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

The results of three times repeated filling cystometry and pressure flow studies in children with non-neurogenic lower urinary tract dysfunction

AIM

We previously reported that some urodynamic parameters change with repetitive filling in children with neurogenic lower urinary tract dysfunction (LUTD). In this study, we aimed to search if three-times repeated filling cystometries (FC) and pressure-flow studies (PFS) would change the urodynamics parameters in children with non-neurogenic LUTD.

MATERIALS AND METHODS

All children with three repeated FC and PFS between June 2017 and December 2018 were included in the study. Urodynamic reports and charts were evaluated retrospectively. The first sensation of bladder filling (FSBF), maximum cystometric capacity (MCC), detrusor pressure at the FSBF (P_{det.first.sens} ), maximum detrusor pressure during filling (P_det.fill.max ), presence of detrusor over activity, compliance, maximum urine flow (Qmax), detrusor pressure at the maximum urine flow (PdetQmax), residual urine and presence of detrusor sphincter dyssynergy (DSD) were compared among three-times repeated urodynamic studies.

RESULTS

Forty children were included in the study. 27 (67.5%) were girls and 13 (32.5%) were boys. Median age was 9 (3.4-17) years. Indications were LUTD with low grade vesicoureteral reflux in 19 (47.5%), LUTD refractory to conservative management in 13 (32.5%), urinary tract infection with LUTD in 6 (15%) and secondary enuresis in 2 (5%). P_{det.first.sens} , presence of DO, MCC, Qmax, PdetQmax, residual urine, flow pattern, and presence of DSD were comparable in all three repeated tests. The third FC may show decreased filling detrusor pressures and increased compliance with no change on capacity.

CONCLUSION

In children with non-neurogenic LUTD, three-times repeated FC and PFS present comparable results except FSBF, P_{det.fill.max,} and compliance at the third test.

Contemporary diagnosis of lower urinary tract dysfunction

Introduction: Diagnosis of lower urinary tract (LUT) dysfunction starts with categorization in clinical syndromes, and initial management is based on the assumptions about pathophysiology that these syndromes contain. However, clinical practice guidelines are ambiguous in clinical specialists' diagnosis of dysfunction after failure of initial management. This is a narrative and critical review of the existing evidence, and the aim is to suggest practice improvements in the process of clinical specialists' diagnosis for patients resistant to initial management. Methods and Results: Evidence is collated on the basis of the author's personal preference in combination with good clinical practice general principles. Statements and suggestions to improve reflect personal opinion. For two groups of patients with LUT dysfunction, the strategy of initial diagnosis is summarized and desirable principles of secondary care diagnosis are discussed. More specifically, a structure for the contemporary care of women with signs and symptoms of urinary incontinence is described and for that of the group of men older than 45 years with symptoms of LUT dysfunction. Conclusions: Urodynamic testing is the undisputed gold standard for objective assessment and is the only way to stage and grade the dysfunction. Clinical practice guidelines and clinical specialists are too modest about the use and applicability of objective or urodynamic testing for referred persons with LUT dysfunction that is resistant to initial pragmatic management. Objective assessment and diagnosis are mainstays in secondary care, and the indication to perform objective assessments in patients with LUT dysfunction should be advised much more specifically in guidelines and practice recommendations.

Urodynamics in male LUTS: when are they necessary and how do we use them?

In this article, the value of urodynamic studies in the evaluation of treatment of male lower urinary tract symptoms is appraised based on current evidence. The information gained by urodynamics can be a valuable tool for counseling patients considering invasive outlet reduction procedures.

Bladder contractility and urethral resistance relation: what does a pressure flow study tell us?

Hydrodynamic analysis of a pressure flow study is the only reliable method to determine the presence or absence of a bladder outlet obstruction, especially benign prostatic obstruction. To interpret the results of pressure flow study in benign prostatic obstruction, understanding the outlines of the basic theory about evaluation of the relationship between bladder contractility and urethral resistance relation is of paramount importance. In contrast, hydrodynamic analysis of pressure flow study in conditions other than benign prostatic obstruction is complicated by the limits of theories about the hydrodynamics of the lower urinary tract. In this review, the proposed hydrodynamic theories about the relationship between bladder contractility and urethral resistance relation are outlined. Then, problems encountered in the application of hydrodynamic analysis of pressure flow study to diseases other than benign prostatic obstruction are discussed.

Quantifying the effect of urodynamic catheters on urine flow rate measurement

INTRODUCTION

The effect of urodynamic catheters on urine flow rate (Q(max) ) is well documented but under-researched. Several studies show reduced Q(max) but methodologies and patient demographics differ. The aims of this study were to further quantify the effect of urodynamic catheters on Q(max) and to explore if this was consistent across different urodynamic diagnoses.

METHODS

Four groups of 50 consecutive men attending for urodynamic studies (UDS) were retrospectively analyzed: Group 1 comprised 50 men with normal UDS, Group 2 was 50 men with BOO, and Group 3 contained 50 men with detrusor underactivity. Groups 1-3 had UDS performed using both 10 Fr filling and 4 Fr measuring catheters in situ. Group 4 comprised 50 men who had UDS performed with a smaller catheter assembly (8 Fr dual-lumen). Values of Q(max) with and without catheters present were compared using paired Student's t-tests. Differences between groups were compared using ANOVA.

RESULTS

Q(max) measured during UDS in men from Groups 1-3 showed a mean reduction of 38% compared to Q(max) from "free" uroflowmetry. ANOVA indicated this reduction was significantly greater among men with normal UDS. Interestingly the group who underwent UDS with a smaller catheter assembly showed no significant reduction in Q(max) measured with catheters in situ.

CONCLUSION

Our findings are in line with previous work suggesting that smaller calibre urethral catheters do not cause a significant obstructive effect during voiding. In addition it would appear that the reduction in Q(max) with larger urethral catheters in situ is greatest in those with normal urodynamics.

Interobserver agreement for noninvasive bladder pressure flow recording with penile cuff

PURPOSE

We assessed variability in interpreting noninvasive measurements of bladder pressure and urine flow between experienced and novice users of the penile cuff.

MATERIALS AND METHODS

Urodynamicists at 6 sites were asked to use the penile cuff test as part of clinical assessment in 30 men presenting with lower urinary tract symptoms. After a short training period they measured maximum flow rate and cuff interruption pressure from penile cuff test recordings to enable categorization of bladder outlet obstruction using a nomogram. Similar measurements were then made on the same traces by 2 expert observers from the originating center. Interobserver differences were assessed.

RESULTS

Complete agreement on obstruction categorization was seen in 77% of subjects, which increased to 86% when plots positioned on category boundary lines were allocated to the favored category. The 95% confidence limits of interobserver variability in maximum flow rate and cuff interruption pressure measurements were +/- 1.7 ml per second and +/- 13 cm H(2)O, respectively, although a small number of studies yielded discrepancies between observers that were larger than expected. They arose from complex recordings but were equally likely between experts as between expert and novice. Investigation of the causes suggested in some cases how such discrepancies may be avoided in the future.

CONCLUSIONS

The excellent level of agreement in measurement and categorization after a short training period suggests that introducing the penile cuff test as part of assessment in men with lower urinary tract symptoms would be straightforward.

A novel intraurethral device diagnostic index to classify bladder outlet obstruction in men with lower urinary tract symptoms

Objectives. Using a urethral device at the fossa navicularis, bladder pressure during voiding can be estimated by a minimal invasive technique. This study purposes a new diagnostic index for patients with lower urinary tract symptoms (LUTSs). Methods. Fifty one patients presenting with LUTSs were submitted to a conventional urodynamic and a minimal invasive study. The results obtained through the urethral device and invasive classic urodynamics were compared. The existing bladder outlet obstruction index (BOOI) equation that classifies men with LUTSs was modified to allow minimal invasive measurement of isovolumetric bladder pressure in place of detrusor pressure at maximum urine flow. Accuracy of the new equation for classifying obstruction was then tested in this group of men. Results. The modified equation identified men with obstruction with a positive predictive value of 68% and a negative predictive value of 70%, with an overall accuracy of 70%. Conclusions. The proposed equation can accurately classify over 70% of men without resorting to invasive pressure flow studies. We must now evaluate the usefulness of this classification for the surgical treatment of men with LUTSs.

New method for minimally invasive urodynamic assessment in men with lower urinary tract symptoms

OBJECTIVES

Urodynamic studies are considered the reference standard to diagnose bladder outlet obstruction. However, the procedure is invasive, expensive, and time-consuming. The purpose of this study was to evaluate a new minimally invasive urodynamic assessment model and compare the results with those of conventional urodynamic evaluation.

METHODS

The study included 50 male patients who presented with lower urinary tract symptoms. Their mean age was 62 years (range 34 to 82). After undergoing a conventional urodynamic study, they underwent the minimally invasive evaluation. The urethral device is a conical apparatus that adapts to the urethral meatus and fossa navicularis. The isometric bladder pressure and interrupted flow were recorded. The results of the conventional assessment were classified according to the Abrams-Griffiths number and a logistic regression fit was applied to the minimally invasive method.

RESULTS

Only two variables demonstrated the predictive capacity: the isometric pressure and interrupted flow. In addition to selecting the relevant variables, logistic regression analysis is a more adequate model that provides a binary result of obstructed and unobstructed, used to predict the normal and equivocal categories of the Abrams-Griffiths classification, and taken as the reference standard. The sensitivity and specificity of the new method was 67% and 79%, respectively.

CONCLUSIONS

The urethral device proved to be simple and easy to use. The minimally invasive method was able to detect most patients with bladder outlet obstruction; thus, the conventional urodynamic assessment could be avoided. We consider this method to have a place as a first-line noninvasive examination.

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.

Lower urinary tract symptoms, prostate volume, uroflowmetry, residual urine volume and bladder wall thickness in Turkish men: a comparative analysis

AIM

To evaluate the association between lower urinary tract symptoms (LUTS) severity and bladder wall thickness (BWT).

MATERIALS AND METHODS

The study included 155 patients referred to outpatient clinics for LUTS. Patients were divided into three groups due to their IPSS. Group A included the patients with mild symptoms, group B included patients with moderate symptoms and group C included patients with severe symptoms. The patients were again divided into two groups due to their uroflowmetry results. Group 1 included the patients whose Q (max) </= 10 ml/s and group 2 included the patients whose Q (max) > 10 ml/s.

RESULTS

The mean BWT was 4.14 + 1.03 mm (from 3 to 9 mm). Although there was no difference between the IPSS groups in BWT (P = 0.325), it was statistically significant between uroflowmetry study groups (P < 0.01).

CONCLUSIONS

BWT seems to be significantly increased in men who have Q (max) values smaller than 10 ml/s.

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.

Evidence of a novel biomarker, αs1-Casein, a milk protein, in benign prostate hyperplasia

Benign prostate hyperplasia (BPH) is a common disease in elderly men. Although it is a non-malignant disease, it has a significant detrimental impact on the quality of life in patients with late-stage disease. Owing to the lack of specific markers, diagnosis of early-stage BPH has been proven unsuccessful. Recently, using two-dimensional electrophoresis, we identified a group of prostatic secretory proteins that are specifically produced by BPH cells (Xu et al., Electrophoresis 2003; 24: 1311). In this study, we investigated the potential diagnostic value of one of the secretory proteins, alphas1-Casein, in BPH by inmmunohistological staining of normal, BPH and prostate cancer tissues. We found that 90% (20 out of 22) of BPH tissues showed moderate to strong alphas1-Casein protein expression whereas none of the normal tissues (0 out of 10) and less than 10% of the prostate cancer tissues (3 out of 30) showed similar staining intensity. Our results suggest that alphas1-Casein may be a potential biomarker for early identification of BPH patients.

Normal ranges of variability for urodynamic studies of neurogenic bladders in spinal cord injury

BACKGROUND/OBJECTIVE

Urodynamic studies are conducted on a regular basis to evaluate changes in bladder function after spinal cord injury. Often, differences in urodynamic parameters exist from one study or one year to the next. The objective of this study was to provide reference ranges for "normal" variability in urodynamic parameters that can be considered as "no real change" from one study to the next.

DESIGN

Retrospective chart review.

METHODS

Fifty consecutive individuals with spinal cord injury had 2 trials (trial 1 and trial 2) of urodynamic studies done 5 minutes apart, and the following data were collected: maximum cystometric capacity, opening pressure, maximum detrusor pressure, volume voided, and postvoid residual. The corresponding data were compared, and the frequency distribution for the change between consecutive studies was plotted. Because there is no standard, variability ranges for 5th to 95th, 10th to 90th, and 25th to 75th percentiles were calculated to give health care providers more choices.

RESULTS

Ranges of variability are as follows in the following format (urodynamic parameter; mean value; +, maximum increase; -, maximum decrease)--5th to 95th percentile: cystometric capacity (234.63 mL, +213.50 mL, -158.05 mL); opening pressure (54.56 cmH2O, +30 cmH2O, -18.00 cmH2O); maximum detrusor pressure (60.82 cmH2O, +17.35 cmH2O, -27.80 cmH2O); volume voided (122.20 mL, +177.25 mL, -176.00 mL); postvoid residual (176.06 mL, +197.25 mL, -118.00 mL); 10th to 90th percentile: cystometric capacity (234.63 mL, +126.40 mL, -74.60 mL); opening pressure (54.56 cmH2O, +13.70 cmH2O, -12.00 cmH2O); maximum detrusor pressure (60.82 cmH2O, +10.00 cmH2O, -20.00 cmH2O); volume voided (122.20 mL, +105.60 mL, -82.00 mL); postvoid residual (176.06 mL, +131.00 mL, -86.00 mL); 25th to 75th percentile: cystometric capacity (234.63 mL, +72.00 mL, -27.00 mL); opening pressure (54.56 cmH2O, +4.00 cmH2O, -9.50 cmH2O; maximum detrusor pressure (60.82 cmH2O, +4.00 cmH2O, -10.00 cmH2O); volume voided (122.20 mL, +50.00 mL, -30.00 mL); postvoid residual (176.06 mL, +50.00 mL, -30.00 mL).

CONCLUSIONS

Urodynamic studies have variability. Knowing these ranges of variability can be helpful in determining whether differences between filling trial 1 and filling trial 2 in a single study or year-to-year changes in urodynamic studies are significant or simply the normal variability of the urodynamic study.

[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.

Correlation of non-invasive urodynamics with International Prostate Symptom Score (IPSS) and prostate volume

AIM

To study the correlation between non-invasive urodynamic data, the International Prostate Symptom Score (IPSS) and the prostate volume.

MATERIALS AND METHODS

Data of 667 healthy volunteers participating in a longitudinal study of changes in urinary bladder contractility secondary to BPE were analyzed. The prostate volume was assessed by transabdominal ultrasonography. Uroflowmetry followed to verify if a minimum free flow rate of 4.5 ml/sec could be achieved. While (re)filling the bladder by drinking, the subjects completed the Dutch version of the IPSS. Next, the bladder pressure was non-invasively measured using the condom catheter method. The urethral resistance (URR) was calculated from the maximum condom pressure and the maximum free flow rate.

RESULTS

The IPSS ranged from 0 to 29, (6.1 +/- 4.8) (mean +/- SD), whereas the prostate volumes ranged from 8 to 140 cm3, (34 +/- 18). Twenty eight percent (185/667) of the subjects had a non-invasively quantified high URR and a significantly higher IPSS (7.3 +/- 5.2) than those with a low URR (IPSS (5.7 +/- 4.6)), Mann-Whitney U-test: P < 0.001. The IPSS and the URR were significantly correlated, Spearman's rho (rho) = 0.20, P < 0.001. A significant difference between the prostate volumes, 36 +/- 21 cm3 in the high URR versus 33 +/- 17 cm3 in the low URR group, was not found, P = 0.18.

CONCLUSIONS

A weak though statistically significant correlation was found between the non-invasively quantified URR and the IPSS. This suggests that an elevated resistance is a necessary, but not a sufficient condition for lower urinary tract symptoms (LUTS). No correlation was found between the URR and the prostate volume.

A pilot study evaluating a new questionnaire for prostatic symptom scoring, the SPSS, and its sensitivity as constructed to objective measures of outflow obstruction

AIM

To evaluate the extent to which our newly developed questionnaire, the Saitama Prostate Symptom Score (SPSS), for prostatic symptom scoring reflects objective findings in benign prostatic hyperplasia (clinical BPH) and to compare it with the International Prostate Symptom Score (IPSS) with regard to diagnostic sensitivity in clinical BPH.

METHODS

In this study, both the SPSS and the IPSS were self-administered by patients. Free uroflowmetry, a pressure-flow study and the measurement of prostatic volume were carried out.

RESULTS

There was no significant correlation between the results of the IPSS questionnaire and the urethral obstruction grade estimated by Schaefer or Abrams-Griffiths nomograms. The total score of the SPSS was correlated with these nomograms (P = 0.0487 and P = 0.0413, respectively). There was no significant correlation between the results of the IPSS questionnaire and the total volume or transition zone volume of the prostate, whereas the total score of the SPSS correlated with the total volume of the gland and transition zone volume (P = 0.0044 and P= 0.0051, respectively).

CONCLUSION

This study revealed the SPSS to correlate with objective findings satisfactorily. However, there are still several aspects of the SPSS which need to be improved upon, and the questionnaire should be studied in larger numbers of patients suffering from lower urinary tract symptoms.

The detrusor muscle cell in bladder outlet obstruction--ultrastructural and morphometric findings

OBJECTIVE

Lower urinary tract symptoms (LUTS) in elderly males are not solely caused by bladder outlet obstruction (BOO) and may be at least partly attributable to detrusor dysfunction. Urodynamically, patients may show instability, hypocontractility, BOO or combinations of these findings. These findings have been related to specific ultrastructural changes in detrusor smooth muscle cells; however, this relationship is controversial. The aim of this study was to correlate ultrastructural findings in patients with BOO with urodynamic parameters.

MATERIAL AND METHODS

In 25 men with BOO verified by means of a full urodynamic evaluation, including a pressure-flow study, a detrusor biopsy was obtained. Six men without BOO served as controls. Biopsies for electron microscopy were analysed semiquantitatively and morphometrically to determine the presence of muscle cell hypertrophy, variation in intercellular distances, occurrence of abnormal cell junctions and configurations and intracellular changes.

RESULTS

The only parameter which was found to relate to the degree of obstruction in BOO was an increase in intra- and interfascicular elastin, all other correlations not reaching significance.

CONCLUSION

This study does not confirm a specific relationship between ultrastructural detrusor smooth muscle features and various types of BOO. Therefore ultrastructural investigation of detrusor smooth muscle cells cannot replace urodynamic evaluation in the classification of LUTS.

Pentosan polysulfate decreases prostate smooth muscle proliferation and extracellular matrix turnover

Benign prostatic hyperplasia (BPH) involves proliferation of smooth muscle cells and increased deposition of extracellular matrix (ECM). We recently found that pentosan polysulfate (PPS) has marked effects on growth and ECM of smooth muscle cells derived from vascular tissues. We examined smooth muscle cells cultured from human prostates and the effects of PPS on their growth and ECM production. Fragments of surgical prostatectomy specimens were diced, digested with collagenase (0.01%), and placed in culture medium supplemented with 20% fetal bovine serum. Outgrowths of elongated cells were characterized by light microscopic examination and immunohistochemical techniques by the presence of F-actin, alpha-smooth muscle actin, and myosin, which is a characteristic of smooth muscle cells. Two independent isolates were propagated, and growth curves and ECM production were assessed in the presence and absence of PPS (10 or 100 microg/ml). PPS decreased cell number beginning at day 1 and throughout the incubation period, up to 4 days. The amount of the ECM degradative enzymes, metallo-proteinases MMP-9 and MMP-2, was examined by zymography. PPS did not alter the amount of MMP-2 in the supernatants but MMP-9 was increased 234.4 +/- 17.23-fold over control cells. Tissue inhibitor of MMP (TIMPS), examined by reverse zymography, increased 200% over control. The amount of alpha I type (IV) and alpha I type (I) collagen released in the supernatant, measured by ELISA, significantly decreased in PPS-treated cultures. In conclusion, we found that the administration of PPS decreased proliferation as well as ECM production in prostate smooth muscle. Since smooth muscle proliferation and ECM are involved in the pathophysiology of BPH, PPS may have therapeutic potential.

Voiding dysfunction and urodynamic abnormalities in elderly patients

Lower urinary tract dysfunction is a major cause of morbidity and decreased quality of life in elderly men and women. With the progressive aging of the population, it is important to understand common micturitional disorders that may occur in this population. Most urinary problems in the elderly are multifactorial in origin, demanding a comprehensive assessment of the lower urinary tract organs, functional impairments, and concurrent medical diseases. Urodynamics is a highly valuable tool in the investigation of elderly patients with lower urinary tract symptoms. Urodynamic tests are not always necessary, being indicated after excluding potentially reversible conditions outside the urinary tract that may be causing or contributing to the symptoms. Although urodynamic tests may reveal common diagnoses such as bladder outlet obstruction and stress urinary incontinence in the elderly population, findings such as detrusor overactivity and impaired detrusor contractility are common and have important prognostic and therapeutic implications. The purpose of this article is to describe common urologic problems in the elderly and review the indications for and clinical aspects of urodynamic studies in these conditions.

Factors associated with voiding function in women with lower urinary tract symptoms: a mathematic model explanation

AIMS

The aim of this study was to explore the relationship between voiding function and factors such as age, gravidity, parity, menopause, and anterior vaginal wall relaxation.

METHODS

One hundred twenty-five women were identified from urodynamic records, 83 premenopausal and 42 postmenopausal. All had had a sonographic assessment of the lower urinary tract and a full urodynamic study, including a pressure-flow study. None had diabetes mellitus, overt neurologic disease, pelvic surgery, anticholinergic medication or estrogen therapy, or voiding difficulty symptoms. Voiding parameters included the following urodynamic variables: maximum flow rate, average flow rate, residual urine, the ratio of residual urine to total bladder volume on spontaneous uroflowmetry, maximum flow rate, and detrusor pressure at maximum flow on a pressure-flow study.

RESULTS

Uroflow rates were significantly correlated with age, parity, and urethral mobility. As a whole, the scatter plots of maximum and average flow rates versus voided volume on uroflowmetry displayed a significant correlation (P < 0.0001 and P < 0.0001, respectively). But, there was no association between maximum flow rate and detrusor pressure at maximum flow in the pressure flow study (P = 0.132). Age, menopause, parity, and urethral mobility may have affected the correlation on uroflowmetry but have no effect on pressure-flow plot. On subgroup analysis, significant correlation was identified only in women aged between 30 and 70, with parity greater than three, and urethral mobility greater than 70 degrees. These groups all had a reduced urethral pressure profile.

CONCLUSIONS

Age, menopause, parity, and urethral mobility may change the hydrodynamics of the lower urinary tract and have varying impact on the voiding function by altering urethral distensibility. Moreover, poor detrusor power in the postmenopausal women may complicate the analysis of voiding function.

Bladder and urethral responses to pelvic nerve stimulation in the pig

OBJECTIVE

The aim of our study of the pig was to investigate the responses of smooth muscle of the bladder and the urethral sphincter to preganglionic parasympathetic stimulation, and to assess the effect on the lower urinary tract of IV administration of alpha,beta-methylene-ATP.

MATERIALS AND METHODS

In seven anaesthetised female pigs, the responses to repeated 20 s pelvic nerve stimulations before and after IV administration of 0.02 mg/kg alpha-beta-methylene-ATP, and the responses to the drug itself, were recorded in the bladder and the urethra separately.

RESULTS

In the urethral high-pressure zone, pre-stimulation pressure was a mean of 61+/-11 cmH2O. During pelvic nerve stimulation, urethral pressure declined by 48+/-9 cmH2O, while the bladder pressure increased to 30+/-18 cmH2O. The rate of pressure changes during the first 3 s of stimulation (initiation of voiding) was larger in the urethra than in the bladder (urethral pressure decrease: 13.0+/-3.1 cmH2O/s, bladder pressure increase: 3.2+/-2.5 cmH2O/s). Administration of alpha,beta-methylene-ATP was followed by a significant but temporary enlargement in the bladder response to pelvic nerve stimulation to 36+/-20 cmH2O, p = 0.028, n = 7, but no change in urethral response.

CONCLUSIONS

At least 80% of the urethral pre-stimulation pressure was exerted by the smooth muscle. The synergic activation of the detrusor and the urethral smooth muscle in response to preganglionic parasympathetic nerve stimulation was controlled by the peripheral nerves or by the neuromuscular transmission. Administration of alpha,beta-methylene-ATP increased the bladder response to pelvic nerve stimulation without changing the urethral response.

Finasteride in the treatment of clinical benign prostatic hyperplasia: a systematic review of randomised trials

BACKGROUND

Benign prostatic hyperplasia affects older men. This systematic review determined efficacy and adverse effects of finasteride.

REVIEW METHODS

PubMed, the Cochrane Library, reference lists of reports, and reviews were searched for randomised, double-blind trials of finasteride in benign prostatic hyperplasia. Outcomes included symptom score, urinary flow rate, prostate volume, discontinuation, and adverse effects. Relative risk and NNT or NNH were calculated for dichotomous data. Sensitivity analyses assessed influences of baseline symptom severity, initial prostate volume, a dominating trial, and previous interventions.

RESULTS

Three trials had active controls and 19 had placebo. In placebo-controlled trials, 8820 patients received finasteride 5 mg and 5909 placebo over 3-48 months. Over 48 months finasteride produced greater improvements in total symptom score, maximum urinary flow rate, and prostate volume. Significantly more sexual dysfunction, impotence, ejaculation disorder and decreased libido occurred with finasteride at 12 months; the NNH for any sexual dysfunction at 12 months was 14. Significantly fewer men treated with finasteride experienced acute retention or had surgery at 24 or 48 months than with placebo; at 12 months the NNT was 49 (31 to 112) to avoid one acute urinary retention and 31 (21 to 61) to avoid one surgery. Sensitivity analyses showed benefit with finasteride 5 mg to be constant irrespective of the initial prostate volume.

CONCLUSIONS

Information from many patients in studies of high quality showed beneficial effects of finasteride in terms of symptoms, flow rate and prostate volume. More utility would result if patient centred outcomes were reported in dichotomous form.

Neurourologic findings in patients with traumatic thoracolumbar vertebra junction lesions

OBJECTIVE

To investigate neurourologic involvement in injuries to the thoracolumbar vertebra junction with magnetic resonance imaging (MRI) and electrophysiologic and urodynamic measurements and to characterize the neurogenic mechanisms of voiding dysfunctions.

DESIGN

Baseline comparisons among 3 anatomic groups before neural repair.

SETTING

Tertiary care center.

PATIENTS

Thirty-five T11 to L2 spinal cord injury patients consecutively admitted to a rehabilitation unit. Eight patients (Group 1) had above-conus lesions without denervation and polyphasic waves revealed in the anal sphincter electromyography; 13 patients (Group 2) had conal and/or above-conus lesions and anal sphincter electromyographic abnormalities; and 14 patients (Group 3) had below-conus lesions and anal sphincter electromyographic abnormalities.

MAIN OUTCOME MEASURES

Comparison of features identified on pudendal nerve terminal motor latency, urethral pressure profiles, and multichannel voiding pressure-flow study.

RESULTS

The pudendal nerve terminal motor latency in Group 3, showing a significantly higher abnormal ratio (100%; p =.011, Fisher's exact test), indicated that cauda equina lesions might be the cause. Urodynamic data from Group 3 showed a significant decrease in maximal urethral closure pressure (48 +/- 17cm H2O, p =.0022, analysis of variance [ANOVA], repeated measure) and an increase in bladder capacity (429 +/- 194mL, p =.037, ANOVA, repeated measure). There were no significant changes in the other groups.

CONCLUSION

Neurourologic abnormalities are less predictable with injuries to thoracolumbar junction, except in patients with cauda equina lesions.

Variability of pressure-flow studies in men with lower urinary tract symptoms

The objective of this study was to assess the short-term test-retest variability of pressure-flow studies (PFS) in men with lower urinary tract symptoms (LUTS). By choosing a short interval between two consecutive PFS, but notably not performing two tests within a single session, both tests represent the same routine testing procedure. Eighty-nine patients with LUTS suggestive of bladder outlet obstruction or detrusor underactivity, who received PFS, were asked to undergo a second urodynamic evaluation within 4 weeks after the initial test. At both visits, specialized physicians performed the PFS. Obstruction was quantified using the Abrams-Griffiths number (AG number). Each patient was classified as obstructed, unobstructed, or equivocally obstructed according to the International Continence Society nomogram. As expected, no systematic difference was observed in AG number between the first and the second visit at the group level. There was, however, considerable variation at the individual level. The average within-patient standard deviation was 14 cm H(2)O. This finding shows that if a patient's AG number is 30 at the first visit, his true AG number can be any value between 30 +/- 1.96 * 14 = 3 to 57, owing to random variability alone. The average within-patient standard deviation did not differ significantly between sub-groups of obstruction and other variables such as patient age, symptom score, prostate volume, or residual volume. The variability appeared to increase slightly with an increased interval between visits. Of all patients, 39% changed at least one category of obstruction at the second visit and 3% changed from definitely obstructed to definitely unobstructed or vice versa. We conclude that PFS cannot stand the test of serving as a gold standard to identify bladder outlet obstruction in patients with LUTS.