Does the patient's position influence the detection of detrusor overactivity?

Impact of patient position on cystometric parameters in pediatric patients with neurogenic bladder: A prospective study

AIMS

Urodynamic studies (UDSs) play a crucial role in evaluating lower urinary tract function in pediatric patients with neurogenic bladder. However, the influence of patient position on urodynamic parameters in this population remains understudied. This study aims to investigate the effect of patient position on urodynamic results in children with neurogenic bladder.

METHODS

A prospective study was conducted with 50 pediatric patients diagnosed with neurogenic bladder. Urodynamic recordings were obtained during a single session, with the first two fillings in the supine position and the third filling in the sitting position. Urodynamic parameters assessed included detrusor overactivity (DO), maximum detrusor pressure (MDP), cystometric bladder capacity (CBC), compliance (C), detrusor leak point pressure (DLPP), and bladder volume at the moment of incontinence (DLPV).

RESULTS

Patient position did not significantly influence CBC, DO, C, and DLPV (p > 0.05). However, there were significant differences in MDP and DLPP between the supine and sitting positions (p < 0.05), with higher values observed in the supine position.

CONCLUSIONS

These findings highlight the importance of considering the patient's position when interpreting urodynamic results and making treatment decisions for children with neurogenic bladder. The higher MDP and DLPP values in the supine position may have clinical implications for assessing upper urinary tract integrity and treatment planning. However, further research is needed to understand the underlying mechanisms and generalize these findings to broader patient populations.

Bladder Capacity in Women With Overactive Bladder Syndrome: A Cross-sectional Study

OBJECTIVE

To evaluate bladder capacity in women with idiopathic overactive bladder syndrome (OAB) through bladder diary, cystomanometry, and uroflowmetry and assess the concordance of the different measures of bladder capacity. A secondary objective is to describe the relationship between bladder capacity and urinary frequency in OAB patients.

METHODS

An observational cross-sectional multicentric study was conducted, including female patients diagnosed with idiopathic OAB. All participants underwent a urodynamic study and completed a 3-day bladder diary (3dBD). Different parameters were used to calculate bladder capacity: maximum cystometric capacity (MCC) assessed at the end of filling cystometry, voided volume (VV) during the uroflowmetry, maximum voided volume (VVmax), and average voided volume (VVmed), both assessed through the 3dBD. Reproducibility analysis was performed to assess the agreement among the different bladder capacity measures. Intraclass correlation coefficient (ICC) and weighted Kappa index were used. Bladder capacity parameters were also assessed in relation to urinary frequency.

RESULTS

Bladder capacity measures were diminished in this population, except for VVmax. Poor correlation was found between the different bladder capacity variables (ICC and weighted Kappa index <0.4). Twenty-four-hour frequency and average VV present a weak negative linear relationship (Pearson coefficient -0.344).

CONCLUSION

MCC and average VV are reduced in OAB patients. MCC does not correlate well with functional bladder volumes determined by voiding diary in the OAB population.

Influence of urodynamic conditions on bladder sensations and detrusor activity in patients with multiple sclerosis

AIMS

The study aimed to assess the impact of bladder filling rate and fluid temperature during urodynamics on bladder sensations and volume of apparition of detrusor overactivity in patients with multiple sclerosis (PwMS).

METHODS

Consecutive PwMS assessed with a standardized urodynamic test including three consecutive cystometries (20 ml/min, 100 ml/min, and 100 ml/min with 4°C fluid (Ice water test [IWT]) between June 2020 and March 2022 were included in this retrospective study. Data collected were bladder sensation with first desire to void (FDV) and strong desire to void (SDV). The presence of detrusor overactivity (DO) and the volume of the first uninhibited detrusor contraction were recorded.

RESULTS

One hundred and fifty-seven patients (mean age 47.4 ± 11.8 years, median EDSS 3 IQR[2-5], 73.9% of women) were included. Increased filling rate induced delayed bladder sensations (FDV 219 ± 109 ml vs. 194 ± 100 ml; SDV 349 ± 113 ml vs. 322 ± 124 ml for 100 ml/min and 20 ml/min filling rate, respectively, p < 0.001). Ice water increased bladder sensations with earlier reports of needs to void (FDV 163 ± 99 ml vs. 218 ± 117 ml; SDV 263 ± 104 ml vs. 351 ± 112 ml respectively; p < 0.001). Thirty-four patients had DO during both 20 ml/min and 100 ml/min fillings, without difference in the volume of apparition (p = 0.78). Forty-four patients had DO during both 100 ml/min and IWT. Detrusor overactivity appeared for a reduced volume during IWT compared with room temperature fluid perfusion (-68 ml [-95 to -41]; p < 0.001).

CONCLUSION

Filling rate and fluid temperature impact bladder sensations during cystometry in PwMS. Ice water decreased the volume of the first uninhibited detrusor contraction.

Tradução para a língua portuguesa do artigo original em inglês “ The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction”

Introdução

No desenvolvimento da terminologia do trato urinário inferior, devido à sua crescente complexidade, a terminologia para os sintomas e a disfunção do trato urinário inferior masculino e assoalho pélvico precisa ser atualizada, utilizando abordagem específica masculina e por meio de um relatório de consenso clinicamente embasado.

Métodos

Este relatório combina a contribuição de membros do Standardisation Committee da International Continence Society em um Grupo de Trabalho com especialistas reconhecidos no campo, assistido por muitos julgadores externos. Categorias clínicas centrais apropriadas e uma subclassificação foram desenvolvidas para fornecer uma codificação numérica para cada definição. Um extenso processo de 22 rodadas de revisão interna e externa foi desenvolvido para examinar exaustivamente cada definição, com tomada de decisão por opinião coletiva (consenso).

Resultados

Um relatório de terminologia para os sintomas e a disfunção do trato urinário inferior e do assoalho pélvico foi desenvolvido, abrangendo cerca de 390 definições/descritores separados. É clinicamente embasado nos diagnósticos mais comuns definidos. A clareza e a facilidade de uso foram os principais objetivos para torná-lo interpretável por profissionais e estagiários em todos os diferentes grupos de especialidades envolvidos na disfunção do trato urinário inferior e do assoalho pélvico masculino. Imagens específicas para homens (ultrassonografia, radiologia, tomografia computadorizada e ressonância magnética) foram um adicional importante, enquanto figuras apropriadas foram incluídas para complementar e ajudar a esclarecer o texto.

Conclusões

Um relatório de terminologia com base em consenso para sintomas e disfunção do trato urinário inferior e do assoalho pélvico masculino foi produzido visando ser um auxílio significativo para a prática clínica e um estímulo para a pesquisa.

Characterizing voiding experiences of men choosing seated and standing positions

AIMS

Voiding positions and preferences in men are not well characterized. In this study, we aim to understand the interplay of voiding characteristics and their impact on voiding position.

METHODS

We designed a 27-item survey to assess voiding characteristics and lower urinary tract symptoms (LUTS) severity in men seen in urology and other outpatient clinics. Participants included adult men patients and adult men accompanying patients at our institution's outpatient clinics. Data collected included demographics, International Prostate Symptom Score questionnaire, stream type (single, split, and dribble), voiding behavior, positional stream quality, and voiding bother.

RESULTS

We received 195 completed surveys (80% response rate). Of men queried, 18% (35/195) preferred to sit while voiding. Overall, men who sit had a higher proportion of LUTS (66% [23/35] vs. 41% [66/160]; p = .01), more physical limitations affecting voiding choice (20% [7/35] vs. 3% [5/160]; (p = .001), and a lower desire to stand (6% [2/35] vs. 24% [38/160]; p = .02), compared to men who stand. Men who sit while voiding reported nearly double the amount of voiding associated bother (34% [12/35]) compared to men who stand (18% [28/160]; p = .04). Older aged men reported a similar rate of seated urination compared to younger men. The most common reasons to void seated included comfort and avoidance of spraying.

CONCLUSIONS

Our findings discourage the use of anecdotal beliefs founded on generalizable characteristics, such as age and stream type, to infer a patient's voiding characteristics. Open dialog with patients regarding voiding preferences may garner important information regarding overall urologic health and better inform urologic care.

Associations between nighttime and daytime maximum voided volumes: Relevance for nocturia?

AIM

The relationship between maximum voided volumes (MVV) during the night and day is poorly understood. Such measurements are important because they are often used to indicate functional bladder capacity (FBC), a relevant parameter for nocturia. This study examined the association of such nighttime and daytime measurements in men with nocturia.

METHODS

We retrospectively analyzed 356 24-hour voiding diaries showing ≥2 nocturnal voids from 220 men at an outpatient urology clinic. We defined small FBC as MVV ≤ 200 mL.

RESULTS

A total of 131 entries demonstrated a nocturnal MVV ≤ 200 mL, of which a majority (98 [74.8%]) also showed a 24-hour MVV ≤ 200 mL (ie, global small FBC), and 33 (25.2%) exceeded the 200 mL threshold during the day (ie, nocturnal-specific small FBC). Correspondingly, among voiding diaries without global small FBC (n = 258), most (225/258 [87.2%]) showed a nocturnal MVV > 200 mL. Data were similar when analyzing only the first complete voiding diary per case, when limiting analyses to those without benign prostatic obstruction, and when limiting analyses to cases with nocturnal polyuria.

CONCLUSION

Nocturia may be attributable to nocturnal-specific small FBC or global small FBC. Although the etiology of nocturnal-specific small FBC remains unclear, it was present in a significant minority of patients with small FBC, thus necessitating more directed research. Conversely, diminished nocturnal MVV was nevertheless relatively uncommon in the absence of global small FBC, such that nocturnal-only voiding diaries may provide a rational alternative for follow-up evaluation in patients with nocturia due to global small bladder capacity.

The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction

INTRODUCTION

In the development of terminology of the lower urinary tract, due to its increasing complexity, the terminology for male lower urinary tract and pelvic floor symptoms and dysfunction needs to be updated using a male-specific approach and via a clinically-based consensus report.

METHODS

This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) in a Working Group with recognized experts in the field, assisted by many external referees. Appropriate core clinical categories and a subclassification were developed to give a numeric coding to each definition. An extensive process of 22 rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus).

RESULTS

A Terminology Report for male lower urinary tract and pelvic floor symptoms and dysfunction, encompassing around 390 separate definitions/descriptors, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in male lower urinary tract and pelvic floor dysfunction. Male-specific imaging (ultrasound, radiology, CT, and MRI) has been a major addition whilst appropriate figures have been included to supplement and help clarify the text.

CONCLUSIONS

A consensus-based Terminology Report for male lower urinary tract and pelvic floor symptoms and dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Audiovisual stimulus during urodynamics to provoke detrusor overactivity: A randomized trial

OBJECTIVE

This study estimated the effect of adding an audiovisual (AV) intervention during urodynamic evaluation (UDE) on increasing detrusor contractions (DO) versus routine UDE testing without AV cues.

METHODS

A randomized trial was conducted of women with overactive bladder (OAB) undergoing UDE with and without AV intervention. The AV intervention was a 1-minute video on continuous loop showing common OAB triggers. A continuous running waterfall provided auditory stimulation. The primary outcome was the proportion of patients who had DO on UDE, interpreted by masked clinicians. Secondary outcomes included the number, amplitude, and duration of DO and urinary leakage associated with DO. A sample size of 109 per group was calculated to have 80% power to detect a 20% difference with a significance level of 0.05.

RESULTS

In all, 109 women each were randomized to standard UDE and to the AV intervention. There was no difference in the proportion of patients with DO on UDE between the intervention and control groups (35% vs 32%, respectively; P = 0.8). Furthermore, there were no differences between the intervention and control groups in leakage with DO on UDE (24% vs 21%, respectively), mean duration of detrusor contractions (23.9 vs 25.3 s, respectively), or mean maximum detrusor pressure during involuntary contractions (18.1 vs 20.6 cm H₂ O, respectively). Clinical severity of OAB symptoms was not associated with the detection of DO or other UDE parameters.

CONCLUSIONS

Addition of AV intervention during UDE did not increase the finding of detrusor contractions. The relationship between OAB triggers, urge incontinence, and urodynamic findings remains unclear.

Is urodynamics necessary to identify occult stress urinary incontinence?

PURPOSE

To investigate Occult Stress Urinary Incontinence (OSUI) using physical exam (PE) and urodynamics (UDS) in women with advanced pelvic organ prolapse (POP), and compare the two methods.

METHODS

This study comprised 105 women with POP stage-III and -IV, according to POP quantification (POP-Q) system, evaluated prospectively between January and December 2015. A standard history, an incontinence questionnaire and PE were completed before the investigation of the OSUI that was performed in the supine and standing positions, reducing the prolapse using gauze and Cheron dressing forceps. The stress test was performed with and without the prolapse reduction.

RESULTS

The mean patient age was 65.7 years, mean parity 5.1 and mean body mass index 27.4. From a total of 105 patients, 70 (66.7%) presented with POP-Q stage III and 35 (33.3%) stage IV. Sixty-three (60%) women were identified as having OSUI, 27 (25.7%) as continent, and 15 (14.3%) having stress urinary incontinence. From the 63 OSUI subjects, 48 (76.2%) were identified in both evaluations, eight were identified only during PE, and seven only during UDS. The sensitivity to detect OSUI during PE and UDS was 88.9 and 87.3%, respectively (P = .783). The kappa value to measure the agreement between both tests was .648 (95% CI .441-.854).

CONCLUSION

UDS and PE are equivalent and concordant to demonstrate OSUI, thus it is not necessary to perform UDS to exclusively identify OSUI. UDS utility in OSUI patients, to evaluate urethral and detrusor function, deserves further investigation.

The effect of posture and repetition on urodynamic parameters: A prospective randomized study

Purpose

To evaluate the effect of posture and repetition of filling cystometry on urodynamic parameters.

Materials and Methods

Seventy-one men with benign prostatic hyperplasia participated in a urodynamic study between September 2015 and August 2016 and were randomly assigned to a supine to supine (group SS, n=16), erect to erect (group EE, n=16), supine to erect (group SE, n=19) or erect to supine (group ES, n=20) group. The patients underwent filling cystometry twice. We evaluated the effect of posture and the effect of repetition on filling cystometric parameters. We also evaluated the correlation between overactive bladder (OAB) and detrusor overactivity (DO) and between maximum voided volume (MVV) and maximum cystometric capacity (MCC) for each posture and filling cystometry time.

Results

There was a decrease in bladder sensation and occurrence of DO, and an increase in bladder compliance and MCC in the supine posture group compared to that in the erect posture group. A more significant decrease in bladder sensation and occurrence of DO as well as an increase in MCC was seen during the second filling cystometry than the first one. The supine posture during first filling cystometry showed a better correlation between OAB and DO and between MVV and MCC than erect posture.

Conclusions

There were clear effects of posture and filling cystometry repetition on urodynamic parameters. The supine posture and repeated filling cystometry caused the bladder to be less sensitive and less overactive. The supine posture showed a better correlation to OAB symptoms than erect posture during first filling cystometry.

Bladder ultrasonography for diagnosing detrusor overactivity: test accuracy study and economic evaluation

BACKGROUND

Urodynamics (UDS) has been considered the gold standard test for detrusor overactivity (DO) in women with an overactive bladder (OAB). Bladder ultrasonography to measure bladder wall thickness (BWT) is less invasive and has been proposed as an alternative test.

OBJECTIVES

To estimate the reliability, reproducibility, accuracy and acceptability of BWT in women with OAB, measured by ultrasonography, in the diagnosis of DO; to explore the role of UDS and its impact on treatment outcomes; and to conduct an economic evaluation of alternative care pathways.

DESIGN

A cross-sectional test accuracy study.

SETTING

22 UK hospitals.

PARTICIPANTS

687 women with OAB.

METHODS

BWT was measured using transvaginal ultrasonography, and DO was assessed using UDS, which was performed blind to ultrasonographic findings. Intraobserver and interobserver reproducibility were assessed by repeated measurements from scans in 37 and 57 women, respectively, and by repeated scans in 27 women. Sensitivity and specificity were computed at pre-specified thresholds. The smallest real differences detectable of BWT were estimated using one-way analysis of variance. The pain and acceptability of both tests were evaluated by a questionnaire. Patient symptoms were measured before testing and after 6 and 12 months using the International Consultation on Incontinence modular Questionnaire Overactive Bladder (short form) (ICIQ-OAB) questionnaire and a global impression of improvement elicited at 12 months. Interventions and patient outcomes were analysed according to urodynamic diagnoses and BWT measurements. A decision-analytic model compared the cost-effectiveness of care strategies using UDS, ultrasonography or clinical history, estimating the cost per woman successfully treated and the cost per quality-adjusted life-year (QALY).

RESULTS

BWT showed very low sensitivity and specificity at all pre-specified cut-off points, and there was no evidence of discrimination at any threshold (p = 0.25). Extensive sensitivity and subgroup analyses did not alter the interpretation of these findings. The smallest detectable difference in BWT was estimated to be 2 mm. Pain levels following both tests appeared relatively low. The proportion of women who found the test 'totally acceptable' was significantly higher with ultrasonography than UDS (81% vs. 56%; p < 0.001). Overall, subsequent treatment was highly associated with urodynamic diagnosis (p < 0.0001). There was no evidence that BWT had any relationship with the global impression of improvement responses at 20 months (p = 0.4). Bladder ultrasonography was more costly and less effective than the other strategies. The incremental cost-effectiveness ratio (ICER) of basing treatment on the primary clinical presentation compared with UDS was £491,500 per woman successfully treated and £60,200 per QALY. Performing a UDS in those women with a clinical history of mixed urinary incontinence had an ICER of £19,500 per woman successfully treated and £12,700 per QALY compared with the provision of urodynamic to all women. For DO cases detected, UDS was the most cost-effective strategy.

CONCLUSION

There was no evidence that BWT had any relationship with DO, regardless of the cut-off point, nor any relationship to symptoms as measured by the ICIQ-OAB. Bladder ultrasonography has no diagnostic or prognostic value as a test in this condition. Furthermore, despite its greater acceptability, BWT measurement was not sufficiently reliable or reproducible.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN46820623.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 7. See the NIHR Journals Library website for further project information.

The Role of Urodynamics in Elderly Patients

Urodynamic testing is the study of the function of the bladder and its outlet. Geriatric patients are at greater risk for lower urinary tract dysfunction owing to age or neurologic disease, such as Parkinson disease or stroke. Although urodynamic testing may best diagnose an individual patient's bladder storage and emptying function, the tests should be tailored to answer the question being asked and the test should only be done when the outcome of the test is going to impact decision making regarding management or treatment.

Can We State Stable Bladder? How Many Repetitions Should We Do for an Appropriate Demonstration of Involuntary Detrusor Contraction?

AIMS

Involuntary Detrusor Contraction (IDC) may alter therapeutic plans; therefore, urodynamic demonstration (UD) is pivotal. We explore if same session repetitions enhance its demonstration and minimize false-negative results.

METHODS

Two hundred fifty two women (mean age 47 ± 5.7) had 4 full repetitions of UD with the last round filled with 4°C fluid (Ice-water test). IDC was diagnosed if with at least 3 cm H2O after artifacts were ruled out.

RESULTS

44.4% of the cases showed IDC in the first round of the exam but it could be demonstrated in 88.5% of the women if 4 rounds are taken into account. Only 2 cases showed IDC exclusively in the first round. Nine cases (3.5%) showed IDC in the first round and only on Ice-test, while all other IDC-detected cases revealed it in scattered patterns along the repetitions. Likewise, IDC detection on the second, third and fourth rounds varied widely and unpredictably, many failing to show a consistent pattern of presentation after its detection. IDC wave amplitude did not show any correlation to the detection.

CONCLUSIONS

Urodynamic repetition is a necessary procedure where IDC is important to demonstrate, as its false-negative rate is high and its unpredictable pattern of detection may be improved by repetition.

Validation of a culturally compliant voiding platform for urodynamics in African vesicovaginal fistula patients

INTRODUCTION AND HYPOTHESIS

Most patients in regions where obstetric vesicovaginal fistulas (VVF) are endemic void using a squatting posture. Additionally, many patients continue to have lower urinary tract symptoms (LUTS) following fistula closure. We designed and validated a prototype platform that allows urodynamic studies to be performed in a squatting position and conducted a pilot study to assess uroflowmetry in this patient population.

METHODS

Sixteen patients with persistent LUTS following fistula surgery were recruited. Posture measurements were taken in each patient's natural voiding posture on the ground and were then repeated using the platform. Nine patients with persistent urinary incontinence also underwent uroflowmetry. The data were compared with normal values in different nomograms. Paired t tests were used to determine significant differences in posture. One-way ANOVA was used to determine statistical significance between flow rate values.

RESULTS

Only the heel-to-heel distance (H-H) measure of posture was significantly increased on the platform compared with on the ground. The mean corrected Qmax was 0.89 ± 0.46. Flow rate values were significantly lower than mean normal flow rates obtained from the nomograms. In general, the patients' uroflowmetry patterns were similar to those indicative of impaired detrusor function.

CONCLUSION

A platform for conducting urodynamic studies in a squatting posture was successfully validated in the VVF patient population. The finding of increased H-H on the platform is expected, since the patient must accommodate a large funnel for urine collection. The pilot data suggest that patients with persistent urinary incontinence following VVF closure may also have significant voiding dysfunction.

The influence of positioning in urination: an electromyographic and uroflowmetric evaluation

PURPOSE

We conducted a cross-sectional study to evaluate whether the different positions during urination influence the electrical activity of the abdominal and perineal musculature, as well as the uroflowmetric parameters of children with lower urinary tract dysfunction (LUTD).

MATERIALS AND METHODS

Ninety-four children between the ages of 3 and 14 years with symptoms of LUTD were evaluated. All underwent uroflowmetry and electromyography tests (abdominal and perineal) in two different positions: oriented position (trunk bent slightly forward and feet flat) and atypical position (standing on toes for boys and buttocks not in contact with the lavatory seat and legs flexed in girls). We excluded nine patients due to suspicions of outside interference or elements complicating the analysis of charts.

RESULTS

Among patients evaluated 55 (64.7%) were girls and 30 (35.3%) were boys with an average age of 8.5 years. Children urinating in atypical position showed higher levels of perineal electrical activity than when they were in normal position (p=0.018). However, there was no difference in the pattern of the curve if normal or abnormal when comparing the two groups (p=0.824). When evaluated separately, the boys demonstrated no difference between positions, in relation to perineal electrical activity (p=0.412) or abdominal electrical activity (p=0.202).

CONCLUSIONS

The electrical activity of the pelvic floor musculature is decreased in the oriented position when compared to atypical positions in female children. Our data suggest that special attention should be given to adopting an adequate posture during urination for girls with LUTD.

Clinical risk factors and urodynamic predictors prior to surgical treatment for stress urinary incontinence: a narrative review

INTRODUCTION AND HYPOTHESIS

Knowledge about clinical risk factors and the value of urodynamic testing is important to optimize treatment strategy and secure true informed consent.

METHODS

We reviewed the relevant literature to clarify the evidence regarding clinical risk factors and the predictive value of urodynamic testing in patients with urinary incontinence, where surgery is considered. Because of the paucity of evidence based on randomized controlled trials, we conducted a narrative review of the published literature.

RESULTS

Clinical risk factors in terms of mixed urinary incontinence, previous incontinence surgery, body mass index (BMI) ≥ 35, age ≥ 75, and presence of diabetes mellitus were significantly related to decreased outcome of incontinence surgery. Furthermore, noninvasive and invasive urodynamic parameters indicating detrusor overactivity, voiding difficulties, low urethral pressure, and bladder-neck immobility were related to poorer outcome of surgery.

CONCLUSIONS

This study summarized the available evidence regarding preoperative clinical risk factors and urodynamic parameters indicating decreased or adverse outcome of surgery, and this report also provides clinical recommendations.

Urinating standing versus sitting: position is of influence in men with prostate enlargement. A systematic review and meta-analysis

Background

It is suggested that the body posture during urination can influence urodynamic parameters in patients with Lower Urinary Tract Symptoms (LUTS) to an extent approaching pharmacological interventions. In this article, the influence of body position during micturition on maximum urinary flow rate (Qmax), voiding time (TQ) and post-void residual volume (PVR) in healthy males and patients with LUTS is analyzed by means of a systematic review and meta-analysis.

Evidence Acquisition

A systematic search was conducted in 14 medical databases. Studies comparing urodynamic parameters in standing versus sitting position were eligible for inclusion. Studies were stratified according to health status of included male participants: healthy individuals and patients with LUTS. Standardized mean differences for Qmax, TQ and PVR were pooled in a random effects model.

Results

Eleven articles were included. In men with LUTS, a significantly lower PVR (−24.96 ml; 95%CI −48.70 to −1.23) was shown in sitting position compared to standing. In accordance, Qmax was increased (1.23 ml/s; 95%CI −1.02 to 3.48), and TQ was decreased (−0.62 s; 95%CI −1.66 to 0.42) in sitting position, although these differences did not reach statistical significance. In healthy men, Qmax (0.18 ml/s; 95% CI −1.67 to 2.02), TQ (0.49 s; 95%CI −3.30 to 4.27) and PVR (0.43 ml; 95%CI −0.79 to 1,65) were similar in sitting and standing position.

Conclusion

For healthy men, no difference is found in any of the urodynamic parameters. In patients with LUTS, the sitting position is linked with an improved urodynamic profile.

Urodynamic investigation by telemetry in Beagle dogs: validation and effects of oral administration of current urological drugs: a pilot study

Background

Vesico-urethral function may be evaluated in humans and dogs by conventional urodynamic testing (cystometry and urethral pressure profilometry) or by electromyography. These techniques are performed under general anaesthesia in dogs. However, anaesthesia can depress bladder and urethral pressures and inhibit the micturition reflex. The primary objective of this pilot study was to evaluate the use of telemetry for urodynamic investigation in dogs. We also aimed to determine the applicability of telemetry to toxicologic studies by assessing the repeatability of telemetric recordings.

Results

Conventional diuresis cystometry was performed in six continent adult female Beagle dogs prior to surgical implantation of telemetric and electromyographic devices. In the first phase of the telemetric study, continuous recordings were performed over 8 days and nights. Abdominal, intravesical and detrusor threshold pressures (Pdet th), voided volume (Vv), urethral smooth muscle electrical activity and involuntary detrusor contractions (IDC) were measured during the bladder filling phase and during micturition episodes.

Vv recorded during telemetry was significantly lower than bladder volume obtained by diuresis cystometry. Repeatability of telemetric measurements was greater for observations recorded at night. IDC frequency and Pdet th were both lower and Vv was higher at night compared to values recorded during daytime.

In the second phase of the telemetric study, phenylpropanolamine, oestriol, bethanechol, oxybutynin or duloxetine were administered orally for 15 days. For each drug, continuous recordings were performed overnight for 12 hours on days 0, 1, 8 and 15. Electromyographic urethral activity was significantly increased 8 days after oestriol or duloxetine administration. No significant changes in bladder function were observed at any time point.

Conclusions

In dogs, the high repeatability of nocturnal telemetric recordings indicates that this technique could provide more informative results for urologic research. Urethral smooth muscle electrical activity appears to be modified by administration of drugs with urethral tropism. In this pilot telemetric study, bladder function was not affected by oral administration of urological drugs at their recommended clinical dosages. Experimental studies, (pharmacokinetic and pharmacodynamic) and clinical studies are warranted to further define the effects of these drugs on vesico-urethral function in dogs.

Clinical and urodynamic effects of tolterodine in women with an overactive bladder

OBJECTIVE

The aim of this study was to compare the changes in urinary symptoms and urodynamic parameters after administration of tolterodine in women with an overactive bladder (OAB).

MATERIALS AND METHODS

Thirty-eight women diagnosed with OAB and treated with tolterodine were reviewed. Urinalysis, pelvic examination, 3-day bladder diary, urodynamic study, and a personal interview to identify urinary symptoms prior to and 3 months after treatment were recorded and interpreted.

RESULTS

Most of our patients were menopausal (76.3%; mean age 55.7 years) and multiparous (mean parity 3.3) women. Urinary symptoms such as urinary frequency, urgency, urge incontinence, and nocturia were decreased significantly (p < 0.05). All urodynamic parameters did not change significantly except for the maximum cystometric capacity (p < 0.05), showing a significant increase after 3 months of medication.

CONCLUSIONS

Tolterodine, at a recommended dose, improves the symptoms of OAB syndrome without causing urine retention, as proved by the changes of urodynamic parameters.

The evidence for urodynamic investigation of patients with symptoms of urinary incontinence

Urodynamic studies are the gold standard to objectively diagnose dysfunction of the lower urinary tract. The widely available evidence for the clinical relevance is, however, fragmented. This article summarizes the published knowledge supporting the use of urodynamic studies in urinary incontinence in female, male and frail patients, as well as patients with relevant neurological disease. Five technological innovations are discussed briefly. Standard urodynamic cystometry can, on the basis of a solid body of evidence, objectively unveil the entire function of the lower urinary tract in all patients with urinary incontinence, regardless of the patients' perception of (ab-)normality of signs and or symptoms.

Does bladder wall thickness decrease when obstruction is resolved?

INTRODUCTION AND HYPOTHESIS

The aim of the current study was to determine if sonographic bladder wall thickness diminishes after symptomatic obstruction is resolved in female patients after stress incontinence surgery.

METHODS

Between December 2008 and December 2010, 62 female patients with symptomatic bladder outlet obstruction, as defined by Blaivas, who had undergone prior surgery for urinary stress incontinence were included in the study. The patients' history was taken and symptoms were noted. Patients underwent gynaecological examination, and multichannel urodynamic assessment was performed. Vaginal sonographic assessment of the bladder wall thickness (BWT) was performed before and after urethrolysis.

RESULTS

62 patients were included in this study, 55 of whom had undergone suburethral sling insertion and seven had Burch colposuspension. Postoperatively, BWT decreased significantly from 9.1 mm  ±  2.1 to 7.6 mm  ±  2.2 (p < 0.0001). In seven patients, obstruction was still unresolved postoperatively; of these, two had undergone a retropubic sling insertion and two had a Burch colposuspension. An ROC curve analysis showed a significant positive association between residual urine and persistent obstruction before surgery (AUC 0.76, 95%CI 0.58-0.94; p < 0.05).

CONCLUSIONS

If obstruction is resolved, bladder wall thickness decreases. Preoperatively elevated residual urine may increase the risk of persistent obstruction after urethrolysis.

Managing unsatisfactory outcome after mid-urethral tape insertion

This article reviews the literature on the assessment and management of women whose previous mid-urethral tape surgery to manage stress urinary incontinence symptoms has failed to produce a satisfactory outcome. In many areas the literature is deficient and the article includes consensus statements drawn from the International Continence Society Research Society meeting in Bristol in June 2010. The need for a structured approach to assessment and management is highlighted, so that further research into areas of uncertainty can be prioritized. The article concludes with a number of research recommendations.

Changes in urodynamic parameters after tolterodine treatment for female overactive bladder syndrome with or without voiding dysfunction

AIM

To investigate changes in urodynamic parameters after tolterodine treatment for female overactive bladder syndrome, especially in patients with voiding dysfunction.

METHODS

Between January and December 2006, 44 patients were enrolled for six months of treatment with tolterodine. Pre-treatment and post-treatment urodynamic studies were scheduled for the enrolled patients.

RESULTS

Among the remaining 33 patients (11 dropped out), bladder capacity (P < 0.001) and post-void residual urine (P = 0.009) increased, and functional urethral length (P = 0.049) and pad weight test (P = 0.03) decreased after treatment. Besides this, detrusor pressure at maximal urine flow, functional urethral length, maximal urethral pressure and maximal urethral closure pressure were less affected by tolterodine in patients with voiding dysfunction, compared to those without voiding dysfunction.

CONCLUSIONS

Tolterodine treatment increased bladder capacity and decreased urine leakage; however, some urodynamic parameters in patients with voiding dysfunction were less affected by tolterodine treatment.

Comparison of ambulatory versus conventional urodynamics in females with urinary incontinence

AIMS

We planned to compare the diagnostic accuracy of conventional urodynamics (UD) and ambulatory UD for the detection of detrusor over activity (DOA) and/or urodynamic stress incontinence (USI) in women presenting with urinary incontinence.

METHODS

We prospectively enrolled 44 women with urinary incontinence and performed both urodynamic (UD) studies after they completed the UDI-6 questionnaire. During ambulatory UD one micturition cycle was recorded. According to responses for individual items on the UDI-6, patients were divided into three groups to define incontinence type irrespective of scoring.

RESULTS

Mean age was 52.2 and mean duration of the symptoms was 4.94 years. The ambulatory UD detected an underlying pathophysiology of urinary incontinence (77.3%) in significantly more women than the conventional UD (6.8%) (P = 0.001). Among women with stress incontinence, 56% had USI on the ambulatory UD and none had abnormalities on the conventional UD (P = 0.002). Seventy-two percent of women with mixed symptoms had abnormal findings (USI and/or DOA) on the ambulatory UD and 9% had abnormal findings on the conventional UD (P = 0.001).

CONCLUSIONS

Our findings suggest that ambulatory UD done in a clinical setting during one micturition cycle with unstandardized provocative activities detects an underlying pathophysiology (urge incontinence, stress incontinence, mixed incontinence) more often than conventional UD in supine position Conventional UD has a higher false-negative rate in diagnosis of DOA and/or USI compared to ambulatory UD.

Sonographic transvaginal bladder wall thickness: does the measurement discriminate between urodynamic diagnoses?

INTRODUCTION

Measurement of bladder wall thickness (BWT) using transvaginal ultrasound has previously been shown to discriminate between women with confirmed detrusor overactivity and those with urodynamic stress incontinence. Aim of the current study was to determine if vaginally measured BWT correlates with urodynamic diagnoses in a female population.

PATIENTS AND METHODS

Between December 2008 and February 2010, adult female consecutive patients undergoing urogynaecologic investigation for lower urinary symptoms were approached to participate in this study. Ethical consent for the current study was obtained. Patients underwent multichannel urodynamics and transvaginal ultrasound measuring the bladder in three location with an emptied bladder.

RESULTS

123 patients were included in the study with a median age of 69 years (range 40-93), median parity of 2 (range 0-3) and a median body mass index of 29.5 kg/m(2) (range 23-38). Urodynamic stress incontinence was diagnosed in 59 patients, DO in 40 and obstruction in 24 cases. Bladder wall thickness was significantly higher in DO patients and in obstruction than in urodynamic stress incontinence. Detrusor pressure at maximum flow rate (pdet/Q(max) ) correlated significantly with BWT.

CONCLUSION

Bladder wall thickness shows a significantly positive correlation to pdet/Q(max) and to urodynamic diagnoses of stress incontinence, DO and obstruction.

Detrusor overactivity persisting at night and preceding nocturia in patients with overactive bladder syndrome: a nocturnal cystometrogram and polysomnogram study

PURPOSE

Nocturia, a common symptom of overactive bladder syndrome, is associated with substantial adverse consequences and yet its pathophysiology has hardly been studied and the capacity to treat it remains limited. We established methods to study the physiology of overactive bladder associated nocturia and better understand this phenomenon.

MATERIALS AND METHODS

We recorded simultaneous, time aligned, nocturnal cystometrogram and polysomnogram data during a single night at a sleep laboratory in 9 patients with overactive bladder and detrusor overactivity on daytime cystometrogram, in 10 patients with insomnia and in 5 healthy controls.

RESULTS

We safely recorded simultaneous polysomnography/nocturnal cystometrography data accurately during the sleep period. Nocturnal detrusor overactivity occurred significantly less often in patients with insomnia and controls than in patients with detrusor overactivity plus overactive bladder (p = 0.02) and only in the 10 minutes before nocturia events in the latter (0%, 0% and 67%, respectively, p = 0.002). Patients with detrusor overactivity plus overactive bladder were awake for a shorter period before nocturia events (p <0.001) and had a greater percent of nocturia associated awakenings. Patients with insomnia had more awakenings unrelated to nocturia. Nocturnal polyuria, another cause of nocturia, was not significantly associated with nocturnal detrusor overactivity.

CONCLUSIONS

Sleep and bladder pressure physiology may be safely monitored during the sleep period accurately. Nocturnal detrusor overactivity occurs in association with nocturia in most patients with detrusor overactivity plus overactive bladder, does not generally occur during sleep and is not due to sleep disturbance or nocturnal polyuria. This study may provide a foundation for research on overactive bladder related nocturia pathophysiology and treatment.

Executive summary: The International Consultation on Incontinence 2008--Committee on: "Dynamic Testing"; for urinary incontinence and for fecal incontinence. Part 1: Innovations in urodynamic techniques and urodynamic testing for signs and symptoms of urinary incontinence in female patients

AIMS

The members of The International Consultation on Incontinence 2008 (Paris) Committee on Dynamic Testing' provide an executive summary of the chapter 'Dynamic Testing' that discusses (urodynamic) testing methods for patients with signs and or symptoms of urinary incontinence. Testing of patients with signs and or symptoms of faecal incontinence is also discussed.

METHODS

Evidence based and consensus committee report.

RESULTS

The chapter 'Dynamic Testing' is a continuation of previous Consultation-reports added with a new systematic literature search and expert discussion. Conclusions, based on the published evidence and recommendations, based on the integration of evidence with expert experience and discussion are provided separately, for transparency.

CONCLUSION

This first part of a series of three articles summarizes the committees recommendations about the innovations in urodynamic study techniques 'in general', about the test characteristics and normal values of urodynamic studies as well as the assessment of female with signs and or symptoms of incontinence and includes only the most recent and relevant literature references.