Uroflowmetry with pelvic floor electromyography: inter-rater agreement on diagnosis of pediatric non-neurogenic voiding disorders

A comparative study between EMG uroflowmetry with and without a catheter in children

OBJECTIVES

To evaluate the effect of urethral catheterization on the accuracy of EMG uroflowmetry in children with non-neurogenic voiding disorders during pressure-flow (PF) studies compared to the non-invasive EMG uroflowmetry test.

METHODS

A retrospective study of children undergoing a urodynamic evaluation at our institution between 8/2018 and 7/2022 was employed. Urination curves and pelvic floor muscle activity were compared between PF studies and non-invasive EMG uroflowmetry test. The non-invasive test was selected as the standard benchmark.

RESULTS

104 children were tested, with 34 children (33%) being able to urinate only in a non-invasive EMG uroflowmetry. The percentage of boys unable to urinate with a catheter was significantly higher than girls (54% vs. 13%, p-value < 0.001). In 70 children, a normal bell-shaped urination curve was found in 13 compared to 33 children in the PF studies and non-invasive uroflowmetry, respectively. PF studies demonstrated a specificity of 39% (95% CI 23-57) and a positive predictive value (PPV) of 61% (95% CI 53-67) in finding non-bell-shaped curves. Relaxation of pelvic muscles was found in 21 (30%) as opposed to 39 (55%) of children in invasive and non-invasive EMG uroflowmetry, respectively (p-value = 0.5).

CONCLUSION

The accuracy of PF studies in children, primarily in boys, compared to the non-invasive uroflowmetry, was poor. This may pose potential errors in diagnosis and subsequent treatment. We recommend completing a non-invasive EMG uroflowmetry in cases where the child refused to urinate, or pathology was found, requiring a modification in treatment.

Diagnoses and Treatment Recommendations-Interrater Reliability of Uroflowmetry in People with Multiple Sclerosis

BACKGROUND

Uroflowmetry (UF) is an established procedure in urology and is recommended before further investigations of neurogenic lower urinary tract dysfunction (NLUTD). Some authors even consider using UF instead of urodynamics (UD). Studies on the interrater reliability of UF regarding treatment recommendations are rare, and there are no relevant data on people with multiple sclerosis (PwMS). The aim of this study was to investigate the interrater reliability (IRR) of UF concerning diagnosis and therapy in PwMS prospectively.

METHODS

UF of 92 PwMS were assessed by 4 raters. The diagnostic criteria were normal findings (NFs), detrusor overactivity (DO), detrusor underactivity (DU), detrusor-sphincter dyssynergia (DSD) and bladder outlet obstruction (BOO). The possible treatment criteria were as follows: no treatment (NO), catheter placement (CAT), alpha-blockers, detrusor-attenuating medication, botulinum toxin (BTX), neuromodulation (NM), and physiotherapy/biofeedback (P/BF). IRR was assessed by kappa (κ).

RESULTS

κ of diagnoses were NFs = 0.22; DO = 0.17; DU = 0.07; DSD = 0.14; and BOO = 0.18. For therapies, the highest κ was BTX = 0.71, NO = 0.38 and CAT = 0.44.

CONCLUSIONS

There is a high influence of the individual rater. UD should be subject to the same analysis and a comparison should be made between UD and UF. This may have implications for the value of UF in the neuro-urological management of PwMS, although at present UD remains the gold standard for the diagnostics of NLUTD in PwMS.

Role of videourodynamic study in precision diagnosis and treatment for lower urinary tract dysfunction

Lower urinary tract symptoms (LUTS) are complicated and cannot be used alone to diagnose lower urinary tract dysfunctions (LUTDs) and guide treatment. Patients with bladder outlet obstruction (BOO), impaired detrusor contractility, and hypersensitive bladder might present with voiding predominant symptoms, whereas patients with detrusor overactivity (DO), dysfunctional voiding, or BOO might also present with storage symptoms. To clearly identify the pathophysiology of LUTD, a comprehensive urodynamic study (UDS) including pressure flow and image during the storage and emptying phases, naming videourodynamic study (VUDS), is necessary. This study is especially mandatory in the diagnosis of (1) male LUTS refractory to medical treatment for benign prostatic hyperplasia, (2) female voiding dysfunction and urinary retention, (3) diagnosis of overactive bladder syndrome refractory to first-line medication, (4) management of female stress urinary incontinence and postoperative LUTS, (5) diagnosis and management of neurogenic LUTD, (6) pediatric urinary incontinence and enuresis, (7) geriatric urinary incontinence, and (8) recurrent bacterial cystitis. Although VUDS should not be used as a screening test for any LUTS, it should be considered when the initial management cannot relieve LUTS, or when invasive surgical procedure is planning to undertake for patients with refractory LUTS. VUDS should be recommended as the second-line investigation when the initial diagnosis and treatment based on the symptoms alone or noninvasive tests fail to improve LUTS.

Interpretation of uroflow curves: A global survey measuring inter and intra rater reliability

INTRODUCTION

There is a large amount of intra and inter observer variability in defining curve shapes. This study aims to evaluate inter and intra rater reliability (RR) on evaluating uroflow curves in a broad spectrum of international practitioners.

METHODS

Eight hundred sixty-four questionnaires were sent by email to health professionals that care for children with voiding dysfunction. It included demographic questions and 11 different uroflow curves and two duplicates.

RESULTS

Four hundred forty-one emails were opened and 29.5% of those responded. Seventy percent of responders were physicians, including 46% pediatric urologists. Europe, South America, North America, Oceania, and Asia represented respondents. For the repeated bell smooth curve the intra rater agreement was 82.1% utilizing the International Children's Continence Society (ICCS) classification and 92.3% for the shape of the curve (bell, plateau, and tower [BPT]) (P = .04). For the repeated interrupted plateau curve it was 69.5% and 97.5% for ICCS and for the continuity of the curve (smooth or fractionated [SF]) classifications, respectively (P < .001). The curves were then divided into two groups for evaluation of inter RR. For the set of seven smooth curves, the inter RR was low in all classifications with α = .282, .497, and .242 for ICCS, SF, and BPT, respectively. The group of six fractionated curves showed a slightly better agreement with α = .533, .404, and .662 for ICCS, SF, and BPT, respectively.

CONCLUSIONS

This is the largest study looking at inter and intra RR of uroflows in a disparate population of readers. It was evident from our findings that inter RR was poor and additionally intra RR was equally poor, indicating the unreliability of uroflow shapes to be used for research purposes.

Usefulness of the classification of urinary dysfunction for the prognosis of the first endoscopic treatment of vesicoureteral reflux in children over the age of 3

OBJECTIVES

To assess the diagnostic performance of urinary dysfunction patterns associated with vesicoureteral reflux (VUR) in children over the age of 3 according to the result of the first endoscopic treatment (ENDT1), grouped into a classification designed by our group (CMD.URI-La Fe). Comparison with other current classifications such as that of Van Batavia et al. MATERIAL AND METHODS: Ambispective cross-cutting study of a sample of 50 children.

EXCLUSION CRITERIA

previous ENDT, age ≤ 3 years, anatomical or neurological anomalies and a history of ureteral or abdominopelvic surgery. Prior to the ENDT1, a bladder voiding function assessment by uroflowmetry+electromyography (UF-EMG) and post-mictional residue (ultrasound). Other variables from the bladder diary, pre-mictional bladder wall thickness and other clinical variables. The correction of VUR was assessed by isotope cystography 3 months after the treatment. Urinary patterns were classified according to the significant variables (URI-La Fe), and the diagnostic performance of this classification was assessed, comparing it to the classification of patients as proposed by Van Batavia et al. RESULTS: Mean age: 6.8±2.28 years. Males/females (44%/56%). Grades of VUR (mild/moderate/severe). ENDT1 VUR correction rate: 77% (n=38). Diagnostic performance (Van Batavia; URI-La Fe): correct prediction (37.5%; 75%), sensitivity (32.4%; 87.8%), specificity (54.5%; 46.6%), positive predictive value (70.6; 78.3%) and negative predictive value (19.4%; 63.6%).

CONCLUSIONS

Our results show the usefulness of the non-invasive test and the classification of urinary dysfunction in children aged over 3 years prior to the first endoscopic treatment of VUR.

Uroflow measurement combined with electromyography testing of the pelvic floor in healthy children

AIMS

To investigate if the standard protocol for uroflowmetry, recommended by the International Children's Continence Society, remains accurate when integrating EMG measurement by means of superficial electrodes.

METHODS

A cross-sectional study was conducted including healthy children. Group A performed two direct repetitions of uroflowmetry in combination with electromyography (uroflow/EMG). Group B performed a preceding measurement of isolated uroflowmetry, followed by two randomized measurements of uroflowmetry with and without EMG. Interpretation of uroflow curve was assessor blinded by a pediatric urologist and secondly performed using the flow index methodology. Statistical analysis compared different voids within each group and between group A and B.

RESULTS

Eighty-three children were included and 206 uroflow measurements were obtained. In both groups statistical findings confirmed the hypothesis that it is preferable to perform an additional measurement before the use of uroflow/EMG. Although both groups showed improvement between voids, the group with initial uroflow measurement followed by uroflow/EMG measurement showed more improvement in concern of curve pattern. An initially better first void in group A, but no statistical difference between the second void in group A and uroflow/EMG testing in group B further demonstrates a higher improvement in group B. This suggests the use of a precedent uroflowmetry without EMG is preferable to immediate testing with EMG.

CONCLUSIONS

It should be mandatory to perform one measurement in advance to ensure the reliability of the results. It is suggested to initiate the procedure with a single uroflowmetry measurement followed by one measurement of uroflow with EMG testing.

Is urotherapy alone as effective as a combination of urotherapy and biofeedback in children with dysfunctional voiding?

Objective:

To compare standard urotherapy with a combination of urotherapy and biofeedback sessions and to determine the changes that these therapies promote in children with dysfunctional voiding.

Patients and Methods:

The data of 45 patients who participated in the study from January 2010 to March 2013 were evaluated. All patients underwent urinary system ultrasonography to determine post-void residual urine volumes and urinary system anomalies. All patients were diagnosed using uroflowmetry - electromyography (EMG). The flow pattern, maximum flow rate, and urethral sphincter activity were evaluated in all patients using uroflowmetry - EMG. Each patient underwent standard urotherapy, and the results were recorded. Subsequently, biofeedback sessions were added for all patients, and the changes in the results were recorded and statistically compared.

Results:

A total of forty - five patients were included, of which 34 were female and 11 were male and the average age of the patients was 8.4 ± 2.44 years (range: 5 - 15 years). After the standard urotherapy plus biofeedback sessions, the post-void residual urine volumes, incontinence rates and infection rates of patients were significantly lower than those with the standard urotherapy (p < 0.05). A statistically significant improvement in voiding symptoms was observed after the addition of biofeedback sessions to the standard urotherapy compared with the standard urotherapy alone (p < 0.05).

Conclusions:

Our study showed that a combination of urotherapy and biofeedback was more effective in decreasing urinary incontinence rates, infection rates and post - void residual urine volumes in children with dysfunctional voiding than standard urotherapy alone, and it also showed that this combination therapy corrected voiding patterns significantly and objectively.