0.168 x age) - (0.095 x Qmax) - (0.007 x detrusor pressure at Qmax). For the four success criteria, the optimal cutoff, obtained from the receiver operating characteristic curves of S(1) and S(2), was 8.83 and 9.21, respectively. A statistically significant difference was not found between S1 and S2. The S1 formula had a sensitivity between 71.8% and 85.2%, specificity between 71.4% and 86.7%, and positive predictive value between 72.2% and 92.9% for the four different criteria using two simple variables (Qmax of uroflowmetry and age).

CONCLUSIONS

Because urodynamic parameters did not add benefit to the formula consisting of age and Qmax of uroflowmetry with considerable sensitivity and specificity, performing urodynamic studies might not be useful for predicting the outcome of transurethral resection of the prostate.

EAU 2004 guidelines on assessment, therapy and follow-up of men with lower urinary tract symptoms suggestive of benign prostatic obstruction (BPH guidelines)

OBJECTIVE

To provide the first update of the EAU guidelines on assessment, therapy and follow-up of men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO).

METHODS

A systematic literature review was conducted based on the results of a MEDLINE search concentrating on the years 1999-2003. In combination with expert opinions recommendations were made on the usefulness of diagnostic tests, therapeutic options and follow-up.

RESULTS

During initial assessment the following tests are recommended: medical history, physical examination including digital-rectal examination, International Prostate Symptom Score, urinalysis, serum creatinine and prostate specific antigen measurement, uroflowmetry and post-void residual volume. All other tests are optional or not recommended. Aim of treatment is to improve LUTS and quality of life and to prevent severe BPE-related complications. Development of a 5alpha-reductase type I and II inhibitor and the data of the MTOPS trial providing scientific evidence for a combination therapy were the most significant innovations since the first version. Finally a more detailed knowledge on the natural history with identification of several risk factors for progression is the basis for a risk-profile orientated (preventive) therapy.

CONCLUSIONS

Updated recommendations for assessment, treatment, and follow-up of patients with LUTS due to BPO are presented.

[Quantification of bladder-outlet obstruction in males: standard method vc VBN method]

GOAL

To compare the merits of two methods, standard (Abrams-Griffiths number, Schafer's classification, etc.) and VBN, to study bladder-outlet obstruction in men with benign prostatic hyperplasia (BPH).

MATERIAL AND METHODS

The parameters deduced from both methods and from repeated pressure-flow studies were computed for a population of patients with BPH. Correlation coefficients between standard and VBN parameters were systematically evaluated. Test-retest reliability and inter-rater reliability of the VBN parameters were investigated.

RESULTS

The VBN obstruction parameter was linearly corelated to the A-G number (R = 0.992) and thus is related to the provisional ICS obstruction nomogram. A simple modification to the standard index projected isometric pressure (PIP) yields an mPIP parameter strongly correlated with the VBN detrusor contraction-strength parameter (R = 0.962). VBN analysis reveals minor phenomena such as premature fading of the detrusor contraction to be responsible for much of the void-to-void variability of pressure-flow studies. Consequently, the primary VBN obstruction and contraction-strength parameters exhibit better test-retest and inter-rater reliability than the standard parameters and are less sensitive to changes in testing circumstances (bladder volume, urethral catheter size and psychological factors).

CONCLUSION

With the standard approach to test bladder obstruction, two values: A-G and mPIP, derived from pressure-flow studies, best qualify the patient's voiding status. These parameters are simple to calculate but are sensitive to testing variations and minor phenomena. The VBN approach is more complicated, but its parameters for obstruction and detrusor contraction strength are less dependent on testing variations.

A urodynamics protocol to optimally assess men with post-prostatectomy incontinence

AIMS

To propose a urodynamic protocol to comprehensively assess all parameters of post prostatectomy incontinence (PPI).

METHODS

Sixty men with a history of PPI after radical prostatectomy prospectively underwent a standardized video urodynamics protocol. A 7F urethral catheter was used for standard cystometry, abdominal leak point pressure (ALPP), and pressure flow measurements. The International Continence Society nomogram classified obstruction and further classification of obstruction was based on fluoro voiding cystourethrography and non-invasive flow rates (free Qmax).

RESULTS

Twenty-four (40%) men had detrusor overactivity with 8 (13%) also having detrusor overactivity incontinence. Only one patient had impaired compliance. All men had urodynamic stress incontinence, but 21 (35%) men demonstrated it only after removal of the urethral catheter. For men leaking with and without the urethral catheter, the respective ALPP was significantly different, 86.3 and 67 cmH2O, respectively (P = 0.002). The men who leaked only in the absence of the urethral catheter had significantly higher ALPP measurements, P < 0.001. After reclassification using the fluoroscopic images of the bladder outlet and free Qmax, only 13.3% patients were obstructed.

CONCLUSIONS

The proposed urodynamic protocol allows for an optimal assessment of bladder and sphincter dysfunction and outlet obstruction in men with PPI.

Bladder dysfunction in patients with cauda equina lesions

AIMS

Data on lower urinary tract (LUT) function obtained in larger, systematically studied populations of patients with cauda equina lesions are limited. We report urinary function in 65 patients with chronic lesions.

METHODS

A urinary function questionnaire was used, and neurological examination, quantitative electromyography (EMG) of the external anal sphincter (EAS) muscles, EMG assessment of the sacral reflex, and conventional urodynamic measurements were performed.

RESULTS

Severe LUT dysfunction was found in 14%/15%, moderate in 27%/46%, and mild in 46%/39% men/women. Urinary symptoms interfered with daily life in 88%/92% and sexual life in 72%/67% of sexually active men/women. Symptoms of disturbed bladder emptying were the most common (95%/92% men/women), followed by urinary incontinence (56%/71%) and symptoms of overactive bladder (40%/56%). Perianal sensation was abnormal in 96%, EMG of the EAS muscle in 88%, and sacral reflex in 84% of patients. In 40%/17% men/women, a postvoid residual (>100 ml) was found. On filling cystometry overactive bladder was found in 21%/0%, reduced detrusor capacity in 9%/15%, and during voiding phase an acontractile detrusor or detrusor underactivity were found in 59%/85% men/women. Using multiple linear regression analysis, perianal sensory loss (P=0.0001) and female gender (P<0.02) had a significant positive effect on urinary incontinence score.

CONCLUSIONS

Our study demonstrated significant LUT dysfunction, which disturbed the life of the majority of patients with chronic lesions of the cauda equina. Due to poor correlation between patients' symptoms and urodynamic findings cystometric surveillance is proposed in all patients with significant cauda equina lesions.

Application of the Blaivas-Groutz bladder outlet obstruction nomogram in women with urinary incontinence

AIMS

To test the applicability of the Blaivas-Groutz nomogram for female bladder outlet obstruction in urinary incontinent women presenting in a general gynecologic practice and to determine how the nomogram results related to the presence of obstructive symptoms according to a standardized questionnaire.

METHODS

All women with complaints of urinary incontinence underwent multichannel urodynamic testing, free uroflowmetry and were asked to complete a standardized quality of life questionnaire consisting of the urogenital distress inventory (UDI). The patients were classified according to the Blaivas-Groutz nomogram.

RESULTS

One hundred and nine patients were classified according to the nomogram. Thirty-three patients (30.3%) were classified as unobstructed, 63 patients (57.8%) as mildly, 12 patients (11%) as moderately, and 1 patient (0.9%) was classified as severely obstructed. Fifty patients correctly completed the UDI. There was no significant difference (P = 0.61) in the score on the domain UDI obstruction between, according to the nomogram, obstructed and unobstructed patients. Only 18% of the obstructed patients had isolated voiding symptoms suggestive of obstruction. Forty-nine percent of the obstructed patients had urgency-frequency symptoms as well as voiding symptoms suggestive of obstruction. There was no correlation (Pearson, r = -0.06, P = 0.61) between the severity of the symptoms (assessed by the UDI scale) and the degree of obstruction (the four nomogram zones).

CONCLUSIONS

Application of the Blaivas-Groutz nomogram gave an unlikely high prevalence of obstruction in our patient group, which showed no correlation with symptoms when measured with the UDI.