Which method is the most reliable in determination of bladder capacity in children with idiopathic overactive bladder? A comparison of maximum voided volume, uroflowmetry and maximum cystometric capacity

Feasibility Analysis of the 3-Day Urination Diary for Children With Enuresis

This study aimed to evaluate the feasibility of the 3-day micturition diary for children with enuresis. We included 53 such children (March 2020-December 2021), who kept a urination diary and filled out a questionnaire. The data were retrospectively analyzed; the differences in completion rate, sensitivity, and specificity between the urination diaries recorded for 3 and 7 days were compared; and factors affecting the completion of the urination diary were assessed. Compared with the 7-day micturition diary, the 3-day micturition diary is easier to complete; the data tend to be more credible; and its application in children with enuresis is feasible.

Comparison of maximum voided volume and maximum bladder capacity in voiding diary, uroflowmetry and cystometrography in children with non-neurogenic lower urinary tract dysfunction

BACKGROUND

Maximum voided volumes (MVV) and maximum bladder capacities (MBC) are important parameters in the evaluation of lower urinary tract functions in children. However, consistency of MVV and MBC measurements between voiding diary (VD), uroflowmetry (UF) and cystometrography (CMG) in children with non-neurogenic lower urinary tract dysfunction (LUTD) has not been addressed specifically.

OBJECTIVE

We aimed to compare the MVV in VD and UF and MBC in CMG in children with non-neurogenic LUT dysfunction and investigate for possible factors for discrepancies.

MATERIALS AND METHODS

Children with non-neurogenic LUTD were retrospectively evaluated with a focus on VD, UF, and CMG. VD applied for 2 days and MVV recorded except for first urine in morning. UF repeated in children with <50% of expected bladder capacity (EBC) for age. Highest value and post voiding residual urine (PVR) was recorded. CMG was performed if these conditions were present: High PVR or LUT dysfunction resistant to standard urotherapy (conservative management with biofeedback) and medical therapy (oral anticholinergics) or LUT dysfunction accompanied by VUR or recurrent UTI. MBC in CMG was recorded according to International Children Continence Society (ICCS) standards. MVV and MBC in VD, UF, CMG were compared and possible factors for discrepancy were investigated.

RESULTS

54 children (median age: 10 (4-17) years) were included in the study. 39 (72.2%) were girls, 15 (27.8%) were boys. Median MVV was 232.50 (20-600) ml in VD, 257.50 (69-683) ml in UF and MBC was 184 (31-666) ml in CMG (p = 0.012) (Summary Table). In the subgroup analysis, it was shown that the bladder capacities obtained from all three tests were not compatible with each other in children younger than 10 years of age, in girls, in those with recurrent urinary tract infection, detrusor overactivity, high PVR and normal flow pattern (p = 0.003, p = 0.016, p = 0.029, p < 0.001, p = 0.045, p = 0.03, respectively).

DISCUSSION

There is a discrepancy between bladder capacities obtained from VD, UF and CMG In children with non-neurogenic LUT dysfunction. In particular, the lower capacity obtained from invasive urodynamic tests may be related to the poor compliance of children during the procedure. Therefore, when invasive urodynamics is required in these cases, we recommend that maximum cystometric capacity to be evaluated by comparing with voided volumes at UF, VD and other clinical signs and symptoms, and urodynamic parameters in more detail.

CONCLUSION

MVV in VD and UF are comparable, but MBC in CMG is lower in children with non-neurogenic LUTD selected for invasive urodynamic studies. More attention should be paid to bladder capacity obtained from urodynamic studies in children exhibiting the characteristics identified in the subgroup analysis. We believe that evaluating bladder capacity values, especially obtained from invasive studies, in conjunction with clinical findings can prevent misdiagnosis, over investigation and overtreatment in children with non-neurogenic LUTD.

Efficacy of peripheral electrical nerve stimulation on improvements of urodynamics and voiding diary in patients with neurogenic lower urinary tract dysfunction: a systematic review and meta-analysis

BACKGROUND

Peripheral electrical nerve stimulation is a routinely recommended treatment for non-neurogenic overactive bladder but has not been approved for patients with neurogenic lower urinary tract dysfunction (NLUTD). This systematic review and meta-analysis was to elucidate the efficacy and safety of electrostimulation and thus provide firm evidence for treating NLUTD.

MATERIALS AND METHODS

We systematically performed the literature search through PubMed, Web of Science, and Cochrane Library databases in March 2022. The eligible studies were identified across the inclusion criteria and the data on urodynamic outcomes, voiding diary parameters, and safety was collected to quantitatively synthesize the pooled mean differences (MDs) with 95% CIs. Subgroup analyses and sensitivity analyses were subsequently used to investigate the possible heterogeneity. This report was achieved in accordance with the preferred reporting items for systematic reviews and meta-analyses statement.

RESULTS

A total of 10 studies involving 464 subjects and 8 studies with 400 patients were included for systematic review and meta-analysis, respectively. The pooled effect estimates indicated that electrostimulation could significantly improve urodynamic outcomes, including maximum cystometric capacity (MD=55.72, 95% CI 15.73, 95.72), maximum flow rate (MD=4.71, 95% CI 1.78, 7.65), maximal detrusor pressure (MD=-10.59, 95% CI -11.45, -9.73), voided volume (MD=58.14, 95% CI 42.97, 73.31), and post-void residual (MD=-32.46, 95% CI -46.63, -18.29); for voiding diary parameters, patients undergoing electrostimulation showed lower MDs of incontinence episodes per 24 h (MD=-2.45, 95% CI -4.69, -0.20) and overactive bladder symptom score (MD=-4.46, 95% CI -6.00, -2.91). In addition to surface redness and swelling, no stimulation-related severe adverse events were reported else.

CONCLUSIONS

The current evidence demonstrated that peripheral electrical nerve stimulation might be effective and safe for managing NLUTD, whereas more reliable data from large-scale randomized controlled trials are necessary to strengthen this concept.

Maximum Voided Volume Is a Better Clinical Parameter for Bladder Capacity Than Maximum Cystometric Capacity in Patients With Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia: A Prospective Cohort Study

PURPOSE

Bladder capacity is an important parameter in the diagnosis of lower urinary tract dysfunction. We aimed to determine whether the maximum bladder capacity (MCC) measured during a urodynamic study was affected by involuntary detrusor contraction (IDC) in patients with Lower Urinary Tract Symptoms (LUTS)/Benign Prostatic Hyperplasia (BPH).

METHODS

Between March 2020 and April 2021, we obtained maximum voided volume (MVV) from a 3-day frequency-volume chart, MCC during filling cystometry, and maximum anesthetic bladder capacity (MABC) during holmium laser enucleation of the prostate under spinal or general anesthesia in 139 men with LUTS/BPH aged >50 years. Patients were divided according to the presence of IDC during filling cystometry. We assumed that the MABC is close to the true value of the MCC, as it is measured under the condition of minimizing neural influence over the bladder.

RESULTS

There was no difference in demographic and clinical characteristics between the non-IDC (n=20) and IDC groups (n=119) (mean age, 71.5±7.4) (P>0.05). The non-IDC group had greater bladder volume to feel the first sensation, first desire, and strong desire than the IDC group (P<0.001). In all patients, MABC and MVV were correlated (r=0.41, P<0.001); however, there was no correlation between MCC and MABC (r=0.19, P=0.02). There was no significant difference in MABC between the non-IDC and IDC groups (P=0.19), but MVV and MCC were significantly greater in the non-IDC group (P<0.001). There was no significant difference between MABC and MVV (MABC-MVV, P=0.54; MVV/MABC, P=0.07), but there was a significant difference between MABC and MCC between the non-IDC and IDC groups (MABC-MCC, P<0.001; MCC/MABC, P<0.001).

CONCLUSION

Maximum bladder capacity from a urodynamic study does not represent true bladder capacity because of involuntary contractions.

Overactivity index: A noninvasive and objective outcome measure in overactive bladder in children

INTRODUCTION

Reports showed that observing detrusor overactivity (DO) and maximum cystometric capacity (MCC) may guide rational pharmacotherapy. Since urodynamic studies (UDS) are challenging for both patients and the healthcare system, a non-invasive objective prognostic marker is preferable.

OBJECTIVES

To investigate the value of the overactivity index (OI), a non-invasive measure calculated from the frequency-volume chart (FVC), for predicting the presence of symptoms and abnormal UDS in children with non-neurogenic OAB.

STUDY DESIGN

This was a prospective interventional study on a consecutive sample of 92 children with urgency treated with anticholinergics and standard urotherapy. Data from history, physical examination, bladder diaries, kidneys and bladder ultrasonography, uroflow, urinalysis, urine culture, and UDS was collected at baseline, and after 3 and 6 months. Binary logistic regression was used to evaluate noninvasive parameters as predictors of Overactive Bladder Symptom Score (OABSS) total score >2 and DO and/or small MCC defined as <65% of expected bladder capacity (EBC) for age. OI was calculated as (1 - (median (all voided volumes in FVC in ml))/(0.65 ∗ EBC in ml)) ∗ 100.

RESULTS

At baseline, 26 patients (36.1%) had DO and small MCC, while 21 patients (29.2%) only had DO. In 18 patients (25.0%) only small MCC was found. Seven patients had normal findings and 20 did not perform a urodynamic study. OI ≥ 23 returned as a single significant predictor of OABSS >2 (OR 7.97, 95% 1.97-32.22, p = 0.004) in multivariate regression (R² = 30.8%; AUC = 0.86). OI correlated with "urgency episodes over two weeks" and MCC/EBC with medium (r = 0.45) and large effect (r = -0.56), respectively, p = 0.001.

DISCUSSION

A strong correlation of OI and MCC/EBC ratio is useful, as rise in MCC is predictive of a positive outcome. Also, calculating the OI is more practical than performing UDS. This could contribute to the use of OI as a predictive marker for starting (or continuing) anticholinergic treatment (when OI ≥ 23) or for maintaining urotherapy alone (when OI < 23) in children with OAB. The limitations were lack of external validation of OI, a 37-49% drop-off rate for follow-up visits at 3 and 6 months, respectively, and not performing UDS on all participants at every follow-up visit.

CONCLUSIONS

OI was found to be a significant predictor of the presence of OAB symptoms and correlated with the number of urgency episodes. It could estimate how much MCC differs from EBC.

Correspondence of uroflowmetry and voiding diary in evaluation of voiding volume in children with lower urinary tract dysfunction

Background

Objective assessment of voided volumes in children with lower urinary tract dysfunction is important. This study aimed to compare and evaluate voided volumes obtained from a 48-h voiding diary and uroflowmetry in children with lower urinary tract dysfunction.

Methods

In this retrospective cohort study, voided volumes obtained by 48-h voiding diary and contemporaneous uroflowmetry were compared in terms of age, sex, and the three most common subtypes of lower urinary tract dysfunction (monosymptomatic nocturnal enuresis, overactive bladder, and dysfunctional voiding) in children. Patients were stratified according to voided volume differences between uroflowmetry and 48-h voiding diary.

Results

A total of 242 children were included in the study. Maximum and average voided volumes in uroflowmetry were higher than those in 48-h voiding diaries in the entire population (P < 0.001). While there was a significant difference between maximum voided volume in the two methods when evaluating patients with overactive bladder and dysfunctional voiding, there was no significant difference in those with monosymptomatic nocturnal enuresis (P = 0.001, P = 0.030, P = 0.206, respectively). A significant difference was observed between the three subtypes of lower urinary tract dysfunction in voided volumes (P < 0.001). When maximum and average voided volumes were compared for age subgroups, there was no significant difference in maximum and mean voided volumes only in voiding diary measurements (P > 0.05). When the two methods were compared, there was a difference in maximum and average voided volumes of more than 30% of the estimated bladder capacity in 94 (38.9%) and 86 (34.3%) children, respectively.

Conclusions

Uroflowmetry and a 48-h voiding diary should not be used interchangeably when evaluating children with lower urinary tract dysfunction. The results of uroflowmetry measurements should be used to support the diagnosis of underlying lower urinary tract dysfunction.

Impact of New vs. Old International Children's Continence Society Standardization on the Classification of Treatment Naïve Enuresis Children at Screening: The Value of Voiding Diaries and Questionnaires

Expert consensus papers recommend differentiating enuresis using questionnaires and voiding diaries into non- (NMNE) and monosymptomatic enuresis (MNE) is crucial at intake to decide the most appropriate workout and treatment. This national, Belgian, prospective study investigates the correlation, consistency, and added value of the two methods, the new against the old International Children's Continence Society (ICCS) definitions, and documents the prevalence of the two enuresis subtypes in our population. Ninety treatment-naïve enuretic children were evaluated with the questionnaire, and the voiding diary and the two clinical management tools were compared. Almost 30% of the children had a different diagnosis with each method, and we observed inconsistencies between them in registering Lower Tract Symptoms (κ = -0.057-0.432 depending on the symptom). Both methods had a high correlation in identifying MNE (rs = 0.612, p = 0.001) but not for NMNE (rs = 0.127, p = 0.248). According to the latest ICCS definitions, the incidence of MNE was significantly lower (7 vs. 48%) with the old standardization.

CONCLUSION

The voiding diary and the questionnaire, as recommended by the ICCS at the screening of treatment-naïve enuretic patients, are considerably inconsistent and have significantly different sensitivities in identifying LUTS and thus differentiating MNE from NMNE. However, the high incidence of LUTS and very low prevalence of MNE suggest that differentiating MNE from NMNE to the maximum might not always correlate with different therapy responses.

Evaluation of bladder capacity in children with lower urinary tract symptoms: Comparison of 48-hour frequency/volume charts and uroflowmetry measurements

INTRODUCTION

Objective evaluation of bladder capacity (BC) in children with lower urinary tract symptoms (LUTS) is important for recognizing types of bladder dysfunction. Bladder capacity is evaluated from 48-hour frequency/volume (48-h F/V) charts or by uroflowmetry with ultrasound post-void assessment. There are limited data on the reliability of both methods of assessment in children.

OBJECTIVE

The aim of the study was to compare two modalities of assessment, (F/V chart and uroflowmetry) in cohorts of children with bladder dysfunctions.

STUDY DESIGN

Maximum bladder capacity (MBC) obtained from 48-h F/V charts was compared with volumes calculated from uroflowmetry in a cohort of 86 children with different bladder dysfunctions. The BC obtained by the two modalities was compared for the three most frequent subtypes of bladder dysfunction: monosymptomatic nocturnal enuresis (MNE), overactive bladder (OAB), and dysfunctional voiding (DV). Considering a 48-h F/V chart as standard, the sensitivity, specificity, negative and positive predictive values of uroflowmetry measurements were calculated for detecting low bladder capacity.

RESULTS

The mean maximal bladder capacity (188 ± 99.42 ml) obtained from home 48-h F/V chart measurement was 17 ml lower than the mean value obtained from uroflowmetry (205 ± 112.11 ml) (P = 0.58). The differences between bladder capacities estimated by 48-h F/V chart and uroflowmetry for subjects were not significant (Figure). Concordance between 48-h F/V chart and uroflowmetry categorization of BC was present in 64 (74%) subjects. The sensitivity and specificity of uroflowmetry, in comparison with 48-h F/V chart evaluation, for recognizing low bladder capacity were 75.5% and 73.17%. The sensitivity and specificity for the different types of LUTS achieved 68.42% and 58.83% for OAB, 80% and 83% for MNE, and 50% and 83.3% for DV.

DISCUSSION

According to the International Children's Continence Society, the management of MNE in children can be made without uroflowmetry. History and MBC evaluation by 48-h F/V charts yields sufficient information. Nevertheless, in situations where F/V charts are unreliable or unavailable, uroflowmetry can be used as an alternative method. The highest discrepancy between both methods of BC evaluation was found in DV; this was mainly due to the mean PVR of 31 ml.

CONCLUSION

For children with MNE, both 48-hour frequency/volume charts and triplicate urine flow measurement with PVR evaluation are reliable methods of maximum bladder capacity evaluation. For children with OAB or DV, both methods may be necessary for accurate evaluation of decreased BC, as F/V chart and uroflow results may not be comparable.

A two-day bladder diary for children: Is it enough?

INTRODUCTION

A bladder diary (BD) is a simple and non-invasive method of evaluating people with lower urinary tract symptoms (LUTS). Recently, the ICCS recommended a 48-h daytime frequency and volume chart (which does not need to be recorded on 2 consecutive days) to evaluate lower urinary tract (LUT) dysfunction. However, some studies on adults have demonstrated that a minimum of 3 days is required. It is believed that, to date, there are no studies in the literature that compare a 2-day BD with a 3-day BD. The advantages of a BD over a shorter period of time are the simplicity and possible better parent compliance.

OBJECTIVE

The aim of this study was to evaluate if a 2-day BD is statistically and clinically comparable to a 3-day BD.

STUDY DESIGN

A voiding diary was filled in over a 3-day period for 92 children (ages ranged from to 3-16 years, mean 7.9 ± 3.07) attending the present institution. By using the voiding diary, the following parameters were calculated: urination frequency, maximum and average volumes of urine (MVV and AVV) and fluid intake. The diary considered the 2 days as the first and second days of the 3-day diary.

RESULTS

Out of the 92 children, eight (8.7%) did not properly complete the diary. The sample predominantly comprised females (n = 55, 59.8%). No differences were seen between 2-day and 3-day bladder diaries regarding fluid intake, maximum and average voided volume. The sensitivity, specificity, positive and negative predictive values of the 2-day bladder diary for detecting frequency were 83.4%, 91.7%, 80% and 93.2%, and for low bladder capacity they were 97.2%, 90.9%, 99% and 88%, respectively (Table).

DISCUSSION

In a 2006 document, the ICCS recommended that a bladder diary be kept for 3 days, but in new documentation (2014) there is a reference stating that 2 days are enough. Bladder capacity is an important parameter in evaluating LUTS. Using a 2-day BD, the data showed that only a small percentage of reduced bladder capacity diagnosis would be lost.

CONCLUSION

When using the 2-day diary, a 16% false negative rate for frequency should be expected. A 2-day bladder diary is sufficient to evaluate bladder capacity and fluid intake.

The correlation between bladder volume wall index and the pattern of uroflowmetry/external sphincter electromyography in children with lower urinary tract malfunction

OBJECTIVE

To evaluate the relationship between bladder volume wall index (BVWI) and the pattern of uroflowmetry in children with lower urinary tract malfunction.

PATIENTS & METHODS

91 children aged 4-15 years with history of bladder dysfunction and 59 age/sex-matched healthy children with negative urine culture in previous month were enrolled. Uroflowmetry and kidney and bladder sonography were performed in all children. BVWI was measured by dividing maximum bladder volume index by mean bladder thickness. It was expressed as percentage by dividing calculated BVWI by expected BVWI, and values between 70% and 130% were presumed normal. Urodynamic study was done in symptomatic cases.

RESULTS

The bladder was thick (<70%) in 39 (28 cases, 11 controls) and thin (>130%) in 35 (18 cases, 17 controls) (P > 0.05). Uroflowmetry was abnormal in 82 (61 cases, 21 controls) (P < 0.05). Severe sphincter dyssynergia was detected in 47% of cases compared with 20% of controls (P < 0.05).There was no relationship between BVWI and uroflowmetry in cases or in controls (P > 0.05). The median post-void residual urine was not statistically different between the groups (20 vs 12.3 ml) (P > 0.05). When both bladder sonography and uroflowmetry were abnormal, they had an association with abnormal urodynamics (P < 0.05).

CONCLUSION

Among children with lower urinary tract dysfunction, the pattern of uroflowmetry could not be predicted from the BVWI, but in cases with combined abnormal bladder sonography and uroflowmetry results, there was a significant association with an abnormal urodynamic study.

Long-term bladder function followup in boys with posterior urethral valves: comparison of noninvasive vs invasive urodynamic studies

PURPOSE

We studied whether noninvasive urodynamic evaluation can be as effective and safe as invasive urodynamics in detecting lower urinary tract dysfunction and in preventing late onset renal failure during long-term management of boys with posterior urethral valves.

MATERIALS AND METHODS

We evaluated 47 boys with posterior urethral valves using repeat urodynamics. A total of 28 patients with followup of at least 3 years and repeat evaluation of serum creatinine were included in the study. The first 14 boys in the series underwent cystometry and pressure-flow study at least every 3 years (group A), and the remaining 14 patients were monitored annually from age 5 with bladder diary, uroflowmetry, post-void residual urine on ultrasound and serum creatinine (group B). Lower urinary tract dysfunction and serum creatinine were compared (Fisher exact test and Mann-Whitney test) between groups A and B, and by stratifying patients into subgroups by age (5 to 6, 7 to 13 and older than 13 years). In all patients urodynamic diagnosis of lower urinary tract dysfunction was matched and confirmed with lower urinary tract symptoms.

RESULTS

During followup the prevalence of lower urinary tract dysfunction did not differ significantly between group A (71% in boys 5 to 6, 43% in boys 7 to 13 and 85% in boys older than 13 years) and group B (36%, 43% and 60%, respectively). Late onset renal failure was observed in 2 boys in group A and 2 in group B.

CONCLUSIONS

Noninvasive urodynamic evaluation seems to be as safe and effective as invasive urodynamic study in the long-term management of boys with posterior urethral valves. Based on these findings, invasive urodynamics may be reserved for cases of progressive deterioration of lower urinary tract dysfunction or renal function.